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Conservative and surgical approaches to the treatment of overactive bladder

Rachel Simmons, RGN.

Urology Nurse Specialist, Royal Hallamshire Hospital, Sheffield.

It has been reported that up to 17% of adults aged over 40 have one or more symptom of overactive bladder (OAB) (Abrams and Wein, 2000). Studies have shown that both men and women are affected, that incidence increases with age (Abrams and Wein, 1998) and that it is the most common cause of urinary incontinence in men (Bulmer and Abrams, 2004). However, the majority of those affected will never seek professional help because of embarrassment, fear, or a belief that nothing can be done (Bulmer and Abrams, 2004).

It has been reported that up to 17% of adults aged over 40 have one or more symptom of overactive bladder (OAB) (Abrams and Wein, 2000). Studies have shown that both men and women are affected, that incidence increases with age (Abrams and Wein, 1998) and that it is the most common cause of urinary incontinence in men (Bulmer and Abrams, 2004). However, the majority of those affected will never seek professional help because of embarrassment, fear, or a belief that nothing can be done (Bulmer and Abrams, 2004).

Overactive bladder is characterised by a number of symptoms and may be idiopathic or develop secondary to another condition (Hampel et al, 1997). For example, it may develop as a result of bladder outlet obstruction, particularly in men with prostatic enlargement, or as a result of a neurological disease such as multiple sclerosis (Hampel et al, 1997).

OAB is referred to as being either neurogenic or non-neurogenic in origin. As yet there is no single known cause for non-neurogenic OAB in the absence of other pathology; however, there are a number of theories (Bulmer and Abrams, 2000).

It is important to recognise that not all patients with symptoms of OAB will experience incontinence (Abrams and Wein, 2000) and also that a significant number of female patients presenting with stress urinary incontinence (SUI) will have some degree of bladder overactivity (Cardozo, 1997). When urinary incontinence does occur as a result of OAB it can be severe and unpredictable; for example, the bladder may empty completely as a result of an involuntary bladder contraction (Bulmer and Abrams et al, 2000).

Quality of life
The effect of OAB on a patient's quality of life can be significant. Loss of urinary control may have an adverse effect on the social, psychological, domestic and sexual lives of patients. Many feel shame, lose self-confidence and, as a result, may withdraw from social activities. OAB appears to have a more negative effect on interpersonal relationships, sexual activity and general quality-of-life issues than SUI (Jackson, 1997).

Urinary incontinence in elderly people can lead to isolation from relatives and can influence a decision on whether or not to put an elderly person into care (Ekelund and Rundgren, 1987). The prevalence of urinary incontinence is high in the general population and within secondary and tertiary care centres (DH, 2000) (see Table 1, page 32). The costs to the NHS are therefore also high.

The Continence Foundation (2000) has estimated that the cost to the NHS of managing incontinence per 1000 population in 1998 was approximately £7000 (see above). These costs were in addition to those incurred by patients buying their own pads, other continence supplies and by the laundry of soiled bed linen and clothing.

All patients presenting with the symptoms of OAB require a full assessment, including a history and an examination involving their gynaecological and neurological systems (Bulmer and Abrams, 2000). Patients are often asked to complete a voiding diary before assessment and this can prove to be a useful tool during the initial interview because not only is the frequency of voiding recorded (Box 1) but also the voided volume and any wet episodes that occurred. Furthermore, the degree of urgency can be recorded, as well as fluid intake.

Symptom scores and quality-of-life measures are now increasingly used to assess the 'bother' factor and the impact of OAB on daily activities. Although not always clinically indicated, these measures can provide further useful information and a baseline from which to measure the outcome of any intervention (Bulmer and Abrams, 2000).

Within the secondary care setting, further investigations may include cystoscopy, uroflowmetry and urodynamics (filling/voiding cystometry) if patients fail to respond to empirical treatment or if they have more complex symptomology (Bulmer and Abrams, 2000).

