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Managing overactive bladder in the community

The International Continence Society (ICS) defines overactive bladder (OAB) as symptoms of urgency with or without urge incontinence, usually associated with urinary frequency and nocturia, in the absence of local pathology and significant endocrine factors. OAB is estimated to impact approximately 350,000 of people over the age of 40 in Ireland.

OAB is a very common presentation in general practice and the vast majority of cases can be successfully managed within primary care, according to Kildare GP Dr Michael Collins, Partner in Kildare Medical Centre.

Speaking to the Medical Independent (MI), he said: “It is a very significant problem and traditionally, we associate it as a problem with females rather than men. However, it can happen at any age in either sex. Most of the treatments or awareness campaigns are aimed at women but it is a male problem too.”

OAB symptoms

OAB symptoms are a collection of urinary storage symptoms. According to the European Association of Urology (EAU), these include:

The sudden need to urinate and having trouble postponing it.

Any involuntary loss of urine.

The need to urinate more often than usual.

The need to wake up at night to urinate.

OAB symptoms are common and can affect both men and women. Between 10 and 20 per cent of people suffer from it at some stage in their lives.

What causes OAB symptoms?

OAB symptoms can have various causes:

Some people experience sudden and spontaneous contractions of the bladder muscle.

Some people are more sensitive to the feeling of their bladder filling. 

In some cases, the kidneys produce too much urine at night, which causes nocturia. This may be related to older age or certain medical conditions.

Some people have a smaller bladder but this is not very common.

High fluid intake, poor kidney function and diabetes can all cause OAB. 

The impact of OAB on patients is often under-recognised and it can have a significant psychological impact, as it is still seen as an embarrassing and taboo issue. It can seriously impact people’s work and social life and necessitate very careful planning in relation to travel, such as knowing where public bathrooms are at all times, Dr Collins noted.

“It can limit socialisation and self-confidence and contribute to anxiety disorders,” he told MI.

Diagnosis

While it is usually patients in their 30s and upwards who present with OAB, it is occasionally seen in younger patients.

Dr Collins advised making as definitive a diagnosis as possible and making sure to differentiate OAB from other urinary issues, such as stress incontinence, prolapses, mechanical type problems, and overflow.

“The critical thing is to get your diagnosis right. Urgency, an overwhelming urge to urinate, is key to the diagnosis of OAB. It is important to differentiate it from stress incontinence.”

Conducting a urine test (urinary tract infections, diabetes, etc, need to be ruled out) and taking a thorough history is key, particularly as diagnostic tools such as urodynamics are not freely available in primary care, he said. Filling out a frequency volume chart is also useful. 

Men and OAB

While OAB is more commonly seen in female patients, OAB is under-diagnosed in men, believes Dr Collins. “There are a lot of men who suffer from OAB but have co-existing prostate/obstructive symptoms, and there is a concern among a lot of GPs and urologists that if we give medication for OAB, we may increase the risk of causing acute urinary retention in patients with an obstructive element.”

Men presenting with OAB are typically older and their classical OAB symptoms such as frequency, urgency, urge incontinence and nocturia can be secondary to prostate problems. Older men with enlarged prostates can experience outflow obstruction, with symptoms such as hesitancy, frequency, reduced stream and terminal dribbling, as well as incontinence.

“I think there are many older men missing out on treatment for OAB because of our concern about putting them into acute urinary retention by prescribing appropriate medication. I do use OAB medication quite a bit in older men who have the obvious symptoms. If there are co-existing obstructive symptoms, I also treat those. It is an informed decision for the patient and I explain the risks to them. If I am concerned, I refer to urology for urodynamics,” said Dr Collins.

Lifestyle alterations to help OAB

Manage fluid intake:

— Drink less in the evening to avoid getting up at night to urinate.

— Reduce alcohol and caffeine, because they increase urine production and irritate the bladder.

— Certain foods can irritate the bladder and worsen OAB symptoms. It may be helpful to reduce artificial sweeteners, spicy foods, citrus fruits and juices and soft drinks in the diet, as per EAU guidelines.

— Maintain a healthy weight (BMI should be between 18-25kg/m2). Reducing weight may lead to improvement in urine leakage.

— Pelvic muscles can weaken with age. Squeezing the pelvic floor muscles, known as Kegel exercise, can help to suppress the urgent desire to urinate and regain muscle strength.

Source: EAU patient OAB guidelines

Treatment

Treatment should be tailored to the individual patient, Dr Collins stressed. Lifestyle alterations that can help OAB (see above panel) should be advised firstly, particularly fluid management. 

“Common sense applies; don’t drink fluids just before bedtime or getting the train, etc. Caffeine, alcohol and citrus drinks/fruits can increase the sense of urgency,” he explained.

HSE guidance on when to refer OAB patients to secondary care

Refer women with OAB/urinary incontinence who have the following symptoms for specialist review: 

Microscopic haematuria (in women aged ≥50 years) or visible haematuria. 

Recurrent or persistent UTI in women ≥40 years. 

Suspected malignant mass of the urinary tract. 

Visible symptomatic or palpable bladder after voiding. 

Refer men with OAB/LUTS for specialist review if they have: 

Recurrent/persistent UTIs. 

Urinary retention. 

Suspected renal impairment. 

Suspected urological cancer. 

Medication-wise, there are over half a dozen oral drugs currently licensed and marketed for the treatment of OAB in Ireland, all of which are reimbursed by the HSE PCRS. Most of these drugs are antimuscarinics, which work through competitive antagonism of acetylcholine at postganglionic muscarinic receptors, causing a relaxation of bladder smooth muscle. 

By this action, they increase the maximum urinary capacity and the volume to the first detrusor contraction and decrease the urgency and frequency of incontinence episodes and voluntary urination. Mirabegron, a beta agonist, is a novel agent that exerts its effect by activating beta adrenoceptors in the detrusor muscle and trigone area of the bladder, facilitating urine storage through the relaxation of the detrusor.

Dr Collins said while anticholinergics (antimuscarinics) are effective, they do have some side-effects (dry mouth and constipation, etc), particularly the older versions. “With OAB, we are trying to improve quality of life so it is important if prescribing medication for OAB that we are not giving the patient a new problem. What is key in choosing the right medication for the patient is the side-effect profile for that particular patient. 

“For example, with some of the older anticholinergics, they are not the best for elderly patients, as they can increase the risk of falls and precipitate episodes of confusion. Thankfully, the latest generation [of antimuscarinics] have less side-effects,” he said.

Dr Collins noted that mirabegron is very effective, but can cause high blood pressure in some patients so the risk of hypertension must be considered.

Tricyclic antidepressants (TCAs) are another option for OAB in suitable patients, though again there are some side-effects, and they are not first-line treatment.

For post-menopausal women, the benefits of hormonal treatments, either oral or topical, should be considered if OAB is thought to be related. 

According to the HSE, it is important to manage expectations of OAB treatment and set realistic targets. Antimuscarinics and mirabegron treat only the symptoms of OAB; they are not curative. The benefits of drug treatment may not be seen until four weeks after commencing drug treatment.

“Most of the time, OAB can be managed in general practice but there are occasions when referral to secondary care is necessary. I would refer when the management strategies employed have not worked,” Dr Collins said, adding that GPs should not be afraid to try a number of different medications and treatment approaches first.

Botox treatment is an option for more difficult-to-treat OAB cases and is available in secondary care.

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