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Management of Overactive BladderFor Gynecologist
Prof Aboubakr ElnasharBenha university Hospital, EgyptAboubakr Elnashar
Definition2002 ICS
OAB defined based on symptoms Urgency, with or without urge
incontinence, usually with frequency and nocturia
In the absence of pathologic or metabolic conditions that might explain these symptoms
ICS = International Continence Society (www.icsoffice.org)Aboubakr Elnashar
Urge IncontinenceUrge Incontinence
• Sudden & involuntary Sudden & involuntary loss of urineloss of urine
Urge IncontinenceUrge Incontinence
• Sudden & involuntary Sudden & involuntary loss of urineloss of urine
FrequencyFrequency
• 8 or more visits to the toilet/24 h8 or more visits to the toilet/24 h
Nocturia Urination at nightUrination at night
• • 2 or more visits to toilet2 or more visits to toilet during sleeping hours during sleeping hours
FrequencyFrequency
• 8 or more visits to the toilet/24 h8 or more visits to the toilet/24 h
Nocturia Urination at nightUrination at night
• • 2 or more visits to toilet2 or more visits to toilet during sleeping hours during sleeping hours
OABOABOABOAB
SymptomsSymptoms
UrgencyUrgency
• Sudden, strong Sudden, strong desire to urinatedesire to urinate
UrgencyUrgency
• Sudden, strong Sudden, strong desire to urinatedesire to urinate
Aboubakr Elnashar
Epidemiology Adult:
1 out of 11
i.e. >osteoporosis or Alzheimer’s disease
All ages
Aboubakr Elnashar
Impact on HRQoLImpact on HRQoL significantly impaired significantly impaired
SocialSocial– Reduction in social interaction/increased social Reduction in social interaction/increased social
isolationisolation– Cessation of some hobbiesCessation of some hobbies
PhysicalPhysical– Limitations or cessation of physical activitiesLimitations or cessation of physical activities
SexualSexual– Avoidance of sexual contactAvoidance of sexual contact
PsychologicalPsychological– Guilt/depressionGuilt/depression– Fear of:Fear of:
» Being a burden Or Having urine odorBeing a burden Or Having urine odor OccupationalOccupational Aboubakr Elnashar
Physical ProblemsPhysical Problems
Limitations or cessation of physical activities
Aboubakr Elnashar
Psychological ProblemsPsychological Problems
Guilt/depressionFear of:
Being a burden Or Having urine odor
Aboubakr Elnashar
Social ProblemsSocial Problems
Reduction in social interaction/increased social isolationCessation of some hobbies
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Sexual ProblemsSexual Problems
• Avoidance of sexual contact
Aboubakr Elnashar
Occupational/Financial Occupational/Financial ProblemsProblems
• Absence from work
• Job loss
• Change of job
• Poor relationship with employers/ employee
• Financial loss
Aboubakr Elnashar
Vicious Circle of Vicious Circle of Bladder Control ProblemsBladder Control Problems
Isolation Guilt
Social, domestic, physical, sexual and psychologicalproblems
Absence from work
DepressionAboubakr Elnashar
Causes
• Majority: Idiopathic unknownunknown.
• Some: ±neurologicalneurological deficit.
• Multiple sclerosis• Stroke• Parkinson’s Disease• Spina Bifida• Spinal cord damage
Aboubakr Elnashar
Screening and DiagnosisScreening and Diagnosis
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* Survey conducted by Gallup Group (European Study).
A Hidden Condition*A Hidden Condition*
Many:Many: Self-manage: Self-manage: voiding frequently, reducing fluid intake, wearing voiding frequently, reducing fluid intake, wearing
padspads Two-thirds:Two-thirds: symptomatic for 2 ys before seeking treatmentsymptomatic for 2 ys before seeking treatment 30% who seek treatment:30% who seek treatment: receive no assessmentreceive no assessment 80%80%not examinednot examined
Aboubakr Elnashar
ScreeningScreening
Assess history, symptoms, and test resultsAssess history, symptoms, and test results
Establish a diagnosisEstablish a diagnosis
“Do you have bladder problems that are troublesome, or do you ever leak urine?”
YES
Aboubakr Elnashar
DiagnosisDiagnosis
A presumptive diagnosis based on A presumptive diagnosis based on – HistoryHistory– Physical examinationPhysical examination– UrinalysisUrinalysis
Initiation of noninvasive treatment may Initiation of noninvasive treatment may not require an extensive further workupnot require an extensive further workup
Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; March 1996. AHCPR publication 96-0682.Aboubakr Elnashar
Medications That May Medications That May Cause IncontinenceCause Incontinence
DiureticsDiuretics
AntidepressantsAntidepressants
AntihypertensivesAntihypertensives
AnalgesicsAnalgesics
Narcotics
Sedatives
Hypnotics
Aboubakr Elnashar
Differential Diagnosis:Differential Diagnosis:OAB and Stress IncontinenceOAB and Stress Incontinence
Symptom Assessment
Medical History and Physical Examination
Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.
