Management of Overactive Bladder

1. Management of Overactive Bladder Judith ten Hof Consultant Obstetrician and Gynaecologist Nottingham University Hospitals

2. Management of Overactive bladder Can we do better?

3. Contents • Definition • Incidence and etiology • Risk factors • History and examination • Management • Referral pathway

4. Definitions • Urinary incontinence: complaint of any involuntary loss of urine causing social and hygienic problems • UUI: accompanied by or immediately preceded by urgency • SUI: on effort, exertion, sneezing or coughing • MUI: combination of both • Overactive bladder: urgency with or without UI usually associated with frequency & nocturia (ICS)

5. UI Prevalence Prevalence 25% (range 10-40%). Age dependent. (Hannestad et al 2000) 7-12% perceive as a problem. (McGrowther et al 2001) OAB 12-17% (Population based survey)

6. Impact of UI • Quality of life • associated with depression and anxiety, work impairment, and social isolation • Sexual dysfunction • 30% (fear of) coital incontinence • Morbidity • perineal infections • falls and fractures • Caregiver burden • 6-10% of nursing home admissions

7. UI Incidence by type 50% Hannestad et al 2000

8. OAB Aetiology • Usually associated with detrusoroveractivity • Idiopathic • Neurogenic Important to exclude other organic causes Renal tract pathology Medical conditions and drug therapy

9. OAB symptom profile

10. OAB Risk factors

11. Case history 55 year old lady presents with symptoms of Frequency Urgency Urge incontinence Occasional stress incontinence No voiding dysfunction No infection

12. Patient journey

13. History

14. Examination General

15. Investigations 3 day bladder diary Urine dipstick +/- MSU 3 day bladder diary

16. NICE RECOMMENDATIONSAssesment • Categorise type of UI as stress/ urge/ mixed • Commence treatment directed towards predominant symptom • Identify factors that may need referral

17. NICE RECOMMENDATIONS Referral • suspected malignancy • persisting bladder or urethral pain • symptoms of voiding difficulty • suspected urogenital fistulae • previous continence surgery • associated faecal incontinence • suspected neurological disease • clinically benign pelvic masses • previous pelvic cancer surgery / radiation therapy

18. UI treatment

20. Patient journey Primary Care/ continence advisors

21. Case history • 55 yr. old with • frequency • urgency • urge incontinence • occasional stress incontinence • no voiding dysfunction • no infection SUI completely resolved with conservative measures Overactive bladder symptoms remains predominant and bothersome

22. Pharmacological OAB treatment

23. Pharmalogical treatment of OABNeurological control

24. Pharmalogical treatment of OABAnticholinergics (OAB) • First line pharmacological therapy • Inhibits action of Acetylcholine • Safe, efficacious • Side effects • Adverse effects influence compliance • Different formularies

25. Pharmalogical treatment of OABAnticholinergics (OAB)

26. NICE RECOMMENDATIONSAnticholinergics for OAB First Line • oxybutynin (immediate release),or • not to frail older women • tolterodine (immediate release), or • darifenacin (once daily preparation) [new 2013] Review in 4 weeks • If not effective or well‑tolerated, offer another drug with the lowest acquisition cost[new 2013] • Offer transdermal to women unable to tolerate oral medication [new 2013] • Do not use flavoxate, propantheline and imipramine

27. NICE RECOMMENDATIONSAnticholinergics for OAB Always take account of • coexisting conditions (for example, poor bladder emptying) • use of other existing medication affecting the total anticholinergic load • risk of adverse effects [new 2013]

28. Anticholinergic burden • Cumulative effect anticholinergic medications • Side effects worse • Reversible cognitive impairment • Associated with increased risk dementia • ABC scale • Classification of commonly prescribed drugs by their anticholinergic effects • Anticholinergics, such as tolterodine, oxybutynin and solifenacin have the highest score on the ACB scale • Gray SL et al. JAMA Intern Med 2015;175(3):401-407. • Anticholinergicburdenscale 2012. Availableat: http://www.agingbraincare.org/tools/abc-anticholinergic-cognitive-burden-scale/. Last accessed: June 2015.

