Transcript overactive bladder

The Overactive Bladder
Lewis Chan
Staff Specialist in Urology
Concord Repatriation General Hospital
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 > 50 years will undergo treatment for voiding
dysfunction in their lifetime
 1 in 3 men or women > 75 years have overactive
bladder symptoms
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!
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.
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?
Mechanisms of Continence
Overactive Bladder - Causes
 urinary tract infections
 Idiopathic
 Bladder outlet obstruction
 neurological disease
 stone
 tumour
Voiding Dysfunction - Assessment
 History
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Symptoms
Severity / degree of bother
Comorbidities / medications
Functional / social issues
 Physical Examination
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General
Urogenital including PR
Pelvic exam – prolapse, muscle tone,sensation,reflexes
Incontinence – Transient Causes
D
I
A
P
P
E
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S
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Delirium
Infection
Atrophic vaginitis
Psychological
Pharmacological
Excess urine output
Restricted mobility
Stool
Drugs and Incontinence
 central inhibition
urge IC / enuresis
Diuretics
 bladder filling
urge IC / polyuria
Sedatives
 awareness / LOC
urge IC / enuresis
 detrusor excitability
urge IC / enuresis
 contractility
overflow IC
relax sphincter
SI
polydipsia
urge IC
Alcohol
Caffeine
Anticholinergics /
Tricyclics
Alpha Blockers
Lithium
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?
Investigations – safety tests
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UMCS
Creatinine
PSA
Ultrasound
Voiding Diary
Haematuria , UTI
Renal function
Prostate Ca
Residual, bladder stone
Functional bladder capacity
 Specialty tests – flow study, urodynamics, cystoscopy
Case One
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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?
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?
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,transdermal
oxybutynin patch
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
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?
Overactive Bladder - Women
 Usually F/U/N +/- urge incontinence
 Exclude UTI, beware recent onset OAB in smokers
 Management
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Bladder training /voiding diary
Anticholinergics
Botox
Continence appliances / Catheter
Case Three
 75 yr old man with Parkinson’s 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?
Case Three
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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?
Urodynamics
Overactive Bladder - Men
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Predominant F/U/N with reasonable flow
Small prostate
No residual
Remember safety tests
Beware neuropaths (CVA, Parkinsons etc)
Management
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Bladder training / fluid modification
Trial of anticholinergics (ditropan, tofranil etc)
If persisting symptoms – urodynamics +/- cystoscopy
Intravesical Botulinum Toxin-A (BTXA) Injection for OAB
 Indication – OAB refractory to medical therapy
 Established efficacy in neurogenic detrusor
overactivity with emerging role in treatment of nonneurogenic overactive bladder
 Response rate in non-neurogenic OAB about 6080% 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
Indications for cystoscopy
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Frank haematuria
Persistent microhaematuria
Persistent irritative symptoms (esp smokers)
Recurrent UTIs
Past history of urethral stricture
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:
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Pelvic floor exercises
Pads/Uridome
Transurethral injection of bulking agents
Perineal sling
Artificial Urinary Sphincter
Surgical treatment of post
prostatectomy incontinence
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
“Remember, this treatment worked much better on mice than it
did on guineapigs, and frankly I think he looks more like a guineapig!”