76

Overactive Bladder

Marcus John Drake

Questions

1.Which definition or definitions appear in the current International Continence Society (ICS) terminology (2002)?

a.Detrusor hyperreflexia

b.Overactive bladder

c.Idiopathic detrusor overactivity

d.Detrusor instability

e.b and c

2.Which symptoms are included in overactive bladder syndrome (OAB)?

a.Dysuria

b.Straining

c.Urgency incontinence

d.Bladder pain

e.Stress incontinence

3.In the community, what percentage of adults have overactive bladder symptoms?

a.Less than 5%

b.5% to 10%

c.10% to 20%

d.20% to 50%

e.More than 50%

4.Mixed incontinence includes:

a.stress urinary incontinence.

b.continuous incontinence.

c.postmicturition leakage.

d.incontinence during sexual intercourse.

e.giggle incontinence.

5.Which features are characteristics of urgency?

a.A normal sensation.

b.It builds up slowly.

c.It is usually felt suprapubically.

d.It develops quickly and may lead to incontinence.

e.a and b

6.Which statements are TRUE for detrusor overactivity (DO)?

a.It is characterized by phasic involuntary detrusor contractions during bladder filling.

b.It is always accompanied by a feeling of urgency.

c.It is a urodynamic diagnosis.

d.It is a feature of the voiding phase of micturition.

e.a and c

7.Detrusor overactivity can be diagnosed:

a.only if involuntary filling phase contractions are greater than 15 cm H2O in amplitude.

b.if an involuntary contraction is seen during bladder filling, irrespective of size.

c.if there is urgency incontinence but no contraction.

d.if leakage occurs during exercise.

e.before urodynamics if the patient has overactive bladder syndrome.

8.Which statement is FALSE with respect to the hypotheses of detrusor pathophysiology?

a.Afferent sensitization signifies an increased afferent firing rate in response to a standardized stimulus.

b.The myogenic and integrative hypotheses require abnormal propagation of excitation in the bladder wall.

c.Synaptic reorganization in the spinal cord may contribute to neurogenic detrusor overactivity.

d.Detrusor overactivity requires volitional control.

e.Synergic coordination of bladder and outlet are determined at the brainstem/midbrain level.

9.Which of the following statements is correct regarding symptom assessment tools?

a.OAB can be diagnosed from the frequency volume chart.

b.A validated questionnaire is mandatory for diagnosis of OAB.

c.Modular components of the International Consultation on Incontinence Questionnaire system (ICIQ) have undergone formal validation.

d.A high urgency score is diagnostic of detrusor overactivity.

e.a and b

Answers

1.e. b and c. Detrusor hyperreflexia has been replaced by neurogenic detrusor overactivity. The concept of tone is poorly understood; hence, the term detrusor instability is not recommended.

2.c. Urgency incontinence. Urgency incontinence is experienced by a large proportion of patients with OAB.

3.c. 10% to 20%. Two large prevalence surveys in North America and Europe have shown the prevalence at 16%, whereas the EPIC study put the figure at nearly 12%. Prevalence of at least one lower urinary tract symptom is greater than 50% according to the EPIC study.

4.a. Stress urinary incontinence. This is one of the two constituents of mixed incontinence, along with urgency urinary incontinence.

5.d. Develops quickly and may lead to incontinence. Urgency is thought to be a symptom of rapid onset. Urgency leads to urgency incontinence in the susceptible patient, but not invariably.

6.e. a and c. Involuntary contractions seen on urodynamic assessment are characteristic of detrusor overactivity.

7.b. If an involuntary contraction is seen during bladder filling, irrespective of size.

8.d. Detrusor overactivity requires volitional control. Patients are unable to inhibit overactive contractions voluntarily.

9.c. Modular components of the International Consultation on Incontinence Questionnaire system (ICIQ) have undergone formal validation. The ICIQ generates new tools and adopts established tools for a system that allows selection of appropriate symptom assessment for specific clinical contexts.

Chapter review

1.DO is a urodynamic diagnosis. OAB is a symptom-based diagnosis, defined as urgency with or without urgency incontinence, usually with frequency and nocturia with no proven infection or other obvious

pathology.

2.The pattern of voided volumes in patients with OAB is erratic.

3.Urgency with at least one other symptom is essential to the diagnosis of OAB.

4.The etiology of DO has been hypothesized to be due to neurogenic or myogenic disorders. Neurogenic disorders may involve (1) reduced suprapontine inhibition, (2) overexpression of primitive spinal bladder reflexes, (3) synaptic plasticity in which new reflexes develop as a response to C-fiber afferent neurons, and (4) sensitization of peripheral afferent terminals. Myogenic disorders involve spontaneous excitation, which may be a result of upregulation of surface membrane receptors.

5.A frequency voiding chart or voiding diary is essential for assessing OAB.

6.The two main urodynamic findings with overactive bladder are DO and increasing filling sensation.

7.Treatment of OAB should begin with conservative management, including lifestyle changes, followed by pharmacotherapy and, finally, for intractable cases, surgical therapy that involves either nerve stimulation or surgical procedures on the bladder itself.

8.Aging, neurologic disease, female gender, bladder outlet obstruction, and the metabolic syndrome are potential contributors to OAB.