AUA: Overactive Bladder (2019)

See Original Guidelines

See Pharmacological Management of LUTS Chapter Notes

Definitions

• Urgency: complaint of a sudden, compelling desire to pass urine which is difficult to defer
• Urgency urinary incontinence: involuntary leakage of urine associated with a sudden compelling desire to void
• Overactive bladder: Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of a urinary tract infection (UTI) or other obvious pathology.
• Nocturia: interruption of sleep one or more times because of the need to void

Diagnosis and Evaluation

• Clinical diagnosis
  • When urinary frequency (both daytime and night) and urgency, with or without urgency incontinence, in the absence of UTI or other obvious pathology are self-reported as bothersome, the patient may be diagnosed with OAB

Recommended Investigations

Mandatory (2)

1. History and Physical Exam
2. Urinalysis

Optional (4)

1. Urine culture
2. Post void residual
3. Bladder diaries
4. Symptom questionnaire

Not recommended in the initial workup of the uncomplicated patient

1. Urodynamics
2. Cystoscopy
3. Diagnostic renal and bladder ultrasound
4. For complicated or refractory patients, the choice of additional diagnostic tests depends on patient history, QoL and clinician judgment. Neurogenic OAB requires specific evaluation.

History

• Characterize lower urinary tract symptoms (storage and voiding/emptying), including duration of symptoms and baseline symptoms
  • Urinary frequency
    • Varies across individuals.
      • In community-dwelling healthy adults, normal frequency consists of voiding every 3-4 hours with a median of approximately 6 voids a day.
      • Traditionally, up to 7 micturition episodes during waking hours has been considered normal, but this number is highly variable based upon hours of sleep, fluid intake, comorbid medical conditions and other factors.
    • Can be reliably measured with a voiding diary.
  • Incontinence
    • Can be measured reliably with a diary.
• Degree of bother
  • If patient is not significantly bothered by his/her bladder symptoms, then there is a less compelling reason to treat the symptoms.
• Amount and type of fluid intake.
  • Excessive fluid intake can produce voiding patterns that mimic OAB symptoms.
  • Can be measured with a fluid diary
• Current medications
  • Should be reviewed to ensure that symptoms are not related to medications.
• Co-morbid conditions such as neurologic diseases and other genitourinary conditions should be considered as they directly impact bladder function.

Physical exam

1. Abdominal exam
2. Rectal/genitourinary exam
3. Assessment of lower extremities for edema.
4. Patient’s attire and ability to dress independently
   • The ability of the patient to dress independently is informative of sufficient motor skills related to toileting habits. This can provide information on the cognitive function of the patient, which is important to evaluate when considering anticholinergics

Urinalysis

• Rule out UTI and hematuria

Urine culture

• May be appropriate in certain patients given that a urinalysis may be unreliable.

Post-void Residual

• Measurement of the PVR is not necessary for patients who are receiving first-line behavioral interventions or for uncomplicated patients receiving antimuscarinic medications.
  • Anti-muscarinics should be used with caution in patients with PVR 250–300 mL.
• Indications to assess PVR (4)
  1. Presence of voiding/obstructive symptoms
  2. History of incontinence surgery or prostatic surgery
  3. Neurologic diagnoses
  4. Clinician discretion

Bladder diaries

• Diaries that document intake and voiding behavior
• May be useful, particularly for patient education and to document baseline symptoms and treatment efficacy              

Symptoms questionnaire

• Validated symptom questionnaires are useful in the quantification of bladder symptoms and bother- changes with OAB treatment.

Differential Diagnosis

1. Nocturia
2. Polydipsia and polyuria
3. Interstitial cystitis/bladder pain syndrome

Nocturia

• Often due to factors unrelated to OAB, including excessive nighttime urine production and sleep apnea.
• The differential of nocturia includes nocturnal polyuria, low nocturnal bladder capacity or both.
  • In nocturnal polyuria, nocturnal voids are frequently normal or large volume as opposed to the small volume voids commonly observed in nocturia associated with OAB.
  • Sleep disturbances, vascular and/or cardiac disease and other medical conditions are often associated with nocturnal polyuria.

Polydipsia and polyuria

• Frequency that is the result of polydipsia and resulting polyuria may mimic OAB; the two are distinguished with the use of frequency-volume charts.
• Polydipsia-related frequency is physiologically self-induced and should be managed with education and consideration of fluid management.

Interstitial cystitis/bladder pain syndrome

• Clinical presentation of interstitial cystitis/bladder pain syndrome shares the symptoms of OAB
• Bladder and/or pelvic pain, including dyspareunia, is a crucial component of its presentation in contradistinction to OAB.

Management

• OAB may compromise QoL but generally does not affect survival. A treatment plan, therefore, should carefully weigh the patient’s potential benefit of a particular treatment against that treatment’s risk for, severity and reversibility of AEs.
• Provide education to patients regarding normal lower urinary tract function, what is known about OAB, the benefits vs. risks/burdens of the available treatment alternatives and the fact that acceptable symptom control may require trials of multiple therapeutic options before it is achieved.
  • Counsel patients that OAB has a variable and chronic course likely requiring multiple management strategies over time with no single ideal treatment and understands that treatments vary in invasiveness, risk of AEs and reversibility.
  • Most OAB treatments improve patient symptoms but are unlikely to eliminate all symptoms
  • Treatment failure occurs when the patient with reasonable expectations does not have the anticipated symptom improvement or is unable to tolerate the treatment due to AEs; lack of efficacy and the presence of intolerable AEs reduce compliance

Options

1. Observation
2. Lifestyle changes
3. Medications
4. Other

Observation

• OAB is not a disease; it is a symptom complex that generally is not a life-threatening condition.
• After assessment has been performed to exclude conditions requiring treatment and counseling, no treatment is an acceptable choice made by some patients and caregivers.

