Overactive bladder

Overactive Bladder (Overactive Bladder, OAB)

1) Disease Description (Causes and Symptoms)

• Definition: The main symptom is urinary urgency (a sudden and strong urge to urinate) in the absence of another clear cause (urinary tract infection, urinary tract stones, neurological disease, etc.), often accompanied by increased daytime and nighttime urinary frequency. When urge urinary incontinence is also present, it is classified as OAB wet; when it is absent, it is classified as OAB dry.
• Pathophysiology: It is explained by abnormal contractions of the detrusor muscle (bladder smooth muscle) (detrusor contractions occurring before voluntary control of urination) or hypersensitivity of bladder sensation. Abnormalities in nervous system and muscle control, and hypersensitivity of sensory signals, are the main mechanisms.
• Main symptoms: Sudden urge to urinate (urinary urgency), increased daytime urinary frequency, nocturia (awakening at night), and urge urinary incontinence (urinary incontinence before reaching the bathroom). The severity of symptoms varies greatly between individuals.
• Epidemiology (summary): It occurs at all ages, but its frequency increases with age. The incidence is generally similar in men and women.

2) Treatment Methods

• First-line: Behavioral therapy (lifestyle improvement)
  • Bladder training (gradually extending the time between urination), timed urination, and keeping a bladder diary (recording frequency, urine volume, and urinary incontinence).
  • Fluid intake control (limiting excessive fluids, caffeine, and alcohol), weight management, and treatment of constipation.
  • Pelvic floor muscle strengthening exercises (Kegel exercises) are recommended in combination, particularly when urinary incontinence is present.
• Second-line: Medication treatment
  • Anticholinergics (antimuscarinics): oxybutynin, tolterodine, solifenacin, etc. — suppress bladder contractions. Side effects: dry mouth, constipation, dizziness, and a risk of cognitive decline in older adults.
  • Beta-3 agonist: mirabegron — promotes bladder relaxation. Side effects: possible increase in blood pressure (caution in patients with hypertension), headache, indigestion, etc.
  • Treatment is combined with behavioral therapy. If there is no response to medication or treatment is discontinued due to side effects, switching to another medication may be considered.
• Third-line (patients unresponsive to medication or with severe symptoms): Procedures/Surgery
  • Intravesical botulinum toxin injection (botulinum toxin A): improves urinary urgency and incontinence. Complications include urinary retention (increased residual urine) and an increased risk of urinary tract infection. Because the effect is temporary (several months), repeated injections are necessary.
  • Sacral neuromodulation: improves symptoms through nerve modulation. Device implantation and adjustment are required.
  • Augmentation cystoplasty: considered only in extreme cases (invasive and associated with many complications).
• Precautions, risk of complications, and self-management considerations
  • When using anticholinergics, older patients should be monitored for possible worsening of cognitive function (such as memory decline).
  • Blood pressure should be checked when taking mirabegron (caution in people with a history of hypertension).
  • If urinary retention occurs after a botulinum toxin injection, intermittent self-catheterization may be necessary.
  • If symptoms of a urinary tract infection occur (fever, severe pain during urination, cloudy urine, etc.), consult a medical professional immediately.
  • The long-term prognosis varies depending on the treatment response and coexisting diseases. Symptoms often improve with behavioral and medication treatment.

3) Outpatient Visit Checkpoints (Including Items to Bring and Example Questions)

• Items to bring (for a hospital visit)
  • A list of recently used medications (including prescription drugs, OTC medications, and herbal medicines).
  • A bladder diary (if possible, record for 2–3 days): urination times, urine volumes, times when urgency occurs, and whether urinary incontinence occurred.
  • Copies of recent test results (urinalysis, ultrasound PVR residual urine measurement, etc.) and previous related test results (uroflowmetry, urodynamic testing).
  • Records of coexisting diseases (hypertension, heart disease, neurological disease, etc.).
• Useful information/symptom records to prepare for the outpatient visit
  • Average number of urinations per day (daytime/nighttime), frequency of urgency, number of incontinence episodes, and specific triggers (caffeine, alcohol, exercise, etc.).
  • Recent weight changes, whether constipation is present, and sleep patterns.
• Example questions (preparatory questions that are useful for patients to ask)
  • "When can I expect this medication to start working?"
  • "What should I do if side effects occur?"
  • "What is the goal of treatment (complete remission or symptom reduction)?"

4) General Example Questions to Ask the Doctor

• What are the expected effects and side effects of this medication? (Especially regarding anticholinergics and mirabegron)
• What lifestyle changes should I prioritize and make immediately?
• If my symptoms do not improve with medication, what are the advantages, disadvantages, and risks of the next steps (botulinum toxin injections, neuromodulation, etc.)?
• How are existing conditions such as blood pressure and cognitive function related to treatment (what should be considered when selecting medication)?

5) Examples of Disease-Specific Questions

• Could my urgency be related to a neurological disease such as Parkinson’s disease, multiple sclerosis, or stroke? Will additional testing (such as a neurological evaluation) be necessary?
• How high is the risk of urinary retention after a botulinum toxin injection, and how can I know in advance whether self-catheterization will be necessary?

Brief summary: A stepwise approach is used: behavioral therapy (bladder training and fluid control) → medication (anticholinergics and beta-3 agonists) → botulinum toxin injections, neuromodulation, or surgery if unresponsive. Preparing a bladder diary and a list of medications before the visit can help with establishing a diagnosis and treatment plan.