The Overactive BladderThe Overactive Bladder

Lewis Chan Lewis Chan

Staff Specialist in UrologyStaff Specialist in Urology

Concord Repatriation General HospitalConcord Repatriation General Hospital

Why are we talking about Why are we talking about this?this?

By 2050, 20% of population will be over 65By 2050, 20% of population will be over 65 Voiding dysfunction is the Voiding dysfunction is the most commonmost common

geriatric problemgeriatric problem Prevalence of urinary incontinence in elderly Prevalence of urinary incontinence in elderly

30-50%30-50% Significant Incontinence 4-8%Significant Incontinence 4-8% 1 in 3 men > 50 years will undergo treatment 1 in 3 men > 50 years will undergo treatment

for voiding dysfunction in their lifetimefor voiding dysfunction in their lifetime 1 in 3 men or women > 75 years have 1 in 3 men or women > 75 years have

overactive bladder symptomsoveractive bladder symptoms

What are lower urinary tract What are lower urinary tract symptoms (LUTS)?symptoms (LUTS)?

Previously known as ‘prostatism’ !Previously known as ‘prostatism’ !

Frequency, urgency, nocturia - “overactive Frequency, urgency, nocturia - “overactive bladder”bladder”

Hesitancy, decreasing stream, dribbling - Hesitancy, decreasing stream, dribbling - “voiding” symptoms“voiding” symptoms

Incontinence - stress, urge or mixedIncontinence - stress, urge or mixed

Dysuria, pain - inflammationDysuria, pain - inflammation

HaematuriaHaematuria

NB – Symptoms do NOT give the Diagnosis!NB – Symptoms do NOT give the Diagnosis!

Facts and MythsFacts and Myths

Incontinence is NOT a normal part of ageingIncontinence is NOT a normal part of ageing BUT there are changes in bladder and pelvic BUT there are changes in bladder and pelvic

structures that can contribute to incontinencestructures that can contribute to incontinence Medical problems that can disrupt the Medical problems that can disrupt the

continence mechanism (DM/CVA) are more continence mechanism (DM/CVA) are more common among older populations.common among older populations.

BPH - increase in incidence with ageing but not BPH - increase in incidence with ageing but not everyone with BPH has obstructioneveryone with BPH has obstruction

Menopause – atrophic changesMenopause – atrophic changes Cognitive and functional impairment.Cognitive and functional impairment.

LUTS - Diagnostic DilemmaLUTS - Diagnostic Dilemma

LUTS in men – is it due to bladder outlet LUTS in men – is it due to bladder outlet obstruction (prostatic hypertrophy) or obstruction (prostatic hypertrophy) or overactive bladder?overactive bladder?

LUTS/ incontinence in women – is it due to LUTS/ incontinence in women – is it due to sphincter/ pelvic floor weakness or overactive sphincter/ pelvic floor weakness or overactive bladder?bladder?

Mechanisms of ContinenceMechanisms of Continence

Overactive Bladder - CausesOveractive Bladder - Causes

urinary tract infectionsurinary tract infections

Idiopathic Idiopathic

Bladder outlet obstructionBladder outlet obstruction

neurological diseaseneurological disease

stonestone

tumourtumour

Voiding Dysfunction - Voiding Dysfunction - AssessmentAssessment

HistoryHistory SymptomsSymptoms Severity / degree of Severity / degree of botherbother Comorbidities / medicationsComorbidities / medications Functional / social issuesFunctional / social issues

Physical ExaminationPhysical Examination GeneralGeneral Urogenital including PR Urogenital including PR Pelvic exam – prolapse, muscle tone,sensation,reflexesPelvic exam – prolapse, muscle tone,sensation,reflexes

Incontinence – Transient CausesIncontinence – Transient Causes

DD -- DeliriumDelirium

II -- InfectionInfection

AA -- Atrophic vaginitisAtrophic vaginitis

PP -- PsychologicalPsychological

PP -- PharmacologicalPharmacological

EE -- Excess urine outputExcess urine output

RR -- Restricted mobilityRestricted mobility

SS -- StoolStool

Drugs and IncontinenceDrugs and IncontinenceAlcohol central inhibition urge IC / enuresis

