OVERACTIVE BLADDER AND THEIR MANAGEMENT.

OVER VIEW OF OVER ACTIVE BLADDER

1. OVERACTIVE BLADDER “An Enigma” Dr. Shanawaz Alam Specialist urologist Aster DM

2. Introduction

3. Introduction Affect all aspect of quality of life

4. Introduction Idiopathic situation where bladder contracts erratically and is out of control

5. Introduction Translate into Agony, Anxiety and Expectation

6. Introduction Under-reported and under-treated

7. Definition

8. International Continence Society (ICS) defined : OAB Syndrome - urinary urgency - usually accompanied by frequency and nocturia, - with or without urgency urinary incontinence (UUI), - in the absence of urinary tract infection (UTI) or other obvious pathology I ntroduction

9. I ntroduction

10. OAB with aging in women in 40s in men in 50s and 60s Fewer than 6% report taking medication for their symptoms Symptom progression - 1% / year Remission - 6% / year Epidemiology

11. Multifactorial Research reveals 3 key aspects : Sensory activity Motor control Reflexes of LUT Pathophysiology and Etiology

12. Sensory Activity

13. Diagnosis of OAB is symptom based and involves: Careful history Physical exam Urinalysis Frequency volume chart Post-micturition residue Clinical Evaluation

14. History should cover the following: Presence or absence severity, and effect on quality of life for each of the OAB symptoms including urgency, frequency, incontinence. Other LUTS should also be assessed. Presence or absence of dysuria and hematuria. Nature and volume of fluid intake. Neurologic disease. Clinical Evaluation

15. History should cover the following: Obstetric and gynecologic history, P revious surgery/ radiotherapy, B owel symptoms. Other medical issues (e.g., closed-angle glaucoma, cognitive impairment can limit treatment options). Drug history Medications that can exacerbate the symptoms of OAB (diuretics, alpha agonist) Clinical Evaluation

16. Physical examination should cover the following: Abdominal and vaginal examinations R ectal examination should also be undertaken. Presence of pelvic organ prolapse, (cystocele may cause urinary urgency and frequency as it drags on the trigone and causes sensation of bladder fullness.) Bimanual examination (r/o pelvic masses,ovarian cysts and uterine enlargement) Physical Evaluation

17. Other possible causes of urgency and frequency of micturition Urological: Urinary tract infection, Bladder tumour, Bladder stone, Urethral diverticulum, Small capacity bladder, Interstitial cystitis, Radiation cystitis. Medical: UMN lesion (Cerebro-vascular stroke , parkinson’s), Impaired renal function, CCF ,Diabetes mellitus, Diabetes insipidus. Evaluation

18. Urine analysis To exclude an underlying UTI. Post-micturition residual To rule out overflow incontinence or incomplete bladder emptying, which can cause symptoms of OAB. Evaluation

19. Bladder diaries are useful tool when assessing patients with urinary symptoms and facilitates history taking. Bladder diary done for a minimum of 3 days and the patient continue his normal eating/drinking patterns as well as daily activities. R ecord of how much fluid intake , how much urine output , and how often patient empty his bladder on a daily basis. Evaluation

20. Evaluation

21. Patient Perception of Intensity of Urgency Scale (PPIUS) is a five-point scale designed to rate the level of urinary urgency No urgency: felt no need to empty my bladder but did so for other reasons. Mild urgency: could postpone voiding for as long as necessary without fear of wetting myself. Moderate urgency: could postpone voiding for a short while without fear of wetting myself. Severe urgency: could not postpone voiding but had to rush to the toilet to avoid wetting myself. Urgency incontinence: leaked before arriving at the toilet. Evaluation

22. Urodynamic indicated when Conservative and drug therapy fail adequately to manage OAB. Complicated cases of OAB. Before invasive surgery. Whether to discontinue anti-muscarinic drugs before the test can be argued either way; Stopping the drugs (48 hr.) gives the best chance of observing DO if present. Two main urodynamic finding associated with OAB are DO and increased filling sensation. Evaluation

