Overactive bladder syndrome (OAB) is a syndrome characterized by symptoms of urinary urgency, often accompanied by urinary frequency and nocturia, with or without urge incontinence, which significantly affects the daily life and social activities of patients and has become a major disease that bothers people. In recent years, as China enters an aging society, and the growth of diabetes and neurological impairment diseases, the incidence of the related diseases secondary to this overactive bladder syndrome is also increasing year by year.
Etiology.
1. The etiology of non-pharmacological OAB is not well defined and is currently considered to be of the following four types.
1, instability of the detrusor muscle: caused by non-neurogenic factors, abnormal contraction of the detrusor muscle during the storage phase causes the corresponding clinical symptoms.
2, bladder sensory hypersensitivity: the desire to urinate occurs at smaller bladder volumes.
3.Abnormal function of urethra and pelvic floor muscles.
4, Other causes: such as abnormal mental behavior, hormone metabolism disorder, etc.
Symptoms.
Typical symptoms of overbladder:Bladder dysfunction (60%) Urinary urgency (60%) Incomplete bladder emptying (55%) Polyuria (55%) Reduction in bladder capacity (50%) Increased residual bladder volume (50%)
Burning pain in the urethra during urination, frequent urination, often accompanied by urinary urgency, in severe cases similar to urinary incontinence, urinary frequency and urgency are often particularly pronounced, up to 5-6 times per hour or more, each urine volume is not much, or even only a few drops, and there may be pain in the lower abdomen at the end of urination.
Diagnosis.
OAB is a separate symptom group. However, OAB symptoms can also occur in many clinical conditions, such as bladder outlet obstruction from various causes, neurogenic voiding dysfunction, and genitourinary infections from 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.
(i) Screening tests: These are tests that should be completed in general patients.
How to examine.
1. Medical history.
(i) Typical symptoms:including assessment of a urinary diary.
(ii) Related symptoms:urinary difficulties, urinary incontinence, sexual function, defecation status, etc.
③Related medical history: history of urinary and male reproductive system diseases and treatment; history of menstruation, fertility, gynecological diseases and treatment; history of neurological diseases and treatment.
2.Physical examination:
①General physical examination.
②Special physical examination: urinary and male reproductive system, neurological system, female reproductive system.
3.Laboratory examination: urinary routine.
4.Special urological examination: urinary flow rate, urological ultrasonography (including residual urine determination).
(B) selective examination: refers to special patients, such as patients suspected of the presence of a certain lesion, should be selective to complete the examination program.
1.Pathogenic examination: pathogenic examination of urine, prostatic fluid, urethral and vaginal secretions should be performed for suspected inflammatory diseases of the urinary or reproductive system.
2, cytological examination: urine cytological examination should be performed for suspected uroepithelial tumor.
3.Urethral plain film, intravenous urography, urological endoscopy, CT or MRI examination: if other diseases of the urinary tract are suspected.
4.Invasive urodynamic examination.
①Objective: to determine the presence or absence of lower urinary tract obstruction and to assess the function of the forced urinary muscle.
②Indications: invasive urodynamic testing is not a routine test, but invasive urodynamic testing should be performed in the following cases: decreased urinary flow rate or increased residual urine; failure of preferred treatment or presence of urinary retention; prior to any invasive treatment; further evaluation is needed for lower urinary tract dysfunction identified during screening tests.
③Selected items: bladder pressure measurement; pressure-flow rate measurement, etc.
5. Other tests: urine culture, blood biochemistry, serum PSA (for men over 40 years of age), etc.
Treatment.
I. Behavioral training
1.Bladder training
(1) Method 1: Delay urination and gradually make each urination volume greater than 300ml.
(1) Treatment principle: relearn and master the skill of controlling urination; interrupt the vicious circle of mental factors; reduce the sensitivity of the bladder.
(ii) Contraindications: low compliant bladder with end-of-filling period forced urinary muscle pressure greater than 40cmH2O.
③Requirements: practical implementation of treatment as planned.
(④Cooperative measures: adequate ideological work; voiding diary; others.
(2) Method 2: Regular urination
①Objective: To reduce the number of incontinence and improve the quality of life.
②Indications: Those with severe incontinence that is difficult to control.
(3) Contraindication: with severe urinary frequency.
