Overactive bladder (OAB) is a common condition that affects millions of Americans. Overactive bladder isn’t a disease. It’s the name of a group of urinary symptoms. The most common symptom of OAB is a sudden urge to urinate that you can’t control. Some people will leak urine when they feel the urge.
Types of Overactive Bladder
Nocturnal polyuria – An individual’s body produces an excessive amount of urine during the night.
Global polyuria – An individual’s body produces too much urine during the day and night.
Low nocturnal bladder capacity– An individual’s bladder isn’t capable of holding as much fluid during the night.
Mixed nocturia – A combination of the aforementioned three types of nocturia.
It is also important to note that nocturia is different from bedwetting. One of the key signs of nocturia is that the individual is waking up more than once a night. The average healthy person can achieve six to eight hours of uninterrupted sleep, without having to get up for a bathroom break.
Sometimes nocturia results in voiding in bed if the person doesn’t wake up or make it to the restroom in time. However, some people with nocturia never wet the bed; they just deal with night after night of interrupted sleep. This compromised sleep hygiene is arguably just as bad, especially long-term!
Need Relief From Overactive Bladder Symptoms?
If you have an overactive bladder, do not despair. There are FDA-approved treatments that can help control your symptoms.
People with overactive bladder have a bladder muscle that squeezes too often or squeezes without warning. This can lead to troubling urinary symptoms such as:
The need to urinate too often (urinary frequency), which is defined as urinating eight or more times a day or two or more times at night (nocturia).
The need to urinate immediately (urinary urgency).
The involuntary leakage of urine as a result of the need to urinate immediately (urge urinary incontinence).
Frequency – The need to pass urine more than 8 times during the day.
Nocturia – The need to get out of bed at night to pass urine more than once.
Nocturnal Enuresis – Urinating during sleep.
Urgency – The sudden need to pass urine before reaching a toilet.
Coital incontinence – Leaking urine during sex.
These symptoms affect more than 33 million Americans. Many people don’t seek treatment, possibly because they’re embarrassed or don’t know about treatment options. In the United States, 30 percent of men and 40 percent of women live with overactive bladder symptoms.
Causes of Overactive Bladder
Some known causes of overactive bladder include neurological disorders, such as spinal cord injury, multiple sclerosis, Parkinson’s disease, and stroke. Often, however, the cause is unknown.
“Some conditions—such as urinary tract infection, early pregnancy, uncontrolled diabetes mellitus, prostate disease and bladder tumors—have symptoms similar to overactive bladder and should be excluded before a proper diagnosis can be made. Also, certain medications, especially diuretics, may cause overactive bladder symptoms,
It is not always easy to identify a common feature responsible for bladder over-activity, however the following are possible causes:
Urinary tract infection – a bacterial infection of the bladder/kidneys.
Outflow obstruction – men with benign prostatic obstruction may complain of symptoms of overactive bladder.
Neurogenic – those with conditions such as Parkinsons Disease, Multiple Sclerosis or those who have suffered a stroke may also develop overactive bladder.
Medicines – some medications may be associated with overactive bladder. These include diuretics, phenothiazides, opioids.
Alcohol/caffeinated beverages – can increase symptoms of OAB.
Options for Consumers
There are several treatment options for overactive bladder that help the bladder muscle relax and stop it from contracting at the wrong times. Easley says that anticholinergics are a widely used class of medications for overactive bladder. These drugs contain oxybutynin, tolterodine, fesoterodine or solifenacin, and are believed to work by inhibiting involuntary bladder contractions.
Recently, FDA approved Myrbetriq (mirabegron), a medication that improves the bladder’s ability to store urine by relaxing the bladder muscle during filling. (Side effects of Myrbetriq include increased blood pressure and urinary tract infection. In certain situations, Myrbetriq may increase your chances of not being able to empty your bladder on your own, for example, if you are also taking other medicines to treat your overactive bladder.)
For women 18 and older, there’s also a patch, called Oxytrol for Women, that is applied to the skin every four days. This over-the-counter patch is available without a prescription and delivers oxybutynin. For men, an oxybutynin patch is available by prescription only and is called Oxytrol. (Side effects of the Oxytrol patch include skin irritation, sleepiness, dizziness, confusion, hallucination and blurry vision.)
For adults who cannot use or do not adequately respond to anticholinergics, there are Botox (onabotulinumtoxinA) injections. Botox is injected directly into the bladder muscle under local or general anesthesia in a doctor’s office using a small camera that enables the urologist to see the inside wall of the bladder.
Testing for an overactive bladder
First, your doctor will take your medical history and ask about your symptoms. You may be asked to keep a bladder diary (a record of how much liquid you drink, how often you urinate, and any times you may have leakage).
A urinalysis will be able to tell if you have a urinary tract infection or bladder stones.
Urodynamics testing uses various tests to look at your urinary tract in more detail.
