Treatment of Overactive Bladder Refractory to Medications - Minimally Invasive Therapy for Urinary Incontinence and Pelvic Organ Prolapse (Current Clinical Urology) 2014th

Minimally Invasive Therapy for Urinary Incontinence and Pelvic Organ Prolapse (Current Clinical Urology) 2014th

11. Treatment of Overactive Bladder Refractory to Medications

Rajveer S. Purohit¹ and Jerry G. Blaivas^{1, 2, 3}

(1)

Department of Urology, Weill Cornell Medical College of Cornell University, 445 E. 77th Street, New York, NY 10075, USA

(2)

Department of Urology, SUNY Downstate College of Medicine, Brooklyn, NY, USA

(3)

Institute for Bladder and Prostate Research, New York, NY, USA

Rajveer S. Purohit

Email: rajpu@yahoo.com

Abstract

Conservative therapy for overactive bladder (OAB) has been shown to be a viable stand alone or adjunctive option to antimuscarinic agents (AMAs). Typically nonsurgical options such as behavioral therapy, pelvic floor muscle therapy (PFMT), and biofeedback have been recommended prior to more invasive options such as electrical stimulation, intravesical Botox, or augmentation enterocystoplasty, ileovesicostomy, and urinary diversion. We believe this standard step-wise algorithmic approach to treatment is reasonable, but in some instances may subject patients to unnecessary expense and delay in treatment. Rather, we prefer to individualize our approach to maximize the likelihood of success in each patient while appropriately weighing relative risks with potential benefits. So, for example, a patient with severe neurogenic OAB refractory to AMA may opt for augmentation cystoplasty rather than intradetrusor injection of Botox or neuromodulation.

Approach to Management

Treatment of associated conditions such as prostatic obstruction in men or vault prolapse in women should be considered prior to starting a nonsurgical regimen for OAB. When referred a patient with OAB refractory to AMAs, clinicians should begin a thorough history with a detailed account of the nature of the patient’s urinary symptoms with each symptom characterized and quantified as accurately as possible by the patient. A physical exam may help elucidate refractory causes of OAB; for example, many patients may report unsuccessful treatment of OAB symptoms with AMAs by their primary doctor, but may be unaware that they have pelvic prolapse causing urethral obstruction that causes the OAB symptoms. Questionnaires, bladder diaries, and pad tests (for incontinent patients) are also useful.

In patients with OAB refractory to AMAs we believe that cystoscopy and videourodynamics (VUD) should be considered to look for (1) remediable causes of OAB (urethral obstruction, urethral diverticulum, bladder cancer, etc.) and (2) to classify the Type of OAB. A VUD-based classification system can help determine which patients would maximally benefit from BT and PFMT [1]. In this system, Type 1 OAB refers to sensory urgency in which patients essentially have a normal VUD without evidence of involuntary detrusor contractions but complain of urinary urgency. Type 2 refers to patients whose urgency can be correlated to a VUD finding of involuntary detrusor contractions but who are able to prevent incontinence by contracting their urinary sphincter. Type 3 refers to those patients who are able to contract their sphincter in response to an involuntary bladder contraction but are ultimately unable to abort the contraction and prevent incontinence. Type 4 refers to those patients who are either unaware or completely unable to prevent any incontinence from developing during a bladder contraction. For patients with Type 1 OAB, behavioral modification will both identify behavioral patterns and external stimuli that trigger the sensory urgency and teach patients to modify it. Type 2 and Type 3 OAB patients can be instructed with the aid of BT and PFMT to identify the onset of a detrusor contraction and contract their striated sphincter in response. For Type 2 patients, who are ideal candidates for BT, this will often cause the contraction to subside preventing incontinence and decreasing urinary frequency; in Type 3 patients, the sphincteric contraction may provide enough of a time window to urinate in the bathroom. BT and PFMT are rarely successful in Type 4 patients.

