**4.1 Symptom and quality of life questionnaires**

One of the most important aspects of the patient's history is to establish the impact of symptoms on their lives. This will guide the rest of the evaluation and subsequent treatment decisions. Most of the currently used symptom scales focus on patient-perceived frequency of symptoms and how much bother the symptoms cause. (Basra et al., 2007; Coyne et al., 2005a; Coyne et al., 2005b) Some newer validated scales have been developed which target more specific aspects of OAB. One of these, the OAB symptom score, is a 7-item questionnaire that records all the symptoms of OAB using consistent terminology. (Blaivas et al., 2007) Additionally, the International Continence Society (ICS) have established questionnaires (eg International Consultation on Incontinence Modular Questionnaire (ICIQ)) (Abrams et al, 2009))

#### **4.2 Bladder diaries**

166 Urinary Incontinence

As stated above, muscarinic receptors play a significant role in OAB. ATP, Acetylcholine (Ach) and other "signaling molecules, interact with the afferent nerve fibers under the urothelium. Bladder distention presumably causes release of Ach (and other molecules) to stimulate muscarinic receptors on myofibroblasts(predominantly M2). (Mansfield et al 2005) It appears that an increase in Ach release from the urothelium and/or upregulation of muscarinic receptors in the urothelium as well as in suburothelial myofibroblasts may increase afferent nerve activity and contribute to the development of detrusor overactivity.

Women with OAB may experience urinary urgency at inconvenient and unpredictable times. Urgency is the complaint of a sudden compelling desire to pass urine which is difficult to defer. In addition, patients may experience increased 24-hour frequency defined as the total number of daytime voids and episodes of nocturia during a specified 24 hours period. Daytime frequency is defined as the number of voids recorded during waking hours and includes the last void before sleep and the first void after waking and rising in the morning. Both frequency and urgency may occur and urine leakage may occur prior to reaching a toilet. These symptoms interfere with work, activities of daily life, intimacy, and sexual function, and they can also cause embarrassment and diminished self-esteem. (Shaw & Burrows, 2011) Many patients with OAB have symptoms that wake them up at night. Nocturia is the complaint that the individual has to wake at

The presumptive diagnosis of OAB can usually be made in the primary care provider's office. Patients who present with the symptoms of urinary urgency and frequency can be evaluated utilizing standardized questionnaires, bladder diaries, a thorough history and physical examination, and simple laboratory tests. Those patients with more complex presentations may require urodynamic studies to confirm the diagnosis of OAB or detrusor

One of the most important aspects of the patient's history is to establish the impact of symptoms on their lives. This will guide the rest of the evaluation and subsequent treatment decisions. Most of the currently used symptom scales focus on patient-perceived frequency of symptoms and how much bother the symptoms cause. (Basra et al., 2007; Coyne et al., 2005a; Coyne et al., 2005b) Some newer validated scales have been developed which target more specific aspects of OAB. One of these, the OAB symptom score, is a 7-item questionnaire that records all the symptoms of OAB using consistent terminology. (Blaivas et al., 2007) Additionally, the International Continence Society (ICS) have established questionnaires (eg International Consultation on Incontinence Modular Questionnaire

**2.2.3.3 Muscarinic** 

(Koelbl et al, 2009)

**3. Clinical presentation** 

night one or more times to void.

(ICIQ)) (Abrams et al, 2009))

**4.1 Symptom and quality of life questionnaires** 

**4. Diagnosis** 

overactivity.

Bladder diaries are an excellent tool that can be utilized to assess the frequency of daytime and nighttime voiding, as well as the timing of incontinence episodes and pad usage. Recently, bladder diaries have been developed that reliably assess the rate and severity of urinary urgency and are readily available. (Abrams et al, 2009) Despite some limitations, bladder diaries do provide a baseline with which to compare treatment efficacy.

#### **4.3 History**

A thorough history should inquire about the onset, duration, severity, and bother of lower urinary tract symptoms. In addition, a medical, surgical, gynecological, and obstetrical history should be obtained. Inquire about current medications which affect bladder function, particularly diuretics, alcohol, caffeine, narcotics, and calcium channel blockers.

#### **4.4 Physical Examination**

The physical examination should be focused on the abdominal and genitourinary examinations. The pelvic examination is used to evaluate the strength of the muscles of the pelvic floor and to assess for pelvic organ prolapse, urethral mobility, and stress urinary incontinence. The rectal examination is used to assess for any masses and to evaluate for constipation and anal tone. A simple, focused neurologic examination to evaluate pelvic reflexes, innervation of the lower extremities, and the patient's mental status completes the physical examination.

