Diagnosis and Management of Overactive Bladder

(Published March 2011)

Non-Pharmacologic Treatment

Treatment overview

• In general OAB is not cured, but patients often experience a reduction in symptoms and an improvement in quality of life.
• The three basic components to the treatment of OAB are:
  • Treatment of remediable conditions
  • Behavioral therapy
  • Pharmacotherapy (see next section)
• All patients should be educated about bladder function, fluid and dietary management, timed or prophylactic voiding, bladder training regimens, keeping a bladder diary, and pelvic floor exercises.

Treatment of remediable conditions

• Health care providers should screen women with possible OAB for remediable conditions, including:¹
  • Uro-gynecologic conditions
    • Pelvic organ prolapse
    • Stress incontinence
    • Urethral diverticulum
    • Bladder and ureteral stones
    • Bladder cancer
  • General medical conditions
    • UTI
    • Polyuria/polydipsia
    • Diabetes
    • Congestive heart failure
    • Medications

Behavioral therapy for OAB

• Behavioral therapy has been shown to reduce incontinence episodes in patients with OAB by 57 percent and to reduce the quantity of urine loss by 54 percent.^2,3 Up to 15 percent of patients experience complete resolution of OAB symptoms with behavioral therapy alone, and half of all patients experience a substantial reduction in symptoms of 50 to 75 percent.^2,3
• The components of behavioral therapy include bladder retraining, use of a bladder diary, lifestyle changes, and strategies to control urgency.

Bladder retraining

• Bladder retraining, which increases bladder capacity and thus reduces OAB symptoms, is a cornerstone of behavioral therapy for OAB.
• Components of bladder retraining include:
  • Scheduled voiding regimen with gradually progressive voiding intervals
  • Urgency control strategies
  • Self-monitoring of voiding behavior (e.g., use of a bladder diary)
  • Positive reinforcement by health care provider
• Research has shown that bladder retraining can reduce incontinence by 50 to 87 percent.⁴
• Bladder retraining can be as effective as medication for urge incontinence.
• Bladder retraining with pelvic muscle rehabilitation is probably better than retraining alone.

Use of a bladder diary

• A bladder diary can be a valuable tool for treating OAB as well as for evaluating the condition. (See the section on Diagnosis for more information.)
• By tracking their voiding habit, patients may recognize the cause of their symptoms by their pattern of voiding.
• Patients may be able to gradually increase the interval between voids or make lifestyle changes that reduce bladder symptoms.

Lifestyle changes

• Several lifestyle changes can help reduce OAB symptoms. Health care providers can advise patients to:
  • Avoid dietary bladder irritants (e.g., alcohol, caffeine, tomatoes, citrus)
  • Moderate fluid intake
  • Improve their mobility
  • Address coexisting health issues
  • Improve bowel habits and regularity (e.g., increase fiber intake)

Strategies to control urge

• Providers can encourage patients to adopt strategies to control urgency by relaxing and selectively contracting appropriate pelvic muscles (i.e., Kegel exercises), rather than rushing to the toilet when they feel the urge to urinate.
• Kegel exercises also can strengthen pelvic floor muscles (see Resources for Patients section for instructions).
• Providers can teach patients to control urgency with the following instructions:
  • Anticipate those activities that bring on symptoms.
  • Contract pelvic muscles quickly.
  • Wait until the urge subsides; do not rush to the bathroom, instead stop and stay still for a few moments.
  • Concentrate on suppressing the urge.
  • Walk to the bathroom at a normal pace.

Limitations of behavioral therapies

• Although successful in the majority of patients, behavioral therapy has limitations.
• Behavioral therapy requires a skilled and trained provider plus motivation and adherence in both the patient and the caregiver.
• Success depends on the intensity of the program.
• Behavioral therapy is expensive in terms of caregiver labor and time in certain settings (e.g., primary care, nursing home).

References

1. Rosenberg MT, Newman DK, Tallman CT, Page SA. Overactive bladder: recognition requires vigilance for symptoms. Cleve Clin J Med. 2007;74(Suppl 3):S21-9.
2. Hanno PM, Wein A, Malkowicz SB, editors. Clinical Manual of Urology, 3rd ed. New York, NY : McGraw-Hill Professional Publishing; 2001.
3. Walsh PC, Retik AB, Vaughan ED, Wein AJ, editors. Campbell’s Urology, 8th ed. Philadelphia: WB Saunders Company; 2002.
4. Burgio KL, Goode PS, Locher JL, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA. 2002;288(18):2293-9.