Overactive bladder is a condition in which the bladder squeezes urine out at the wrong time.
You may have overactive bladder if you have two or more of these symptoms:
You urinate eight or more times a day or two or more times at night
You have the sudden, strong need to urinate immediately
You leak urine after a sudden, strong urge to urinate
You also may have incontinence, a loss of bladder control. Nerve problems, too much fluid, or too much caffeine can cause it. Often the cause is unknown.
Your doctor may prescribe a medicine that can calm muscles and nerves. The medicine may come as a pill, a liquid, or a patch.
The medicines can cause your eyes to become dry. They can also cause dry mouth and constipation. To deal with these effects, use eye drops to keep your eyes moist, chew sugarless gum or suck on sugarless hard candy if dry mouth bothers you, and take small sips of water throughout the day.
Urgency: This means that you have a sudden urgent desire to pass urine. You are not able to put off going to the toilet.
Frequency: This means going to the toilet often - more than seven times a day. In many cases it is a lot more than seven times a day.
Nocturia: This means waking to go to the toilet more than once at night.
Urge incontinence occurs in some cases: This is a leaking of urine before you can get to the toilet when you have a feeling of urgency.
An OAB occurs when the bladder squeezes (contracts) suddenly without you having control and when the bladder is not full.
OAB syndrome is a common condition where no cause can be found for the repeated and uncontrolled bladder contractions. (For example, it is not due to a urine infection or an enlarged prostate gland.)
OAB syndrome is sometimes called an irritable bladder or detrusor instability. (Detrusor is the medical name for the bladder muscle.)
3 Causes
Overactive bladder can have more than one cause, including pre-existing conditions.
The urinary bladder is comprised of nerves, muscles, and connective tissue. The most important muscle in the bladder is the detrusor muscle. In normal circumstances, when the bladder fills with urine, it can stretch to hold the urine.
When the volume in the bladder reaches close to 300 cc, the stretch in the wall of the bladder can trigger a nerve response to initiate urination (micturition). This reaction results in loosening of the sphincter in the neck of the bladder (connecting the bladder to the urethra) and contraction of the detrusor muscle so that urination can ensue. This response can be overridden voluntarily by an individual to prevent urination if it is not the right time or place.
Overactive bladder can result from dysfunction of the nerves or muscles in the bladder, most commonly the dysfunction of the detrusor muscle. In OAB, the detrusor can contract inappropriately regardless of how much urine is stored in the bladder, hence the term detrusor overactivity.
Sometimes no identifiable cause for overactive bladder can be found. This is termed idiopathic overactive bladder.
The most common risk factor for overactive bladder is increasing age. Approximately 20% of people over the age of 70 report symptoms suggestive of overactive bladder.
The following are other common risk factors for overactive bladder:
Race and gender are not considered major risk factors for overactive bladder.
4 Making a Diagnosis
A diagnosis of overactive bladder depends on the presence of urgency, which differs from a simple urge to void.
The term overactive bladder (OAB) refers to a symptom complex. Therefore, the first part of the evaluation of OAB is to review the patient's lower urinary tract symptoms to ensure that the symptoms are consistent with OAB.
The American Urologic Association (AUA) guidelines recommend assessing for comorbid conditions that may affect bladder function, such as
A typical urge to void is a normal sensation that progressively strengthens when deferred. In contrast, urgency is an abnormal condition characterized by a sudden onset of urgency and difficulty in deferring urination.
Other causes of urinary frequency, urgency, and urinary incontinence must be excluded. Incontinence has several subtypes: stress incontinence, mixed urinary incontinence, overflow incontinence, and transient incontinence. Transient incontinence may be related to
The patient's history should include information about the following:
Onset, nature, duration, severity, and bother of lower urinary tract symptoms
Medical and surgical history
Obstetric and gynecologic history
Prescription and over-the-counter medications: Medications that can affect bladder function include anticholinergics or antimuscarinics, antidepressants, antipsychotics, sedatives or hypnotics, diuretics, caffeine, alcohol, narcotics, alpha-adrenergic blockers, alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers.
Review of systems, including genitourinary, obstetric and gynecologic, and neurologic findings
Social history, including smoking, alcohol consumption, fluid intake, and number of children (in women)
Bladder diary: This is used to record the times of micturitions and voided volumes, incontinence episodes, pad usage, and other information (e.g., fluid intake, degree of urgency, degree of incontinence). A 3-day diary is ideal.
Physical examination should include the following:
Abdominal examination
Genitourinary examination
Gynecologic examination to evaluate the strength of the muscles of the pelvic floor and to assess for prolapse of pelvic organ, urethral mobility, and stress urinary incontinence
Rectal examination to assess rectal tone and the prostate (in men)
Focused neurologic examination to examine pelvic reflexes, innervations of the feet, and the patient's mental status
Postvoid residual test: The AUA guidelines indicate that the measurement of postvoid residual (PVR) is not necessary for patients who are receiving first-line behavioral interventions or for uncomplicated patients receiving antimuscarinic medications.