#### **4.5 Urinalysis**

Because some patients who present with acute symptoms of frequency and urgency have a urinary tract infection, a urinalysis (UA) is performed. In addition a UA will detect hematuria or glucosuria.

#### **4.6 Postvoid residual**

A post-void residual (PVR) is performed as a rough evaluation of as a measurement of the efficiency of evacuation of the bladder. This can be measured by bladder ultrasonography or post-void catheterization. Although there is no universally accepted definition of an abnormally elevated PVR, a high post-void residual (greater than 100 cc) may be cause for further, more complex testing. In addition, patients with high PVR's are at high risk for urinary retention, especially when anticholinergic medications are prescribed.

#### **4.7 Urodynamic studies**

Urodynamic studies can provide additional insight into bladder pathophysiology and can be a key to making the diagnosis of OAB and destrusor overactivity. Urodynamic studies are a series of clinical tests, such as flow studies, filling cystometry, pressure-flow studies and/or urethral function measurements. These can be combined with electromyography (EMG) recording and/or imaging by either X-rays or ultrasound. (Abrams et al, 2009)

Diagnosis and Treatment of Overactive Bladder 169

intravesical, abdominal and detrusor pressures, the patient is allowed to void and empties their bladder on a flow meter. Measurement of both flow rate and pressure allows voiding to be assessed. In patients whose bladder emptying is poor, it may determine if poor flow is

Urethral pressure profilometry is a test that measures the urethra's ability to maintain pressure along its length. This test is performed by placing a pressure sensor transurethrally into the bladder and usually withdrawing it along the urethra by a mechanical puller at a constant rate. The pressure along the length of the urethra is measured and graphically represented. The maximum pressure measured in the urethra gives an indication of the

Similar to urethral pressure profilometry, abdominal leak point pressure is used as a measure of the urethra's ability to act as a valve to store urine. Intravesical or abdominal pressure is assessed while the patient is asked to increase their abdominal pressure by valsalva or by coughing. The abdominal pressure at which the patient leaks urine gives a measure of the closure pressure of the urethra. The greater the pressure required to produce

The most commonly used measure of urinary incontinence (UI) treatment efficacy is a reduction in urinary incontinence episodes. Generally, this is recorded as the reduction in mean number of daily episodes, percent reduction from baseline, or reduction in leakage volume. Other outcome measures commonly used for OAB are urinary frequency (total number of daytime and nighttime voids) and frequency of urgency symptoms (with or without leakage). Cure is usually defined as complete absence of urinary incontinence.

One of the most important measures from the patient's perspective is quality of life. In the literature, many investigations measure patient perception of improvement of OAB, general satisfaction questions, and urinary incontinence-specific quality of life measures. The ICS recommends using patient reported outcome questionnaires that have been rigorously

Once the diagnosis of OAB has been made, the combination of dietary and lifestyle modification, bladder training, pelvic floor muscle training (PFMT), and biofeedback should be recommended as the initial intervention for OAB. (Burgio, 2002) The Agency for Health Care Policy and Research as well as the Third International Consultation on Incontinence recommends behavioral therapy as first-line therapy. (Wilson et al., 2005) The advantages of behavioral methods include avoidance of surgery, improved central control of bladder

due to outflow obstruction or poor detrusor contractility.

**4.7.4 Urethral pressure profilometry** 

closure function of the urethra.

**5. Management** 

(Abrams, 2009)

evaluated. (Koelbl et al, 2009)

**5.1 Conservative therapies** 

function and no adverse drug reactions.

**4.7.5 Abdominal leak point pressure** 

leakage, the better the closure function of the urethra.

The goal of urodynamic studies is to reproduce the symptom(s) of the patient under controlled and measurable conditions. According to the 4th International Consultation on Continence (Abrams et al, 2009) the role of urodynamic studies can be:


In addition to recommending the role of urodynamic studies, The International Continence Society (ICS) has provided standards for urodynamic terminology and techniques (Abrams, 2002) For example, urodynamic detrusor overactivity is defined by the ICS as "Loss of urine as a result incontinence of involuntary detrusor activity during the storage phase of urodynamic testing.

Following is a brief description of the most commonly used urodynamic studies.