Bladder diary
Urine culture
Bladder scan
Cystoscopy
Urodynamic testing
Treatment
Your physician may suggest one or more options to treat an overactive bladder:
Bladder training, or urinating according to a timetable (instead of according to urge)
Kegel exercises to strengthen pelvic muscles
Dietary changes to avoid foods that trigger your symptoms
Medications, including hormone replacement therapy and anticholinergics (which prevent bladder spasms)
A pessary, a ring inserted into the vagina that helps support the bladder and uterus
Sacral nerve stimulation therapy, an electrical device to stimulate nerves, affecting signals to the bladder
Acupuncture, yoga and other alternative treatments
Overactive bladder medications
Medication brand (generic)
Dosage
Route
t1/2(hours)
Detrola (tolterodine tartrate)
2 mg or 4 mg bid vs daily
Oral
8
Ditropana (oxybutynin chloride)
5 mg, 10 mg, or 15 mg bid, tid, or daily
Oral
12–13b
Oxytrol (oxybutynin)
3.9 mg/d patch twice weekly
Transdermal patch
7–8b
Gelnique (oxybutynin)
3% three pumps (84 mg) daily and 10% one sachet (100 mg) daily
Transdermal gel
NA
Toviaz (fesoterodine)
4 mg or 8 mg daily
Oral
7–8b
Enablex (darifenacin hydrobromide)
7.5 mg or 15 mg daily
Oral
12
Vesicare (solifenacin succinate)
5 mg or 10 mg daily
Oral
45–68b
Sanctura (trospium chloride)
20 mg bid
Oral
18.3
Sanctura XR (trospium chloride)
60 mg daily
Oral
36
Myrbetriq (mirabegron)
25 mg or 50 mg daily
Oral
50
Notes:
aAvailable in short-acting and long-acting formulations.
bThis data is presented as range.
Abbreviations: bid, twice daily; d, day; NA, not available; t1/2, half life; tid, three times daily; XR, extended release.
Percutaneous tibial nerve stimulation (PTNS)
This is a non-surgical, low-risk treatment to consider if Kegel exercises and medication have failed to relieve urinary symptoms.
PTNS works by indirectly providing electrical stimulation to the nerves responsible for bladder and pelvic floor function.
During this office procedure, the patient’s foot will be elevated and supported, and a slim needle electrode will be placed near the tibial nerve at the ankle.
A device is then connected to the electrode that sends mild electrical pulses to the tibial nerve. These impulses then travel to the group of nerves at the base of the spine—the sacral nerve plexus—that are responsible for bladder function.
Promo block
This treatment stimulates the nerves through gentle electrical impulses, and this can lead to gradual changes in bladder activity over time.
Typically, patients will undergo a series of 12 weekly, half-hour sessions. Improvements with PTNS are typically noted five to six weeks later. Studies have reported that upwards of 80 percent of patients benefit from the procedure.
• Sacral neuromodulation
InterStim therapy is a proven neuromodulation therapy that targets the communication problem between the brain and the nerves that control the bladder.
Bladder function is regulated by a group of nerves at the base of the spine called the sacral nerve plexus. When those nerves are stimulated through gentle electrical impulses similar to that in a heart pacemaker, bladder overactivity can be calmed or eliminated.
The implantation of the InterStim device sends continuous impulses to the sacral nerve plexus, which inhibits urgency and spontaneous uncontrolled bladder activity.
Autonomic dysreflexia
Autonomic dysreflexia associated with intradetrusor injections of BOTOX® could occur in patients treated for detrusor overactivity associated with a neurologic condition and may require prompt medical therapy. In clinical trials, the incidence of autonomic dysreflexia was greater in patients treated .
Antimuscarinic (antispasomodic) medications
These medications reduce the number of involuntary bladder contractions by preventing spasm of the detrusor muscle that causes them, and increase bladder capacity. In general, these medications can reduce leakage of urine caused by OAB by 60% to 75%. Examples of antimuscarinic medications include:
The most common side effects of antimuscarinic medications are dry mouth, dry eyes, increased pressure inside the eye, and constipation. Be sure to tell your doctor about all of the medications you are taking and all of your medical conditions, as there are some people who should not take antimuscarinic medications. These side effects can be minimized bv starting with a low dose of medication and gradually increasing the dose.
Beta3-agonist
This is a new type of medication for the treatment of OAB. It helps relax the detrusor muscle (in the bladder wall) to prevent unwanted spasms that may cause symptoms of OAB. Currently there is only one drug in this category called “mirabegron”. An uncommon side effect of mirabegron is an increase in blood pressure. Be sure to tell your doctor about all of the medications you are taking and all of your medical conditions, as there are some people who should not take this medication.
Other medications
Medications known as tricyclic antidepressants (e.g., amitriptyline, imipramine) and calcium channel blockers (e.g., nifedipine, diltiazem) have been used with mixed results in the treatment of OAB. They may be prescribed for urinary incontinence, but this is an “off-label” or unapproved use and is not recommended.