Diuretics bladder filling urge IC / polyuria

Sedatives awareness / LOC urge IC / enuresis

Caffeine detrusor excitability urge IC / enuresis

Anticholinergics /Tricyclics

contractility overflow IC

Alpha Blockers relax sphincter SI

Lithium polydipsia urge IC

Case OneCase One

70 yr old man with 2 year Hx of worsening 70 yr old man with 2 year Hx of worsening frequency urgency poor stream and nocturia frequency urgency poor stream and nocturia x3x3

PR – moderate size soft prostatePR – moderate size soft prostate Otherwise well but bothered by symptomsOtherwise well but bothered by symptoms What tests would you do?What tests would you do?

Investigations – safety testsInvestigations – safety tests

UMCS UMCS Haematuria , UTIHaematuria , UTI CreatinineCreatinine Renal functionRenal function PSAPSA Prostate CaProstate Ca UltrasoundUltrasound Residual, bladder stoneResidual, bladder stone Voiding DiaryVoiding Diary Functional bladder Functional bladder

capacitycapacity

Specialty tests – flow study, urodynamics, Specialty tests – flow study, urodynamics, cystoscopycystoscopy

Case One Case One

MSU – normalMSU – normal Creatinine and PSA normalCreatinine and PSA normal Ultrasound – residual 90mls, normal kidneysUltrasound – residual 90mls, normal kidneys Does he need other tests?Does he need other tests? What is the likely cause of his urinary What is the likely cause of his urinary

symptoms?symptoms? What treatment do you suggest?What treatment do you suggest?

Case TwoCase Two

67 yr old woman with worsening frequency, 67 yr old woman with worsening frequency, urgency and mixed stress and urge urgency and mixed stress and urge incontinenceincontinence

O/E – moderate descent of bladder base on O/E – moderate descent of bladder base on coughing and straining with reduced PF muscle coughing and straining with reduced PF muscle tonetone

What tests do you ask for?What tests do you ask for? What treatment would you suggest?What treatment would you suggest?

Pharmacological treatment of Pharmacological treatment of OABOAB

Anticholinergic therapy – oxybutynin, Anticholinergic therapy – oxybutynin, propanthelinepropantheline

Tricyclics – imipramineTricyclics – imipramine Use often limited by side-effects – dry mouth, Use often limited by side-effects – dry mouth,

constipation, blurred vision, constipation, blurred vision, drowsiness,confusiondrowsiness,confusion

Newer ‘bladder selective’ drugs now available Newer ‘bladder selective’ drugs now available in Australia – in Australia – tolterodine,darifenacin,solifenacin,transdermal tolterodine,darifenacin,solifenacin,transdermal oxybutynin patchoxybutynin patch

So many choices – what to So many choices – what to do?do?

Oxybutynin and tolterodine are recognised first Oxybutynin and tolterodine are recognised first line treatments for OAB world wideline treatments for OAB world wide

In patients intolerant of oxybutynin consider In patients intolerant of oxybutynin consider solifenacin if significant OAB or transdermal solifenacin if significant OAB or transdermal oxybutynin patchoxybutynin patch

In frail patients with high risks for complications In frail patients with high risks for complications of anticholinergic therapy consider transdermal of anticholinergic therapy consider transdermal patch or tolterodinepatch or tolterodine

Selected patients who fail drug therapy may Selected patients who fail drug therapy may benefit from intravesical Botulinum Toxin benefit from intravesical Botulinum Toxin injectionsinjections

Case TwoCase Two

Urgency and frequency improved with bladder Urgency and frequency improved with bladder training and ditropan training and ditropan

Still needs to wear pads for stress Still needs to wear pads for stress incontinence and occasional urge ICincontinence and occasional urge IC

What would you recommend?What would you recommend?