Surgical treatment of OAB is considered under two circumstances: when there is an underlying remediable condition, and when the OAB symptoms have proven refractory to nonsurgical treatments. For refractory OAB unassociated with a remedial condition, Botox injections, neuromodulation, enterocystoplasty, and urinary diversion may be considered.

Behavioral Therapy

Behavioral therapy (BT) is a process of teaching patients to measure and empirically alter observable behaviors that cause or exacerbate their OAB symptoms. There is consensus among experts that it is effective [2] and may be even more effective than AMAs [3]. The use of behavioral therapy in conjunction with AMAs may be more efficacious than either therapy alone [4, 5]. BT is most often used when the etiology of OAB is unknown, but it may also be effective when OAB is secondary to an underlying condition such as prostatic obstruction or even neurogenic conditions such as multiple sclerosis or Parkinson’s disease [6]. But successful outcomes require a motivated patient committed to the regimen prescribed by the behavioral therapist which can sometimes require substantial changes in behavior.

BT should begin with a careful history, which is crucial in understanding potential behavioral influences on OAB. The patient should be queried in regard to his daytime and nocturnal urinary patterns and his or her ability to postpone micturition once an urge develops. Causes for voiding (e.g., severe urgency or convenience voiding) and contributing factors such as caffeine usage should also be determined.

The primary tools used to measure outcomes and evaluate the nature and severity of OAB symptoms is the 24-h bladder diary whose reproducibility has been previously confirmed (Fig. 11.1) [7, 8]. The diary measures the volume and time of each void and annotates associated symptoms. The bladder diary that we prefer, also records the reason for and the severity of urgency for each void—the urge perception score (Table 11.1) [9]. It can distinguish polyuria with normal volume voids from patients who effectively have a small bladder capacity. For patients who complain of OAB symptoms and are found to have polyuria, fluid restriction may be sufficient to alleviate symptoms, but changing ingrained behaviors can be difficult and diaries can assess the degree of compliance with fluid restriction. Critical for behavioral modification, repeat diaries provide data on the effects that changes to variables, such as caffeine, may have on urination.

Fig. 11.1

Twenty four-hour OAB bladder diary

Table 11.1

Case report—before and after BT bladder diaries

	Pre-BT	Post-BT
24 h voided volume (mL)	2,640	1,320
Daytime voided volume (mL)	730	1,080
Nighttime voided volume (mL)	380	240
Total 24 h # voids	11	6
# Daytime voids	8	6
# Night voids	3	1
Maximum voided volume (mL)	250	360
# Incontinent episodes	3	0
# Urgency episodes	4	0

Behavioral modification can be used for patients with both sensory urgency without detrusor overactivity (DO) and those with DO. For patients with sensory urgency, without DO, the diary helps to determine at what volume the patient experiences symptoms; and the patient can be taught to void prior to reaching that volume. In addition because many external variables such as caffeine and spicy foods or stress may trigger urinary urgency in these patients, the 24-h bladder diary in conjunction with records of environmental causes may help determine what these variables might be.

There is data that caffeine is one variable that patients should consider altering as part of their BT regimen. A small study of patients with OAB who were given relatively high doses of caffeine (4.5 mg/kg) and subsequently underwent urodynamics found that caffeine decreased the threshold at first sensation to void [10]. Detrusor overactivity and increased bladder sensory signaling with high doses of caffeine (150 mg/kg) has also been found in animal models of mice [11]. In another study of women with detrusor overactivity, while high caffeine intake (>400 mg day) was correlated to bladder symptoms, moderate and low intake did not significantly affect detrusor overactivity [12]. Anecdotally, some patients have reported worsening OAB symptoms with tobacco use, but there is little good data to confirm this.

Stress and anxiety may also exacerbate OAB symptoms and these should be considered as potentially modifiable variables that may impact symptoms when patients undergo BT. [13–15] Teaching stress reduction techniques should be one component of BT for these patients. Obesity has been strongly linked to both developing OAB symptoms and to the severity of symptoms [16, 17]. Weight loss may aid in alleviating OAB symptoms [18]. Furthermore, BT should also include some evaluation of bowel patterns (e.g., constipation) as these are potentially modifiable variables that also alter OAB symptoms [19–21].

