Overactive bladder

When The Bladder Becomes Too Active – A Case Of “Overactive Bladder”

In the urology clinic, very often we will see patients who complained of urinary frequency and urgency. They need to go to the toilet every hour or so. This makes lfe very difficult for them as they cannot cope in their work.

Furthermore, this is also very embarrassing and they will shy away from social activities with their friends. They do not want to be seen to visit the toilet all the time while having a meal or gathering with their friends.

Some patients even have to wake up many times at night to pass urine. This will disturb their sleep thus making them very tired during daytime. They therefore could not focus on their daily work.

In the more serious cases, urinary leakage occurs. This is called urinary incontinence. These patients have to wear protective pads or diapers to avoid embarrassment. The quality of life is adversely affected by this predicament.

Overactive Bladder (OAB)

These patients suffer from a condition called overactive bladder. The technical definition for this condition is “urinary urgency, with or without urge incontinence, usually with frequency and nocturia”. This encompasses all the symptoms we described above. The main symptom being the patient having a sensation of urinary urgency, i.e. a feeling that he or she needs to go to the toilet to empty the bladder. The other associated symptoms with this sensation are urinary frequency, nocturia (having to wake up to pass urine at night) and urinary incontinence.

How Common Is This Condition?

Is this condition common? In a study in Asian women in 11 countries, including Malaysia, the prevalence is found to be 53%. The subjects presented with various symptoms of urinary urgency, frequency, nocturia and incontinence. This percentage is of course very high as it depends on the age and population studied. It is generally accepted that the prevalence is about 12 % and increasing with age.

A few factors were found to be associated with OAB. These included increasing age, multiparity, positive family history of OAB, use of sitting toilet and residence in rural area.

In another study in Northern Peninsular Malaysia, it was found that the areas most affected by these urinary problems are sleep and energy. However, a lot of patients do not seek treatment from doctors as they thought it is not a major health problem and accept this condition as it is.

This issue of patients not seeking treatment has to be addressed as there are ways to tackle this problem. Furthermore, the patient’s quality of life and productivity will be adversely affected if this condition is left alone untreated.

How Is OAB Diagnosed? 

Nowadays doctors are more familiar with OAB and will be able to help in the diagnosis and treatment.

The doctor will get a history from the patient to assess the main symptoms and their impact on the daily life of the patients. Clinical examination will also be done by the doctor to make sure that nothing sinister is missed.

For investigation, a urinalysis is a must to look for other causes that could mimic OAB such as bladder infection (cystitis), bladder cancer etc. Further investigation such as ultrasound will be ordered if necessary based on the clinical assessment by the doctor.

Very often, the doctor will ask the patient to keep a bladder diary. This simple record is very helpful for the doctor to assess the urinary problem. To do a proper bladder diary, the patient is asked to record the time of passing urine and the amount of urine passed each time. With that, there will be a 24-hour record of the urinary pattern of the patient. It is useful for the patient to record this 24-hour pattern for at least 3 days. With this record (bladder diary), the doctor will be able to see how serious the problem is.

If no other sinister problem is identified, and the patient has persistent urinary urgency, with or without urge incontinence, and urinary frequency and nocturia, then OAB is the most likely diagnosis.

How To Treat OAB?

The first step in treatment of OAB is actually not taking medicine. There are many lifestyle modifications that can be made to improve the condition. The fluid intake record is important. Some patients simply take in too much water thinking that taking a lot of water is good. Taking a lot of water is of course good but taking too much will be of no use and it will produce overproduction of urine with its consequence of urinary frequency, urgency and nocturia.

The next step is to assess the intake of caffeine. Drinks like coffee, tea and cola all contain caffeine. Excessive caffeine intake will stimulate the bladder wall muscles. This will produce symptoms of urinary urgency, frequency and nocturia. Therefore, if a patient suffers from OAB, the intake of caffeine-containing drinks should be reduced. Also de-caffeinated drinks could be used as a replacement.

Another commonly recommended method of treatment is bladder training. This simple maneuver involves asking the patient to try to hold on when he/she feels the sensation to pass urine. At the beginning, the patient will try to hold on for an extra 5 minutes. Later this time period could be increased to 10, 15 minutes and so on.

Is There A Medicine For OAB? 

If simple lifestyle modification and bladder training fail to improve symptoms, then medical therapy could be tried.

The kind of medicine used belongs to a group of drug called anticholinergics. They act to block the nerve stimulation to the bladder that induces bladder contraction. With this blockage, the bladder will be ‘calmer’ and less likely to contract unnecessarily. The symptoms of urinary urgency, frequency and nocturia will thus be reduced.

The traditional anticholinergic is oxybutynin. There are also a few drugs available now in the market such as tolterodine, solifenacin, trospium etc. The newer medicine has less side effects compared to older generation of anticholinergics.

The common side effects of anticholinergics are dry mouth, dry eye and constipation. With newer medicine, these side effects are more tolerable.

There is one important thing to keep in mind before the doctor prescribes anticholinergics: patient who has glaucoma cannot be prescribed anticholinergic as this will make their condition worse. Otherwise, this medicine is quite safe to be taken.

Many clinical trials had proven the efficacy of anticholinergic in improving various symptoms associated with OAB.

What Happen If Symptoms Persist After Anticholinergic Medication?

This is a more challenging clinical scenario. Patients who failed to respond to anticholinergic medication need to be referred to the urologist for further assessment.

In refractory cases, many other methods had been tried to reduce the pressure in the bladder, such as botox injection into the bladder muscle (yes, this is the same botox that people use to make their faces look beautiful), augmentation of the bladder (surgical procedure that stiches a piece of small bowel into the bladder to increase the bladder capacity) etc.

Fortunately, these cases are very rare. Most patients will respond to simple lifestyle modification and anticholinergic. Therefore, if you have disturbing symptoms suggestive of OAB, it is worthwhile to seek an opinion from your doctor. You do not have to suffer in silence. As you can see, there is a solution to this problem. 

Written by Dr Ong Teng Aik. Last review: August 2013.

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