The Overactive Bladder

1. The Overactive Bladder Raji Gill, D.O., M.Sc. Clinical Assistant Professor of Surgery Division of Urology Tulsa Regional Medical Center & Cancer Treatment Centers of America

3. 2002 ICS Terminology: Overactive Bladder OAB defined based on symptoms • Urgency, with or without urge incontinence, usually with frequency and nocturia • In the absence of pathologic or metabolic conditions that might explain these symptoms ICS = International Continence Society (www.icsoffice.org)

4. OAB Symptoms • Frequency • 8 or more visits to the toilet per 24 hours • Urination at night • • 2 or more visits to toilet during sleeping hours • Urgency • Sudden, strong desire to urinate • Urge Incontinence • Sudden & involuntary loss of urine OAB

5. Types of Urinary Incontinence • Urge • urine loss accompanied by urgency resulting from abnormal bladder contractions • Mixed symptoms • combination of stress and urge incontinence • Stress • urine loss resulting from sudden increased intra-abdominal pressure (eg, laugh, cough, sneeze) Sudden increase in intra-abdominal pressure Uninhibited detrusor contractions Urethral pressure

7. Differential Diagnosis:OAB and Stress Incontinence Medical History and Physical Examination Symptom Assessment Overactive Symptoms Stress incontinence bladder Urgency (strong, sudden desire to Yes No void) Yes No Frequency with urgency (>8 times/24 h) No Yes Leaking during physical activity; eg, coughing, sneezing, lifting Amount of urinary leakage with Large Small (if present) each episode of incontinence Often no Yes Ability to reach the toilet in time following an urge to void Waking to pass urine at night Usually Seldom Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.

8. Estimated Prevalence of OAB in Comparison With Other Selected Chronic Conditions: 1990s Data Condition Millions of Americans Chronic Sinusitis 37 Arthritis 33 Heart Conditions* 21 OAB 17 Asthma 15 Osteoporosis 10 Diabetes 9 Alzheimer’s Disease 5 * Excludes hypertension Payne CK. Campbell’s Urology Updates. 1999;1:1-20. Evans DA et al. Milbank Q. 1990;68:267-289. Bureau of the Census, Population Estimate Data, 1995. National Institutes of Health. Osteoporosis and Related Bone DiseasesNational Resource Center. Osteoporosis Overview. National Center for Health Statistics. Vital Health Stat. 10(199):1998.

9. 40 Men 35 Women 30 25 Prevalence (%) 20 15 10 5 0 18–24 25–34 35–44 45–54 55–64 65–74 75+ Prevalence of OAB in the US • Overall, 16.6% had symptoms of OAB • Prevalence of OAB increased with age Age (years) Adapted from Stewart W et al. WHO/ICI 2001. Poster.

10. Prevalence of OAB: Wet versus Dry 12.2 million (6.1% of the population) Wet (37% of OAB) OAB Dry (63% of OAB) 21.2 million (10.5% of the population) Adapted from Stewart W et al. WHO/ICI 2001. Poster.

12. Diagnosis of OAB • A presumptive diagnosis of OAB can be based on • patient history, symptom assessment • physical examination • urinalysis • Initiation of noninvasive treatment may not require an extensive further workup Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; March 1996. AHCPR publication 96-0682.

13. A Hidden Condition* • Many patients self-manage by voiding frequently, reducing fluid intake, and wearing pads • Nearly two-thirds of patients are symptomatic for 2 years before seeking treatment • 30% of patients who seek treatment receive no assessment • Nearly 80% are not examined * Survey conducted by Gallup Group (European Study).

14. Barriers to Treatment • Patient misconceptions and fears: “Part of normal aging or everyday life” “Not severe or frequent enough to treat” “Too embarrassing to discuss” “Treatment won't help”

15. Screening andDiagnosing OAB • Assess history, symptoms, and test results • Establish a diagnosis “Do you have bladder problems that are troublesome, or do you ever leak urine?” YES

16. Local pathology infection bladder stones bladder tumors interstitial cystitis outlet obstruction Metabolic factors diabetes polydipsia Medications diuretics antidepressants antihypertensives hypnotics & sedatives narcotics & analgesics Other factors pregnancy psychological issues OAB Screening Can Help Diagnose Other Causes of Bladder Symptoms Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; March 1996. AHCPR publication 96-0682.

17. Differential Diagnosis:Physical Examination • Perform general, abdominal (including bladder palpation), and neurologic exams • Perform pelvic and/or rectal exam in females and rectal exam in males • Observe for urine loss with vigorous cough Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

18. Differential Diagnosis: Laboratory Tests • Urinalysis • to rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria • Blood work if compromised renal function is suspected or if polyuria (in the absence of diuretics) is present Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

19. Care Pathway Working diagnosis? Yes OAB? Yes No Treat if: Frequency and urgency, with or without urge incontinence, and normal urinalysis Consider referral to specialist >8 weeks tx Failed Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

20. Symptoms do not respond to initial treatment within 2 to 3 months Hematuria without infection on urinalysis Recurrent symptomatic UTI Symptoms suggestive of poor bladder emptying Pelvic bladder, vaginal, or urethral pain Evidence of complicated neurologic or metabolic disease Failed previous incontinence surgery Elevated PVR volume Radical pelvic surgery Symptomatic prolapse Prostate problems Surgery planned (2nd opinion) Suggested Reasons for Referral Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

21. Treatment Options • Behavioral therapy • Medication • Combined therapy: behavioral and pharmacologic therapy • Minimally invasive therapies • Botulinum A-toxin • Neuromodulation • Surgery

22. So when the Drug Rep. visits, which drug do I use?

24. Pharmacotherapy • Anticholinergic Agents • Oxybutynin (Ditropan) • Oxybutynin transdermal (Oxytrol) • Tolterodine (Detrol) • Solifenacin (Vesicare) • Trospium chloride (Sanctura) • Darifenacin (Enablex)

25. Oxybutynin (Ditropan) • Immediate and long acting form • Immediate – TID dosing • Long acting XL – once a day, 5 or 10 mg. • Side effects – dry mouth, constipation, headache • Approved for pediatric use (age 6 or older)

26. Oxybutynin Transdermal (Oxytrol) • 3.9 mg patch, twice weekly • Similar in effects to po • Side effects – less dry mouth but erythema/pruitis

27. Tolterodine (Detrol) • Immediate 2 mg. and long acting LA 4 mg dosing • Side effects profile similar to oxybutynin

28. Solifenacin (Vesicare) • 5 – 10 mg daily dose • Side effects – dry mouth, constipation

29. Trospium Chloride (Sanctura) • Quaternary amine as opposed to tertiary amine • 20 mg BID dose • Theoretically harder to pass through blood/brain barrier with less side effects • Not metabolized by liver • 60% excreted in the urine unchanged

30. Darifenacin (Enablex) • M3 selective anticholinergic • 7.5 mg or 15 mg once a day • Side effects – constipation and dry mouth