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Overactive Bladder

Patients who suffer from overactive bladder (OAB) complain of urgency and frequent urination both day and night. These people often experience urgency at inconvenient and unpredictable times and may even leak urine before reaching a toilet (urge incontinence). This causes embarrassment, diminish self-esteem and affect their quality of life.

Overactive bladder afflicts men and women equally. Some 15% of the population suffer from OAB, with higher prevalence in older patients.

Diagnosis

The diagnosis of OAB is made after excluding underlying causes such as:

• Bladder infection (UTI)
• Bladder stones
• Drug side-effects
• Neurological disease (e.g. Parkinson's disease, stroke, spinal cord lesions)
• Nerve damage from pelvic trauma or surgery
• Bladder or prostate cancer

A complete medical history is taken, including a voiding diary [Fig 1], physical examination, and urine analysis. Examination of the urine may identify medical conditions such as bacteria (indicating infection) and excess sugar (indicating diabetes mellitus). If blood is detected, a flexible cystoscopy examination may be needed to exclude bladder cancer. Occasionally, other diagnostic procedures like urodynamics are done, especially when there is no response to medication.

Treatment

Treatment include one or more of the following:

• Bladder training
• Medication
• Botox injection
• Neuromodulation
• Surgery

1) Bladder Training with Timed Voiding

In bladder training, biofeedback and Kegel exercise help to resist the sensation of urgency and postpone urination. This is done in conjunction with a voiding diary which records all episodes of urination and leakage.

2) Medication

Drugs such as oxybutynin (Ditropan®) and tolterodine (Detrusitol®) are tablets taken once to twice a day [Fig 2]. These medications work to relax the smooth muscle of the bladder and reduce their contractions. The effectiveness is usually seen within 2 weeks. Newer drugs include trospium chloride (Spasmolyt®), propiverine (Mictonorm®), and solifenacin (Vesicare®).

The main limitation to these medications is the side-effects, especially dry mouth, constipation, headache, blurred vision, dry eyes, drowsiness, and urinary retention. This occurs in approximately 30 to 80 % of patients. They should be not be used in patients with narrow-angle glaucoma.

3) Botox injections

Botox can be injected into the bladder to treat cases that do not respond to oral medication [Fig 3]. The botox is injected into the wall of the bladder to paralyze the bladder muscle and suppress the involuntary contractions that cause urge incontinence. The effect is seen as early as 2 weeks after injection. This is done under general anesthesia as a day case and takes less than 15 mins to do. Success rates are about 70 to 80% but the effect last only up to 9 months. Repeat injections may then be needed. Complications include bloody urine and retention of urine that may require self-catheterisation.

4) Sacral Nerve Stimulation (also called sacral nerve neuromodulation)

This is reserved for those with urge incontinence caused by overactive bladder who do not respond to behavioural treatments or medication. It has the advantage of longer effectiveness compared to botox bladder injections but it requires special equipment and is an expensive procedure. It may not work for all patients, hence an electrode is first implanted into the sacrum bone [Fig 4]. This lead electrode will subsequently be attached to the neurostimulation device system, which sends mild electrical pulses to the sacral nerve at regular intervals. Prior to implantation of the device, the effectiveness of the electrode is tested with an external meter. For a period of 3 to 5 days, the patient records voiding patterns that occur with stimulation. The record is compared to recorded voiding patterns without stimulation. The comparison demonstrates whether the device will effectively reduce symptoms. If the test is successful, the patient can then choose to have the neurostimulator device implanted under the skin at the level of the upper buttock.

5) Surgery

If all else fails, surgery can be done to enlarge the bladder by splitting it and patching a segment of small intestine onto it [Fig 5]. This is a major undertaking and irreversible, hence, patients must be aware of possible problems like mucus blockage of the bladder. infections and incomplete emptying.

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