Conservative management
Behavioural therapy

For many patients, the symptoms of OAB can be improved through education and support. The aim of behavioural therapy is to educate patients about bladder function and dysfunction, advise about diet and fluids and teach them to re-train their bladders through timed voiding and urge inhibition (Payne, 2000) (Figure 1).

Electrical stimulation

The least invasive method of electrical stimulation is via a TENS machine with external electrodes or vaginal/rectal probes (Bulmer and Abrams, 2000). Stimulation of the striated pelvic floor muscles initiates a muscle contraction and inhibits inappropriate bladder contractions (Brubaker, 2000). Studies have shown a 50% improvement/cure rate in OAB (Bulmer and Abrams, 2000). However, treatment needs to be maintained and patients are often unwilling to purchase their own stimulator, while others discontinue treatment because they dislike wearing the device.

Pharmacotherapy

Pharmacotherapy, in combination with bladder re-training, is the mainstay of the management of OAB and, although a number of agents have been used, muscarinic receptor antagonists have become the most widely adopted (Chapple, 2000). The aim of these drugs is to block the action of acetylcholine, which is responsible for the contraction of the detrusor (bladder) muscle. However, antimuscarinics have a number of side-effects that can be severe enough for patients to discontinue treatment (Yarker et al, 1995). The most commonly reported side-effect is a dry mouth. Patients may also complain of dry eyes, blurred vision, headaches, constipation, dyspepsia and palpitations. Systemic side-effects occur because muscarinic receptors are not confined to the bladder and are found in the salivary glands, eyes, heart, liver, stomach and colon (Abrams and Wein, 1998).

Oxybutynin (Ditropan, Lyrinel XL) has been the most widely used pharmacologic agent, and its clinical effectiveness is well reported. However, up to one-third of patients will discontinue treatment as a result of side-effects (Yarker et al, 1995).

Tolterodine (Detrusitol, Detrusitol XL) was the first antimuscarinic developed specifically for OAB. Clinical trials have shown a similar efficacy to oxybutynin but with a lower side-effect profile (Abrams et al, 1998).

Propiverine (Detrunorm) has both antispasmodic and antimuscarinic properties. It has been shown to be as effective and as well tolerated as tolterodine (Junemann et al, 2003) and as effective and better tolerated than oxybutynin (Madersbacher et al, 1999.

Solifenacin (Vesicare) is a recent addition to the agents available. Once again, studies have demonstrated efficacy and tolerability (Cardozo et al, 2004).

Surgical management
Botulinum toxin type A

Botulinum A toxin (BTX) is a relatively new addition to the treatments available for OAB. It is a powerful toxin that can be injected into muscle, inducing selective and reversible muscle weakness. Intra-detrusor injections of BTX have been shown to be effective in reducing unwanted involuntary bladder contractions and therefore the symptoms of OAB are improved. It appears to be more effective in patients with neurogenic OAB, although non-neurogenic patients have been treated with success (Leippold et al, 2003). The treatment is performed under local anaesthetic and is generally well tolerated. Effects of treatment lasts two to nine months and can then be repeated. Side-effects are relatively uncommon; however, patients have experienced generalised muscle weakness, fatigue and blurred vision (Leippold et al, 2003). Urinary retention is common following treatment and all patients must be counselled with regard to intermittent self-catheterisation, particularly those with neurogenic OAB.

Sacral neuromodulation

Sacral neuromodulation involves the implantation of an electrical stimulator into the sacral nerves. Stimulation of these nerves has been shown to improve the symptoms of OAB (Hohenfellner et al, 2000). The technique is expensive and technically demanding, requiring the support of experienced staff. It is therefore not widely available and is carried out in only a relatively small number of specialised centres.

