Overactive Bladder Clinical Presentation
- Author: Pamela I Ellsworth, MD; Chief Editor: Edward David Kim, MD, FACS more...
The patient’s history should include information about the following:
Onset, nature, duration, severity, and bother of lower urinary tract symptoms
Medical and surgical history
Obstetric and gynecologic history
Prescription and over-the-counter medications - Relevant medications include anticholinergics or antimuscarinics, antidepressants, antipsychotics, sedatives or hypnotics, diuretics, caffeine, alcohol, narcotics, alpha-adrenergic blockers, alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers
Review of systems, including genitourinary, obstetric and gynecologic, and neurologic findings
Social history, including smoking, alcohol consumption, fluid intake, and number of children (in women)
Bladder diary - This is used to record the times of micturitions and voided volumes, incontinence episodes, pad usage, and other information (eg, fluid intake, degree of urgency, degree of incontinence); a 3-day diary is ideal.
Key screening questions should be asked, focusing on urgency, nocturia (>3 times per night), frequency (>8 times per day), and urinary incontinence. If the patient answers affirmatively to the screening questions, a bladder diary should be given to the patient to complete and reviewed during a subsequent visit. Sample questions can include the following:
Do you ever leak urine when you have a strong urge on the way to the bathroom? How often?
How frequently do you empty your bladder during the day?
How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?
How many pads a day do you wear for protection?
Does this problem inhibit any activity or prevent you from doing things you like to do?
A comprehensive physical examination can help to determine the nature, severity, and impact of the symptoms in patients with overactive bladder (OAB).
Pulmonary and cardiovascular evaluation may be indicated to assess control of cough or the need for medications such as diuretics.
An abdominal examination is performed to rule out diastasis recti, masses, ascites, and organomegaly, which can influence intra-abdominal pressure and urinary tract function. A palpable bladder may imply overflow incontinence or an obstructive problem.
A pelvic examination is used to evaluate for inflammation, infection, atrophy, and pelvic organ prolapse. Such conditions can increase afferent sensation, leading to urinary urgency, frequency, dysuria, and OAB. Because the urethra and trigone are estrogen-dependent tissues, estrogen deficiency can contribute to urinary incontinence and urinary dysfunction. The most common signs of inadequate estrogen levels include thinning and paleness of the vaginal epithelium, loss of rugae, disappearance of the labia minora, and presence of a urethral caruncle.
In females, the levator ani muscle function can be evaluated by asking the patient to tighten her vaginal muscles and to hold the contraction as long as possible. Normally, a woman can hold such a contraction for 5-10 seconds. Voluntary levator ani muscle contractions that are very weak or absent are an indication that biofeedback training sessions with a pelvic floor physical therapist may be necessary (see Treatment and Management).
The bimanual examination should also include a rectal examination to check anal sphincter tone and, for fecal impaction, the presence of occult blood or rectal lesions. In males, the rectal examination should also be focused on the prostate to rule out benign prostate hypertrophy (BPH) or prostate cancer.
A neurologic examination is important. This involves assessment of the lumbosacral nerve roots and should include evaluation of the deep-tendon reflexes, lower-extremity strength, sharp/dull sensation, and the bulbocavernosus and clitoral sacral reflexes. Abnormal findings (eg, deep tendon hyperreflexia or an absent bulbocavernosus reflex) should alert the physician to possible underlying neurologic lesions contributing to urinary incontinence.
Individuals with OAB and urinary incontinence may have other medical comorbidities. For instance, urinary tract infections (UTIs), skin infections and irritation, falls, and fractures are more likely in persons with OAB and urinary incontinence. In older women with daily urge incontinence, the risk of falls and fractures is increased by 26% and 34%, respectively. The ramifications of hip fractures in elderly persons go well beyond the initial event.
In addition, depression is more common in individuals with OAB. However, it is unclear whether the depression is due to OAB or whether the 2 conditions share similar underlying neurologic etiologies.
Fortunately, treatment of OAB decreases the incidence of UTI and skin irritation and infection.
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