Overactive bladder (OAB) is a syndrome characterized by a sudden and unstoppable need to urinate. OAB affects physical functioning, social functioning, vitality, and emotional roles.

Signs and symptoms

Clinical manifestations of overactive bladder OAB include the following:

• Urinary urgency (hallmark symptom)
• Urgency urinary incontinence (may or may not be present)
• Urinary frequency and nocturia (usually present)

See Presentation for more detail.

Diagnosis

Diagnosis of OAB requires exclusion of infection and other pathologic conditions. In complicated cases, demonstration of underlying detrusor overactivity (phasic increases in detrusor pressure) can be valuable.

Diagnostic guidelines

Guidelines for diagnosis of OAB by the American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) include the following :

• A thorough history, physical examination, and urinalysis should be done initially
• If necessary, a urine culture, or postvoid residual assessment, or both can be done, along with use of bladder diaries or symptom questionnaires
• Urodynamic study, cystoscopy, and diagnostic renal and bladder ultrasonography are not necessary in the initial workup of uncomplicated cases and should be reserved for refractory or otherwise complicated cases
• Urine cytology is not recommended in the absence of hematuria when the patient responds to therapy

Examination and testing

A comprehensive physical examination for OAB includes the following:

• Pulmonary and cardiovascular evaluation
• Abdominal examination
• Pelvic examination and rectal examination
• Neurologic examination

Office and laboratory tests for OAB include the following:

• Urinalysis
• Urine culture (if infection is suspected)
• Postvoid residual testing
• Cystometry
• Urodynamic study

Management

The three main treatment approaches are as follows:

• Behavioral therapy (eg, bladder training, biofeedback, pelvic floor muscle therapy, and pelvic floor electrical stimulation)
• Pharmacologic therapy (eg, anticholinergic/antimuscarinic agents)
• Surgical therapy (eg, neuromodulation and augmentation cytoplasty [rarely necessary])

Treatment guidelines

Guidelines for the treatment of OAB by AUA/SUFU include the following:

• First-line therapy: Behavioral therapies and education should be offered first; starting antimuscarinic agents at the same time as behavior therapies may prove clinically beneficial
• Second-line therapy: Antimuscarinics; extended-release preparations should be used instead of immediate-release preparations when possible; transdermal oxybutynin can also be used
• Third-line therapy: Sacral neuromodulation or peripheral tibial nerve stimulation (PTNS) for carefully selected patients with severe refractory OAB symptoms or those who are not candidates for second-line therapy and are willing to undergo a surgical procedure; intradetrusor injection of onabotulinumtoxinA is another option

Chronic incontinence

Recommendations for improving symptoms of chronic incontinence and reducing cost of care include the following:

• Scheduled toileting
• Prompted voiding
• Improved access to toilets
• Management of fluids and diet
• Use of disposable absorbent pads or garments