Diagnosis and Management of Overactive Bladder
(Published March 2011)
- OAB generally presents in one of three ways:
- The patient states, "I have OAB," because she is familiar with the term from advertisements, the Internet, other patients, or other health care providers.
- The patient offers a complaint of LUTS that the health care provider interprets as OAB.
- Upon querying, the patient admits to OAB symptoms.
Lower Urinary Tract Symptoms
LUTS can be divided into symptoms that occur during bladder storage and during voiding:
- Storage-related symptoms
- Urinary frequencyUrgency
- Voiding-related symptoms
- Hesitancy, weak stream, or straining
- Incomplete emptying
- Post-void dribbling
Pelvic Organ Prolapse
Pelvic organ prolapse is defined as vaginal protrusion of the pelvic organs past their normal anatomic positions. The examination for pelvic organ prolapse is most conveniently performed in the dorsal lithotomy position with a full bladder. The provider asks the patient to push and strain down and assesses the degree of descent, using the remnants of the hymenal ring as a reference point for the grading system.
Pelvic organ prolapse is a potentially remediable cause of OAB.1 A patient with pelvic organ prolapse also may experience overflow incontinence, in which urethral "kinking" caused by the prolapse results in incomplete emptying and quicker filling of the bladder.
The Baden-Walker Classification of prolapse is delineated here:2
- Grade 0 - No descent
- Grade 1 - Descent halfway to the hymen
- Grade 2 - At the hymen
- Grade 3 - Halfway past the hymen
- Grade 4 - > halfway past the hymen
- The key components of the diagnostic evaluation of OAB include a history, a questionnaire, a physical examination, urinalysis, possibly with urine culture, and a bladder diary.
- The evaluation should begin with a focused history and questionnaire, as well as a focused physical exam, including a vaginal exam.
- A urinalysis should be conducted for all patients with OAB symptoms.
- A urine culture should be sent if the history and physical exam suggest a possible UTI.
- Patients should be instructed in how to keep a bladder diary (see below).
Focused history and questionnaire
- During the focused history and questionnaire, the health care provider should ask about LUTS, as well as the presence or absence of:
- Neurologic disorders
- Recurrent UTI
- Kidney stones
- Previous lower abdominal or pelvic surgery
- Pelvic organ prolapse
Focused physical exam
- The focused physical exam should include evaluation of these functional areas, as they pertain to the urinary system:
- During the vaginal exam, the provider should:
- Assess perineal sensation and reflexes
- Assess post-void residual volume
- Palpate for masses or tenderness
- Examine for atrophic vaginitis, pelvic organ prolapse, and urethral diverticulum
Algorithm for OAB management
- Women with hematuria, advanced pelvic organ prolapse (i.e., grade 3 or 4), SUI, or recurrent UTIs should be referred to a urologist or gynecologist for further workup.
- Women without these conditions should be treated empirically for OAB.
- Women for whom empiric treatment fails should be referred for further workup.
The bladder diary can be a very useful tool for dagnosis and management decisions for the treatment of OAB. The figure shows one version of a bladder diary. (An electronic version of a similar diary from the National Institute of Diabetes and Digestive and Kidney Diseases, which is available for download, is listed in the Patient Resources section of this Quick Reference Guide.)
- In the first column, the patient records the time of each urination or incontinent episode.
- In the second column, she records the reason she voided, using the Urgency Perception Score (see below).
- In the third column, she records the measured amount of urine.
- In the fourth column, she records the amount of incontinence.
Urgency Perception Score3
Health care providers can use this questionnaire to assess the severity of urinary urgency.
Please select the number next to your answer and use it for your response to the questions.
(a) Why did you urinate?
(0) out of convenience (no urge or desire)
(1) because I have a mild urge (but can delay urination for more than an hour if I have to)
(2) because I have a moderate urge (but can delay urination for more than 10 but less than 60 minutes if I have to)
(3) because I have a severe urge (but can delay urination for less than 10 minutes)
(4) because I have a desperate urge (must stop what I am doing and go immediately)
(b) Incontinence grade
(0) Grade 1 – some drops
(1) Grade 2 – moderate loss (wet underwear)
(2) Grade 3 – severe loss (wet outer clothes)
Normal Voiding Amounts
In order to evaluate the data in the bladder diary, it is important to be familiar with normal voiding values.
- Mean 24-hour urinary output (both men and women):4 1700 ml
- Mean number of voids:4 6 to 7
- Mean bladder capacity:4 330 ml (although there is great variability among individual patients, 300 to 700 ml is considered the normal range)
|Volume Day (ml)
||1261 (1126) |
|Volume Night (ml)
||6.7 (6.5) |
|Bladder Capacity Day
||229 (220) |
|Bladder Capacity Night
||332 (294) |
|* Extrapolated from references 4 and 5|
- de Boer TA, Salvatore S, Cardozo L, et al. Pelvic organ prolapse and overactive bladder. Neurourol Urodyn. 2010;29(1):30-9.
- Baden WE, Walker TA, Lindsay HJ. The Vaginal Profile. Tex Med J. 1968;64:56-8.
- Blaivas JG, Panagopoulos G, Weiss JP, et al. The urgency perception score: validation and test-retest. J Urol. 2007;177(1):199-202.
- Parsons M, Amundsen CL, Cardozo L, et al. Bladder diary patterns in detrusor overactivity and urodynamic stress incontinence. Neurourol Urodyn. 2007;26(6):800-6.
- Amundsen CL, Parsons M, Tissot B, et al. Bladder diary measurements in asymptomatic females: functional bladder capacity, frequency, and 24-hr volume. Neurourol Urodyn. 2007;26(3):341-9.