Overactive Bladder Syndrome OAB

What is overactive bladder syndrome?

Overactive bladder (OAB) syndrome means that the bladder, which is a bag made of muscle, squeezes (contracts) suddenly without you having control and when the bladder is not full. OAB syndrome is a common condition where no cause can be found for the repeated and uncontrolled bladder contractions. (For example, it is not due to a urine infection or an enlarged prostate gland.)

Overactive bladder syndrome is more common in women than in men, so is included in our women's health information. However, this problem can affect men as well as women.

OAB syndrome is sometimes called detrusor instability or overactivity (detrusor is the medical name for the bladder muscle) or an irritable bladder.

What are the symptoms of overactive bladder syndrome?

The symptoms of OAB syndrome include:

• Urgency:
• This means that you have a sudden urgent desire to pass urine. You are not able to put off going to the toilet.
• Latch key urgency is the name given to the urgent need you might feel to pass urine as soon as you get home and put your key in the door.
• Frequency:
• This means going to the toilet more often than normal - usually more than eight times a day. In many cases it is a lot more than eight times a day.
• Nocturia:
• This means waking to go to the toilet more than once at night.
• Urge incontinence:
• This occurs in some people with OAB. It is a leaking of urine, sometimes quite large amounts, before you can get to the toilet when you have a feeling of urgency. You can find out more about this in the separate leaflet called Urge Incontinence.

You can read more about other urinary symptoms and their causes in the two separate leaflets called Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women (LUTS).

Filling out a bladder diary will help your doctor work out which treatments would be best for you. Ideally, this should include details of your symptoms, what you ate and drank and your activities. It is best to complete the diary for at least three days and cover variations in your usual activities, such as both working and leisure days.

Causes

The cause of OAB syndrome is not fully understood. The bladder muscle (detrusor) seems to become overactive and squeeze (contract) when you don't want it to.

Normally, the bladder muscle is relaxed as the bladder gradually fills up. As the bladder is gradually stretched, we get a feeling of wanting to pass urine when the bladder is about half full. Most people can hold on quite easily for some time after this initial feeling until a convenient time to go to the toilet. However, in people with an OAB, the bladder muscle seems to give wrong messages to the brain. The bladder may feel fuller than it actually is.

The bladder contracts too early when it is not very full and not when you want it to. This can make you suddenly need the toilet. In effect, you have much less control over when your bladder contracts to pass urine.

In most cases, the reason why an OAB develops is not known and the condition is then referred to as 'overactive bladder syndrome'. Symptoms may become worse at times of stress. Symptoms may also be made worse by caffeine in tea, coffee, cola, etc and by alcohol (see below).

In some cases, symptoms of an OAB develop as a complication of a nerve- or brain-related disease such as:

• Following a stroke.
• Parkinson's disease.
• Multiple sclerosis.
• After a spinal cord injury.

Strictly speaking, these conditions are not classed as OAB syndrome as they have a known cause. OAB in this situation is sometimes referred to as neurogenic OAB.

Also, similar symptoms may occur if you have a urine infection or a stone in your bladder.

Continence adviser

Your GP may refer you to the local continence adviser or specialist physiotherapist. They can give advice on treatments, especially about bladder training (see below) and pelvic floor exercises. If incontinence remains a problem, they can also give lots of advice on how to cope. For example, they may be able to supply various appliances and aids to help, such as incontinence pads, absorbent pants, etc.

Treatments

• Some general lifestyle measures may help.
• Bladder training is the main treatment. This can work well in up to half of cases.
• Medication may be advised instead of, or in addition to, bladder training.
• Pelvic floor exercises may also be advised in some cases.

Some general lifestyle measures which may help

• Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.
• Caffeine. This is in tea, coffee, cola and energy drinks (some of which can have very large amounts of caffeine). It is also part of some painkiller tablets. Caffeine has the effect of making urine form more often (a diuretic effect). Caffeine may also directly stimulate the bladder to make urgency symptoms worse. It may be worth trying without caffeine for a week or so to see if symptoms improve. If symptoms do improve, you may not want to give up caffeine completely. However, you may wish to limit the times that you have a caffeine-containing drink. Also, you will know to be near to a toilet whenever you have caffeine.
• Alcohol. In some people, alcohol may make symptoms worse. The same advice applies as with caffeine drinks.
• Drink normal quantities of fluids. It may seem sensible to cut back on the amount that you drink so the bladder does not fill so quickly. However, this can make symptoms worse as the urine becomes more concentrated, which may irritate the bladder muscle (detrusor). Aim to drink normal quantities of fluids each day - enough to quench your thirst.
• Constipation. Bladder and continence problems are often made worse by constipation. Increasing the amount of fibre in your diet, as well as getting enough exercise and not restricting your fluid intake too much, can help improve constipation. If you have significant problems with constipation, speak with your GP.
• Go to the toilet only when you need to. Some people get into the habit of going to the toilet more often than they need. They may go when their bladder only has a small amount of urine so as 'not to be caught short'. This again may sound sensible, as some people think that symptoms of an overactive bladder will not develop if the bladder does not fill very much and is emptied regularly. However, again, this can make symptoms worse in the long run. If you go to the toilet too often the bladder becomes used to holding less urine. The bladder may then become even more sensitive and overactive at times when it is stretched just a little. So, you may find that when you need to hold on a bit longer (for example, if you go out), symptoms are worse than ever.
• Try to lose weight if you are overweight. It has been shown that even 5-10% weight loss can help symptoms, particularly incontinence.