In addition to altering triggers to urination, behavioral modification regimens may also consist of timed voiding in which patients gradually increase the amount that can comfortably be held in the bladder. Upon completing an initial voiding diary to elucidate the frequency of their voiding, patients are instructed to void at a timed interval that is initially more frequent than reported on the diary. After doing this for typically 1–2 weeks, the voiding interval is usually increased by 15–30 min per week and the process repeated once the patient is able to consistently void prior to experiencing the more severe urges that prompted treatment. This process generally takes about 8–12 weeks and although the exact physiological mechanism of timed voiding is not known, data has demonstrated its efficacy [22, 23].

For patients who definitely have or are presumed to have detrusor overactivity (DO), behavioral therapy can either prevent or abort involuntary detrusor contractions. If the bladder diary suggests that symptoms are related to bladder volume, patients are taught to void at a volume before DO is triggered. Patients are also taught to recognize patterns that seem to cause the DO—running water, “key lock and garage door syndrome,” etc. If that does not work, the third step is to teach the patient to contract his or her pelvic floor (Kegel maneuver) to prevent or abort involuntary detrusor contractions. Unfortunately, the Kegel maneuver is only effective in aborting the involuntary detrusor contraction in about half of OAB patients. When the patient feels a strong urge to void, she is instructed to contract her pelvic floor in rapid succession for short bursts until the urge subsides. If that does not resolve the urgency, several prolonged contractions for 10 or 15 s may be useful. In either case, she is instructed that once the urge subsides, she should breathe in and out slowly in a relaxed fashion and walk slowly to the bathroom. Rushing or running, we believe, tends to reignite the stimulus for urgency and detrusor overactivity and also may induce sphincteric incontinence.

An additional component to behavioral therapy includes altering patients’ reaction to the initial urge to urinate. Patients complaining of OAB will often void preemptively in order to prevent urgency or urge incontinence. This manifests on the bladder diary as UPS voids designated 0–1. By encouraging patients to void only when a stronger urge occurs (UPS score of 2), substantial declines in urinary frequency can occur. In addition to this, a behavioral modification regimen may also look to distraction techniques or even hypnosis to alter urgency perception [24].

The importance of the Urodynamic OAB Classification system and bladder diary cannot be overestimated when behavioral therapy is utilized. The OAB type has a crucial impact on how BT proceeds. For example, patients with Type 2 OAB have involuntary detrusor contractions, but the patient perceives a warning and is able to contract his sphincter, prevent incontinence, and make the detrusor contraction subside so that he can walk to the bathroom in an unhurried fashion. All the behavioral therapist needs to do is incorporate what the patient already is capable of into the BT program. In patients with Type 4 OAB, the patient has no awareness or control of the involuntary detrusor contractions, so a completely different treatment paradigm must be constructed based on the particulars of the patients life style. This type of patient needs to either “relearn” bladder sensations as well as control, or void before the involuntary detrusor contractions occur. The bladder diary provides the metrics by which the initial OAB diagnosis is made and then serves as a monitor of the patient’s progress as well as a tool for understanding the behaviors that need to be integrated into the BT process.

Pelvic Floor Muscle Training and Biofeedback

PFMT (often called Kegel exercises) and biofeedback have been used for decades to treat OAB as an alternative and/or adjunct to medications. PFMT, by repeated contractions of the pelvic floor, strengthens the pelvic floor muscles through an unknown neurologic reflex, which shuts off the involuntary detrusor contraction that causes urgency in some patients [25–27].

PFMT can be conducted by the patient after proper instruction from a therapist, with or without biofeedback training. Biofeedback for OAB has two applications: to teach the patient how to control the pelvic floor muscles, and to strengthen those muscles. Biofeedback may be used as an adjunctive technique to PFMT [28] and is particularly effective when combined with behavior modification [29]. The patient is taught how to contract the pelvic floor and to do so whenever an uncomfortable urge to void is felt. By contracting the sphincter, incontinence is prevented during the involuntary bladder contraction; the contraction also activates a neurologic reflex that stops the bladder contraction and provides the patient more time to comfortably find a bathroom.

