Obstetric & Gynaecology Malaysia

Overactive bladder is a problem with bladder-storage function that causes a sudden urge to urinate. The urge may be difficult to stop, and overactive bladder may lead to the involuntary loss of urine (incontinence).

If you have an overactive bladder, you may feel embarrassed, isolate yourself, or limit your work and social life. The good news is that a brief evaluation can determine whether there's a specific cause for your overactive bladder symptoms.

Management of overactive bladder often begins with behavioral strategies, such as fluid schedules, timed voiding and bladder-holding techniques using your pelvic floor. If these initial efforts don't help enough with your overactive bladder symptoms, second line and third line treatments are available.

With an overactive bladder, you may:

• Feel a sudden urge to urinate that's difficult to control
• Experience urge incontinence — the involuntary loss of urine following an urgent need to urinate
• Urinate frequently, usually eight or more times in 24 hours
• Awaken two or more times in the night to urinate (nocturia)

Although you may be able to get to the toilet in time when you sense an urge to urinate, unexpected frequent urination and nighttime urination can disrupt your life.

When to see a doctor

Although it's common among older adults, overactive bladder isn't a normal part of aging. If your symptoms distress you, consider behavior strategies and management options. Treatments are available that might help you.

Discussing such a private matter with your doctor might not be easy, but it's worthwhile to take that risk — especially if your symptoms disrupt your work schedule, social interactions and everyday activities.

Your doctor is likely to recommend a combination of treatment strategies to relieve your symptoms.

Behavioral interventions

Behavioral interventions are the first choice in helping manage an overactive bladder. They're often effective, and they carry no side effects. Behavioral interventions may include:

• Pelvic floor muscle exercises. Kegel exercises strengthen your pelvic floor muscles and urinary sphincter. These strengthened muscles can help you stop the bladder's involuntary contractions. Your doctor or a physical therapist can help you learn how to do Kegel exercises correctly. It may take as long as six to eight weeks before you notice a difference in your symptoms.
• Avoid or reduce caffeine intake-coffee & tea
• Healthy weight. If you're overweight, losing weight may ease your symptoms. Weight loss may help if you also have stress urinary incontinence.
• Fluid consumption. Your doctor may recommend that you cap the fluids you consume at a certain amount and may suggest appropriate times during which to consume them.
• Double voiding. To help empty your bladder more completely, you wait a few minutes after urinating and then try again to empty your bladder again.
• Absorbent pads. Wearing absorbent pads or undergarments can protect your clothing and help you avoid embarrassing incidents, which means that you won't have to limit your activities. Absorbent pads come in a variety of sizes and absorbency levels eg Poise pad, Tena undergarment
• Bladder training. Bladder training involves training yourself to delay voiding when you feel an urge to urinate. You begin with small delays, such as 30 minutes, and gradually work your way up to urinating every 2 to 4 hours. Bladder training is possible only if you're able to tighten (contract) your pelvic floor muscles successfully.

Medications

Medications that relax the bladder can be helpful for relieving symptoms of overactive bladder and reducing episodes of urge incontinence. These drugs include:

Beta-3 adrenergic agonist 

Mirabegron (Betmiga/ Myrbetriq ) 25 mg once daily.  RM10.60 for a 25mg tablet. 

Tablet should be swallowed whole and avoided in individuals with poorly controlled hypertension or who develop new hypertension while using the medication May increase to 50 mg once daily after 4 to 8 weeks based on response and tolerability.

Lower rates of dry mouth and constipation with beta-3 adrenergic agonist compared with antimuscarinics. Common side effects of beta 3 agonists include headache, runny nose, and gastrointestinal upset, which are often mild and rarely lead to discontinuation.

Anticholinergic Agent

Tolterodine (Detrusitol) 2mg bd. RM5.60 a tablets.

Oxybutynin (Voxytane/ Ditropan) 5mg od as a skin patch (Oxytrol), Oxybutynin gel (Gelnique)

Trospium (Spasmolyt/ Sanctura) 20mg bd. RM2.80 a tablet. (need to purchase RM280 for 100 tablets a box). Administer with water on an empty stomach at least 1 hour prior to meals

Solifenacin (Vesicare) 5md od. RM8.10 a tablet.

Darifenacin (Enablex) 7.5 mg once daily. If response is not adequate after a minimum of 2 weeks, dosage may be increased to 15 mg once daily.

Fesoterodine (Toviaz) 4 mg once daily. RM9.70 for a 8mg tablet. (need to purchase $273 for 28 tablets a box). May be increased to a maximum dose of 8 mg once daily based on individual response and tolerability

Common side effects of most of these drugs include dry eyes and dry mouth, but drinking water to quench thirst can aggravate symptoms of overactive bladder. Constipation — another potential side effect — can aggravate your bladder symptoms. Extended-release forms of these medications, including the skin patch or gel, may cause fewer side effects.

Treating the side effects of a medication that's working is more important than stopping the medication. For example, your doctor may recommend that you suck on a piece of sugar-free candy or chew sugar-free gum to relieve dry mouth, and use eyedrops to keep your eyes moist.

Over-the-counter preparations, such as Biotene products, can be helpful for long-term dry mouth. To avoid constipation, your doctor might recommend a fiber-rich diet or use of stool softeners

Antispasmodic Agent, Urinary

Flavoxate (Urispas) 200 mg tds. RM 1.40 a tablet 200mg

Antispasmodic to provide symptomatic relief of dysuria, nocturia, suprapubic pain, urgency, frequency and incontinence in patients with cystitis, urethritis, urethrocystitis, urethrotrigonitis, and prostatitis.

Tricyclic Antidepressant

Amitriptyline 10mg ON. RM0.30 a tablet.

Interstitial cystitis (bladder pain syndrome) (off-label use): Oral: Initial: 10 mg once daily at bedtime; based on response and tolerability, increase dose after 1 week to 25 mg once daily and then at weekly intervals in 25 mg increments to a target dose of 75 mg/day. Allow 14 days to elapse between discontinuing amitriptyline and initiation of another anti-depressant eg MAOI

Bladder medications aren't likely to help with getting up during the night to urinate. Often, this isn't a problem with the bladder at all, rather it's related to the way your kidneys and heart manage your body fluids — which can change over time. As you get older, you may make as much or more urine at night than you do during the day.

Desmopressin is used to treat nocturnal diuresis, nighttime bed-wetting, central diabetes insipidus, and increased thirst and urination caused by head surgery or head trauma. Desmopressin is a man-made form of a hormone that occurs naturally in the pituitary gland and regulates how the body uses water. Risk of hyponatremia if excessive water intake during desmopressin administration. Fluid intake should be limited a minimum of 1 hour prior to dose until at least 8 hours after administration.

Administer Desmopressin 1 hour prior to bedtime. RM10.50 a tablet of 120mg SL. Initial oral Desmopressin dose 0.05-0.1 mg. Sublingual Desmopressin 120mcg administered 1 hour before bedtime, tablet should be kept under the tongue until completely dissolved without water. Sublingual Desmopressin may titrate by 120 mcg/day every 3 days as necessary to a maximum dose of 360 mcg/day to achieve desired response. Treatment period is up to 3 months and then reassess with 1 week off treatment.

Bladder injections

OnabotulinumtoxinA, also called Botox, is a protein from the bacteria that cause botulism illness. Used in small doses directly injected into bladder tissues, this protein partially paralyzes muscles.