Overactive bladder (OAB) facts

• Overactive bladder is an involuntary and sudden contraction of the muscle in the wall of the urinary bladder.
• Overactive bladder can also result in urinary incontinence, otherwise termed urge incontinence (wet OAB).
• Overactive bladder is not a normal part of aging.
• OAB affects both men and women and can significantly impact the quality of life.
• Many treatments are available for overactive bladder, including pelvic-muscle strengthening, behavioral therapies, medications, neuromodulation, and surgery.

What is an overactive bladder?

Overactive bladder (OAB) is a condition that is characterized by sudden, involuntary contraction of the muscle in the wall of the urinary bladder. This results in a sudden and unstoppable need to urinate (urinary urgency), even though the bladder may only contain a small amount of urine. Key features are the sudden urge to void along with urinary frequency (voiding < 2 hour intervals). Irritating fluids, such as caffeinated beverages (coffee, tea), spicy foods, and alcohol can worsen the symptoms. It is common for those affected to compensate for OAB by toilet mapping, fluid restriction, and timed voiding. There is no pain, burning, or blood in the urine with OAB.

Overactive bladder coupled with urinary leakage (inability to suppress the urge to void) is also referred to as urge incontinence and is a form of urinary incontinence (unintentional loss of urine). Another common type of urinary incontinence is called stress incontinence, which is caused by anatomic weakness in the structures that prevent the bladder from leaking. Such patients will leak with coughing, straining, jumping, or other physical activity that contracts the abdominal muscles. Treatment for stress incontinence is very different than urge incontinence. Stress incontinence is treated with methods that support the weakened support structures, including Kegel exercises, urethral bulking agents, and urethral mesh surgery to strengthen the pelvic floor muscles. In some, there can be a combination of urge and stress incontinence (mixed incontinence). In general, urinary incontinence is more common in women compared to men.

• Feel a sudden urge to urinate that's difficult to control
• Experience unintentional loss of urine immediately after an urgent need to urinate (urgency incontinence)
• Urinate frequently, usually eight or more times in 24 hours
• Wake up more than two times in the night to urinate (nocturia)

Even if you are able to get to the toilet in time when you sense an urge to urinate, unexpected frequent urination and nighttime urination can disrupt your life.

How a healthy bladder works 

Your urinary system includes the kidneys, ureters, bladder and urethra. The urinary system removes waste from the body through urine. The kidneys are located toward the back of the upper abdomen. They filter waste and fluid from the blood and produce urine. Urine moves from the kidneys through narrow tubes to the bladder. These tubes are called the ureters. The bladder stores urine until it's time to urinate. Urine leaves the body through another small tube called the urethra.

Male urinary system

Your urinary system includes the kidneys, ureters, bladder and urethra. The urinary system removes waste from the body through urine. The kidneys are located toward the back of the upper abdomen. They filter waste and fluid from the blood and produce urine. Urine moves from the kidneys through narrow tubes to the bladder. These tubes are called the ureters. The bladder stores urine until it's time to urinate. Urine leaves the body through another small tube called the urethra.

The kidneys produce urine, which drains into your bladder. When you urinate, urine passes from your bladder through a tube called the urethra (u-REE-thruh). A muscle in the urethra called the sphincter opens to release urine out of the body.

In women, the urethral opening is located just above the vaginal opening. In men, the urethral opening is at the tip of the penis.

As your bladder fills, nerve signals sent to your brain eventually trigger the need to urinate. When you urinate, these nerve signals coordinate the relaxation of the pelvic floor muscles and the muscles of the urethra (urinary sphincter muscles). The muscles of the bladder tighten (contract), pushing the urine out.

Involuntary bladder contractions

Overactive bladder happens when the muscles of the bladder start to contract on their own even when the volume of urine in your bladder is low. These are called involuntary contractions, and they create an urgent need to urinate.

Several conditions may contribute to signs and symptoms of overactive bladder, including:

• Neurological disorders, such as stroke and multiple sclerosis
• Diabetes
• Urinary tract infections that can cause symptoms similar to those of an overactive bladder
• Hormonal changes during menopause in women
• Conditions affecting the bladder, such as tumors or bladder stones
• Factors that get in the way of urine leaving the bladder, such as enlarged prostate, constipation or previous surgery to treat incontinence

Overactive bladder symptoms may also be associated with:

• Medications that cause your body to make a lot of urine or require that you take them with lots of fluids
• Drinking too much caffeine or alcohol
• Declining cognitive function due to aging, which may make it more difficult for your bladder to understand the signals it receives from your brain
• Difficulty walking, which can lead to bladder urgency if you're unable to get to the bathroom quickly
• Incomplete bladder emptying, which may lead to symptoms of overactive bladder, as you have little urine storage space left

The specific cause of an overactive bladder may be unknown.

