Biofeedback Treatment for Overactive Bladder

For several decades, biofeedback has been utilized to help patients gain control of urinary problems. First described in the 1950s, pelvic floor muscle training employing biofeedback techniques has re-emerged as many patients seek to improve their urinary symptoms without medications or invasive procedures. Developing evidence and clinical agreement suggest that the pelvic floor musculature plays an important and often overlooked role in the etiology of lower urinary tract symptoms. New techniques involving computerized visual feedback and electrical stimulation or magnetic stimulation seek to improve the efficacy of pelvic floor muscle exercises. However, findings from the literature for increased response to these exercises with intensity of biofeedback programs are conflicting. While they pose few risks or side effects, biofeedback programs are a time-consuming exercise for patients and providers. As we explore the promising role of pelvic floor rehabilitation in treatment of pelvic floor disorders, we must continue to assess the efficacy and cost-effectiveness of biofeedback as an adjunct to pelvic floor muscle exercises.     

Recent Advances in Intravesical Treatment of Overactive Bladder

The traditional medication for overactive bladder (OAB) is antimuscarinic agent, which targets muscarinic receptors. Recent investigations have revealed that muscarinic receptors are present in the urothelium and suburothelial sensory fibers, as well as in the detrusor. Urothelial dysfunction and abnormality of sensory receptor expression or transmitter release in suburothelial nerves could contribute to OAB refractory to antimuscarinics. Intravesical treatment to inhibit abnormal receptor expression or transmitter release in the sensory nerve terminals in the suburothelial space might provide beneficial therapeutic effects in the treatment of OAB. Intravesical resiniferatoxin (RTX) instillation and intravesical botulinum toxin A (BoNT‐A) injection are two promising treatment alternatives for refractory OAB. RTX at a high dose may cause undesired adverse events, such as hematuria, bladder pain or autonomic dysreflexia. RTX at a low concentration can decrease sensory urgency without influencing detrusor contractility; multiple instillations of low‐dose RTX may be required to achieve adequate desensitization of OAB. BoNT‐A, however, has a beneficial effect on detrusor contractility and causes large post‐void residual after injection in some patients. Therefore, careful dosage and injection site adjustment is mandatory to achieve satisfactory results using intravesical therapy.     

Biomarkers in Overactive Bladder

Overactive bladder (OAB) remains a remarkably common urologic condition and results in significant clinical and economic sequelae. Although likely underestimated, the overall prevalence of OAB is projected to be between 15% and 38%. The diverse etiologies of this symptom complex have limited attempts to develop reproducible biological markers of disease. Recent advances in bladder and urothelial physiology have dramatically expanded our repertoire of potential markers for use in diagnosis and to monitor treatment. Herein we present an overview of several emerging options for OAB diagnosis and review the available literature regarding these prospective biomarkers. Despite intensive awareness into OAB diagnostics, we are witness to the genesis of exploration on detrusor function and urothelial biology that will guide interventions in the coming decades. Immense opportunity exists for future evaluation of OAB pathophysiology to advance our knowledge regarding management of this multifactorial urologic disorder and define biomarkers of the disease process.     

Overactive Bladder in Children

Overactive bladder in children is a bothersome and prevalent disorder that presents with a variety of different symptoms, ranging from irritative voiding symptoms such as frequency and urgency to urinary incontinence and/or nocturnal enuresis. In almost all cases of overactive bladder in neurologically intact children, the root cause has been linked to dysfunctional elimination syndrome. Although a great deal of progress has been made in the diagnosis and treatment of dysfunctional elimination, and previous harmful therapies have been for the most part abandoned, several unanswered questions remain regarding this disorder, which are partly due to a wide spectrum of presenting disorders and the difficulty of performing complex urodynamic evaluations in small children. In this review, we seek to address some of these uncertainties, such as the causes of pediatric overactive bladder, how it can be prevented, and how it can be most efficaciously treated.     

