Overactive Bladder (OAB)

Overactive bladder (OAB) is a common condition that affects millions of Americans. Overactive bladder isn’t a disease. It’s the name of a group of urinary symptoms. Overactive bladder causes a sudden urge to urinate. The urge may be difficult to stop, and overactive bladder may lead to the involuntary loss of urine (urge incontinence). Having to go to the bathroom many times during the day and night is another symptom of OAB.

Normal Bladder Function

The kidneys produce urine, which drains into your bladder. When you urinate, urine passes from your bladder through an opening at the bottom and flows out a tube called the urethra.

In women, the urethral opening is located just above the vagina.

As your bladder fills, nerve signals sent to your brain eventually trigger the need to urinate. When you urinate, nerve signals coordinate the relaxation of the pelvic floor muscles and the muscles of the urethra (urinary sphincter muscles). The muscles of the bladder tighten (contract), pushing the urine out.

Involuntary Bladder Contractions

Overactive bladder occurs because the muscles of the bladder start to contract involuntarily even when the volume of urine in your bladder is low. This involuntary contraction creates the urgent need to urinate.

Several conditions may contribute to signs and symptoms of overactive bladder, including:

• Neurological disorders, such as stroke and multiple sclerosis
• Diabetes
• Medications that cause a rapid increase in urine production or require that you take them with lots of fluids
• Acute urinary tract infections that can cause symptoms similar to an overactive bladder
• Abnormalities in the bladder, such as tumors or bladder stones
• Factors that obstruct bladder outflow — constipation or previous operations to treat other forms of incontinence
• Excess consumption of caffeine or alcohol
• Declining cognitive function due to aging, which may make it more difficult for your bladder to understand the signals it receives from your brain
• Difficulty walking, which can lead to bladder urgency if you’re unable to get to the bathroom quickly
  Incomplete bladder emptying, which may lead to symptoms of overactive bladder, as you have little urine storage space left

The specific cause of an overactive bladder may be unknown.

Risk Factors

As you age, you’re at increased risk of developing overactive bladder. You’re also at higher risk of diseases and disorders, such as diabetes, which can contribute to other problems with bladder function.

Many people with cognitive decline — for instance, after a stroke or with Alzheimer’s disease — develop an overactive bladder. Incontinence that results from situations like this can be managed with fluid schedules, timed and prompted voiding, absorbent garments, and bowel programs.

Some people with an overactive bladder also have bowel control problems.

Symptoms

With an overactive bladder, you may:

• Feel a sudden urge to urinate that’s difficult to control
• Experience urge incontinence — the involuntary loss of urine immediately following an urgent need to urinate
• Urinate frequently, usually eight or more times in 24 hours
• Awaken two or more times in the night to urinate (nocturia)

Evaluation and Diagnosis

If you have an abnormal urge to urinate, your doctor will check to make sure that you don’t have an infection or blood in your urine. Your doctor may also want to make sure that you’re emptying your bladder completely when you urinate.

Your doctor will look for clues that might also indicate contributing factors. The work-up will likely include a:

• Medical history
• Physical exam, focusing on your abdomen and genitals
• A focused neurological exam that may identify sensory problems or abnormal reflexes
• A bladder diary, where you will note how often you go to the bathroom and any time you leak urine
• Urine sample to test for infection, traces of blood or other abnormalities

Other Tests

• Urine culture — Your health care provider may ask you to leave a sample of your urine to test for infection or blood.
• Bladder scan — This type of ultrasound shows how much urine is still in the bladder after you go to the bathroom.
• Cystoscopy — During this test, the doctor inserts a narrow tube with a tiny lens into the bladder. This can be used to rule out other causes of your symptoms.
• Urodynamic testing — These tests check to see how well your lower urinary tract stores and releases urine.
• Symptom questionnaire — Many doctors use a written quiz to ask questions about your bladder problems and what causes you the most bother.

Treatment

A combination of treatment strategies may be the best approach to relieve overactive bladder symptoms.

Behavioral Interventions

Behavioral interventions are the first choice in helping manage an overactive bladder. They’re often effective, and they carry no side effects. Behavioral interventions may include:

Pelvic floor muscle exercises — Kegel exercises strengthen your pelvic floor muscles and urinary sphincter. These strengthened muscles can help you stop the bladder’s involuntary contractions.

