1. Overactive Bladder Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Hospital Adjunct Professor of Urology SUNY-Downstate Medical Center

2. Prevalence of OAB OAB 9 - 17% of adults Hampel, Urologe A 2003;42:776; Stewart, World J Urol 2003;20:327; Tikkenen, et al, (2007) PLoS ONE 2(2): e195. doi:10.1371

3. Prevalence of OAB (USA) Wet versus Dry 37% Wet 63% Dry OAB Hampel, Urologe A 2003;42:776; Stewart, World J Urol, 2003;20:327;

4. Prevalence of OAB by Age Stewart, World J Urol, 2003;20:327

5. Overactive Bladder (ICS Definition): “a syndrome…urgency, with or without urge incontinence usually with frequency and nocturia…if there is no proven infection or other pathology” Abrams et al, 2002

6. Urgency Abrams, et al, Neurourol Urodyn, 2002. 21(2): p. 167-78 “...a sudden compelling desire urge to pass urine, which is difficult to defer.”

7. Incontinence associated with urgency Urge Incontinence

8. Urgency ICS, 2002 “…it is important to differentiate between ‘urge’ …a normal…sensation, & urgency which (is) pathological …Central to this distinction is…whether urgency is…an extreme form of ‘urge.’

9. Urgency Chapple, et al, BJU Int, 2005. 95(3): p. 335-40. “ If this was a continuum, then normal people could experience urgency, but in the model we propose, urgency is always abnormal.” Urgency is like a light switch; it is either on or off It cannot be graded

10. Urgency should be redefined: –“...a sudden compelling desire urge to pass urine, which is difficult to defer.” Urgency is not an all-or-none phenomena; it can be graded There are at least two types of urgency OAB: A New Paradigm

11. OAB is a symptom complex, not a syndrome OAB has a differential diagnosis OAB can be classified by urodynamics A New OAB Paradigm

12. Types of Urgency Type 1 - An intensification of the normal urge to void (69%) Type 2 - A sudden urge that is a different sensation (31%) Some patients report a constant feeling of the need to void – not really urgency May have different etiologies May respond differently to treatment Blaivas et al, Two Types of Urgency. Neurourol Urodyn. 2009;28(3):188

13. Type 0 - no urge Type 1 - mild urge (can delay for > 1H) Type 2 - moderate urge (can delay for 10 – 60 minutes) Type 3 - severe urge (can delay for < 10 minutes) Type 4 - precipitous urge (must void immediately) Urgency Perception Grade Blaivas et al, Urgency Perception Score, J Urol, 2007

14. Type 4 - “...a sudden compelling desire to pass urine, which is difficult to defer.” and / or Type 3 - A short warning time between the first and a severe urge and / or Type 2 - Waiting too long Urgency

15. Why did you urinate? (0) Convenience (no urge or desire) (1) Mild urge (can delay urination for an hour) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min) (4) Desperate urge (must go immediately) Incontinence grade. Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes) OAB Bladder Diary Instructions

16. TimeUPSVolume (ml)Incontinence Grade 6 AM41201 7:303900 8:004901 9:103900 12:3021200 5:501900 8:002600 10:002300 12:0041001 3:0041002 8:402600 6:0041201 OAB Diary

17. volume

20. 24 Hour Voided Volume1110 ml Day time voided volume730 ml Night time voided volume380 ml Total 24 H # voids11 # daytime voids 8 # night voids 3 Maximum voided volume120 ml # incontinent episodes5 # urgency episodes5 Bladder volume urgency quotientR =.51 Bladder Diary Summary

21. Overactive Bladder: Symptom Complex or Syndrome? “urgency, with or without urge incontinence usually with frequency and nocturia…if there is no proven infection or other pathology” ICS, 2002

22. Differential Diagnosis (non-neurogenic) Urinary tract infection Urethral obstruction: – Pelvic organ prolapse – Post-op – Urethral diverticulum – Stricture – Primary bladder neck

23. Differential Diagnosis (non-neurogenic) Mixed stress & urge incontinence Foreign body Bladder cancer Bladder stones

24. Differential Diagnosis (neurogenic) Synergy –Stroke –Parkinson’s –MS (supraspinal) –Spina bifida Dyssynergy –SCI –MS (spinal) –Spina bifida –Other spinal conditions

25. Diagnosis# % Stress incontinence5333% Pelvic organ prolapse3924% Idiopathic3723% Bladder outlet obstruction1610% Miscellaneous149% Neurogenic127% Total171106% Differential Diagnosis Marks et al, 2012)

26. Miscellaneous#% Prior pelvic surgery96% Bladder cancer21% Urethral diverticulum21% Vesicovaginal fistula11% Differential Diagnosis Marks et al, 2012

27. Urodynamic Classification During filling: –Type 1 - 4 based on control mechanisms –+ / - low bladder compliance During voiding: –normal Q / p –urethral obstruction –impaired detrusor contractility Flisser, J. Urol 169: 529-534, 2003

28. Urodynamic Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter Type IV: IDC, no awareness or control Flisser, J. Urol 169: 529-534, 2003

29. OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics

30. HMR Voluntary detrusor contraction FSF = 66 ml, FSF = 66 ml 1st urge = 80 ml severe urge = 105 ml Capacity = 346 ml

32. OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC

33. Involuntary detrusor contractions HO

34. Relaxes sphincter Involuntary detrusor contractions HO

35. Sphincter relaxes Involuntary detrusor contractions HO Incontinent

36. Involuntary detrusor contraction HO

37. Asked to hold: contracts sphincter Involuntary detrusor contraction HO

38. Asked to hold: contracts sphincter Aborts detrusor contraction Involuntary detrusor contraction HO

39. Asked to hold: contracts sphincter Aborts detrusor contraction Involuntary detrusor contraction Prevents incontinence HO

40. OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter

41. BA Involuntary Contraction

42. BA Involuntary Contraction Trying to hold

43. BA Involuntary Contraction No flow Trying to hold

44. BA Involuntary Contraction Trying to hold Can’t hold any longer

45. BA Involuntary Contraction Trying to hold incontinent Can’t hold any longer

46. OAB Classification Type I: symptoms of overactive bladder, no IDC at urodynamics Type II: IDC present; patient is aware and can abort the IDC Type III: IDC patient aware, cannot abort but can temporarily maintain continence by contracting the sphincter Type IV: IDC, no awareness or control

47. RS Involuntary detrusor contraction incontinent

48. Diagnostic Evaluation History & questionnaire Physical exam Urinalysis & culture Bladder diary

49. Initial Treatment Treatment of remediable conditions Behavioral therapy Pharmacotherapy Electrical stimulation

50. Remediable Conditions Uro-gynecologic Pelvic organ prolapse Stress incontinence Urethral diverticulum Bladder & ureteral stones Bladder cancer Medical UTI Polyuria Diabetes Congestive heart failure Medications

51. Indications for Further Workup Hematuria Recurrent UTI Diagnosis unclear Voiding symptoms Elevated PVR Neurologic disease Pelvic organ prolapse Prior pelvic surgery Bladder pain No Rx response after 2 – 3 months

52. 52 52 Further Workup Urodynamics Cystoscopy

53. Type 3 OAB Mixed Stress & Urge Incontinence

54. Rest

55. VLPP = 98 cm H20

56. IDC cough

57. Type 3 OAB Obstruction due to urethral Diverticulum in a woman

58. BG JTJT Involuntary detrusor contraction (pdetmax = 48 cm H 2 0) Qmax = 1 ml/S

59. Type 2 OAB Grade 4 prolapse Normal voiding mechanics

60. IC Involuntary detrusor contraction cough

61. IC thigh cystocele bladder catheter

62. IC cystocele

63. IC Cystocele

64. IC Cystocele

65. IC Cystocele

66. Urethra Urine in vagina Cystocele

68. IC Cystocele

69. IC Cystocele

70. Type 4 OAB Grade 4 prolapse Occult sphincteric incontinence

71. gdl coughs (no leak)

72. gdl Involuntary detrusor contraction Incontinent

73. gdl VLPP Sphincteric incontinence

74. gdl Voluntary detrusor contraction Normal voiding

75. Type 3 OAB Grade 3 prolapse Grade 1 urethral obstruction

76. FK Involuntary detrusor contraction Incontinent

77. FK Voluntary Low flow

78. Urethral catheter Urethral meatus Bladder capacity cystocele

79. Urethral catheter Urethral meatus Onset of voiding cystocele

80. Qmax urethra

81. Type 4 OAB Impaired Detrusor Contractility (DHIC)

82. AL Involuntary detrusor contractions Sphincter relaxation Incontinent

84. Type 3 OAB Low Bladder Compliance

85. DS Steep rise in pressure Involuntary detrusor contraction V-U reflux

86. Type 4 OAB Without Obstruction Bladder cancer

87. Involuntary detrusor contraction Incontinent Filling defects

88. So, how does cystoscopy help?

89. Bladder Neck Contracture

90. contracture

91. Fibroadenomatous Urethral Polyp

92. `

93. Urethral Erosion of Synthetic Sling

94. Bladder neck Eroded mesh

95. Bladder Erosion of Mesh Sling

96. Strands of eroded mesh

97. Urethral Diverticulum

98. distal mid proximalbladder neck ostia tic

99. Urethral Stricture

100. stricturefalse passage

101. Radiation Cystitis

103. Bladder Stones

105. mesh stone

106. Low Grade Papillary Transitional Cell Bladder Cancer

108. Carcinoma in Situ

109. CIS

110. Diagnostic Evaluation History & questionnaire Physical exam Urinalysis & culture Bladder diary

111. Initial Treatment Treatment of remediable conditions Behavioral therapy Pharmacotherapy Electrical stimulation

112. Remediable Conditions Uro-gynecologic Pelvic organ prolapse Stress incontinence Urethral diverticulum Bladder & ureteral stones Bladder cancer Medical UTI Polyuria Diabetes Congestive heart failure Medications

113. Indications for Further Workup Hematuria Recurrent UTI Diagnosis unclear Voiding symptoms Elevated PVR Neurologic disease Pelvic organ prolapse Prior pelvic surgery Bladder pain No Rx response after 2 – 3 months

114. 114114114 114 Further Workup Urodynamics Cystoscopy

115. Treatment of Refractory OAB Botox injections Neuromodulation Enterocystoplasty Urinary diversion

116. The Many Faces of OAB

117. Is it really necessary to make these distinctions? That’s for you to decide, but remember, If the only tool you have is a hammer, everything looks like a nail!