Lifestyle interventions
The frequency–volume chart, or urinary diary, is an important tool in the investigation of patients with lower urinary tract symptoms and voiding dysfunction.[rx] This facilitates history taking regarding frequency, nocturia and volume voided, and has been shown to be valuable and reliable for the assessment of micturition patterns.9 There is poor correlation between subjective estimates of diurnal and nocturnal urinary frequency and objective charted measurements.[rx] Moderation of fluid intake to 1–1.5 litres per day reduces urine production and can ease symptoms. Alcohol, caffeine, and medication such as diuretics are major causes of acute incontinence, especially in the elderly.rx Drug regimens avoiding diuretics, control of chronic cough and constipation, cessation of smoking, exclusion or treatment of urinary tract infection, and weight reduction are desirable.
Behavioural therapy for detrusor overactivity was first reported by Jeffcoate and Francis who, in the 1960s, advocated the practice of voiding “by the clock” for urge incontinence.[rx] Treatment frequently consists of bladder re‐training by “bladder drill”, to re‐learn the cortical inhibition of detrusor contractions. This may be time consuming and frustrating—correct diagnosis is necessary to ensure maximum patient compliance with treatment. Behavioural modification improves central control of bladder function, avoiding the mortality and morbidity of surgery, and the side‐effects of drug treatment. However, this type of treatment requires high levels of motivation and encouragement, and suffers from high relapse rates.
Studies of “bladder drill” lack consistency in their nomenclature and methodology. However, in a review of the randomised clinical trials of conservative treatments, Berghams et al[rx] showed strong evidence that bladder drill is more effective than no treatment, and weak evidence that bladder drill is better then drug treatment. There is insufficient evidence, though, of the efficacy of bladder drill with drug treatment, bladder drill with pelvic floor exercises and biofeedback, or biofeedback and behavioural therapy, due to inadequate clinical trials.
Drug treatment
Oxybutynin
Oxybutynin is a tertiary amine that undergoes extensive first‐pass metabolism to an active metabolite, N‐desmethyl oxybutynin,[rx] which occurs in high concentrations[rx] and is thought to be responsible for a significant part of the action of the parent drug. It has a mixed action consisting of both an antimuscarinic and a direct muscle relaxant effect, in addition to local anaesthetic properties. The latter is important when given intravesically but probably has no effect when given systemically. Oxybutynin has been shown to have a high affinity for muscarinic receptors in the bladder[rx] and has a higher affinity for M1 and M3receptors over M2.[rx]
The effectiveness of oxybutynin in the management of patients with detrusor overactivity is well documented.
Extended release oxybutynin
More recently a controlled release oxybutynin preparation using an osmotic system (OROS) has been developed which has been shown to have comparable efficacy to immediate release oxybutynin, although associated with fewer adverse effects.[rx] These findings are in agreement with a further study of controlled release oxybutynin (Ditopan XL, Lyrinel XL) which reported the incidence of moderate to severe dry mouth to be 23%, with only 1.6% of participants discontinuing the medication due to adverse effects.[rx] A recent study, however, has also found that use of extended release oxybutynin in elderly subjects may impair recent memory.[rx]
Transdermal oxybutynin
In order to maximise efficacy and minimise adverse effects, alternative delivery systems are currently under evaluation. An oxybutynin transdermal delivery system (Kentera) has recently been developed and compared with extended release tolterodine in 361 patients with mixed urinary incontinence. Both agents significantly reduced incontinence episodes, increased volume voided and led to an improvement in quality of life when compared to placebo. The most common adverse event in the oxybutynin patch arm was application site pruritis in 14%, although the incidence of dry mouth was reduced to 4.1% compared to 7.3% in the tolterodine arm.rx]
Oxybutynin gel is also a new development currently being pursued.
Propiverine
Propiverine has been shown to combine anticholinergic and calcium channel blocking actions[rx] and is the most popular drug for detrusor overactivity in Germany, Austria and Japan. Open label studies in patients with detrusor overactivity have demonstrated a beneficial effect[rx]; in a double blind placebo‐controlled trial of its use in neurogenic detrusor overactivity it has been shown to increase bladder capacity and compliance significantly in comparison to placebo. Dry mouth was experienced by 37% in the treatment group as opposed to 8% in the placebo group, with dropout rates being 7% and 4.5%, respectively.[rx]
Tolterodine
Tolterodine is a competitive muscarinic receptor antagonist with relative functional selectivity for bladder muscarinic receptors[rx]; while it shows no specificity for receptor subtypes it does appear to target the bladder over the salivary glands.[rx] The drug is metabolised in the liver to the 5‐hydroxymethyl derivative, which is an active metabolite with a similar pharmacokinetic profile and is thought to contribute to the therapeutic effect.[rx]
Tolterodine is also available as an extended release once daily preparation, Detrusitol XL. A recent double blind multicentre trial of 1235 women compared extended release tolterodine to immediate release tolterodine and placebo and found that the extended release preparation was found to be significantly more effective.[rx] In addition to increased efficacy, extended release tolterodine has been shown to have better tolerability. In a double‐blind, multicentre, randomised placebo controlled trial of 1529 patients, extended release tolterodine was found to be 18% more effective in the reduction of episodes of urge incontinence while having a 23% lower incidence of dry mouth.[rx]
Comparative randomised controlled trials such as the OPERA (Overactive bladder: Performance of Extended Release Agents),[rx] OBJECT (Overactive Bladder: Judging Effective Control and Treatment)[rx]and ACET (Antimuscarinic Clinical Effectiveness Trial) study[rx] have confirmed its effectiveness.
