Overactive bladder

M.S. em Dr SN Medical College Jodhpur
20 de Jun de 2015

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Overactive bladder

  2. CONTENTS • Introduction • Nerve supply • Physiology of Micturition • Urinary continence • Definition Overactive bladder • Etiology • Pathophysiology • Symptoms • Diagnosis • Treatment • Differential diagnosis
  3. Introduction • Bladder- Detrusor, Trigone, Bladder neck • Urethra- Proximal, Mid, Distal, Submucous & Mucous layers • Supports to Bladder neck & urethra - 1. INTRINSIC: Rhabdosphincter, Cavernous plexus, Urethral smooth muscles, Sympathetic activity, Estrogen 2. EXTRINSIC: Pubococcygeus, Pubourethral ligaments & condensed endopelvic fascia, Urogenital diaphragm, uterus & cervix, Exercise
  4. Nerve supply of Vesicourethral unit
  5. Micturition Reflex Filling of bladder Stimulation of stretch receptors Afferent impulses via Pelvic nerve Sacral segments of spinal cord Efferent impulses via pelvic nerve Contraction of detrusor Relaxation of sphincter Flow of urine into urethra & stimulation of stretch receptors Efferent impulses via pelvic nerve Inhibition of pudendal nerve & relaxation external sphincter
  6. • Once it begins it is self regenerative • Initial contraction increases sensory impulses from bladder & urethra. These further increase in reflex bladder contraction • Cycle is repeated until force of bladder contraction reaches maximum. • HIGHER CENTRES FOR MICTURITION- 1. Inhibitory Areas: mid brain, Frontal cerebral cortex 2. Facilitatory Areas: Pons & posterior hypothalamus
  7. Physiology of Micturition STORAGE PHASE: • Fills at rate of 0.5- 5 ml/min. • Intravesical pressure 10 cm of water even with 500ml volume. • Intravesical pressure kept lower by- 1. Proximal urethral musculature 2. Detrusor stretching reflex contraction of neck 3. Spinal centres inhibit cholinergic system 4. Stimulation of β (relax detrusor) & α (contracts) adrenergic 5. External sphincter
  8. • VOIDING PHASE: • Stimulation of stretch receptors Untrained bladder Trained At spinal level Hypothalamus & Frontal lobes Controls spinal reflex arcInvoluntary voiding Voluntary inhibited Voiding
  9. Process of micturition Abdominal ms contracts & pelvic floor relax Drop in intraurethral pressure, sympathetic blockade, obliteration of post urethro vesicle angle Detrusor contracts Funneling of proximal urethra Urine leaks into upper urethra EUS opens & Voiding occurs Distal end of urethra closes, milking back last drop into bladder Post UrV angle restored & EUS closes
  10. Urinary Continence • Intraurethral pressure > Intravesical at rest & stress 20-50 cm of water 10 cm of water
  11. Pathophysiology of Continence • Maintained by: (at rest) 1. Apposition of longitudinal mucosal folds 2. Submucous vascular plexus (washer effect) 3. Rhabdosphincter & levator ani 4. Abundance of collagen & elastic tissue 5. Tonic contraction of prox. urethra & bladder neck • In stress- 1. Intra abdominal pressure at bladder neck 2. Reflex contraction of external sphincter 3. Kinking of urethra 1/3rd each
  12. Urinary incontinence • Objectively demonstrable involuntary loss of urine so as to cause hygienic &/ or social inconvenience for day to day activity. • Pathophysiology- Intravesical > intraurethral pressure Due to- childbirth, surgery, ageing Injury to supports of bladder neck
  13. Classification URETHRAL • Genuine Stress Incontinence • Overactive Bladder • Mixed • Overflow incontinence • Functional (DIAPPERS) • Congenital • Others (UTI) EXTRAURETHRAL • Congenital- Ectopic ureter • Acquired- Fistulae
  14. Definitions (Abnormal storage) • INCONTINENCE- Involuntary leakage of urine. • STRESS URINARY INCONTINENCE- Involuntary leakage due to sudden rise in intra-abdominal pressure. • GENUINE STRESS INCONTINENCE- Involuntary loss of urine when intravesical pressure exceeds intraurethral pressure in absence of detrusor overactivity. (Following urodynamic assessment only) • URGENCY- Sudden compelling desire to pass urine which is difficult to defer • URGE INCONTINENCE- Involuntary loss of urine associated with urgency
  15. • FREQUENCY- no. of voids per day from waking up until falling asleep at night. (pollakisuria) • NOCTURIA- interruption of sleep one or more time because of need to micturate. (It excludes last void before going to bed & includes first void after waking up in morning) • NOCTURNAL ENURESIS- Involuntary loss of urine that occurs during sleep. • OVERACTIVE BLADDER- urgency, usually with frequency and nocturia, with or without incontinence, in the absence of UTI or other obvious pathology
  16. Abnormal sensory symptoms • Increased bladder sensation • Reduced • Absent • HESITANCY- delay in initiating micturition • RETENTION- inability to pass urine despite persistent effort. • INTERMITTENCY- urine flow that stops & starts on one or more occasions during voiding. Abnormal emptying
  17. Others • OVERFLOW INCONTINENCE: involuntary release of urine from overtly full bladder, often in absence of urge to urinate • PAINFUL BLADDER SYNDROME: Chronic inflammatory condition resulting in painful voiding • Urge incontinence two types 1. Motor- overactive bladder 2. Sensory- unable to control escape of urine once there is urge to void. Can be controlled with adequate encouragement. Infection may be present. Cystometry is normal
  18. Overactive Bladder • Definition – symptom complex of urgency, usually with frequency and nocturia, with(wet) or without(dry) incontinence, in the absence of UTI or other obvious pathology. • Prevalence – 16.9% in North America, increases with age • Overall 12-15% • Detrusor overactivity - Ach induced stimulation of muscarinic receptors (urodynamic diagnosis) • 64% of OAB have detrusor overactivity. • 83% of patients with detrusor overactivity have OAB.
