As the subtle hues of pink which shade the month of October aid in helping us remember our dues to the fairer sex, among these are the urological afflictions commonly affecting women. The common misconception is that urological issues arise only in men. Women, in fact, in addition to most of the common conditions, have a few ailments that trouble them more (as with almost all conditions, certain gender predilections are known). Among them are urinary tract infections and overactive bladders. While it is known that women bear the unfortunate onslaught of urinary infections more than men, overactive bladders have come to become more prominent in the last few years.
What is an overactive bladder?
OAB or overactive bladder is an entity affecting bladder function. It is defined as urinary urgency with or without incontinence, with increased urinary frequency and nocturia, if there is no proven infection or other causes. This affects up to 12 percent of women and can be extremely distressing, affecting their quality of life.
OAB is seen to be more common in women than men, especially those of African descent; with an increased incidence with age where it can partly be associated with bladder outlet obstruction, certain neurological diseases (such as Parkinson’s disease, cerebrovascular diseases, multiple sclerosis, etc.) due to loss of cortical inhibition and it also be related to a few disorders such as metabolic syndrome, fibromyalgia, bowel function and hormone associated conditions.
OAB is still an enigma at times. The suggested pathophysiology is that it arises from the increased or inappropriate sensory activity of the pathologically sensitised or abnormal afferent nerve endings of the bladder. Hence, either a nerve mediated excitation of the detrusor muscle or spontaneous excitation within the smooth muscle or multiple localised contractions with a spread to the rest of the bladder is to be considered. Once this occurs, there is a sudden urge to pass urine.
So where do we start at managing the patient then? Right at the history, of course, to identify any implicating factors. A detailed history should include fluid and caffeine intake, the presence of hematuria or pain or other lower urinary tract symptoms, and other contributory components. Details of the patient’s medical history including neurological, gynaecological and surgical are noted. The intake of certain medications such as diuretics can falsely implicate OAB as a cause. The presence of pain, in general, is associated with interstitial cystitis more than OAB. A questionnaire may aid in diagnosing.
Evaluation and Management
After a thorough examination, an initial workup including a complete urine analysis, radiological imaging and uroflowmetry is done to rule out any obvious causes of the symptoms. As a second line of evaluation in refractory OAB, cystoscopy and urodynamic evaluation may be added. The patient is advised to maintain a frequency volume chart, where a comprehensive analysis of the fluid intake (including caffeine intake) and urine output is maintained for ideally 7 days, though practically, a 3 day chart can be easier. It is also useful to note the presence of urgency and urge urinary incontinence in association with each void.
Primary management starts with behavioural therapy comprising of weight management, modified fluid intake, avoidance of bladder irritants (such as caffeine, alcohol, smoking, etc.), and treatment of co-existent conditions (such as diabetes, calculus disease, etc). Patients are advised to train their bladders and practice scheduled or timed voiding, where they may refer to their frequency-volume chart to identify the pattern or likely time interval at which they void. Pelvic floor muscle training (PFMT) is taught and encouraged.
After a significant period of behavioural therapy, if the patient continues to have symptoms, drug therapy may be initiated in the form of anti-muscarinics or beta-3 adrenergic receptor agonists. Further, in case of diminutive response to therapy, Botox injections to the detrusor cystoscopically, sacral neuromodulation and percutaneous tibial nerve stimulation may be attempted as first line surgical therapy in an effort to alter the hypersensitivity of the detrusor. With persisting or refractory OAB patients, more advanced surgical management in the form of either detrusor myomectomy or augmentation cystoplasty (segment of bowel used to increase the bladder capacity) can be advised.
A few points we need to remember when we address a patient with suspected OAB is to have an in-detail assessment of fluid-caffeine intake and to note any key triggering factors. It is of tremendous aid to identify this, to treat and do right by our patients.
Dr. Anu Ramesh
Kauvery Hospital Chennai