Several randomised, double‐blind, placebo controlled trials, both on patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity, have demonstrated a significant reduction in incontinent episodes and micturition frequency.[rx] Further studies have confirmed the safety of tolterodine, and at the recommended daily dosage the incidence of adverse events was no different to that in patients taking placebo.[rx]
In addition, the safety and efficacy of tolterodine has also been compared to that of oxybutynin. These have suggested that although clinical efficacy is comparable for both drugs, oxybutynin was associated with higher withdrawal rates and a higher incidence of adverse events, notably dry mouth.[rx]
More recently tolterodine has also been developed as an extended release once daily preparation, Detrusitol XL.
Trospium
Trospium chloride is a quaternary ammonium compound which is non‐selective for muscarinic receptor subtypes, and shows low biological availability.[rx] It crosses the blood–brain barrier to a limited extent and hence would appear to have few cognitive effects.[rx] In a recent placebo‐controlled, randomised, double‐blind, multicentre trial trospium chloride produced significant improvements in maximum cystometric capacity and bladder volume at first involuntary contraction. Clinical improvement was significantly greater in the group receiving trospium and the frequency of adverse events was similar in both groups.[rx]Trospium chloride has also been compared to oxybutynin in a randomised, double‐blind, multicentre trial. With both agents there was a significant increase in bladder capacity, a decrease in maximum voiding detrusor pressure, and a significant increase in compliance although there were no statistically significant differences between the two treatment groups. Those taking trospium had a lower incidence of dry mouth (4% vs 23%) and were also less likely to withdraw (6% vs 16%) when compared to the group receiving oxybutynin.[rx]
Solifenacin
Solifenacin is a potent M3 receptor antagonist that has selectivity for the M3 receptors over M2 receptors and has much higher potency against M3 receptors in smooth muscle than it does against M3 receptors in salivary glands. Despite solifenacin expressing a higher potency than darifenacin in a model of inhibition of M3 receptor mediated calcium ion mobilisation in guinea pig colonic smooth muscle cells,[rx] it has been shown to be 40‐fold less potent than oxybutynin and 79‐fold less potent than tolterodine in its inhibition of salivary secretion[rx] as well as being more selective for the M3 receptor.
The clinical efficacy of solifenacin has been assessed in several multicentre, randomised trials at the dose of 5 mg and 10 mg once daily in patients with overactive bladder.[rx]
These studies suggest that solifenacin appears to be an effective treatment for OAB, with the most commonly reported adverse events being dry mouth, constipation and blurred vision.
Darifenacin
Darifenacin is a tertiary amine with moderate lipophilicity and is a highly selective M3 receptor antagonist, which has been found to have a fivefold higher affinity for the human M3 receptor relative to the M1receptor.[rx] Darifenacin is equipotent with atropine in the ileum and bladder and six times less potent at inhibiting muscarinic receptors in the salivary gland. Salivary responses are inhibited at doses 6–10‐fold higher than those required to inhibit bladder responses.
The efficacy of darifenacin has been investigated in multicentre studies.[rx] The most common adverse events were mild‐to‐moderate dry mouth and constipation with a central nervous system (CNS) and cardiac safety profile. Darifenacin was significantly superior to placebo for improvements in micturition frequency, bladder capacity, frequency of urgency, severity of urgency, and number of incontinence episodes leading to a change in clothing or pads. However, there was no significant reduction in nocturia.
Darifenacin has been launched in Europe and North America, and has just been licensed for use in the UK. Since it is the most M3 specific of the newer anti‐muscarinic agents, may offer a better balance between efficacy and unwanted effects.
Botulinum toxin (Botox)
There are seven immunologically distinct antigenic subtypes of botulinum toxin, of which type A is the most widely used. Botulinum toxin A (Botox) is a purified neurotoxin complex, which blocks the release of acetylcholine and other transmitters from presynaptic nerve endings. This results in decreased muscle contractility and muscle atrophy at the injection site. The produced chemical denervation is reversible as axons are regenerated in about 3–6 months. Botox cannot cross the blood–brain barrier and hence has no CNS side effects.
