Detrusor
Overactivity
Presented by:
Dr Sidra Sadiq (PGR 18)
Pre-test:
True/false:
1. OAB is synonyms with detrusor overactivity.
2. In pathophysiology of DOA there is increased
sympathetic activity.
3. Conservative management is for 3 months with
bladder retraining for 3-4 weeks.
4. In DOA there is involuntary contraction of Detrusor
muscle In voiding phase.
5. Pt can’t tolerate anti-muscarinic, oxybutynin is
offered.
Learning Objectives:
At the end of this discussion student will be able to
define
Detrusor over activity
Tell about Pathophysiology of Detrusor overactivity
Explain the aetiology of Detrusor overactivity
Make the diagnosis of Detrusor overactivity
Manage Detrusor overactivity
Detrusor overactivity:
Detrusor overactivity is defined as a urodynamic observation
characterized by involuntary contractions during the filling phase
that may be spontaneous or provoked.(Urodynamic diagnosis)
Overactive bladder (OAB) urgency with or without urge
incontinence with frequency and nocturia in the absence of UTI or
any obvious cause (symptoms based diagnosis)
64% of patients with OAB have urodynamically proven detrusor
overactivity
83% of patients with detrusor overactivity have symptoms
suggestive of OAB
Incidence:
Variable, usually between 4.8%-30.9%
Second most common cause of urinary
incontinence (SI>UI)
Etiology:
Most common cause is idiopathic.
Elderly
Failed incontinence surgery
Upper motor neuron lesion(Multiple sclerosis)termed as
Neurogenic detrusor overactivity
Stress
Pathophysiology:
Increased parasympathetic (Muscarinic) activity.
Normal filling:
Parasympathetic inhibition Reduces detrusor
Sympathetic stimulation
tone
Normal emptying:
Parasympathetic stimulation
Sympathetic inhibition
Increase detrusor tone
Intravesical pressure< intraurethral
pressure Bladder filling
Intravesical pressure> intraurethral Bladder
pressure
emptying
4 theories have been proposed To explain the
pathophysiology of OAB.
1. Neurogenic theory
2. Myogenic theory
3. Autonomous bladder theory
4. Afferent Signalling theory
Symptoms:
Frequency is the most common symptoms (85%)
Urgency (54%)
Urge incontinence (36%)
Nocturia
Stress incontinence
Enuresis
Incontinence at orgasm
Other definitions:
Term Definition
Urgency A sudden compelling desire to void that is
difficult to defer
Urinary >8 micturitions/24 hours
frequency
Nocturia Interruption in sleep > 2 times due to need to void
Polyuria >40ml urine/kg body weight during 24 hours
Urgency UI Involuntary loss of urine associated with urgency
Detrusor Detrusor contractions during the filling phase
overactivity
Diagnosis:
History
Examination
Investigation
History:
Detailed symptoms questionnaire is used to asses QoL.
1. Frequncy
2. Nucturia
3. Urgency, urge incontinence
4. Voiding difficulty ( hesitancy, poor stream, incomplete
voiding, post void dribble)
5. Dysuria
6. Stress urinary incontinence
Examination:
Physical examination
Abdominal examination for scars,masses,hernias, distension
of bladder
Neurological examination for UMNL such as Parkinson’s
disease and neurological screen for LMNL i.e. Sacral nerve
root lesion
Rectal examination can determine anal sphincter tone.
Fecal impaction distends distal sigmoid and rectum leads
to inadequate detrusor activity
Vaginal examination will reveal prolapse of pelvic organs
Investigation:
1. Urine analysis and culture
2. Bladder diary
3. USG(post void residual volume)
4. Urodynamics
Bladder diary:
Bladder diary for 3 days atleast
Important point noted in bladder diary:
Time
Type
Volume of fluid intake
Urine volume voided
Urgency episodes
Incontinence episodes
Information achieved From the diaries:
Number of voids in day time
Number of voids in night time
Total number of voids in 24 hours
Volume of urine voided in 24 hours
Maximum voided volume
Average voided volume
Median Max voided volume
Nocturnal Urine volume
Post void residual volume:
Ultrasound should be done before urodynamics and starting
medication to measure PVR.
Ultrasound measure of PVR is preferable to catheterization.
PVR INFERENCE
<50ml Normal
50-150ml Gray zone(should be investigated)
150-250ml Demands attention
>250ml Warrants special attention
Urodynamics
Indications
Symptoms that have failed to respond to
conservative measures.
A patient being considered for any form of
incontinence surgery of there is a clinical suspicion of
Detrusor overactivity
Voiding difficulties.
Mixed symptoms.
Previous unsuccessful inconvenience surgery.
Suspected neuropathic bladder disorder.
Urodynamics
Cystometry:
Two catheters are inserted to measure
intraabddominal and intravesicle pressure
Bladder is then slowly filled with 500ml of warm saline
slowly and pressure changes are measured via
intravesical and bladder catheters
Detrusor pressure is measured by subtracting
intraabdominal pressure from intravesicle pressure.
