Just come out of the toilet and want to urinate, a night up to urinate N times, sleep is not good, and each time is very urgent, as if immediately do not go to the toilet will drip wet underwear, which makes many people troubled, in fact, this is the legendary “overactive bladder syndrome”.
Overactive bladder syndrome (OAB)
Overactive bladder (OAB) is one of the common urological disorders. There are approximately 50-100 million cases of OAB worldwide. The incidence of OAB increases with age and is in the top 10 of chronic diseases, and is higher than the incidence of diabetes and peptic ulcers.
Typical case
Female patient, 64 years old, with urinary urgency for 10 years, aggravated by urinary incontinence for 1 year, accompanied by urinary frequency and urgency after urination, urinating 1~2 times at night, requiring 4~5 pads daily. No difficulty in urination and defecation, no uterine prolapse. No history of childbirth, no history of pelvic or abdominal surgery or urinary tract infection. 50 years of age with menopause, drinking 14 glasses of water per day (240 ml per glass).
Relevant examinations and diagnosis
The examination showed a residual urine volume of 20 ml after 350 ml of urination, normal urinalysis, atrophic changes in the vaginal and urethral orifices, no vaginal bulge during the Valsalva maneuver, and a grade 2 pelvic floor muscle function test (i.e., the pelvic floor muscle contraction time was initially maintained for 8 seconds, but the contraction maintenance time decreased after several repetitions). The patient was diagnosed with OAB.
Treatment history
Initial treatment measures ① Pelvic floor muscle training (PFME), 3 sets of 10 reps per day. The duration of each session was 3 seconds at first and increased to 10 seconds as muscle tolerance increased. ②Teach the patient urinary urge suppression techniques, i.e., slow deep breathing, rapid alternating contractions, relaxation of the pelvic floor muscles and distraction to attenuate the urge to urinate. (iii) Oral tolterodine was administered.
After 2 months treatment plan patient’s symptoms improved significantly after 2 months, nighttime urination was reduced to 0~1 time and the number of leakage was significantly reduced.
At the review of the treatment regimen after 5 months, the patient’s symptoms improved further, with occasional urgency and 1 nocturia. Considering that the patient still had symptoms of urinary urgency after receiving tolterodine, the treatment was changed to solifenacin 5 mg Qd and the rest of the treatment as before.
At 14 months, the patient’s symptoms recurred and the doctor increased solifenacin to 10 mg Qd. The patient continued to have urinary urgency, incontinence several times a day and nocturia once a day. Urodynamic examination showed involuntary contractions of the detrusor muscle during the filling phase of the bladder with a pressure of 70 cmH2O, which was eliminated by applying the urgency suppression technique.
During bladder filling, Valsalva’s maneuver resulted in a small amount of urine outflow. Urine flow rate measurements were normal. Due to the ineffectiveness of medication and conservative treatment, the patient was recommended to undergo neuromodulation therapy. Electrode placement surgery was performed after confirming the effectiveness of electrical stimulation. After the surgery, the results were good, with a 50% reduction in the frequency of urinary urgency and 6 to 7 urinations per day.
OAB diagnosis
OAB is a syndrome characterized by symptoms of urinary urgency, often accompanied by symptoms of urinary frequency and nocturia, and may be accompanied by urge incontinence.
OAB has no clear etiology and does not include diseases caused by acute urinary tract infections or localized lesions of the bladder urethra. It is currently believed that the pathogenesis of OAB is due to instability of the detrusor muscles, bladder sensory hypersensitivity, and abnormal urethral and pelvic floor muscle function.
The diagnosis of the disease must be based on a comprehensive assessment of the patient’s symptoms, examination and relevant indicators, and other etiologies (e.g., infection, tumor) must be excluded.
Relevant examinations include history taking, physical examination and laboratory tests. History collection includes: (1) urinary diary (including daily urination time, urine volume, frequency of incontinence and accompanying conditions); (2) related symptoms (difficulty in urination, incontinence, sexual function and defecation status, etc.); (3) history of the urinary system, menstruation, childbirth, gynecology, and neurological history. Physical examination included urinary system, neurological system and female reproductive system examination. Specialist urological examinations include urinary flow rate, urological ultrasonography (including residual urine determination), etc.