The minimal invasiveness of Botox‐A toxin injection in the bladder makes it attractive in the treatment of refractory detrusor overactivity. Studies have shown success rates between 26–80%.[rx], Data are lacking on dose, concentration, site, and number of injection and long term efficacy and side effects. A recent prospective, non‐randomised, ongoing study has evaluated the efficacy and safety of botulinum‐A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment.[rx] Eighty‐eight per cent of the patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p<0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1–2 weeks after botulinum‐A toxin injections. There were no severe side effects except temporary urine retention in four cases. Mean (SD) efficacy of duration was 6 (2) months.
Calcium channel blocking agents
Contractile activity in bladder smooth muscle is activated by the movement of extracellular calcium into the cell. Spontaneous and evoked contractile activity is mediated by membrane depolarisation and the movement of calcium into the smooth muscle cell through L‐type Ca2+ channels.[rx] The inhibition of the entrance of extracellular calcium with L‐type Ca2+ blocking agents, such as nifedipine, can prevent spontaneous and evoked contractile activity.[rx]
Nifedipine has been shown to reduce the frequency and amplitude of detrusor contractions,[rx] although these findings were not confirmed in a further study which found there was no significant effect on detrusor contractions.[rx] Similar contradictory findings have been reported regarding the use of flunarizine.6,59 Diltiazem has also been shown to significantly increase bladder capacity, lower bladder pressure and decrease the number of episodes of incontinence.[rx]
At present there is insufficient evidence to suggest that calcium channel blocking agents are effective in the treatment of detrusor overactivity, although the development of a selective calcium channel blocking agent which eliminates spontaneous contractions without affecting micturition may prove to be of use in the treatment of detrusor overactivity.
Other
Imipramine and other tricyclic antidepressants have been shown to have systemic anticholinergic effects[rx]and blocks reuptake of serotonin. Some authorities have found a significant effect in the treatment of patients with detrusor overactivity[rx] although others report little effect.[rx] Their role in detrusor overactivity remains of uncertain benefit, although they are often useful in patients complaining of nocturia and bladder pain. These must be used with caution in the elderly due to possible cardiac effects and an increase in falls.
Desmopressin (DDVAP)—synthetic vasopressin—has a potent antidiuretic effect, being used in the management of diabetes insipidus and nocturnal enuresis. More recently it has been shown to be effective in reducing nocturia in patients with both neuropathic and non‐neuropathic bladders.[rx] Recent studies have also demonstrated benefit in daytime urinary frequency and urinary incontinence.[rx]
Intravesical instillations of capsaicin, a neurotoxin extracted from red chilli peppers,rx] have significant effect over placebo in the treatment of neurogenic detrusor overactivity. Its analogue resiniferatoxin[rx] has been shown to have fewer side effects, with an increase in bladder capacity. However, the place of these neurotoxins in clinical practice is still uncertain.
Potassium channel opening agents
The opening of K+ ion channels in the membrane of the detrusor muscle cell results in an increase in K+movement out of the cell, resulting in membrane hyperpolarisation[rx] This reduces the opening probability of ion channels involved in membrane depolarisation and hence excitability is reduced.[rx] Three types of potassium channels have been identified in the detrusor muscle: ATP sensitive channels, calcium‐dependent large conductance channels; and calcium‐dependent large conductance channels.[rx] At present the relationship between each of these types of channels and the myogenic, neurogenic and micturition forms of detrusor contraction has not been determined. To date cromakalim, nicorandil and pinacidil have been investigated, although newer agents are currently under development.[rx]
Potassium channel openers are thought to be active during the bladder filling phase and, while abolishing spontaneous detrusor contractions, are not thought to affect normal bladder contractions. However, their clinical usefulness is limited by significant cardiovascular effects, with cromakalim and pinacidil being found to be up to 200 times more potent as inhibitors of vascular preparations than of detrusor muscle.[rx] In clinical trials assessing the use of these drugs in patients with detrusor overactivity, no bladder effects have been found at doses which already lower blood pressure.]rx] More recently newer drugs with KATP channel opening properties have been described,[rx] which may be useful for the treatment of bladder overactivity; however, at present, there is no evidence to suggest that K+ channel openers represent a viable treatment alternative. A recent randomised double‐blind study also failed to show any beneficial effect of potassium channel openers over placebo in patients with overactive bladder.[rx] Hence, more work is needed to establish the role of this form of therapy in OAB.
α‐Adrenoceptor antagonists
While it is well known that α‐adrenoceptor antagonists are useful in the treatment of benign prostatic hyperplasia in men,[rx] there are no clinical trials showing their efficacy in OAB. In addition, in women these drugs may exacerbate or result in stress incontinence.[rx]
β‐Adrenoceptor agonists
There is evidence that β‐adrenoceptor agonists increase bladder capacity in man.[rx] In a double‐blind study, clenbutorol was shown to have a good therapeutic effect in women with detrusor overactivity.[rx] Other studies have shown no effect in the elderly with detrusor overactivity [rx] or in the young with neurogenic detrusor overactivity.
