Hypertonic Bladder

Hypertonic bladder, commonly known as overactive bladder, is a chronic condition that causes sudden and strong urges to urinate that may be difficult to control, affecting millions of people worldwide and significantly impacting daily activities and quality of life.

Table of contents

• What is overactive bladder?
• Recognizing the symptoms
• What causes this condition?
• Who is affected?
• How doctors diagnose overactive bladder
• First-line treatments: Behavioral approaches
• Second-line treatments: Medications
• Third-line treatments: Advanced options
• Lifestyle changes that help
• Living with overactive bladder

Overactive bladder, OAB

• Bladder
• Detrusor muscle
• Urethra
• Pelvic floor muscles

What is overactive bladder?

Overactive bladder is a condition where the bladder squeezes urine out at the wrong time^[1]. The bladder is a hollow organ in your lower abdomen that stores urine, much like a balloon. In a healthy bladder, you can control when it’s convenient to urinate. With overactive bladder, it becomes difficult to control the urinary urgency when the bladder is full^[2].

This condition is characterized by urinary symptoms including urgency, frequency, and nocturia (the need to wake up at night to urinate), with or without urge incontinence^[1]. The term overactive bladder describes a collection of symptoms rather than a specific disease. These symptoms occur when the detrusor muscle, a collection of smooth muscle fibers in the wall of your bladder, contracts too often, creating an urgent need to go to the toilet^[2].

Recognizing the symptoms

You may have overactive bladder if you experience two or more of the following symptoms^[3]:

• You urinate eight or more times a day or two or more times at night
• You have the sudden, strong need to urinate immediately
• You leak urine after a sudden, strong urge to urinate

The key symptom is urinary urgency, which is a sudden, uncontrollable need to urinate. Once you feel the need to go, you have a short amount of time to get to a bathroom^[2]. Some people with overactive bladder experience urge incontinence, which means you may leak urine when you feel the sudden urge. Others may not lose urine but still have urgency, frequency, or nocturia^[1].

Even if you can get to the toilet in time when you feel an urge to urinate, having to urinate often during the day and night can disrupt your life^[1]. Many people with overactive bladder report that nocturia is the most bothersome symptom, as it affects sleep quality and can lead to decreased health-related quality of life^[5].

What causes this condition?

The main cause of overactive bladder is problems with the detrusor muscle in the bladder wall. Conditions or injuries that affect this muscle can lead to overactive bladder symptoms^[2].

Sometimes your body sends signals to your brain and bladder to urinate at the wrong time. This appears to be caused by a communication problem between the brain and the bladder^[2]. Several factors can contribute to this problem:

• Nerve damage: Certain diseases and trauma can cause nerve damage, including pelvic or back surgery, herniated discs, radiation therapy, Parkinson’s disease, multiple sclerosis, or a stroke^[2]
• Abdominal trauma: Pregnancy and childbirth can stretch and weaken your pelvic muscles, which support the organs in your lower abdomen. Your bladder may sag out of its normal position if your pelvic muscles weaken^[2]
• Medications, alcohol, and caffeine: These can dull your nerves, which affect signals to your brain and cause your bladder to overflow. Diuretics and caffeine may cause your bladder to fill rapidly and potentially leak^[2]
• Infections: A urinary tract infection can irritate your bladder nerves and cause your bladder to squeeze without warning^[2]
• Extra weight: Being overweight can put extra pressure on your bladder, which can cause urge incontinence^[2]
• Hormonal changes: Estrogen deficiency after menopause may cause urge incontinence^[2]

In about 75% of cases, overactive bladder symptoms are due to what doctors call idiopathic detrusor activity, meaning the cause is unknown. In other cases, neurological disease, bladder outflow obstruction, intrinsic bladder pathology, and other chronic pelvic floor disorders are implicated^[5].

Who is affected?

Overactive bladder is common. It affects up to 33 million adults in the United States, including as many as 30% of men and 40% of women^[2]. However, that number may be higher because many people feel embarrassed and don’t seek help. Studies from six European countries show incidence rates ranging between 12-17%^[5].

