Overactive Bladder Disease: Overcoming the Urge to Go

Drs. Lee Ghin and Barna are bothclinical assistant professors in theDepartment of Pharmacy Practice andAdministration, Ernest Mario Schoolof Pharmacy, Rutgers—The StateUniversity of New Jersey, Piscataway,New Jersey.

Overactive bladder (OAB) diseaseis a common disorderaffecting millions of Americans.According to the NationalOveractiveBladder Evaluation program,the overall prevalence in theUnited States in adults older than18 years of age was 16.5%, including16.9% of women and 16% of men, withprevalence increasing with age amongpatients of both sexes.¹ When theserates are extrapolated against 2000census data, approximately 33 millionpeople living in the United States havesymptoms of OAB.² The overall cost ofOAB was estimated to be $12.6 billionin the year 2000, with $9.1 billion attributedto community costs and $3.5 billionto institutional costs.³ In the community,the cost of OAB treatmentfor women was more than 3 timesthat for men, with costs for womentotaling $7.37 billion, compared with$1.79 billion for men.²

In OAB, the detrusor, or bladdermuscle, inappropriately contracts andprevents the bladder from completelyfilling. This leads to sudden, forceful,and often unpredictable urges to urinateand sometimes results in prematureurinary leakage. Additionally, neurologicconditions, such as dementia, stroke,or spinal cord injury, bladder irritation,and medications, including diuretics,can also cause impaired detrusor musclestability. In 2002, the InternationalContinence Society classified OAB asa symptom-based syndrome defined asurinary urgency, with or without urgeincontinence, usually with frequencyand nocturia in the absence of infectionor other proven pathology. Urgeincontinence affects only one third ofthe entire OAB population (OAB wet),whereas two thirds have OAB withouturge incontinence (OAB dry).²

Treating OAB

Therapeutic interventions for OABconsist of lifestyle modifications, drugtherapy, and surgery. Lifestyle or behavioraltechniques are considered first-linetreatment for most types of OAB andare generally associated with no adverseeffects. Pelvic floor muscle trainingexercises (eg, Kegel exercises) can betaught to patients by their physiciansduring a routine urological examinationor can be learned from patient educationalmaterials.⁴ These exercises canbe augmented by the use of biofeedbackto help patients learn to selectively contractand strengthen pelvic muscles totighten the bladder outlet and cope withsymptoms of urinary urgency.⁵ In additionto pelvic floor training, educatingpatients about bladder functioning, fluidintake management, including the timingof fluid intake and maintenance ofhydration, management of constipation,and dietary alterations, such as decreasingcaffeine or alcohol consumption, areother nonpharmacologic interventionsthat are reported to improve symptomsof OAB. For older patients or patientswith cognitive impairment or limitedmobility, toileting assistance, use of bedsidecommodes, or prompted voidingmay additionally alleviate symptoms ofOAB.⁶ These changes should always beincorporated into a patient's treatmentplan as they have been proven to be beneficial.^7-10 Patients' expectations of treatmentalso should be addressed, as thiscan have a negative impact on treatmentoutcomes as well as medication adherence.^11,12 Pharmacologic interventions forOAB are generally noncurative, and nonadherencecan result if treatment resultsdo not meet the patient's expectations.

Drug Therapy, Medical Devices,and Surgical Interventions

Anticholinergic or antimuscarinic medicationsare the mainstay of pharmacologictreatment for OAB. These agentswork to improve detrusor muscle functionby competitively antagonizing theeffects of acetylcholine on bladder muscarinicreceptors to improve symptomsof incontinence. The Table includes alist of available medications in this classand their respective formulations andstrengths. One of the major limitationsof using immediate-release products inthe management of OAB is the higherincidence of adverse effects (eg, drymouth, constipation, headache, blurredvision, and drowsiness), which mayresult in patients preferring to cope withtheir symptoms rather than take themedication. For patients who are unableto take oral medications, oxybutyninalso is available as an extended-releasetransdermal patch. This formulation isassociated with a lower incidence of drymouth and constipation than any of theoral preparations. All of these agents arecontraindicated in patients with closedangleglaucoma or gastric retention.

In controlled studies, all of these productshave been proven efficacious in reducingsymptoms, with the extended-releaseproducts offering better patient adherence.^8,13 No head-to-head clinical studycomparisons of the extended-release formulationsof these products have beencompleted, making direct efficacy comparisonsof these products difficult.

A variety of medical devices are availablefor alleviating symptoms of OAB,including continence pessaries, urethralplugs, magnetic and electrical stimulationinterventions, and self-catheterization.For patients with severe symptoms,or those who have failed nonpharmacologicor pharmacologic therapies, severalsurgical modalities also are available.These procedures are not first-lineinterventions, and the type of procedureis dependent on the type of incontinencethe patient is experiencing.