The treatment for overactive bladder depends on the capabilities of the patient. Generally, treatment can be behavioral retraining, pharmacological (medications), and surgical.

Here are commonly recommended treatments.

Pelvic muscle rehabilitation to improve pelvic muscle tone and prevent leakage

• Kegel exercises: Regular, daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful for younger women. These exercises should be performed 30-80 times daily for at least eight weeks. These exercises are thought to strengthen the muscles of the pelvis and urethra, which can support the opening to the bladder to prevent incontinence. Their success depends on practicing the proper technique and the recommended frequency.
• Biofeedback: Used in conjunction with Kegel exercises, biofeedback helps people gain awareness and control of their pelvic muscles.
• Vaginal weight training: Small weights are held within the vagina by tightening the vaginal muscles. These exercises should be performed for 15 minutes, twice daily, for four to six weeks.
• Pelvic-floor electrical stimulation: Mild electrical pulses stimulate muscle contractions. This should be done in conjunction with Kegel exercises.

Behavioral therapies to help people regain control of their bladder

• Bladder training teaches people to resist the urge to void and gradually expand the intervals between voiding.
• Toileting assistance uses routine or scheduled toileting, habit-training schedules, and prompted voiding to empty the bladder regularly to prevent leaking.

What is the role of medications in treating overactive bladder?

There are several medications recommended for the treatment of overactive bladder. Using these medications in conjunction with behavioral therapies has shown to increase the success rate for the treatment of overactive bladder.

The main goals of OAB treatment are to

1. reduce urinary urgency and frequency,
2. increase voided volume (bladder capacity),
3. decrease urge incontinence (reduce leakage episodes).

Typically, the medications for overactive bladder start to work within one to two weeks, and optimal relief of OAB symptoms is achieved by 12 weeks. The most common medications (anticholinergics) target to decrease the overactivity of the detrusor muscle. Anticholinergics should be used under the direction of the physician prescribing them. They may have some common side effects, including dry mouth, constipation, blurry vision, and confusion (in the elderly). Here is a list of the most commonly recommended medications for overactive bladder.

Anticholinergic class

• Oxybutynin (Ditropan) prevents urge incontinence by relaxing the detrusor muscle. This is typically taken two to three times a day (Ditropan XL is extended release, taken once a day). This medication was the first-generation therapy available, and its main side effects include dry mouth (60%) and constipation. Ditropan patch (Oxytrol) is also available with fewer side effects, but it releases a smaller dose than the oral form. The patch is placed on the skin once to twice weekly, and it may cause some local skin irritation.
• Tolterodine (Detrol, Detrol LA) is indicated for the treatment of an overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence. This medication affects the salivary glands less than oxybutynin, thus, it is better tolerated with fewer side effects (dry mouth). Detrol is usually prescribed twice a day, whereas the long-acting type (Detrol LA) is taken only once a day.
• Solifenacin (Vesicare) is a relatively newer medication in this group. It is generally similar to tolterodine, but it has a longer half-life and needs to be taken once a day.
• Darifenacin (Enablex) is also a newer anticholinergic medicine for treating overactive bladder with fewer side effects, such as confusion. Therefore, it may be more helpful in the elderly with underlying dementia. This medication is also typically taken once a day.
• Fesoterodine fumarate (Toviaz) is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. The medication is taken once daily. Common side effects include constipation and dry mouth.

B3-Agonist class

• Mirabegron (Myrbetriq) is a new type of medication to treat overactive bladder that is not an anticholinergic and can be used alone or with anticholinergic medications. The side effects include increased blood pressure, incomplete bladder emptying, sinus irritation, constipation and dry mouth (< 2%-3%).

Botox injection class

• OnabotulinumtoxinA (Botox) is injected directly into the bladder muscle with a cystoscope and may be repeated every four to six months. Serious side effects are unusual but may include difficulty breathing, difficulty swallowing, difficulty talking, muscle weakness, urinary tract infection, and urinary retention.
• Estrogen, either oral or vaginal, may be helpful in conjunction with other treatments for postmenopausal women with urinary incontinence.

Neuromodulation is a newer method of treating overactive bladder with electrical stimulation that results in reorganization of the spinal reflexes involved in bladder control. There are two types of neuromodulation available: percutaneous tibial nerve stimulation (PTNS) and sacral neuromodulation (Interstim).