#### **4.7.1 Uroflowometry**

Uroflowometry is a non-invasive measurement of urine flow rate. The patient urinates into a flow meter in private. (Schafer,2002) The flow rate is measured and displayed graphically. The volume voided, shape of the curve and the maximum flow rate are automatically graphed. These parameters determine if the patient is emptying their bladder normally. When an abnormal recording is obtained, it is best to repeat the assessment for reproducibility.

#### **4.7.2 Filling cystometry**

Filling cystometry is an invasive measurement of the pressure inside the bladder to assess its storage capabilities. It involves placing a pressure sensor into the bladder and another pressure sensor rectally or vaginally to measure abdominal pressure. A computer subtracts the abdominal pressure from the bladder pressure to provide the clinician with a graphic representation of pressure changes due to the true detrusor muscle. The bladder is usually filled with normal saline through the transurethral filling channel of a dual lumen catheter. The filling rate is usually controlled by a computer and the intravesical abdominal and detrusor pressure are monitored graphically. The storage ability of the bladder is assessed and presented graphically in terms of the volumes required to elicit various bladder sensations from the patient, its capacity, its compliance and its stability. The filling (storage) phase of cystometry is also the only method of demonstrating urodynamic stress incontinence (USI). (Abrams et al, 2009)

#### **4.7.3 Pressure-flow studies (Voiding cystometry)**

Voiding cystometry is a measurement of the mechanics of micturition. Generally this study is performed after bladder filling during cystometry is complete. While monitoring

The goal of urodynamic studies is to reproduce the symptom(s) of the patient under controlled and measurable conditions. According to the 4th International Consultation on

To identify or to rule out factors contributing to the lower urinary tract(LUT)

 To predict the outcome, including undesirable side effects, of a contemplated treatment To confirm the effects of intervention or understand the mode of action of a particular

To understand the reasons for failure of previous treatments for urinary incontinence,

In addition to recommending the role of urodynamic studies, The International Continence Society (ICS) has provided standards for urodynamic terminology and techniques (Abrams, 2002) For example, urodynamic detrusor overactivity is defined by the ICS as "Loss of urine as a result incontinence of involuntary detrusor activity during the storage phase of

Uroflowometry is a non-invasive measurement of urine flow rate. The patient urinates into a flow meter in private. (Schafer,2002) The flow rate is measured and displayed graphically. The volume voided, shape of the curve and the maximum flow rate are automatically graphed. These parameters determine if the patient is emptying their bladder normally. When an

Filling cystometry is an invasive measurement of the pressure inside the bladder to assess its storage capabilities. It involves placing a pressure sensor into the bladder and another pressure sensor rectally or vaginally to measure abdominal pressure. A computer subtracts the abdominal pressure from the bladder pressure to provide the clinician with a graphic representation of pressure changes due to the true detrusor muscle. The bladder is usually filled with normal saline through the transurethral filling channel of a dual lumen catheter. The filling rate is usually controlled by a computer and the intravesical abdominal and detrusor pressure are monitored graphically. The storage ability of the bladder is assessed and presented graphically in terms of the volumes required to elicit various bladder sensations from the patient, its capacity, its compliance and its stability. The filling (storage) phase of cystometry is also the only method of demonstrating urodynamic stress

Voiding cystometry is a measurement of the mechanics of micturition. Generally this study is performed after bladder filling during cystometry is complete. While monitoring

Following is a brief description of the most commonly used urodynamic studies.

abnormal recording is obtained, it is best to repeat the assessment for reproducibility.

dysfunction To obtain information about other aspects of LUT dysfunction To predict the consequences of LUT dysfunction for the upper urinary tract

Continence (Abrams et al, 2009) the role of urodynamic studies can be:

type of treatment

urodynamic testing.

**4.7.1 Uroflowometry** 

**4.7.2 Filling cystometry** 

incontinence (USI). (Abrams et al, 2009)

**4.7.3 Pressure-flow studies (Voiding cystometry)** 

or for LUT dysfunction in general.

intravesical, abdominal and detrusor pressures, the patient is allowed to void and empties their bladder on a flow meter. Measurement of both flow rate and pressure allows voiding to be assessed. In patients whose bladder emptying is poor, it may determine if poor flow is due to outflow obstruction or poor detrusor contractility.

#### **4.7.4 Urethral pressure profilometry**

Urethral pressure profilometry is a test that measures the urethra's ability to maintain pressure along its length. This test is performed by placing a pressure sensor transurethrally into the bladder and usually withdrawing it along the urethra by a mechanical puller at a constant rate. The pressure along the length of the urethra is measured and graphically represented. The maximum pressure measured in the urethra gives an indication of the closure function of the urethra.
