KUALA LUMPUR, Feb 20 — Changes in an individual’s urinary habits can have a negative impact on the quality of life.
For the uninitiated, urinary urgency refers to a situation when a person has a strong desire to empty the urinary bladder, which cannot be deferred.
Sometimes, it can be accompanied by urinary frequency, typically emptying the bladder at least eight times in the day, followed by nocturia condition, which would make you wake up at night to empty the bladder at least once.
If urgency leads to the involuntary passage of urine, this is termed urge incontinence.
This set of symptoms encompasses the overactive bladder (OAB) syndrome, as defined by the International Continence Society.
In most cases, OAB does not have a specific underlying cause.
The prevalence of OAB among East Asians aged more than 40 years is 20.8 per cent, with women slightly more affected than men.
In contrast, the overall OAB prevalence among Europeans and Americans were reported to be 11.8 per cent and 16 per cent respectively, with no gender preponderance among the Americans.
It is known that the prevalence of OAB increases with age in both sexes; therefore it is not surprising that OAB can co-exist or be made worse by ageing-related conditions such as benign prostatic enlargement, Parkinsonism and dementia.
OAB affects the general well-being of the patient considerably.
The most bothersome symptom seems to be nocturia among Asian men; therefore, OAB can affect the quality of sleep, sexual function, mental health and work performance.
Studies have also reported an association with urinary tract infection, fall injuries and an increase in medical consultations of up to 61 per cent, especially in the elderly population.
The diagnosis of OAB is made from a patient’s history of urinary tract symptoms as well as a measure of the severity.
A bladder or voiding diary helps the physician assess the link between fluid intake and urination pattern.
In OAB, voiding diaries usually reveal small and frequent passage of urine with possible incidences of urinary incontinence.
Confounding factors can be gleaned from a patient’s other medical conditions and medications are taken.
Clinical examination involves assessment of the abdomen and pelvis, including the genital organs and neurological system.
A urinary test may be required to exclude infections, while a simple bladder scan may also be performed to assess the completeness in emptying the urinary bladder.
Once a diagnosis of OAB is made, the patients are first engaged in their treatment plans via behavioural therapies and lifestyle changes.
This includes bladder training (BT) which incorporates bladder control strategies, as well as pelvic floor muscle training (PFMT).
Studies have shown that after three months of BT and PFMT, patients benefited from a reduction in incontinence episodes and have better quality of life.
Lifestyle changes include fluid and caffeine intake advisory, diet as well as weight reduction management.
Second-line treatment involves the use of medications with the aim of controlling and alleviating bothersome symptoms.
The two main classes of medications are antimuscarinics and beta-3 adrenoceptor agonist (mirabegron).
Antimuscarinic come in different formulations as they primarily act by reducing the contractility of the bladder by blocking nerve signalling at the M2 and M3 receptors of the bladder.
Pooled studies have shown remarkable effectiveness and improved quality of life at three months of treatment.
Side-effects, especially dry mouth, may result in poor treatment compliance among patients.
Another type of medication, mirabegron, acts by relaxing the bladder, therefore improving bladder filling and urine storage.
It is also shown to be efficacious in reducing incontinence and the number of voiding episodes at three months of therapy.
Commonly reported side effects also include hypertension and nasopharyngitis.
Selective patients may also benefit from a combination therapy of both medication groups.
Botox as a treatment method
Everyone is familiar with the use of Botox, or botulinum toxin, in aesthetics medicine.
It has now been shown that injecting onabotulinumtoxinA (Onta) into the bladder smooth-muscle in minute amounts, can lead to an effective, safe and long-term treatment for OAB refractory to the drugs mentioned above.
Patients who opted for this therapy will need to be followed up closely as there will be a need for bladder catheterization and repeated injections to maintain symptom improvement.
Apart from Onta, other third-line OAB treatment includes peripheral tibial nerve stimulation (PTNS) and sacral neuromodulation (SNM).
PTNS and SNM both work on the principle of modulating the nerve signalling pathway that controls the passage of urine.
PTNS is a less invasive, out-patient treatment which involves placing a small needle electrode into the lower inner aspect of either leg.
The treatment typically involves 12-weekly 30-minute sessions.
SNM is more invasive due to an implantable device and it is reserved for OAB refractory to other treatment methods.
Both treatment modalities have been proven effective in reducing the number of voids and episodes of incontinence.
The overactive bladder has a significant negative impact on a patient’s quality of life; nevertheless, various step-wise treatment strategies are available to help alleviate the symptoms and the associated inconveniences.
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* Dr Ngoo Kay Seong is a Consultant Urologist with many years of experience under his belt. He graduated MBChB with Commendation from the University of Aberdeen, Scotland and went on to pursue his Master of Surgery (General Surgery) at the National University of Malaysia. His sub-specialisation training in Urology under the Malaysian Board of Urology was undertaken at Selayang Hospital and the Institute of Urology and Nephrology at Kuala Lumpur Hospital. Subsequently, Dr Ngoo received the diploma of Fellowship in Urology from the Royal College of Surgeons and Physicians of Glasgow. He was also the recipient of the 2017 Young Urologist Fellowship from the Urological Association of Asia. In 2018, Dr Ngoo won the International Foundation Scholarship for Young Urologist in Asia to pursue a mini Fellowship in Minimally Invasive Uro-oncology at Tottori University, Yonago, Japan. He was the Scientific Committee member of the 17th Urological Association of Asia Congress 2019 and is also an Organising Committee member of Men’s Health World Congress 2020.