The Overactive Bladder Lewis Chan Staff Specialist in Urology Concord Repatriation General Hospital

Why are we talking about this? By 2050, 20% of population will be over 65 Voiding dysfunction is the most common geriatric problem Prevalence of urinary incontinence in elderly 30-50% Significant Incontinence 4-8% 1 in 3 men > 50 years will undergo treatment for voiding dysfunction in their lifetime 1 in 3 men or women > 75 years have overactive bladder symptoms 2

What are lower urinary tract symptoms (LUTS)? Previously known as ‘prostatism’ ! Frequency, urgency, nocturia - “overactive bladder” Hesitancy, decreasing stream, dribbling - “voiding” symptoms Incontinence - stress, urge or mixed Dysuria, pain - inflammation Haematuria NB – Symptoms do NOT give the Diagnosis! 3

Facts and Myths Incontinence is NOT a normal part of ageing BUT there are changes in bladder and pelvic structures that can contribute to incontinence Medical problems that can disrupt the continence mechanism (DM/CVA) are more common among older populations. BPH - increase in incidence with ageing but not everyone with BPH has obstruction Menopause – atrophic changes Cognitive and functional impairment.

LUTS - Diagnostic Dilemma LUTS in men – is it due to bladder outlet obstruction (prostatic hypertrophy) or overactive bladder? LUTS/ incontinence in women – is it due to sphincter/ pelvic floor weakness or overactive bladder? 5

Mechanisms of Continence

Overactive Bladder - Causes urinary tract infections Idiopathic Bladder outlet obstruction neurological disease stone tumour 7

Voiding Dysfunction - Assessment History Symptoms Severity / degree of bother Comorbidities / medications Functional / social issues Physical Examination General Urogenital including PR Pelvic exam – prolapse, muscle tone,sensation,reflexes

Incontinence – Transient Causes D - Delirium I - Infection A - Atrophic vaginitis P - Psychological P - Pharmacological E - Excess urine output R - Restricted mobility S - Stool 9

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Drugs and Incontinence

Case One 70 yr old man with 2 year Hx of worsening frequency urgency poor stream and nocturia x3 PR – moderate size soft prostate Otherwise well but bothered by symptoms What tests would you do? 12

Investigations – safety tests UMCS Haematuria , UTI Creatinine Renal function PSA Prostate Ca Ultrasound Residual, bladder stone Voiding Diary Functional bladder capacity Specialty tests – flow study, urodynamics, cystoscopy 13

Case One MSU – normal Creatinine and PSA normal Ultrasound – residual 90mls, normal kidneys Does he need other tests? What is the likely cause of his urinary symptoms? What treatment do you suggest? 14

Case Two 67 yr old woman with worsening frequency, urgency and mixed stress and urge incontinence O/E – moderate descent of bladder base on coughing and straining with reduced PF muscle tone What tests do you ask for? What treatment would you suggest?

Pharmacological treatment of OAB Anticholinergic therapy – oxybutynin, propantheline Tricyclics – imipramine Use often limited by side-effects – dry mouth, constipation, blurred vision, drowsiness,confusion Newer ‘bladder selective’ drugs now available in Australia – tolterodine,darifenacin,solifenacin,transdermal oxybutynin patch 17

So many choices – what to do? Oxybutynin and tolterodine are recognised first line treatments for OAB world wide In patients intolerant of oxybutynin consider solifenacin if significant OAB or transdermal oxybutynin patch In frail patients with high risks for complications of anticholinergic therapy consider transdermal patch or tolterodine Selected patients who fail drug therapy may benefit from intravesical Botulinum Toxin injections 18

Case Two Urgency and frequency improved with bladder training and ditropan Still needs to wear pads for stress incontinence and occasional urge IC What would you recommend?

Overactive Bladder - Women Usually F/U/N +/- urge incontinence Exclude UTI, beware recent onset OAB in smokers Management Bladder training /voiding diary Anticholinergics Botox Continence appliances / Catheter

Case Three 75 yr old man with Parkinson’s Disease. Worsening frequency, urgency and urge incontinence over 6 mths – requiring 3-4 pads a day PR – small soft prostate What tests should he have? 21

Case Three MSU – clear Voiding diary – vol 50-100mls every 2 hours Ultrasound – no residual Would bladder training be useful? What drug should he have? If no improvement on medical therapy – what next? 22

Urodynamics 23

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Overactive Bladder - Men Predominant F/U/N with reasonable flow Small prostate No residual Remember safety tests Beware neuropaths (CVA, Parkinsons etc) Management Bladder training / fluid modification Trial of anticholinergics (ditropan, tofranil etc) If persisting symptoms – urodynamics +/- cystoscopy 25

Intravesical Botulinum Toxin-A (BTX-A) Injection for OAB Indication – OAB refractory to medical therapy Established efficacy in neurogenic detrusor overactivity with emerging role in treatment of non-neurogenic overactive bladder Response rate in non-neurogenic OAB about 60-80% with duration of response around 6-12 months. Most will require repeat injections Currently available data showed no dysplastic changes to bladder after BTX therapy 26

Indications for cystoscopy Frank haematuria Persistent microhaematuria Persistent irritative symptoms (esp smokers) Recurrent UTIs Past history of urethral stricture

Urinary Incontinence following Prostate Surgery Seminar - August 11 15/04/2017 Urinary Incontinence following Prostate Surgery Incontinence following TURP generally due to overactive bladder Incontinence following radical prostatectomy (for prostate cancer) usually due to sphincter muscle weakness Treatment: Pelvic floor exercises Pads/Uridome Transurethral injection of bulking agents Perineal sling Artificial Urinary Sphincter 28

Surgical treatment of post prostatectomy incontinence Seminar - August 11 15/04/2017 Surgical treatment of post prostatectomy incontinence 29

Take Home Messages Voiding dysfunction can significantly affect quality of life in the elderly but is not an inevitable part of ageing Careful consideration of comorbidities, effects of medications, functional and social issues essential in management Conservative measures should be considered before pharmacotherapy and invasive tests Surgery still has an important role in those who fail conservative treatment or pharmacotherapy

“Remember, this treatment worked much better on mice than it did on guineapigs, and frankly I think he looks more like a guineapig!”