1. The Overactive Bladder
Lewis Chan
Staff Specialist in Urology
Concord Repatriation General Hospital

2. Why are we talking about this?
By 2050, 20% of population will be over 65
Voiding dysfunction is the most common geriatric problem
Prevalence of urinary incontinence in elderly 30-50%
Significant Incontinence 4-8%
1 in 3 men > 50 years will undergo treatment for voiding dysfunction in their lifetime
1 in 3 men or women > 75 years have overactive bladder symptoms 2

3. What are lower urinary tract symptoms (LUTS)?
Previously known as ‘prostatism’ !
Frequency, urgency, nocturia - “overactive bladder”
Hesitancy, decreasing stream, dribbling - “voiding” symptoms
Incontinence - stress, urge or mixed
Dysuria, pain - inflammation
Haematuria
NB – Symptoms do NOT give the Diagnosis! 3

4. Facts and Myths Incontinence is NOT a normal part of ageing
BUT there are changes in bladder and pelvic structures that can contribute to incontinence
Medical problems that can disrupt the continence mechanism (DM/CVA) are more common among older populations.
BPH - increase in incidence with ageing but not everyone with BPH has obstruction
Menopause – atrophic changes
Cognitive and functional impairment.

5. LUTS - Diagnostic Dilemma
LUTS in men – is it due to bladder outlet obstruction (prostatic hypertrophy) or overactive bladder?
LUTS/ incontinence in women – is it due to sphincter/ pelvic floor weakness or overactive bladder? 5

6. Mechanisms of Continence

7. Overactive Bladder - Causes
urinary tract infections
Idiopathic
Bladder outlet obstruction
neurological disease
stone
tumour 7

8. Voiding Dysfunction - Assessment
History
Symptoms
Severity / degree of bother
Comorbidities / medications
Functional / social issues
Physical Examination
General
Urogenital including PR
Pelvic exam – prolapse, muscle tone,sensation,reflexes

9. Incontinence – Transient Causes
D - Delirium
I - Infection
A - Atrophic vaginitis
P - Psychological
P - Pharmacological
E - Excess urine output
R - Restricted mobility
S - Stool 9

10. 10

11. Drugs and Incontinence

12. Case One
70 yr old man with 2 year Hx of worsening frequency urgency poor stream and nocturia x3
PR – moderate size soft prostate
Otherwise well but bothered by symptoms
What tests would you do? 12

13. Investigations – safety tests
UMCS Haematuria , UTI
Creatinine Renal function
PSA Prostate Ca
Ultrasound Residual, bladder stone
Voiding Diary Functional bladder capacity
Specialty tests – flow study, urodynamics, cystoscopy 13

14. Case One MSU – normal Creatinine and PSA normal
Ultrasound – residual 90mls, normal kidneys
Does he need other tests?
What is the likely cause of his urinary symptoms?
What treatment do you suggest? 14

15. Case Two
67 yr old woman with worsening frequency, urgency and mixed stress and urge incontinence
O/E – moderate descent of bladder base on coughing and straining with reduced PF muscle tone
What tests do you ask for?
What treatment would you suggest?

17. Pharmacological treatment of OAB
Anticholinergic therapy – oxybutynin, propantheline
Tricyclics – imipramine
Use often limited by side-effects – dry mouth, constipation, blurred vision, drowsiness,confusion
Newer ‘bladder selective’ drugs now available in Australia – tolterodine,darifenacin,solifenacin,transdermal oxybutynin patch 17

18. So many choices – what to do?
Oxybutynin and tolterodine are recognised first line treatments for OAB world wide
In patients intolerant of oxybutynin consider solifenacin if significant OAB or transdermal oxybutynin patch
In frail patients with high risks for complications of anticholinergic therapy consider transdermal patch or tolterodine
Selected patients who fail drug therapy may benefit from intravesical Botulinum Toxin injections 18

19. Case Two
Urgency and frequency improved with bladder training and ditropan
Still needs to wear pads for stress incontinence and occasional urge IC
What would you recommend?

20. Overactive Bladder - Women
Usually F/U/N +/- urge incontinence
Exclude UTI, beware recent onset OAB in smokers
Management
Bladder training /voiding diary
Anticholinergics
Botox
Continence appliances / Catheter

21. Case Three 75 yr old man with Parkinson’s Disease.
Worsening frequency, urgency and urge incontinence over 6 mths – requiring 3-4 pads a day
PR – small soft prostate
What tests should he have? 21

22. Case Three MSU – clear Voiding diary – vol 50-100mls every 2 hours
Ultrasound – no residual
Would bladder training be useful?
What drug should he have?
If no improvement on medical therapy – what next? 22

23. Urodynamics 23

24. 24

25. Overactive Bladder - Men
Predominant F/U/N with reasonable flow
Small prostate
No residual
Remember safety tests
Beware neuropaths (CVA, Parkinsons etc)
Management
Bladder training / fluid modification
Trial of anticholinergics (ditropan, tofranil etc)
If persisting symptoms – urodynamics +/- cystoscopy 25

26. Intravesical Botulinum Toxin-A (BTX-A) Injection for OAB
Indication – OAB refractory to medical therapy
Established efficacy in neurogenic detrusor overactivity with emerging role in treatment of non-neurogenic overactive bladder
Response rate in non-neurogenic OAB about 60-80% with duration of response around 6-12 months. Most will require repeat injections
Currently available data showed no dysplastic changes to bladder after BTX therapy 26

27. Indications for cystoscopy
Frank haematuria
Persistent microhaematuria
Persistent irritative symptoms (esp smokers)
Recurrent UTIs
Past history of urethral stricture

28. Urinary Incontinence following Prostate Surgery
Seminar - August 11
15/04/2017
Urinary Incontinence following Prostate Surgery
Incontinence following TURP generally due to overactive bladder
Incontinence following radical prostatectomy (for prostate cancer) usually due to sphincter muscle weakness
Treatment:
Pelvic floor exercises
Pads/Uridome
Transurethral injection of bulking agents
Perineal sling
Artificial Urinary Sphincter 28

29. Surgical treatment of post prostatectomy incontinence
Seminar - August 11
15/04/2017
Surgical treatment of post prostatectomy incontinence 29

30. Take Home Messages
Voiding dysfunction can significantly affect quality of life in the elderly but is not an inevitable part of ageing
Careful consideration of comorbidities, effects of medications, functional and social issues essential in management
Conservative measures should be considered before pharmacotherapy and invasive tests
Surgery still has an important role in those who fail conservative treatment or pharmacotherapy

31. “Remember, this treatment worked much better on mice than it
did on guineapigs, and frankly I think he looks more like a guineapig!”