Overactive Bladder Disease Treatment Guidelines

Definition

Overactive Bladder (OAB) is a syndrome characterized by symptoms of urinary urgency, often associated with urinary frequency and nocturia, with or without urge incontinence; it may manifest urodynamically as detrusorinstability,ordetrusoroveractivity, or as other forms of urethrocystic dysfunction. OAB has no clear etiology and does not include symptoms due to acute urinary tract infection or other forms of localized lesions of the vesicourethra.

The difference between OAB and lowerurinarytractsymptoms (LUTS) is that OAB only includes symptoms of the urinary storage phase, whereas LUTS includes both storage and voiding symptoms.

Diagnosis

(i) Screening tests

Refers to the examination items that should be completed in general patients.

Medical history ① Typical symptoms:including assessment of urinary diary; ② Related symptoms:urinary difficulties, urinary incontinence, sexual function, defecation status, etc.; ③ Related medical history: history of urinary and male genital system diseases and treatment; history of menstrual, fertility, gynecological diseases and treatment; history of neurological diseases and treatment.

Physical examination ① general physical examination; ② special physical examination: urinary and male genital system, neurological system, female genital system.

Laboratory examination urinary routine.

Special urological examination of urinary flow rate, urological ultrasonography (including residual urine determination).

(II) Selective examination

Refers to special patients, such as patients suspected of the presence of a certain pathology, should be selective to complete the examination program.

Pathogenic examination of urine, prostatic fluid, urethral and vaginal secretions should be performed in patients suspected of having inflammatory diseases of the urinary or reproductive system.

Cytological examination of urine for suspected uroepithelial tumors.

Urinary tract imaging, invasive urodynamic examination.

Principles of OAB diagnosis and treatment

(I) Preferred treatment

Behavioral training

(1) Bladder training: delay urination and gradually make each urination volume greater than 300ml.

Therapeutic rationale: relearning and mastering the skills to control voiding; interrupting the vicious cycle of psychological factors; reducing bladder sensitivity.

Contraindications: low compliant bladder with end-of-filling period forced urinary muscle pressure greater than 1000pxH2O.

2）Timed voiding

I. Purpose: To reduce the number of urinary incontinence and improve the quality of life.

Ⅱ. Indications: Those with severe incontinence and difficult to control.

Ⅲ. Contraindication: with severe urinary frequency.

Drug treatment

(1) First-line drugs: Tolterodine, Trospium, Solifenacin

(2) Other optional drugs

(1) Other M receptor antagonists: Oxybutynin, Propiverine, Probenecid, etc.

(2) Sedative and anxiolytic drugs: promethazine, doxorubicin, valium, etc.

(3) Calcium channel blockers: isoproterenol, cardiac painkillers.

4) Prostaglandin synthesis inhibitors: anti-inflammatory pain.

Indications for changing the preferred treatment

1) Ineffectiveness.

2）Patients are unable to adhere to treatment or request a change of treatment.

3) the appearance or possibility of intolerable side effects.

4) Significant decrease in urinary flow rate or significant increase in residual urine volume during treatment.

(II) Optional treatment

Multi-point injection of botulinum toxin type A into the bladder forced urinary muscle is effective in severe forced urinary muscle instability.

Bladder perfusion of RTX, hyaluronidase, capsaicin above substances can be involved in bladder sensory afferents, and decrease bladder sensory afferents after perfusion, which can be tried for severe bladder sensory allergy.

Neuromodulation sacral electro-modulation therapy is effective in some patients with intractable urinary frequency and urgency and urge incontinence.

Surgical procedures

(1) Surgical indications: should be strictly controlled, only for those with severe hypo-compliant bladder, small bladder capacity, and endangering the function of the upper urinary tract, and ineffective with other treatments.

(2) Surgical methods: transection of the forced urinary muscle, autologous bladder enlargement, bowel bladder enlargement, urinary diversion.

Guidelines for combined medication: Since the etiology of OAB is unknown and some patients have poor treatment results, it is recommended in the selection of treatment that: (1) bladder training, although it can be performed alone, is more acceptable to patients when combined with medication; (2) in medication, other medications are used in conjunction with first-line medications, depending on the patient’s condition.

For patients with significant neurasthenia, poor sleep and nocturnal urinary frequency, sedative and anxiolytic drugs can be added; for postmenopausal patients, female hormones can be added on a trial basis; for patients with mild bladder outlet obstruction, α-blockers can be combined with α-blockers.

For patients with severe symptoms, especially those with significant detrusor instability, one or two detrusor contraction inhibitors with different therapeutic mechanisms can be used; the dose can be started from a small dose and gradually increased until the efficacy or side effects appear; the duration of medication should not be too short, and the efficacy should be evaluated after 2 weeks of continuous use (except for those with side effects) until the symptoms are completely controlled and then gradually reduced; ③ Botulinum toxin type A, RTX and other optional treatments can be used only after the symptoms are fully controlled. RTX and other optional treatments should only be considered when the symptoms are heavy and other treatments are not effective.

Principles of diagnosis and treatment of OAB symptoms in other diseases

OAB is an independent symptom group. However, OAB symptoms can occur in many clinical conditions, such as bladder outlet obstruction (BOO) of various causes, neurogenic voiding dysfunction, and genitourinary infections of various causes. In these diseases, OAB symptoms can be secondary or may be concomitant with the primary disease, such as OAB symptoms in patients with benign prostatic hyperplasia. Because OAB symptoms in these diseases often have their own specificity. For this reason, this guideline will introduce the principles of diagnosis and management of OAB symptoms in several common clinical conditions in order to provide clinical assistance in the management of OAB symptoms along with the treatment of the primary disease.

(A) The principles of OAB in patients with bladderoutflowobstruction (BOO)

Common causes: benign prostatic hyperplasia, female bladder neck obstruction, etc.

Treatment principles.

(1) Treatment for bladder outlet obstruction.

(2) Develop appropriate treatment for OAB symptoms according to the status of contractile function of the detrusor muscle: those with normal or enhanced detrusor contractility may be treated with appropriate adjunctive anti-OAB; those with impaired detrusor contractility should be treated with anti-OAB with caution.

(3) Those whose OAB is not relieved after the obstruction is lifted should undergo further examination, and the treatment can be handled according to OAB.

(2) Principles of diagnosis and treatment of OAB in patients with neurogenic voiding dysfunction

Common causes: stroke, spinal cord injury and Parkinson’s disease, etc.

Principles of diagnosis and treatment.

Active treatment of the primary disease.

For those who are able to urinate spontaneously and wish to maintain spontaneous urination, OAB should be treated accordingly according to the presence or absence of lower urinary tract obstruction. For those without lower urinary tract obstruction, refer to the above OAB treatment principles; for those with obstruction, follow the BOO treatment principles.

For those who cannot urinate on their own, treat according to OAB to relieve symptoms.

(① Anti-OAB treatment is preferred for those with OAB as the main symptom. (2) If stress urinary incontinence is still severe after OAB is relieved, treatment related to stress urinary incontinence should be used.

(iv) OAB treatment for patients with impaired contraction of the detrusor muscle

Voiding training, regular voiding; appropriate anti-OAB medication based on detection of residual urine; assisted abdominal pressure voiding; receptor blockers may be added to reduce bladder outlet resistance; interstitial catheterization.