  19. Etiology • Idiopathic • Psychosomatic • Following surgery for incontinence • Neurogenic- Multiple sclerosis, diabetic neuropathy, spinal injuries, parkinsonism, CVA
  20. Pathophysiology • OUTFLOW OBSTRUCTION HYPOTHESIS- Lead to partial denervation & in AchEsterase. Supersensitivity to Ach. Instability of membrane potential Facilitation of Spinal reflex mediated by C-fibres. NGF & tachykinins • NEUROGENIC HYPOTHESIS- When cause is Idiopathic. Increased α adr activity causes increased detrusor contractility.
  21. Incompetent bladder neck Urine in proximal urethra Detrusor overactivity Incontinence • URETHRAL REFLEX-
  22. • MYOGENIC HYPOTHESIS- Common in all cases of detrusor overactivity Alteration of properties of smooth muscles Loss of nerves & hypertrophy of cells with collagen & elastin. Increased excitability & cell to cell propagation Coordinated myogenic contractions of whole detrusor • UROTHELIAL AFFERENT HYPOTHESIS- C- fibres afferent activation in the urothelium & suburothelial myofibroblasts. Bladder distension releases NO (inhibitory)& prostanoids (stimulatory)in urothelium Supported by use of Capsaicin & Resiniferatoxin intravesically
  23. Symptoms • Urgency • Frequency • Nocturia • Nocturnal enuresis • SIGNS- vulval excoriation, urogenital atrophy, residual urine & stress incontinence
  24. Diagnosis • History & QOL Questionnaire & Urgency severity scales • Physical examination • Pelvic examination with bladder full – Stress test, Q-tip, cystocele, levator ani & anal sphincter function • Simple (primary care level) Tests- 1. Voiding Diary 2. Urinalysis 3. Post Void Residual volume 4. Cough stress test 5. Pad test
  25. Advanced Testing • Urodynamics- 1. Uroflowmetry 2. Filling Cystometry 3. Urethral pressure profile 4. Leak point pressure 5. Voiding cystometrogram • Imaging tests- USG, Fluoroscopy, Functional neuroimaging, MRI • Neurophysiologic test- 1. Pudendal nerve terminal motor latency 2. Sacral reflexes 3. Somatosensory evoked potentials 4. EMG 5. Emerging techniques- PET
  26. Urodynamics • I/c- 1. Diagnosis is uncertain/mixed disorder 2. Surgery is being considered 3. Failure of multiple surgical corrections 4. Elevated PVR 5. Neurological condition 6. Frequency/voiding difficulties/nocturia 7. Marked pelvic organ prolapse
  27. UROFLOWMETRY • Volume of urine voided plotted over time • Flow rate- 15-25ml/sec • Peak flow rate • Time to peak flow
  28. CYSTOMETRY • Assess bladder & urethral function during filling phase • Single channel & multi channel • Steps conducting multichannel urodynamic study- 1. Insert pressure & filling bladder catheter. 2nd in vg/ rectum 2. Infuse saline @ 50-100ml/min. Record volume & pressure 3. Note the point at which any leakage occurs. 4. Record first desire to void & strongest desire to void & maximum cystometric capacity 5. If no detrusor overactivity, do provocative test. • Pdet = Pves - Pabd
  29. Normal findings in cystometry • Residual volume 0-50ml • First sensation of urination 150-200ml • Strong desire to void >250ml • Cystometric Capacity 400-600ml • Intravesical pressure on filling & standing 0-15 cm of water
  30. • Bladder compliance after 60sec of reaching capacity 20- 100ml/cm of water • Maximum detrusor pressure during voiding <50 cm of water • Peak urinary flow rate >15ml/sec • No uninhibited detrusor contraction despite provocation • No stress or urge despite provocation
  31. • Cystometrogram- • Graphical registration of pressure changes in bladder in relation to rise in the volume of urine. • Segment 1, 2 & 3
