According to the new concept proposed by the International Urological Control, the syndrome consisting of symptoms such as urinary frequency, urinary urgency and even urge incontinence is collectively called overactive bladder (OAB), and these symptoms can occur individually or in any combination. Frequent urination is defined as urination > 8 times in 24h and > 2 times at night, with a volume < 200ml per urination, often after the bladder has been emptied. Urinary urgency refers to a sudden urge to urinate, which often leads to an urgent need to go to the toilet.
The first step is to rule out or diagnose frequent urination due to abnormal increase in urine volume based on medical history and urination diary.
Frequent urination can be divided into two types: physiological and pathological. In physiological cases, the frequency of urination is related to the amount of water drunk, the warm and cold climate, and the amount of sweating. Frequent urination due to excessive water intake, nervousness or cold weather is called physiological frequency of urination. Therefore, it is necessary to ask the patient’s medical history in detail (daily intake, whether he/she is taking relevant medications, etc.);
If necessary, the patient can be asked to record a 24-hour urinary diary, which is very important to record the patient’s fluid intake and urination during the day and night, and can indirectly reflect the patient’s bladder function; certain medications, such as diuretics or antihypertensive drugs containing diuretic ingredients, or drinking coffee, strong tea or large amounts of beer, can cause excessive urine production in the body, which can also lead to symptoms of frequent urination.
In addition, if the total volume of urine also increases when excessive urine is produced, and the volume of urine increases each time, and there is no history of related medication, further exclude or diagnose whether the frequency of urination is caused by an abnormal increase in urine volume due to diabetes mellitus, uremia, polyuria in acute renal failure or primary aldosteronism.
The second step is to rule out or diagnose neurogenic OAB based on the presence or absence of neurological disease and injury.
Neurogenic OAB is mainly due to the hyperreflexia of the supraspinal nervous system (cerebrovascular disease, brain tumor, traumatic brain injury and Parkinson’s disease, etc.). symptoms. Patients may also be characterized by reduced bladder capacity and small amounts of residual urine.
In 78% of patients with cerebrovascular disease and in 40-70% of Parkinson’s patients, urodynamic testing reveals a hyperreflexia of the detrusor muscle (diagnosed as an uninhibited contraction of the bladder on urodynamic examination – a detrusor systolic pressure of more than 15 cmH2O during the bladder storage phase), and most patients have clinical symptoms of urinary frequency and urgency.
In addition to routine physical examination and urodynamic examination, the ice water test is also feasible: after emptying the bladder with an F16 catheter, 60 ml of 14°C ice water is injected rapidly, and the ice water (e.g., together with the catheter) will be ejected from the urethra within a few seconds if there is hyperreflexia of the detrusor muscle into the bladder. In addition, some patients may also have a synergistic dysfunction of the forceps-urethral sphincter, i.e. there are also symptoms of difficulty in urination, which aggravates the damage to the upper urinary tract, causing hydronephrosis and affecting renal function, and should be treated early.
The third step is to rule out or diagnose OAB caused by inflammatory stimulation based on urine/prostate fluid examination.
Urinary frequency and urgency are common symptoms in the case of inflammation of the urethra, bladder or prostate. In addition to the symptoms of urinary frequency and urgency, patients often have symptoms such as pain or burning sensation in the urethra, back pain, soreness in the lower abdomen or perineum, and fever. Laboratory tests are.
(a) Routine urinalysis with increased leukocytes and pus in urine;
(ii) urine sediment smear to find bacteria;
(iii) urine bacterial culture to find bacteria and urine colony count >105/ml;
(iv) routine examination of prostate fluid in male patients with leukocytes >10/HP;
(v) Positive culture of prostate fluid for bacteria, mycoplasma or chlamydia in men; (vi) Routine blood tests: elevated white blood cells and leftward shift of neutrophil nuclei.
Urinary tract infections can be found at: http:///zhuanjiaguandian/zhangyaoguang1_604046547.htm
Prostatitis can be divided into two types: acute and chronic.
The main symptoms of acute prostatitis are perineal swelling and discomfort, vague pain in the lower abdomen, which can radiate to the lumbosacral area, penis and thighs. If it is caused by a urinary tract infection, the symptoms may include frequent urination, urgent urination, painful urination or hematuria. The onset of the disease is rapid and may be accompanied by fever, chills, anorexia, fatigue and other systemic symptoms. On examination, the peripheral blood white blood cells are increased, and a large number of white blood cells can be seen in the urine. The enlarged prostate can be palpated by rectal palpation, with obvious pressure pain and fluctuating sensation when an abscess is formed.
Chronic prostatitis The main symptoms are frequent and incomplete urination as well as burning and itching in the urethra. The pain is often distended and throbbing, radiating to the head of the penis and perineum, and there is suprapubic and lumbosacral discomfort. Patients often have prostatic overflow, which mostly occurs at the end of urination or during bowel straining, with a white discharge from the urethra. The prostate is unevenly soft and hard with mild tenderness on rectal palpation.
Step 4 Exclude or diagnose OAB due to obstruction/foreign body irritation based on ultrasound/anal finger examination.
