Overactive bladder syndrome is a syndrome consisting of clinical symptoms such as urinary urgency, urinary frequency and urge incontinence. In the past, the terms were confusing, such as female urethral syndrome, detrusor hyperreflexia, detrusor instability, and unstable bladder. In order to standardize the definition of terms and treatment techniques, the first edition of the guidelines for the diagnosis and treatment of overactive bladder was revised by the Urological Control Group, which was assigned by the Urology Branch of the Chinese Medical Association.
I. Definition
OAB is a syndrome characterized by symptoms of urinary urgency, often accompanied by urinary frequency and nocturia symptoms, with or without urge incontinence; it can be urodynamically manifested by overactivity of the detrusor muscle or other forms of urethral-vesical dysfunction. Urinary urgency is a sudden, strong desire to urinate that is difficult to suppress subjectively and delays urination; urge incontinence is incontinence that accompanies, or immediately follows, urinary urgency; and frequency is a complaint that refers to the patient’s self-consciousness of urinating too frequently each day. On the basis of subjective perception, the frequency of urination in adults is considered to be frequent when the number of urination reaches: ≥8 times during the day, ≥2 times at night, and the volume of urine <200ml each time. Nocturia is defined as a patient's complaint of urination due to the urge to urinate ≥2 times/night or more.
The difference between OAB and lower urinary tract syndrome is that OAB only includes symptoms of the storage phase, while LUTS includes both storage and voiding symptoms, such as difficulty in urination.
Etiology and pathogenesis
The etiology of OAB is not well understood, but there are four types of OAB, as follows.
(1) Unstable detrusor muscle: caused by non-neurogenic factors, abnormal contraction of 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 the urethra and pelvic floor muscles;
(4) Other causes: such as abnormal mental behavior, hormone metabolism disorder, etc.
III. Diagnosis
1.Screening test
It refers to the examination items that should be completed by general patients.
(1) Medical history.
(1) Typical symptoms: including urinary diary assessment.
(2) Related symptoms: difficulty in urination, 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.
(1) General physical examination.
(2) Special physical examination: urinary and male reproductive system, neurological system, female reproductive system.
(3) Laboratory examination: routine urine, urine culture, blood biochemistry, serum PSA (male over 40 years old).
(4) Special urological examination: urinary flow rate, urological ultrasonography (including residual urine determination).
2.Elective examination
Refers to special patients, such as patients suspected of the presence of a certain pathology, 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) Cytologic examination: urine cytologic examination should be performed for suspected uroepithelial tumors.
(3) KUB, IVU, urological endoscopy, CT or MRI examination: for suspected other diseases of the urinary tract.
(4) Invasive urodynamic examination.
(1) Purpose: To further confirm OAB, determine the presence or absence of lower urinary tract obstruction, and assess the function of the forced urinary muscle.
(2) Indications: 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; before any invasive treatment; further evaluation is needed for lower urinary tract dysfunction found during screening tests.
3.OAB diagnosis and treatment principles
(1) Preferred treatment.
①Bladder training
Method 1: Delay urination and gradually make each urination volume greater than 300ml.
Treatment principle: relearn and master the skill of controlling urination; interrupt the vicious cycle of mental factors; reduce the sensitivity of the bladder.
Indications: OAB symptoms such as urinary urgency and frequency.
Contraindications: low compliant bladder, bladder pressure greater than 40cmH2O at the end of the storage period.
Requirements: practical implementation of treatment as planned
②Cooperative measures: adequate ideological work; urinary diary; others.
Method 2: Timed Voiding (Timed Voiding)
Objective: To reduce the number of incontinence and improve the quality of life.
Indications: Severe incontinence that is difficult to control.
Contraindication: with severe urinary frequency.
③Biofeedback therapy
④)Pelvic floor muscle training
⑤ Other behavioral therapy: hypnotherapy.
(2) Drug therapy
1) First-line drugs: tolterodine (Tolterodine).
①Advantages: non-selective M receptor antagonist, is currently the most selective effect on the forced urinary muscle tissue, and less side effects, better tolerability.
②Problems: The organ-selective effect remains to be studied, and the route of administration of the dosage form should be improved to reduce side effects.
2) Other optional drugs.
① other M receptor antagonists: Oxybutynin (Oxybutynin), Probenecid, etc.
② sedative and anxiolytic drugs: promethazine, doxorubicin, valium, etc.
③Calcium channel blockers: isoparaben, cardiac painkillers.
④Prostaglandin synthesis inhibitor: anti-inflammatory pain.
3) Other drugs: the efficacy of flavone permethrin is not exact, and herbal preparations are still lack of credible bulk trial reports.
(3) Indications for changing the preferred treatment: ① ineffective; ② patients cannot adhere to treatment or request to change treatment; ③ intolerable side effects; ④ possible irreversible side effects; ⑤ significant decrease in urinary flow rate or significant increase in residual urine volume during treatment.
2.Optional treatment
(1) Bladder perfusion with capsaicin, RTX, hyaluronidase.
The above substances can be involved in bladder sensory afferents and reduce bladder sensory afferents after instillation, which can be tried for those with severe bladder sensory allergy.
(2) Botulinum toxin type A multi-point injection into the bladder forced urinary muscle: It is effective for severe forced urinary muscle instability.
(3) Neuromodulation: Sacral nerve electrical modulation therapy is effective in patients with intractable urinary frequency and urgency and urge incontinence. Commonly known as a bladder pacemaker, this treatment is minimally invasive, reversible, adjustable and other advantages, and is the treatment of choice for poor results of drug therapy.