  32. URETHRAL FUNCTION TEST 1. Urethral pressure profilometry-  catheter with microtip pressure transducer slowly pulled along urethra measuring intravesical & urethral pressure.  P ure – P ves = P clos  <20cm of water poor prognosis after surgery 2. Fluoroscopic & cystoscopic assessment of bladder neck
  33. 3. Leak point pressure- urodynamic measure of the minimum intra abdom or intravesical pressure to cause incontinence . 1. Valsalva LPP 2. Cough LPP Intrinsic sphincter deficiency found in women cutoff 60 cm water Bulking agents (collagen) are used <100cm water LPP when bladder is filled with 150ml
  34. Voiding Cystometrogram • Valsalva voiding, low preoperative flow rate & high detrusor pressure during voiding are risk factors for postoperative voiding dysfunction
  35. Treatment • General measures- Psychotherapy for psychosomatic problems, treating other medical conditions • Behavioral therapy- o Limit fluid intake (1-1.5 litres/d) o Reduce tea, coffee, alcohol o Diuretics stopped o Weight loss o Bladder retraining : bladder drill, biofeedback, hypnotherapy. 83% asymp 6mth 40% relapse in 3 yrs
  36. Drug Therapy • Inhibit bladder contractility, • Increase bladder neck & urethral resistance. • Antimuscarinic agents- Reduce incontinence episodes per day Reduce frequency, urgency • Immediate release- Oxybutinin, tolterodine • Extended release- Trospium, solifenacin • Conjugated Estrogen- should not be prescribed • Ephedrine, pseudoephedrine, phenylpropanolamine- risks of complications , hemorrhagic cerebral vascular accident
  37. NATURE DRUGS & DOSES RELIEVES SIDE EFFECT CONTRAINDICATION ANTI CHOLINERGIC M1 & M3 antagonist Oxybutinin 5mg BD PO/ transdermal patch 3.9mg twice a wk Frequency Urgency Dry mouth Blurred vision Constipation Glaucoma Myasthenia Intestinal obstruction Ulcerative colitis Urinary retention ANTI MUSCARINIC M3 antagonist Tolterodin 1-2mg PO BD ANTI MUSCARINIC M3 anatgonist Solifenacin 5-10 mg OD Flatulence Chest pain also TCA Imipramine 50mg HS Nocturia Sedation Hip fracture Orthostatic htn Coronary Artery Dis HTN SYNTHETIC ANTIDIURETIC HORMONE ANALOGUE DDAVP Intranasal 20-40µg HS Nocturnal enuresis Fluid retention Rhinitis Nausea Hyponatremia Cardiac insufficiency
  38. Other drugs • Darifenacin- same as solifenacin • Fesoterodine- Prodrug, active metabolite 5 hydroxy methyl tolterodine • Flavoxate (similar to oxybutinin)- 200mg TDS urinary frequency, urgency, dysuria • Propiverine- antichl & CCB, urgency frequency, urge incontinence, M3 antagonist • Trospium- cautiously in renal & hepatic, parasympatholytic, reduces tone of smooth ms in bladder, not distributed to CNS because of large molecular size & hydrophilicity • Bumetanide- loop diuretic, decrease nocturia • Furesemide- mid afternoon. Decrease night time urine production
  39. Refractory OAB • Distressing symptoms continue despite conservative & drug therapy • INTRAVESICAL THERAPY- • Temporary effect & risk of voiding difficulties • Capsaicin (in neurogenic DOA), • Resiniferatoxin, • Botulinum Toxin (idiopathic DOA) • NEUROMODULATION- • Peripheral – using posterior tibial nerve (similar effect as antimuscarinics) • Sacral neuromodulation- expensive, invasive • Cutaneous sacral neuromodulation- less invasive
  40. • SURGERY- Denervation (interrupt nervous pathway) Augmentation & clam cystoplasty (increase bladder capacity) Urinary diversion (ileal conduit) Detrusor myectomy • RECENT DEVELOPMENTS- Oxybutinin patch, gel Mirabegron – β3 agonist Solabegron – also in Irritable Bowel Synd , produces visceral analgesia by releasing somatostatin & adipocytes
  41. • THANK YOU..