Volume Pressure Charts are then plotted.
Normal subtracted cystometry findings
are:
Residual volume is < 50 ml
First sensation to void at 150-250ml
Full bladder capacity 400-600 ml
Maximum intravesical P < 15cm of water
Normal
Detrusor overactivity
Detrusor
overactivity
Stress incontinence
Management
1st line 2nd line 3rd line & 4th line
Conservative management Pharmacological Surgical
•Education, Bladder training Anti-muscarinic Minimally invasive
•Lifestyle changes, Pelvic floor B-3 agonist Invasive
exercises
TCA
Anti Diuretics
Psychotherapy, hypnotherapy, Local estrogens
acupuncture
Conservative management:
1. Lifestyle changes
Weight loss in obese patient
Cessation of smoking
Avoid diuretics
Avoid too much or too little fluid intake (1.5 – 2.5 L/day )
Treat constipation
Avoid caffeine, alcohol,spicy and acidic food
In patients with lower extremity edema elevation of leg
before bed time helpto prevent nocturia
Pelvic floor muscles exercises:
Bladder Training (6 weeks)
Principal of bladder retraining are based on the ability
to suppress urinary urge and to extend interval
between voiding.
This continues until a suitable time span is achieved,
usually 3-4 hours.
Cure rate using bladder retraining alone reported
between 44 & 90 %
Pharmacological
Drugs
Inhibit
Improve local Reduce urine
bladder
tissue production
contraction
• Anticholinergic
• Beta agonist • Oestrogens • DDAVP(synthetic
(mirabegron) vasopressin)
• Musculotrophic
relaxant
• Tricyclic
antidepressants
Anti-muscarinic:
Tolterodine (M2>M3)
1st line drug(immediate release)
Solifenacin (M3>M2)
Darifenacin
Oxybutynin
Side effects: dry mouth and constipation
Beta 3 agonists:
Mirabegron 50mg once a day
Reduce to 25mg OD if moderate hepatic
impairment or eGFR <30ml/min
Contraindicated in uncontrolled
hypertension>180/110
Blood pressure should be taken before staring
mirabegron and monitored during treatment.
Tricyclic antidepressants:
Useful in patients with nocturia and bladder pain
Anti-diuretic
Desmopressin is a synthetic vasopressin analogue.
Has strong anti-diuretic effects
Safe for long term use
Should be used with care in elderly owing to risk of
hyponatremia
Surgical Management:
Intravesical therapy:
Botulinum toxin
Role of botulinum toxin has been established in treatment
of neurogenic and idiopathic detrusor overactivity using
200 and 100 units respectively.
Alternative to surgery with interactable detrusor
overactivity
Effect last for 9 months
Neuromodulation
Peripheral neuromodulation
•Stimulation of posterior tibial nerve
Sacral neuromodulation
•Stimulation of dorsal sacral nerve
using permanent device in the S3
sacral foramen
Surgery:
Clam cystoplasty:
bladder is bisected almost completely and a patch
of gut(usually ileum 25 cm) is sewn in place.
Urinary diversion:
Women with severe detrusor overactivity or neurogenic detrusor
overactivity who cannot manage clean intermittent catheterization.
Usually this will utilise an ileal conduit to create an abdominal stoma for
urinary diversion.
Alternative is to form diversion using appendix
Nice guidelines:
Bladder retraining lasting for a min of 6 weeks
should be offered to all women with OAB and
mixed incontinence
Combination of bladder retraining and anti-
muscarinic should be considered in women who
do not achieve Satisfactory benefit from bladder
retraining.
Nice guidelines:
Immediate release tolterodine should be offered
as 1st line drug treatment
If immediate release tolterodine is not well
tolerated darifenacin, solifenacin,trospium or
extended release formulation of tolterodine
should be considered.
Propiverine should be considered as an option
to treat frequency of micturition not
recommended for UI.
Nice guidelines:
Desmopressin considered to reduce nocturia in
women
HRT should not be recommended
Intravaginal estrogens are recommended for
treatment of OAB in PM women with urogenital
atrophy.
Overactive bladder
Conservative
management
Improve
Review at 3 months Continue
Ongoing problems
Medical therapy
(Anticholinergic)
Improve
Review at 4-8 weeks Continue
Troublesome side effects/
Lack of efficacy
2nd line (beta 3 agonist)
Mirabegron 50mg × OD
Improve
Review 4-8 weeks Continue
Troublesome side effects/
Consider referral to Lack of efficacy
urology/urogynecology
3rd line Solifenacin +
Mirabegron 50mg × OD
Troublesome side effects/ Improve
Review 4-8 weeks Continue
Lack of efficacy
Post-test:
True/false:
1. OAB is synonyms with detrusor overactivity.
2. In pathophysiology of DOA there is increased
sympathetic activity.
3. Conservative management is for 3 months with
bladder retraining for 3-4 weeks.
4. In DOA there is involuntary contraction of Detrusor
muscle In voiding phase.
5. Pt can’t tolerate anti-muscarinic, oxybutynin is
offered.
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