1. The Overactive Bladder
Raji Gill, D.O., M.Sc.
Clinical Assistant Professor of Surgery
Division of Urology
Tulsa Regional Medical Center
&
Cancer Treatment Centers of America

3. 2002 ICS Terminology: Overactive Bladder
OAB defined based on symptoms
Urgency, with or without urge incontinence, usually with frequency and nocturia
In the absence of pathologic or metabolic conditions that might explain these symptoms
At the ICS meeting in Seoul, Korea in September of 2001, a consensus definition of OAB was derived.
The definition is “urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of pathologic or metabolic conditions that might explain these symptoms.”
This definition focuses on the symptoms of OAB rather than on urodynamic parameters and is much more clinically useful for physicians, because most do not conduct urodynamic studies on patients with OAB.
In addition, this definition improves communication between physicians and their patients, since it includes terms that are much more intuitive and less likely to confuse or even alarm the patient.
Thus, the new definition encompasses all of the important clinical aspects of OAB, without using terminology that is only interpretable by a specialist in urology.
ICS = International Continence Society (

4. OAB Symptoms OAB Frequency Urination at night Urgency
8 or more visits to the toilet per 24 hours
Urination at night
• 2 or more visits to toilet during sleeping hours
Urgency
Sudden, strong desire to urinate
Urge Incontinence
Sudden & involuntary loss of urine
Among the symptoms of OAB, frequency is defined as eight or more visits to the toilet per 24-hour period, two or more of which may be during the night.
Urgency is defined as a sudden, strong desire to urinate.
Urge incontinence is defined as the sudden, involuntary loss of urine.
OAB

5. Types of Urinary Incontinence
Urge
urine loss accompanied by urgency resulting from abnormal bladder contractions
Mixed symptoms
combination of stress and urge incontinence
Stress
urine loss resulting from sudden increased intra-abdominal pressure (eg, laugh, cough, sneeze)
Urge urinary incontinence is caused by uncontrollable contractions of the detrusor muscle; there may be very little warning time, and the volume of leakage is usually large.
Stress incontinence occurs when the pressure on the bladder is greater than the urethral pressure, resulting in a sudden loss of urine (usually a small volume). Stress incontinence is typically due to weakened or damaged pelvic floor muscles.
Mixed incontinence occurs when the symptoms of OAB and stress incontinence are present in the same person. Individuals with mixed incontinence may experience leakage of urine due to a sudden uncontrollable urge to urinate and when coughing or sneezing.
Detrol ® LA is not indicated for stress or mixed incontinence.
Sudden increase
in intra-abdominal
pressure
Uninhibited
detrusor
contractions
Urethral pressure

7. Differential Diagnosis: OAB and Stress Incontinence
Medical History and Physical Examination
Symptom Assessment
Symptoms
Overactive
Stress incontinence
bladder
Urgency (strong, sudden desire to
Yes No
void)
Frequency with urgency
Yes No
(>8 times/24 h)
Leaking during physical activity; No
Yes
eg, coughing, sneezing, lifting
A simple symptom assessment can differentiate between OAB, stress incontinence, and mixed incontinence.
OAB is associated with urgency (a strong, sudden desire to void); frequency (more than 8 times per 24 hours); and a large amount of urinary leakage in patients who have episodes of incontinence.
Patients with OAB are often unable to reach the toilet in time after an urge to void and usually wake up to pass urine during the night.
Urine leakage associated with physical activity is not a symptom of OAB.
Detrol ® LA is not indicated for stress or mixed incontinence.
Amount of urinary leakage with
Large
Small
each episode of incontinence
(if present)
Ability to reach the toilet in time
Often no
Yes
following an urge to void
Waking to pass urine at night
Usually
Seldom
Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.

8. Estimated Prevalence of OAB in Comparison With Other Selected Chronic Conditions: 1990s Data
Millions of Americans
Chronic Sinusitis 37
Arthritis 33
Heart Conditions* 21
OAB 17
Asthma 15
Osteoporosis 10
Diabetes
OAB is a highly prevalent condition in the United States and is more common than many other chronic conditions.
Reports in the 1990s indicated that the prevalence of OAB was higher than rates of asthma, osteoporosis, diabetes, or Alzheimer’s disease. 9
Alzheimer’s Disease 5 *
Excludes hypertension
Payne CK. Campbell’s Urology Updates. 1999;1:1-20.
Evans DA et al. Milbank Q. 1990;68:
Bureau of the Census, Population Estimate Data, 1995.
National Institutes of Health. Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis Overview.
National Center for Health Statistics. Vital Health Stat. 10(199):1998.

9. Prevalence of OAB in the US5 10 15 20 25 30 35 40
18–24
25–34
35–44
45–54
55–64
65–74
75+
Prevalence (%)
Men
Women
Overall, 16.6% had symptoms of OAB
Prevalence of OAB increased with age
The prevalence is similar in men, approximately 16%, and women, approximately 16.9%.
Consistent with other epidemiologic studies, the data from this program indicate that the incidence of OAB increases with age in both men and women.
Age (years)
Adapted from Stewart W et al. WHO/ICI Poster.

10. Prevalence of OAB: Wet versus Dry
12.2 million (6.1% of the population)
Wet
(37% of OAB)
OAB
Dry
(63% of OAB)
Of the total number of cases of OAB in the United States, 63% are classified as “dry.” This figure translates into 21.2 million people, or 10.5% of the overall US population.
The other 37% of cases of OAB are classified as “wet.” This translates into 12.2 million people, or 6.1% of the population.
21.2 million (10.5% of the population)
Adapted from Stewart W et al. WHO/ICI Poster.

