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Overactive Bladder

2/1/2017 - Julie DeCesare, MD

Editor:  Christopher M. Zahn, MD

Overactive bladder (OAB) is defined as “urinary urgency, typically accompanied by frequency and nocturia, with and without urge urinary incontinence, in the absence of urinary tract infection or other obvious pathology.” OAB impacts approximately 18 million women per year, and accounts for about 7% of all ambulatory visits made by women.

Normal micturition occurs when the smooth detrusor muscle contracts and triggers an automatic relaxation of the urethral sphincter muscles. In cases of overactive bladder, the detrusor muscle contracts when the bladder is not full, often randomly. This triggers the patient to feel the sudden urge to void with resultant episodic incontinence, although not all women with OAB will have actual urinary leakage. Most patients describe an overwhelming urge to void with difficulty getting to the bathroom in time. Frequency and nocturia are also common symptoms.

Initial evaluation of this condition includes complete history, bladder diary, physical exam (including the assessment of the pelvic support, urethral mobility, and provoked incontinence), urinalysis, and post void residual. Multichannel urodynamic studies should be reserved for complex cases in which an initial office diagnosis is unclear.

Initial treatment involves non-invasive lifestyle and behavior modifications. These include physical therapy with or without biofeedback, bladder training, and dietary modifications, including fluid restriction, avoidance of caffeine, and weight loss. Timed voids may also decrease episodes of incontinence.

First-line pharmacologic treatment is anti-muscarinic medications. It is reasonable to start with these agents in well-counseled patients who decline behavior or lifestyle modifications. These medications increase the storage capacity of the bladder and reduce urgency symptoms. Common agents include oxybutynin and tolterodine tartrate. Side effects are problematic and include dry mouth, constipation, and somnolence. Less common effects include nausea, dry eyes, and headache. These medications only have a minimal effect on the number of voiding episodes, which is one of the most bothersome symptoms.

Additional treatments have been described for OAB. Botulinum Toxin A injections have shown promise, but overtreatment can lead to urinary retention. Acupuncture has been effective. Mirabegron is a relatively new pharmacological agent with side effect profile similar to placebo. Nerve modulators, including posterior tibial nerve stimulation and sacral neuromodulation, have also been shown to promote relief from OAB. Neuromodulation is an additional alternative for patients with recalcitrant urgency urinary incontinence who have not responded to other conservative measures.

Further reading:

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 155: Urinary Incontinence in Women.  Obstet Gynecol. 2015 Nov;126(5):e66-81. doi: 10.1097/AOG.0000000000001148..

Olivera C, Meriwether K, El-Nashar S, et al. Nonantimuscarinic treatment for overactive bladder: a systematic review. Am Obstet Gynecol 2016;215:34-57.

Initial Approval: January 2017; Revised 1/2018.

 

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The Foundation for Exxcellence in Women’s Health, Inc (“Foundation”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The Foundation reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. The Foundation does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the Foundation, the ABOG, SASGOG nor their respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

 

 

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