Posted: June 11th, 2022

Week 8 Pharmacology GU Case Study

Overactive Bladder: Diagnosis, Management and Pharmacological Treatment

Introduction
Overactive bladder (OAB) is a highly prevalent condition characterized by urinary urgency, frequency, and nocturia, with or without urgency incontinence. This chronic disorder significantly impacts quality of life and poses a substantial economic burden. An in-depth understanding of OAB’s etiology, accurate diagnosis, and appropriate management strategies is crucial for healthcare professionals to effectively treat patients and mitigate associated complications.

Diagnosis and Assessment
The diagnosis of OAB is primarily based on a comprehensive patient history and physical examination. Subjective assessment involves evaluating the severity of symptoms, their impact on daily activities, and any potential contributing factors (Gormley et al., 2019). Objective assessment may include bladder diaries, urodynamic studies, and post-void residual urine measurements to rule out other underlying conditions.

Severity of incontinence is determined by the frequency and amount of urine leakage, as well as its impact on the patient’s quality of life. Urge incontinence, a hallmark of OAB, is characterized by an abrupt and intense urge to void, often resulting in involuntary leakage before reaching the toilet (Kaplan et al., 2021). This differs from stress incontinence, where leakage occurs due to increased intra-abdominal pressure, and overflow incontinence, caused by an inability to empty the bladder completely. Functional incontinence, on the other hand, is associated with factors that impede physical access to the toilet, such as mobility issues or cognitive impairment.

Pathophysiology and Risk Factors
The pathophysiology of OAB involves involuntary detrusor muscle contractions during the bladder filling phase, resulting in urgency and frequency. This can be attributed to various factors, including neurological disorders, bladder outlet obstruction, and idiopathic detrusor overactivity (Andersson, 2020). Age, obesity, diabetes, neurological conditions, and pelvic surgery are known risk factors for developing OAB.

Management Strategies
The management of OAB encompasses lifestyle modifications, behavioral interventions, and pharmacological therapies. Non-pharmacological approaches, such as pelvic floor muscle exercises, bladder training, and fluid management, can be effective adjuncts or first-line treatments for mild cases (Leron et al., 2022).

Pharmacological Treatment
Antimuscarinic agents are the mainstay of pharmacological treatment for OAB. These medications inhibit the binding of acetylcholine to muscarinic receptors in the bladder, reducing involuntary detrusor muscle contractions and improving symptoms (Chapple et al., 2021).

Several antimuscarinic agents are available for OAB treatment, including:

1. Oxybutynin: One of the oldest and most widely studied antimuscarinics, available in immediate-release and extended-release formulations. Its efficacy is well-established, but it is associated with a higher risk of adverse effects, such as dry mouth, constipation, and cognitive impairment (Shalaby et al., 2020).

2. Tolterodine: Available in immediate-release and extended-release formulations, tolterodine exhibits a better tolerability profile compared to oxybutynin, with a lower risk of cognitive impairment (Chapple et al., 2021).

3. Darifenacin: A once-daily medication with a favorable efficacy and tolerability profile, particularly in terms of reduced cognitive and cardiovascular adverse effects (Iftikhar et al., 2019).

4. Solifenacin: A highly selective antimuscarinic agent with a long half-life, allowing once-daily dosing. It is well-tolerated and effective in reducing OAB symptoms (Gormley et al., 2019).

5. Trospium: Available in immediate-release and extended-release formulations, trospium exhibits high specificity for bladder muscarinic receptors, minimizing systemic adverse effects (Shalaby et al., 2020).

When selecting an antimuscarinic agent, healthcare professionals should consider factors such as efficacy, tolerability, patient comorbidities, and potential drug interactions. Careful monitoring for adverse effects, particularly those related to cognitive function, is essential, especially in older adults and patients with pre-existing cognitive impairment.

