Overactive bladder (OAB) is a feeling of urgency that may be accompanied by urge incontinence and is usually accompanied by frequent urination and nocturia (night urination). OAB syndrome is the feeling of urgency even though there is no local pathological or metabolic reason that can explain these symptoms.
Detrusor (bladder muscle) overactivity (DAA) is a urodynamic observation and is recorded by recording detrusor contractions that occur spontaneously or with provocation during the bladder filling phase. Characterized by these contractions, they may lead to overactive bladder symptoms or they may be inhibited and not present. DAA is examined in two parts:
-Neurogenic detrusor overactivity: It is used if there is a relevant neurological cause
.
-Unexplained ( Idiopathic) detrusor overactivity: It is used if there is no specific
reason.
Urgency is the key symptom and is a sudden compelling urge to urinate that is difficult to postpone. It is physiologically caused by overfilling of the bladder. It must be distinguished from strong desire to urinate (urinary urge). Urgency causes frequent urination (frequency = at least 8 urinations/24 hours), night urination (nocturia) and urge urinary incontinence (RITI) in 1/3 patients.
1/3 of the patients with OAB have RIA or Mixed type urinary incontinence (CUI), which are called Wet type OAB, and 2/3 do not have IOB, sudden feeling of urgency is evident, and these are called dry type OAB.
OAB causes:
-
Neurogenic causes:
-Stroke
-Parkinson's disease .
-Multiple sclerosis
-Medulla Spinal traumas
-Inflammatory diseases and developmental anomalies of the medulla spinalis.
-
Non-neurogenic:
-Bladder infection
-Bladder Outlet Obstruction[benign prostatic hyperplasia (BPH), pelvic
organ prolapse, urethral diverticulum ..]
-Post-surgery (incontinence surgery)
-Bladder stone, bladder tumor and foreign body.
In the USA and Europe The incidence of OAB is 17% and 37% of them have urinary incontinence and treatment is required.
The frequency of wet and dry OAB increases with age, dry OAB is common in men (M = 13.6% vs F = 7.6%) ). Wet OAB is common in women (F=9.3% vs M=2.4)
Urge urinary incontinence (RITI) is often accompanied by BPH in men.
OAB must be identified and treated because:
-OAB significantly impairs the quality of life
-OAB The incidence of depression in diabetes is similar to that of diabetes, hypertension and rheumatoid arthritis
-OAB increases fall-related injuries in the elderly. Studies show that squeezing once or more a week. Type of urinary incontinence
The probability of falls and fractures has increased by 26-34% in the elderly
-It brings high costs to the country's budgets (63% incontinence pads,
20% dr. . consultations, 10% drug cost)
DIAGNOSIS OF OVERACTIVE BLADDER:
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History is very important: bladder diary day and night urine frequency, comfortable time between urination, are there any sudden urges, how long can he delay it, does he have urinary incontinence and what type of incontinence, does he use a pad and how often does he change it, difficulty in starting and/or urinating, history of retention (inability to urinate),
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History of neurological disease
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History of vaginal or incontinence surgery
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Radiotherapy history
Treatment in OAB:
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Change in lifestyle
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Pelvic floor muscles training
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Behavioral treatments
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Electrical and magnetic stimulation
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Pharmacological treatments
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Intravesical treatments
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Sacral neuromodulation
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Surgical treatments.
Intervention in lifestyle
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Loosing weight in obese people; StressTIK is 4.4 times more in obese people and HERITA is 2.2 times more
-
Reducing caffeine intake
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Restriction in excessive fluid intakes and reduction of carbonated liquids
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Relieving constipation (foods with plenty of fibrin)
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Quitting smoking; Nicotine causes an increase in contractions with a direct stimulating effect on the detrusor.
Training of the pelvic floor muscles
The contractions of the pelvic floor muscles are reflex or It is based on the logic that it inhibits voluntary detrusor contractions. For this purpose:
-
Kegel exercises
-
Biofeedback can be applied.
Behavioral treatments
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Bladder training
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Timed voiding
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Habit training
Bladder training
Active participation of the patient It requires and is based on three main foundations.
