Mathilde Lacombe

An overactive bladder often has a significant impact on quality of life and, according to research, affects about 13% of women and 11% of men. The incidence increases as we age.

But it should be noted that overactive bladder syndrome is not a normal part of aging, just as it is not a normal condition in patients with an enlarged prostate nor is it caused by something you have done.

An overactive bladder is a daily and all-day problem for such patients, which, of course, affects all aspects of life. It reduces work productivity and affects the mental health of individuals who avoid prolonged absence from a familiar environment, most often their own home.

Such patients are more likely to have episodes of depression, withdraw from social events, and reduce social contacts. They often waste time and energy planning every outing according to available toilets. Affected patients have a higher rate of erectile dysfunction and, in general, decreased sexual desire. Therefore, it is very important to recognize the symptoms in time and contact your doctor in order to start treatment and treatment.

Diagnostic

Urodynamics is an excellent test that provides insight into bladder function during the filling and emptying phase and thus, with certainty, confirms or denies the existence of signs of overactive bladder.

History is the basis of any medical examination, and is especially important in the case of an overactive bladder. With a detailed medical history, the doctor will do a clinical examination to possibly detect other causes of symptoms and urinary disorders.

Symptoms often start very mildly and intensify over time and become an increasing problem. One of the most common symptoms is urinary frequency, which is defined as a frequent urge to urinate. According to some studies, most people urinate up to 8 times in 24 hours, which gives us a framework for the frequency symptom. But the number of urinations cannot be taken as a firm limit that indicates the frequency. Fluid intake, type of fluid (coffee, alcoholic beverages, etc.), type of work performed by the person, proximity and possibility of using the toilet and other external factors that affect the schedule of urination during the day, medications taken, especially diuretics in heart patients.

Frequency, too, can be caused by a urinary tract infection. Therefore, one of the first laboratory tests is the analysis of urine sediment, which indicates the possible presence of urinary tract inflammation factors. This test may also indicate some other diseases that may have an effect on urination such as unrecognized diabetes or urinary tract stones, and even a tumor.

Another sign of an overactive bladder is urgency. It is a sudden and urgent need to urinate that can occur regardless of the volume of urine in the bladder. In case the so-called urinary incontinence or urinary incontinence is called urgent urinary incontinence.

The third symptom associated with an overactive bladder is nocturia, which is defined as sleep deprivation due to a feeling of urge to urinate and consequent getting out of bed and urinating. It should be well distinguished whether it is nocturia or nocturnal polyuria. If the volume of urine that a person urinates during the night exceeds one third of the total urinated volume in 24 hours, we say that it is nocturnal polyuria. Then it is important to refer the person for further cardiological and endocrinological treatment.

The urination diary is an objective indicator of fluid intake and the number of urination and the volume of urine urinated, as well as nocturnal urination and the total volume urinated. Without a well-kept urination diary, it is difficult to objectively assess frequency symptoms. You can get a urination diary, as a booklet, from your doctor and it is usually monitored for 3 consecutive days.

Treatment further includes urinary tract ultrasound, which can visualize anatomical abnormalities, prostate size in men, urinary tract stones, urinary retention in the kidney or bladder, and pathological changes such as tumors.

An additional examination such as urine cytology gives us information about the possible oncological cause of urinary incontinence by analyzing the microscopic appearance of cells in the urine. In case there is a reasonable suspicion on any of the above tests for the anatomical, physiological or pathological cause of the urination problem, cystoscopy may be done. It is an endoscopic examination by which we visually analyze the inside of the urethra and bladder looking for anomalies.

If we are not able to confirm with certainty that this is an overactive bladder syndrome after the above-mentioned tests and analyzes and examinations, it is recommended to do a urodynamic test. Urodynamics is an invasive examination by which we objectify the subjective difficulties of patients. It is performed in an outpatient setting with the help of a specialized urodynamics machine and measuring catheters placed in the anus and bladder. We fill the bladder with sterile saline, at a certain rate, and get a record of the pressures that occur in the bladder and abdomen, which, with a mathematical model, gives the pressure of the muscles of the bladder called the detrusor.

Urodynamics is an excellent test that provides insight into bladder function during the filling and emptying phase and thus, with certainty, confirms or denies the existence of signs of overactive bladder. Also, in the case of a positive finding, we can differentiate different forms of urination disorders. The leading sign of an overactive bladder is a sudden, uncontrolled increase in detrusor pressure that causes a feeling of urgency, or a sudden urge to urinate. Such a form is called an overactive detrusor, which can be caused by a neurological disorder or idiopathic. The pressure exerted by the detrusor can sometimes be so high that it poses a risk of kidney damage. That is why it is very important to recognize the symptoms in time, try to investigate the causes and start treatment.