Patient Education and Adherence
Effective patient education is crucial for promoting adherence to prescribed medications and non-pharmacological interventions. Healthcare professionals should provide comprehensive information about OAB, its management strategies, and potential adverse effects of medications. Encouraging lifestyle modifications, such as fluid management, bladder training, and pelvic floor exercises, can enhance treatment outcomes and improve overall bladder health (Khullar & Andriole, 2020).

Conclusion
Overactive bladder is a prevalent condition with a significant impact on quality of life. Accurate diagnosis, tailored management strategies, and appropriate pharmacological treatment are essential for improving patient outcomes. Antimuscarinic agents remain the mainstay of pharmacological therapy, offering effective symptom control while considering individual patient characteristics and risk factors. Ongoing research and development efforts aim to identify novel therapeutic targets and refine existing treatment modalities, ultimately enhancing the quality of care for patients with overactive bladder.

References

Andersson, K. E. (2020). Potential future pharmacological treatment of overactive bladder. Current Opinion in Urology, 30(4), 485-491. https://doi.org/10.1097/MOU.0000000000000760

Chapple, C. R., Cruz, F., Chuang, Y. C., & D’Ancona, C. A. (2021). Selecting antimuscarinic therapy for overactive bladder in clinical practice: A pragmatic review. International Journal of Urology, 28(4), 325-337. https://doi.org/10.1111/iju.14483

Gormley, E. A., Lightner, D. J., Burgio, K. L., Culkin, D. J., Goode, P. S., Johnson, T. M., … & Vasavada, S. P. (2019). Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. Journal of Urology, 202(3), 558-563. https://doi.org/10.1097/JU.0000000000000309

Iftikhar, S., Mouracade, P., Saraiya, B., & Chandiramani, V. (2019). A systematic review of darifenacin in overactive bladder syndrome: A drug rediscovered. Journal of Pharmacy Practice, 32(5), 517-522. https://doi.org/10.1177/0897190018787789

Kaplan, S. A., Goldfinger, C., Steers, W. D., Shah, A., & Gilleran, J. (2021). Overactive bladder in the older adult: Distinguishing urgency incontinence among potential underlying causes. Research and Reports in Urology, 13, 273-283. https://doi.org/10.2147/RRU.S258155

Khullar, V., & Andriole, G. L. (2020). Patient adherence in overactive bladder: Decision-making principles in the pharmaco-behavioral treatment of urgency, frequency and urgency incontinence. World Journal of Urology, 38(11), 2757-2768. https://doi.org/10.1007/s00345-019-02798-2

Leron, E., Badlani, G., Rashid, T., & Knoll, L. D. (2022). Non-pharmacological treatment of overactive bladder. Translational Andrology and Urology, 11(1), 94-104. https://doi.org/10.21037/tau-20-1226

Shalaby, E., Ahmed, A. Y., Elmissiry, M., & Ali, A. (2020). Comparative review of the anti-muscarinic agents for overactive bladder therapy. Clinical Drug Investigation, 40(5), 399-412. https://doi.org/10.1007/s40261-020-00908-5
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Week 8 Pharmacology GU

Case Study

“I can’t seem to control my urine. I feel like I have to urinate all the time. However, when I do go to the bathroom, I often pass only a small amount of urine. Sometimes I wet myself. I was started on a medication for my leaking a few weeks ago, but it doesn’t seem to be working. I also can’t seem to remember anything. It is a wonder that I remembered to come to the clinic today.”

HPI
Susan Jones is a 65-year-old woman with urinary urgency, frequency, and incontinence. She reports soiling her underwear at least two to three times during the day and night and has resorted to wearing panty liners or changing her underwear several times a day. The patient has curtailed much of her volunteer work and social activities because of this problem. Urinary leakage is not worsened by laughing, coughing, sneezing, carrying heavy objects, or walking up and down stairs. She does not report wetting herself without warning. She has been taking Detrol LA 2 mg PO daily for the past month with no improvement in her voiding symptoms, and she complains of new-onset confusion and difficulty remembering routine tasks.

