Transcript overactive bladder
The Overactive Bladder
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
What are lower urinary tract
Previously known as ‘prostatism’ !
Frequency, urgency, nocturia - “overactive bladder”
Hesitancy, decreasing stream, dribbling - “voiding”
Incontinence - stress, urge or mixed
Dysuria, pain - inflammation
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
Bladder outlet obstruction
Voiding Dysfunction - Assessment
Severity / degree of bother
Comorbidities / medications
Functional / social issues
Urogenital including PR
Pelvic exam – prolapse, muscle tone,sensation,reflexes
Incontinence – Transient Causes
Excess urine output
Drugs and Incontinence
urge IC / enuresis
urge IC / polyuria
awareness / LOC
urge IC / enuresis
urge IC / enuresis
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
Haematuria , UTI
Residual, bladder stone
Functional bladder capacity
Specialty tests – flow study, urodynamics, cystoscopy
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?
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
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
Urgency and frequency improved with bladder training
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
Bladder training /voiding diary
Continence appliances / Catheter
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?
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
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
Persistent irritative symptoms (esp smokers)
Past history of urethral stricture
Urinary Incontinence following
Incontinence following TURP generally
due to overactive bladder
Incontinence following radical
prostatectomy (for prostate cancer)
usually due to sphincter muscle
Pelvic floor exercises
Transurethral injection of bulking agents
Artificial Urinary Sphincter
Surgical treatment of post
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!”