What is Irritable bladder?

Irritable Bladder

What is Irritable bladder?

It is a condition of a sudden desire to void urine (called as Urgency), single or multiple times a day, which sometimes may even cause wetting of the underclothes (called as incontinence). This increased frequency of voiding may also be present during the night time (nocturia), disturbing sleep.

Is it caused by infection of urine?

No, it is not. Only after ruling out the infection of urine, the condition is termed as Irritable bladder.

What are the key symptoms of irritating bladder?

1. Urinary urgency: It is the complaint of a sudden compelling desire to void urine that is difficult to defer. It should not be confused with a strong desire to void, which is normal when bladder is fully filled.1
2. “Fear of involuntary leakage of urine”: It is mainly due to urgency of need to void.
3. Urinate frequently, usually more than eight times or more in 24hours.
4. Waking up from sleep more than twice (nocturia).
5. Urgency is typically felt at the perineum or the base of the genitals.

Why is it so concerning?

Going bathroom for multiple times, and wetting of undergarments causes social and hygiene effects. It affects the performance of daily activities and social function such as work, traveling, physical exercise and sexual function. Getting up to void at night times is the most bothersome and is related to decreased sleep quality, decreased health-related quality of life, and depression in the elderly population. This condition is not a part of the normal aging process.

What causes patient to micturate frequently?

Urine gets stored in a bag like organ, called as urinary bladder and its walls are made of muscles called as detrusor muscle. In normal people, in between voiding, detrusor muscle is in relaxed state allowing urine to fill. After filling up to a limit, detrusor muscle is stretched and starts contracting and then only there is a feeling of the need to void.

In irritable bladder detrusor muscle is overactive, so this condition is also known as “overactive bladder syndrome”. Overactive detrusor causes patients to have a feeling of “need to void”. Sometimes this urge can cause leakage of urine.

How common is Irritable bladder?

The overall prevalence is approximately 12%.2 Men have a higher prevalence of “overactive bladder syndrome, dry”, meaning urgency only. Women had a higher prevalence of “overactive bladder syndrome wet”, meaning urgency and wetting of under-garments.

Is the condition age-related?

Yes. Although the mechanism is not clearly understood, this condition rises with aging process. Most of the patients are older than 65years of age.

Who are likely to develop this condition?

Older individuals, patients with neurological diseases, prostate problems, fibromyalgia, and patients with altered bowel function are more likely to develop the condition.

What are the tests that doctors will ask for?

Doctors have to rule out various other diseases like urine infections, bladder stones or tumors, diabetes, stroke, etc. before making the diagnosis of Irritable bladder.

Lab tests like urine analysis, urine culture, and blood tests to determine blood sugar level and HbA1C, electrolytes, and levels of creatinine for kidney function evaluation.

Sometimes ultrasound test is also done to measure post-voidal residual urine, and uroflometry analysis.3

How is this condition treated?

Various medicines are available for the treatment, but they are started only if other simple treatment measures fail. These simple measures, commonly called as lifestyle interventions includes:

1. Educating and awaring the patients about the condition.
2. Dietary alterations like restricting caffeine drinks, acidic foods and alcohol.
3. Weight loss and exercise.
4. Smoking cessation.
5. Bladder retraining exercise involving urination at regular intervals disregarding the normal urge to void. Initially voiding interval may be short as 30minutes and training will gradually increase the voiding interval period up to 3-4hours.
6. Pelvic floor muscle training exercises (Kegel exercise) will reduce detrusor contractions and increase the tone of pelvic floor muscles so that the bladder will relax for longer durations ultimately reducing urgency and incontinence.3
7. Maintaining a bladder diary.

Most doctors prescribe medicine only if the above measures fail. Drugs like festerodine, oxybutynin (transdermal patch and gel) are commonly prescribed medicines.3

Are the medicines used for this condition safe?

Medicines used for this condition mainly belong to the group of Anti-muscarinics.4 These medicines are effective and they work by relaxing the culprit muscle, Detrusor. Their efficacy is counterbalanced by potential side effects such as:

1. Dry mouth.
2. Constipation.
3. Cognitive effects, confusions preventing their use in older patients.
4. Blurring of vision.
5. Urinary retention.
6. Somnolence.
7. Cardiac effects.

Dry mouth and constipation are very common and may even lead to discontinuation of medication in many patients.  

Other drugs which belong to the group alpha-1 adrenergic blocker, beta-3 adrenergic agonist have fewer side effects than anti-muscarinic drugs but most of them are under clinical trial.

What if medicines don’t work?

If medicines and lifestyle modifications do not work despite strictly following them, then specialist referral is appropriate. Urodynamic studies are done to identify and record detrusor muscle over activity, increased sensation of bladder filling, incontinence (wetting of under-garments) and incomplete bladder emptying.

Are there any surgeries?

Yes, there are. Common surgeries include:

1. Botulinum neurotoxin-A injection into the bladder wall.

This procedure provides temporary relief of symptoms, thus requiring injections every six months. Furthermore, it carries risk of urine infection.

2. Sacral nerve stimulation.

Alternative to botulinum injection, this procedure can be used for patients who do not respond to the injection. However, the procedure is costly.

3. Augmentation cystoplasty.

It is a rare and a major procedure, with a significant number of complications. It is last-resort procedure when every other treatment measures fail.

To summarize

Irritable bladder, also called as overactive bladder syndrome is highly prevalent condition and is increasingly so with aging. It is characterized by urinary urgency, with or without incontinence, increased voiding frequency, and nocturia. Some serious medical disorders might present with similar symptoms, and a bladder diary is an invaluable part of understanding the presentation.

The condition is initially treated with education, bladder training and advice on fluid intake. Drug therapy options include anti-muscarinic medications and beta-3 adrenergic receptor agonists. Specialist review and urodynamic testing are considered in cases of no recovery. Surgery including botulinum neurotoxin-A bladder injections are used in severe cases. Sacral nerve stimulation and tibial nerve stimulation and major reconstructive surgery, such as augmentation cystoplasty, is rarely undertaken in modern practice.

References:

1.        Wallace KM, Drake MJJF. Overactive bladder. 2015;4.

2.        Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. 2006;50(6):1306-15.

3.        Leron E, Weintraub AY, Mastrolia SA, Schwarzman PJCu. Overactive bladder syndrome: evaluation and management. 2017;11(3):117-25.

4.        Novara G, Galfano A, Secco S, D'Elia C, Cavalleri S, Ficarra V, et al. A systematic review and meta-analysis of randomized controlled trials with antimuscarinic drugs for overactive bladder. 2008;54(4):740-64.