9 Kuliah Overactive Bladder

Penanganan ‘overactive
bladder’ (OAB)
Dr. Budi Enoch Sp.D.

Urinary System
The urinary system is responsible

for getting rid of waste products
in the form of urine.
Anatomy of the Urinary Tract
Female Male
Upper Kidney
Urinary
Tract
Ureter
Bladder
Lower
Urinary Urethra
Tract
Anatomy of the
Female Urinary Tract
Ureter
Abdominal
muscles
Rectum
Bladder
Pubic bone
Pelvic
floor External
urethral
sphincter
Urethra
Vagina
Structure of the Bladder
Ureter
Detrusor
smooth muscle
External Prostate
gland
urethral sphincter
Pelvic floor
Micturition Reflex
Direction of
Brain nerve impulse
Spinal cord
Bladder
Pelvic floor
Bladder Control System
bladder muscle bladder muscle
bladder bladder
urine urine
Urethra closed Urethra open
Sphincter Muscles Sphincter Muscles

Squeezed Shut Relaxed
Bladder Filling & Emptying
Cycle
1. Bladder fills
Detrusor muscle relaxes
2. First desire to
urinate (bladder
Urethral half full)
sphincter
contracts
The cycle of
bladder filling
and emptying
Detrusor
muscle Urethral
contracts sphincter
relaxes
Urination 3. Urination
voluntarily inhibited
until time and place
are right
Normal Control of Urination
Overactive Bladder
Problems with Bladder Control
Bladder Control Problems
Problems of:
• Bladder Emptying
• Bladder Storage
Bladder Emptying Problems
Bladder
Prostate
Seminal Vesicle
BPH Obstructive conditions
constricting (e.g. Benign Prostatic
the urethra Urethra Hyperplasia [BPH])
Image source: Virginia Urology Center

Bladder Storage Problems
• Overactive Bladder
• Stress Incontinence
• Mixed Incontinence
• Overflow Incontinence
Stress Incontinence
Stress incontinence occurs when a

small amount of urine escapes while
the person coughs, sneezes,
laughs, jumps or lifts something
heavy.
Stress Incontinence
(a) Continent woman (b) Woman with stress
incontinence
External
urethral
sphincter
Sudden increase in intra-abdominal pressure
Overflow Incontinence
 happens when urine leaks from an
overfilled bladder.
Mixed Incontinence
Sudden increase
in intra-abdominal
pressure
Uninhibited detrusor
contractions
Overactive Bladder —
A Disturbing Problem
Overactive Bladder
Definition:
Overactive bladder is a chronic condition in

which the bladder starts to contract too early
when it is filling with urine.
Symptoms of
Overactive Bladder
Frequency
Urgency Bladder pressure Urge

> urethral pressure Incontinence
Diagrammatic Representation
of Overactive Bladder
Bladder pressure
Pressure > urethral pressure
Frequency
Going to the toilet often (more than
eight times in a 24-hour period)
Urgency
A strong and sudden desire to urinate
Urge Incontinence
Urge incontinence occurs

when there is a very
strong urge to pass urine
and which cannot be held
back, resulting in the
person wetting himself
on the way to the toilet
Image source: Society for Continence (Singapore)

Problems Associated with
Lack of Bladder Control
• Physical
• Psychological
• Social
• Sexual
• Occupational/Financial
Physical Problems
• Limitation or stopping of
physical activities
• Discomfort due to
dampness
• Unpleasant odor
• Skin rashes/ ulcers
• Falls
• Insomnia
• Dehydration
Psychological Problems
• Loss of independence —
feels tied to home
• Fear of embarrassment
• Loss of dignity & self esteem
• Depression
• Feeling of being a burden
• Suicide
• Affects career
Social Problems
• Reduction in social
interaction/
increased social
isolation
• Alteration of travel
plans (e.g. plan
around availability
of toilets)
• Cessation of some
hobbies
Sexual Problems
• Avoidance
of sexual
contact
Occupational/Financial
Problems
• Absence from work
• Job loss
• Change of job
• Poor relationship with
employers/ employee
• Financial loss
Vicious Circle of
Bladder Control Problems
Isolation Guilt
Absence Social, domestic,

from physical, sexual
work and psychological
problems
Depression
Quality of Life
• Studies show that the quality of life

is significantly impaired in people
with overactive bladder.
OAB has greater detrimental
effect on QOL than NIDDM
Cause
Symptoms of OAB occur because: detrusor muscle
overactive and contract inappropriately during the
filling phase of micturition
OAB
Detrusor hyperreflexia
due to neurologic problems Detrusor instability
• Multiple sclerosis Due to non neurologic
• Stroke
• Parkinson’s Disease problems (most cases)
• Spinal cord damage
• Neurological disorders :
stroke, Parkinson’s disease
Many patients do not seek
medical help :
• Patient and family :

embarrassment, part of normal
aging, nothing can be done,
unaware UI is a medical problem
• Doctor/nurse : lack of awareness,
more focus on chronic and acute
diseases
Patient strategies to cope with
their condition
• Voiding frequently
• Mapping out the location of
toilets
• Restricting fluid intake
• Wearing sanitary towels
Epidemiology
• 50 million people in developed countries
• 17 million people in USA
• APCAB survey (1998), 7875 pts, 11 countries (Asia)
Prevalence of UI: 12,2 %.
OAB occurs in 50,6%of individuals
with UI (53,1% of women and 45% of men)
Survey at Geriatric Clinic Dr. Cipto Mangunkusumo

