Overactive bladder syndrome

What is the bladder?

The bladder is the organ which stores urine produced by the kidneys. It is a muscle in the shape of a bag which can hold around 400 millilitres of urine (Fig. 1a and b).

Most people become aware their bladder is filling when it is half full. In order to empty the bladder, you have to be able to relax. This usually means being in a socially convenient environment, such as a toilet or a private space. The brain will then send a signal to the bladder to start squeezing out the urine.

How often you urinate depends on many factors, but one in particular is how much you drink. Most people urinate less than 8 times during the day, and either not at all or once during the night.

Fig. 1a: The male lower urinary tract.
Fig. 1a: The male lower urinary tract.
Fig. 1b: The female lower urinary tract.
Fig. 1b: The female lower urinary tract.

What are overactive bladder symptoms?

Overactive bladder symptoms (OAB) are common and can affect both men and women. Between 10 and 20% of people suffer from it at some stage in their lives.

OAB symptoms are a set of urinary storage symptoms. Storage symptoms
include:

  • The sudden need to urinate and having trouble postponing it
  • Any involuntary loss of urine
  • The need to urinate more often than usual
  • The need to wake up at night to urinate.

What causes overactive bladders symptoms?

OAB symptoms can have various causes:

  • Some people experience sudden and spontaneous contractions of the bladder muscle
  • Some people are more sensitive to the feeling of their bladder filling
  • In some cases, the kidneys produce too much urine at night, which causes nocturia. This may be related to older age or certain medical conditions
  • Some people have a smaller bladder which is filled to capacity more quickly, but this is not very common

Diagnosis

The doctor does a series of tests to understand what causes your symptoms. This is called a diagnosis.

Overactive bladder symptoms (OAB) can point to other conditions. Part of the diagnosis is ruling out other possible explanations for the symptoms, such as urinary infection or diabetes.

First, the doctor or nurse will take your medical history and do a physical examination. If needed, other tests will be performed. This section offers general information about the diagnosis of OAB and situations can vary from country to country.

Medical history

The doctor will take a detailed medical history and ask questions about your symptoms. You can help your doctor by preparing for the consultation:

  • Describe your current symptoms
  • Note how long you have had the symptoms for
  • Make a list of the medication you are taking
  • Make a list of previous surgical procedures
  • Mention other diseases or conditions you suffer from
  • Describe your lifestyle (exercising, smoking, alcohol, and diet)

Physical examination

Your doctor or nurse will do a general physical examination focussing on:

  • Your abdomen
  • Your genitals
  • The nerves in your back

Urine test

You will need to give some of your urine for testing. The test will show if you have a urinary tract infection and if there are traces of blood or sugar in the urine.

Bladder diary

Your doctor may ask you to keep a bladder diary. Here you can note down how much you drink, how often you urinate, and how much urine you produce. The bladder diary is important because it helps your doctor to understand your symptoms better.

Uroflowmetry

This is a simple test which electronically records the rate of urine flow. It is easily done in privacy at the hospital or clinic. You will urinate into a container, called a uroflowmeter. This test helps your doctor to check whether there is any obstruction to the flow of urine.

Imaging of the bladder

You will get an ultrasonography (also known as ultrasound), which uses high-frequency sounds to create an image of your bladder. The doctor or nurse will scan your bladder to check how much urine is left in the bladder after urinating. This information helps to see if your symptoms are caused by urine retention in the bladder after urinating.

Bladder examination

If there is blood in the urine, you may need a bladder examination. The doctor uses a type of endoscope – called a cystoscope – to look inside the bladder, usually under local anaesthesia.

Urodynamic evaluation

A urodynamic test is done to get more information about your urination cycle and how your bladder muscles work. During the test, your doctor inserts small catheters in your urethra and rectum to measure the pressure in your bladder and abdomen.

Self-management

The symptoms of overactive bladder are often bothersome but not life-threatening. OAB symptoms can last
for a long time and there is no simple cure. There are various treatment options available. In most cases, self-management is offered as the first step of treatment. It is common to try different treatment options to figure out which one works best in your individual situation. You can discuss this with your doctor.