Neurokinin antagonists
Neurokinins are widely distributed neuropeptides in both the central and peripheral nervous system. Some studies have confirmed the presence of NK2 receptors in human detrusor muscle.[rx] NK2 receptors may play a role in the pathophysiology of OAB, and NK2 receptor antagonists have been shown to reduce the frequency and amplitude in animal studies.[rx[ Hence these neurokinin antagonists may prove to be useful in the treatment of detrusor overactivity.
National guidelines from NICE
The National Institute for Health and Clinical Excellence (NICE) has recently published guidelines on the management of urinary incontinence in women. This can be downloaded from www.nice.org.uk/CG040. The guidelines for management of OAB are summarised below:
Assessment and investigation—At initial clinical assessment, incontinence should be categorised based on the patient’s symptoms and treatment should be directed towards the predominant symptom. Bladder diaries should be used in the initial assessment with a minimum of 3 days of the diary. The use of urodynamics is not recommended before conservative treatment.
Conservative management—Bladder training for a minimum of 6 weeks should be offered as first line treatment.
Drug treatment—Immediate release non‐proprietary oxybutynin should be offered as first line drug treatment if bladder training has been ineffective. If this is not well tolerated, darifenacin, solifenacin, tolterodine, trospium or an extended release or transdermal formulation of oxybutynin should be considered as alternatives. Women should be counselled about the side effects of antimuscarinic drugs.
Surgical management—Sacral nerve stimulation is recommended for women who have detrusor overactivity not responsive to conservative or medical treatment.
Competence of surgeons performing operative procedures for incontinence in women—Surgery for incontinence should only be undertaken by surgeons who have received appropriate training in the management of incontinence and associated disorders or who work within a multidisciplinary team with this training and who regularly carry out this form of surgery.
Surgery
Many different surgical treatments have been tried in the management of detrusor overactivity, but few are still in regular use today. Abandoned procedures include bladder distension, vaginal denervation, bladder transection, and sacral neurectomy. Their demise was caused by an unacceptably high rate of complications and limited efficacy.
Surgical solutions for detrusor overactivity include sacral neuromodulation, detrusor myectomy, augmentation cystoplasty, or urinary diversion.
Sacral neuromodulation
Stimulation of the S3 nerve root by an implanted electrical pulse generator can provide effective relief from frequency‐urgency symptoms. In a prospective randomised trial of sacral neuromodulation versus delay, incontinence episode frequency (IEF), severity, and pad use were all reduced in the active arm (p<0.0001); 47% were dry, and 29% reported a reduction in IEF of more than 50% at 6 months.[rx]Neuromodulation is, however, very expensive. Patients need expert assessment, and management—although it is not suitable for routine use, sacral neuromodulation appears to be useful for a selected minority. The stimulator is a small electrical pulse generator, approximately the same size as a cardiac pacemaker, and is commonly implanted in the upper outer quadrant of the buttock. Complications most commonly reported are generator site pain (15.9%) and implant site pain (19.1%). Lead migration may occur in up to 7%. The surgical revision of technical failures and complications was 32.5%. This may be expected to reduce in the future as the technological development of generators and implant leads progresses.
Clam augmentation cystoplasty
Augmentation cystoplasty is used to increase the size of the urinary reservoir and render the bladder less contractile. It is indicated in patients who lack adequate bladder capacity or detrusor compliance; who manifest debilitating frequency‐urgency symptoms, with urge incontinence, urinary tract infections; who have failed to derive benefit from medical treatment; whose lifestyle is severely limited; or with high pressure urine storage endangering the upper renal tracts.
The operation most frequently used is the “clam” cystoplasty. In this procedure,[rx] the bladder is bisected almost completely and a patch of gut (usually ileum) equal in length to the circumference of the bisected bladder (about 25 cm) is sewn in place. This often cures the symptoms of detrusor overactivity[rx] by converting a high‐pressure system into a low‐pressure system, although inefficient voiding may result. Patients have to learn to strain to void, or may have to resort to clean intermittent self‐catheterisation, sometimes permanently. In addition, mucus retention in the bladder may be a problem, but this can be partially overcome by ingestion of 200 ml of cranberry juice each day[rx] in addition to intravesical mucolytics such as acetylcysteine. The chronic exposure of the ileal mucosa to urine may lead to malignant change.[rx] There is a 5% risk of adenocarcinoma arising in ureterosigmoidostomies, where colonic mucosa is exposed to N‐nitrosamines found in both urine and faeces, and a similar risk may apply to enterocystoplasty. Biopsies of the ileal segment taken from patients with “clam” cystoplasties show evidence of chronic inflammation of villous atrophy, and diarrhoea caused by disruption of the bile acid cycle is common.[rx] This may be treated using cholestyramine. In addition, metabolic disturbances such as hyperchoraemic acidosis, B12 deficiency and occasionally osteoporosis secondary to decreased bone mineralisation may occur.
