1. Prevalence, Evaluation and Management of Overactive Bladder in Primary Care SUNY-DOWNSTATE MEDICAL CENTER BROOKLYN, New York NADIA KHAN, MD* Miriam Vincent, MD, PhD* Wellman Cheung, MD ‡ Karmina Choi, MS 3* Departments of Family Medicine* and Urology ‡

2. GOALS GOALS Conduct clinical study of significance in inner city population, mainly African American; Conduct clinical study of significance in inner city population, mainly African American; Goal was to determine prevalence, possible risk factors of OAB in our population; Goal was to determine prevalence, possible risk factors of OAB in our population; Importance of role of PCPs to educate patients with OAB Importance of role of PCPs to educate patients with OAB

3. OVERVIEW OF SURVEY All 1000 adult visitors to our Family Medicine centers were invited to complete questionnaire; All 1000 adult visitors to our Family Medicine centers were invited to complete questionnaire; Questionnaire reviewed by PCP at the end of visit Questionnaire reviewed by PCP at the end of visit 214 respondants; 214 respondants; 80.8% women 80.8% women 50% postmenopausal 50% postmenopausal

4. DEMOGRAPHIC DATA IN OUR POPULATION

5. Table 2. Characteristics of participants Characteristic, n (%) Male (n=41) Female (n=173) Total (N=214) Age, years <251(2.4)10(5.8)11(5.1) 25-344(9.8)23(13.3)27(12.6) 35-444(9.8)18(10.4)22(10.3) 45-549(22.0)31(17.9)40(18.7) 55-6410(24.4)30(17.3)40(18.7) 65-746(14.6)35(20.2)41(19.2) ≥755(12.2)17(9.8)22(10.3) Not stated 2(4.9)9(5.2)11(5.1) Race Black35(85.4)136(78.6)171(79.9) Hispanic0(0)9(5.2)9(4.2) White1(2.4)3(1.7)4(1.9) Other2(4.9)10(5.8)12(5.6) 3(7.3)15(8.7)18(8.4) Education Less than high school 0(0)8(4.6)8(3.7) High school graduate 14(34.1)63(36.4)77(36.0) Some college / college graduate 10(24.4)41(23.7)51(23.8) Graduate school 3(7.3)14(8.1)17(7.9) Not stated 14(34.1)47(27.2)61(28.5) *n=41 for male, n=169 for female **n=41 for male, n=170 for female ***n=167

6. Characteristic, n (%) Male (n=41) Female (n=173) Total (N=214) Body mass index (BMI), kg/m 2 <25.05(12.2)31(17.9)36(16.8) 25.0-29.911(26.8)34(19.7)45(21.0) ≥307(17.1)63(36.4)70(32.7) Not stated 18(43.9)45(26.0)63(29.4) History of smoking* Yes26(63.4)54(31.2)80(37.4) No15(36.6)115(66.5)130(60.7) Previous surgical history Bladder surgery** 2(4.9)6(3.5)8(3.7) Urinary leakage surgery** 2(4.9)2(1.2)4(1.9) Hysterectomy***----34(19.7)-- Prostate surgery 4(9.8)------ OAB status Normal13(31.7)105(60.7)118(55.1) OAB with UI 18(43.9)57(32.9)75(35.0) OAB without UI 10(24.4)11(6.4)21(9.8)

7. What is an overactive bladder An overactive bladder is a condition that results from spontaneous or provoked contraction of the detrusor muscle in the wall of the urinary bladder. (International Continence Society)

8. EPIDEMIOLOGY detected in 9 to 55 % women presenting with incontinence (Journal of OB/Gyn) detected in 9 to 55 % women presenting with incontinence (Journal of OB/Gyn) increases with age increases with age 46% incontinent nursing home patients but in only 8 percent of randomly selected elderly women living in the community (J of Urology) 46% incontinent nursing home patients but in only 8 percent of randomly selected elderly women living in the community (J of Urology) Incontinent black women are more likely to have detrusor instability than Caucasians (J of Ob/ Gyn) Incontinent black women are more likely to have detrusor instability than Caucasians (J of Ob/ Gyn)

