Diseases
Clinic Location & Map
#16-11 Mount Elizabeth Medical Centre
3 Mount Elizabeth
Singapore 228510
| Phone: | +65 6235 1180 |
| Fax: | +65 6235 1186 |
| Emergency: | +65 6535 8833 |
| Email: | ccm@ccmurology.com |
Clinic Hours
| Monday - Friday | 8:30am - 5:00pm |
| Saturday | 8:30am - 1:00pm |
| Sunday / Public Holiday | Closed |
Overactive Bladder
Patients who suffer from overactive bladder (OAB) complain of urgency and frequent urination both day and night. They 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 prevalence being higher in older patients. The cause is unknown, but aggravating factors are excess caffeine intake, cold weather and mental stress. Many men with prostate enlargement (BPH) also develop OAB symptoms.
Patients with overactive bladder often have to rush to the toilet because of the strong desire to pass urine (urgency).
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 bacteria (indicating infection) and excess sugar (indicating diabetes mellitus). If blood is detected, a flexible cystoscopy may be needed to exclude bladder cancer. Occasionally, other diagnostic procedures like urodynamics are done if there is no response to medical measures.
Fig 1.Bladder diary to record fluid intake, number of toilet visits & leak episodes
Treatment
Treatment is step-wise and proceeds in the following order:
- Behaviour modification and Bladder training
- Medication
- Botox injection
- Neuromodulation
- Surgery
1) Behaviour modification and Bladder Training
The first step is identifying and correcting habits that aggravate this condition eg. excess water / coffee drinking. Self-help advice is also given eg. bladder training and Kegel exercises to help resist the sensation of urgency and postpone urination. This is done in conjunction with a bladder diary which gives a record and feedback on the episodes of urination.
2) Medication
Many drugs are available to control the urge and desire to pass urine. These medications work by relaxing the muscle of the bladder and reduce their contractions. The most commonly prescribed drug is tolterodine (Detrusitol®). Others are oxybutynin (Ditropan®), trospium chloride (Spasmolyt®), propiverine (Mictonorm®), and solifenacin (Vesicare®). These tablets are taken once to twice a day and the effect is seen by 2 weeks. Up to 80% of patients are cured by 3 to 6 months.
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 up to 30% of patients. They are also contraindication in narrow-angle glaucoma.
3) Botox injections
Botox can be injected into the bladder to treat cases that do not respond to oral medication [Fig 2]. The botox is injected into the wall of the bladder to paralyze the bladder muscle and suppress the contractions that cause urge incontinence. The effect is seen as early as 2 weeks after injection. It is easily done as a day case and takes 15 mins to do. Success rates vary from 50% to 70% and the effect last up to 9 months. Repeat injections may then be needed. Complications include bloody urine and prolonged retention of urine that require self-catheterisation.
Fig 2. Botox can be injected into the bladder for severe cases
4)Sacral Nerve Stimulation (also called sacral nerve neuromodulation)
This is reserved for those who do fail on behavioural treatments, medication and botox injection. It requires a special device and hence, is an expensive procedure. It consists of a neurostimulation device system which sends mild electrical pulses to the sacral nerve at regular intervals to modulate it. As it may not work for all patients, a trial electrode is first implanted into the sacrum [Fig 3]. This wired electrode is tested with an external meter over a period of 3 to 5 days as 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 neurostimulator device is then implanted under the skin at the level of the upper buttock. The most common complications are infection and breakage of the device / wire.
Fig 3. Neuromodulation of the bladder through sacral nerve stimulation
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 4]. This is a major undertaking and irreversible, hence, patients must be aware of possible complications like mucus blockage of the bladder, incomplete bladder emptying, nighttime incontinence and infection.
Fig 4. Augmentation cystoplasty where the bladder is enlarged by patching a segment of small intestine over it