Wednesday September 30, 2009
A matter of urgency
By MAJORIE CHIEW
An overactive bladder is a common affliction which affects both men and women of all ages.
PATIENTS with an overactive bladder (OAB) often wrongly assume that it is a normal part of ageing. They also “mark” (the location of) toilets wherever they go. Their sexual lives suffer as well because of their urinary incontinence problem, says Dr Andrea Tubaro, Associate Professor of Urology at the Second School of Medicine of “La Sapienza” University of Rome, Italy. He is also a Clinical Associate in Urology at Sant’Andrea Hospital in Rome.
OAB affects 11% to 22% of adults over 40 in Europe, Asia and the United States. In Malaysia and Japan, there is a high prevalence of OAB in men and the condition is getting more common with age, says Dr Tubaro who gave a media presentation on The Urgent Need To Treat Overactive Bladder. He was a guest speaker of Pfizer Malaysia at the recent 20th Video Urology World Congress in Kuala Lumpur.
While OAB affects young adults and the elderly, it is “more common” (16.6%) than other diseases such as asthma (8.6%), diabetes (5.5%), Alzheimer’s disease (4%) and cancer (2%).
Retention problem: One-third of OAB patients are ‘wet’ (from urinary leakage) compared to the majority who experience urgency without urinary leakage, says Dr Andrea Tubaro (pic inset). One-third of OAB (37%) patients are “wet” (from urinary leakage) compared to the majority (63%) who experience urgency without urinary leakage (OAB dry).
Dr Tubaro says: “The big question is whether untreated OAB leads to urge incontinence; that is, OAB dry will turn into OAB wet if not treated.”
The three types of urinary incontinence are: urge incontinence, which is a condition of urine loss accompanied by urgency resulting from abnormal bladder contractions; stress incontinence is urine loss from sudden increased intra-abdominal pressure (for example, when one laughs, coughs or sneezes); and mixed symptoms, a combination of stress and urge incontinence.
OAB is bothersome and patients suffer more from urge incontinence and mixed symptoms than stress incontinence, cites Dr Tubaro, adding that more than 10% of patients (which is a significantly higher percentage) are diagnosed with OAB in urology clinics than other clinics.
“OAB affects both men and women. The symptoms are the same although the anatomy is different. In men, lower urinary tract symptoms are considered related predominantly to the prostate,” he says.
In “probable OAB” cases, Dr Tubaro says that a significantly higher percentage of male (11%) and older patients (12.3%) seem more likely to have it. His finding (based on OAB-V8 screener, a screening tool to aid diagnosis of OAB) also cites that 11.4% of Indian patients appear more prone to having OAB compared to Malay (8.4%) and Chinese patients (6.5%).
Still, about 40% patients worldwide do not raise bladder control issues with their physicians. Perhaps, they feel shy or it could be due to racial and ethnic issues.
Costly condition
“It’s costly to treat OAB. Contrary to popular belief, it’s not because of drugs, which accounts for 10% of the cost of managing this condition. The rest comes from taking care of the patient,” he says.
One of the reasons the condition is very expensive is its impact on working and social conditions. The number of patients who lose working days because of OAB is between 20% and 25%. OAB is also a “high cost” problem because of falls that lead to fractures when sufferers wake up frequently at night.
There is a consensus worldwide that OAB can be treated by GPs. It is only if it fails that it is referred to specialists.
“Drugs are not the only answer. Methods of treatment include behaviour modification, physiotherapy/pelvic-floor muscle training, other non-pharmacologic therapies and pharmacotherapy and in very rare cases, surgery,” he says.
First-line treatment includes behavioural therapy and physiotherapy, and only after that, pharmacotherapy. There is solid data that a combination of physiotherapy and pharmacotherapy works better than pharmacotherapy alone. Unfortunately, treatment is lifelong, he says.
“We have to set the patient’s expectation right. Every patient is looking at getting dry after drug treatment but it happens in only 50% of cases,” he says.
In 30% of patients, he adds, urgency leads to incontinence because the condition behind the symptoms is an overactive bladder, an involuntary contraction of the detrusor muscle of the bladder while it is filling up.
“In women particularly, this contraction may lead to incontinence. It is very bothersome because it is impossible to prevent. The only thing the patient can do is to go to the toilet as often as possible and leave with an empty bladder,” he says.
Behaviour modification, Dr Tubaro, says involves bladder retraining and lifestyle changes which include reducing caffeine and alcoholic intake, reducing fluid intake, improving mobility and addressing other health issues that may cause the symptoms to become more severe.
Patients are trained to do simple physiotherapy exercises like pelvic floor (Kegel) exercises at home, which are very effective.
Other types of physiotherapy are electrostimulation and pelvic cone, which gynaecologists are very familiar with. In extreme and rare cases, certain devices will be inserted into the body but this requires major surgery.
Drug treatment
The No.1 and most common drug to treat OAB is an antimuscarinic (dry mouth and constipation are common side effects).
In northern countries in Europe, physiotherapy with drugs is a common practice. This requires a lot of participation from the patient (twice a day, every day of one’s life) but it works, says Dr Tubaro.
“For example, the patient is asked to resist the desire to void (empty the bladder) for five to 10 minutes and it helps. Even electrical stimulation of the pelvic floor helps. We don’t know how exactly but it works,” he says.
On children and OAB, Dr Tubaro says: “Young girls (up to 10 years old) suffering from the condition will develop bad habits in voiding if they are not properly treated. Children suffering lower urinary tract symptoms have a much higher chance of suffering these symptoms again in their adult life. We often use drugs in lower doses to treat children.”
OAB is getting to be “a big concern” for the medical community. The reason is that patients suffer a decreased quality of life due to this condition.
And if untreated, voiding can lead to urinary incontinence.
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