© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
a diagnosis of OAB, see Table 1.
7
The clinician needs
to determine the presence (or absence), frequency,
severity, bother, and effect on quality of life of OAB
symptoms in a patient.
8
Abasic patient evaluation for
OAB includes taking a history, performing a physical
exam, and making appropriate clinical investigations,
see Table 2.
9
The clinical investigations should at least
include a urinalysis and an assessment of bladder
emptying, which can be done by either palpating
or doing an ultrasound scan of the lower abdomen.
8
A simple voiding diary, in which a patient lists the
number of voids, time of day, and general fluid intake,
for about 3 days, can be very helpful to assess daytime
and nighttime voiding frequency.
In practical terms, voiding frequency is considered
abnormal if an individual voids more than seven
or eight times a day. However, according to the
International Continence Society (ICS) guidelines,
voiding frequency is considered abnormal if a patient
feels he or she voids too often during the day.
1
Nocturia
is generally considered abnormal if the patient voids
more than once a night. Fluid intake has a significant
impact on frequency and nocturia. Increasing fluid
intake after supper may increase nighttime voids.
Patient history
Urgency and urge incontinence are relatively easy
for the physician to assess. The physician can ask a
patient questions such as “When you get the urge to
void, can you easily put it off?” or “When you have
the urge to void, can you make it to the bathroom in
time or do you have urine leakage?” Urine leakage
may also occur without warning or urgency, and
the physician should ask about this. It is unclear
why patients have no sensation of this type of urine
leakage, but it is common. In many instances, OAB
wet may be confused with stress incontinence. Stress
incontinence is urine leakage that is directly associated
with an increase in intraabdominal pressure, which
can be caused, for example, by straining or heavy
lifting. Urgencymay coexist with stress incontinence.
8
About a third of patients with OAB have both
conditions.
8
In some cases, physical activity may provoke
urgency incontinence due to an unstable bladder or
due to a bladder contraction caused by an increase
in abdominal pressure. This unwanted bladder
contraction can be mistaken for stress incontinence,
and at times it can be difficult to differentiate the two
conditions. For example, in some patients, walking
briskly, or just getting out of bed in the morning
and putting their feet on the floor can provoke
bladder contractions that can be mistaken for stress
incontinence.
Physicians need to assess the duration of symptoms,
and, if applicable, the type of leakage protection and
number of pads/diapers that a patient uses per day.
This can vary due to cost, patient preference, etc.
Intake and timing of all fluids, especially caffeinated
beverages (tea, coffee, hot chocolate) and alcohol, also
needs to be assessed. If an individual has nocturia,
then limiting fluid intake after dinner or before bed
can be helpful.
Physicians also need to ask patients about other
medical problems and medications that may be
associated with urinary frequency, see Table 3. These
include diabetes, blood sugar control, congestive
heart failure, diuretic use, constipation, neurologic
conditions, medications used to treat dementia, and
interstitial cystitis.
If a patient is diabetic, good blood sugar control
is important, since elevated blood sugar may cause
diuresis and hence frequency. Patients, especially
elderly ones, may be taking therapies for constipation
that have anticholinergic effects and thus impact OAB.
Neurological conditions such as stroke, multiple
sclerosis, or Parkinson’s disease can affect the lower
urinary tract. It is important to ask men about BPH or
3
Medical management of overactive bladder
TABLE 1.
Causes of lower urinary tract symptoms
other than overactive bladder
•
Urinary tract infection (recurrent)
•
Interstitial cystitis
•
Bladder cancer
•
Excessive fluid intake and output
•
Urinary retention
•
Benign prostatic hyperplasia
•
Urethral strictures
•
Bladder stones
•
Chronic prostatitis
•
Constipation
•
Medications
TABLE 2.
Basic evaluation of overactive bladder
•
History (duration, severity, degree of bother,
fluid and caffeine intake, medications, etc.)
•
Physical exam (abdominal, pelvic, rectal exam)
•
Urinalysis and urine culture
•
Post-void residual urine volume
•
Simple voiding diary
