Guideline on diagnosis and treatment of non-neurogenic overactive bladder

Non-neurogenic overactive bladder (OAB) is a common problem characterized by urgency, frequency, and/or nocturia with or without incontinence. The symptoms are not associated with urinary tract infection and do have an adverse effect on an individual’s quality of life (QOL). Severity of symptoms often increases with age. OAB has a prevalence of 7%-27% in men and 9%-43% in women. As OAB is predominantly a diagnosis of exclusion, it is imperative that other diagnoses including UTI, polydipsia, diabetes insipidus, and bladder pain syndrome are ruled out.

Diagnosis: Initial evaluation includes a detailed history and physical exam with urinalysis. Documentation includes duration of symptoms, impact on QOL, amount of fluid intake and output, and comorbid conditions that may affect bladder function such as neurologic diseases, uncontrolled diabetes mellitus, and prior pelvic surgeries or radiation.

Physical examination includes abdominal exam; rectal/genitourinary exam with assessment of perineal sensation/rectal sphincter tone to rule out such pelvic floor abnormalities as uterine prolapse or constipation; prostate exam in men; and assessment for atrophic vaginitis. Urine culture is needed if urinalysis shows evidence of infection. Hematuria requires urologic work-up.

A postvoid residual (PVR) is not necessary for patients with uncomplicated OAB symptoms who are receiving first-line behavioral therapy or antimuscarinic medications. PVR can be considered in patients with complicated OAB such as those with history of or risk factors for urinary retention, incontinence, prostatic surgery, or neurologic disorders. PVR can be measured with bladder ultrasound or postvoid urethral catheterization if ultrasound is unavailable. Caution should be exercised if antimuscarinic therapy is used with a PVR greater than 150-250 cc. Bladder diaries for 3-7 days can be useful in defining degree of symptoms, establishing a baseline, and evaluating the effect of treatment. Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not be used in initial work-up, but may be considered in the setting of complicated OAB or OAB not responsive to treatment.

Treatment: Since OAB affects QOL, treatment options should weigh the benefits and adverse events. Most treatments will improve symptoms but do not entirely eliminate them. Some patients and caregivers may choose not to be treated.

First-line treatment is behavioral therapy, which includes fluid management, bladder training, delayed voiding, prompted voiding, and pelvic floor muscle exercises to control symptoms of urge incontinence. Randomized trials have shown behavioral therapy to be as or more effective than anti-muscarinic medications in reducing symptoms without the risk of adverse effects.

Second line treatment includes oral or transdermal antimuscarinics, which can often be combined with behavioral therapies. Antimuscarinics include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium, which all have similar efficacy. In general, patients with more severe symptoms have a greater degree of response to medications, regardless of which medication is chosen. Adverse effects of antimuscarinic medication include dry mouth (20%-40%), blurred vision, impaired cognitive function, constipation, and urinary retention.

While efficacy is similar for all the antimuscarinic medications, the rate of side effects differs. The rate of dry mouth with oxybutynin (61%) was statistically significantly higher than that for tolterodine (24%). The rate of constipation with darifenacin (17%) was higher than that for many of the other agents (7-9%) and the rate of constipation with oxybutynin (12%) was significantly greater than with tolterodine (5%). The guidelines panel concluded that there was more dry mouth and constipation with oxybutynin than tolterodine. Extended release formulations may be preferable when available since they have lower rates of dry mouth. Also available is transdermal oxybutynin as a patch or gel.

It is recommended that if a patient does not tolerate, or has an inadequate response to one antimuscarinic agent, another drug in that class may be tried. Antimuscarinics should not be used in patients with narrow angle glaucoma and should be used cautiously in patients with impaired gastric emptying or history of urinary retention. They are contraindicated in those taking oral potassium supplements as absorption may be impaired in the setting of delayed gastric emptying. Caution should be taken in patients being treated with medicines that also have anticholinergic effects including tricyclic antidepressants, as well as drugs for parkinsonism or Alzheimer’s dementia. Antimuscarinics should also be used with caution in the frail elderly, in whom commonly reported side-effects, as well as less commonly reported side-effects such as memory difficulty are likely to be more frequent and severe.

