Step 5 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 resolution. In the early stage, OAB is mainly caused by the 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 very small and round, the edges are not smooth, not folded, and in severe cases the bladder neck is open; cystoscopy shows a small bladder volume, poor compliance, and the entire bladder mucosa is congested and edematous. Treatment of bladder contracture often requires surgery, and if there is no stricture in the urethra, it can be treated by bladder enlargement. Lu Jianwei, Department of Urology, Shanghai Renji Hospital
Interstitial cystitis is a multifactorial symptom cluster that manifests as urinary frequency, urinary urgency and pain in the bladder area. The main cause of OAB may be the disruption of the bladder mucosal barrier, which allows the leakage of urinary toxic substances (potassium ions, etc.) into the bladder interstitium, damage to muscles and nerves, and the reduction of bladder capacity due to advanced bladder muscle fibrosis, which leads 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 hydrodilation of the bladder under anesthesia).
The sixth step is the presence of anxiety 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 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 is also helpful.
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, and in urodynamics it is called idiopathic detrusor instability (DI). The majority of patients are children and women.
[Principles of treatment]
The general principle of treating 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 are the main factors; for secondary OAB such as urinary tract infection, prostatitis, prostatic hyperplasia, bladder tumor, stone, etc., the primary disease is actively treated and anti-OAB drugs are used to relieve symptoms; for tuberculous small bladder with no urethral stricture, bladder enlargement is feasible; for interstitial cystitis, the common treatment methods For interstitial cystitis, oral medications, bladder irrigation, bladder hydrodilation, sacral nerve electrical stimulation, and urinary diversion are commonly used; for neurogenic OAB and idiopathic OAB, bladder training and medications (tolterodine, etc.) are the preferred treatment, and bladder irrigation, sacral nerve electrical stimulation, and urinary diversion are the second-line treatments.