AUA: Overactive Bladder (2019)
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
- History and Physical Exam
- Urinalysis
Optional
- Urine culture
- Post void residual
- Bladder diaries
- Symptom questionnaire
Not recommended in the initial workup of the uncomplicated patient
- Urodynamics
- Cystoscopy
- Diagnostic renal and bladder ultrasound
- 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
- Duration of symptoms and baseline symptom levels to ensure that symptoms are not related to some other condition and to determine the complexity of the OAB presentation that may require referral. Questions should assess bladder storage symptoms and bladder emptying.
- 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.
- Patient reports of bladder function are related to amount and type of fluid intake. Excessive fluid intake can produce voiding patterns that mimic OAB symptoms. A fluid diary can be helpful in this regard.
- Urinary frequency varies across individuals. In community-dwelling healthy adults, normal frequency consists of voiding every three to four hours with a median of approximately six voids a day.
Urinary frequency can be reliably measured with a voiding diary.
Traditionally, up to seven micturition episodes during waking hours has been considered normal,3 but this number is highly variable based upon hours of sleep, fluid intake, comorbid medical conditions and other factors.
. Incontinence episodes can be measured reliably with a 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. The clinician should consider referring these patients to a specialist for further evaluation and treatment.
Physical exam
- Abdominal exam
- Rectal/genitourinary exam
- Assessment of lower extremities for edema.
- 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.
- PVR should be assessed in patients with obstructive symptoms, history of incontinence or prostatic surgery, neurologic diagnoses and at 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
- Nocturia
- Polydipsia and polyuria
- 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
- While the 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.
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 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.
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
Options
- Observation
- Lifestyle changes
- Medications
- 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
bladder control strategies, pelvic floor muscle training, fluid management) as first-line therapy to all patients with OAB
Behavioral treatments are a group of risk-free tailorable therapies, which improve individual symptoms by changing patient behavior or the patient’s environment.
They are first-line treatments because they are as effective in reducing symptom levels as are antimuscarinic medications. There are two fundamental approaches to behavioral treatment. One modifies bladder symptoms by changing voiding habits, as with bladder training and delayed voiding. The other focuses on pelvic floor muscle training to improve control and techniques for urge suppression.
While most patients do not experience complete symptom relief, most patients experience significant reductions in symptoms and improvements in QoL.
The literature supports the positive effects of weight loss on incontinence specifically
Fluid management with a 25% reduction in fluid intake reduced frequency and urgency
randomized trials indicates that behavioral treatments are generally either equivalent to16–18 or superior to12,19,20 medications in terms of reducing incontinence episodes, improving frequency and nocturia and improving QoL.
Behavioral therapies may be combined with anti-muscarinic therapies.
Medications
Anticholinergics
- Options
- Darifenacin
- Fesoterodine
- Oxybutynin
- Solifenacin
- Tolterodine
- Trospium
no compelling evidence for differential efficacy across medications
Patients with more severe symptoms, on average, experienced greater symptom reductions. Only patients with relatively low baseline symptom levels
are likely to experience complete symptom relief
As similar efficacy was observed for all oral antimuscarinic medications, the choice of medication is patient dependent; however, AE profiles for dry
mouth and constipation vary with medications
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 resulted in statistically significantly fewer patient reports of dry mouth than the IR formulations of either medication.
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.
Transdermal (TDS) oxybutynin (patch or gel) may be offered
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.
Clinicians should not use anti-muscarinics in patients with narrow angle glaucoma unless approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention
Prior to initiation of anti-muscarinics, 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-muscarinics are also contraindicated in patients using solid oral forms of potassium chloride, as the reduced gastric emptying potentially caused by the anti-muscarinics may increase the potassium absorption of these agents.
Anti-muscarinic therapy may be used with caution with alternative forms of potassium chloride.
Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic therapy. Management may include bowel management, fluid management, dose modification or alternative anti-muscarinics.
Patients should be educated about the possible AEs of these medications on bowel function, the roles of adequate dietary fiber and fluid, psylliumbased fiber supplements, regular exercise and normal bowel habits. Treatment advice regarding possible dry mouth could include oral lubricants, avoiding mouthwashes with alcohol, small sips of water, sucking on sugar-free hard candies and chewing sugar-free gum. In older patients who may metabolize drugs differently, it is advisable to start
with a minimal dose and titrate as tolerated.
use caution in prescribing
anti-muscarinics in patients who are using
other medications with anti-cholinergic properties.
Medications with anti-cholinergic properties include
tricyclic antidepressants, acetylcholinesterase
inhibitors and 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.
use caution in prescribing
anti-muscarinics 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.
Clinicians should begin with the lowest possible dose
and titrate slowly while carefully assessing for the
balance between symptom control and AEs.
While newer agents (eg, darifenacin) are reported
to be less likely to produce cognitive deficits in elderly
patients, the literature is limited; the twoweek
drug administration period in these studies is
not long enough to yield definitive conclusions.31,32
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,33 placing them at higher risk for AEs, including impaired cognition. In dementia patients,
anti-muscarinics may be contraindicated entirely
depending on the level of cognitive impairment.
Patients who are refractory to behavioral
and medical therapy should be evaluated
by an appropriate specialist if they desire additional
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 therapies
are FDA-approved for OAB treatment; however, the
use of onabotulinumtoxinA in non-neurogenic OAB
patients is not FDA-approved.
Neuromodulation