Overactive bladder syndrome (OAB): Detrosal over activity

Peviously called Detrosal instability

Dr. Basima Sh. Al- Ghazali

DEFINITION

Is a urodynamic obsevation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked.

Overactive bladder syndrome (OAB) is a chronic condition, defined as urgency, with or without urge incontinence, usually with frequency or nocturia.
It is used to imply probably underlying detrusor overactivjty (DO) but this is a diagnosis made on urodynarnic testing .

 OAB is a common condition affecting around 1 in 6 women.

The incidence of OAB increases with age.

OAB is the second most common cause of urinary incontinence. OAB is the most common cause of incontinence in elderly women, Urodynamic assessment is required to make a diagnosis of DO. QoL is often severely affected by OAB symptoms.

AETIOLOGY
Idiopathic in most cases.
Neurogenic DO is found in the presence of conditions such as multiple sclerosis, spina bifida, or upper motor neuron lesions. Secondary to pelvic or incontinence surgery. OAB due to outflow obstruction is uncommon in women Smooking and poor toilet habit training and psychological factors have been implicated.

CLINICAL FEATURES OF OAB

Symptoms of OAB include urinary frequency, urgency, urge incontinence, nocturia, and nocturnal enuresis. Provocative factors often trigger it, such as cold weather, opening the front door, or hearing running water. Bladder contractions may also be provoked by increased intra-abdominal pressure (coughing or sneezing), leading to complaint of stress incontinence, which may be misleading. Quality of life can be significantly impaired by the unpredictability and large volume of leakage.

INVESTIGATIONS
Urine culture Exclusion of infection is mandatory, as symptoms overlap those of UTl.

Frequency/volume chart Typical features are increased diurnal frequency associated with urgency and episodes of urge incontinence. Nocturia is a common feature of OAB.
Urodynamics Characterized by involuntary detrusor contractions during the filling phase of the micturition cycle, which may be spontaneous or provoked, Video-urodynamic testing is more appropriate in women with neurological diseases, to exclude vesicoureteric reflux or renal damage secondary to a persistent significant rise in intravesical pressure.

DIAGNOSIS
Urodynamic assessment is essential for the diagnosis of OAB in women with multiple and complex symptoms. Other factors, such as metabolic abnormalities (diabetes or hypercalcaemia), physical causes (prolapse or faecal impaction)

or urinary pathology (UTl or interstitial cystitis), need to be excluded when a diagnosis of OAB is made.

OVERACTIVE BLADDER SYNDROME (OAB):

MANAGEMENT

Conservative management It is wise to start with the simplest of conservative therapies and progress through to more radical treatments if necessary. Behavioural therapy Advice to consume 1-1.5 L of liquids per day. Avoid caffeine-based drinks (tea, coffee, cola) and alcohol. Various drugs, such as diuretics and antipsychotics, alter bladder function and should be reviewed.

Bladder retraining The principles of bladder retraining are based on the ability to suppress urinary urge and extend the intervals between voiding. Reported cure rates using bladder retraining alone are 44-90%. Hypnotherapy and acupuncture These can be successful in some cases. The relapse rate is very high.

PHARMACOLOGICAL INTERVENTIONS
Anticholinergic (antimuscarinic) drugs These remain the mainstay of pharmacotherapy, they block the parasympathetic nerves thereby relaxing the detrusor muscle, Patients should be advised about the side effects before starting treatment (some preparations may be better tolerated than others) . The dosage may need to be titrated against efficacy and adverse effects. Adverse effects of anticholinergics may include: dry mouth (up to 30%) constipation, nausea, dyspepsia, and flatulence blurred vision, dizziness, and insomnia palpitation and arrhythmias..

Contraindications to anticholinergics Acute (narrow angle) glaucoma. Myasthenia gravis.

Urinary retention or outflow obstruction,

Severe ulcerative colitis. Gastrointestinal obstruction.

Anticholinergic agents such as oxybutynin 2.5 mg twice daily or tolterodine 2 mg twice daily can be equally as effective. The latter has fewer side effects, mainly dry mouth and constipation.

Antidepressants Imipramine has marked systematic anticholinergic effects. Its use is limited due to side effects. Desmopressin (an antidiuretic hormone analogue) is useful for nocturia. Oestrogens In women with vaginal atrophy, intravaginal oestrogens may be tried.