(4) Surgery.
①Surgical indications: should be strictly controlled, only for those with severe hypo-compliant bladder with too small bladder capacity and endangering the function of the upper urinary tract, and ineffective by other treatments.
(2) Surgical methods: transection of the forced urinary muscle, bladder autotomy, bowel bladder enlargement, and urinary diversion.
(5) Acupuncture treatment: Some data show that acupuncture at the foot San Li, San Yin Jiao, Qi Hai, and Guan Yuan points can help relieve symptoms.
The guiding principle of combined medication: Since the etiology of OAB is unknown, some patients have poor treatment results. For postmenopausal patients, female hormones can be added on a trial basis. Until the symptoms are completely controlled, then gradually reduce the dose; ③ Capsaicin, A-type botulinum toxin and other optional treatments should only be considered when the symptoms are heavy and other treatments are not effective; ④ Surgical treatment should be strictly controlled for the indications.
V. Principles of diagnosis and treatment of OAB symptoms in other diseases
OAB is an independent symptom group, but clinically, there are many diseases that can also show OAB symptoms, such as various causes of bladder outlet obstruction (BOO), neurogenic voiding dysfunction, and various causes of genitourinary system infections. 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. As OAB symptoms in these diseases often have their own specificity, this consultation guide will introduce the principles of diagnosis and management of OAB symptoms in several common clinical diseases, in order to provide clinical assistance in the management of OAB symptoms while treating the primary disease.
(a) OAB in patients with Bladder Outflow Obstruction (BOO).
Common etiologies: benign prostatic hyperplasia, female bladder neck obstruction, etc.
1. Screening tests: symptoms, Qmax, residual urine, etc. Consider BOO when maximal urine flow rate <15ml/s and residual urine >50ml.
2, Selective examination: filling cystometry and pressure/flow rate measurement to determine the presence or absence of BOO, the degree of BOO, and the function of the forced urinary muscle.
3, Treatment principles.
(1) Treatment for bladder outlet obstruction.
(2) Develop the appropriate treatment for OAB symptoms according to the status of the contractile function of the detrusor muscle: those with normal, enhanced or hyperactive detrusor contractile function may be treated with appropriate adjunctive anti-OAB; those with impaired detrusor contractile function should be treated with anti-OAB with caution.
(3) If OAB is not relieved after the obstruction is lifted, further examination should be performed, 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.
1.Actively treat the primary disease.
2.Treat OAB according to the presence or absence of BOO: OAB with stable primary disease and no lower urinary tract obstruction, the principles of diagnosis and treatment are the same as OAB.
3, Those with BOO are treated according to the principles of diagnosis and treatment of BOO.
(3) Principles of diagnosis and treatment of OAB in patients with Stress Urinary Incontinence (SUI).
1. Screening examinations should suspect the possible coexistence of stress urinary incontinence in the following cases: (1) history suggesting both urge urinary incontinence and stress urinary incontinence manifestations. (2) Significant changes in urinary control function before and after childbirth and before and after menopause. (3) If both stress and urge incontinence symptoms are present. (4) Female pelvic organ bulge.
2. Selective examination: (1) Physical examination: bladder neck lift test and swab test. (2) Urodynamic examination: cystometry, abdominal pressure leak point pressure or urethral pressure tracing. (3) Cystourethrography during voiding: closure of the bladder neck and proximal urethra, downward migration or mobility. The purpose of the examination is to determine whether there is combined stress incontinence, and to determine the degree of stress and urge incontinence.
3. Treatment principles: (1) Anti-OAB treatment is preferred for those with OAB as the main symptom. (2) If stress incontinence is still severe after OAB is lifted, the treatment related to stress incontinence will be used.
(4) Principles of OAB diagnosis and treatment in patients with impaired contractility of the detrusor muscle
1. Screening tests should highly suspect OAB with impaired contractility of the detrusor muscle in the following cases: (1) difficult urination symptoms. (2) The presence of diseases that significantly affect the function of the detrusor muscle, such as diabetes mellitus and stroke. (3) Indications of possible impaired function of the forced urinary muscles, such as relaxation of the anal sphincter and markedly decreased perineal sensation. (4) Maximum urinary flow rate <10 ml/s with a low flat graphic. (5) Severe difficulty in urination, significantly reduced urine flow rate or a large amount of residual urine, but the prostate is not large.
2, Selective examination diagnostic criteria: (1) Pressure-flow rate measurement suggests low pressure – low flow. (2) No bladder outlet obstruction.
3, First-line treatment: (1) Urinary training and regular urination. (2) Appropriate use of anti-OAB drugs on the basis of detecting residual urine. (3) Assist with abdominal pressure for urination. (4) Use intermittent catheterization or other treatment if necessary. (5) Receptor blocking agents can be added to reduce bladder outlet resistance.
4. Second-line treatment: (1) Sacral neuromodulation therapy. (2) Temporary or permanent urinary flow diversion.
(V) Others
In addition to the aforementioned diseases, there are many urological and male genital system diseases that can cause or accompany OAB syndrome. For example, acute and chronic urinary tract specific and nonspecific infections, acute and chronic prostatitis, urinary tract tumors, bladder stones, and bladder spasm after bladder and prostate surgery. Although these localized bladder lesions are not referred to as OAB, the principles may still be used to guide treatment after control and resolution of localized bladder lesions to relieve OAB symptoms.
Principles of diagnosis and treatment.
(1) Aggressive treatment of the primary disease.
(2) Use anti-OAB drugs along with aggressive treatment of the primary disease to relieve symptoms.