Generality
Overactive bladder syndrome is a urological condition defined by a set of symptoms - such as the urgent need to urinate - that do NOT depend on other pathologies with similar manifestations (including bladder tumors, infections or obstructive diseases of the urinary tract).
What is an overactive bladder?
Overactive bladder syndrome (OAB, OverActive Bladder or more simply overactive bladder) includes a set of symptoms that includes:
- Urgent urge : sudden and unbearable need to urinate, which often results in the inability to retain urine;
- Increased voiding frequency : more than 8 times within 24 hours;
- Urge incontinence: involuntary loss of urine immediately after feeling the urge to urinate;
- Nocturia: repeated stimulus to eliminate urine during night rest (at least twice a night);
- Abdomen stretching .
These symptoms, taken in isolation, may coincide with those associated with other conditions affecting the bladder, including interstitial cystitis or tumors. A brief medical evaluation allows the exclusion of these diseases and the exclusion of the diagnosis of overactive bladder syndrome.
Although the disorder is more common among older adults, it should not be considered an inevitable consequence of the aging process. The available treatments can in fact greatly reduce or even eliminate the symptoms, helping to manage their impact on daily life.
Causes
The normal functioning of the bladder is the result of a complex interaction between neurological and psychological factors, and musculoskeletal and renal activity. The set of these physiological mechanisms, in part voluntary and partly involuntary, determines the bladder filling and the emptying - in times and places considered appropriate - of the urine collected. Even a single problem at various levels of this system can contribute to the onset of overactive bladder syndrome.
Involuntary contractions of the bladder . The disorder is often associated with hyperactivity of the detrusor muscle, which has the function of contracting during urination to determine the expulsion of urine. The anomalous and involuntary contractions of this muscle during the filling of the bladder determine an impelling urge to urinate, before the bladder has filled to normal volumes.
Several other conditions can contribute to the onset of overactive bladder symptoms, including:
- High urine production, as could happen in case of excessive fluid intake, poor kidney function or diabetes;
- Abnormalities in the bladder, such as tumors, bladder stones or other factors that hinder normal outflow (enlarged prostate, constipation or previous uro-gynecological surgery). In humans, overactive bladder syndrome is very often related to benign prostatic hypertrophy;
- Altered sensitivity of the bladder wall ;
- Pelvic muscle weakness, due to pregnancy and childbirth (conditions that can also stretch the sphincter sphincter to damage it and cause incontinence).
- Neurological disorders, such as Parkinson's disease, stroke and multiple sclerosis. The overactive bladder can be an expression of damage to the central nervous system, spinal cord or nerves, which can lead to the interruption of the nerve pathway cerebral cortex-bladder, along which the impulses that prevent the muscle from contracting correctly travel . Traumas or iatrogenic spinal injuries can also lead to alterations in the urination reflex: this is the case of disc hernia, urological-gynecological surgery and exposure to radiation.
- Taking diuretic drugs and excessive consumption of caffeine or alcohol can cause a rapid increase in urine production.
- Acute infections of the urinary tract cause symptoms similar to an overactive bladder, as they can irritate the nerves and induce urination urgency.
- Excess weight . Overweight increases intra-abdominal pressure, which in the long run can degrade the urethral sphincter and cause urine leakage.
- Estrogen deficiency after menopause : may contribute to urine loss of urgency. Together with the doctor, the patient can evaluate a local or general estrogen therapy.
Diagnosis
If the patient continuously feels a sudden and uncontrollable urge to urinate, with an increase in both daytime and nighttime urination and possible urge incontinence, the doctor may suspect that the bladder is overactive.
The diagnosis is established after the exclusion of other relevant pathologies, such as urinary tract infections, obstruction of the lower urinary tract and bladder tumors. The doctor then proceeds with the search for clues that could indicate the factors favoring the onset of the condition.
The diagnostic path will probably include:
- General assessment and medical history;
- Physical examination, which includes physical examination of the abdomen and genitals, rectal exploration in men (to assess size, consistency and overall prostate mass) and pelvic examination in women (to assess atrophy, inflammation, infections) ;
- In humans, PSA (prostate specific antigen) dosage ;
- Urinalysis and urine culture: they allow to exclude the presence of urinary infections, traces of blood or analytical anomalies in the urine;
- Neurological examination : identifies sensory problems or abnormal reflexes;
- Urodynamic test : evaluates the function of the bladder and its ability to empty and fill up correctly. If the bladder does not completely empty during urination, the residual urine may cause symptoms identical to the overactive bladder. To measure the amount of urine not emitted, the doctor can proceed with an ultrasound bladder examination or insert a thin catheter through the urethra to drain and measure the residual post-urination fluid still present in the bladder.