23. M anagement

24. Non invasive Treatment : Behavioral therapy Oral Medication ( anticholinergic or beta 3 agonist) Combined therapy:behavioral and pharmacologic therapy. Estrogen for postmenopausal women. Role of alpha blocker. Minimally invasive Treatments: Botulinum A-toxin. Neuromodulation (post tibial nerve , sacral nerve stimulation) Interruption of innervation (central subarachnoid block or sacral rhizotomy, Peripheral motor and/or sensory block) Highly invasive Treatments: Augmentation cystoplasty, Urinary diversion. Treatment

25. Patients Misconceptions and fears Part of normal aging or everyday life. Not severe or frequent enough to treat. Too Shy to discuss. Treatment won't help. Barriers to Treatment

26. Dietary Changes and fluid Management Weight loss in obese patient. Cessation of smoking. Avoid Diuretics and excessive fluid intake especial before bed time. Treat constipation. Foods and drinks should avoided in overactive bladder (bladder irritants). Spicy foods Coffee Alcohol Soda Orange juice Tomatoes (acidic) Chinese Flavor (Monosodium Glutamate ) Behavioral Modifications

27. Bladder training : It involves two processes 1. Modification of voiding interval by : Gradual increase of voiding interval by 15- 60 min every 1-2 week until an acceptable voiding interval is achieved without incontinence. 2. Urge control (bladder inhibition) : Suppressing the urge using any of following methods : keeping the body calm until urge subsides. taking slow deep breath. concentration on elimination the urge by mental calculation or mental imaging. Contraction of pelvic floor muscle. Behavioral Modifications

28. Behavioral Modifications

29. Pelvic floor Training (kegel exercises) Intermittent voluntary maximal contraction of pelvic floor muscles Each contraction is held 6-8 seconds and followed by brief period of relaxation. A common regimen is set of 10 contraction 3 times per day. Continence improved 6 -12 weeks after PFME. Behavioral Modifications

30. Pelvic floor Training with Biofeedback Biofeedback by auditory or visual methods is very helpful to gain better voluntary control over pelvic floor muscle than verbal instruction alone. Sensors are applied to vagina or rectum and measure degree of pelvic floor muscle contraction. Behavioral Modifications

31. Medications

32. Anticholinergics

33. Contraindications : Urinary retention Intestinal obstruction Uncontrolled narrow angle glaucoma Myasthenia gravis Duration of treatment : It improve symptoms within 1 week but max benefit is achieved by 3 months. Over 5o% of patients stop it within 3 months due to Ineffectiveness, side effect, or cost. Medication

34. Avoid application to same skin site with in 7 days. (abdomen,hip ,buttock) 3.9 mg patch, twice weekly (every 3- 4 days) It bypasses first-pass hepatic metabolism Less active metabolic (N -Desethyloxybutynin) So less side effects Erythema/pruitis Less dry mouth. Now, a New : 1g topical gel is also available in US. It delivers approx 4g of drug. Oxybutinin Transdermal patch Translucent matrix-type patch Twice weekly application

35. Medications Oxybutynin Tolterodine Solifenacin Darifenacin Trospium chloride Chemical structure Tertiary amine Tertiary amine Tertiary amine Tertiary amine Quaternary amine Receptor selectivity Non selective Non selective M3 selective M3 selective Non selective Route Oral Transdermal (patch or gel) Oral Oral Oral Oral bioavailability only 10% Dosing 5 mg 3 times Day 1-2 mg Twice Day 5-10 mg/Day 7.5-15 mg/Day 20-60 mg/Day Half life 2hours patch 8hrs ER 12hrs 2hours ER 9hrs 45 -86 hours 13 -19hours 12 -20hours Metabolism Hepatic Hepatic Hepatic Hepatic 60 % Excreted unchanged in urine Side effects Transdermal has less side effect Dry mouth Constipation Blurred vision Dry mouth Constipation Dry mouth Constipation Lower risk of CNS side effect FDA Approval Yes Yes Yes YES YES

36. Medications

37. Medications

38. Medications

39. Medications

40. Medications

41. Medications

42. Botulinum A-toxin Intravesical injection. Inhibit detrusor contraction by inhibit release of Ach at neuromuscular Junction. FDA approved in treatment of OAB refractory to Antimuscarinic medications Side effects Increase risk of UTI and Urinary retention that required catheterization. Contraindications UTI, Pregnancy , myasthenia gravis. Minimally invasive treatment

43. Medications

44. Thank you