Overactive Bladder Clinical Presentation

  • Author: Pamela I Ellsworth, MD, FACS; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Jan 10, 2012
 

History

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?
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Physical

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.

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Comorbidities

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.[21] 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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Contributor Information and Disclosures
Author

Pamela I Ellsworth, MD, FACS  Associate Professor of Urology, The Warren Alpert Medical School of Brown University; Consulting Staff, University Urological Associates

Pamela I Ellsworth, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Urological Association, Phi Beta Kappa, Society for Fetal Urology, and Society of University Urologists

Disclosure: Pfizer Consulting fee advisory board, speaking; allergan Honoraria advisory board

Coauthor(s)

Wellman W Cheung, MD, FACS  Clinical Associate Professor of Urology, Clinical Associate Professor of Obstetrics and Gynecology, State University of New York Downstate Medical School

Wellman W Cheung, MD, FACS is a member of the following medical societies: American Board of Urology, American College of Surgeons, American Medical Association, American Urogynecologic Society, American Urological Association, Chinese American Medical Society, Endourological Society, International Urogynaecology Association, and Society of Urodynamics and Female Urology

Disclosure: Astallas Grant/research funds PI

LiAnn N Handel, MD  Resident Physician, Department of Urology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University

LiAnn N Handel, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Aneela Naureen Hussain, MD, FAAFM  Assistant Professor, Department of Family Medicine, State University of New York Downstate Medical Center; Consulting Staff, Department of Family Medicine, University Hospital of Brooklyn

Aneela Naureen Hussain, MD, FAAFM is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Medical Women's Association, Medical Society of the State of New York, and Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Nadia Hasan Khan, MD  Clinical Assistant Instructor, Staff Physician, Department of Family Practice, State University of New York Downstate Medical Center

Nadia Hasan Khan, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Miriam T Vincent, MD, PhD  Professor and Chair, Department of Family Practice, State University of New York Downstate Medical Center

Miriam T Vincent, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association for the Advancement of Science, Medical Society of the State of New York, North American Primary Care Research Group, Sigma Xi, and Society of Teachers of Family Medicine

Disclosure: Joslin Diabetes Group, Harvard Honoraria Speaking and teaching

Specialty Editor Board

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

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Communication between urothelium and suburothelium. ACh—acetylcholine; ATP—adenosine triphosphate; M2—muscarinic receptor subtype 2; M3—muscarinic receptor subtype 3; NO—nitric oxide; P2X1—purinergic receptor P2X, ligand-gated ion channel 1; P2X3—purinergic receptor P2X, ligand-gated ion channel 3; sGC—soluble guanyl cyclase; VR1—vanilloid receptor 1.
Overactive bladder (OAB) and quality of life (QoL). Short Form-36 (SF-36). Reprinted with permission from Blackwell.
Total community and institutional costs of overactive bladder (OAB) (in millions of dollars). UTI—urinary tract infection (UTI). Reprinted with permission from Elsevier.
 
 
 
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