2.Biofeedback therapy
3.Pelvic floor muscle training
4.Other behavioral therapy: hypnotherapy.
Second, drug treatment
1.First-line drugs: Tolterodine, Trospium, Solifenacin.
(1) Mechanism of action.
(1) Inhibition of contraction of the detrusor muscle through antagonism of M receptors, improvement of bladder sensory function and inhibition of detrusor instability contraction possible.
(ii) Highly selective action on the bladder, a property that is the main basis for the ability of the above drugs to be used as first-line therapeutic agents, thus enabling such drugs to ensure efficacy and minimize side effects.
(2) Problems.
(i) Efficacy needs to be improved, the main reason being that the etiology of OAB is unknown and blocking M receptors does not necessarily improve symptoms.
(2) Organ-selective effects need to be studied, and the route of administration of the dosage form should also be improved to reduce side effects.
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 blocking agents: isoproterenol, cardiac pain.
(4) prostaglandin synthesis inhibitor: anti-inflammatory pain.
(3) Other drugs: the efficacy of flavone permethrin is inaccurate, and there is a lack of credible trial reports on Chinese herbal preparations.
Third, change the indications of preferred treatment
1, ineffective.
2, patients can not adhere to treatment or request a change in treatment.
3.The occurrence or potential occurrence of intolerable side effects.
4.Significant decrease in urinary flow rate or significant increase in residual urine volume during treatment.
These treatments still do not change the symptoms can be considered sacral nerve stimulation treatment.
Sacral nerve stimulation therapy – bladder pacemaker treatment I have described in detail before, please browse.
Pelvic floor training alone is less effective in treating OAB and is generally difficult to maintain over time. Biofeedback therapy refers to the use of simulated acoustic or visual signals to provide feedback to indicate normal or abnormal pelvic floor muscle activity status in order to enable patients to obtain correct and more effective pelvic floor training, i.e. biofeedback is not a treatment in itself, but only used to assist pelvic floor training, which is an enhanced pelvic floor training. The efficacy of biofeedback in the treatment of OAB varies widely in the literature, and in general, about 1/3 of patients with OAB symptoms can be significantly improved. “
Most of the electrical stimulation treatments are administered through anal electrodes or vaginal electrodes with intermittent low-voltage pulsed wave stimulation of different frequencies to achieve therapeutic goals. The optimal frequency for inhibiting contraction of the detrusor muscle has been found to be 10 Hz. The efficacy of electrical stimulation treatment also varies widely depending on the patient’s condition and treatment modality, but most studies have shown that about 50% of OAB patients achieve some degree of improvement.
Sacral nerve electrical stimulation is a new type of electrical stimulation treatment that has emerged in recent years, which requires the surgical insertion of electrodes that can be permanently implanted in the body next to the S3 nerve to provide continuous electrical pulse stimulation. Sacral nerve stimulation has now become an important treatment option for patients with recalcitrant OAB.
Traditional surgical procedures are equally effective for severe OAB, including forced urinary muscle transection, bladder autodilation, bowel bladder enlargement, and urinary diversion. However, the indications should be strictly controlled and should only be used for severe hypocompliant bladder with too small a bladder capacity that jeopardizes the function of the upper urinary tract and has failed with other treatments. “
In recent years there has been active research on intravesical drug instillation and drug injection for OAB, such as bladder instillation of capsaicin and hyaluronidase, which reduces bladder sensory afferents through the action of instilled drugs and is a better option for severe bladder sensory hypersensitivity. Although the specific mechanism of action of botulinum toxin bladder forcing muscle multipoint injection is poorly understood, clinical reports have shown some efficacy in severe forceps instability.
The main adverse effects of anticholinergic drugs are related to their antimuscarinic effects. Common adverse reactions include dry mouth, dyspepsia, headache, dizziness, constipation, dry eyes, and difficulty in urination. Regular monitoring of urinary flow rate and residual urine volume during anticholinergic drug treatment for OAB is important to avoid difficulty in urination or even urinary retention.
Anticholinergic drugs should be used with caution in patients with pre-existing constipation and glaucoma. It is wise to start with a small dose and gradually increase it for any patient. Recently, M3 blockers have been developed abroad, which are expected to reduce the side effects of the drug due to their high bladder selectivity and make it easier for patients to take them for a long time.