Current Treatment Options for Nonneurogenic Overactive Bladder in Children

Nonneurogenic overactive bladder (OAB) is one of the most common types of voiding dysfunction in children. Treatment options vary, ranging from conservative behavioral management to medical therapy and even surgical intervention. Treatment, however, should progress in a step-wise manner with surgery reserved for those refractory to more conservative interventions. Urotherapy is an important first step with bowel management of value in patients with both urinary and bowel symptoms. In addition, biofeedback can be used to treat pelvic floor dysfunction. Anticholinergics are the mainstay of medical treatment. Neuromodulation is another means of controlling urinary symptoms and includes temporary patches or needles as well as surgically placed permanent leads. Botulinum toxin injections are another surgical option, albeit with concerns for only temporary response. Despite OAB being associated with significant morbidity for both patient and parent, various treatment options exist to address this all too commonly seen problem.     

COX Inhibitors and Overactive Bladder: The Potential for Future Therapy

Studies spanning four decades suggest that prostaglandins (PGs) are synthesized at high levels within the bladder by cyclooxygenase (COX)-1 and COX-2 and that PG biosynthesis during bladder filling provides a non-neuronal vesicular volume signal. Evidence is presented that interstitial cells of Cajal within the bladder seem to play a key role in PG biosynthesis, that bladder PG concentration is a function of the degree of bladder wall stretch, and that PGs serve to 1) assist in detrusor smooth muscle length adaptation of tension during bladder storage by permitting synchronized spontaneous rhythmic contraction, 2) positively modulate sensory recognition of the bladder fill state, and 3) enhance voiding contraction. Provocative clinical and experimental data support a role for PGs in overactive bladder, but the data are of limited scope. Additional studies are needed to clarify the roles played by mechanical stretch, COX isotypes, PG species and receptor subtypes, and cell-to-cell communication in bladder biology.     

Economics of Overactive Bladder

OAB is a prevalent, costly disease that has significant personal and societal burdens. Therapy should graduate in invasiveness as necessary. Behavioral modification techniques are the ideal starting point. Anticholinergic medications should be used as the initial medical management. Drug selection should take into consideration individual patient needs regarding side-effect profile. Patients who fail to improve on medication alone should be offered 2nd line therapies including neuromodulation (SNS or PTNS) or intravesical injection of botulinum toxin A. Surgical options such as augmentation cystoplasty and diversion should be reserved for patients with neurogenic OAB who have failed other more conservative measures.     

Dementia and Overactive Bladder

Overactive bladder (OAB) and urinary incontinence are common in patients with dementia. The etiology is likely multifactorial making it very challenging to treat. Furthermore, the use of anticholinergics, the mainstay of medical management of OAB, in patients with dementia is controversial. The optimal treatment strategy requires setting realistic goals and communicating with family members and care providers.     

The Effectiveness of Bladder Training in Overactive Bladder

Overactive bladder (OAB) is often a cause of depression, social isolation and a decline in general health and quality of life. The International Consultation on Incontinence guidelines recommend pharmacotherapy and behavioral therapy as a first-line therapy in OAB patients. Behavioral therapy modalities include dietary modification, pelvic floor muscle exercise, biofeedback, and bladder training (BT) among other bladder control programs. Pharmacotherapy and neuromodulation can be added if these measures fail to control symptoms. Behavioral intervention is suitable for primary care setting. The efficacy of BT on OAB symptoms has been reported as resolution of symptoms ranging from 12 % to 90 %, and improvement ranging from 57 % to 87 %. However, such protocols for BT vary from study to study, and not many studies report on its efficacy on OAB. Considering the increasing prevalence of OAB and the increasing need for a systematized protocol for BT we aimed to provide an overview of evidence supporting BT for OAB patients, to examine its efficacy, and to provide useful information on its clinical application.     

Role of Topical Vaginal Estrogen in the Treatment of Overactive Bladder

Overactive bladder (OAB) is one of the most common urological and medical conditions. It is gaining increasing attention perhaps due to its prevalence and the wide variety of treatment options for symptom management. While the role of topical vaginal estrogen (TVE) remains to be clearly defined with regard to OAB, TVE use does show some benefit in helping with urinary urgency and frequency.     

