WHAT IS OAB?
OAB, sometimes called as OAB syndrome is quite common. It refers to the combination of frequency and urgency, which may be associated with urgency related leakage of urine (urge incontinence). It is estimated that 1 in 6 adults have some symptoms of OAB; 1 in 3 of these are likely to have urge incontinence.
OAB is better understood if we go through the mechanism of urine formation, it’s storage and expulsion.
The kidneys produce urine, which is actively propelled down the ureter into the bladder. The bladder, like a balloon, expands as it gets filled with urine; it stores urine for more than 98% of its life. That is all it does, apart from the remaining time, when it actively expels urine by contraction of the bladder muscle. The act of urination happens, when the muscles in our pelvic floor relax, followed by active relaxation of the sphincter (the group of muscles that surround the urethra in both men and women, that keeps us dry) and then contraction of the bladder muscle.
For this sequence to happen correctly every time, there is a complex interaction between the nerve cells in the bladder, pelvic floor, spinal cord and brain. Also, there is a constant relay of signals from the bladder to the brain indicating the level of fullness of the bladder.
WHY DOES ONE GET OAB?
When the bladder fills up it relaxes actively to accommodate and increase the capacity. Most people get a desire to pass urine when the bladder is half full, but the majority of us can hold on for longer and can postpone going to the toilet. In OAB, the bladder is sending wrong messages to the brain.
Therefore, the bladder may ‘feel’ fuller than it actually is; it also makes the bladder contract suddenly even when it is not full and you do not want it to. This, in effect, results in your losing control of the bladder (the bladder literally takes control of you in OAB).When this becomes frequent, it results in urinary frequency and urgency. If the pelvic floor and sphincters are not strong enough to resist the urge to pass urine it results in leakage of urine as well.
WHAT ARE THE CAUSES OF OAB?
OAB is quite common and there is usually no underlying cause. It can be due to bladder outflow obstruction caused by enlargement of the prostate gland (see LUTS – pt guide) in men or urethral narrowing caused by lack of estrogen in post-menopausal women. It can also be caused by irritation due to infection, stone or tumour in the bladder. Although urgency is not common in undiagnosed diabetes mellitus, the frequency can be debilitating; some of these patients may present with OAB.
It can occur as a complication of nerve or brain related problems like Parkinson’s disease, stroke, multiple sclerosis or spinal cord injury. In these cases it is not labeled as OAB.
In some people, OAB worsens with periods of stress. Some of these patients are likely to have an urgency to pass motion as well
After eliciting a focused history and clinical examination, your urologist is likely to request or arrange some of the following:
– Urinary diary: a chart of how frequently and how much urine you pass in a 24 hour period.
– Fasting and post-meal blood sugar (if you are not a known diabetic).
– Serum creatinine (to assess kidney function).
– Urine examination and culture to rule out bacterial infection.
– Ultrasound of the kidneys and bladder.
– Flexible cystoscopy (see CYSTOSCOPY – pt guide)
– Urine cytology (especially if you are a smoker).
– Urodynamics – bladder pressure flow test
These tests help rule out underlying problems that can cause OAB.
The following measures may be advised individually or in combination:
Lifestylemeasures: coffee, tea, alcohol, bottled drinks – these are likely to worsen OAB symptoms and need moderation.
Bladder training / drill: The aim with this is to gradually stretch the bladder so that it can hold increasingly larger volumes of urine. In time, the bladder muscle becomes less overactive and you take control of the bladder again. This also means that more time can elapse between feeling the desire to pass urine, and having to get to a toilet. Leaks of urine are then less likely.
Whenever there is an urge to pass urine, it is best to sit down and distract yourself by counting to 50 backwards, slowly. Usually the nuisance bladder contraction that causes the urge sensation will pass. You should then be able to get up slowly and resume your activity. In the initial stages of bladder training, it is better to pass urine when there is a call to pass urine the next time there is an urge sensation. Over time, the interval between voids will increase. To increase the interval between voids by 15 minutes in the first 4-6 weeks is realistic. The aim, eventually, is to achieve voids every 2.5-3 hours.
Bladder training works best when it is combined with pelvic floor exercises
Strengthening the pelvic floor helps resist the urge to pass urine whenever there is a ‘nuisance’ bladder contraction. So, when you are in the process of bladder training and you sit down counting backwards slowly from 50, a strong pelvic floor helps in ‘squeezing’ the pelvic floor until the sensation of urgency passes off.
The pictures above show the pelvic floor – the one on the left shows the floor from the top ie looking into the pelvic floor from the head end. The picture on the right looks at the floor from the bottom ie looking at it from the foot end.
It is important that you exercise the correct muscles. You may be referred to a physiotherapist to perform these correctly. The sort of exercises is as follows (following text on pelvic floor exercises courtesy of Patient.co.uk):
1. Sit in a chair with your knees slightly apart. Imagine you are trying to stop wind escaping from your anus (back passage). You will have to squeeze the muscle just above the entrance to the anus.
You should feel some movement in the muscle. Don’t move your buttocks or legs.
2. Now imagine you are passing urine and are trying to stop the stream. You will find yourself using slightly different parts of the pelvic floor muscles to the first exercise (ones nearer the front). These are the ones to strengthen.
If you are not sure that you are exercising the right muscles, put a couple of fingers into your vagina. You should feel a gentle squeeze when doing the exercise.
1. You need to do the exercises every day.
2. Sit, stand or lie with your knees slightly apart. Slowly tighten your pelvic floor muscles under the bladder as hard as you can. Hold to the count of five, and then relax. Repeat at least five times. These are called slow pull-ups.
3. Then do the same exercise quickly for a second or two. Repeat at least five times. These are called fast pull-ups.
4. Keep repeating the five slow pull-ups and the five fast pull-ups for five minutes.
5. Aim to do the above exercises for about five minutes at least three times a day, and preferably 6-10 times a day.
6. Ideally, do each five-minute bout of exercise in different positions. That is, sometimes when sitting, sometimes when standing, and sometimes when lying down.
7. As the muscles become stronger, increase the length of time you hold each slow pull-up. You are doing well if you can hold each slow pull-up for a count of 10
8. Do not squeeze other muscles at the same time as you squeeze your pelvic floor muscles. For example, do not use any muscles in your back, thighs, or buttocks.
9. In addition to the times you set aside to do the exercises, try to get into the habit of doing exercises whilst going about everyday life. For example, when answering the phone, when washing up, etc.
10. After several weeks the muscles will start to feel stronger. You may find that you can squeeze the pelvic floor muscles for much longer without the muscles feeling tired.
It takes time, effort and practice to become good at these exercises. It is advised that you do these exercises for at least three months to start with. You should start to see benefits after a few weeks. However, it often takes 8-20 weeks for most improvement to occur. If possible, continue exercising as a part of everyday life for the rest of your life to stop the problem recurring.
Medication: You may be prescribed some tablets (in the family of anti-muscarinics) to slow down the frequency and strength of unwanted bladder contractions. These tablets have some side effects and the urologist will discuss these with you.
BoTox: Injection of botulinum toxin into the bladder wall is an alternative once the trial of medications is exhausted and symptoms persist. This is a relatively expensive affair and the urologist will discuss this with you.
Surgery: A few options are available in the worst affected cases. Again, the urologist will discuss these with you.