Overactive Bladder Screening and Treatment

The symptoms of overactive bladder – urinary frequency, urgency, and urge incontinence – affect an estimated 1 in 11 adults of all ages in the United States. Recent studies have shown that this condition can cause significant social, psychological, occupational, domestic, physical, and sexual problems. Nonetheless, people are often reluctant to discuss their symptoms due to embarrassment or the mistaken belief that the symptoms are a normal part of aging. Many are unaware that effective treatment for overactive bladder is available. For all of these reasons, healthcare professionals play an extremely important role in identifying and treating the many patients who suffer needlessly with this chronic condition.

The symptoms and their impact
Clinically, overactive bladder can present as:
· Urgency – a strong, sudden, and unpredictable desire to urinate 
· Frequency – more than 8 micturitions in a 24-hour period
  – Frequency can include nocturia (waking up 2 or more times per night to urinate)
· Urge Incontinence – episodes of involuntary urine loss associated with a sudden, strong desire to void 

Patients with these symptoms suffer from considerable disruptions in their daily lives, including interrupted sleep due to nocturia; decreased workplace productivity; limitation of activities away from home; and inhibition of sexual activity.

Despite this dramatic impact on daily life, many patients may characterize their symptoms as “manageable” and do not seek evaluation and treatment. However, with the availability of new treatments, patients no longer have to endure their symptoms in silence. By probing during an office visit for symptoms of the overactive bladder or the use of adaptive behaviors, you may help patients recognize and acknowledge the many ways that overactive bladder negatively impacts their lives.

Patient interview
Discussing bladder control problems, including overactive bladder, can be a very uncomfortable topic for patients. Without prompting, they may not mention their symptoms. To help patients overcome their feelings of embarrassment, it is important to try to approach bladder control problems in a nonconfrontational and nonjudgmental way. 

An initial screening for bladder control problems can be easily integrated into routine office visits by including a few specific questions in the patient interview. To initiate screening, ask all patients:
· Do you have bladder or bladder control problems that are bothersome?

If the answer is “yes,” continue questioning. Further questions might include:
· Tell me about the problems you are having with your bladder. 
· Tell me about any trouble you have holding your urine (water).
· How many times per day do you urinate?
· How often do you get up to urinate at night?
· How often do you have a wetting accident?
· Does leakage occur when you cough, laugh, sneeze, or lift heavy objects?
· Are there other voiding symptoms present, such as a weak urine stream, straining to void, hesitancy, dribbling, or a sense of incomplete emptying? 

Treatment
Options for treatment of overactive bladder include bladder training, pharmacologic therapy, and surgery. The goal of bladder training is to help patients delay voiding to allow for the storage of progressively larger volumes of urine and to promote longer intervals between voids. Patient education is an important component of this approach. 

For patients with overactive bladder, the most common treatment approach involves combining behavioral therapy with pharmacologic treatment. Anti-muscarinic agents are the medication of choice. The rationale for use of these agents is that bladder contractility is mediated by the stimulation of post-ganglionic muscarinic receptors. Competitive blockade of muscarinic receptors can reduce the frequency and intensity of involuntary bladder contractions by interfering with transmission at neuromuscular junction. Some of the FDA-approved antimuscarinic agents are tolterodine tartrate and oxybutinin. Tolterodine tartrate (DETROL) is the brand of medication most frequently prescribed by urologists for the treatment of overactive bladder. 

Tolerability data show that more than 86% of patients remained on therapy with tolterodine in placebo-controlled studies, and no significant differences in discontinuation due to any adverse event were observed with tolterodine vs. placebo. Dry mouth was the most frequently reported adverse event in these studies, but fewer than 1% of patients discontinued therapy for that reason.

Safety and tolerability has been demonstrated by the use of tolterodine in U.S. clinical trials in more than 1,600 patients aged 19 to 91 years. In addition, tolterodine has been prescribed to more than 1.5 million overactive bladder patients.

Therapeutic goals
Effective therapy for overactive bladder can have a dramatic impact on patients’ lives, by helping them to:
· Spend more time outside the home 
· Regain confidence in personal relationships 
· Acquire normal workplace activity 
· Sleep with fewer disruptions

Help your patients talk to you about overactive bladder. By asking a few basic questions, you can play a critical role in identifying and treating patients with this common but often hidden condition.

For more information about overactive bladder and its treatment, visit:American Foundation for Urologic Disease 
www.afud.orgAmerican Medical Women's Association www.amwa-doc.orgAmerican Uro-Gynecologic Society www.augs.orgAmerican Urological Association Inc. 
www.auanet.orgMedscape Urologywww.medscape.com/Home/Topics/urology/urology.htmlNational Association for Continence (NAFC) www.nafc.orgNational Kidney and Urologic Diseases Information Clearinghouse www.niddk.nih.gov/health/urolog

OBGYN.net Urogynecologywww.obgyn.net/urogyn/urogyn.aspPharmacia & Upjohn – Overactivebladder.com www.overactivebladder.comThe Simon Foundation for Continence 
www.laborie.com/simon.htmlSociety of Urologic Nurses and Associates www.inurse.com/~sunaWound Ostomy and Continence Nurses Societywww.wocn.orgSymptom assessment tools
The following Overactive Bladder Screening Questionnaire can help to confirm a diagnosis in patients who report symptoms that may indicate overactive bladder. It was derived from the items included in a recent survey of more than 81,000 overactive bladder patients in the United States, which was endorsed by the American Foundation for Urologic Diseases (AFUD).

You may want to print this questionnaire for reference during patient interviews.

These questions were adapted from a questionnaire provided by the Bladder Health Council of the American Foundation for Urologic Diseases (AFUD) as part of the Overactive Bladder Screening Initiative. 

The following Diagnostic Algorithm was developed for primary care physicians to easily identify and differentiate patients with overactive bladder from those with stress urinary incontinence. It was published in 1999 in the International Journal of Fertility.

SYMPTOMS

Urgency

Frequency with urgency

Leaking during physical activity

Amount of urinary leakage with each episode of incontinence

Ability to reach the toilet in time

Nocturia

Yes

Yes

No

Large if present

No or just barely

Usually

STRESSINCONTINENCE

No

No

Yes

Usually small

Yes

Seldom

   WORKING DIAGNOSIS                                                                                                                                     STRESS INCONTINENCE

References:

Reprinted from Int J Fertil. 1999;44(2):60.