Overactive bladder is a syndrome characterized by a sudden need to urinate, involuntary discharge of urine, frequent urge to urinate, including at night (nocturia). Sometimes symptoms occur in isolation. The diagnosis is based on ultrasound data of the bladder, kidneys, cystoscopy, urodynamic studies; to exclude the infectious and inflammatory process, urine analysis, bacposev is prescribed. Treatment is based on changes in behavioral reactions, the use of pharmacological agents, less often – surgical interventions.
N31 Neuromuscular dysfunction of the bladder, not classified elsewhere
Overactive bladder in women is a disorder of urination that violates the quality of life, hinders socialization. Pathology occurs in millions of patients all over the world, regardless of race. The prevalence increases with age, but imperative urges, frequent urination, nocturia are not normal signs of aging. Women over the age of 75 face vesical hyperactivity in 30-50%. It has been proven that the higher the body mass index, the greater the risk of developing the syndrome.
Overactive bladder is a neuromuscular dysfunction in which the detrusor is excessively reduced during the filling phase with a small volume of urine. The idiopathic form is established in the absence of the main neurological, metabolic or urological causes that can mimic the diagnosis, for example, with cancer, cystitis or urethral obstruction. The disease is most often caused by:
- Neurological conditions. Spinal cord injury, demyelinating diseases (multiple sclerosis), medullary lesions can lead to vesico-urinary dysfunction, cause incontinence. Similar changes occur in diabetic and alcoholic polyneuropathy.
- Taking medications. Signs of an urgent disorder are caused by some medications. So, diuretics provoke incontinence due to the rapid filling of the tank. Taking the prokinetic betanehol enhances intestinal and urinary tract peristalsis, which in a number of cases is accompanied by hyperreflexia.
- Other pathologies. Heart failure, peripheral vascular diseases in the decompensation stage are accompanied by symptoms of hyperactivity. During the day, in such patients, excess fluid is deposited in the tissues. At night, most of this fluid is mobilized, absorbed into the bloodstream, thereby increasing nocturnal diuresis.
Risk factors for the development of an overactive bladder include:
- complicated childbirth (forceps, muscle rupture)
- urogynecological surgical interventions
- age >75 years
- the use of alcohol, caffeine (cause transient hyperreflexion of detrusor due to irritating action).
In some women, characteristic symptoms develop during the menopausal period, which is associated with a deficiency of estrogens. On the other hand, hormone replacement therapy for breast cancer in young patients increases the risk of detrusor hypersensitivity.
The cerebral cortex, bridge, spinal centers with peripheral autonomous, somatic, afferent and efferent innervation ensure the normal functioning of the urinary tract due to the coordination of a number of processes. Changes (functional or morphological) at any level provoke urinary disorders.
This pathology is a multifactorial disorder, both in etiology and pathophysiology. It is based on the hypersensitivity of the detrusor of neurogenic-muscular, myogenic or idiopathic genesis, as a result of which imperative urges and /or incontinence arise. A certain role in the development of hyperactive detrusor against the background of obstruction and damage to the spinal cord belongs to M-2 receptors.
The interaction of acetylcholine with the M-3 receptor activates phospholipase C by binding to G proteins. This causes the release of calcium, the contraction of smooth muscles. Hypersensitivity to stimulation of muscarinic receptors causes hyperreflexia. Acetylcholine helps to reduce detrusor, activation of sensory afferent fibers, as a result of which a hyperactive response develops in the form of pollakiuria, nocturia, urgency of urination.
In clinical urology, there is a “dry” overactive bladder and a “wet” one, accompanied by incontinence against the background of urgent urges. Hyperreflexia occurs in isolation or is combined with stress incontinence. Pathology is also systematized by assessing the severity of symptoms, for this purpose patients pre-fill out a special questionnaire, where they note the peculiarities of urinary excretion for three days. According to the received data , they establish:
- An easy degree. The frequency of daily urination is slightly higher than normal. A single imperative urge is allowed; incontinence associated with urgency is episodic (once a week or less). The amount of urine excreted at a time is about 80-100 ml. An overactive bladder retains its normal volume (250-300 ml).
- Moderate degree. The number of daily urination is equal to or more than 10, imperative urges are 2 or more, there are episodes of incontinence, the volume allocated is 60-75 ml, the organ capacity is 200-220 ml.
- Severe degree. The number of urination per day is 15 or more, imperative urges from 5 and above, many episodes of incontinence (it is constantly necessary to use urological pads or diapers). The amount of urine is 50-60 ml, the overactive bladder holds 200 ml or less.
Clinical manifestations correlate with the severity of the process. The main signs include frequent urination with an empty bladder in small portions, imperative urges (a sudden, irresistible desire to urinate), urgent urinary incontinence. Often there is a need for a night visit to the toilet more than 2 times (nocturia).
The desire to urinate provokes the sound of pouring water, in mild cases a few drops of liquid are lost, in severe cases the entire volume. Pollakiuria and nocturia may be present in isolation, without the manifestation of incontinence. Sometimes, after urination, there is a feeling of discomfort in the perineum.
The disease leads to a violation of socialization. The constant fear of not having time to go to the toilet, the leakage of urine during sexual contact, the unpleasant odor accompanying incontinence initiates the development of a depressive state. Uncontrolled urination provokes urinary dermatitis, eczema.
The constant presence of pathogenic microflora contributes to recurrent infections of the urinary system. The bladder often loses its normal volume, i.e. microcysts are formed, which in the most serious cases can lead to organ-bearing surgery, disability.