The Overactive Bladder: New Concepts of Etiology and Treatment

Overactive bladder (OAB) is a disorder characterized by urinary urgency. In the past, the pathophysiology and treatment of OAB focused on the parasympathetic efferent innervation of detrusor smooth muscle cells. However, recent evidence has provided a clearer understanding of the neurological, chemical, and functional physiology of the bladder and how it relates to the pathophysiology of OAB. Urothelial cells, sensory neurons, and interstitial cells of Cajal have secretory and receptor functions that play an important role in bladder function and dysfunction. As we learn more about bladder function and the mechanism of current OAB treatments, newer forms of therapy are emerging. These include neuromodulation, botulinum toxin, and the development of new drugs based on the pathophysiology of OAB.     

Medical Causes of Overactive Bladder

Overactive bladder (OAB), defined as a symptom complex consisting of urgency, with or without urge incontinence, in the absence of urinary tract infection or other obvious pathology, is a diagnosis affecting millions of Americans and patients around the world and is associated with significant secondary morbidity and mortality. The economic burden and prevalence of OAB is increasing in the United States, and its underlying etiology can be attributed to multiple factors. In addition to aging, pelvic floor weakness and bladder outlet obstruction, a number of medical conditions can lead to the symptoms of overactive bladder. Recognition and proper management of associated medical conditions can lead to improved patient outcomes and decreased expenditure of healthcare resources.     

Management of Overactive Bladder in Children

Purpose of Review

Childhood urinary urgency and frequency are common and can negatively affect self-esteem and quality of life. As compared to adults, there is an increased focus on the diagnosis of overlapping bowel and bladder dysfunction in children. Here, we will review a framework for management as well as recent research.

Recent Findings

While not FDA approved, newer research has shown benefits with clinic neuromodulation, previously unstudied anticholinergics, mirabegron, multiple drug regimens, and botulinum toxin A in children.

Summary

The management of overactive bladder in children is typically approached in a step-wise manner starting first with conservative therapies including treatment of constipation or stool retention, avoidance of bladder irritants, and modification of fluid intake. Biofeedback and pelvic floor exercises can also be helpful. For refractory cases, anticholinergic medications have been utilized with only oxybutynin being FDA approved for use in children over 5 years of age without neurologic detrusor overactivity.

     

Topical Pharmacotherapy for Overactive Bladder

The mainstays of treatment for overactive bladder are antimuscarinic medications. Oral formulations are limited by low patient adherence secondary to anticholinergic side effects (eg, dry mouth). The transdermal oxybutynin formulations oxybutynin transdermal patch (OXY-TD) and oxybutynin transdermal gel (OXY-TGEL) were developed to decrease levels of N-desethyloxybutynin and potentially limit anticholinergic adverse events. Both are efficacious in decreasing urge incontinence compared with placebo. The pharmacokinetics of OXY-TD and OXY-TGEL are similar. Compared with oral oxybutynin, OXY-TD evokes a lower proportion of N-desethyloxybutynin, likely translating to decreased dry mouth. Another advantage of OXY-TD is ease of administration (twice weekly). Unfortunately, application site reactions limit patient adherence. In 12-week studies, OXY-TGEL is effective in decreasing urinary incontinence and urinary frequency. Incidence of application site reactions appear lower than for OXY-TD. Future studies are required to evaluate the impact of OXY-TGEL on quality of life, and long-term studies are needed to confirm its safety and efficacy.     

Obesity and the Overactive Bladder

Obesity (BMI greater than 30 kg.m^-2) and overweight (BMI greater 25-30 kg.m^-2) are associated with an increased prevalence of pelvic floor disorders, including urinary incontinence and overactive bladder (OAB) syndrome. A positive association between obesity and OAB is present in women, although it is more difficult to demonstrate in men. OAB may result from several obesity-related conditions including the mechanical effect of increased body mass on the bladder, a result of type-II diabetes or the presence of metabolic syndrome. The underlying metabolic defects of the latter two conditions in generating OAB are discussed. Finally the involvement of endothelial dysfunction as a cause of OAB is considered, as this pathology is a result of several obesity-related conditions.     

