© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
health-related quality of life from OAB. Apatient can
fill in this type of questionnaire in his or her physician’s
waiting room.
Imaging studies
In general, inOAB, imaging is only used to assess post-
void residual (PVR) urine volume. Most urologists
have a portable bladder scanner in their offices.
Other physicians can generally easily order a pelvic
ultrasound to assess PVR urine volume. Caution is
needed when performing pelvic ultrasounds and
PVR urine volume studies. Overfilling the bladder
prior to a pelvic ultrasound can make it difficult for
many individuals to empty their bladders completely,
and hence, the test can give a false positive PVR urine
volume. We recommend that patients be “comfortably
full” for ultrasound tests to determine PVR urine
volume. Generally, imaging the upper urinary tract
is not necessary for patients with OAB, unless there
is concern because the patient has hematuria, urinary
retention, or possibly a “high pressure bladder.” A
“
high pressure bladder” may occur in neurological
conditions such as spinal cord injury, and it may cause
hydronephrosis, renal scarring, or atrophy.
Other diagnostic tests
Cystoscopy:
This test allows direct examination of
the urethra and bladder with a thin, lighted telescope.
Cystoscopy is not necessary for an initial patient work
up for OAB or for themanagement of OAB. It is helpful
when a patient has hematuria, or may have BPH,
IC, a urethral stricture, a bladder stone, or a bladder
tumor. This test is usually requested by a urologist or
urogynecologist.
Urodynamic testing:
This testing involves inserting
small catheters into the bladder and rectum to assess
bladder functionuponfilling andvoiding, after instilling
saline or, for video urodynamics, after instlling contrast
material. It is the most sophisticated testing available
to assess bladder function. For the initial patient work
up andmanagement of OAB, urodynamic testing is not
necessary. It too is generally requested by a urologist,
urogynecologist, or geriatrician. It is often performed
in patients who do not respond to therapy for OAB
and in patients with complex cases of incontinence (for
example, mixed incontinence or a history of previous
incontinence that was treated and has now recurred) or
with prolapse surgery or radiation to the pelvis.
Management of OAB
The recommended initial management of OAB is
conservative therapywithorwithout pharmacotherapy.
If a patient fails to respond to this type of treatment
that is initiated by a primary care physician, then, in
general, he or she should be referred to a specialist
such as a urologist, urogynecologist, or geriatrician
who specializes in the treatment of OAB or voiding
dysfunction.
Conservative management
Physicians should start by correcting processes that can
be corrected: they should assess and treat a patient’s
UTI, elevated fasting blood sugar, constipation, and
congestive heart failure. They should also instruct
patients to avoid or limit consumption of caffeine (in
food or drinks), alcohol, and salty foods. Excessive
caffeine intake is an independent risk factor for
detrusor overactivity, and the relationship may be
dose dependent.
13
Fluid intake should not be excessive
unless it is medically necessary (for example, if the
patient has kidney stones). A 25% reduction in fluid
intake has been shown to significantly reduce urgency,
frequency, and nocturia, while increasing fluid intake
has been shown to worsen frequency.
14
In general,
consuming 2 to 2.5 liters of fluid per day is adequate.
Keep inmind that fluids also include fruits, vegetables,
salads, soups, cereal withmilk, etc. The timing of fluid
consumption is important if a patient has nocturia.
Reducing consumption of fluids and caffeine after
dinner will be helpful. Diuretics taken at bedtime
will increase nocturia. Timed voiding (i.e., voiding
every 3 to 4 hours) may also help prevent urgency
and urge incontinence. Voiding every 3 to 4 hours
and not delaying when the urge is present can reduce
urine leakage due to urgency. However, when timed
voiding is excessive, that is, every 1 to 2 hours, this can
be just as bothersome for the patient. Lastly, weight
loss in moderately and morbidly obese women has
been shown to decrease incontinence.
15
Bladder retraining
This includes two techniques: pelvic floor rehabilitation
with biofeedback, and bladder drill techniques. The
first technique involves using strengthened pelvic
floor muscles to improve bladder control. A nurse
or physiotherapist teaches patients how to do this.
This therapy is often most effective in cases of stress
incontinence, but it has been effective in cases of OAB.
15
Bladder drill is a technique, a patient intentionally
increases the length of time between urinating despite
the need to void. This method attempts to retrain
the bladder to lessen urgency and lengthen the time
intervals between voids. In some cases, this may be
helpful.
5
Medical management of overactive bladder