Table

Anticholinergic Medications for Treatment of OAB

Drug

Formulation

Strength

Darifenacin (Enablex)

Extended-release tablets

7.5 mg

15 mg

Oxybutynin (Ditropan XL)

Extended-release tablets

5 mg

10 mg

15 mg

Oxybutynin (Ditropan)

Immediate-release tablets

5 mg

Oxybutynin Patch (Oxytrol)

Extended-release transdermal system

3.9 mg/24 hr

(1 patch applied twice weekly)

Solifenacin (Vesicare)

Tablets

5 mg

10 mg

Tolterodine (Detrol LA)

Extended-release capsules

2 mg

4 mg

Tolterodine (Detrol)

Immediate-release tablets

1 mg

2 mg

Trospium (Sanctura XR)

Extended-release capsules

60 mg

Trospium (Sanctura)

Immediate-release tablets

20 mg

Approach to the Patient

When discussing the condition of OABwith a patient, the pharmacist needsto be sensitive to this treatable, butoften embarrassing, medical condition.Realizing the sensitive nature of thiscondition and the fact that patientsmay attempt self-treatment without theguidance of a primary care physician,pharmacists must inquire about medicalevaluation before recommendingother interventions or offering advice onOTC incontinence aids. Patients shouldbe advised to seek medical attention iffrank incontinence occurs, if the urge tovoid occurs more than twice a night, orif pain or hematuria is present.

For patients diagnosed with OAB, recommendingavoidance of aggravating factorsis an important first step in symptomimprovement. Lifestyle interventions,including smoking cessation and weightloss, may also improve OAB symptoms.Discussing the importance of performingpelvic floor exercises and bladder trainingtechniques with a primary care physicianshould be emphasized.

Regarding the anticholinergic agentsthat are commonly prescribed for OAB,patients and caregivers should be cautionedabout the potential for theseagents to cause bothersome symptomsof dry mouth and constipation. Thesemedications can additionally affect thecentral nervous system and can causealtered mentation, hallucinations, somnolence,and confusion, especially in theelderly population. Patients reportingintolerance to side effects of immediate-releasepreparations should be advisedto discuss with their physician the possibilityof switching to an extended-releaseor alternative formulation that may beassociated with fewer side effects.

Patients with symptoms of OAB mayseek pharmacist recommendations forabsorbent undergarments to help manageurinary overflow. Although theseproducts are helpful in the managementof OAB, absorbent products should beused in conjunction with other therapeuticmodalities, including medications.Inappropriate use of these products canresult in delays in diagnosis and treatmentand can also increase the risk ofskin breakdown. When asked for a recommendationon such a product, pharmacistshave an opportunity to addresspatient concerns about their disorder,including advising patients to seek furthermedical evaluation from a physician,discussing potential bothersomeadverse effects, as well as providinghelpful educational materials.

Conclusion

OAB affects the quality of life of millionsof Americans. Pharmacists are wellpositioned to educate patients regardingnonpharmacologic and pharmacologicinterventions and to recommend OTCproducts for managing incontinence,when appropriate.

References

• Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20(6):327-336.
• Tubaro A. Defining overactive bladder: epidemiology and burden of disease. Urology. 2004;64(6 Suppl 1):2-6.
• Hu TW, Wagner TH, Bentkover JD, Leblanc K, Zhou SZ, Hunt T. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology. 2004;63(3):461-465.
• 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):2293-2299.
• Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA. 1998;280(23):1995-2000.
• Ouslander JG, Schnelle JF, Uman G, et al. Predictors of successful prompted voiding among incontinent nursing home residents. JAMA. 1995;273(17):1366-1370.
• Burgio KL, Kraus SR, Menefee S, et al. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med. 2008;149(3):161-169.
• Alhasso AA, McKinlay J, Patrick K, Stewart L. Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2006;4:CD003193.
• Berghmans LC, Hendriks HJ, De Bie RA, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU Int. 2000;85(3):254-263.
• Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148(6):459-473.
• Marschall-Kehrel D, Roberts RG, Brubaker L. Patient-reported outcomes in overactive bladder: the influence of perception of condition and expectation for treatment benefit. Urology. 2006;68(Suppl 2):29-37.
• Mullins CD, Subak LL. New perspectives on overactive bladder: quality of life impact, medication persistency, and treatment costs. Am J Manag Care. 2005;11(4 Suppl):S101-S102.
• Novara G, Galfano A, Secco S, et al. A systematic review and meta-analysis of randomized controlled trials with antimuscarinic drugs for overactive bladder. Eur Urol. 2008;54(4):740-763.

Table

Counseling the Patient with OAB

Nonpharmacologic Interventions

• Recommend avoidance of aggravating factors, including fluid intake management, preventing constipation, and limiting caffeine and alcohol consumption.
• For elderly patients, recommend caregivers provide toileting assistance or the use of bedside commodes.
• Educate patients that absorbent undergarments can help manage urinary overflow and should be used in conjunction with other therapeutic modalities.

Pharmacologic Interventions

• Anticholinergic medications are associated with bothersome adverse effects, particularly inelderly patients, including:

• Dry mouth
• Constipation
• Altered mentation
• Hallucinations
• Somnolence
• Confusion

• Extended-release or alternative formulations (eg, transdermal patches) may be associatedwith fewer side effects compared with immediate-release formulations.
• Address patient's expectations from medication therapy, keeping in mind pharmacologicinterventions for OAB are generally noncurative.

Physician Referral

• Refer patients with symptoms of frank incontinence, having the urge to void more than twicea night pain, or hematuria to their physician or urologist.
• Recommend patients discuss the importance of performing pelvic floor exercises with theirphysician.

OAB = overactive bladder