New Pharmacologic and Minimally Invasive Therapies for the Overactive Bladder

Michael Franks, MD, Emmanuel Chartier-Kastler, MD, Michael B. Chancellor, MD

Disclosures
In This Article

Diagnosis of Incontinence

Evaluation of a patient with OAB and/or urinary incontinence should include a formal history, a focused physical examination, voiding diary, and possibly urodynamic testing. The history should be directed toward symptoms and onset of the problem. The use of a voiding diary is a useful tool to help quantify the amount and the frequency of problems and correlate them with the patient's symptoms. The voiding diary should provide 3 key pieces of information. First, does urgency always precede leakage? Second, does the leakage occur with coughing, sneezing, or standing? Finally, do both situations occur at different times? Medical history should also include questions to exclude an underlying contributing medical illness such as diabetes, Alzheimer disease, Parkinson disease, or multiple sclerosis. Urinary tract infection, bladder tumors, carcinoma in situ, bladder stones, and interstitial cystitis must also be considered and ruled out when appropriate.

We cannot talk about urge incontinence and OAB without taking into account stress incontinence. The bladder does not exist alone in a vacuum. It is intimately attached to and functions with the sphincter. In many patients, especially women, OAB commonly coexists with stress urinary incontinence (SUI). If a patient complains of both stress and urge symptoms, and the stress incontinence is a significant component of her symptoms, then there is more than an 85% chance that after corrective surgery (pubovaginal sling), both conditions will be cured or improved.[7,8,9,10,11,12] It should be made clear to the patient that preoperative detrusor instability does not preclude surgical repair for SUI. Medical treatment of the detrusor instability is effective after surgery.[7] In other words, both conditions should be managed independently and concurrently. Patients with defined stress and urge incontinence require a clear understanding of both problems if treatment is to be adequate.

Outlet obstruction or denervation of the bladder may cause detrusor instability in women after anti-incontinence surgery. Iatrogenic urethral obstruction is not uncommon following anti-incontinence surgery, with an incidence ranging from 2.5% to 24%.[13,14,15,16,17,18] Detrusor instability was reported to be 34% in a group of women with iatrogenic urethral obstruction.[18] In this same series, urgency occurred in 73% and urge incontinence in 39%,before corrective surgery. Following corrective surgery (urethrolysis), urgency and urge incontinence decreased to 32% and 20%, respectively. Normal values for pressure flow data in women are scarce and, for that reason, the diagnostic criteria for urethral obstruction has not been well established. Accordingly, the incidence of urethral obstruction in women is not known, and the relationship between obstruction and detrusor overactivity is conjectural at best. Nevertheless, since symptomatic detrusor instability usually subsides after relief of obstruction, we believe that it is important to rule out urethral obstruction as part of the routine evaluation of women with presumed or definite detrusor overactivity.

The principle of treatment of urinary incontinence due to detrusor instability is abolition of involuntary contractions. This is most commonly accomplished pharmacologically, but it may also be achieved surgically. Over the past decade, a number of other therapies have been advocated including behavior modification, electrical stimulation, and biofeedback (Table 2).

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