If patients who are refractory to treatment with behavioral and anti-muscarinic therapy would like their symptoms addressed further then referral to a specialist may be indicated. Treatment options that may be provided by the specialist at that point include sacral neuromodulation, peripheral tibial nerve stimulation, and intradetrusor onabotulinumtoxinA injection. Surgical interventions such as augmentation cystoplasty or urinary diversion are used only in treatment of neurogenic OAB and therefore are rare.

The bottom line: Non-neurogenic OAB usually presents with urinary urgency, frequency and nocturia with or without incontinence. Initial work up includes detailed history and physical exam and urinalysis. Treatment options are based on weighing benefit versus risk. Some patients and their caregivers may opt for no treatment. Behavioral therapy should be offered to all patients since it has essentially no adverse effects. Antimuscarinics are the only FDA approved medications. All oral antimuscarinics are equally effective, though they vary in side-effects. Close follow up is crucial to assess side effects and efficacy.

Reference

• Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Guideline (J. Urol. 2012 Dec;188:2455-63 [doi:10.1016/j.juro.2012.09.079]).

Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Tien is a third-year resident in the Family Medicine Residency Program at Abington Memorial Hospital, and a new mom to her wonderful son, Andrew.

Non-neurogenic overactive bladder (OAB) is a common problem characterized by urgency, frequency, and/or nocturia with or without incontinence. The symptoms are not associated with urinary tract infection and do have an adverse effect on an individual’s quality of life (QOL). Severity of symptoms often increases with age. OAB has a prevalence of 7%-27% in men and 9%-43% in women. As OAB is predominantly a diagnosis of exclusion, it is imperative that other diagnoses including UTI, polydipsia, diabetes insipidus, and bladder pain syndrome are ruled out.

Diagnosis: Initial evaluation includes a detailed history and physical exam with urinalysis. Documentation includes duration of symptoms, impact on QOL, amount of fluid intake and output, and comorbid conditions that may affect bladder function such as neurologic diseases, uncontrolled diabetes mellitus, and prior pelvic surgeries or radiation.

Physical examination includes abdominal exam; rectal/genitourinary exam with assessment of perineal sensation/rectal sphincter tone to rule out such pelvic floor abnormalities as uterine prolapse or constipation; prostate exam in men; and assessment for atrophic vaginitis. Urine culture is needed if urinalysis shows evidence of infection. Hematuria requires urologic work-up.

A postvoid residual (PVR) is not necessary for patients with uncomplicated OAB symptoms who are receiving first-line behavioral therapy or antimuscarinic medications. PVR can be considered in patients with complicated OAB such as those with history of or risk factors for urinary retention, incontinence, prostatic surgery, or neurologic disorders. PVR can be measured with bladder ultrasound or postvoid urethral catheterization if ultrasound is unavailable. Caution should be exercised if antimuscarinic therapy is used with a PVR greater than 150-250 cc. Bladder diaries for 3-7 days can be useful in defining degree of symptoms, establishing a baseline, and evaluating the effect of treatment. Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not be used in initial work-up, but may be considered in the setting of complicated OAB or OAB not responsive to treatment.

Treatment: Since OAB affects QOL, treatment options should weigh the benefits and adverse events. Most treatments will improve symptoms but do not entirely eliminate them. Some patients and caregivers may choose not to be treated.

First-line treatment is behavioral therapy, which includes fluid management, bladder training, delayed voiding, prompted voiding, and pelvic floor muscle exercises to control symptoms of urge incontinence. Randomized trials have shown behavioral therapy to be as or more effective than anti-muscarinic medications in reducing symptoms without the risk of adverse effects.

Second line treatment includes oral or transdermal antimuscarinics, which can often be combined with behavioral therapies. Antimuscarinics include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium, which all have similar efficacy. In general, patients with more severe symptoms have a greater degree of response to medications, regardless of which medication is chosen. Adverse effects of antimuscarinic medication include dry mouth (20%-40%), blurred vision, impaired cognitive function, constipation, and urinary retention.

