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Overactive Bladder

Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital
Definition of
Overactive Bladder
A medical condition referring to the
 Symptoms of frequency and urgency,
 With or without urge incontinence
 In the absence of local pathology or
metabolic factors that would account for
these symptoms
 A profound impairment of quality of life
due to urge and frequency

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Overactive bladder
 Sensory urgency (hypersensitivity)

 Motor urgency (detrusor overactivity)

Detrusor instability
(non-neurogenic)
Detrusor hyperreflexia
(neurogenic)

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Symptomatology of Overactiv
e bladder
 Those with frequency and urgency

 Those with frequency urgency and urge

incontinence

 Those with mixed stress and urge

incontinence

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Sensory urgency
 Might be a micro-motor urgency due to
micro-motion of detrusor during bladder
filling
 Rapid bladder filling
 Diuresis
 Detrusor instability can be elicited by 0.
4M KCl or resiniferatoxin instillation

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Detrusor overactivity
 Neurogenic detrusor hyperreflexia
 Detrusor instability related to bladder ou
tlet obstruction
 Idiopathic detrusor instability
 ICS recommended Detrusor overactivity
May be neurogenic, myogenic or idiop
athic

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Micturition Control

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Incontinence
 In women 49% stress incontinence
22% urge incontinence
29% mixed stress & urge
 In men 73% urge incontinence
 In elderly >65 years, prevalence rate is
33-61%,accompany with incomplete
empty

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Non-urological incontinence
(Diappers)
 Delirium
 Infection
 Atrophic vaginitis
 Psychological disorders
 Pharmacological effects
 Excessive urine output
 Restricted motility
 Stool impaction

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Urodynamic finding in Detruso
r overactivity
 An involuntary rise in detrusor pressure
during the filling phase of a urodynamic
study
 Associated with an urge sensation or uri
ne leakage
 May associate with a low bladder compli
ance, but phasic detrusor contractions s
hould exist

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Neurogenic Detrusor overactivity
 Cerebral vascular accidents
 Dementia
 Intra-cranial lesions
 Parkinson’s disease
 Supra-sacral cord injuries
 Multiple sclerosis

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Detrusor overactivity related to
Bladder Outlet Obstruction
 Benign prostatic obstruction
 Bladder neck dysfunction
 Bladder neck stricture
 Urethral stricture
 Spastic urethral sphincter
 Iatrogenic obstruction (after anti-incontin
ence surgery)

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Idiopathic Detrusor Overactivity
 Children & young adult – diurnal enuresi
s or nocturnal enuresis
 Adults women – after delivery, associat
ed with stress incontinence or urgency f
requency
 Elderly patients of either sex – occult ne
uropathic or poor cortical perfusion

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Diagnosis of
idiopathic detrusor overactivity
 Exclude bladder outlet obstruction
 Exclude neurogenic lesion
 Cystometry with sphincter EMG
 Pressure flow study for associated voidi
ng dysfunction
 Videourodynamic study to investigate u
pper tract and urethral conditions conco
mitantly

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Detrusor overactivity in a child
idiopathic detrusor instability

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Detrusor overactivity in a child
Pseudodyssynergia & VUR

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Detrusor overactivity in a girl
with Pseudodyssynergia

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Detrusor overactivity in a woman
with Stress incontinence

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Detrusor overactivity in a wom
an with BN dysfunction

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Detrusor overactivity in a woman
after anti-incontinece surgery

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Detrusor overactivity in a man
with BPH obstruction

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Detrusor overactivity in a man
after CVA

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Detrusor overactivity in a man
with anterior urethral valve

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Detrusor overactivity in a man
with Parkinson’s disease

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Clinical Presentation of OAB
 Frequency & nocturia
 Urgency – sudden sensation of strong d
esire to void, during increasing fullness
sensation or in isolation especially durin
g coughing or jumping, changing postur
e or activities
 Urge incontinence – with or without urge
sensation, may confused with SUI

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Clinical Presentation of OAB

 Bedwetting – not nocturnal enuresis, patient i

s awaked and has urge sensation
 Pain – suprapubic or perineal pain associated
with an urge sensation
 Psychological symptoms – a high incidence o
f affective disorders, neuroticism, emotional di
sturbance, difficulty in interpersonal relationsh
ips

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Detrusor overactivity
-- Urethra as an etiology ?

 Bladder neck incompetence is highly

prevalent in women with urgency & urge
incontinence
 Suspension of the bladder neck cure part of
the women with sensory urgency and urge
incontinence
 Pelvic floor exercises improved urgency
frequency, increased capacity, and urge
incontinence as well as stress incontinence
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Physical examination for
Overactive Bladder
 Suprapubic palpation for a chronically di
stended bladder
 Perineal sensation, anal tone, voluntary
contraction, bulbocavernous reflex
 DRE & vaginal examination for BPH, pr
olapse, SUI, meatal stricture
 Uroflowmetry & cystoscopy
 Ultrasound of lower urinary tract

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Voiding Diary
for Overactive Bladder

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Detrusor overactivity during ur
odynamic study
 Spontaneous detrusor contractions
 Provoked detrusor contractions – cough
ing, laughing, running water
 Low compliance and spontaneous detru
sor contractions
 Pre-micturition detrusor contraction
 Post-micturition after contraction

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Spontaneous detrusor contractions

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Provoked detrusor contractions

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Low compliance and spontaneous de
trusor contractions

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Detrusor instability during cha
nging position in CMG

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Pre-micturition detrusor contraction

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Post-micturition after contraction