Notas do Editor

  1. Bladder detrusor has outr long, mid circular, inn long. Acts as syncitial mass & contain acetylcholinesterase Trigone mesodermal Neck no sphincteric action Prox Urethra weakest part Mid strongest as it has additional support by rhabdosph urethrae(intrinsic striated ms / slow twitch/ urethral closure at rest) n its upper part enforced by levator ani(extrinsic/ first twitch/ support on stress) Distal is a passive conduit Submucous is vascular layer 2 venous plexus prox n distal, prox undergos chngs wid age. Urethral vasculature plays significant role in maintainence of resting urethral pressure . Mucosa is for apposition & distension Supports…symp actv to maintain urthral tone by alpha adr receptors, estrogen to incrs collagen conn tissue…………….excercise incrs collagen turnovr
  2. Autonomic & somatic Parasym voids & symp fills. Pelvic splanchnic & pudendal M3 direct stimulation of smooth ms contraction M2 oppose sympathetically mediated sm ms relaxation mediates contractn in neurogenic bld dysfunctn Muscarinic receptors – M1 to M5
  3. Transection of spine above pons doa & below pons overflow incontinence
  4. Kinking is due to hammock like attachment of pubocervical fascia wid urethra vg & ATFP Bladd base rocks dwnwrd & back Bld neck pulled up & frwd
  5. DELIRIUM, infection atrophy urethra vagina, pharmac, psych disorder, excess uop, restricted mobility, stool impaction
  6. Desire to void during filling occurs earlier than previous experience Acute inability to void > 12hrs widout catheterisn Chronic retention inability to empty bladder >50% of its vol
  7. OAB - Involuntary contraction of detrusor muscle during filling phase of micturition cycle.
  8. Sudden Compellin desire to urinate which is diff to defer >8times/d 1 or 2 times disturbing excludes last void before gng to bed n includes first void after waking up in morning Involuntary loss of urine occuring during sleep
  9. History includes review of her symptoms, medical(dm,vascular insuff, chr pulm dis, neurological) & surgical history, drug history(sedativ, alcohol, anticholi, alpha blocker, CCB, ACEI). Most troubling symp is ascertained & she is asked how often how much urine she leaks what provokes or improves or worsen the problem wat t/t she took if any QOL assessment is done by askin dem about d way incontin affect der lives & to wat degree. Questionnaires to asses symp & QOL r given eg Short form36, kings health questionnaire Phys exam: CV insuff, pulm dis, neurological(sacralneurological exam for UMNL, brief neurol examankle jerk reflex S1 S2, arch of feetflexion of toe S2 S3, sphincter tone S2 3 4 bulbocavernous reflex ), abd masses, mobility , pelvic exam (prolapse, atrophy, urethral mobility, levator ani anal sphincter function) Voiding diary- 24hr uop, total voids, no. of night voids, avg voided vol, funct bladder capacity. 3days Urinalysis- hematuria in absence of bacteriuria needs to rule out kidney n bladder tumors, asymp bacteriuria further Antib t/t unecessary PVRv cause bladder ovrdist which can cause reflex detrusor contractn, or it may incrs intraabd press n forces sphinc openin. Estimated within 10 min of voiding urine by direct cath or usg <50ml normal >200ml abn Pad test- preweighed pads worn, drink 500ml, rest 15min, walk/climb 30min, provocation exc 15min, weigh pad >1g
  10. Objective evidence of lower urinary tract function
  11. <10ml/sec atonic bladder/ urethral obstruction
  12. Single channel assess bl pressure in filling phase only. Multichannel actual pressure in bladder by detrusor ms activity Pressure cather in vg/ rectum Do cystometry in standing … First desire to void dat wud lead her to void at next convenient moment but can b delayed Strongest desire to void persistent desire widout fear of leakage
  13. Wen bladder is empty intravesical pressure is 0, 100ml of fluid is collected the pressure rises sharply to about 10 cm water Seg 2 plateau even though vol 300- 400 ml pressure remains 10 cm Because of laplace law p= tension/ radius Wen vol rises to 400ml pressure rises rapidly. Beyond 600ml voluntary control fails as pressure rises 40 cm water & pain starts
  14. Bladd filled wid 200-300ml vol & pt are asked to cough & to strain slowly. Lowest pressure at wich leakage occurs Women wid low LPP, poor urethral function, open bladder neck r at higher risk for t/t failure
  15. Bladder drill is voiding by the clock at progressively increasing intrvl for 6wks initial response is gud but failure rate is high. Not in neurological dis only idiopathic. NICE & ICI guidelines it is first line of treatment in all Oab pts. But grtr improvement wid antimuscarinic & bladdr retraining
  16. Desamino deoxy arginine vasopressin Trospium- atropine derivative, antimuscarinic Propiverine- ccb & anticholinergic Oxybutinin vesical spasm spina bifida nocturnal enuresis
  17. Capsaicin neurotoxin obtained from red chillies, used in 30% alcohol Resinferatoxin more potent & less sideeffects of pain & burning