While efficacy is similar for all the antimuscarinic medications, the rate of side effects differs. The rate of dry mouth with oxybutynin (61%) was statistically significantly higher than that for tolterodine (24%). The rate of constipation with darifenacin (17%) was higher than that for many of the other agents (7-9%) and the rate of constipation with oxybutynin (12%) was significantly greater than with tolterodine (5%). The guidelines panel concluded that there was more dry mouth and constipation with oxybutynin than tolterodine. Extended release formulations may be preferable when available since they have lower rates of dry mouth. Also available is transdermal oxybutynin as a patch or gel.

It is recommended that if a patient does not tolerate, or has an inadequate response to one antimuscarinic agent, another drug in that class may be tried. Antimuscarinics should not be used in patients with narrow angle glaucoma and should be used cautiously in patients with impaired gastric emptying or history of urinary retention. They are contraindicated in those taking oral potassium supplements as absorption may be impaired in the setting of delayed gastric emptying. Caution should be taken in patients being treated with medicines that also have anticholinergic effects including tricyclic antidepressants, as well as drugs for parkinsonism or Alzheimer’s dementia. Antimuscarinics should also be used with caution in the frail elderly, in whom commonly reported side-effects, as well as less commonly reported side-effects such as memory difficulty are likely to be more frequent and severe.

If patients who are refractory to treatment with behavioral and anti-muscarinic therapy would like their symptoms addressed further then referral to a specialist may be indicated. Treatment options that may be provided by the specialist at that point include sacral neuromodulation, peripheral tibial nerve stimulation, and intradetrusor onabotulinumtoxinA injection. Surgical interventions such as augmentation cystoplasty or urinary diversion are used only in treatment of neurogenic OAB and therefore are rare.

The bottom line: Non-neurogenic OAB usually presents with urinary urgency, frequency and nocturia with or without incontinence. Initial work up includes detailed history and physical exam and urinalysis. Treatment options are based on weighing benefit versus risk. Some patients and their caregivers may opt for no treatment. Behavioral therapy should be offered to all patients since it has essentially no adverse effects. Antimuscarinics are the only FDA approved medications. All oral antimuscarinics are equally effective, though they vary in side-effects. Close follow up is crucial to assess side effects and efficacy.

Reference

• Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Guideline (J. Urol. 2012 Dec;188:2455-63 [doi:10.1016/j.juro.2012.09.079]).

Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Tien is a third-year resident in the Family Medicine Residency Program at Abington Memorial Hospital, and a new mom to her wonderful son, Andrew.

Non-neurogenic overactive bladder (OAB) is a common problem characterized by urgency, frequency, and/or nocturia with or without incontinence. The symptoms are not associated with urinary tract infection and do have an adverse effect on an individual’s quality of life (QOL). Severity of symptoms often increases with age. OAB has a prevalence of 7%-27% in men and 9%-43% in women. As OAB is predominantly a diagnosis of exclusion, it is imperative that other diagnoses including UTI, polydipsia, diabetes insipidus, and bladder pain syndrome are ruled out.

Diagnosis: Initial evaluation includes a detailed history and physical exam with urinalysis. Documentation includes duration of symptoms, impact on QOL, amount of fluid intake and output, and comorbid conditions that may affect bladder function such as neurologic diseases, uncontrolled diabetes mellitus, and prior pelvic surgeries or radiation.

Physical examination includes abdominal exam; rectal/genitourinary exam with assessment of perineal sensation/rectal sphincter tone to rule out such pelvic floor abnormalities as uterine prolapse or constipation; prostate exam in men; and assessment for atrophic vaginitis. Urine culture is needed if urinalysis shows evidence of infection. Hematuria requires urologic work-up.

