Overactive Bladder Syndrome

Question 1

What are the types of urinary incontinence?

Answer 1

• Stress = increased pressure on bladder
• Urge = strong urge to urinate and often don’t get to toilet in time
• Mixed = ≥2 types (often stress and urge incontinence together)
• Overflow = difficulty emptying bladder → filling
• Functional = cannot get to the toilet in time (issues in mobility)

Question 2

What are the risk factors for stress incontinence?

Answer 2

• Age
• Children
• Traumatic delivery
• Pelvic surgery
• Obesity

Question 3

What are the risk factors for urge incontinence?

Answer 3

• Age
• Obesity
• Smoking
• FHx
• DM

Question 4

What are the appropriate investigations for suspected overactive bladder syndrome?

Answer 4

• Speculum examination → exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles
  
  • ‘Kegel’ exercises
    
    • Ask patient to cough during exam to check for fluid leakage
• Urine dipstick and MC&S – rule out DM or UTI
• Bladder diaries
• Urodynamic Testing (if mixed incontinence) – 3 pressures measured from inside rectum and urethra
  
  • Bladder pressure = detrusor + IAP
  • Detrusor = bladder – IAP

Question 5

What is the management of stress incontinence?

Answer 5

• 1st line = lifestyle advice and pelvic floor exercises (8 contractions, TDS, 3 months)
• 2nd line = surgical treatment or SNRI duloxetine
  
  • Burch colposuspension = stitching the neck of the bladder higher
  • Autologous rectus fascial sling = asling placed around the neck of the bladder
  • Bulking agents = put bulking agents into urethral wall to provide more force

Question 6

What is the management of urge incontinence?

Answer 6

• 1st line (conservative) = lifestyle advice, bladder training
  
  • Bladder training → progressively hold off going to the toilet
  • Avoid fizzy drinks (carbonic acid can stimulate detrusor muscles)
  • Control any diabetes well
• 2nd line (medical) = antimuscarinic (oxybutynin, tolterodine), ADH analogues (desmopressin)
• 3rd line (medical) = mirabegron (beta-3 agonist)
  
  • Used if concerns about using anticholinergics in older, frail women
• 4th line (surgical) = Botox injection, sacral nerve stimulation, cystoplasty, urinary diversion

Question 7

What are the contraindications of antimuscarinics?

Answer 7

• Closed angle glaucoma
• Oxybutynin = increased risk of falls – do not give if frail and elderly

Question 8

What is the management of overflow incontinence?

Answer 8

Timed voiding

Question 9

What are the signs of vesicovaginal fistula?

Answer 9

Dribbling incontinence after having a child with a prolonged labour

• Urinary dye studies should be done

Question 10

What counselling should be given to women with overactive bladder syndrome?

Answer 10

• Risk Factors:
  
  • Stress: age, traumatic delivery (forceps), obesity, previous pelvic surgery, children
  • Urge: age, obesity, smoking, family history, diabetes mellitus
• Explain diagnosis and mechanism
• Explain lifestyle measures
  
  • Controlling fluid intake
  • Avoiding caffeine
  • Losing weight
• Explain treatment
  
  • Urge: bladder retraining – increase time between going to the toilet
  • Stress: pelvic floor training
• Explain further medical and surgical options