Patients should also undergo urodynamic testing for the following conditions: decreased urinary flow rate or increased residual urine volume, failure of preferred therapy or development of urinary retention and prior to invasive therapy.
OAB treatment strategy
Treatment measures for overactive bladder disorder include behavioral and pharmacological therapy, with combination therapy being more effective than monotherapy. If combination therapy fails, neuromodulation (including sacral and peripheral nerve electrical stimulation) therapy or surgical treatment (bladder enlargement, urinary diversion surgery) may be considered.
Preferred treatment options
This treatment measure is an important part of the initial treatment of OAB and includes bladder training, physical therapy, urgency suppression techniques, self-monitoring, and diet and fluid intake modification.
Bladder training includes delayed voiding and regular voiding. This is done by drinking more water during the day and maximizing the interval between voiding. No more water after nightfall, no stimulating or stimulating drinks, and defining the time of voiding with reference to last week’s voiding diary.
Physical therapy includes pelvic floor muscle training and biofeedback therapy. Pelvic floor muscle training is used by patients to prevent and treat female urinary incontinence through voluntary, repetitive contraction and diastole of the pelvic floor muscle groups to enhance pelvic floor muscle tone, increase urethral resistance, and restore relaxed pelvic floor muscles.
Biofeedback therapy (BFB) is also an active pelvic floor rehabilitation method, which helps the doctor to guide the patient to perform correct and autonomous pelvic floor muscle training with the help of an electronic biofeedback device placed in the vagina or rectum.
The first line of treatment for OAB is anticholinergic drugs, which are designed to reduce bladder parasympathetic excitability and block bladder afferent nerves. Cholinergic receptors (M2 and M3) are abundant in the bladder forceps, and forceps contraction is mediated by agonism of cholinergic M receptors.
Indications for anticholinergic drugs are patients with normal pelvic floor muscle function, low bladder capacity, hyperreflexia of the detrusor muscle, detrusor instability, or a sense of urgency.
Drugs commonly used clinically include.
(i) simple-acting anticholinergics [e.g., tolterodine (non-selective M2 receptor antagonist), trasylcholine (high affinity for M1 and M3 receptors and higher selectivity for the bladder)].
(ii) mixed-action anticholinergic drugs (e.g., oxybutynin, which is both an antimuscarinic drug and a calcium channel blocker with high affinity for M1 and M3 receptors, acts on the bladder forceps to release smooth muscle spasm and reduce intravesical pressure).
(iii) New anticholinergic drugs (such as solifenacin), which are more selective for M receptors, have stronger therapeutic effects and have fewer side effects.
Sedative and anxiolytic drugs can be used for those with severe neurological deficits, poor sleep quality and more frequent nighttime urination. Estrogen therapy should be added for postmenopausal patients with overactive bladder. Estrogen significantly improves urinary frequency, urgency, nocturia, dyspareunia and recurrent urinary tract infections and is effective with both oral and topical treatment.
Secondary treatment options
In the event that the above preferred treatment options are ineffective, the patient is unable to adhere to treatment, or intolerable side effects occur, the patient may receive the following treatments
Bladder infusion of capsaicin and hypericin These drugs act on the peripheral nervous system, and capsaicin receptors (VR1) are class C afferent nerve fiber surface ion channels that control the bladder voiding reflex. Capsaicin receptor concentrations can be increased by bladder overactivity, and capsaicin and hypericin (RTX) can interact with capsaicin receptors in the bladder to inhibit nerve growth factor uptake, interfere with capsaicin receptor upregulation, and reduce the frequency of urge incontinence during detrusor overactivity.
Patients may also receive botulinum toxin therapy (intravesical injection), which blocks the release of acetylcholine from the cholinergic nerve terminals at the neuromuscular junction, thereby causing paralysis of the detrusor muscle and increasing bladder volume and decreasing voiding pressure.
Neuromodulation therapy This treatment includes.
(1) Sacral nerve electrical modulation therapy, which is effective for some patients with intractable urinary frequency and urgency and urge incontinence by continuously stimulating specific sacral nerves with an embedded “pacemaker” in the body to interfere with the abnormal reflex arc of the sacral nerves.
Peripheral nerve stimulation therapy (such as transcutaneous tibial nerve stimulation) can significantly improve the amplitude of involuntary contraction of the detrusor muscle and increase bladder capacity, thus improving the patient’s symptoms.