Overactive Bladder - WomenOveractive Bladder - Women

Usually F/U/N +/- urge incontinenceUsually F/U/N +/- urge incontinence Exclude UTI, beware recent onset OAB in Exclude UTI, beware recent onset OAB in

smokerssmokers ManagementManagement

Bladder training /voiding diaryBladder training /voiding diary AnticholinergicsAnticholinergics BotoxBotox Continence appliances / CatheterContinence appliances / Catheter

Case ThreeCase Three

75 yr old man with Parkinson’s Disease. 75 yr old man with Parkinson’s Disease. Worsening frequency, urgency and urge Worsening frequency, urgency and urge

incontinence over 6 mths – requiring 3-4 pads incontinence over 6 mths – requiring 3-4 pads a daya day

PR – small soft prostatePR – small soft prostate What tests should he have?What tests should he have?

Case ThreeCase Three

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

next?next?

UrodynamicsUrodynamics

Overactive Bladder - MenOveractive Bladder - Men

Predominant F/U/N with reasonable flowPredominant F/U/N with reasonable flow Small prostateSmall prostate No residualNo residual Remember safety testsRemember safety tests Beware neuropaths (CVA, Parkinsons etc)Beware neuropaths (CVA, Parkinsons etc) ManagementManagement

Bladder training / fluid modificationBladder training / fluid modification Trial of anticholinergics (ditropan, tofranil etc)Trial of anticholinergics (ditropan, tofranil etc) If persisting symptoms – urodynamics +/- cystoscopyIf persisting symptoms – urodynamics +/- cystoscopy

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

Indication – OAB refractory to medical therapyIndication – OAB refractory to medical therapy

Established efficacy in neurogenic detrusor Established efficacy in neurogenic detrusor overactivity with emerging role in treatment overactivity with emerging role in treatment of non-neurogenic overactive bladderof non-neurogenic overactive bladder

Response rate in non-neurogenic OAB about Response rate in non-neurogenic OAB about 60-80% with duration of response around 6-12 60-80% with duration of response around 6-12 months. Most will require repeat injections months. Most will require repeat injections

Currently available data showed no dysplastic Currently available data showed no dysplastic changes to bladder after BTX therapy changes to bladder after BTX therapy

Indications for cystoscopyIndications for cystoscopy

Frank haematuriaFrank haematuria Persistent microhaematuriaPersistent microhaematuria Persistent irritative symptoms (esp Persistent irritative symptoms (esp

smokers) smokers) Recurrent UTIsRecurrent UTIs Past history of urethral stricturePast history of urethral stricture

Urinary Incontinence following Urinary Incontinence following Prostate SurgeryProstate Surgery

Incontinence following TURP Incontinence following TURP generally due to overactive generally due to overactive bladder bladder

Incontinence following radical Incontinence following radical prostatectomy (for prostate prostatectomy (for prostate cancer) usually due to sphincter cancer) usually due to sphincter muscle weakness muscle weakness

Treatment:Treatment: Pelvic floor exercisesPelvic floor exercises Pads/UridomePads/Uridome Transurethral injection of bulking agentsTransurethral injection of bulking agents Perineal slingPerineal sling Artificial Urinary SphincterArtificial Urinary Sphincter

Surgical treatment of post Surgical treatment of post prostatectomy incontinence prostatectomy incontinence

Take Home MessagesTake Home Messages

Voiding dysfunction can significantly affect Voiding dysfunction can significantly affect quality of life in the elderly but is not an quality of life in the elderly but is not an inevitable part of ageinginevitable part of ageing

Careful consideration of comorbidities, effects Careful consideration of comorbidities, effects of medications, functional and social issues of medications, functional and social issues essential in managementessential in management

Conservative measures should be considered Conservative measures should be considered before pharmacotherapy and invasive testsbefore pharmacotherapy and invasive tests

Surgery still has an important role in those who Surgery still has an important role in those who fail conservative treatment or pharmacotherapyfail conservative treatment or pharmacotherapy

“Remember, this treatment worked much better on mice than itdid on guineapigs, and frankly I think he looks more like a guineapig!”