Urodynamic study: This is not indicated as part of the first-line evaluation of patients with OAB unless a neurologic etiology is suspected. Urodynamic study is most commonly performed in individuals in whom first-line therapies for OAB fail.
Several treatment methods are used for overactive bladder.
First-Line Treatments
Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first line therapy to all patients with OAB. Behavioral therapies may be combined with pharmacologic management.
Second-Line Treatments
Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as second-line therapy. If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth.
Transdermal (TDS) oxybutynin (patch [now available to women ages 18 years and older without a prescription]* or gel) may be offered. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one antimuscarinic medication, then a dose modification or a different anti-muscarinic medication or a β3-adrenoceptor agonist may be tried.
Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention.
Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic therapy. Management may include
bowel management,
fluid management,
dose modification
or alternative antimuscarinics.
Clinicians must use caution in prescribing anti-muscarinics in patients who are using other medications with anticholinergic properties.
Clinicians should use caution in prescribing anti-muscarinics or β3-adrenoceptor agonists in the frail OAB patient.
Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy.
Third-line Treatments
Clinicians may offer intradetrusor onabotulinumtoxin A (100U) as third-line treatment in the carefully-selected and thoroughly-counseled patient who has been refractory to first- and second-line OAB treatments. The patient must be able and willing to return for frequent post-void residual evaluation and able and willing to perform self catheterization if necessary.
Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third line treatment in a carefully selected patient population. Clinicians may offer sacral neuromodulation (SNS) as third line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure.
Practitioners and patients should persist with new treatments for an adequate trial in order to determine whether the therapy is efficacious and tolerable. Combination therapeutic approaches should be assembled methodically, with the addition of new therapies occurring only when the relative efficacy of the preceding therapy is known. Therapies that do not demonstrate efficacy after an adequate trial should be ceased.
Indwelling catheters (including transurethral, suprapubic, etc.) are not recommended as a management strategy for OAB because of the adverse risk/benefit balance except as a last resort in selected patients. In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB patients may be considered.
6 Prevention
There are no specific preventive measures for overactive bladder syndrome. However, some of the symptoms such as frequency or incontinence can be prevented by simple steps.
For example, limiting fluid intake, especially prior to going to bed, may reduce urinary frequency and nocturia.
Additionally, avoidance of
spicy foods,
chocolate,
carbonated beverages,
caffeine,
alcohol
may help reduce symptoms of overactive bladder. A high-fiber diet may be encouraged in individuals with OAB.
7 Lifestyle and Coping
Lifestyle modifications are necessary in order to cope with overactive bladder.
Getting to the toilet
Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.
Caffeine
This is in tea, coffee and cola and is part of some painkiller tablets. Caffeine has the effect of making urine form more often (a diuretic effect). Caffeine may also directly stimulate the bladder to make urgency symptoms worse.
It may be worth trying without caffeine for a week or so to see if symptoms improve. If symptoms do improve, you may not want to give up caffeine completely.
However, you may wish to limit the times that you have a caffeine-containing drink. Also, you will know to be near to a toilet whenever you have caffeine.
Alcohol
In some people, alcohol may make symptoms worse. The same advice applies as with caffeine drinks.
Drink normal quantities of fluids
It may seem sensible to cut back on the amount that you drink so the bladder does not fill so quickly. However, this can make symptoms worse as the urine becomes more concentrated, which may irritate the bladder muscle (detrusor).
Aim to drink normal quantities of fluids each day. This is usually about two litres of fluid per day - about 6-8 cups of fluid, and more in hot climates and hot weather.
Go to the toilet only when you need to
Some people get into the habit of going to the toilet more often than they need. They may go when their bladder only has a small amount of urine so as "not to be caught short".
This again may sound sensible, as some people think that symptoms of an overactive bladder will not develop if the bladder does not fill very much and is emptied regularly. However, again, this can make symptoms worse in the long run.
If you go to the toilet too often the bladder becomes used to holding less urine. The bladder may then become even more sensitive and overactive at times when it is stretched a little. So, you may find that when you need to hold on a bit longer (for example, if you go out), symptoms are worse than ever.
Bladder training (sometimes called bladder drill)
The aim is to slowly stretch the bladder so that it can hold larger and larger volumes of urine. In time, the bladder muscle (detrusor) should become less overactive and you should become more in control of your bladder.
This means that more time can elapse between feeling the desire to pass urine and having to get to a toilet. Leaks of urine are then less likely. A doctor, nurse, or continence advisor will explain how to do bladder training. The advice may be something like the following:
You will need to keep a diary
On the diary make a note of the times you pass urine, and the amount (volume) that you pass each time. Also make a note of any times that you leak urine (are incontinent).
