overactive bladder

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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
 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”
 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
 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
Severity / degree of bother
Comorbidities / medications
Functional / social issues
 Physical Examination
Urogenital including PR
Pelvic exam – prolapse, muscle tone,sensation,reflexes
Incontinence – Transient Causes
Atrophic vaginitis
Excess urine output
Restricted mobility
Drugs and Incontinence
 central inhibition
urge IC / enuresis
 bladder filling
urge IC / polyuria
 awareness / LOC
urge IC / enuresis
 detrusor excitability
urge IC / enuresis
 contractility
overflow IC
relax sphincter
urge IC
Anticholinergics /
Alpha Blockers
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
Voiding Diary
Haematuria , UTI
Renal function
Prostate Ca
Residual, bladder stone
Functional bladder capacity
 Specialty tests – flow study, urodynamics, cystoscopy
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?
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
 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 –
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
 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
Bladder training /voiding diary
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
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?
Overactive Bladder - Men
Predominant F/U/N with reasonable flow
Small prostate
No residual
Remember safety tests
Beware neuropaths (CVA, Parkinsons etc)
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
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
 Treatment:
Pelvic floor exercises
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
 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!”