Biofeedback for OAB is any technique whereby patients are given immediate information about the activity of their pelvic floor thereby allowing patients to better isolate and control its function [30]. Biofeedback is typically done through the use of electromyography (EMG) leads but can also be accomplished with weighted vaginal cones or by sensing the strength of sphincteric contraction by digital palpation. With vaginal cones, when patients feel the cones descending they are instructed to contract their pelvic floor to prevent the cones from falling out. As patients’ pelvic floor strength improves, the weight of the vaginal cones can also be increased which allows for a graded approach towards strengthening the sphincter.

We typically use EMG sensors around the vagina or perineum to evaluate the activity of the pelvic floor and use an anal manometer to measure abdominal pressure. Measurement of abdominal pressure allows patients to better isolate their pelvic floor muscles and identify and minimize counterproductive abdominal contractions during exercises. The patients are taught how to contract their pelvic floor, and the strength and duration of each muscle contraction is displayed on a screen as is the abdominal pressure. The sessions are usually scheduled for 30–60 min once a week or every other week. Patients may also purchase or rent a portable unit for use at home and are instructed to continue their PFMT exercise regimen at home. Variables tracked every week include voiding diaries (and 24-h pad tests if patents are incontinent) and changes in the nature (e.g., strength and duration) of contraction that patients were able to generate during the biofeedback session. Based on the progress made each week, an exercise program is planned for the following week.

Although, complications of biofeedback and PFMT are rare, a standardized PFMT and biofeedback regimen has not been accepted. Short-term studies with up to 6-month follow-up have suggested between 54 and 87 % improvement in incontinence [31, 32]. One meta-analysis found biofeedback with pelvic floor exercises to be superior to pelvic floor exercises alone [33]. Although long-term efficacy has not been established in well-designed studies, evidence does suggest it remains effective [4, 29].

Electrical Stimulation

Electrical stimulation of the pelvic floor has been advocated by some for refractory OAB. There are essentially two models of electrical stimulation. The first is high frequency stimulation that is hypothesized to work by using electrodes in or near the vagina, rectum, or perineum to repetitively stimulate the pelvic floor to increase strength and tone of the muscles [34]. The electrodes can either be placed cutaneously or inserted into the rectum or vaginal vault. They cause minimal pain during stimulation and sessions are usually scheduled weekly or at biweekly intervals. In some instances, home stimulation units may be rented. It is hypothesized that repetitive stimulation results will strengthen the muscle, increase its tone, and also, through a negative feedback system, inhibit the bladder from contracting, to much the same effect as biofeedback.

The second type of electrical stimulation utilizes low frequency electrical stimulation to activate inhibitory pathways in the spinal cord and inhibit detrusor contraction. The most common form available is the Percutaneous Tibial Nerve Stimulator (PTNS) which was developed by Marshall Stoller at the University of California in San Francisco and sold as the Stoller Afferent Nerve Stimulator (SANS). PTNS involves placement of a 34 gauge needle cephalad to the medial malleolus to stimulate the posterior tibial nerve with 30 min weekly sessions typically lasting for 12 weeks. Side effects generally are minimal but can include pain and bleeding at the needle insertion site.

Studies are lacking as to the long-term efficacy, but short-term studies, suggest that both local stimulation and PTNS are more efficacious than sham procedures and the addition of AMAs increase their efficacy [35–37]. High frequency (transvaginal) and low frequency stimulation (PTNS) appear to have similar efficacy [38].

