Do you suffer from sudden urge to urinate that is almost impossible to postpone? Do you start searching for the location of the restroom as soon as you go to a mall or movie theatre? Do you suffer from sudden embarrassing leaks of urine? Do you need to wake up at night to pass urine?
Do you feel enslaved to your bladder?
If yes, then you may be suffering from a symptom complex called as Overactive Bladder (OAB) syndrome.
What is an Overactive Bladder and what are Overactive Bladder symptoms?
What is normal?
Typically most people urinate less than 8 times a day and not more than once at night.
Normally the bladder can hold up to 500 ml of urine. Most of us start feeling that our bladder is filling when it is about half full. When we find a socially convenient place, our brain sends a signal to the bladder to start contracting and evacuating the urine. The number of times we urinate depends on several factors, chief amongst them being how much fluids we drink. Typically most people urinate less than 8 times a day and not more than once at night.
Overactive Bladder syndrome is a constellation of bladder storage symptoms in which the patient may
- Have a sudden urge to urinate which she may have difficulty postponing. This is called ‘urgency’ and is the most common symptom of OAB.
- Have involuntary loss of urine, associated with the feeling of urgency, if she cannot reach a toilet in time. This is called as urgency incontinence.
- Need to go the restroom more often than normal or usual
- Need to wake up at night to pass urine.
How common is this problem?
Prevalence of the problem in India is not known but OAB symptoms affect between 10 to 20% of people worldwide at some point in their lives. It can affect both men and women.
What causes overactive bladder symptoms?
There are many causes for OAB:
- Some patients could have sudden and involuntary contractions of the bladder (detrusor) muscle called as detrusor overactivity.
- The bladder in some patients may be highly sensitive to the filling of urine. This may result in an urge to ‘go’ setting in much before the bladder is even half full.
- In some older patients and because of some medical disorders, the kidneys may produce increased urine at night causing nocturia. You can read about nocturia here.
- Uncommonly, the bladder in some patients may be smaller in size than normal and hence is filled to capacity quickly.
- Urinary tract infections
- Rarely, these symptoms are caused by pathology within the bladder like a stone, tumor etc.
It is important to differentiate OAB and urgency incontinence from stress urinary incontinence through a thorough history, physical examination and proper investigations.
Remember that the treatment for the two conditions is different.
Diagnosis of OAB
Remember that OAB is a set of symptoms which point to other underlying conditions. It is important to differentiate OAB, especially urgency incontinence from stress urinary incontinence as the treatment is different. Performing a sling surgery in a patient with OAB can lead to worsening of the problem.
Steps of the diagnosis:
- A detailed history and physical examination is imperative. An important part of diagnosis is to rule out all other possible explanations for the symptoms, such as urinary tract infections, diabetes, pathology within the bladder etc.
- Bladder diary: This is a three day record of your fluid intake, urine output, urine leakage and the situations under which the urine leakage occurs. The diary is invaluable for the doctor to understand your symptoms better. You can download a bladder diary here.
- Urine test for infection and hematuria: It is important to rule out bladder infection as a cause of your symptoms. The urine test also helps assess if there is blood in the urine that could suggest that an internal bladder pathology may be responsible for the problem.
- An ultrasound of the bladder may be done to determine if you retain excessive urine in the bladder after voiding which may be responsible for your symptoms.
Spontaneous spasms of your bladder muscle (called as detrusor over activity) can be diagnosed only on advanced urodynamics.
- Advanced urodynamics: The bladder’s ability to fill, store and evacuate urine is assessed with the help of catheters inserted in your urethra and rectum. The doctor attempts to mimic your real life problems to get a better understanding of your symptoms. You can read more about urodynamics here.
Urodynamics is very important to differentiate urgency incontinence and overactive bladder symptoms from stress incontinence. Detrusor overactivity, a condition in which spontaneous spasms of the bladder (detrusor) muscles lead to involuntary loss of urine, can be diagnosed only with urodynamics.
- Cystoscopy: A lighted telescope is inserted into the bladder to rule out any pathology that may be responsible for the symptoms. If there is blood in the urine, then it is invaluable in assessing the cause of the same.
OAB is not a normal part of aging.
It isnever too late to seek help!!
Following the treatment protocol diligently will help you regain control of your life.