1-Education: continence mechanisms are explained and urgency control techniques are taught.
-Causal warnings (e.g. dripping tap, water sound) are eliminated. lift
-applying perineal pressure and contracting the pelvic muscles
-encouraging to think about other things
-standing, crossing legs and walking on tiptoes
2-Voiding schedule:
He/she is directed to urinate every hour, whether he/she catches it or misses it, he/she should not urinate voluntarily in between
he/she should not urinate, urgency control techniques are also used here.
In the urination diary, between urinations. If it is less than an hour, it can be started with 30 minute
intervals. Patients should take their normal fluids.
15 minutes a week when a one-hour interval is provided.
3- Positive support:
To evaluate compliance and progress with the program and to see the prolongation in voiding intervals
patients record the voiding event with a voiding diary
p>They should follow it themselves. During this training period, the doctor should evaluate the progress by seeing the patient every week
and adjust the voiding intervals,
encourage and support the patient
Timed voiding:
A fixed-interval voiding schedule does not change throughout the treatment.
Especially for those who cannot toilet independently, an assistant
helps them urinate every 2-4 hours.
In outpatients, 2-hour intervals may be useful for those with moderate incontinence and those who do not show a frequent urination pattern.
Electrical stimulation:
Electrical stimulation is given to the pelvic floor muscles with probes placed in the vagina. The important disadvantages are that it needs to be applied every day and for periods extending up to 2 years.
Electromagnetic treatment:
A vaginal without probe It aims to stimulate the pelvic muscles and sacral roots. Although its mechanism of action is not fully known, it is thought to act by passive pelvic floor exercises and suppressing detrusor overactivity. Its most important disadvantage is that it requires repeated sessions in the office environment. It has no known side effects. Both Heat TIC and Stress TIC can be effective.
Pharmacological Treatment:
Different medications can be used to reduce involuntary contractions in the bladder muscle (detrusor).
The most commonly used among these are antimuscarinic (anticholinergic) drugs. Stimulation of the bladder muscle occurs by stimulating acetylcholine through muscarinic receptors. These antimuscarinic drugs compete with acetylcholine at the receptor level, blocking the receptors and reducing acetylcholine stimulation. It is suggested that these drugs suppress sensory receptors as well as contractile muscarinic receptors. The effectiveness of current antimuscarinics is very similar, their effects begin on average in 2 weeks.
The effectiveness and side effects of the drugs may vary from patient to patient:
Urinary incontinence decreases by 70-75%
Vicination Its frequency may decrease by 20-30%
Voiding volume may increase by 10-20%.
Muscarinic receptors may have undesirable side effects because they are found in the cardiovascular system, gastrointestinal system, eye, and central nervous system outside the bladder. , the most important of which are:
Dry mouth, constipation, blurred vision, cognitive disorders (decreased attention, memory problems), palpitations.
Agents administered intra-bladder
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Capcaisin
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Resiniferatoxin (RTX)
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Botulinum toxin (botox) =BTX)
The first two substances act by desensitizing and inactivating sensory neurons with different mechanisms with repeated applications. They have not been used routinely and there are no preparations in Turkey.
Botulinum toxin. Botox = BTX, as it is known in the market, is applied especially to those who are resistant to anti-muscarinic treatment. Effective results have been obtained in both neurogenic and idiopathic OAB. A total of 100-200 units of BTX are diluted and injected into 30 different areas in the bladder muscle, and it must be repeated every 6-9 months.
Sacral neuromodulation
Medulla It is based on continuous stimulation of the sacral 3 level (S3) in the spinalis with an electrode and generator placed through an intervention. Although more than 50% improvement in storage symptoms is observed in 80% of the patients, it is a very expensive method.
Augmentation cystoplasty (Clam operation):
Resistant to treatment, especially neurogenic Last option in patients with severe symptoms of OAB. The aim is to create a low-pressure, high-functional capacity bladder. By dividing the bladder in half like a seashell, it is aimed to reduce detrusor contractions, and by adding a piece of bowel in between, it is aimed to increase functional capacity and act as a buffer against involuntary contractions.
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