Overactive bladder and urgency urinary incontinence

Overactive bladder (OAB) is a condition characterized by nocturia, urinary frequency, and urinary urgency with or without incontinence. Urgency urinary incontinence (UUI) is considered a severe form of OAB and is characterized by a sudden urge to urinate that results in the involuntary loss of urine. Both conditions are typically idiopathic but can also result from neurological conditions (e.g., spinal cord injury, stroke), bladder abnormalities (e.g., bladder stones, tumor), or infection. The prevalence of OAB and UUI increases with age, and women are more commonly affected than men. Diagnosis is usually made after performing an initial evaluation of urinary incontinence, assessing for red flags in urinary incontinence, and ruling out stress urinary incontinence. Additional studies are indicated if there is diagnostic uncertainty. Conservative management of OAB and UUI includes pelvic floor physical therapy, bladder training, lifestyle modifications, management of comorbidities, and use of incontinence products. Additional management options include pharmacological treatment with beta-3 agonists and/or antimuscarinic agents, and minimally invasive treatments (e.g., botulinum toxin injection or posterior tibial nerve stimulation). Surgery may be considered in refractory cases.

• Overactive bladder (OAB) ^[1][2]
  • A condition characterized by urinary urgency (often in combination with nocturia and urinary frequency) that is not attributable to urinary infection or other pathology
  • May occur with or without urinary incontinence
• Urgency urinary incontinence (UUI) ^[2][3]
  • A condition characterized by a sudden, strong need to urinate that results in the involuntary loss of urine
  • Considered a severe form of OAB

• Prevalence increases with age.
• Sex: ♀ > ♂

Epidemiological data refers to the US, unless otherwise specified.

• Idiopathic detrusor overactivity (most common)
• Neurological conditions: lesions above the brain stem, spinal cord injury, stroke, Parkinson disease, dementia, and multiple sclerosis
• Genitourinary conditions: bladder cancer, inflammation, or renal stones
• Risk factors include:
  • Recurrent urinary tract infections
  • Bladder symptoms (e.g., bed wetting) in childhood
  • Constipation
• See also “Etiology” in “Urinary incontinence.”

Detrusor overactivity is a common cause of OAB and UUI and may be idiopathic or occur secondary to neurological conditions. ^[5]

• Urinary urgency: a sudden urge to urinate
• Involuntary loss of urine with urinary urgency (urgency incontinence)
• Urinary frequency
• Nocturia

The diagnostic evaluation for OAB and UUI is the same.

• Perform diagnostics for urinary incontinence, including:
  • Urinary stress test to exclude stress urinary incontinence ^[5][7]
  • Urinalysis
  • Postvoid residual volume ^[5][7]
  • Diagnostics for BPH (e.g., PSA) as appropriate ^[8]
• Assess for severity using:
  • A validated symptom questionnaire ^[8]
  • A voiding diary ^[9]
  • Pad test ^[2][7]
• Refer to urology or urogynecology for additional studies (e.g., urodynamic studies, cystoscopy) for:
  • Red flags in urinary incontinence
  • Diagnostic uncertainty

• Stress urinary incontinence
• Mixed urinary incontinence
• Overflow incontinence
• Total incontinence

The differential diagnoses listed here are not exhaustive.

Treatment for OAB and UUI is the same.

Approach ^[3][5][8]

• Offer incontinence products to prevent dermatologic complications of urinary incontinence.
• Assess for features of stress urinary incontinence; manage as mixed incontinence if present.
• Educate on lifestyle and behavioral modifications (e.g., bladder training, smoking cessation, dietary changes). ^[7][10]
• Treat underlying conditions (e.g., obesity, diabetes, genitourinary syndrome of menopause).
• Use shared decision-making to determine further management, which includes (alone or in combination):
  • Pelvic floor physical therapy
  • Pharmacological treatment
  • Referral for minimally invasive therapy
• Refer patients with red flags in urinary incontinence or refractory symptoms to urology or urogynecology.

Treatment of genitourinary syndrome of menopause with topical estrogen may improve urinary incontinence symptoms. ^[7]

Pharmacological treatment ^[5][8]

• Follow the principles of prescribing for older adults, especially the Beers Criteria.
• First-line pharmacological treatment: beta-3 agonists (preferred) or antimuscarinic agents ^[5][8]
• Assess response to pharmacotherapy after 4–8 weeks; if there has been minimal or no response: ^[8]
  • Change medications.
  • Consider combination medical therapy. ^[3][8]

Discuss the risk of cognitive impairment and major neurocognitive disorder with patients before initiating antimuscarinic medications. ^[8]

Oxybutynin treats Overactive bladder.

Minimally invasive therapy ^[8]

• Can be used first-line, alone, or in combination, to manage OAB and UUI
• Options include:
  • Intradetrusor botulinum toxin injection
  • Sacral neuromodulation
  • Posterior tibial nerve stimulation

Management of refractory UUI

Management of refractory UUI is usually overseen by a specialist (e.g., urology or urogynecology) and may include:

• Surgical treatment (e.g., augmentation cystoplasty, urinary diversion)
• Long-term urethral or suprapubic catheters ^[8]