© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
7
A practical primary care approach to overactive bladder
patient with hematuria or who is refractory to therapy.
Radiological evaluation, beyond a portable bladder
ultrasound, is reserved for those with hematuria or a
palpable mass noted on examination.
Red flags
Referral toaspecialist shouldbeconsideredifasignificant
finding is discovered during a work up. Criteria for
referral include an uncertain diagnosis, unsuccessful
therapy, previous surgery such as a hysterectomy,
previous incontinence surgeries, hematuria without
infection, recurrent urinary tract infections, difficulty
emptying the bladder, symptomatic pelvic prolapse,
prostatic nodule enlargement, abnormal PVR volume,
or the presences of neurological conditions, such as
spinal cord injury, stroke or an abnormal PSA, if tested.
Treatment choices: is therapy wanted?
The PCP should recognize that not all patients
desire intervention. They may have been concerned
that the symptoms they presented with represent
something life threatening. They may believe that
taking medications or any other intervention is of
greater concern than symptoms or even some of the
associated quality-of-life issues.
18
One simple question
at this point may be enough: “Are your symptoms
bad enough that it would justify taking a medication
each day or having a surgical procedure?” This should
be asked in such a way that the patient is aware that
they can come back at any time if, and when, they
are ready for intervention. All patients, whether
they choose intervention or not, may benefit from
behavioral modifications. Behavioral modification
involves educating the patient as to the normal
process of micturition and then showing them how
their specific symptoms define an abnormal situation.
The goal of this intervention is to teach the patient to
inhibit urgency and to improve voluntary control over
bladder function. If the patient is actively involved
in the diagnosis and then subsequent treatment, their
expectations are more readily attainable. Behavioral
therapy may involve pelvic floor muscle exercises,
bladder retraining (which includes patient education
and timed or delayed voiding), changing the timing
of various medications like diuretics, dietary changes
(i.e., reducing or eliminating the intake of caffeinated
beverages) or encouraging exercise and weight loss.
Preventing or alleviating constipation can also help
avoid OAB symptoms.
This behavioral modification should be offered
to all patients regardless of the chosen interventions.
The literature shows that the combination of both
behavioral and pharmacological therapies greatly
enhances the likelihood of a positive outcome
compared with either intervention alone.
19
Treatment choices: overactive bladder
This is for the patient with identified irritative symptoms
who desires therapy.
The principle of pharmacologic management of OAB
is to curb the symptoms. The most bothersome and
most significant symptom of OAB is urgency with or
without urgency incontinence. The patients will void
frequently with small volumes. The goals of treatment
are to decrease the urgency, increase the voidedvolumes
and interval between voids. Therefore, medications
to treat OAB should either block contraction of the
bladder or facilitate storage. Although, many PCPs are
apprehensive about treatingmenwithOAB for the fear of
causing retention the risk is, in fact, very low.
12
Currently
there are two classes of medications to treat OAB,
antimuscarinicswhich inhibit contraction of the bladder
and beta 3 agonists that facilitate bladder relaxation.
The antimuscarinic class has been available for
many years and there are several options, Table 3.
20
They are all efficacious in treating the symptoms of
OAB within a few weeks, although titration of the
medication or switching within the class may be
necessary to achieve a suitable result for the patients.
The side effects of dry mouth, constipation, headaches
and blurred vision occur across the class, however,
the degree for each agent varies and the extended
release medications fare better in this regard than the
immediate release. The contraindications for use of
antimuscarinics include urinary or gastric retention
as well as uncontrolled narrow-angle glaucoma.
Warnings include angiodema (face, lips, tongue, and
larynx), clinically significant bladder outlet obstruction
and decreased gastric motility. There are precautions
for CNS effects (especially in the elderly) as well as
in use in patients with myasthenia gravis. There
have been some recent studies, such as DuBeau et al
(fesoterodine) that have demonstrated the safety and
efficacy of certain OAB drugs in medically complex
vulnerable elderly patients (mean age 75).
21
The beta 3 agonist class is the new entry for
the treatment of OAB. Currently there is only one
medication available, mirabegron, Table 3.
20
The
recommended starting dose of 25mg is effective within
8 weeks. Based on patient efficacy and tolerability the
dose may be increased to 50 mg anytime within that
8 week period. There are no contraindications listed
