Overactive bladder--a practical approach to evaluation and management.

Abstract

The overactive bladder (OAB) is a highly prevalent condition characterized by the combination of urgency and frequency with or without urge incontinence. The pathophysiology is multifactorial; the background is complicated and not yet fully understood. The basic diagnostic workup comprises symptoms assessment, targeted physical examination, urine analysis, post-void residual urine estimation which mostly allows to make a working diagnosis and to find out which patients can be treated also by the nonspecialist. The bladder diary is an optimal diagnostic instrument with a lot of information, whereas urodynamics are expensive and somewhat unverified in their value. The symptom-focused diagnosis is absolutely sufficient to start nonoperative therapy for OAB symptoms. The OAB presents a treatment challenge, as the management of OAB patients is not standardized. An algorithm should include an initial period of at least 6 weeks of conservative therapy consisting of antimuscarinic drugs in combination with behavioral therapy including pelvic floor exercises. If this combination is not successful, the primary diagnosis should be questioned and additional diagnostic tests may be required. If the therapy is successful after 8 weeks, a continuation should be considered in case the symptoms occur after stopping pharmacological therapy. Further therapy depends on the severity of the initial symptoms, the presence of side effects and the motivation of the patient. If pharmacotherapy is not successful or additional therapy desirable, electrical neuromodulation can be added for another period of 6 weeks for up to 3-6 months considering firstly non-invasive therapeutic modalities before recommending invasive sacral neuromodulation. Neuromodulation should be discussed before more invasive procedures, such as bladder augmentation, are considered. There are potentially promising new therapies on the horizon for the OAB. The use of intravesical agents, which decrease the afferent-sensory input, may herald a new therapeutic paradigm for the treatment of the OAB. Refinements in the techniques and the delivery vehicle for electrical stimulation may offer an even less invasive method of neuromodulation. Finally, ongoing research in biotechnology and tissue engineering may produce a functional, stable, compatible tissue substitute suitable for bladder augmentation. The objectives are (1) to define the overactive bladder, (2) to understand the prevalence of the overactive bladder and its impact on the quality of life, (3) to review the basic evaluation of the patient with symptoms suggestive of the overactive bladder and how to differentiate the overactive bladder from other types of urinary dysfunction, and (4) to understand the rationale for and the approach to therapy for the overactive bladder.