Weight Loss and Overactive Bladder

Purpose of Review

We sought to explore the relationship between obesity and overactive bladder (OAB) and to review the available literature that supports weight loss as a means to alter OAB severity and bother.

Recent Findings

Over the past 15 years, several population-based human studies and animal models have identified obesity as a risk factor for the development of OAB. The bariatric surgery literature demonstrates that substantial weight loss following some form of gastric bypass can lead to at least subjective improvement in OAB symptoms. Ongoing research seeks to further elucidate the role of anti-inflammatory agents, anti-oxidants, and β3-receptor agonists in obesity-associated OAB.

Summary

The currently available literature has identified obesity as a risk factor for the development OAB. Data taken from the bariatric surgery literature indicates that surgical weight loss can lead to a significant improvement in OAB severity and bother. Future studies will determine if less dramatic weight changes can lead to significant and sustained changes in OAB parameters. Based on the available literature, clinicians should start to counsel their obese patients with OAB that weight loss can help improve their OAB severity and bother.

     

Neuromodulation in the Treatment of Overactive Bladder With a Focus on Interferential Therapy

The application of various forms of neuromodulation has become more common and has been reported to be effective for stress and urgency urinary incontinence. In clinical practice, external (vaginal, anal, and surface electrodes) and internal stimulation (sacral nerve stimulation) are popular treatment modalities. However, appropriate treatment strategies using various neuromodulation techniques with or without pelvic floor muscle training or anticholinergics are still unclear. Further studies are needed not only to elucidate modes of action and to choose the optimal modality to improve results, but also to understand the appropriate indication and reduce morbidity and invasiveness.     

Defining Causes for Overactive Bladder Symptoms in Women

Objectives: The aim of the present study was to determine the causes for overactive bladder (OAB) symptoms in women visiting a urological clinic. Methods: We prospectively recruited female patients with OAB symptoms between December 2008 and February 2010. All patients were interviewed for their detailed personal and medical history. All patients completed a 3‐day frequency‐volume chart. Symptom severity was evaluated using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS) questionnaires. All patients underwent either conventional pressure‐flow urodynamic studies or video‐urodynamic studies. On the basis of these evaluations, patients were assigned to one of the following categories: idiopathic OAB, stress urinary incontinence (SUI)‐associated, neurogenic bladder, or bladder outlet obstruction (BOO). Results: A total of 108 female patients were recruited into the study. The mean age of the patients was 63.75 ± 14.02 years (range: 23–89). Detrusor overactivity was demonstrated in 55 patients (51%). The differential diagnosis was idiopathic OAB in 51 women (47.2%), SUI‐associated in 46 (42.6%), neurogenic bladder in 13 (12.0%) and BOO in 7 (6.5%). Conclusion: Our study suggests that the causes for OAB symptoms could be defined in half of the women visiting a urological clinic. Among them, SUI was the most common. Moreover, OAB symptoms in women might relate to BOO. Detailed history taking and sophisticated urodynamic studies are required for a substantial group of female patients with OAB symptoms to make the correct diagnosis and provide optimal therapy.     

Relationship Between Heart Failure and Overactive Bladder

The prevalence of heart failure and overactive bladder, both of which are already quite common, will continue to increase as the population ages. Both create caregiver and self-management burdens, but additional research is needed to understand the burden overactive bladder creates for heart failure patients and their caregivers. Emerging evidence suggests a relationship between heart failure and overactive bladder in which they share a common pathophysiologic pathway via the parasympathetic system. The authors conducted a systematic literature review of overactive bladder in heart failure patients from 2007 to the present. Conflicting evidence exists for the role diuretics play in the prevalence of overactive bladder. Further research is needed to better understand the role of heart failure disease trajectory and its medical management in the natural history of overactive bladder.