Sections

Workup

Approach Considerations

A few simple office and laboratory tests, in conjunction with the history and physical examination, usually suffice for a diagnosis of overactive bladder (OAB). Urinalysis and culture (if urinary tract infection [UTI] is suspected) are indicated in patients being evaluated for OAB. In select individuals, further testing, such as an assessment of postvoid residual, may be indicated.

Guidelines for diagnosis of OAB by the American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) include the following^[2]:

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. For more information, see Cystoscopy and Urethroscopy in the Assessment of Urinary Incontinence.
Urine cytology is not recommended in the absence of hematuria when the patient responds to therapy.

Urine Studies

Urinalysis is used to exclude microhematuria, pyuria, urinary tract infection, and glucosuria. In those individuals with microhematuria, further evaluation including a urine cytology is recommended. In individuals at risk for bladder cancer, a cytology study may be indicated even in the absence of microhematuria.

Postvoid Residual Testing

Postvoid residual testing is not indicated in all patients. It is helpful in men with both obstructive and OAB symptoms and in women who have undergone prior pelvic surgery (eg, prior incontinence surgery) and those with significant pelvic organ prolapse.

Postvoid residual volume is assessed by means of urethral catheterization or ultrasonography. No definitive upper level of normal for postvoid residual has been established, but many would argue that postvoid residuals greater than 150-200 mL are indicative of incomplete bladder emptying and may warrant further evaluation.

Cystometry

Cystometry is a simple method for testing the bladder’s storage function and provides information on bladder capacity, the extent of accommodation or compliance, the ability to sense bladder filling, and temperature. It can also help assess for detrusor overactivity during bladder filling.

Urodynamic Study

Urodynamic study is not indicated as part of the first-line evaluation of patients with OAB unless a neurologic etiology is suspected. It is most commonly performed in individuals in whom first-line therapies for OAB fail and/or in whom a neurogenic etiology is suspected.

A urodynamic study consists of cystometrography (CMG) and uroflow/electromyelography. CMG assesses the storage phase of bladder function, which includes the following:

Bladder capacity
Bladder compliance
Detrusor overactivity
Sensation of filling

Uroflow/electromyelography assesses the voiding phase, which includes the following:

Detrusor pressure during voiding
Relaxation of the pelvic floor muscles during voiding
The nature of the flow pattern (ie, bell-shaped curve, staccato)
Presence or absence of Valsalva voiding

Intravesical pressure is a combination of intra-abdominal pressure and detrusor pressure. To determine the detrusor pressure, the intra-abdominal pressure is measured with a rectal catheter; this pressure is subtracted from the total intravesical pressure (measured with the bladder catheter). In males, a nomogram is available, the pressure/flow study, whereby detrusor pressure is plotted against flow rate, and this is used to assess for bladder outlet obstruction.

Treatment & Management

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Media Gallery

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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Author

Pamela I Ellsworth, MD Chief, Division of Pediatric Urology, Nemours Children's Hospital; Professor of Urology, University of Central Florida College of Medicine

Pamela I Ellsworth, MD is a member of the following medical societies: American Urological Association, Massachusetts Medical Society, Society for Fetal Urology, Society of Women in Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Wellman W Cheung, MD, FACS Clinical Professor, Department of Urology and Department 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 College of Surgeons, American Medical Association, American Urological Association, Chinese American Medical Society, Endourological Society, American Urogynecologic Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Received grant/research funds from Astallas for pi.

Aneela Naureen Hussain, MD, MBBS, FAAFM Consulting Staff, Department of Family Medicine, South Texas Veterans Health Care System in San Antonio

Aneela Naureen Hussain, MD, MBBS, 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, 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, JD Professor and Chair, Department of Family Practice, State University of New York Downstate Medical Center

Miriam T Vincent, MD, PhD, JD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Bar Association, American Bar Association, American Academy of Family Physicians, Sigma Xi, The Scientific Research Honor Society, Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department 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 Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Additional Contributors

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 Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

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.

Overactive Bladder Workup

Approach Considerations

Urine Studies

Postvoid Residual Testing

Cystometry

Urodynamic Study

References

Tables

Contributor Information and Disclosures

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