9. National Overactive BLadder Evaluation (NOBLE) Program National Overactive BLadder Evaluation (NOBLE) Program Aims of study designed to provide specific information on the prevalence and impact of overactive bladder (OAB) symptoms in the USA. Aims of study designed to provide specific information on the prevalence and impact of overactive bladder (OAB) symptoms in the USA. Qualitative study examined the effect of symptoms of a small group of predominantly continent OAB patients on health- related quality-of-life (HRQoL) and coping behaviours. Qualitative study examined the effect of symptoms of a small group of predominantly continent OAB patients on health- related quality-of-life (HRQoL) and coping behaviours. Conclusions OAB symptoms of frequency and/or urgency without incontinence do cause an impact on lifestyle that is similar to that reported in patients with incontinence. Conclusions OAB symptoms of frequency and/or urgency without incontinence do cause an impact on lifestyle that is similar to that reported in patients with incontinence. The overall prevalence of overactive bladder was similar in men and women (16 to 17 percent), but women were more likely to be symptomatic at a younger age (40's versus 60's) and also have incontinence. The overall prevalence of overactive bladder was similar in men and women (16 to 17 percent), but women were more likely to be symptomatic at a younger age (40's versus 60's) and also have incontinence.

10. RISK FACTORS OF OAB RISK FACTORS OF OAB Idiopathic Idiopathic Diabetus Mellitus (30- 70%) Diabetus Mellitus (30- 70%) Neurogenic (multiple sclerosis (50-80%), Parkinson's disease, cerebrovascular disease, or spinal cord injury Neurogenic (multiple sclerosis (50-80%), Parkinson's disease, cerebrovascular disease, or spinal cord injury Surgery urethropexy, hysterectomy Surgery urethropexy, hysterectomy

11. RISK FACTORS OF OAB Although disruption of the innervation of the bladder during hysterectomy has been cited as a risk factor for postoperative incontinence, particularly urge incontinence these studies are flawed for several reasons: Although disruption of the innervation of the bladder during hysterectomy has been cited as a risk factor for postoperative incontinence, particularly urge incontinence these studies are flawed for several reasons: patients with pelvic organ prolapse as an indication for hysterectomy have a higher incidence of incontinence than controls,patients with pelvic organ prolapse as an indication for hysterectomy have a higher incidence of incontinence than controls, the observational studies did not control for confounding variables, in some series all types of incontinence were lumped together, control groups were not well matched, and data on how many surgical patients had incontinence before surgery were not providedthe observational studies did not control for confounding variables, in some series all types of incontinence were lumped together, control groups were not well matched, and data on how many surgical patients had incontinence before surgery were not provided many of these patients improve within six months of the procedure.many of these patients improve within six months of the procedure.

12. WHILA Study (Women’s Health in the Lund Area) SETTING: Southern Sweden (WHILA 1995–2000), 64% of the invited women (aged 50–59 years old) participated. SETTING: Southern Sweden (WHILA 1995–2000), 64% of the invited women (aged 50–59 years old) participated. Objective To investigate the prevalence of and factors associated with overactive bladder in middle-aged women. Objective To investigate the prevalence of and factors associated with overactive bladder in middle-aged women. Conclusions Overactive bladder and stress incontinence are intimately associated with each other. Both OAB and stress incontinence are associated with abnormal metabolic factors, mainly increased BMI. Conclusions Overactive bladder and stress incontinence are intimately associated with each other. Both OAB and stress incontinence are associated with abnormal metabolic factors, mainly increased BMI.