Detrusor myectomy
Detrusor myectomy offers an alternative to clam cystoplasty by increasing functional bladder capacity without the complications of bowel interposition. In this procedure the whole thickness of the detrusor muscle is excised from the dome of the bladder, thereby creating a large bladder diverticulum with no intrinsic contractility.[rx] While there is a reduction in episodes of incontinence there is little improvement in functional capacity and thus frequency remains problematic.[rx]
Urinary diversion
As a last resort for those women with severe detrusor overactivity or neurogenic detrusor overactivity who cannot manage clean intermittent catheterisation, it may be more appropriate to perform a urinary diversion. Usually this will utilise an ileal conduit to create an abdominal stoma for urinary diversion. An alternative is to form a continent diversion using the appendix (Mitrofanoff) or ileum (Koch pouch) which may then be drained using self‐catheterisation.
The Complete Nighttime Guide to an Overactive Bladder
If you are part of the approximately 16-18% of the population who suffers from overactive bladder syndrome (OAB), you already know how badly it can interfere with your life. From the embarrassment of an incident to the exhaustion after a poor night’s sleep, anyone experiencing the effects of OAB is likely seeking to remedy them. And that’s exactly what this nighttime guide to overactive bladder will cover!
Overactive Bladder and Sleep
“[OAB] can disrupt sleep completely, and people can be extremely overtired,” said Luis Sanz, MD, director of urogynecology and pelvic surgery at Virginia Hospital Center.
We tend to think of wet sheets as the worst potential effect of nocturia, but endless nights of interrupted sleep and the ensuing days of exhaustion can start to feel just as bad– even if you never wet the bed. Many of us tend to dismiss being “tired” as a common thing in our modern society, or even herald it as a side effect of being busy and successful, but long term sleep deprivation is a serious issue.
Not only can OAB interfere with your general wellbeing, it can interfere with your sexual wellbeing too. Losing control of your bladder as an intimate evening starts to unfold can certainly pull the plug on the moment. This is a common experience for people with OAB, because sexual activity itself is irritating to the bladder. Luckily, most of the preventative measures that help with OAB in general will also help in regard to sex!
Preventative Measures
When it comes to overactive bladder, your best offense is often a well-prepared defense. Here are some things you can do to help decrease the effects of your condition.
Bladder-Approved Nutrition
As with any health-related issue, it’s best to build the plan of attack on a sound foundation. This sound foundation includes good nutrition and avoiding the foods you shouldn’t eat if you have OAB.
Here are some of the foods and beverages known to irritate your bladder:
Alcohol
Artificial sweeteners
Caffeine – a diuretic that increases urine output
Chocolate
Citrus juices – since they are acidic
Cranberry juice – a surprising culprit that can be good for bladder health in those not affected, but is actually an irritant for individuals with OAB
Honey
Tea – if it’s caffeinated or is made with any other potential irritants
Tomato juice or sauce
One thing to be especially vigilant about is whether a food is okay for your condition, even if it’s a “healthy” food overall. Options like unsweetened fruit juices, tomatoes, and other acidic foods and drinks may be good for the average person, but are irritants for you and your bladder. It’s always good to do a quick internet search on which foods are acidic and to talk to your doctor about nutrition.
No Smoking, Please!
Another big irritant is nicotine. You likely already know that smoking isn’t good for you, but if you do happen to smoke, this is yet another reason to quit. Remember not to be ashamed if you’ve tried to quit before and have failed. It’s not easy, but you can do it!
We recommend talking to your doctor about quitting methods and giving it another attempt. You never know if this one change will be what cures your OAB; it has definitely made a big difference for some patients in the past.
Keep Up the Kegels
If you’re a little overwhelmed by all the “don’ts,” here is a “do”!
Do Kegel exercises regularly to help control your OAB. As you might already know, Kegels are done by contracting and then releasing the muscles around your urethra’s opening. If you’ve never done one before, try stopping your urine stream next time you use the restroom. This is what a Kegel feels like.
Not only can doing Kegels regularly help you build strength over time, doing one when you have the sudden urge to go can also help you control your bladder as you seek out the next bathroom.
Daytime Hydration
This might be the least predictable tip of them all: drink water! Though hydrating too much at night is of course a bad idea (we will get further into that in the next section), drinking enough over the course of the day is a good idea. Drinking too little water will cause your urine to become more concentrated, which can then actually irritate the bladder from the inside out. Having insufficient amounts of fluid in your body can also promote bacteria growth, which can in turn trigger incontinence.
Your Evening Routine
Now that you have some tips and tricks for day-to-day life, let’s get into evening specifics. There are two simple steps that can make a big difference.