Surgery is rarely necessary in treating overactive bladder unless symptoms are debilitating and unresponsive to other treatments. Reconstructive bladder surgery (cystoplasty) is the most common surgical procedure. This surgery involves enlarging the size of the bladder by using part of the intestine.

What are treatments for the chronically incontinent?

Although many people will improve their continence through medications, pelvic-muscle exercises, and bladder training, some will never achieve complete dryness. Sometimes treatment failures are due to concurrent use of other necessary medications, such as diuretics (water pills that increase urination), that actually can cause incontinence. Others may have dementia or other physical impairments that keep them from being able to perform pelvic-muscle exercises or retrain their bladders. Many will be cared for in long-term care facilities or at home. The following recommendations can help keep the chronically incontinent drier and reduce their cost of care:

• Scheduled toileting (timed voiding): Take people to the toilet every two to four hours or according to their toilet habits.
• Prompted voiding: Check for dryness and encourage use of the toilet.
• Improved access to toilets: Use equipment such as canes, walkers, wheelchairs, and devices that raise the seating level of toilets to make toileting easier.
• Managing fluids and diet: Behavioral modifications can directly impact symptoms of OAB. These include eliminating dietary caffeine, alcohol, and spicy foods (for those with urge incontinence) and encourage adequate fiber in the diet.
• Disposable absorbent garments: Use these to keep people dry.

What measures can be taken at home to prevent overactive bladder symptoms?

There are simple steps that can reduce symptoms of overactive bladder. For example, caffeine may exacerbate urinary urgency and it is potentially an irritant to the bladder. Eliminating caffeine intake can diminish some of the symptoms of overactive bladder.

Some experts suggest that avoidance of certain foods, such as chocolate, spicy foods, alcohol, carbonated beverages, and nuts, can be beneficial in preventing symptoms of overactive bladder. Others encourage increasing the amount of dietary fiber for people with overactive bladder. Limiting fluid intake can also help to reduce urinary frequency.

Excess weight can put more pressure on the bladder, causing urinary incontinence. Therefore, weight loss can also help with urinary incontinence in general.

As you age, you're at increased risk of developing overactive bladder. You're also at higher risk of diseases and disorders, such as enlarged prostate and diabetes, which can contribute to other problems with bladder function.

Many people with cognitive decline — for instance, those who have had a stroke or have Alzheimer's disease — develop an overactive bladder. Incontinence that results from situations like this can be managed with fluid schedules, timed and prompted voiding, absorbent garments, and bowel programs.

Some people with an overactive bladder also have bowel control problems; tell your doctor if this is a problem for you.

Cure/medications for Overactive bladder (OAB):

1. After menopause, vaginal estrogen therapy can help strengthen the muscles and tissues in the urethra and vaginal area. Vaginal estrogen comes in the form of cream, suppository, tablet, or ring and can significantly improve symptoms of overactive bladder.

2. Medications that relax the bladder can be helpful for relieving symptoms of overactive bladder and reducing episodes of urge incontinence. These drugs include:

• Tolterodine (Detrol)
• Oxybutynin, which can be taken as a pill (Ditropan XL) or used as a skin patch (Oxytrol) or gel (Gelnique)
• Trospium
• Solifenacin (Vesicare)
• Fesoterodine (Toviaz)
• Mirabegron (Myrbetriq).

3. AbotulinumtoxinA injections, also called Botox, is a protein from the bacteria that cause botulism illness. Used in small doses directly injected into bladder tissues, this protein relaxes the muscles.

4. Nerve stimulation

• Sacral nerve stimulator
• Percutaneous tibial nerve stimulation (PTNS)

5. Surgery

• Surgery to increase bladder capacity. This procedure uses pieces of your bowel to replace a portion of your bladder.
• Bladder removal. This procedure is used as a last resort and involves removing the bladder and surgically constructing a replacement bladder (neobladder) or an opening in the body (stoma) to attach a bag to the skin to collect urine.

Symptoms
Feel a sudden urge to urinate that's difficult to control,Urinate frequently (eight or more times) in 24 hours,Experience unintentional loss of urine immediately after an urgent need to urinate,Wake up more than two times in the night to urinate (nocturia)
Conditions
Frequent urge to urinate and waking up at night to urinate
Drugs
Tolterodine (Detrol),Trospium,Oxybutynin, which can be taken as a pill (Ditropan XL) or used as a skin patch (Oxytrol) or gel (Gelnique),Fesoterodine (Toviaz),Solifenacin (Vesicare),Mirabegron (Myrbetriq)