Lifestyle changes

• First-line therapy to all patients with OAB includes (2):
  1. Behavioral treatments
     1. Bladder control strategies
     2. Pelvic floor muscle training
  2. Fluid management
• While most patients do not experience complete symptom relief, most patients experience significant reductions in symptoms and improvements in QoL.
  • Randomized trials indicates that behavioral treatments are generally either equivalent to or superior to medications in terms of reducing incontinence episodes, improving frequency and nocturia and improving QoL.
• Behavioral treatments
  • A group of risk-free tailorable therapies, which improve individual symptoms by changing patient behavior or the patient’s environment.
  • First-line treatments because they are as effective in reducing symptom levels as are antimuscarinic medications.
  • Fundamental approaches (2):
    1. Bladder control strategies, such as with bladder training and delayed voiding, to modify bladder symptoms by changing voiding habits,
    2. Pelvic floor muscle training to improve control and techniques for urge suppression.
• Fluid management
  • 25% reduction in fluid intake reduces frequency and urgency
• Weight loss may improve incontinence specifically

Medications

Anti-cholinergics

• Options
  1. Oral
     1. Darifenacin
     2. Fesoterodine
     3. Oxybutynin
     4. Solifenacin
     5. Tolterodine
     6. Trospium
  2. Transdermal oxybutynin (patch or gel)

• Efficacy
  • No compelling evidence for differential efficacy across oral medications
    • Since similar efficacy observed for all oral anti-cholinergic medications, the choice of medication is patient dependent; however, AE profiles for dry mouth and constipation vary with medications
  • Patients with more severe symptoms, on average, experience greater symptom reductions.
    • Only patients with relatively low baseline symptom levels are likely to experience complete symptom relief
• Contraindications
  • Clinicians should not use anti-cholinergics in patients with narrow angle glaucoma unless approved by the treating ophthalmologist and should use anti-cholinergics with extreme caution in patients with impaired gastric emptying or a history of urinary retention
  • Prior to initiation of anti-cholinergics, a patient at risk for gastric emptying problems or for urinary retention should receive clearance from a gastroenterologist or urologist, respectively. A PVR may be useful in any patient suspected of a higher risk of urinary retention.
  • Anti-cholinergics are also contraindicated in patients using solid oral forms of potassium chloride
    • Reduced gastric emptying potentially caused by the anti-cholinergics may increase the potassium absorption of these agents.
    • Anti-cholinergic therapy may be used with caution with alternative forms of potassium chloride.
  • Use caution in prescribing anti-cholinergics in the frail OAB patient.
    • OAB medication trials generally are not conducted in the frail elderly, resulting in a lack of efficacy and AE data in this group. Additional AEs are reported in this group, including impaired thermoregulation with dangerous core temperature elevation.
  • While newer agents (eg, darifenacin) are reported to be less likely to produce cognitive deficits in elderly patients, the literature is limited; the two-week drug administration period in these studies is not long enough to yield definitive conclusions.
  • Patients may not recognize that memory deterioration has occurred, making it essential for monitoring by the clinician, family members and caregivers.
  • Polypharmacy is common in frail communitydwelling patients,placing them at higher risk for AEs, including impaired cognition. In dementia patients, anti-cholinergics may be contraindicated entirely depending on the level of cognitive impairment.
• Adverse events
  • Constipation
    • Can be mitigated with adequate dietary fiber and fluid, psylliumbased fiber supplements, regular exercise and normal bowel habits.
  • Dry mouth
    • Can be mitigated with oral lubricants, small sips of water, sucking on sugar-free hard candies and chewing sugar-free gum, and avoiding mouthwashes with alcohol.
    • If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth.
      • ER formulations of oxybutynin and tolterodine result in significantly fewer patient reports of dry mouth than the IR formulations of either medication.
  • Constipation and dry mouth should be managed before abandoning effective anti-cholinergic therapy.
    • Management may include bowel management, fluid management, dose modification or alternative anti-cholinergics.
  • Use caution in prescribing anti-cholinergics in patients who are already using other medications with anti-cholinergic properties.
    • Medications with anti-cholinergic properties include (3)
      1. Tricyclic antidepressants
      2. Acetylcholinesterase inhibitors
      3. Medications for Parkinsonism, other extra-pyramidal diseases and Alzheimer’s disease.
    • Certain anti-nausea medications and those with atropine-like properties may also potentiate AEs.
  • Begin with the lowest possible dose and titrate slowly while carefully assessing for the balance between symptom control and AEs.
    • In older patients who may metabolize drugs differently, it is advisable to start with a minimal dose and titrate as tolerated.
• Patients who are refractory to behavioral and medical therapy should be evaluated by an appropriate specialist if they desire additional
• Optimizing medication tolerability is critical to obtaining patient compliance in the treatment of this chronic condition.
  • Compliance with a once daily dosing is greater than with medications taken more than once a day.
• If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication may be tried.

Other

• Before a patient is exposed to third-line therapies with increased risk compared to behavioral or medical therapy, the patient’s realistic desire for further treatment should be ascertained, and a comprehensive evaluation should be conducted to confirm the diagnosis of OAB and not another disease process

• Neuromodulation or onabotulinumtoxinA therapy may be offered to the carefully selected patient who has failed behavioral and anti-muscarinic therapy or who is not a candidate for these therapies and continues to have bothersome symptoms after appropriate counseling.

Neuromodulation

• FDA-approved for OAB treatment

OnabotulinumtoxinA

• Not FDA-approved in non-neurogenic OAB patients