The Overactive Bladder

1
The Overactive Bladder

• Lewis Chan
• Staff Specialist in Urology
• Concord Repatriation General Hospital

2
Why are we talking about this?

• By 2050, 20 of population will be over 65
• Voiding dysfunction is the most common geriatric
  problem
• Prevalence of urinary incontinence in elderly
  30-50
• Significant Incontinence 4-8
• 1 in 3 men gt 50 years will undergo treatment for
  voiding dysfunction in their lifetime
• 1 in 3 men or women gt 75 years have overactive
  bladder symptoms

3
What are lower urinary tract symptoms (LUTS)?

• Previously known as prostatism !
• Frequency, urgency, nocturia - overactive
  bladder
• Hesitancy, decreasing stream, dribbling -
  voiding symptoms
• Incontinence - stress, urge or mixed
• Dysuria, pain - inflammation
• Haematuria
• NB Symptoms do NOT give the Diagnosis!

4
Facts and Myths

• Incontinence is NOT a normal part of ageing
• BUT there are changes in bladder and pelvic
  structures that can contribute to incontinence
• Medical problems that can disrupt the continence
  mechanism (DM/CVA) are more common among older
  populations.
• BPH - increase in incidence with ageing but not
  everyone with BPH has obstruction
• Menopause atrophic changes
• Cognitive and functional impairment.

5
LUTS - Diagnostic Dilemma

• LUTS in men is it due to bladder outlet
  obstruction (prostatic hypertrophy) or overactive
  bladder?
• LUTS/ incontinence in women is it due to
  sphincter/ pelvic floor weakness or overactive
  bladder?

6
Mechanisms of Continence
7
Overactive Bladder - Causes

• urinary tract infections
• Idiopathic
• Bladder outlet obstruction
• neurological disease
• stone
• tumour

8
Voiding Dysfunction - Assessment

• History
• Symptoms
• Severity / degree of bother
• Comorbidities / medications
• Functional / social issues
• Physical Examination
• General
• Urogenital including PR
• Pelvic exam prolapse, muscle tone,sensation,refl
  exes

9
Incontinence Transient Causes

• D - Delirium
• I - Infection
• A - Atrophic vaginitis
• P - Psychological
• P - Pharmacological
• E - Excess urine output
• R - Restricted mobility
• S - Stool

10
(No Transcript)
11
Drugs and Incontinence
12
Case One

• 70 yr old man with 2 year Hx of worsening
  frequency urgency poor stream and nocturia x3
• PR moderate size soft prostate
• Otherwise well but bothered by symptoms
• What tests would you do?

13
Investigations safety tests

• UMCS Haematuria , UTI
• Creatinine Renal function
• PSA Prostate Ca
• Ultrasound Residual, bladder stone
• Voiding Diary Functional bladder capacity
• Specialty tests flow study, urodynamics,
  cystoscopy

14
Case One

• MSU normal
• Creatinine and PSA normal
• Ultrasound residual 90mls, normal kidneys
• Does he need other tests?
• What is the likely cause of his urinary symptoms?
• What treatment do you suggest?

15
Case Two

• 67 yr old woman with worsening frequency,
  urgency and mixed stress and urge incontinence
• O/E moderate descent of bladder base on
  coughing and straining with reduced PF muscle
  tone
• What tests do you ask for?
• What treatment would you suggest?

16
(No Transcript)
17
Pharmacological treatment of OAB

• Anticholinergic therapy oxybutynin,
  propantheline
• Tricyclics imipramine
• Use often limited by side-effects dry mouth,
  constipation, blurred vision, drowsiness,confusion
  
• Newer bladder selective drugs now available in
  Australia tolterodine,darifenacin,solifenacin,tr
  ansdermal oxybutynin patch

18
So many choices what to do?

• Oxybutynin and tolterodine are recognised first
  line treatments for OAB world wide
• In patients intolerant of oxybutynin consider
  solifenacin if significant OAB or transdermal
  oxybutynin patch
• In frail patients with high risks for
  complications of anticholinergic therapy consider
  transdermal patch or tolterodine
• Selected patients who fail drug therapy may
  benefit from intravesical Botulinum Toxin
  injections

19
Case Two

• Urgency and frequency improved with bladder
  training and ditropan
• Still needs to wear pads for stress incontinence
  and occasional urge IC
• What would you recommend?

20
Overactive Bladder - Women

• Usually F/U/N /- urge incontinence
• Exclude UTI, beware recent onset OAB in smokers
• Management
• Bladder training /voiding diary
• Anticholinergics
• Botox
• Continence appliances / Catheter

21
Case Three

• 75 yr old man with Parkinsons Disease.
• Worsening frequency, urgency and urge
  incontinence over 6 mths requiring 3-4 pads a
  day
• PR small soft prostate
• What tests should he have?

22
Case Three

• MSU clear
• Voiding diary vol 50-100mls every 2 hours
• Ultrasound no residual
• Would bladder training be useful?
• What drug should he have?
• If no improvement on medical therapy what next?

23
Urodynamics
24
(No Transcript)
25
Overactive Bladder - Men

• Predominant F/U/N with reasonable flow
• Small prostate
• No residual
• Remember safety tests
• Beware neuropaths (CVA, Parkinsons etc)
• Management
• Bladder training / fluid modification
• Trial of anticholinergics (ditropan, tofranil
  etc)
• If persisting symptoms urodynamics /-
  cystoscopy

26
Intravesical Botulinum Toxin-A (BTX-A) Injection
for OAB

• Indication OAB refractory to medical therapy
• Established efficacy in neurogenic detrusor
  overactivity with emerging role in treatment of
  non-neurogenic overactive bladder
• Response rate in non-neurogenic OAB about 60-80
  with duration of response around 6-12 months.
  Most will require repeat injections
• Currently available data showed no dysplastic
  changes to bladder after BTX therapy

27
Indications for cystoscopy

• Frank haematuria
• Persistent microhaematuria
• Persistent irritative symptoms (esp smokers)
• Recurrent UTIs
• Past history of urethral stricture

28
Urinary Incontinence following Prostate Surgery

• Incontinence following TURP generally due to
  overactive bladder
• Incontinence following radical prostatectomy (for
  prostate cancer) usually due to sphincter muscle
  weakness
• Treatment
• Pelvic floor exercises
• Pads/Uridome
• Transurethral injection of bulking agents
• Perineal sling
• Artificial Urinary Sphincter

29
Surgical treatment of post prostatectomy
incontinence
30
Take Home Messages

• Voiding dysfunction can significantly affect
  quality of life in the elderly but is not an
  inevitable part of ageing
• Careful consideration of comorbidities, effects
  of medications, functional and social issues
  essential in management
• Conservative measures should be considered before
  pharmacotherapy and invasive tests
• Surgery still has an important role in those who
  fail conservative treatment or pharmacotherapy

31
Remember, this treatment worked much better on
mice than it did on guineapigs, and frankly I
think he looks more like a guineapig!