Surgical Options

Surgery may also be an option for patients with OAB not secondary to a remediable condition (e.g., pelvic prolapse). Surgery should be considered if they continue to have bothersome symptoms after failing the therapies previously discussed or if the clinician feels that the chance of success is low. These therapies will be discussed elsewhere in the book but include sacral neuromodulation, intravesical Botox, or enterocystoplasty or urinary diversion. Data have demonstrated that neuromodulation can be effective in patients who have failed other treatments [39]. Intravesical Botox has recently been approved by the FDA for OAB treatment and has been shown to be effective in treating patients with refractory OAB for both non-neurogenic detrusor overactivity (DO) and neurogenic DO (particularly multiple sclerosis and spinal cord injury). The RELAX study, a placebo-controlled, double-blind randomized study of 240 women with refractory OAB, found substantial improvement in 24 h voiding frequency (8.3 vs. 9.67), urgency episodes (3.8 vs. 6.67), and episodes of leakage (1.67 vs. 6.0) as compared to placebo. Urinary tract infection (31 %) and urinary retention (16 %) were the most common side effects reported [40]. Multiple other studies have confirmed the utility of Botox in patients with refractory OAB [41–44]. These therapies are discussed in more detail elsewhere in this book.

Finally, enterocystoplasty, ileovesicostomy, or other forms of urinary diversion should be considered when the patient deems symptoms bothersome enough to warrant a major abdominal operation. The success rate of augmentation enterocystoplasty in relieving OAB symptoms, which greatly increases bladder capacity and prevents DO, is in excess of 90 % although, postoperatively, patients may require intermittent self-catheterization [45–47]. For patients with disabilities that make catheterizing through the urethra impractical, a continent abdominal stoma may be created for intermittent catheterization, or an ileovesicostomy or ileal loop may be considered. In patients in whom intermittent catheterization is impractical, a urinary conduit may also relieve the OAB symptoms.

Case Report and Discussion

Patient is a 53-year-old male stock broker who presented with a 20-year history of bothersome urinary frequency, urgency, urge incontinence, and enuresis refractory to treatment with Terazosin 5 mg nightly, prior transurethral microwave therapy, and trials with multiple AMAs.

His exam was consistent with a small (approximately 10 g) prostate without any nodules, normal neurologic exam, and was otherwise normal. Free flow showed a maximum flow rate of 16 mL/s with a voided volume of 251 mL and a residual urine of 50 mL. Cystoscopy demonstrated trilobar prostatic enlargement with an elevated bladder neck, and severe bladder trabeculations and cellules.

VUD can be seen in Figs. 11.2, 11.3, and 11.4. The patient initially demonstrated an involuntary detrusor contraction which caused incontinence while the patient’s sphincter was relaxed. With further filling, the patient was instructed to contract his sphincter when he sensed the involuntary detrusor contraction. The patient was able to successfully abort the contraction and prevent incontinence (Fig. 11.2).

Fig. 11.2

Case report—urodynamic tracing

Fig. 11.3

Filling phase

Fig. 11.4

Voiding phase

The VUD was also consistent with bladder outlet obstruction. He subsequently underwent an uncomplicated transurethral resection of his prostate (TURP). Postoperatively his flow rate increased to 28 mL/s (from 16 mL/s) on a voided volume of 360 mL and he was noted to have no residual urine. However, his OAB symptoms persisted after his TURP and he underwent a formal course of BT and PFMT. Bladder diaries pre- and post-BT are demonstrated in Table 11.1.

The voiding diaries suggest substantial improvement in his urinary symptoms. The BT emphasized volume restriction. The patient’s urge perception score for each void was recorded (not presented) and he was encouraged to contract his sphincter when he developed a mild or moderate urge to void to abort his involuntary detrusor contraction. By doing this, he eliminated his urge incontinence and substantially reduced his voiding frequency.

We typically first address surgically treatable remediable causes of refractory OAB such as prostatic obstruction as we did in this patient. The substantial improvement in his flow rate post-TURP suggests that his diagnosis of bladder outlet obstruction was correct despite a relatively good free flow. If his symptoms were completely cured after this point, the need for BT would have been averted. Because his OAB symptoms remained, BT was started with an excellent outcome.

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