A postvoid residual (PVR) is not necessary for patients with uncomplicated OAB symptoms who are receiving first-line behavioral therapy or antimuscarinic medications. PVR can be considered in patients with complicated OAB such as those with history of or risk factors for urinary retention, incontinence, prostatic surgery, or neurologic disorders. PVR can be measured with bladder ultrasound or postvoid urethral catheterization if ultrasound is unavailable. Caution should be exercised if antimuscarinic therapy is used with a PVR greater than 150-250 cc. Bladder diaries for 3-7 days can be useful in defining degree of symptoms, establishing a baseline, and evaluating the effect of treatment. Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not be used in initial work-up, but may be considered in the setting of complicated OAB or OAB not responsive to treatment.

Treatment: Since OAB affects QOL, treatment options should weigh the benefits and adverse events. Most treatments will improve symptoms but do not entirely eliminate them. Some patients and caregivers may choose not to be treated.

First-line treatment is behavioral therapy, which includes fluid management, bladder training, delayed voiding, prompted voiding, and pelvic floor muscle exercises to control symptoms of urge incontinence. Randomized trials have shown behavioral therapy to be as or more effective than anti-muscarinic medications in reducing symptoms without the risk of adverse effects.

Second line treatment includes oral or transdermal antimuscarinics, which can often be combined with behavioral therapies. Antimuscarinics include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium, which all have similar efficacy. In general, patients with more severe symptoms have a greater degree of response to medications, regardless of which medication is chosen. Adverse effects of antimuscarinic medication include dry mouth (20%-40%), blurred vision, impaired cognitive function, constipation, and urinary retention.

While efficacy is similar for all the antimuscarinic medications, the rate of side effects differs. The rate of dry mouth with oxybutynin (61%) was statistically significantly higher than that for tolterodine (24%). The rate of constipation with darifenacin (17%) was higher than that for many of the other agents (7-9%) and the rate of constipation with oxybutynin (12%) was significantly greater than with tolterodine (5%). The guidelines panel concluded that there was more dry mouth and constipation with oxybutynin than tolterodine. Extended release formulations may be preferable when available since they have lower rates of dry mouth. Also available is transdermal oxybutynin as a patch or gel.

It is recommended that if a patient does not tolerate, or has an inadequate response to one antimuscarinic agent, another drug in that class may be tried. Antimuscarinics should not be used in patients with narrow angle glaucoma and should be used cautiously in patients with impaired gastric emptying or history of urinary retention. They are contraindicated in those taking oral potassium supplements as absorption may be impaired in the setting of delayed gastric emptying. Caution should be taken in patients being treated with medicines that also have anticholinergic effects including tricyclic antidepressants, as well as drugs for parkinsonism or Alzheimer’s dementia. Antimuscarinics should also be used with caution in the frail elderly, in whom commonly reported side-effects, as well as less commonly reported side-effects such as memory difficulty are likely to be more frequent and severe.

If patients who are refractory to treatment with behavioral and anti-muscarinic therapy would like their symptoms addressed further then referral to a specialist may be indicated. Treatment options that may be provided by the specialist at that point include sacral neuromodulation, peripheral tibial nerve stimulation, and intradetrusor onabotulinumtoxinA injection. Surgical interventions such as augmentation cystoplasty or urinary diversion are used only in treatment of neurogenic OAB and therefore are rare.

The bottom line: Non-neurogenic OAB usually presents with urinary urgency, frequency and nocturia with or without incontinence. Initial work up includes detailed history and physical exam and urinalysis. Treatment options are based on weighing benefit versus risk. Some patients and their caregivers may opt for no treatment. Behavioral therapy should be offered to all patients since it has essentially no adverse effects. Antimuscarinics are the only FDA approved medications. All oral antimuscarinics are equally effective, though they vary in side-effects. Close follow up is crucial to assess side effects and efficacy.

Reference

• Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Guideline (J. Urol. 2012 Dec;188:2455-63 [doi:10.1016/j.juro.2012.09.079]).

Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Tien is a third-year resident in the Family Medicine Residency Program at Abington Memorial Hospital, and a new mom to her wonderful son, Andrew.