Overactive Bladder and Urinary Incontinence Management

Diagnosis and Assessment

• The American Urological Association recommends urinalysis to rule out urinary tract infection and hematuria, and post-void residual measurement in patients with concomitant emptying symptoms, history of urinary retention, enlarged prostate, neurologic disorders, prior incontinence or prostate surgery, or long-standing diabetes 1
• Validated symptom questionnaires, such as LURN-SI-29, LURN-SI-10, and Bristol Female LUTS questionnaire, can be used to assess symptoms, and a 24-72 hour voiding diary can be used to record voiding patterns and incontinence episodes 1
• Urodynamics should be considered when patient has mixed incontinence, obstructive voiding symptoms, elevated PVR, or possible neurogenic dysfunction 1
• Cystoscopy is helpful in patients with hematuria, recurrent UTIs, obstructive voiding, or history of prior sling for stress urinary incontinence 1
• The following table summarizes the diagnostic considerations for UUI:

• Co-morbid neurological diseases can directly impact bladder function and should be considered in the diagnosis and treatment of UUI 3

Treatment

• The American Urological Association recommends a stepwise approach to treating urinary urgency, starting with behavioral modifications, such as timed voiding, fluid management, and pelvic floor muscle training (PFMT), followed by pharmacological options for OAB-related urgency, and advanced therapies for refractory cases 3
• Behavioral modifications, such as timed voiding, urgency suppression techniques, fluid management, avoidance of bladder irritants, and bladder training with gradual extension of voiding intervals, can be effective in managing OAB symptoms 1
• Optimization of comorbidities that affect OAB severity, including BPH, constipation, diuretic use, obesity, diabetes mellitus, genitourinary syndrome of menopause, pelvic organ prolapse, and tobacco use, is recommended 1
• Non-invasive therapies, such as pelvic floor muscle training, biofeedback, transcutaneous tibial nerve stimulation, and electromagnetic therapy, can be used to manage OAB symptoms 1
• Pharmacologic therapies, including antimuscarinic medications and beta-3 agonists, can be effective in managing OAB symptoms, with combination therapy considered if monotherapy is partially effective 1, 2
• Minimally invasive therapies, such as botulinum toxin injection of bladder, sacral neuromodulation, percutaneous tibial nerve stimulation, acupuncture, and implantable tibial nerve stimulation, can be used to manage OAB symptoms 1
• Invasive therapies, such as urinary diversion and bladder augmentation cystoplasty, are rarely used and typically reserved for severe cases 1
• For SUI, first-line treatment is recommended as PFMT for at least three months, with weight loss and exercise for obese women, and surgical options including midurethral synthetic slings, urethral bulking agents, and Burch colposuspension 4
• For UUI, behavioral therapy, including bladder training, is recommended, with pharmacologic therapy for overactive bladder symptoms 5
• A combined approach of PFMT with bladder training is recommended for patients with both SUI and UUI symptoms 5

Quality of Life and Considerations

• Urinary urgency can have profound negative effects on quality of life, including disruption of daily activities and social interactions, sleep disturbances due to nocturia, anxiety about potential incontinence episodes, and reduced participation in physical activities 3
• Clinicians should document the presence and severity of urgency symptoms, distinguish urgency from other lower urinary tract symptoms, and consider using voiding diaries to quantify frequency and timing of urgency episodes, while also ruling out other conditions that can cause similar symptoms 3
• Approximately 30% of patients may continue to experience urgency symptoms even after successful surgical correction of prolapse and stress incontinence, and thorough counseling regarding the potential for persistent urgency symptoms is essential 6, 7