13. SYMPTOMS OF OAB SYMPTOMS OF OAB may be Asymptomatic may be Asymptomatic Urgency: sudden compelling desire to pass urine that is difficult to defer. Urgency: sudden compelling desire to pass urine that is difficult to defer. Frequency: voiding greater 8 voids in 24 hours Frequency: voiding greater 8 voids in 24 hours increased sensory urgency (a strong, uncomfortable need to void) motor urgency (frequent urination to avoid incontinence episodes from involuntary bladder contraction). increased sensory urgency (a strong, uncomfortable need to void) motor urgency (frequent urination to avoid incontinence episodes from involuntary bladder contraction). Nocturia Nocturia Incontinence (1/3 pts with OAB) Incontinence (1/3 pts with OAB)

14. OAB-V8 (Reliable and valid Instrument used across disciplines to evaluate patients for OAB) with two questions related to SUI Frequent urination during the daytime hour Frequent urination during the daytime hour An uncomfortable urge to urinate An uncomfortable urge to urinate A sudden urge to urinate with little or no warning A sudden urge to urinate with little or no warning Accidental loss of small amounts of urine Accidental loss of small amounts of urine Frequent urination in the evening Frequent urination in the evening Waking up from sleep because you had to urinate Waking up from sleep because you had to urinate An uncontrollable urge to urinate An uncontrollable urge to urinate Urine loss associated with a strong desire to urinate Urine loss associated with a strong desire to urinate Urine loss associated with physical activities, such as lifting heavy objects or exercising Urine loss associated with physical activities, such as lifting heavy objects or exercising Urine loss associated with sneezing, coughing, or laughing Urine loss associated with sneezing, coughing, or laughing Feeling you are unable to empty your bladder completely Feeling you are unable to empty your bladder completely

15. Symptom Evidence to determine OAB/SUI Urgency Answer ≥1 to any one of the three OAB-V8 questions on urge to urinate Frequency Answer ≥1 to any one of the two OAB-V8 questions on frequent urination Nocturia Answer ≥1 to the OAB-V8 question on nocturia Urge urinary incontinence (UUI) Answer ≥1 to one of the two OAB-V8 questions on urine leakage associated with urge Stress urinary incontinence (SUI) Answer ≥1 to one of the two questions on urine leakage associated with physical activities, sneezing, coughing, or laughing Mixed urinary incontinence (MUI) Meet the criteria for both UUI and SUI described above Incomplete emptying Answer ≥1 to the question on incomplete emptying

16. Symptom Evidence to determine OAB/SUI OAB with frequency alone (OAB-F) OAB-V8 score ≥8 with symptoms of frequency and/or nocturia only OAB with urgency without incontinence (OAB-U) OAB-V8 score ≥8 with symptoms of urgency without incontinence OAB with urge urinary incontinence (OAB-UUI) OAB-V8 score ≥8 with symptoms of UUI and no SUI OAB with stress urinary incontinence (OAB-SUI) OAB-V8 score ≥8 with symptoms of SUI and no UUI OAB with mixed urinary incontinence (OAB-MUI) OAB-V8 score ≥8 with symptoms of MUI

17. DIAGNOSIS OF OAB DIAGNOSIS OF OAB By comparison, overactive bladder refers to the symptom of urgency, usually with frequency and nocturia in the absence of infection or other pathology By comparison, overactive bladder refers to the symptom of urgency, usually with frequency and nocturia in the absence of infection or other pathology The clinical diagnosis of OAB is independent of the urodynamic findings. The clinical diagnosis of OAB is independent of the urodynamic findings. WORLD JOURNAL OF UROLOGY

18. RESULTS (Sample size? Selection Bias) 68.3% men and 39.3% women (p<.001) with OAB 68.3% men and 39.3% women (p<.001) with OAB Prevalence of OAB increased with age in men but did not vary with age in women (?) Prevalence of OAB increased with age in men but did not vary with age in women (?)

19. RESULTS RESULTS 90% OAB patients has OAB-defining symptoms, urgency, frequency, and nocturia (?). 90% OAB patients has OAB-defining symptoms, urgency, frequency, and nocturia (?). Of pts with OAB, urge urinary incontinence prevalent in both genders, greater women (79.4% vs 64.3%) (?). Of pts with OAB, urge urinary incontinence prevalent in both genders, greater women (79.4% vs 64.3%) (?). Incomplete emptying present in 1/2 OAB patients, more common in women (55.9% vs 10.7%, p<.001) (? not reported). Incomplete emptying present in 1/2 OAB patients, more common in women (55.9% vs 10.7%, p<.001) (? not reported).

