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Overactive Bladder
The Overactive Bladder
a report by
Marcus Drake
Consultant Urological Surgeon, Bristol Urological Institute, Southmead Hospital
The concept at the heart of overactive bladder (OAB) syndrome is the clinical needs.
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Over the last few years, a more systematic and scientific
presence of urinary urgency, commonly associated with storage-type approach has been taken with the development of the International
urinary symptoms, including frequency and nocturia (see Table 1).
1
Patients Consultation on Incontinence Modular Questionnaires (ICIQ).
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The ICIQ
can be described as having OAB syndrome regardless of whether they have has incorporated established tools and developed new ones, addressing
urgency incontinence. The emphasis on urgency reflects a perception that requirements for validation during development. The initiative allows
it is this symptom that affects quality of life and help-seeking behaviour the practitioner to select from a range of options according to the
and, accordingly, places the patient and his or her bothersome symptoms requirements of the specific situation. The European Association of
at the centre of clinical management. Urology (EAU) Guidelines on Urinary Incontinence recommend the ICIQ
short form (SF) questionnaire as a good compromise between scientific
There is no doubting the sheer scale of the problem, with numerous rigour and practicality.
studies establishing a substantial overall prevalence, the effect of ageing
and accelerating incidence in older age groups. Using the standardised Standard First-line Treatment of Overactive Bladder
International Continence Society (ICS) definitions, the overall prevalence The EAU Guidelines split management of urinary incontinence into initial
is estimated at 11.8%, with a clear increase with ageing, and showing treatment and specialised therapy. For OAB, initial management should
that men are affected as much as women.
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Likewise, the potential be offered to symptomatic patients who are bothered by the problem
influence on quality of life is well documented, affecting many aspects of and includes:
daily living.
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Thus, OAB represents a considerable economic burden
estimated at billions of euros
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in terms of both clinical management and • fluid advice as a component of coping behaviour strategies for
social/occupational function. patients,
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and the physician should discuss appropriate volumes and
types of fluid with the patient;
Diagnosis and Evaluation • bladder training is probably beneficial and safe,
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with or without
Diagnosis requires a urological history focused on storage- and voiding- pelvic floor muscle exercise training,
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although the evidence on which
phase symptoms, symptom severity and risk factors – the latter including to base the recommendations is not strong; and
malignancy, neurological or endocrine disease. Physical examination and • timed voiding, or prompted voiding in older age groups,
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can help by
simple tests, e.g. dipstick urinalysis and urinary tract ultrasound, are used preventing the bladder reaching the critical volume at which urgency
to exclude other causes of similar symptoms, such as urinary tract or incontinence becomes overt.
infection. A frequency volume chart (FVC) or bladder diary is used to
document the scale of the problem, ascertaining frequency, nocturia, In the absence of contraindications – such as poorly controlled closed-
typical voided volumes and fluid output (the latter revealing the presence angle glaucoma
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– antimuscarinic drugs can appropriately be started
of any fluid restriction or polyuria).
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The FVC can be combined with once the concerns discussed above have been addressed. There is no need
simple ‘urgency scales’ of which several have been put forward;
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to undertake invasive cystometry beforehand unless there is a significant
although they are sometimes omitted in general clinical practice, they do post-void residual volume. This applies to men as well as women, as
give the advantage of revealing changes in response to treatment, which the risk of urinary retention has not been shown to increase even in the
can be difficult if relying solely on patient-reported condition. At presence of bladder-outlet obstruction.
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There are several drugs now
presentation it is important to consider the relationship between urgency available with strong evidence and high-grade recommendations.
and frequency, as frequent voiding may be a prophylactic measure taken
to prevent the bladder ever filling to the volume at which urgency
Marcus Drake is a Consultant Urological Surgeon at the
becomes a concern; therefore, the patient may never report the
Bristol Urological Institute at Southmead Hospital,
urgency that is the core defining symptom of OAB. Most centres also
subspecialising in female and reconstructive urology,
measure flow rates and post-void residual volumes, because OAB (a
neuro-urology and urodynamics. He is a Visiting Professor
in Health and Applied Sciences at the University of the
storage-phase symptom) can co-exist with detrusor underactivity (which
West of England. Professor Drake is Editor of the British
manifests in the voiding phase) – the latter affecting the prospective
Journal of Urology International Website and a member of
the Editorial Boards of Autonomic Neuroscience and
response to OAB treatment.
Neurourology and Urodynamics. He is Co-Chairman of the
Neural Control Committee for the fourth International Consultation on Incontinence.
Questionnaire-based tools for assessment of symptoms and
Professor Drake was awarded his PhD by the University of Oxford.
measurement of severity have been available for some time, and address E: marcus.drake@bui.ac.uk
the fact that physician assessment of symptoms is usually insufficient for
© TOUCH BRIEFINGS 2008 55