You can actively manage your symptoms. The following self-management measures may help you:

  • Together with your doctor you can discuss adapting when, what, and how much you drink
  • If urine leakage is a problem, your doctor may recommend wearing an absorbent pad to prevent wetting your clothes
  • If recommended by your doctor, encourage yourself to “hold it” longer when you feel the urgency to urinate. This will train your bladder and gradually increase the time between toilet visits
  • Pelvic muscles can weaken with age. Different exercises can help to regain muscle strength and suppress the urgent desire to urinate. A physiotherapist can help you do these exercises the right way.

Lifestyle advice

In addition, general lifestyle changes can help manage your symptoms and improve your quality of life.

  • Drink at least 1-1.5 litre every day and discuss with your doctor if you can drink more
  • Drink more if you live in a hot climate or do a lot of physical exercise
  • Drink less before and during long trips
  • Drink less in the evening to avoid getting up at night to urinate
  • Reduce alcohol and caffeine because they increase urine production and irritate the bladder
  • Certain foods can irritate the bladder and worsen OAB symptoms. It may be helpful to reduce artificial sweeteners, spicy foods, citrus fruits and juices, caffeine and soft drinks in your diet
  • Maintain a healthy weight (your Body Mass Index should be between 18-25 kg/m2). Reducing your weight may lead to improvement in urine leakage symptoms

Read more about continence products, such as different types of pads, at the Continence Product Advisor website

Drug treatment

In about one third of people, self-management of overactive bladder symptoms does not work (See Self-management of OAB). If self-management measures did not improve your symptoms, your doctor may suggest drug treatment.

This section describes different groups of drugs. Together with your doctor you can decide which approach is  best for you. Factors which influence this decision include:

  • Your symptoms
  • Your medical history
  • Any other medication you are taking
  • Drugs available in your country
  • Your personal preferences and values

This section offers general information about drug treatment for OAB symptoms and situations can vary
from country to country.

There are several groups of drugs to treat OAB symptoms:

  • Muscarinic receptor antagonists
  • Beta-3 agonists
  • Desmopressin
  • Oestrogen

Muscarinic receptor antagonists

Muscarinic receptor antagonists (MRAs) are a group of drugs which reduce the abnormal contractions of the bladder and improve urgency symptoms. This is the most commonly recommended group of drugs for OAB symptoms. There are several types of MRAs:

  • Darifenacin
  • Fesoterodine
  • Oxybutynin
  • Propiverine
  • Solifenacin
  • Tolterodine
  • Trospium chloride

Beta-3 agonists

Beta-3 agonists are a new class of drugs which improve OAB symptoms by reducing abnormal contractions of the bladder, similar to MRAs. Currently, only mirabegron is used for the treatment of OAB symptoms.

Mirabegron is recommended if your symptoms have not improved when taking MRAs or if you experience bothersome side effects from the MRAs. The side effects of mirabegron are usually mild.

Watch this video to learn more about drug treatment with MRAs or Beta-3 agonists.

Desmopressin

Desmopressin reduces the amount of urine the body produces. This drug is recommended if your main OAB 2017symptom is nocturia. Desmopressin may reduce the number of times you wake up to use the toilet and allow you more hours of uninterrupted sleep. It comes as a tablet, a nasal spray, or a melt-in-the-mouth tablet and is taken right before sleeping. The drug is effective for 8-12 hours.

Desmopressin can cause a drop in blood sodium (salt) levels. That is why it is common to have your blood tested before and during your treatment. Less common side effects are headache, nausea, diarrhoea, pain in the abdomen, dizziness, or dry mouth. In rare cases, desmopressin can cause high blood pressure and swelling of the feet and ankles (known as peripheral oedema).

Oestrogen

The hormone oestrogen plays an important role in female continence. Oestrogen is  known to improve blood flow and increase nerve function. It also helps maintain the  strength and flexibility of tissues in the urethra and vagina. As women age, they  produce less oestrogen. Lower levels of oestrogen cause vaginal dryness and may  affect the bladder and urethra. This can contribute to problems with bladder control.

Local oestrogen therapy can be recommended for women who suffer from urinary  incontinence and have already gone through menopause. The treatment comes as a  vaginal cream, or can be released through a vaginal ring or pessary.

Vaginal oestrogen therapy may improve or even cure urge urinary incontinence. It  can be used in combination with other drug treatments for incontinence. When  vaginal cream is used correctly, it usually does not cause side effects. The ideal  duration of vaginal oestrogen therapy is unknown and the long-term side effects are  still being researched.