20. RESULTS from patients w/o OAB 118 patients without OAB (105 women, 13 men) 118 patients without OAB (105 women, 13 men) Few men without OAB have lower urinary tract symptoms Few men without OAB have lower urinary tract symptoms Women report Women report 65.7% frequency 61.0% nocturia 18.1% urgency 21.1% (urge urinary incontinence). 21.9% stress incontinence

21. RESULTS OAB is present in 36.6% pre-menopausal women / 40.2% postmenopausal women studied (?) OAB is present in 36.6% pre-menopausal women / 40.2% postmenopausal women studied (?) OAB- mixed urinary incontinence is more prevalent in Postmenopausal women(60.6%) than premenopausal women (43.3) with OAB (?) OAB- mixed urinary incontinence is more prevalent in Postmenopausal women(60.6%) than premenopausal women (43.3) with OAB (?) OAB-Urgency (20.0% vs 9.1%) and OAB- urge urinary incontinence (26.7% vs 24.2%) prevalent in Premenopausal women (?) OAB-Urgency (20.0% vs 9.1%) and OAB- urge urinary incontinence (26.7% vs 24.2%) prevalent in Premenopausal women (?)

22. RESULTS RESULTS Obesity (BMI  30) in women (2X) RR 2.03, 1.07-3.86, p=.010) and smoking in men (p=.024) strongly associated with OAB (?) Obesity (BMI  30) in women (2X) RR 2.03, 1.07-3.86, p=.010) and smoking in men (p=.024) strongly associated with OAB (?) OAB and history of hysterectomy RR=2.72, (1.73- 4.27) (p=.004) and OAB and smoking (p=.011) are strongly associated in premenopausal women (?) OAB and history of hysterectomy RR=2.72, (1.73- 4.27) (p=.004) and OAB and smoking (p=.011) are strongly associated in premenopausal women (?) OAB was not shown to vary with menopause status in women or BMI in men (p>.05) (?) OAB was not shown to vary with menopause status in women or BMI in men (p>.05) (?)

23. Relative Risk (RR) Reference group Comparison group RR 95% CI p Men History of smoking 1.730.98-3.07.024 No history of smoking All women BMI 25.0-29.9 1.030.45-2.33.951 BMI <25.0 BMI ≥30.0 2.031.07-3.86.013 BMI <25.0 Premenopausal women History of hysterectomy 2.721.73-4.27.004 No history of hysterectomy History of smoking 2.091.20-3.64.011 No history of smoking Relative risk for OAB by Risk Factor

24. Percent of OAB patients diagnosed and treated by PCPs by OAB-V8 scores 0 5 10 15 20 25 8-1011-13 ? 14 OAB score Diagnosed before surveyDiagnosed after survey Will treat/referNot diagnosed

25. TREATMENT OF OAB Bladder training Bladder training Biofeedback Biofeedback Pelvic floor exercises Pelvic floor exercises Medication Medication Electrical stimulation Electrical stimulation Surgery Surgery Acupuncture Acupuncture

26. What We Know For Sure OAB underreported OAB underreported Patients with OAB are embarassed Patients with OAB are embarassed Patients consider to be part of aging Patients consider to be part of aging willing to accept it as a complication willing to accept it as a complication Social issues Impact on lifestyle Impact on lifestyle nursing home nursing home Sensitize PCP to educate patients condition treatable condition treatable minimize risk factors minimize risk factors

27. What We Learn From This Study… Important results (Smoking, Obesity) Important results (Smoking, Obesity) Selection Bias Selection Bias Good demographics, good instrument, but,Good demographics, good instrument, but, Limited response (21.4%) Plan to repeat the study

28. Thank you