- Uroflowmetry : functional investigation that allows to measure the volume and velocity of urinary flow. The patient urinates normally in a device connected to a computer, which records the parameters of the urinary flow and converts the data into a frequency / volume chart, which shows the variations in flow compared to the norm.
Other urodynamic techniques:
- Cystometry : can identify if involuntary muscle contractions occur or the bladder is unable to store urine correctly;
- Uretrocystoscopy: allows the exclusion of tumors and kidney stones.
Management and Therapy
Behavioral interventions
Once the diagnosis is confirmed, it is necessary to intervene first of all on the lifestyle. These interventions do not lead to complete resolution of the disorder, but can significantly reduce the number of incontinence episodes.
Behavioral interventions may include:
- Weight loss, regularization of diet and water intake : these are interventions that can improve all types of urinary incontinence and general health conditions. Overweight can add pressure to the bladder and contribute to bladder control problems. Your doctor may recommend the quantity and timing of fluid consumption.
- Elimination of irritants for the urothelium : limit the consumption of caffeine, theine and alcohol; eliminate spicy, acidic foods and beverages containing artificial sweeteners.
- Smoking cessation : cigarette smoke is irritating to the bladder muscle. Furthermore, repeated coughing spasms caused by smoking can cause urine leakage.
- Pelvic floor rehabilitation exercises: Kegel exercises strengthen the pelvic floor and urinary sphincter muscles. The muscles that surround the bladder and control the flow of urine, if reinforced, can help to limit involuntary contractions. The doctor or a physiotherapist can tell the patient how to perform Kegel exercises correctly. Before noticing improvement in symptoms may take up to six to eight weeks.
- Double urination and bladder training: after urination, patients who have problems emptying their bladder completely may wait a few minutes and then try again to expel residual urine. Occasionally, your doctor may recommend other strategies to train you to delay emptying when you feel the need to urinate (only if you are able to contract your pelvic floor muscles successfully). Other "learning" techniques allow to increase the time interval between the urge to urinate and urination: the patient can start with a small delay from when he feels the stimulus, such as 30 minutes, and gradually reach intervals of 3-4 hours.
- Clean intermittent catheterization (CIC): periodically resorting to a catheter can facilitate complete emptying of the bladder. Medical personnel can provide guidance on how to insert the small cannula through the urethra. It is necessary to remember that urinary tract infections are more common among people who use a catheter.
- Absorbents: it is possible to use absorbents of various sizes and absorbency levels to protect clothing and avoid embarrassing accidents. This measure makes it possible not to restrict one's activities for fear of presenting symptoms in public.
- Proper management of chronic conditions, such as diabetes, could help alleviate symptoms of overactive bladder.
drugs
Your doctor may recommend a combination of multiple therapeutic strategies to alleviate symptoms. These also include the use of pharmacological products .
Medications can work very well to restore normal bladder function. Treatment generally begins with the prescription of a low dose drug, followed by a gradual increase. The intent is to use the minimum effective dose, which in turn reduces the risk of experiencing any side effects.
| antimuscarinics | |
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| These drugs include: tolterodine, oxybutynin, trospium, solifenacin, darifenacin. | |
Β3 adrenergic receptor agonists . Another drug indicated for the treatment of overactive bladder is mirabegron, an β3 adrenergic receptor agonist, which acts on the bladder detrusor, inducing muscle relaxation and increased bladder capacity.
Intravesical injections with botulinum toxin A. In cases resistant to therapies, it is possible to apply intravesical drugs, such as injections of small doses of botulinum toxin directly into the bladder tissues. This poison partially paralyzes the muscles, can suppress involuntary bladder contractions and can be useful for resolving severe urge incontinence. The use of botulinum toxin A is approved in adults with neurological diseases, including multiple sclerosis and spinal cord injury. The effects are temporary, lasting about six to nine months, and the intervention also involves a risk of worsening of bladder emptying in older adults and in people already weakened by other health problems.
Sacral neuro-modulation
In this procedure, at sacral level, a sort of bladder pacemaker (similar to the cardiac one) is implanted, which provides electrical impulses. The resulting regulation of nerve signals successfully reduces the symptoms of overactive bladder.
Surgery
Any surgical intervention for the treatment of overactive bladder is reserved for patients with severe symptoms that do not respond to other conservative therapies.
The procedures include:
- Surgery to increase bladder capacity. This procedure uses intestinal tissues to replace a portion of the bladder and increase its containment capacity. The intervention is used only in cases of severe urge incontinence that does not respond to all other treatment measures. If the patient undergoes this surgical procedure, he may need an intermittent catheter for the rest of his life.
- Bladder removal (partial or total cystectomy). This procedure is used as a last resort and involves the partial or total surgical removal of the bladder, with ureterocutaneostomy to fix an external collection device for urine.
