Overactive Bladder Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Hospital Adjunct Professor of Urology SUNY-Downstate Medical Center

Prevalence of OAB (USA) OAB (33.3 million) 17% of adults Hampel, Urologe A 2003;42:776; Stewart, World J Urol 2003;20:327;

Prevalence of OAB (USA) Wet versus Dry 37% Wet (12 million) 63% Dry (21 million) OAB Hampel, Urologe A 2003;42:776; Stewart, World J Urol, 2003;20:327;

Prevalence of OAB by Age Stewart, World J Urol, 2003;20:327

Prevalence of OAB Compared to Other Chronic Conditions Hu T, et al. Urology. 2004;63(3):

Falls and Fractures Brown et al. JAGS. 2000;48(7): Increased Risk (%) 26% 34% Falls Fractures

7 7 Impact of Urinary Incontinence on Quality of Life Quality of Life Physical Limitations or cessation of physical activities Sexual Avoidance of sexual contact and intimacy Occupational Absence from work Decreased productivity Social Reduction in social interaction Alteration of travel plans Increased risk of institutionalization of frail older persons Domestic Requirements for specialized underwear, bedding Special precautions with clothing Psychological Guilt/depression Loss of self-respect and dignity Fear of:  Being a burden  Lack of bladder control  Urine odor Apathy/denial

Overactive Bladder: “urgency, with or without urge incontinence usually with frequency and nocturia…if there is no proven infection or other pathology” ICS, 2002

Urgency ICS, 2002 “...a sudden compelling desire urge to pass urine, which is difficult to defer.”

Urgency is not an all-or-none phenomena; it can be graded Urgency should be redefined: –“...a sudden compelling desire urge to pass urine, which is difficult to defer.” There are at least two types of urgency OAB: A New Paradigm

OAB is a symptom complex, not a syndrome OAB has a differential diagnosis OAB can be classified by urodynamics A New OAB Paradigm

Types of Urgency Type 1 - An intensification of the normal urge to void (69%) Type 2 - A sudden urge that is a different sensation (31%) Some patients report a constant feeling of the need to void – not really urgency May have different etiologies May respond differently to treatment Blaivas et al, Two Types of Urgency. Neurourol Urodyn. 2009;28(3):188

Incontinence associated with urgency Urge Incontinence

A subtle sensation, gradual in onset, felt in the suprapubic area as fullness or in the penis, vagina or urethra as a tingling If patient waits too long > urgency Normal Urge to Void

Type 0 - no urge Type 1 - mild urge (can delay for > 1H) Type 2 - moderate urge (can delay for 10 – 60 minutes) Type 3 - severe urge (can delay for < 10 minutes) Type 4 - precipitous urge (must void immediately) Urgency Perception Grade Blaivas et al, Urgency Perception Score, J Urol, 2007

Type 4 - “...a sudden compelling desire to pass urine, which is difficult to defer.” and / or Type 3 - A short warning time between the first and a severe urge and / or Type 2 - Waiting too long Urgency

Healthy Volunteers Grade of UrgePer cent 019% 146% 226% 310% 4 0% 65% DeWachter & Wyndaele, Neurourol & Urodynam, 2004

Urge gradeNormal*LUTS**OAB*** 08 (10)2 (3)2 (2) 131 (37)22 (36)7 (9) 234 (41)28 (45)36 (45) 36 (7)5 (8)19 (24) 44 (5)5 (8)16 (20) Total *vs** p=0.24 *vs***p<0.001 **vs***p<0.001 Blaivas, J Urol, % 47%

A ll of these sensations need to be put into context by relating them to bladder volume If a patient experiences all of the UPS sensations of the course of 2 hours & the bladder volume is only 90 ml, that is OAB If she experiences all of the UPS sensations of the course of 2 hours and the bladder volume is 300 ml, the bladder is probably normal The bladder diary is the best method for evaluating sensations related to volume

Why did you urinate? (0) Convenience (no urge or desire) (1) Mild urge (can delay urination for an hour) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min) (4) Desperate urge (must go immediately) Incontinence grade. Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes) OAB Bladder Diary Instructions

TimeUPSVolume (ml)Incontinence Grade 6 AM : : : : : : : : : : : OAB Diary

volume

TimeUPSVolume (ml)Incontinence Grade 6 AM : : : : : : : : : : : OAB Diary

volume

TimeUPSVolume (ml)Incontinence Grade 6 AM : : : : : : : : : : : OAB Diary

volume

Guan et al, Euro Urol, 2011

volume

Overactive Bladder: Symptom Complex or Syndrome? “urgency, with or without urge incontinence usually with frequency and nocturia…if there is no proven infection or other pathology” ICS, 2002

Clinical Presentation of OAB Lower urinary tract symptoms (LUTS) – the physician elicits OAB symptoms “I have OAB” – the patient self diagnoses The physician probes a reluctant patient who admits she has OAB symptoms

Differential Diagnosis (non-neurogenic) Urinary tract infection Urethral obstruction: – Pelvic organ prolapse – Post-op – Urethral diverticulum – Stricture – Primary bladder neck