The condition is most common in people 65 and older, though women may develop overactive bladder at a younger age, usually around 45^[2]. The prevalence and severity of symptoms increase with age^[5]. Although common among older adults, overactive bladder is not a typical part of aging^[1].

It’s important to understand that overactive bladder doesn’t go away on its own. If you don’t treat it, your symptoms can get worse, the muscles in your bladder that help control when you urinate can become weak, and your pelvic floor tissues can get thinner^[2].

How doctors diagnose overactive bladder

A healthcare provider can diagnose overactive bladder by reviewing your symptoms and conducting a physical examination^[2]. Your appointment will likely include a medical history, a neurological exam to look for sensory issues or reflex problems, and a physical exam, which may include a rectal exam and a pelvic exam in women^[4].

Your doctor will check for an infection or blood in your urine and may check to see if you’re emptying your bladder all the way when you urinate^[4]. They may ask you questions such as what your symptoms are, how long you’ve had them, whether you have a family history of overactive bladder, what medications you take, and what kinds of fluids you drink^[2].

Additional procedures may be necessary in some patients to confirm the diagnosis and exclude other disorders. A urine culture or postvoid residual urine assessment may be performed, and information can be obtained from bladder diaries or symptom questionnaires^[4].

Your health professional may suggest tests to see how well your bladder works and whether it can empty all the way, called urodynamic tests^[4]. These may include measuring urine left in the bladder after you urinate, measuring urine flow rate, or testing bladder pressures. However, urodynamics, cystoscopy, and diagnostic renal and bladder ultrasonography typically should not be used in the initial workup^[4].

First-line treatments: Behavioral approaches

Behavioral therapies should be offered as first-line therapy to all patients with overactive bladder^[4]. These simple lifestyle changes work, are safe and easy, and cost little or nothing^[1].

Bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine^[10]. The goal is to help you control your urinary urgency by deciding when it’s convenient to urinate rather than having the bladder control you.

Pelvic floor muscle training, also known as Kegel exercises, helps hold urine in the bladder. Your pelvic floor muscles surround the bladder and control the flow of urine as you urinate^[10]. Daily exercises can strengthen these muscles, which can help keep urine from leaking when you sneeze, cough, lift, laugh, or run. To do these exercises, imagine you are trying to prevent passing gas. Squeeze and hold these muscles for 5 seconds while continuing to breathe, then relax for 5 seconds. Repeat this 10 times in a row, 3 sessions a day^[2].

Other behavioral approaches include timed toileting (going to the bathroom at regular intervals), double voiding (immediately after urinating, lean forward and gently rock back and forth to help empty the bladder better), and urgency suppression techniques^[13].

Limited evidence suggests that initiating behavioral and pharmacologic therapy simultaneously may improve outcomes, including frequency, voided volume, incontinence, and symptom distress^[4].

Second-line treatments: Medications

Second-line therapies for overactive bladder include oral antimuscarinic agents. Several drugs that have been proven safe and effective in clinical trials have been approved for the treatment of overactive bladder^[5]. These medications work by calming the muscles and nerves that control bladder function.

Common antimuscarinic medications include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium^[4]. If immediate-release and extended-release formulations are available, the extended-release formulation is preferred because of lower rates of dry mouth^[4]. Transdermal oxybutynin (gel or patch) may also be offered.

Common side effects of antimuscarinic medications include dry eyes and mouth, and constipation^[3]. To deal with these effects, you can use eye drops to keep your eyes moist, chew sugarless gum or suck on sugarless hard candy if dry mouth bothers you, and take small sips of water throughout the day^[3]. Constipation and dry mouth should be managed before abandoning antimuscarinic therapy^[4].

A newer medication called mirabegron, which is a beta3-adrenergic agonist, works differently from the antimuscarinics and is not associated with dry eyes, dry mouth, or constipation. However, it may raise blood pressure and may not be a good option for patients with advanced cardiovascular disease^[13].