12. Diagnosis of OAB A presumptive diagnosis of OAB can be based on
patient history, symptom assessment
physical examination
urinalysis
Initiation of noninvasive treatment may not require an extensive further workup
A presumptive diagnosis of OAB can be made on the basis of the patient’s history, an assessment of the symptoms, a physical examination, and urinalysis.
The initiation of noninvasive treatment may not require a more extensive workup.
Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management.
Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health
Care Policy and Research; March AHCPR publication

13. A Hidden Condition*
Many patients self-manage by voiding frequently, reducing fluid intake, and wearing pads
Nearly two-thirds of patients are symptomatic for 2 years before seeking treatment
30% of patients who seek treatment receive no assessment
Nearly 80% are not examined
A survey conducted by the Gallup Group in Europe found that many patients with OAB attempt to self-manage their problem by voiding frequently, reducing fluid intake, and wearing pads.
Nearly two-thirds of patients experience symptoms for 2 years before seeking treatment.
Notably, of those who do seek treatment, 30% do not receive an assessment of their symptoms. Equally alarming is the finding that nearly 80% of patients are not examined.
* Survey conducted by Gallup Group (European Study).

14. Barriers to Treatment Patient misconceptions and fears:
“Part of normal aging or everyday life”
“Not severe or frequent enough to treat”
“Too embarrassing to discuss”
“Treatment won't help”
There are several barriers to the treatment of OAB. Among the most important are patients’ misconceptions and fears.
Individuals with OAB are often under the mistaken impression that bladder dysfunction is a normal part of aging or everyday life.
Some may feel that their symptoms are not severe enough or frequent enough to warrant treatment.
Embarrassment comes into play, as many individuals feel ashamed of their problem and are reluctant to discuss it with a healthcare professional.
Another common misperception is that there is no effective treatment available for OAB.

15. Screening and Diagnosing OAB
“Do you have bladder problems that are troublesome, or do you ever leak urine?”
YES
Healthcare professionals should routinely ask patients whether they have bladder problems that are troublesome or whether they ever leak urine.
If the answer is yes, the clinician should proceed with an assessment of the patient’s history and symptoms, as well as tests such as urinalysis, to determine whether a diagnosis of OAB can be established.
Assess history, symptoms, and test results
Establish a diagnosis

16. OAB Screening Can Help Diagnose Other Causes of Bladder Symptoms
Local pathology
infection
bladder stones
bladder tumors
interstitial cystitis
outlet obstruction
Metabolic factors
diabetes
polydipsia
Medications
diuretics
antidepressants
antihypertensives
hypnotics & sedatives
narcotics & analgesics
Other factors
pregnancy
psychological issues
Bladder symptoms may be caused by a wide variety of factors other than OAB. Screening for OAB can help uncover these disorders.
Bladder symptoms may be due to local pathology, metabolic factors, the use of certain medications, or other medical or psychological factors.
Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; March AHCPR publication

17. Differential Diagnosis: Physical Examination
Perform general, abdominal (including bladder palpation), and neurologic exams
Perform pelvic and/or rectal exam in females and rectal exam in males
Observe for urine loss with vigorous cough
Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January AHCPR publication

18. Differential Diagnosis: Laboratory Tests
Urinalysis
to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria
Blood work if compromised renal function is suspected or if polyuria (in the absence of diuretics) is present
The differential diagnosis of OAB should include urinalysis to rule out hematuria, pyuria, bacteriuria, glucosuria, and proteinuria.
Additional blood work (such as measures of glucose, BUN, creatinine, and calcium) should be performed, as appropriate.
Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January AHCPR publication

19. Consider referral to specialist
Care Pathway
Working diagnosis?
Yes
OAB?
Yes No
Treat if:
Frequency and urgency, with or without urge incontinence, and normal urinalysis
Consider referral to specialist
>8 weeks tx Failed
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition

20. Suggested Reasons for Referral
Symptoms do not respond to initial treatment within 2 to 3 months
Hematuria without infection on urinalysis
Recurrent symptomatic UTI
Symptoms suggestive of poor bladder emptying
Pelvic bladder, vaginal, or urethral pain
Evidence of complicated neurologic or metabolic disease
Failed previous incontinence surgery
Elevated PVR volume
Radical pelvic surgery
Symptomatic prolapse
Prostate problems
Surgery planned (2nd opinion)
Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition

21. Treatment Options Behavioral therapy Medication
Combined therapy: behavioral and pharmacologic therapy
Minimally invasive therapies
Botulinum A-toxin
Neuromodulation
Surgery

22. So when the Drug Rep. visits, which drug do I use?

24. Pharmacotherapy Anticholinergic Agents Oxybutynin (Ditropan)
Oxybutynin transdermal (Oxytrol)
Tolterodine (Detrol)
Solifenacin (Vesicare)
Trospium chloride (Sanctura)
Darifenacin (Enablex)

25. Oxybutynin (Ditropan)
Immediate and long acting form
Immediate – TID dosing
Long acting XL – once a day, 5 or 10 mg.
Side effects – dry mouth, constipation, headache
Approved for pediatric use (age 6 or older)

26. Oxybutynin Transdermal (Oxytrol)
3.9 mg patch, twice weekly
Similar in effects to po
Side effects – less dry mouth but erythema/pruitis

27. Tolterodine (Detrol) Immediate 2 mg. and long acting LA 4 mg dosing
Side effects profile similar to oxybutynin

28. Solifenacin (Vesicare)
5 – 10 mg daily dose
Side effects – dry mouth, constipation

29. Trospium Chloride (Sanctura)
Quaternary amine as opposed to tertiary amine
20 mg BID dose
Theoretically harder to pass through blood/brain barrier with less side effects
Not metabolized by liver
60% excreted in the urine unchanged

30. Darifenacin (Enablex)
M3 selective anticholinergic
7.5 mg or 15 mg once a day
Side effects – constipation and dry mouth