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    Overactive bladder: Special considerations across a woman’s life span

    Ob/gyns have a key role to play in improving quality of life for women with OAB.


    Judy Yeh, MDToby C. Chai, MD

    Introduction

    Bladder health is an important component of a woman’s well-being,1 and overactive bladder (OAB) remains a multifactorial symptom complex that gynecologists are uniquely positioned to address. This article summarizes guidelines for diagnosis and treatment, highlighting special considerations for management of OAB across a woman’s life span.

    Diagnosis and workup

    The diagnosis of OAB is established clinically. The International Continence Society (ICS) defines OAB as a syndrome with symptoms of urinary urgency, with or without
    urge incontinence, usually with frequency and nocturia,2 in the absence of urinary tract infection (UTI) or other obvious pathology.

    Urgency is defined as the complaint of a sudden compelling desire to pass urine, which is difficult to defer. Urge incontinence is defined as the complaint of involuntary leakage of urine accompanied by or immediately preceded by urgency. Increased daytime frequency and nocturia are determined by patient bother per ICS definitions, without needing to meet a certain threshold for number of voids.3 As a reference for what is considered “normal,” median voiding frequency is determined to be every 3 to 4 hours during the day and 1 or fewer during sleep at night, based on a cross-sectional, epidemiologic study involving more than 4,000 community-dwelling women aged 25 to 84.4

    The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) have published guidelines regarding diagnosis and treatment of non-neurogenic OAB5: history, physical exam, and urinalysis (to rule out urinary tract infection and hematuria) at a minimum, with the addition of urine culture, post-void residual assessment, bladder diary, and/or symptom questionnaires at the clinician’s discretion. Urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound should not be used in the initial workup of the uncomplicated patient.

    Treatment

    Patient education is key. Clinicians should include as part of their counseling information that acceptable symptom control may require trials of multiple therapeutic options. Treatment should be offered only if a patient’s symptoms are bothersome. Behavioral therapies are considered first-line treatment and include bladder training, bladder control strategies, pelvic floor muscle training, weight loss, avoidance of caffeinated beverages/alcohol and fluid management. Considered second-line treatment, pharmacologic management may be combined with behavioral therapies. Pharmacologic agents include antimuscarinics (oxybutynin, trospium, solifenacin, tolterodine, fesoterodine, darifenacin) and β3-adrenoceptor agonist (mirabegron) (Table 1); extended-release formulations are generally recommended over immediate-release formulations because of lower rates of dry mouth.  Oxybutynin is available over the counter in a transdermal formulation. Management of dry mouth and constipation should be attempted before abandoning effective therapy. Follow-up should be offered and encouraged to assess compliance, efficacy, side effects, and possible alternative treatments.
     


    NEXT: When to refer?

    Judy Yeh, MD
    Dr. Yeh is a Fellow in the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and ...
    Toby C. Chai, MD
    Dr. Chai is Professor, Vice Chair of Research, and Co-Director in the Division of Female Pelvic Medicine and Reconstructive Surgery, ...

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