Evaluating and Treating the Overactive Bladder
Evaluating and Treating the Overactive Bladder
Ross A. Rames, M.D., F.A.C.S.
Department of Urology, MUSC
November 1, 2002
Incontinence is the uncontrolled loss of urine. It affects over 10 million people in the United States and costs over 10 billion dollars per year for management and treatment. It is more common in women and especially the elderly; however, incontinence should not be considered a normal part of aging and is usually treatable. The overactive bladder (OAB) is even more prevalent in women; they have the same prostate screening scale scores as men - suggesting both obstruction and irritation symptoms despite no prostates - and they have more incontinence than men.
The impact of incontinence and OAB includes social isolation, depression, and is often the final event leading to placement in a nursing-home setting.
Evaluation includes:
• History, with particular attention to characteristics of the incontinence, previous surgery, current medications, childbirth.
• Physical exam noting the general condition of the patient, neurological status, and thorough pelvic exam.
• Laboratory evaluation to rule out infection, metabolic abnormalities, malignancy, especially u/s.
• Voiding diary (time and amount of voiding - can help pin down ETOH use/polyuria/small frequency voidings), in some cases urodynamics, cystoscopy, and upper tract studies.
It is important to rule out reversible causes of incontinence during the initial evaluation of the patient. This type of incontinence is most responsive to conservative therapy and is more common in the elderly patient. High index of suspicion should be present when the incontinence is acute in onset. Remember DRIP and DIAPPERS.
|D |= Delirium |D |= Delirium |
|R |= Retention, Restricted mobility |I |= Infection |
|I |= Infection, Inflammation, Impaction |A |= Atrophic vaginitis |
|P |= Polyuria, Pharmaceuticals |P |= Pharmaceuticals |
| | |P |= Psychiatric illness |
| | |E |= Excess urine |
| | |R |= Restriction in mobility |
| | |S |= Stool impaction |
Classification of incontinence:
• Urge
• Stress
• Overflow
• Functional
Treatment:
• Medical: Medicines found effective were anticholinergic (muscarinic receptor antagonists): Ditropan XL, Oxybutynin, Detrol and Propantheline (7.5 to 30 mg p.o. t.i.d., but dose titration problematic); TCA's: imipramine; and estrogens. Ditropan XL and Detrol are best tolerated. Capsaicin desensitizes c-fiber afferents, and can be helpful.
• Behavioral: Training, Kegel's biofeedback, fluid modification.
• Surgical: suspensions, sling procedures, Contingen injection (helps stress incontinence, especially after prior surgical repair), repair of other pelvic defects.
• Neuromodulation (InterStim) - implanted electrode; in patient who responds to peripheral stimulator
• Refer: hematuria, recurrent UTI, risk factors for bladder cancer (smoking, chemicals), failure to respond to treatment
Alpha-blockers caused incontinence in 1/3 of menopausal women.
Most health care providers practice "don't ask don't tell" with their patients continence, and it is unlikely that the patient will raise the issue without prompting. This results in unnecessary suffering that could be ameliorated in most cases. Medical treatment and behavioral modification often result in significant improvements.
Ditropan XL has much decreased first pass metabolism; metabolite cause of side of effects.
Detrol may work a little better (only 1 study; contradicted by others), but only at the 4 mg dose; 2 mg equivalent to 5 mg XL Ditropan.
Imipramine works at the spinal nucleus level, causing increased sphincter tone; dose 25 at bedtime to three times daily; best for nocturia (DDAVP also works).
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Combo gives best results
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