Bladder outlet obstruction (male prostate enlargement, female bladder neck obstruction, etc.) may cause urinary frequency and urgency (OAB). For prostate enlargement in the early stage, it is caused by prostate congestion and stimulation, which is more significant at night and manifests as increased nocturia; as the obstruction worsens, the bladder forced urinary muscle gradually loses its function, and the urine in the bladder cannot be purged every time you urinate, and residual urine appears, which reduces the effective capacity of the bladder and makes the urination The effective capacity of the bladder is reduced and the interval time between voiding is shortened, and the frequency of urination is gradually increased; in addition, the hypersensitivity of the detrusor muscle due to the increased pressure during voiding is also an important factor;
If there are bladder stones or infections, the frequency of urination will be more obvious. The differential diagnosis can be made clinically by anal examination, ultrasound and urodynamic examination (maximum urethral pressure, functional urethral length, P-Q diagram analysis, etc.). (See the section on prostatic nodules for details)
Foreign bodies in the bladder (stones, ducts, tumors, etc.) can irritate the bladder mucosa, resulting in secondary symptoms of urinary frequency and urgency (OAB). Most bladder stones present clinically with urinary pain, dysuria, and hematuria in addition to frequency and urgency, often triggered or exacerbated by activity and vigorous exercise, and can be diagnosed by ultrasound, radiographs, and cystoscopy.
About 10% of bladder tumors may have starting symptoms as urinary frequency and urgency, which may be extensive carcinoma in situ or invasive carcinoma, especially those growing in the third region of the bladder; the clinically important symptom is painless intermittent carnal hematuria, which can be diagnosed by ultrasound, cystoscopy, and CT examination.
The fifth step is to exclude or diagnose OAB due to small bladder capacity based on KUB+IVP and cystoscopy.
About 75-85% of patients with renal TB have symptoms of urinary frequency and urgency. The symptoms of urinary frequency in renal tuberculosis are characterized by the earliest onset, progressive worsening and the latest subsidence. In the early stage, OAB is mainly caused by inflammation of tuberculosis stimulating the bladder. In a few cases, early occlusion can be caused by ureteral lesions, and tuberculosis lesions cannot extend to the bladder without symptoms such as urinary frequency, urinary urgency, and urinary pain.
In late stage, OAB is mainly caused by significant reduction of bladder capacity due to tuberculous bladder contracture, which is mainly due to severe fibrosis caused by tuberculous lesions invading the bladder muscle layer, and clinical symptoms, except for urinary frequency and urgency, are often without painful urination, pyuria, hematuria, etc. Symptoms do not improve after anti-tuberculous treatment, and sometimes symptoms are aggravated due to further fibrosis of bladder lesions.
In KUB+IVP examination, the bladder is shown to be very small and round, with unsmooth edges, not folded, and in severe cases, the bladder neck is open; cystoscopy shows small bladder volume, poor compliance, and congestion and edema of the entire bladder mucosa. Treatment of bladder contracture often requires surgery, and if there is no stricture in the urethra, it can be treated with bladder enlargement.
Interstitial cystitis is a multifactorial cluster of symptoms that manifests as urinary frequency, urgency and pain in the bladder area. The main etiology of OAB may be the disruption of the bladder mucosal barrier, which allows leakage of urinary toxic substances (potassium ions, etc.) into the interstitial bladder, damage to the muscles and nerves, and decreased bladder capacity due to advanced bladder muscle fibrosis leading to urinary frequency and urgency.
Since pathologic biopsy is not very helpful in the diagnosis of interstitial cystitis, clinical diagnosis is based on symptoms, exclusion of other diseases, and cystoscopy under anesthesia (multiple renal filamentous hemorrhages seen after bladder water dilatation under anesthesia).
The sixth step is the presence of anxiety disorders or psychological disorders to exclude or diagnose OAB caused by psychiatric factors.
In clinical practice, you will often encounter patients who habitually urinate when they are about to board a train, board a plane, or depart, but many of them have the urge to urinate again soon afterwards, which is the result of psychiatric effects. Mental stress or neuropathy related to urination can cause disturbances in the reflexes of the nervous system, leading to the appearance of OAB. The frequency of urination caused by psychogenic factors is usually more and less frequent, and there are obvious “signs” of psychogenic effects. In a large group of OAB patients, a significant number of them are caused by mental factors.
For example: frequent insomnia, indigestion, or severe neurasthenia, before going to bed often urinate frequently, this situation is mostly seen in middle-aged and elderly women; work pressure, life tension and anxiety so that the nervous system can not relax caused by the OAB common in the office of white-collar male and female patients; some patients suffering from depression or anxiety disorders in free time involuntarily to think of urination, even with a certain compulsion, but once busy with But once they are busy with work or other things, the symptoms of urinary frequency and urgency disappear, indicating that the shift of attention can also help them.
Step 7 After all the examinations, there is no obvious cause, and the diagnosis is idiopathic OAB.
After all clinical examinations (history, physical examination, laboratory tests, imaging tests and endoscopy, etc.) no obvious cause is found, this kind of urinary frequency and urgency is called idiopathic OAB, which can be considered for confirmation by urodynamic examination, and in urodynamics it is called idiopathic detrusor instability (DI). It is predominantly seen in children and female patients.
Principles of treatment.
The general principle of treatment of OAB: is to remove the primary cause and improve the symptoms. For OAB caused by abnormal increase in urine volume, appropriate control of water intake and control of the primary disease is the main focus; for urinary tract infection, prostatitis, prostatic hyperplasia, bladder tumors, stones and other secondary OAB is to actively treat the primary disease, while using anti-OAB drugs to relieve symptoms; for tuberculous small bladder and no narrowing of the urethra is feasible bladder enlargement treatment;
For interstitial cystitis, oral medications, sacral nerve electrical stimulation (bladder pacemaker), and urinary diversion are commonly used; for neurogenic OAB and idiopathic OAB, bladder training and medications (tolterodine, etc.) are the preferred treatment, and second-line treatment is sacral nerve electrical stimulation (bladder pacemaker) and urinary diversion.
Minimally invasive, reversible sacral nerve electrical stimulation (bladder pacemaker) is preferred as second-line treatment when first-line treatment (medication and behavioral therapy) is not effective.