Detrusor myectomy

Detrusor myectomy or autoaugmentation involves the excision of the detrusor muscle from the top of the bladder, resulting in the creation of a 'bulge' of epithelium which, in turn, increases the storage capacity of the bladder (Chapple and Bryan, 1998). As this is a lesser procedure than a cystoplasty it can seem attractive to patients, but there is still a risk of long-term bladder-emptying problems requiring intermittent self-catheterisation (Chapple and Bryan, 1998).

Augmentation cystoplasty or clamcystoplasty

This is a much more invasive procedure than myectomy, but with a higher success rate. The surgery involves opening the bladder along its coronal plane (as one would a clam shell), and anastomosing a length of small bowel to the dome of the bladder. This leads to increased bladder capacity and a low-pressure system (Chapple and Bryan, 1998).

Despite the high rates of success at 'curing' OAB by surgery, there are associated risks of morbidity and mortality. It also has a number of potential long-term side-effects, including:

- Poor bladder emptying, requiring intermittent self-catheterisation

- Recurrent urinary tract infections

- The voiding of mucus

- Bowel disturbance.

Patients require extensive pre-operative counselling, long-term follow-up and support. Annual cystoscopy is also performed in many centres as the bowel segment may be at an increased risk of malignancy in the long term (Soergel et al, 2004).

The role of the nurse in OAB
All nurses, whether specialists in bladder management or not, have an important role to play in the identification and treatment of patients with OAB. During the initial assessment, nurses not only assess patients' symptoms but also their social situation, toilet facilities, mobility and dexterity. The symptoms of OAB can be much harder to live with if mobility is restricted, making it difficult to get to a toilet, or if poor manual dexterity makes it difficult to remove clothing. Often, simple measures such as providing a downstairs commode or appropriate pads, pants and bed protection will improve patients' quality of life and reduce their anxiety and embarrassment.

The success of conservative treatment relies on education and support. Specialist nurses are able to provide information on bladder function and dysfunction, diet and fluids and to offer support with bladder re-training. They are also able to give advice with regard to any medication prescribed, and to monitor the patient's progress. If one particular medication is not tolerated or does not appear to be effective, an alternative may be recommended.

For those patients who do not respond to conservative therapy, who do not tolerate medication or who have more complex symptoms, referral to a secondary care centre may be appropriate. Urodynamic studies are often recommended and many specialist nurses are involved with performing and reporting these often complex tests. Surgery may be discussed, in which case nurses are able to provide in-depth information on the options available, counsel patients extensively before surgery and provide the follow-up care required. Patients who opt for surgery will often become long-term patients and it is important in these cases that the nurse develops a rapport with them.

Quality of life
Overactive bladder is a prevalent and often distressing condition that has a significant negative effect on the quality of life of those affected. It also contributes to the huge burden of incontinence on NHS resources both in terms of the cost of containment and the provision of tertiary care places for patients whose incontinence makes caring for them at home impossible. Effective treatment is readily available; however, most patients will never admit their problems, seek advice or be identified.

Nurses are ideally situated in all areas of practice to recognise symptoms and refer on to specialist services or advise and initiate treatment. Community continence services are provided throughout the country and many patients can be managed effectively and treated in the primary care setting. Secondary care centres are able to provide more complex investigations and treatments, and here the nurse is a vital member of the multidisciplinary team, delivering expert care and support and thus contributing to patients' quality of life.

An index of continence services is available from The Continence Foundation and can be found on their website: www.continence-foundation.org.uk.

Latest policy
The following documents charge all nurses working in primary, secondary and tertiary care centres with identifying, assessing and treating incontinence and ensuring appropriate refererral when required:

- Department of Health. (2000) Good Practice in Continence Services

- Department of Health. (2001) National Service Framework for Older People

- Department of Health. (2001) The Essence of Care: Patient-focused benchmarking for healthcare practitioners.

Author contact details
Rachel Simmons, Urology Nurse, Royal Hallamshire Hospital, Sheffield; email: Rachel.Simmons@sth.nhs.uk

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