SURGICAL MANAGEMENT FOR OAB

Surgery is reserved for those with debilitating symptoms and who have failed to benefit from medical and behavioural therapy. Bladder emptying can be achieved either by clean intermittent self_catheterization or by an indwelling suprapubic or urethral catheter. Procedures, such as bladder distention, sacral neuromodulation, detrusor myomectomy, and augmentation cystoplasty have limited efficacy and complication rates are high. Permanent urinary diversion ( ureterostomy) is occasionally indicated in women with intractable incontinence.

BOTULINIUM TOXIN A
Botulinium toxin A blocks neuromuscular transmission, causing the muscle to become weak.

Not yet licensed for use in OAB but is nevertheless being used increasingly in OAB refractory to anticholinergics, rather than resorting to the surgery.
It is injected cystoscopically into the detrusor, usually under local anaesthetic It can cause urinary retention in 520% of cases, in which case intermittent self-catheterization may be required. Repeat injections are required every 6-12 months. The long-term effects of repeat injections are unknown and are the subject of ongoing research.

CONGENITAL URTHRAL CAUSES

Epispadias, which is due to faulty midline fusion of mesoderm, results in a widened bladder neck, shortened urethra, separation of the symphysis pubis and imperfect sphincteric control. The patient complains of stress incontinence which may not be apparent when lying down but is noticeable when standing up. The physical appearance of epispadias is pathognomonic, and a plain X-ray of the pelvis will show symphysial separation.

It is unlikely that a conventional suprapubic operation to elevate the bladder neck will be sufficient. It may be wiser to proceed straight to urethral reconstruction or an artificial urinary sphincter.

EXTRA-URETHRAL CAUSES OF INCONTINENCE CONGENITAL Bladder exstrophy and ectopic ureter In bladder exstrophy there is failure of mesodermal migration with breakdown of ectoderm and endoderm, resulting in absence of the anterior abdominal wall and anterior bladder wall.

Extensive reconstructive surgery is necessary in the neonatal period.

EXTRA-URETHRAL CAUSES OF INCONTINENCE CONGENITAL An ectopic ureter may be single or bilateral and presents with incontinence only if the ectopic opening is outside the bladder, when it may open within the vagina or onto the perineum. The cure is excision of the ectopic ureter and the upper pole of the kidney that it drains.

FISTULA
fistulae have obstetric and gynaecological causes. The former include obstructive labour with compression of the bladder between the presenting head and the bony wall of the pelvis.

The gynaecological causes are associated with pelvic surgery or pelvic malignancy or radiotherapy.
Whatever the cause, the fistula must be accurately localized.

FISTULA
It can be treated by primary closure or by surgery and can be delayed until tissue inflammation and oedema have resolved at about 4 weeks. The surgical techniques involve isolation and removal of the fistula tract, careful debridement, suture and closure of each layer separately and without tension and, if necessary, the interposition of omentum, which brings with it an additional blood supply.

RETENTION WITH OVERFLOW

Insidious failure of bladder emptying may lead to chronic retention and finally, when normal voiding is ineffective, to overflow incontinence. The causes may be; -Lower motor neuron or upper motor neuron lesions.

-Urethral obstruction,
-Pharmacological.

RETENTION WITH OVERFLOW

The patient may be aware of and present with increasing difficulty in bladder emptying or she may present only with frequency. Ultimately normal emptying stops and a stage of chronic retention with overflow develops. Symptoms include poor stream, incomplete bladder emptying and straining to void, together with overflow stress incontinence. Often there will be recurrent urinary tract infection. Cystometry is usually required to make the diagnosis, and bladder ultrasonography or intravenous urogram may be necessary to investigate the state of the upper urinary tract to exclude reflux.

FREQUENCY AND URGENCY

Frequency and urgency are two common urinary symptoms that present singularly or combined. Approximately 15-20 per cent of women have frequency and urgency. Clinical examination and investigation can be directed towards discriminating between the common causes. These include masses that cause compression and prolapse. Investigations should rule out infection, stones and malignancy. A simple urinary diary may show signs of increased fluid intake or evidence of ingestion of too much caffeine.

VOIDING DIFFICULTIES
Voiding difficulty and acute and chronic urinary retention represent a gradation of failure of bladder emptying. Of women attending a urodynamic clinic, 10-15 per cent may have voiding difficulties. The underlying mechanism is either failure of detrusor contraction or sphincteric relaxation, or urethral obstruction, and this may be due to causes such as an impacted retroverted gravid uterus.

MISCELLANEOUS
Acute urinary tract infection or faecal impaction in the elderly may lead to temporary urinary incontinence. A urethral diverticulum may lead to post-micturition dribble, as urine collects within the diverticulum and escapes as the patient stands up.