Differential Diagnosis (non-neurogenic) Mixed stress & urge incontinence Foreign body Bladder cancer Bladder stones

Differential Diagnosis (neurogenic) Synergy –Stroke –Parkinson’s –MS (supraspinal) –Spina bifida Dyssynergy –SCI –MS (spinal) –Spina bifida –Other spinal conditions

Diagnosis# % Stress incontinence5333% Idiopathic3723% Pelvic organ prolapse3924% Bladder outlet obstruction1610% Miscellaneous149% Neurogenic127% Total171106% Differential Diagnosis in Women

Miscellaneous#% Prior pelvic surgery96% Bladder cancer21% Urethral diverticulum21% Vesicovaginal fistula11% Differential Diagnosis in Women

Urodynamic Classification During filling: –Type based on control mechanisms –+ / - low bladder compliance During voiding: –normal Q / p –urethral obstruction –impaired detrusor contractility Flisser, J. Urol 169: , 2003

Urodynamic Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter Type IV: IDC, no awareness or control Flisser, J. Urol 169: , 2003

OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics

HMR Voluntary detrusor contraction FSF = 66 ml, FSF = 66 ml 1st urge = 80 ml severe urge = 105 ml Capacity = 346 ml

OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC

Asked to hold: contracts sphincter Aborts detrusor contraction Involuntary detrusor contraction Prevents incontinence HO

OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter

BA Involuntary Contraction Trying to hold incontinent Can’t hold any longer

OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter Type IV: IDC, no awareness or control

Voi Rbn IDC Incontinent

Type 4 OAB Without Obstruction

RS IDC = 12 cm H 2 0) Qmax = 18 ml/S

Type 2 OAB Impaired Detrusor Contractility (DHIC)

AL Involuntary detrusor contractions Sphincter relaxation Incontinent

Type 3 OAB Obstruction due to urethral Diverticulum in a woman

BG JTJT IDC (detmax = 48 cm H 2 0) Qmax = 1 ml/S Urethral obstruction

Type 2 OAB Grade 4 prolapse Normal voiding mechanics

IC Involuntary detrusor contraction cough

IC thigh cystocele bladder catheter

IC cystocele

IC Cystocele

IC Cystocele

IC Cystocele

Urethra Urine in vagina Cystocele

IC Cystocele

IC Cystocele

Type 4 OAB Grade 4 prolapse Occult sphincteric incontinence

gdl coughs

gdl Involuntary detrusor contraction Incontinent

gdl VLPP Sphincteric incontinence

gdl Voluntary detrusor contraction Normal voiding

Type 3 OAB Grade 3 prolapse Grade 1 urethral obstruction

FK Involuntary detrusor contraction Incontinent

FK Voluntary Low flow

Urethral catheter Urethral meatus Bladder capacity cystocele

Urethral catheter Urethral meatus Onset of voiding cystocele

Qmax urethra

Type 4 OAB Impaired Detrusor Contractility

AL IDC = 17 cm H 2 0) Qmax = 9 ml/S

Type 3 OAB Low Bladder Compliance

DS Steep rise in pressure IDC V-U reflux

Type 4 OAB Neurogenic Detrusor Overactivity Detrusor sphincter dyssynergia (DESD)

PS Involuntary detrusor contraction Involuntary sphincter contraction Obstruction due to sphincter contraction

Type 1 OAB Painful bladder syndrome Acontractile detrusor

Command to void HMR FSF = 66 ml, FSF = 25 ml 1st urge = 50 ml severe urge = 80 ml Capacity = 105 ml

Type 4 OAB Without Obstruction Bladder cancer

Involuntary detrusor contraction Incontinent Filling defects

So, how does cystoscopy help?

Bladder Neck Contracture

Fibroadenomatous Urethral Polyp

`

Urethral Erosion of Synthetic Sling

Bladder neck Eroded mesh

Bladder Erosion of Synthetic

Strands of eroded mesh

Urethral Diverticulum

distal mid proximalbladder neck ostia

Urethral Stricture

Radiation Cystitis

Bladder Stones

Low Grade Bladder Cancer

Carcinoma in Situ

CIS

Diagnostic Evaluation History & questionnaire Physical exam Urinalysis & culture Bladder diary

Initial Treatment Treatment of remediable conditions Behavioral therapy Pharmacotherapy Electrical stimulation

Remediable Conditions Uro-gynecologic Pelvic organ prolapse Stress incontinence Urethral diverticulum Bladder & ureteral stones Bladder cancer Medical UTI Polyuria Diabetes Congestive heart failure Medications

Indications for Further Workup Hematuria Recurrent UTI Diagnosis unclear Voiding symptoms Elevated PVR Neurologic disease Pelvic organ prolapse Prior pelvic surgery Bladder pain No Rx response after 2 – 3 months

Further Workup Urodynamics Cystoscopy

Treatment of Refractory OAB Botox injections Neuromodulation Enterocystoplasty Urinary diversion

The Many Faces of OAB

Is it really necessary to make these distinctions? That’s for you to decide, but remember, If the only tool you have is a hammer, everything looks like a nail!