Symptoms Overactive bladder
Stress incontinence
Urgency (strong, sudden desire to void)
Yes No
Frequency with urgency (>8 times/24 h)
Yes No
Leaking during physical activity; eg, coughing, sneezing, lifting
No Yes
Amount of urinary leakage with each episode of incontinence
Large (if present)
Small
Ability to reach the toilet in time
following an urge to void Often no
Yes
Waking to pass urine at night
Usually
Seldom
Aboubakr Elnashar
ManagementManagement
Aboubakr Elnashar
Who Manages Patients?Who Manages Patients?
• General practitioners
• Gynecologists
•Geriatricians
• Urologists
• Others E.g.
•pediatricians, neurologists, physiotherapists and psychologists
Aboubakr Elnashar
Barriers to TreatmentBarriers to Treatment
Patient misconceptions and fears:Patient misconceptions and fears:
““Part of normal aging or everyday life”Part of normal aging or everyday life”
““Not severe or frequent enough to treat”Not severe or frequent enough to treat”
““Too embarrassing to discuss”Too embarrassing to discuss”
““Treatment won't help”Treatment won't help”
Aboubakr Elnashar
Care PathwayCare Pathway
Screening OAB? Yes
Treat if:
Urgency and Frequency, with or without urge incontinence, and
normal urinalysis
>8-12 w TT Failed
Referral to specialist
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.
Aboubakr Elnashar
ReferralReferral
Symptoms do not respond Symptoms do not respond to initial TT within 2 to 3 to initial TT within 2 to 3 monthsmonths
Hematuria without infection Hematuria without infection on urinalysison urinalysis
Symptoms suggestive of Symptoms suggestive of poor bladder emptyingpoor bladder emptying
Pelvic, bladder, vaginal, or Pelvic, bladder, vaginal, or urethral painurethral pain
Evidence of complicated Evidence of complicated neurologic or metabolic neurologic or metabolic diseasedisease
Failed previous Failed previous incontinence surgeryincontinence surgery
Elevated PVR volumeElevated PVR volume Radical pelvic surgeryRadical pelvic surgery Symptomatic prolapseSymptomatic prolapse
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.
Aboubakr Elnashar
Treatment OptionsTreatment Options
I.I. Life style changesLife style changes
II.II. Behavioral therapyBehavioral therapy
III.III. MedicationMedication
IV.IV. Minimally invasive therapiesMinimally invasive therapiesBotulinum A-toxinBotulinum A-toxin
NeuromodulationNeuromodulation
I.I. Surgery Surgery
Aboubakr Elnashar
I. Lifestyle changesI. Lifestyle changes
Moderate fluid intake
Reduce or eliminate caffeine
Avoid fluids before bed
Aboubakr Elnashar
II. Behavioral Therapy Bladder education/retraining
Pelvic floor muscle exercises
Aboubakr Elnashar
Bladder Training:Bladder Training:• Helps patients regain control of their bladder by Helps patients regain control of their bladder by
teaching them to resist the urge to pass urineteaching them to resist the urge to pass urine• Helps to increase bladder capacity and reduce Helps to increase bladder capacity and reduce
the number of episodes of incontinence.the number of episodes of incontinence.- delayed/timed voidingdelayed/timed voiding
- urge suppression exercisesurge suppression exercises
• Effective but requires a high degree of Effective but requires a high degree of motivation and commitment from patients.motivation and commitment from patients.
Aboubakr Elnashar
Pelvic Floor ExercisesPelvic Floor Exercises
Repeat, as recommended
by physician
1. Locate pelvic floor muscles
Squeeze pelvic floor muscles as tightly as possible for a few seconds (maximum of 10 sec)
Relax completely for at least 10 seconds
Aboubakr Elnashar
III. MedicationsIII. Medications
Anticholinergic AgentsAnticholinergic Agents1.1. Trospium chloride (Spasmex)Trospium chloride (Spasmex)
2.2. Oxybutynin (Ditropan)Oxybutynin (Ditropan)
Oxybutynin transdermal (Oxytrol)Oxybutynin transdermal (Oxytrol)
3. Tolterodine (Detrol)3. Tolterodine (Detrol)
4. Solifenacin (Vesicare)4. Solifenacin (Vesicare)
5. Darifenacin (Enablex)5. Darifenacin (Enablex)
Aboubakr Elnashar
Spasmex
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Aboubakr Elnashar
Onset of actionOnset of actionTrospium chlpride has looked to onset of action in the first Trospium chlpride has looked to onset of action in the first weekweek
Rudy D. BJU International. 2006;97:540-546.