If symptoms are not adequately controlled or if adverse effects become intolerable with one antimuscarinic agent, the dosage should be modified or a different agent should be tried^[4]. Antimuscarinics should not be prescribed to patients with narrow-angle glaucoma unless approved by the treating ophthalmologist. These medications should be used with caution in frail patients, in patients with impaired gastric emptying or a history of urinary retention, and in those taking other anticholinergic medications^[4].

Vaginal estrogen (in the form of a cream, tablet, or ring) is also a commonly prescribed treatment for overactive bladder, particularly in women after menopause^[13].

Third-line treatments: Advanced options

Patients who have symptoms that are refractory to behavioral and medical therapy should be evaluated by a subspecialist if they desire additional therapy^[4].

Sacral neuromodulation may be offered as third-line treatment in select patients with severe refractory symptoms or in those who are not candidates for second-line therapy and are willing to undergo surgery. This treatment involves surgically placing a device that sends electrical impulses to nerves that control the bladder^[4].

Peripheral tibial nerve stimulation is a minimally invasive option that may also be offered in select patients. This treatment can help with pelvic floor muscle coordination and bladder habits^[13].

Intradetrusor onabotulinumtoxin A (Botox) may be offered as third-line treatment in select patients who have symptoms that are refractory to first- and second-line treatments. The patient must be willing to return for frequent postvoid residual urine assessments and must be able and willing to perform self-catheterization if necessary^[4].

In rare cases, augmentation cystoplasty or urinary diversion may be considered for severe, refractory, complicated overactive bladder^[15]. Indwelling catheters are not recommended as a management strategy for overactive bladder except as a last resort^[14].

Lifestyle changes that help

Simple lifestyle changes may improve bladder control or help medicine work better^[16]. Your doctor may suggest you make changes to your lifestyle to improve your symptoms.

Fluid management: Everyone needs to drink enough fluid, but too much can make bladder problems worse. How much you need depends on your health, your activities, and where you live. If you get up several times at night to urinate, drink more fluids in the morning and afternoon, not at night. Stop drinking a few hours before bedtime^[16]. However, drinking too little fluid can cause waste products to build up in urine, which can irritate the bladder.

Dietary changes: Certain foods and beverages might irritate the bladder. Different people can find different foods and drinks irritating to their bladder^[19]. Consider eliminating or limiting:

• Caffeinated beverages (coffee, tea, and cola)
• Alcohol
• Chocolate
• Citrus fruits and juices
• Spices, sugar, and artificial sweeteners
• Carbonated drinks^[16]

Bowel management: Constipation can irritate and put pressure on the bladder, which is then interpreted by the body as the need to urinate^[19]. Eating a high-fiber diet or talking to your care team about adding a daily stool softener can help avoid constipation.

Weight management: If you are overweight or obese, losing weight may help improve your symptoms, as extra weight can put pressure on your bladder^[1].

Living with overactive bladder

Overactive bladder is a chronic condition, much like diabetes and high blood pressure. The treatment is long term, but good control is achievable^[13]. It’s important to understand that overactive bladder is a complex of symptoms that generally do not affect survival, but may compromise quality of life^[4].

People with overactive bladder might feel self-conscious, which can cause them to keep away from others or limit their work and social life^[1]. Overactive bladder symptoms can cause stress and affect your quality of life^[2]. However, you should know that this condition has physical, psychological, and social consequences that can be managed with appropriate treatment^[5].

Although it might not be easy to talk about your symptoms, if the symptoms distress you or disrupt your life, talk to your healthcare professional. There are many treatments that might help^[1]. You should be informed that several treatments may need to be tried before symptoms are successfully controlled^[4].

The patient requires a clear explanation and the full support of the attending physician. The collaboration and understanding of patients are extremely important aspects. Improving the quality of life in these patients is the main purpose in managing this condition^[5].