Your doctor or a physical therapist can help you learn how to do Kegel exercises correctly. It may take as long as six to eight weeks before you notice a difference in your symptoms.

Healthy weight — If you’re overweight, losing weight may ease symptoms. Weight loss may help if you also have stress urinary incontinence.

Scheduled toilet trips — Setting a schedule for toileting — for example, every two to four hours — gets you on track to urinate at the same times every day rather than waiting until you feel the urge to urinate.

Intermittent catheterization — Using a catheter periodically to empty your bladder completely helps your bladder do what it can’t do by itself. Ask your doctor if this approach is right for you.

Absorbent pads — Wearing absorbent pads or undergarments can protect your clothing and help you avoid embarrassing incidents, which means that you won’t have to limit your activities. Absorbent garments come in a variety of sizes and absorbency levels.

Bladder training — Bladder training involves training yourself to delay voiding when you feel an urge to urinate. You begin with small delays, such as 30 minutes, and gradually work your way up to urinating every three to four hours. Bladder training is possible only if you’re able to tighten (contract) your pelvic floor muscles successfully.

Medications

Medications that relax the bladder can be helpful for relieving symptoms of overactive bladder and reducing episodes of urge incontinence. These drugs include:

• Tolterodine (Detrol, Detrol LA)
• Oxybutynin (Ditropan XL)
• Oxybutynin as a skin patch (Oxytrol)
• Oxybutynin gel (Gelnique, Gelnique 3%)
• Trospium (Sanctura)
• Solifenacin (Vesicare)
• Darifenacin (Enablex)
• Mirabegron (Myrbetriq)
• Fesoterodine (Toviaz)

Common side effects of most of these drugs include dry eyes and dry mouth but drinking water to quench thirst can aggravate symptoms of overactive bladder. Constipation — another potential side effect — can aggravate your bladder symptoms. Extended-release forms of these medications, including the skin patch or gel, may cause fewer side effects.

Your doctor may recommend that you suck on a piece of sugar-free candy or chew sugar-free gum to relieve dry mouth and use eyedrops to keep your eyes moist. Over-the-counter preparations, such as Biotene products, can be helpful for long-term dry mouth. To avoid constipation, your doctor might recommend a fiber-rich diet or use of stool softeners.

Bladder Injections

OnabotulinumtoxinA, also called Botox, is a protein from the bacteria that cause botulism illness. Used in small doses directly injected into bladder tissues, this protein partially paralyzes muscles.

Clinical research shows that it may be useful for severe urge incontinence. The temporary effects generally last five months or more, but repeat injections are necessary.

About half of people had side effects from these injections, including 9 percent who had urinary retention. So, if you’re considering Botox treatments, you should be willing and able to catheterize yourself if urinary retention occurs.

Nerve Stimulation (Neuromodulation Therapy)

Another treatment for people who need extra help is nerve stimulation, also called neuromodulation therapy. This type of treatment sends electrical pulses to nerves in your bladder. In OAB, the nerve signals between your bladder and brain don’t work the right way. These electrical pulses interrupt the nerve signals, set them right, and improve OAB symptoms.

There are two types:

Sacral neuromodulation (SNS) — changes how the sacral nerve works. This nerve carries signals between the spinal cord and the bladder. Its job is to help hold and release urine. In OAB, these nerve signals aren’t doing what they should. SNS uses a “bladder pacemaker” to control these signals to stop OAB symptoms. SNS is a two-step surgical process. The first step is to implant an electrical wire under the skin in your lower back. This wire is first connected to a handheld “pacemaker” to send pulses to the sacral nerve. You and your doctor will test whether or not this pacemaker can help you. If it helps, the second step is to implant a permanent pacemaker that can regulate the nerve rhythm.

Percutaneous tibial nerve stimulation (PTNS) — is another way to correct the nerves in your bladder. For this type of nerve stimulation, you will not have to have surgery. PTNS is performed during an office visit that takes about 30 minutes. PTNS is done by placing a small electrode in your lower leg near your ankle. It sends pulses to the tibial nerve. The tibial nerve runs along your knee to the sacral nerves in your lower back. The pulses help control the signals that aren’t working right. Often, patients receive 12 treatments, depending on how it’s working.