Bladder training (sometimes called bladder drill)

The aim is to slowly stretch the bladder so that it can hold larger and larger volumes of urine. In time, the bladder muscle should become less overactive and you should become more in control of your bladder. This 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. A doctor, nurse, or continence advisor will explain how to do bladder training. The advice may be something like the following:

You will need to keep a diary. On the diary make a note of the times you pass urine, and the amount (volume) that you pass each time. Also make a note of any times that you leak urine (are incontinent). Your doctor or nurse may have some pre-printed diary charts for this purpose to give you. Keep an old measuring jug by the toilet so that you can measure the amount of urine you pass each time you go to the toilet.

When you first start the diary, go to the toilet as usual for 2-3 days at first. This is to get a baseline idea of how often you go to the toilet and how much urine you normally pass each time. If you have an OAB you may be going to the toilet every hour or so and only passing less than 100-200 ml each time. This will be recorded in the diary.

After the 2-3 days of finding your baseline, the aim is then to hold on for as long as possible before you go to the toilet. This will seem difficult at first. For example, it you normally go to the toilet every hour, it may seem quite a struggle to last one hour and five minutes between toilet trips. When trying to hold on, try distracting yourself. For example:

• Sitting straight on a hard seat may help.
• Try counting backwards from 100.
• Try doing some pelvic floor exercises (see below).

With time, it should become easier as the bladder becomes used to holding larger amounts of urine. The idea is gradually to extend the time between toilet trips and to train your bladder to stretch more easily. It may take several weeks but the aim is to pass urine only 5-6 times in 24 hours (about every 3-4 hours). Also, each time you pass urine you should pass much more than your baseline diary readings. (On average, people without an OAB normally pass 250-350 ml each time they go to the toilet.) After several months you may find that you just get the normal feelings of needing the toilet, which you can easily put off for a reasonable time until it is convenient to go.

Whilst doing bladder training, perhaps fill in the diary for a 24-hour period every week or so. This will record your progress over the months of the training period.

Bladder training can be difficult but becomes easier with time and perseverance. It works best if combined with advice and support from a continence advisor, nurse or doctor.

Medication

• Medicines called antimuscarinics (also called anticholinergics) may also help. The drugs routinely offered first are oxybutynin, tolterodine and darifenacin. Trospium, propiverine or solifenacin may also be considered. These medicines work by relaxing the bladder muscle and so increasing the bladder capacity.
• Medication improves symptoms in some cases but not in all. The amount of improvement varies from person to person.
• Side-effects are quite common with these medicines but are often minor and tolerable. The most common is a dry mouth. Some carry a higher risk of confusion or drowsiness than others - your doctor will advise.
• The medicines have differences and you may find that if one medicine causes troublesome side-effects, a switch to a different one may suit you better.
• Another medicine available is called mirabegron. It is a type of medicine called a beta-3 agonist. This acts by helping the bladder muscle to relax. Side-effects can include a fast heartbeat, headache, diarrhoea and a tendency to urine infections.

You can read more about medicines used for OAB in the separate leaflet called Medicines for Urinary Urgency and Incontinence.

Surgery

If the above treatments are not successful and intermittent self-catheterisation is also not appropriate, surgery may be suggested to treat OAB syndrome. Procedures that may be used include:

• Botulinum injections. Botulinum toxin type A injections into your bladder can help reduce or completely get rid of symptoms of OAB. You would need to be prepared to have a temporary catheter or (if you are a woman) to insert a catheter yourself several times a day if there were complications from the procedure. This treatment may also carry a risk of getting urine infections more often.
• Sacral nerve stimulation. This involves placing small electrodes into the back where the bladder nerves are. Electrical impulses then stimulate the nerves, which can help reduce your symptoms. The electrodes are attached to a small device that can be inserted under the skin. The device can be taken out at any time if you and your doctor agree this is needed.
• Augmentation cystoplasty. In this operation, a small piece of tissue from the intestine is added to the wall of the bladder to increase the size of the bladder. However, not all people can pass urine normally after this operation. You may need to insert a catheter into your bladder in order to empty it. The operation is sometimes done by opening the tummy (abdomen) and sometimes through an operating telescope (laparoscope).
• Urinary diversion. In this operation, the tubes from the kidneys to the bladder (the ureters) are routed directly to the outside of your body. There are various ways that this may be done. Urine does not flow into the bladder. This procedure is only done if all other options have failed to treat your OAB syndrome.