Treatment

Sacral nerve stimulation involves an implantable electrode in the opening of the spine that continuously stimulates the nerve root. It is possible to benefit up to 5 years in patients who respond positively to therapy.

The first line of therapy is a change in life habits with certain aids and supplements. In the case of initial changes and a milder form of overactive bladder, a change in life habits can lead to a calming of the problem. First, fluid intake before bedtime should be limited to reduce the number of nocturnal urination. Caffeinated beverages, carbonated beverages, spicy and sour foods are bladder irritants and should be limited, even avoided. It is advisable to regulate body weight, increase fiber intake and quit smoking.

Behavioral therapy includes various treatments that aim to educate the patient about his condition and gain insight into it and to learn to minimize or eliminate the problem through various behavioral changes. Behavioral therapy includes, for example, bladder training, urination according to a schedule, the procedure of delaying urination for ten minutes when the urge to urinate occurs.

Double urination is a procedure that involves urinating and then forcing urination again after a few minutes, all with the goal of completely emptying the bladder. Exercises of the pelvic floor muscles, especially in women, rats, can strengthen the control of urination in case of urgency, aim to strengthen the pelvic floor muscles and improve the response of the muscles to the increase in intra-abdominal pressure, and for success it is crucial to work properly, regularly and sufficiently. long.

Also, the so-called biofeedback, a device that measures the response of the muscles during contractions and gives patients feedback on the effectiveness of exercise. Electrostimulation, which is used to treat static, urgent and mixed incontinence, is also considered. The goal of electrostimulation in patients with urgent urinary incontinence is to inhibit overactivity of the bladder muscles.

The second line of therapy is pharmacotherapy. Although a conservative approach is initially justified, drug therapy remains integral in the treatment of patients with overactive bladder and a number of different antimuscarinic drugs are currently available, as well as a newer beta-3-receptor agonist, mirabegron. Antimuscarinics such as solifenacin, darifenacin, tolterodine or oxybutynin have been the basis of pharmacological treatment for many years and are considered the first line of pharmacological treatment. They act by blocking muscarinic receptors located in the bladder wall, thus achieving reduced detrusor contractility. In this way, the frequency and intensity of urgency symptoms are prevented or at least reduced.

A newer drug, mirabegron, is a beta-3-receptor agonist and is considered a second-line pharmacotherapy (according to HZZO guidelines). It is thought to cause an increase in bladder capacity and changes in the mode of bladder contraction, resulting in fewer bladder contractions and therefore fewer unwanted urination. Mirabegron should not be used in people who have severe and uncontrolled hypertension.

The third line of therapy is intravesical instillation of botulinum toxin, which prevents the release of acetylcholine at the neuromuscular node resulting in temporary chemical denervation and muscle relaxation. The effect is achieved very quickly and usually lasts 6 to 9 months. The technique is to place multiple injections under cystoscopic guidance directly into the detrusor. According to research, complete urination control can be achieved in 40-80% of patients, and bladder capacity is improved by 56% to 6 months.

The fourth line of therapy is sacral neuromodulation. It involves placing an electrode in the area of ​​the sacral plexus of nerves. Sacral nerve stimulation involves an implantable electrode in the opening of the spine that continuously stimulates the nerve root. It is possible to benefit up to 5 years in patients who respond positively to therapy. Current indications for sacral nerve stimulation include refractory incontinence, urgency and frequency, and idiopathic urinary retention.

The fifth line of therapy is surgical treatment, when none of the aforementioned therapies have been successful. It is recommended to perform augmentation cystoplasty in which the bladder is expanded by implanting a part of the intestine. Indications for bladder enlargement include small, shrunken, and dysfunctional bladder. In the most severe cases, even surgical removal of the bladder is performed, which is really a rarity nowadays.

Conclusion

Excessively active bladder is a syndrome that is increasingly being diagnosed in urological clinics. It is a condition that can seriously impair the quality of life of an individual and, if treatment and treatment are not started in time, leads to greater health problems. Therefore, it is important to take the symptoms of urination disorders in time seriously and contact your doctor or urologist to take the first steps towards resolving the problem.