The diagnosis of “overactive bladder” is established by a urologist based on the data of a physical examination, anamnesis, laboratory and instrumental examination. The woman is asked to fill out a questionnaire (urination diary). In some cases, the consultation of a neurologist, gynecologist is justified. The research algorithm includes:
- Laboratory tests. When pathological changes (leukocyturia, bacteriuria) are detected in urine tests, culture seeding is performed to identify pathogens and determine their sensitivity to drugs. Cytology is performed when a large number of red blood cells are detected to exclude the neoplastic process. Glucosuria requires examination for diabetes mellitus.
- Instrumental diagnostics. Ultrasound of the urinary organs with the control of residual urine, cystoscopy, complex urodynamic studies are indicated in cases of neurogenic etiology refractory to treatment, as well as in cases of suspected pathology provoking symptoms of urgent incontinence – inflammation, tumor, blocking stone.
Differentiation is performed with other forms of incontinence, tumor process, cystitis, atrophic vaginitis against the background of a decrease in estrogen levels. Similar symptoms are recorded with uterine prolapse, vesicovaginal fistula.
If a specific cause of pathology is determined, all measures are aimed at its elimination. For example, the treatment of urinary tract infection involves the appointment of antibiotics, with atrophic urethritis, a cream containing estrogens is used. For the idiopathic form, there are three main therapeutic approaches: changing behavioral reactions, taking medications, and surgical intervention. Treatment depends on the severity of the symptoms, their impact on lifestyle.
With a mild and moderate degree, conservative measures may be carried out. Their variants:
- Behavioral therapy. First-line treatment, sometimes combined with medication. It is recommended to refuse to take liquids 3 hours before bedtime, exclude alcohol, coffee, spicy dishes, carbonated drinks. They develop a plan for urination: even if there is no desire, it is necessary to visit the toilet at a certain time. With the urge, you should be patient for a few minutes (against the background of taking medications, this is available), gradually the intervals between acts of urination increase.
- Physical therapy. Physical therapy in the treatment of an overactive bladder involves performing exercises to strengthen the pelvic floor muscles. Gymnastics is effective when performed regularly, especially in young patients. It is also possible to use vaginal devices (cones). A woman contracts the pelvic muscles to hold the simulator transvaginally, gradually increasing its weight. Within 4-6 weeks, a positive trend is noted in 70%.
- Electrical stimulation of the pelvic floor. The procedure involves the supply of electrical impulses to cause contractions of a certain muscle group. The current is delivered using an anal or vaginal probe. Electrical stimulation is performed in combination with physical therapy, the duration of the course is several months.
Medical treatment of an overactive bladder in women is referred to the second line. As part of drug therapy , prescribe:
- Antimuscarinic/anticholinergic drugs: tropsium chloride, solifenacin, darifenacin, oxybutinin. They have a prolonged antispasmodic, anesthetic effect, block the sensitivity of M-cholinergic receptors of smooth muscle fibers.
- Selective beta-3 adrenergic receptor agonists (mirabegron). Relax the muscles in the accumulation phase by acting on beta-3 adrenoreceptors, thereby restoring (increasing) the capacity of the organ. According to the results of the study, the combination of mirabegron and solifenacin is more effective than monotherapy.
- Desmopressin and its analogues. It is prescribed for the neurological genesis of the disease, for which a decrease in the production of antidiuretic hormone and melatonin is typical, which causes nocturnal polyuria. Additionally, it is possible to prescribe anticholinergic agents.
- Alpha-1-adrenoblockers (tamsulosin, alfuzosin, silodosin, doxazosin). It is used for detrusor-sphincter dissinergia to reduce intraurethral resistance and the amount of residual urine. Inhibit the activity of postsynaptic alpha-1-adrenergic receptors of the neck, arteries, urethral sphincter.
- Tricyclic antidepressants. They are justified exclusively in combined schemes on the recommendation of a neurologist or psychiatrist.
Surgical interventions are reserved for the most difficult cases, resistant to conservative therapy, or if there are contraindications to taking medications. Cystectomy is currently rarely performed. Operations and manipulations in this disease:
- augmentation cystoplasty: implies an increase in the capacity of the organ through the use of its own tissues (replacement with an intestinal reservoir);
- sacral and pudendal neurotomy: the intersection of nerves provoking an overactive bladder, their blockade with anesthetics is performed;
- pyelostomy, epicystostomy: performed for alternative urine removal, if there has been a shrinking of the bladder with the development / threat of attachment of chronic renal failure;
- sacral neuromodulation: the sacral nerve is stimulated with a weak high-frequency electric current using an implanted electrode connected to a pulse generator. This allows you to restore the coordination of the urination act.
- introduction of botulinum toxin A: normalizes muscle tone by inhibiting the release of acetylcholine from nerve endings, blocking signal transmission from the nerve cell to the muscle. The neurotoxin is injected into the sphincter or detrusor during cystoscopy. The disadvantages include the need for repeated manipulations after 8-12 months.
Prognosis and prevention
With timely treatment and diagnosis, it is possible to avoid complications. An overactive bladder has an impact on women’s quality of life. The combined approach is effective in 92%, the syndrome is considered as a chronic disorder requiring long-term medication.
Prevention includes an active lifestyle, giving up nicotine and alcohol, controlling sugar levels, and a balanced diet. Medications that can provoke symptoms of hyperactive urination disorder in a woman should be prescribed by a doctor. Timely consultation of a specialist at the first appearance of urological complaints, identification of the cause, adequate treatment are significant factors for a favorable prognosis.