Second-line treatment

Sometimes the drugs your doctor prescribed do not improve your overactive bladder symptoms (OAB). In  these cases, other treatment options are available. Together with your doctor you can decide which approach is best for you.

This section offers general information about second line treatment for OAB symptoms and situations can vary from country to country.

Common treatment options for OAB symptoms are:

  • Botulinum toxin bladder injection
  • Nerve stimulation, also known as neuromodulation
  • Surgery to increase bladder volume

Botulinum toxin

Botulinum toxin is widely known by one of its trade names, Botox® and is often used in cosmetic surgery.

For OAB symptoms, the toxin is injected into the lining of the bladder to reduce the activity of the nerves which cause the symptoms. This treatment may improve urgency, frequency of urinating, and urgency incontinence.

For botulinum toxin injections, you will generally receive local anaesthesia. Sometimes other forms of anaesthesia are used. The doctor uses a type of endoscope, known as a cystoscope, to enter your bladder through the urethra. The cystoscope has a small camera to show a high-quality image of your bladder on a video monitor. The doctor injects a small dose of botulinum toxin into different areas of your bladder wall (Fig. 2).

The effect of the procedure will wear off with time and after 4-9 months you will need to undergo repeat treatment. Some people (less than 10%) may have difficulty urinating after a botulinum toxin injection, and may need a catheter. Catheters may increase the risk of urinary tract infection and your doctor may prescribe antibiotics.

Fig. 2: Botulinum toxin is injected into the lining of the bladder

Nerve stimulation

Nerve stimulation, also known as neuromodulation, is a treatment which uses electrical pulses to stimulate the sacral nerves, which control the bladder. There are two types of nerve stimulation:

  • Tibial nerve stimulation uses a needle at the level of the ankle
  • In sacral nerve modulation a device is implanted in your lower back

Bladder surgery

In case your symptoms have not improved with drug or other treatments, you may need surgery on your bladder. The goal of the procedure is to increase the capacity of the bladder. This will reduce the pressure in the bladder as it fills so that it can hold more urine.

The doctor makes an incision in your lower abdomen and uses a piece of your bowel to increase the size of the bladder. This procedure is called bladder augmentation or clam cystoplasty, and is rarely performed nowadays (Fig. 3). If this surgery is recommended you will need to discuss its implications and side effects with your doctor because they can be significant.

Fig. 3: Bladder surgery to increase the size of the bladder.

Living with OAB

Although overactive bladder symptoms (OAB) are not life-threatening, they usually have a negative impact on your quality of life. Different people cope differently with their symptoms and the possible side effects of treatment. Your personal preferences and values and the impact of OAB symptoms on your life should not be underestimated.

Quality of life involves both physical and psychological health. It is important not only to feel healthy but also to feel free from the psychological pressure of living with OAB symptoms.

Symptoms such as urgency or the need to urinate frequently are likely to have a negative effect on your quality of life. Someone with OAB symptoms often needs to locate toilets before leaving the house and may avoid certain activities altogether. Also, losing sleep because of waking up at night to urinate may lower your energy levels, which makes it more difficult to maintain your daily activities. Episodes of urgency which result in leakage of urine are embarrassing and may lower your self-esteem.

These problems can also impact your loved ones. For example, your partner might be awoken by night time toilet visits. Because of your OAB symptoms you may avoid social activities. This can also affect your partner’s social life and lead to a feeling of isolation which prevents you and your loved ones from fully enjoying life.

There are many ways to keep the symptoms under control. They should not stop you from being happy in your relationships and participating in the social, cultural, and economic life of your community. Seek help if your symptoms bother you: consult your family doctor, general practitioner, or a urologist.

Seeking help

OAB symptoms become more common with increasing age. However, they should not be seen as a normal part of ageing or an untreatable problem. If you have bothersome symptoms it is important that you go to your  doctor and are not embarrassed to discuss your situation.

This information was produced by the European Association of Urology (EAU).

  • Prof. Christopher Chapple, Sheffield (UK)
  • Prof. Stavros Gravas, Larissa (GR)
  • Dr. Nadir Osman, Sheffield (UK)

This information was updated by the EAU Patient Information Working Group, March 2018.

The content is in line with the EAU Guidelines on Overactive Bladder 2017.

  • Dr. Jan-Peter Jessen, Sindelfingen (DE)
  • Dr. Marta Sochaj, Warsaw (PL)