Week 2 Week 4 Week 6 Week 8 Week 10 Week 12Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
TROSPIUMTROSPIUM
OXYBUTININ VS. TOLTERODINE OXYBUTININ VS. TOLTERODINE
SOLIFENACIN
TOLDERODINE
DARIFENACIN
TROSPIUM
Aboubakr Elnashar
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Side EffectsSide Effects
Aboubakr Elnashar
1. Trospium Chloride 1. Trospium Chloride ((SpasmexSpasmex)) Quaternary amine as opposed to Quaternary amine as opposed to
tertiary aminetertiary amine 20 mg BID dose20 mg BID dose No pass through blood/brain barrier No pass through blood/brain barrier
with less side effectswith less side effects Rapid onsetRapid onset Not metabolized by liverNot metabolized by liver 60% excreted in the urine unchanged60% excreted in the urine unchanged
Aboubakr Elnashar
2. Oxybutynin (Ditropan)2. Oxybutynin (Ditropan) Previous standard of treatment for urge Previous standard of treatment for urge
incontinenceincontinence
Effectively reduces symptomsEffectively reduces symptoms
High incidence of dry mouth severe enough to High incidence of dry mouth severe enough to cause discontinuationcause discontinuation
Reported to cause CNS adverse events and Reported to cause CNS adverse events and cognitive dysfunctioncognitive dysfunction
Katz IR et al. Am J Geriatr Soc. 1998;46:8-13.Donnellon CA et al. BMJ. 1997;315:1363-1364.
Yarker YE et al. Drugs and Aging. 1995;6:243-262.Aboubakr Elnashar
Oxybutynin Transdermal Oxybutynin Transdermal (Oxytrol)(Oxytrol) 3.9 mg patch, twice weekly3.9 mg patch, twice weekly Similar in effects to poSimilar in effects to po Side effects – less dry mouth but Side effects – less dry mouth but
erythema/pruitiserythema/pruitis
Aboubakr Elnashar
3. Tolterodine (Detrol. Detrusitol) 3. Tolterodine (Detrol. Detrusitol)
Immediate: 2 mg. Immediate: 2 mg.
long acting LA 4 mg dosinglong acting LA 4 mg dosing Side effects: similar to oxybutyninSide effects: similar to oxybutynin Develop a potent and pure muscarinic Develop a potent and pure muscarinic
receptor antagonistreceptor antagonist Equipotent to oxybutynin on the bladderEquipotent to oxybutynin on the bladder Less potent than oxybutynin on Less potent than oxybutynin on
glands/salivationglands/salivation
Aboubakr Elnashar
4. Solifenacin (Vesicare)4. Solifenacin (Vesicare)
5 – 10 mg daily dose5 – 10 mg daily dose Side effects: dry mouth, constipationSide effects: dry mouth, constipation
Aboubakr Elnashar
5. Darifenacin (Enablex)5. Darifenacin (Enablex)
MM33 selective anticholinergic selective anticholinergic
7.5 mg or 15 mg once a day7.5 mg or 15 mg once a day
Aboubakr Elnashar
IV. Minimally invasive therapies
1. Botox® injection• 100 units diluted in 10ml saline in 30 injection sites,
sparing the trigone• Under local anesthesia (xylocaine 2% in 20ml, 20
minutes)
Aboubakr Elnashar
2. Sacral NeuromodulationImplantation of programmable stimulator SC which delivers low amplitude electrical stimulation via a lead to the sacral nerve, usually accessed via the S3 foramen. FDA has approved InterStim Therapy, by Medtronic, as a safe sacral nerve stimulator for treatment of Urinary Urge Incontinence, Urinary Frequency, and Urinary Retention.
Aboubakr Elnashar
V. SurgeryV. Surgery
All measures: failedfailed. CystoplastyCystoplasty a portion of the bowel is attached to the bladder to increase its capacity
Aboubakr Elnashar
Conclusion
1. Definition• Urgency• Frequency ± Urge incontinence
1. Screening and Assessment• History, Physical
1. Management Approach• Lifestyle, Behavioural, Pharmacological
1. Safety of Pharmacologic agents in the Elderly• Use agents which don’t cross the BBB
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Thank YouThank YouAboubakr ElnasharAboubakr Elnashar
Aboubakr Elnashar