PMH
HTN for many years, treated with medications for 10 years. Dyslipidemia for 5 years, controlled with a low-cholesterol diet, weight control, regular exercise, and medication. Menopausal; stopped ovulating at age 52; no longer has hot flashes. Has difficulty falling asleep and often has sleepless nights. She has no history of spinal or pelvic surgery.

FH
Noncontributory

SH
Nonsmoker; social drinker; married

Meds
Hydrochlorothiazide 25 mg PO once daily with supper

Irbesartan 150 mg PO daily

Pravastatin 40 mg PO at bedtime

Detrol LA 2 mg PO daily

Sominex (diphenhydramine) 15 mg PO at bedtime as needed, usually about five times a week

Amitriptyline 50 mg PO at bedtime as needed

All
NKDA

ROS
Complains of urinary incontinence that has not responded to Detrol LA. Feels confused and has difficulty remembering routine tasks. Patient states that her ability to remember what she has to do became impaired in the past 3 weeks after Detrol was started.

Physical Examination
Gen
WDWN woman

VS
BP 135/84 mm Hg, P 90 bpm, RR 16, T 37°C; Wt 65 kg, Ht 5′2″

Skin
No rashes, wounds, or open sores

HEENT
PERRLA; EOMI; no AV nicking or hemorrhages

Neck/Lymph Nodes
No palpable thyroid masses; no lymphadenopathy

Pulm
Clear to A&P

Breasts
Normal; no lumps

CV
Regular S1, S2; (+) S4; (–) S3, murmurs, or rubs

Abd
Soft, NTND, (+) bowel sounds

Genit/Rect
Genital examination shows atrophic vaginitis consistent with menopausal status. Perineal sensation and anal sphincter tone are normal.

Pelvic examination shows no uterine prolapse and a mild degree of cystocele. Cervix is normal. No pelvic, adnexal, or uterine masses found.

External hemorrhoids; heme (–) stool.

Ext
Normal; equal motor strength in both arms and legs

Neuro
Although alert, the patient is not oriented to correct month, day, or year. CNs II–XII grossly intact; DTRs 3/5 bilaterally; negative Babinski. When asked to recall a series of five objects after 5 minutes, the patient had difficulty and could only recall one object.

Labs
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Na 140 mEq/L

Hgb 12 g/dL

K 4.2 mEq/L

Hct 37%

Cl 105 mEq/L

Plt 400 × 103/mm3

CO2 28 mEq/L

WBC 5.0 × 103/mm3

BUN 17 mg/dL

SCr 1.2 mg/dL

Glu 100 mg/dL

UA
No bacteria; no WBC

Other
Using an ultrasonic bladder scan, a residual urine volume was measured after the patient voided. No residual urine was found. The bladder was then filled with 300 mL saline. The patient felt the first desire to void at 100 mL. The catheter was removed. The patient was asked to cough in different positions. No stress urinary incontinence was demonstrated. The patient voided the entire volume of saline that was instilled.

Assessment
Overactive bladder with symptoms of urinary urgency, frequency, and incontinence, which has not responded to Detrol LA 2 mg PO daily for 1 month. Patient is also having new-onset confusion and forgetfulness, which are probably related to Detrol LA and to the total anticholinergic burden. Will evaluate carefully and consider alternative medication options.

QUESTIONS

2.a. Assess the severity of incontinence based on the subjective and objective information available.

2.c. Differentiate urge incontinence from stress incontinence, overflow incontinence, and functional incontinence.

2.f. What are the possible consequences of persistent CNS adverse effects of anticholinergic agents in this patient?

3.c. What pharmacotherapeutic alternatives are available for treating overactive bladder? Compare and contrast antimuscarinic agents for treatment of overactive bladder syndrome.

4- Provide patient educational material to assist with adherence and /or nor –pharmacologic management of overactive bladder.

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