OAB symptoms affect the quality of life though they are not life-threatening. There is no simple cure. However, if the treatment protocol is followed diligently and the required lifestyle changes are introduced and maintained, most women have a significant improvement in their symptoms.
Your nurse continence specialist will work with you to ensure compliance to the various lifestyle and behavioural changes that will help you regain control of your life!
It is natural to be embarrassed. But there is no need to suffer needlessly in silence. Positive attitude and an active participation in the treatment will lead to a much better quality of life for you and your family.
General Lifestyle Changes: It is the first step that can help to improve the quality of your life immensely. It is also a necessary corollary to the other treatments you may be advised. They include
- Managing the amount of fluids you drink: Drink at least 1 – 1.5 lakh litres every day. However it is necessary to drink more in summer and during exercise and drink less before and during trips and in the evening.
- Reduce alcohol andcaffeine as they increase production of urine and irritate the bladder
- Reduce the consumption of food that irritates the bladder. These include spicy foods, citrus fruits, juices, caffeine, soft drinks, artificial sweeteners etc.
- Maintain healthy weight: If you are overweight, losing 10% of your body weight can significantly improve symptoms.
- Stop smoking: Smoking leads to chronic cough that can put pressure on the pelvic floor muscles. Smoking also damages the bladder and urethra.
- Maintain regular and predictable bowel habits; avoid constipation
- Timed Toileting: Voiding urine at regular predetermined intervals, except when asleep, will help empty the bladder better and reduce urine leakage.
- Double voiding: Immediately after you urinate, do not get up.Lean back, count for ten seconds and then lean forward again, all the while keeping the pelvic floor muscles relaxed. This will improve the elimination of urine from the bladder and reduce post void residual urine.
- Kegel exercises (pelvic floor exercises): These are a series of “squeeze, hold and relax” exercises of the pelvic floor muscles that need to be repeated atleast 10 times in a row, three times a day. Toning the appropriate group of muscles helps reduce urgency.
- Practice urgency suppression techniques: These help to suppress the urge and postpone urination to when it is more convenient.
- Bladder retraining: Once the technique to control the bladder until you reach the bathroom is learnt, the same exercises can be used to increase the length of time between trips to the bathroom. This is done through slow increments of 5-10 minutes initially and then 15 minutes.
- Maintain regular and predictable bowel habits; avoid constipation
Pelvic Floor Physical Therapy: A specially trained physiotherapist works with you at an individual level after assessing your pelvic floor. She will help improve your pelvic floor muscle coordination and bladder habits.
One of the techniques that the physiotherapist uses is biofeedback/electrical stimulation. A pressure probe is introduced into your vagina and connected to a visual or sound display. Biofeedback helps to isolate the right muscles and improve their tone, strength and coordination so that they can contract to reduce urgency.
Medications: In about a third of patients, lifestyle changes, behavioural modification and physical therapy alone may not work. In them, medications may be beneficial.
Anticholinergics: This is a class of drugs that act by relaxing the bladder, thereby reducing the urgency symptoms. There are several drugs that are available and the best drugs for you are often decided by trial and error. The doctor will counsel you on the side effects and importance of compliance.
Vaginal estrogen therapy: Estrogen helps to reduce urgency because of its indirect effects on the bladder.
PTNS (Percutaneous Tibial Nerve Stimulation): This is a technique of reducing urgency symptoms by dampening the signals to and from the bladder. It is offered to the patients in whom multiple other interventions have not worked. A small thin needle is inserted temporarily in the ankle near the leg nerve and connected to a battery powered stimulator. The stimulator sends impulses through the leg nerve to the nerves in the pelvis which supply the bladder. 12 sessions are done in the office and lasts about 30 minutes each time.
Botox injection of the bladder: Botox is injected into designated spots in the bladder to reduce the spontaneous spasms of the bladder wall. It works in those patients who have OAB due to spontaneous involuntary contractions of the bladder wall muscle (detrusor), a condition known as detrusor instability. The effect lasts for 6 to 9 months and can be repeated. You can read about botox injection for OAB here.
Neuromodulation (Interstim): This is a 2-step technique in which a thin wire is places in the lower back near the bladder nerves and connected to a pacemaker placed in the buttocks to electrically stimulate the bladder nerves. Interstim helps in patients who have failed non-surgical treatments. You can read about interstim here.