Hospital Jakarta (2003) in 169 elderly.
Symptoms of OAB :
• Micturition > 8x/24 hour :
Men : 14.5%; Women : 17.9%
• Micturition > 1x at night :
Men : 30.2%; Women 31.2%
Epidemiology
Survey at PUSAKA Jakarta (2002) in 208
elderly
Signs & symptoms of OAB :

• Micturition > 8x/24 hour : 21.6%
• Urgency : 25.0%
• Micturition >1x at night : 55.3%
Diagnosis
1. Medical history
- Onset & symptoms

- Patient’s functional ability & mental status
- Previous/current medical or pharmacological
treatment
- Previous examinations or medical procedures
- Precipitating factors
- Alteration in bowel habits
- Social consequences of bladder problems
- Presence of any neurological symptoms
- Fluid intake
Diagnosis
2. Six key questions :
1. Totally, how many times do you go to

the toilet in a-24 hour period?
2. How often do you go to the toilet during
the day ?
3. How often do you go to the toilet during
the night ?
4. How often do you feel a strong and
sudden desire to urinate during the day ?
5. If you fail to reach the toilet in time, how
much urine do you usually leak ?
6. Do you leak when laugh, sneeze,
cough, jump or run ?
Diagnosis
3. Physical examination
- Abdomen
- Rectum
- Pelvis
4. Urinary Analysis  To rule out

urinary tract infection
Bladder Diary
Date: Monday 19 March
Time Drinks Amount Did you feel a If leakage occurs,
(types and of urine strong and amount of urine
amount) passed sudden desire to leaked
(ml) urinate ( if yes)
Sm al l M edium L arg e
8:00 am Tea, 2 cups
8:30 am 150 ml

10:00 am Coffee, 1 mug

11:15 am 200 ml
12:00 pm 100 ml
1:00 pm 100 ml
2:00 pm Cola, 1 can
2:30 pm

Management & Treatment
• Pharmacotherapy and bladder

training  the foundation of
treatment
• Incontinence pads & protective

devices for absorbing leakage
• Pelvic floor muscle exercise

Drugs used to treat OAB
• Antimuscarinic drugs
- Tolterodine
- Oxybutinin
- Emepronium
- Propantheline
- Hyoscyamine
• Drugs with mixed action
- Trospium
- Propiverine
- Imipramine
• Drugs with direct actions
- Flavoxate
Drugs therapy
• Anti-muscarinic drug : drug of choice of
OAB
• OAB symptoms can be reduced by :
- stop contraction of involuntary detrusor muscle
- increase bladder capacity
• Side effects of anti-muscarinic therapy
are : dry mouth, constipation, &
impairment of CNS.
• SE is more frequent in geriatric patient
even with a lower dose !!!
Tolterodine (anti muscarinic)
• Gives effective bladder control
• Minimizes voiding frequency in 24 hours
• Increases urine volume in bladder
• Minimal side effect (uro-selective)
• Minimal effect to CNS:
– Relatively large and bulky molecule
– Positive electrical charge
– 30 times less lipophilic than Oxybutinin
 Bladder training
• Can be used alone or combined with
pharmacological treatment
• - To increase the time intervals between
bladder emptying.
- To increase bladder capacity by
teaching patients to resist and
suppress the urge to pass urine.
 Pelvic floor muscle exercise
 Incontinence pads
Pelvic Floor Exercises
Locate pelvic floor muscles
Repeat, as Squeeze pelvic

recommended floor muscles
as tightly as
by physician/ possible for a
continence few seconds
advisor (maximum of
10 seconds)
Relax completely for at

least 10 seconds
Review Diet and Fluid Intake
Drink appropriate amount of
fluid
 Reduce consumption of:
- Caffeine (i.e. tea and
coffee)
- Carbonated soft drinks
- Alcoholic drinks
Special attentions in the
management of OAB in elderly
• Skin infection, decubitus
• Falls and fracture
• Impairment of cognitive function,
dementia
• Sleep disorders
• Depression
• Poly-pharmacy : SE, antagonistic
effect, synergistic effect

9 Kuliah Overactive Bladder

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Penanganan ‘overactive

Dr. Budi Enoch Sp.D.

The urinary system is responsible

Urethra closed Urethra open

Sphincter Muscles Sphincter Muscles

Image source: Virginia Urology Center

Stress incontinence occurs when a

Overactive bladder is a chronic condition in

Urgency Bladder pressure Urge

Urge incontinence occurs

Image source: Society for Continence (Singapore)

Absence Social, domestic,

• Studies show that the quality of life

• Patient and family :

Survey at Geriatric Clinic Dr. Cipto Mangunkusumo

Signs & symptoms of OAB :

- Onset & symptoms

1. Totally, how many times do you go to

4. Urinary Analysis  To rule out

2:00 pm Cola, 1 can

• Pharmacotherapy and bladder

• Incontinence pads & protective

• Pelvic floor muscle exercise

Locate pelvic floor muscles

Repeat, as Squeeze pelvic

Relax completely for at

Drink appropriate amount of

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