[醫如往常] Senior Clerkship Day 5: Ob/Gyn Grand Round: OAB; overactive bladder syndrome

OAB; overactive bladder syndrome

R1 Dr. 謝 / Prof. 林

Symptom diagnosis: Urinary Urgent ± urgency incontinence, frequency or nocturia

• Urgency : sudden compelling desire to urinate, difficult to defer
• Frequency : > 8 times / 24hrs
• Nocturia : > 1 times, wake to void
• OAB-dry, OAB-wet : incontinence or not
• Dry37%
• Wet63%

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Impacts on quality of life

Depression

Daily activity

UTI

Falls, fracture

Quality of sleep

Skin infection or irritation

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Pathophysiology

• Idiopathic
• Inflammation
• Myogenic  ( structure, receptors of cell membrane )
• Enhanced coupling tetanic contraction
• Increased connective tissue
• M2: inhibit smooth muscle relaxation
• M3: contract smooth muscle
• Beta 3: smooth muscle relaxation
• Neuroplasticity ( NGF, urothelium hypersensitivity, new spinal circuit,
  alter Na channel function, reawaken silent C-fiber )
• 5-HT (serotonin) deficit ( Brain stem, spinal cord )
• Low pH, high K
• Afferent plasticity

TCA (5HT) can inhibit circuit

Lidocaine inhibit sodium

NGF antibody

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Etiology

Idiopathic

Neurologic

Spinal cord injury, Stroke, Multiple sclerosis, Dementia, Parkinson disease

Diabetic neuropathy

Inflammatory

UTI, post-RT

Structural

Tumor, BPH, Stones, post-OP

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Diagnosis

1. Review medical history, and present symptoms
2. Bladder diary: Record everyday urinary situation
3. Exclude other disease, such as stress incontinence, mixed urinary incontinence, overflow incontinence, and transient incontinence
4. Postvoid residual test, Urodynamic study ( not first-line evaluation )

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OABSS; overactive bladder symptom score questionnaire

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Pdet=Pves-Pabd

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1. Behavioral therapies
1. lifestyle modification, bladder training, pelvic floor muscle therapy,
2. Pharmacotherapy
1. antimuscarinics, Beta-3 agonists, Botulinum toxins, TCA, Capsaicin
3. Surgery
1. Augmentation cystoplasty, Sacral Neuromodulation, percutaneous tibial nerve stimulation
4. Treat specific causes
1. UTI
2. Atrophic urethritis

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Frequent nocturia episodes, a suboptimal response to treatment, and small bladder capacity predict the need for persistent antimuscarinic therapy or re-treatment after discontinuation of antimuscarinics in female overactive bladder

Menopause, 2016 ( in press )

For predicting persistent or re-treatment for female OAB

• Suboptimal response
• Nocturia<2
• VSD: volume at strong desire to void

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Discussion

1. Nocturia : a new predictor of the need of persistent treatment or re-treatment
2. If the change of OABSS is less than 3, continuous therapy is recommended
3. Strong desire volume is an another predictor, thus, women with small bladder
   capacity may need continuous therapy
4. Urodynamic study, Age, OABSS, urinary NGF/Cr, etc. are not predictors in this study.
5. Limitation : sample size, only one medication (solifenacin), low ROC area 

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林教授講評

Severe IC(interstitial cystitis), OAB(Overactive bladder) overlap

很難治，轉給泌尿科

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Urodynamics

• Anatomy: POP; Pelvic organ prolapse
• Functional: OAB, SUI; Stress Urinary Incontinence
• LUTD; Lower Urinary Tract Dysfunction
• Sexual dysfunction: FSFI: Female Sexual Function Index
• Anorectal incontinence