Your doctor or nurse may have some pre-printed diary charts for this purpose to give you. Keep an old measuring jug by the toilet so that you can measure the amount of urine you pass each time you go to the toilet.
When you first start the diary, go to the toilet as usual for 2-3 days at first. This is to get a baseline idea of how often you go to the toilet and how much urine you normally pass each time. If you have an OAB you may be going to the toilet every hour or so and only passing less than 100-200 ml each time. This will be recorded in the diary.
After the 2-3 days of finding your baseline, the aim is then to hold on for as long as possible before you go to the toilet. This will seem difficult at first. For example, it you normally go to the toilet every hour, it may seem quite a struggle to last one hour and five minutes between toilet trips. When trying to hold on, try distracting yourself. For example:
Sitting straight on a hard seat may help.
Try counting backwards from 100.
Try doing some pelvic floor exercises.
With time, it should become easier as the bladder becomes used to holding larger amounts of urine. The idea is gradually to extend the time between toilet trips and to train your bladder to stretch more easily.
It may take several weeks but the aim is to pass urine only 5-6 times in 24 hours (about every 3-4 hours). Also, each time you pass urine you should pass much more than your baseline diary readings. (On average, people without an OAB normally pass 250-350 ml each time they go to the toilet.)
After several months you may find that you just get the normal feelings of needing the toilet, which you can easily put off for a reasonable time until it is convenient to go.
Whilst doing bladder training, perhaps fill in the diary for a 24-hour period every week or so. This will record your progress over the months of the training period.
Bladder training can be difficult but becomes easier with time and perseverance. It works best if combined with advice and support from a continence advisor, nurse or doctor.
Make sure you drink a normal amount of fluids when you do bladder training
8 Risks and Complications
There are several risks and complications associated with overactive bladder.
Overactive bladder (OAB) is a chronic condition with symptoms that can disrupt your normal activities during the day and disrupt your sleep at night. It can lead to embarrassment, depression, and emotional distress. While the condition is often treatable, finding the right treatment can take time.
In the meantime you may experience negative symptoms and the consequences of these symptoms. For most people, it’s the inconvenience of these symptoms and not the symptoms themselves that make OAB such a problem.
Quality of Life
Symptoms of OAB can have a significant effect on a person’s daily life. These symptoms and the coping strategies to manage them can disrupt normal routines at home, at work, and in social settings. From having to interrupt conversations to ducking out of meetings, OAB has a way of making you feel rude or disruptive when you have no choice.
You may begin planning your outings around your OAB. While ensuring there are nearby restrooms wherever you are is smart, it can also inhibit your activities.
Sexual Activity
There have been studies and surveys that have determined OAB can have a negative impact on your sex life. It seems that some people with OAB, especially women, avoid sex out of fear that they will have leakage. Interrupting sex to run to the bathroom can also inhibit sexual satisfaction.
Since urinary issues and sexual organs are so closely linked, OAB is sometimes related to the reproductive organs and affects general sexual function.
Productivity
Urgency, frequency, or chronic fatigue due to sleep disruption can interfere with work and daily routines and lead to lower productivity at work and at home. You make far less progress when you constantly have to interrupt what you are doing to run to the bathroom.
Social Interaction
People living with OAB often avoid leaving the house out of fear of a flare-up in symptoms, especially urge incontinence. This could cause them to miss out on important or fun events that are an essential part of a healthy lifestyle.
Someone who once got great joy out of social events may find themselves more isolated and homebound out of fear and embarrassment.
Fatigue
Nocturia is a common symptom of OAB. It’s defined as the need to get out of bed two or more times at night to urinate. It can cause chronic fatigue and lack of energy that may exacerbate other OAB complications.
Each time the urge to urinate interrupts your night you have to struggle to return to the deep and most restful stages of sleep. This can lead to fatigue.
Depression
A lower quality of life can have emotional effects on people with OAB. The self-imposed isolation and embarrassment can limit beneficial relationships and cause people to feel poorly about themselves. According to the Mayo Clinic, there is an association between depression and OAB symptoms.
Infections
If an infection causes your OAB, failure to treat it can lead to complications. Untreated urinary tract infections (UTIs) can lead to bladder infections. They can also increase the risk of more UTIs in the future.
Dehydration
There’s a misconception out there that urinary incontinence will not occur if a person with OAB limits the amount of fluid intake to a very small amount.
In fact, not drinking enough fluids can cause distress on the bladder and worsen OAB symptoms. Your doctor can help you find a balance between hydration and worsening symptoms.
Falls and Fractures
Studies have found that urgency and incontinence significantly increase the risk of recurrent falls and fractures in the elderly. Risk of falling and fear of falling increase with OAB.
This is largely because people with OAB may rush to the restroom, increasing the risk of an accident.
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