29. NICE RECOMMENDATIONSAnticholinergics for OAB Discuss • likelihood of success and associated common adverse effects • frequency and route of administration • some adverse effects such as dry mouth and constipation may indicate that treatment is starting to have an effect, and • that they may not see the full benefits until they have been taking the treatment for 4 weeks. [new 2013]

30. Pharmalogical treatment of OABBeta 3 adrenoceptor agonist Mirabegron • Relatively new • 25 / 50mg OD • Relatively new • selective b3-adrenoceptor agonist • most common adverse reactions • Tachycardia • Urinary tract infections • serious adverse reaction • Atrial fibrillation • No contribution to anticholinergic burden

31. NICE RECOMMENDATIONSBeta 3 adrenoceptor agonist Only when anticholinergics are • contraindicated • clinically ineffective • unacceptable side effects • ? Cognitive impairment • recommended dose 50 mg daily • 25 mg if renal or hepatic impairment Technology appraisal guidance [TA290] Published date: 26 June 2013

33. Case history • 55 yr. old with • frequency • urgency • urge incontinence • occasional stress incontinence • no voiding dysfunction • no infection SUI completely resolved with conservative measures Marginal improvement of overactive symptoms with 1/2 different anticholinergics. Symptoms still bothersome

34. Patient journey Referral to secondary care Primary Care/ continence advisors Further investigations Trial 2nd line anticholinergics Urodynamics

35. NICE RECOMMENDATIONSQOL Questionnaire • Use incontinence‑specific quality‑of‑life scales when therapies are being evaluated: ICIQ, BFLUTS, I‑QOL, SUIQQ, UISS, SEAPI‑QMM, ISI and KHQ [2006] • ICIQ • Kings Health/Bristol LUTS/Nottingham Health Profile • Electronic Patient Assessment (EPAQ) • Urinary • Bowel • Vaginal • Sexual

36. Investigations

37. Urodynamics in OAB/mixed UIindications Before surgical intervention Recurrence following previous incontinence surgery Complex clinical picture Failure after conservative Mx Symptoms suggestive of voiding dysfunction Anterior compartment prolapse

38. Urodynamics

39. Urodynamic diagnosis

40. Patient journey MDT Referral to secondary care Primary Care/ continence advisors Surgery for OAB Further investigations Trial 2nd line anticholinergics Urodynamics

41. Invasive / surgical

42. Botulinum Toxin • Not licensed for OAB • Intravesical injections ? Avoid trigone • Inhibits release of acetylcholine • 70% improvement • Complication • Voiding dysfunction (10-15%) • Infection (20%) • Rash/flu like symptoms • Pain/haematuria

43. Sacral Neuromodulation (DOA) • S3/S4 electrode implant • Significant symptomatic benefit >70% • Selected/refractory cases • Expensive • Needs high patient compliance • Complications • Pain • Change in bowel function • Infection

44. Percutaneous Tibial Nerve Stimulation (DOA) • New procedure, minimally invasive, minimum morbidity • Peripheral neuromodulation • Electrode near tibial nerve • Stimulated impulses to sacral plexus • Outpatient procedure • Initially 12 weekly sessions lasting 30 mins • Limited data • Bleeding and discomfort • Effective in selected cases The Obstetrician & GynaecologistVolume 18, Issue 3, pages 173-181, 23 JUL 2016 DOI: 10.1111/tog.12265

45. Augmentation cystoplasty / Urinary diversion

46. Key issues • Patience and commitment • Conservative and medical treatments are effective, but there is poor long-term compliance with medication, and many patients seek alternative treatments • Need favourable balance between efficacy & tolerability • Patient satisfaction & appropriate counselling • Safety in elderly patients with co-morbidities

47. Patient care pathway • Common condition • Can be diagnosed and treated in primary care • Inappropriate referral may occur • Cost implications • Implications to patient

48. Management of Overactive bladder Can we do better? Yes we can!!

49. Questions?