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Urodynamic diagnosis of Detr
usor overactivity
 Urgency or urge incontinence: sensitivity 78%
, specificity 39%
 Cystometry: sensitivity 88%, specificity 75%
 Provocative test: increased sensitivity compar
ed with a 30-40% false negative rate in those
without provocation
 Rapid filling CMG is more provocative
 Diuresis CMG is also more provocative

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Detrusor overactivity
 Demonstration of involuntary detrusor c
ontraction (>15cm water or phasic contr
action with urge sensation) during filling
cystometry
 Catheter effect should be eliminated
 Repeat cystometry with lower filling rate
 Ask patients if they are voluntarily to voi
d immediately at urge sensation
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Treatment modalities of Idiopathi
c Detrusor Overactivity
Behavioral therapy Bladder drill
Timed/prompted toileting
Medical therapy Anticholinergic/antimuscarinics
Tricyclic antidepressants
Neurotoxins
Estrogens
Electrical therapy Vaginal or anal electrical stimulation
Trancutaneous electrical simulation
Sacral nerve neuromodulation
Surgical therapy Partial detrusor myomectomy
Augmentation cystoplasty
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Behavioral Therapy
 Incorrect cognition of frequent urination
 Education of normal voiding physiology
 Avoid irritants or diuretics
 Normal fluid intake 1.5 to 2 L daily
 Establish cortical control of urgency
 Bladder training and pelvic muscle
exercises

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Bladder re-education
 Gradual increase in voiding intervals
 Voiding by the clock rather than by urge
 Hold micturition before the voiding time
 Suppress detrusor contraction by stoppi
ng activity, concentration, crossing leg,
pelvic floor contractions
 Repeat protocol until voiding interval of
3 hours in the daytime

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Behavioral Therapy with CMG
 Attempts to hold urine for increasing len
gth of time during urge to void
 May be initiated in bathroom or toilet
 Cystometry with EMG can be used if fea
sible to treat detrusor instability
 A 6-week course or longer may be nece
ssary

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Medical Therapy
 Modulation of CNS control mechanism
 Blockage of peripheral nervous system
receptors
 Direct relaxation of smooth muscle
 Regulation of contractile function
 A combination of behavioral therapy
with medical therapy is often helpful

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Common medical therapies
Drug Dose Frequency
Oxybutynin 2.5-10 mg 2-3 time per day
Tolterodine 1-4 mg Twice daily
Propiverine 15 mg 2-4 time per day
Imipramine 10-25 mg 1-3 times per day
Propantheline 7.5-60 mg 3-5 times per day
Dicyclomine 10-20 mg 3 times per day
Flavoxate 200-400 mg 3-4 times per day

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Anticholinergics
 5 types of muscarinic postganglionic parasym
pathetic receptors inbody
 M2 & M3 subtype in bladder contraction as w
ell as salivary gland and intestine
 Side effects include dry mouth, drowsiness, c
onstipation, tachycardia, blurred vision; is con
traindicated in glaucoma
 Patient may increase fluid intake due to dry m
outh and influence the effect on frequency

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Oxybutynin Tolterodine Imipramine
 Oxybutynin reduce incontinence by 19 – 58%
over placebo
 Tolterodine is 8x less affinity for parotid gland
M-receptor(40% v 78%), but is equivalent pot
ent than oxybutynin
 Imipramine is tricyclic antidepressan with anti
cholinergic and alpha-adrenergic effects that
produce detrusor relaxation and urethral sphi
ncter contraction

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Capsaicin & Resiniferatoxin
 Cause excitation and desensitization of
C- afferent fibers
 Capsaicin in 1-2mM and RTX in 10-6M f
or detrusor hyperreflexia
 Increased capacity and reduced detruso
r contractility
 Hematuria and initial inflammation

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Initial responses of RTX

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Results of RTX in Treatment o
f Detrusor hyperreflexia
Baseline Post-RTX Stastistics

Cystometric capacity
102.1±31.5 236.6±88.6 P<0.001
(ml)

Bladder compliance
23.7±12.1 25.9±15.3 P>0.05
(ml/cmH2O)

Voiding pressure
55.9±23.2 47.5±28.1 P>0.05
(Pdet, cmH2O)

Presence of DESD 100% 100%

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Change in Bladder capacity
after RTX instillation

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Botulinum toxin A injection
 Injection of botulinum toxin A directly to
detrusor muscle can effectively reduce
detrusor overactivity
 Detrusor underactivity will develop
 Patients may need clean intermittent cat
heterization
 Clinical trial in SCI and severe DH child

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Surgical Therapy
 Cystoscopic hydrodilatation
 Subtriginal phenol injection
 Sacral nerve rhizotomy
 Bladder denervation
 Partial detrusor myomectomy
 Augmentation cystoplasty
 Urinary diversion (ileal conduit or Kock pouch
formation)

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Complication of surgical therapy
 Bladder hyposensitivity
 Residual detrusor instability
 Incomplete bladder empty
 Urinary tract infection
 Chronic urinary retention and CISC
 Stone or malignancy formation
 Metabolic problem (acidosis)

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Detrusor myomectomy

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Detrusor myomectomy
( Autoaugmentation )

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Improved in bladder capacity
after autoaugmentation

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Enterocystoplasty- technique

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Augmentation cystoplasty

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Results of Enterocystoplasty
Cystometri End filling Bladder MUCP
c pressure compliance cmH2O
capacity cmH2O Ml/cmH2O
cmH2O

Preoperative 165±97 50±23 10.8±2.7 62±28

Postoperative 760±289 13±4.7 75±43 －

Statistics P<0.005 P<0.005 P<0.005

MUCP=Maximal urethral closure pressure.

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Changes in capacity and bladder pressur
e after augmentation cystoplasty

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