The Double Void Trick
If you’ve just started having bladder troubles, perhaps you haven’t previously thought much about when that last bathroom trip of the evening happens. Maybe it’s before brushing your teeth. Maybe when you turn off the TV or finish the dinner dishes or whatever marks the end of your day and beginning of your “winding down” routine. Perhaps you don’t go again after your nighttime routine.
Now that you are battling OAB, try the double-voiding trick instead of just urinating sometime in the evening. Double-voiding involves urinating twice right before bed. Use the restroom once, then brush your teeth and go through your routine. Use the restroom again right before going to bed, even if you don’t feel like it or your bedtime routine only took five minutes. Even squeezing out a last couple drops can help.
Your Fluid Cut-Off Time
Often, we make the mistake of forgetting to drink water during the day and then trying to catch up at night. It makes sense that people get into this habit; days are filled with work, errands, volunteering, and countless activities, while evenings are more of a time to wind down… and sip some glasses of water.
Try to be aware of your hydration timeline and whether you’ve fallen into this habit. If so, turn that routine on its head! Hydrating during the day but not drinking any liquids after 5 or 6 pm is a good idea for anyone who struggles with nocturia.
This cut-off time is a good rule of thumb for irritants as well as liquids. If you’re like most people, it probably sounds rough to never again drink a fresh squeezed fruit juice, eat pasta with tomato sauce, or enjoy a chocolate bar. On days you want to indulge, try to have that fruit juice in the morning, eat the pasta for lunch, or have your chocolate in the early afternoon. And try not to do all those things in the same day!
OAB “Safety Nets”
Perhaps you’re already taking all of those preventive measures, but still have an overactive bladder. That’s when the safety nets come into play.
Absorbent Briefs
The technology that goes into absorbent briefs has come a long way, and many look as discreet as regular underwear. Slipping one on at night can do a lot to protect your mattress and ease your mind.
Plastic Sheets
Plastic sheets or vinyl covers aren’t always the most comfortable, but they can be highly effective. These options are affordable, not to mention quick and easy to wipe down.
Mattress Covers
Mattress covers and protectors can be a great option as well. Unlike the plastic options, mattress covers are often made from softer terry material and are less noticeable. They are sometimes also less affordable, but are a good investment to make in your health and hygiene, not to mention that they protect a mattress likely costing far more.
Bed Pads
If you sleep like a rock and are more vulnerable to nighttime voiding than waking up, a bed pad might be your new best friend. Bed pads tend to be an optimal match for people who don’t move much in their sleep. The waterproof pads simply slip underneath your body toward the middle of the mattress (above the sheets). If anything happens, all you need to wash is the pad. If nothing goes wrong, you can store it for the day or simply make your bed over it.
Catheter
This is probably the most extreme-sounding option but is great for some people. A catheter doesn’t technically require a prescription, but we do recommend talking to your doctor before trying one out. He or she will be able to advise whether or not a catheter is necessary in your specific case.
Medications to treat Overactive Bladder
The following list of medications are in some way related to, or used in the treatment of this condition.
Classification of drugs
Most drugs used to treat overactive bladder are muscarinic antagonists.
Comparison of drugs
Comparison of overactive bladder medication
agent
traits
Oxybutynin (short-acting)
well-known by physicians
available in market longer than other drugs for OAB
many studies provide support of effectiveness
available as generic in places including the United States
more side effects than alternatives, including dry mouth and constipation
severe dry mouth more often reported
user takes 2-3 pills a day
Oxybutynin (extended release)
fewer side effects than short-acting Oxybutynin
1 pill per day
Oxybutynin (transdermal patch)
no pill
the patch changed every 3–4 days
lower rate of dry mouth as compared to pill form
patch commonly causes skin irritation which can be severe
Oxybutynin (Topical medication)
fewer side effects than short-acting Oxybutynin
topical gel applied to abdomen, arms, or thighs daily
new on market
little existing research on this drug
Tolterodine (short-acting)
fewer side effects than short-acting Oxybutynin
2 pills per day
10% of Caucasians and 19% of black people have a genetic difference which causes them to lack a certain enzyme. Lack of this enzyme makes the drug less effective.
Tolterodine (extended release)
fewer side effects than short-acting Oxybutynin
1 pill per day
10% of Caucasians and 19% of black people have a genetic difference which causes them to lack a certain enzyme. Lack of this enzyme makes the drug less effective.
Solifenacin
1 pill per day
More effective for some symptoms than Tolterodine
higher rates of constipation and dry mouth than tolterodine
less researched for safety and efficacy than Tolterodine and Oxybutynin
Trospium (short acting)
severe dry mouth less common than with oxybutynin
less researched for safety and efficacy than Tolterodine and Oxybutynin
Trospium (extended release)
1 pill per day
little existing research on this drug
Darifenacin
1 pill per day
less researched for safety and efficacy than Tolterodine and Oxybutynin
Fesoterodine
same metabolite as Tolterodine, but does not require that enzyme to be active
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