FHEA Clinical Pointers:
Overactive Bladder: An Update on Assessment and Intervention

by Margaret A. Fitzgerald, MS, RN, CS-FNP

Introduction

Overactive bladder is a common condition that affects an estimated 17 million Americans and is the leading cause of incontinence in the elderly. This condition is characterized by a strong urge to urinate as well as increased frequency of urination. Interspersed with these troubling symptoms are episodes of urinary incontinence accompanied by the sudden need to urinate but the inability to reach a toilet in time. Overactive bladder symptoms affect more Americans than Alzheimerís disease or osteoporosis. In the majority, overactive bladder is idiopathic in nature.

The typical person with overactive bladder is an adult who urinates more than 8 times per 24 hours with a voiding volume averaging approximately 150ml. In addition to the life-disrupting need to use the bathroom frequently, this person typically has episodes of incontinence caused by failure to reach the toilet in time. These issues frequently cause the patient to significantly limit or alter normal daily activities, limiting fluid intake prior to planned trips out of the home, investigating and mentally mapping rest rooms available during the outing. Wearing incontinence protecting pad or garment "just in case" becomes a fact of life. Overactive bladder can severely restrict quality of life, negatively impact healthy habits such as regular exercise and adequate fluid intake, and limit social interaction and occupational function. Loss of urine control is an important influence on the decision of a family to place an elder in a nursing home.

As common a problem as overactive bladder is, patients seldom mention it to health care providers. This may be due to embarrassment. In fact, one survey revealed that patients are more reluctant to mention bladder control issues to a health care provider than issues of a sexual nature. In addition, there may be the misconception that bladder problems are part of normal aging. In any event, the health care provider can easily screen for overactive bladder-related problems during a primary care visit by inquiring about the following:

  • frequency of day and night time voiding

  • frequency of night time voiding and its effect on length and quality of sleep

  • bladder accidents caused by inability to hold urine until reaching the toilet

  • use of urinary incontinence protective products

  • the impact of overactive bladder on social and occupational function

As with other health problems, it is important to differentiate overactive bladder from other conditions requiring prompt urologic referral and/or treatment. These include the following clinical "red flags":

  • Signs and symptoms suggestive of bladder outlet obstruction

  • Dysuria or any finding suggestive of genitourinary tract infection

  • Hematuria

  • Sudden and unexpected loss of bladder control

Treatment Options for Overactive Bladder: Behavioral Intervention

Behavioral intervention in overactive bladder can be most helpful in helping to reverse some of the patientís learned response to overactive bladder. In addition, urge triggers may be identified. As part of a bladder training programs, the patient to keep a voiding and diet diary. Upon completion, the patient and NP can review this and identify the association of possible bladder irritants intake in the diet including caffeine-containing beverages. In addition, patterns of liquid intake, including rapid intake of large volumes of liquids leading to sudden bladder filling or insufficient fluid intake leading to concentrated potentially irritating urine become apparent. Once frequency of micturation is documented, suggesting that the patient increase the length of time between voidings may lead to an increase in bladder volume and new appreciation for the ability to control urine. As with most life-style modification programs, these behavioral interventions should be given a minimum of a three-month trial before full efficacy can be appreciated. Helping the patient track small gains over time is an important part of the primary care relationship.

Treatment Options for Overactive Bladder: Pharmacologic Intervention

Pharmacological therapy for treatment of overactive bladder is based on the use of muscarinic receptor antagonists. Bladder contraction is largely regulated by the stimulation of muscarinic receptors. Hence, blocking these receptor sites will cause less frequency and forceful bladder contracts, allowing for improved bladder filling and reduced urge incontinence. Tolterodine (Detrol), a muscarinic receptor antagonist, is new therapeutic agent for treatment of overactive bladder. Highly selective for blocking bladder receptor sites, tolterodine (Detrol) is an effective agent to reduce both the numbers of voids per day as well as episodes of urge incontinence.

Tolterodine vs. Oxybutynin

Variable Tolterodine
(Detrol)
Oxybutynin Placebo
Number of micturation/ 24 hours -21% -19.5% -10.5%
Number of incontinent episodes/ 24 hours -47% -71% -19%
Increase in voiding volume +27% +31% +7%
Moderate to severe dry mouth <25% >70% 10%

Oxybutynin (Ditropan) is also a muscarinic receptor antagonist that has been vailable for a numbers of years. While its use is associated with a decreased umber of voidings and episodes of incontinence, its side effect profile is problematic. Because oxybutynin is a nonspecific antagonist, it also blocks muscarinic receptor ites in the salivary glands, causing significant problems with mouth dryness. In a study by Abrams, Freeman, Anderson, and Mattiason (1998) 86% of those taking xybutynin reported dry mouth, with more than 50% reporting it as moderate to severe. In addition, 75% of those who discontinued oxybutynin therapy did so due to mouth dryness. Tolterodine (Detrol) differs from oxybutynin, as it is eight times more selective for the bladder receptor sites over those in the salivary glands. As a result, there is a significantly lower occurrence of mouth dryness. In the Abrams, et al study (1998), 50% of those taking tolterodine problems had no problem with dry mouth, while those who did have mouth dryness during tolterodine use reported it to be mild or moderate, rarely severe. There is a low drop out rate for any causes with tolterodine use.

Conclusion

Overactive bladder is a signficant health problem. NPs can play an important part in improving the health and well being of patients by asking about overactive bladder symptoms. Once identified, a plan of intervention involving behavioral and pharmacological therapies can be helpful in assisting the patient to alleviate this life-disrupting condition.

References:

Abrams, P., Wein, A. (1997) Introduction to overactive bladder: From basic science to clinical management. Urology. 50 (6A) 1-3.

Abrams, P., Freeman, R., Anderstrom, C., Mattiasson, A. (1998) Tolterodine, a new antimuscarinic agent: as effective but better tolerated than oxybutynin in patients with overactive bladder. British Journal of Urology. 81. 801-810.

Nilverbrant, L., Hallen, B., Larsson, G. (1997) Tolterodine- A new bladder selective muscarinic receptor antagonist: Preclinical pharmacological and clinical data. Life Sciences. 60 (13/14) 1129-1136.

Posted May 29, 2000


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