over-active bladder

• Learning outcomes


  • Relate previous knowledge of physiology/pharmacology of the GU system to the understanding of clinical situations of OAB
  • Describe, with named examples, the different treatment strategies, and their place in pharmaceutical care of GU disorders with symptoms of urinary retention and/or incontinence
  • Begin to critically appraise these treatment strategies, recognising the need for caution and potential for therapeutic failure with their application to the pharmaceutical care of (often elderly) patients
  • Be aware of the place of the evidence-base/clinical guidelines for management of these conditions in both women and men
• Overactive bladder (OAB) syndrome


  • The bladder, which is a bag made of muscle, contracts suddenly without control and when not full
  • A common condition where no cause can be found for the repeated and uncontrolled bladder contractions
  • Usually caused by muscles in the bladder wall overactivity; occurs in 65% of men with OAB
• Symptoms of OAB


  • Urinary frequency
  • Urgency
  • Nocturia
  • Enuresis
  • Urinary Incontinence
• In some cases, symptoms of OAB develop as a complication of a nerve- or brain-related disease such as following a stroke, Parkinson's disease, multiple sclerosis, or after a spinal cord injury
• OAB (wet)


  • Urgency AND urge incontinence with leakage on the way to the toilet
  • 2-3 times more prevalent in women than men
  • Affects more women in older age groups; symptoms reported by 2% aged 18-24 and 10x greater proportion in women aged 65-74 years
  • Associated with increased risk of falling and sustaining a fracture
• Risk factors for urinary incontinence in women

  • Age
  • Postmenopausal urogenital changes
  • Being overweight
  • Number of children
  • Poor obstetric care
  • Abnormalities of the urogenital system
  • Congenital female genital tract abnormalities
  • Pelvic organ prolapse; result of pelvic surgery/other disease
  • Obesity and other co-morbidities such as type 2 diabetes and chronic urinary tract infection can increase urgency symptoms
• Most elderly men have at least one LUTS; however, symptoms are often mild or not very bothersome
• Pelvic organ prolapse causes


  • Result of pelvic surgery
  • Other disease
• Co-morbidities that can increase urgency symptoms

  • Obesity
  • Type 2 diabetes
  • Chronic urinary tract infection
• Most elderly men have at least one Lower Urinary Tract Symptom (LUTS); however, symptoms are often mild or not very bothersome
• Benign prostatic enlargement (BPH) is a common cause of LUTs
• Other causes of LUTs

  • Neurological conditions (such as dementia and diabetic neuropathy)
  • Infection
  • Injury to the urethral area
  • Drugs (such as diuretics and antimuscarinics)
  • Cancer
• Red flag symptoms should be considered
• Conservative measures to control symptoms

  Should be attempted before any other therapy and encouraged throughout treatment
• Pharmacological treatment


  Should be considered within the context of all potential interventions
• OAB management


  1. Behavioural Therapies/techniques

  2. Pharmacological treatment
• First-line treatments for OAB

  • Bladder retraining
  • “double voiding”
  • Biofeedback
  • Pelvic muscle exercises
  • Pelvic Muscle Exercises
  • Bladder re-training
• Pelvic Muscle Exercises


  Physical therapy kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum
• Bladder re-training


  Frequent voluntary voiding; timed voiding, urge suppression techniques
• Lifestyle, Fluids And Diet

  1. Small changes to lifestyle may alleviate bladder frequency

  2. Drinking enough fluids to avoid bladder irritation/infection

  3. Patients should aim to drink normal quantities of fluid per day (about two litres)
• Lifestyle advice


  1. Limit intake of fizzy drinks, caffeine, and alcohol

  2. Trial of reduction in caffeine intake

  3. Advise patients with a body mass index over 30 to lose weight

  4. Smoking cessation

  5. Limit alcohol consumption
• Bladder training


  1. First-line treatment for a minimum of six weeks

  2. Involves pelvic muscle training, scheduled voiding intervals with stepped increases, and suppression of urge with distraction or relaxation techniques
• Before starting treatment with a medicine for OAB


  Explain likelihood of success, common adverse effects, time for substantial benefits, and uncertain long-term effects on cognitive function
• When offering anticholinergic medicines to treat OAB

  Take account of coexisting conditions and current use of other medications
• Long-term effects of anticholinergic medicines on cognitive function

  Uncertain
• Considerations when offering anticholinergic medicines to treat OAB

  Coexisting conditions (e.g. poor bladder emptying, cognitive impairment or dementia), Current use of other medicines affecting total anticholinergic load, Risk of adverse effects, including cognitive impairment
• Pharmacological intervention for first line OAB or mixed UI

  Antimuscarinics (anticholinergics) e.g. Oxybutynin, Tolterodine, Solifenacin, Adverse effects can limit treatment success, Constipation; dizziness; drowsiness; dry mouth; dyspepsia; flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders; vomiting, Can be reduced by starting low dose and gradually increasing until a satisfactory clinical response is achieved, Start low go slow especially in the elderly
• Pharmacological intervention if first treatment not effective or well-tolerated

  Offer another drug, Do not offer oxybutynin (immediate release) to frail older women, Offer a transdermal OAB drug to women unable to tolerate oral medication
• Pharmacological intervention for anticholinergic load or burden

  Anticholinergic load is the cumulative effect of taking medication with anticholinergic properties, Consider other drugs with significant antimuscarinic action, A high anticholinergic load can lead to physical and cognitive impairment in older adults
• Pharmacological intervention for Mirabegron

  Selective beta3 agonist, Licensed for treatment of urinary frequency, urgency, and urge incontinence associated with OAB, Recommended where antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects
• Pharmacological intervention for Desmopressin

  Considered specifically to reduce troublesome nocturia in women with UI or OAB, Particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension
• Pharmacological intervention for Duloxetine (SSRI)

  Do not use first-line for women with predominant stress UI, Do not routinely offer second-line as treatment for women with stress UI, unless women prefer pharmacological to surgical treatment or are not suitable for surgical treatment, Requires counselling on adverse effects
• Management of OAB in Older Women


  Associated with an increased risk of falls, hip fractures, anxiety/depression, social isolation, Leading to a significant reduction in quality of life
• Frailty and OAB


  Frailty is a decline in physiologic reserves that leads to increased susceptibility to adverse events, In addition to frailty being associated with a diagnosis of OAB, frail older adults are known to be at increased risk of night-time falls, making it particularly dangerous for them to get up at night to void, Frail older adults with OAB symptoms have a higher risk of morbidity when compared to asymptomatic older adults
• Shared decision making


  NICE recognise the important role families and carers have in supporting women with urinary incontinence
• Higher risk of morbidity when compared to asymptomatic older adults, making proper diagnosis and management of frailty a health priority
• Shared decision making


  Healthcare professionals should ensure that family members and carers are involved in the decision-making process about investigations, treatment, and care
• NICE recognises the important role families and carers have in supporting women with urinary incontinence
• When to ask about continence


  During structured medication reviews or with patients prescribed diuretics or hypnotics, other drugs with risk of falls or higher anti-cholinergic burden (ACB) scores
• How to ask about continence

  1. 'Are you having trouble controlling your bladder?'

  2. 'Do you leak urine when you cough & sneeze?'

  3. 'Do you leak on the way to the bathroom?'