Continuing our series showcasing highlights from our Nursing in Practice 365 event sessions, continence nurse specialist Jane Simpson outlines the principles of overactive bladder management and how nurses can support patients to control the condition.
It is estimated that 12-14% of the population are affected by an overactive bladder (OAB): about one in 6 people. While the prevalence does increase significantly with age, it affects a significant number of adults of all ages and is by no means only a problem among older people.
OAB is defined as urinary urgency (the sudden urge to pass urine), often accompanied by urinary frequency (passing urine more than 6-8 times a day) and nocturia, with or without urge incontinence.
Urge incontinence is where the initial desire to pass urine becomes overwhelming, so the person simply can’t hold on.
What causes overactive bladder and urge incontinence?
The condition involves involuntary contractions of the bladder that cause an urgent or frequent need to pass urine.
It can have several underlying causes such as:
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- Conditions that affect the brain – for example stroke, Parkinson’s disease and multiple sclerosis.
- Hormonal changes at the menopause, vaginal prolapse, urinary tract infections, constipation and diabetes.
- Cognitive changes in older age and not being able to get to the toilet in time.
- Medication that causes the body to make more urine.
- Learned behaviour, anxiety due to life stressors or going to the toilet ‘just in case’ may also be factors.
What treatments are available?
Lifestyle changes
Lifestyle can play a big part in the treatment of OAB. Explore factors such as your patient’s intake of alcohol, fizzy drinks, caffeine and spicy foods which may be causing or exacerbating the problem and advise them to cut down if their intake is too high.
Bladder retraining and pelvic floor rehabilitation
The first line of treatment for OAB is bladder retraining and pelvic floor rehabilitation. This helps about 50% of patients. It can be helpful to tell patients that they need to put themselves back in control of their bladder, not let their bladder rule their lives.
Bladder retraining consists of trying to get the bladder to hold more urine. It involves patients consciously learning to hold on when they have the urge to pass urine, and slowly increasing the time between visits to the toilet.
Advise your patients to keep a bladder diary in the form of a fluid input and output chart – ask them to record how often they pass urine and what they are drinking for about three days. It is often very revealing. It may prompt a very easy solution, such as reducing excess caffeine.
Other contributing factors like constipation and obesity may also need to be addressed.
Pelvic floor rehabilitation principally involves exercises to help strengthen the pelvic floor muscles. Patients can be given simple exercises to do at home. These essentially involve consciously squeezing and lifting the area around the vagina and anus and then relaxing again. The ‘squeeze and hold’ should be done regularly three times a day, to a count of 5-10, with occasional shorter, sharper contractions done once a day. The downloadable Squeezy App offers examples of exercises and support for patients.
For those who find it difficult to sense their pelvic floor, biofeedback – use of technology to generate visual or auditory cues that help a person sense and control their muscles – can also be incorporated. This involves using a vaginal device that feeds back on the pelvic floor muscle contraction and relaxation.
Various pelvic floor gadgets such as vaginal weights are now available for people to buy and these similarly involve element of biofeedback to help with pelvic floor strengthening. These can be helpful to keep up with exercises during busy daily lives.
Medications for OAB
If pelvic floor rehabilitation and bladder retraining doesn’t work, there are medications available. The main groups of drugs used to treat OAB are anticholinergics, antimuscarinics and beta-3 agonists.
The anticholinergic and antimuscarinic drugs work by helping to relax the bladder muscle and reduce bladder contractions. Patients sometimes struggle to adhere to these drugs due to their side effects.
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Beta-3 agonists also work by relaxing the bladder muscles but are more targeted specifically to the bladder, so the side effects are less troublesome.
Nonetheless, all these drugs are prescription only with side effects and contraindications that must be considered.
For women, genitourinary symptoms of the menopause can cause OAB symptoms. In this case, vaginal oestrogen in the form of a pessary, gel, ring or cream may help and NICE menopause guidelines now recommend low-dose vaginal oestrogen as the first line treatment for genitourinary syndrome of menopause. (Note that this is unsuitable for some women with a history of breast cancer, in whom NICE recommends some non-hormonal alternatives.)
Specialist treatments
If medication is contraindicated, badly tolerated or doesn’t work there are some further options which require referral to specialist urology clinics.
One option they can offer is percutaneous tibial nerve stimulation (PTNS). This is usually a clinic-based treatment but for some patients it can be performed at home.
There are also hospital-based treatments in the form of Botox injections into the bladder or sacral nerve stimulation (SNS) with a spinal implant.
Key points
- Overactive bladder (OAB) is urinary urgency that may be accompanied by urinary frequency (passing urine more than 6-8 times a day) and nocturia. It can also result in urge incontinence.
- It is relatively common, affecting around 12-14% of the population.
- OAB can be effectively treated in around half of people using conservative measures including lifestyle changes, bladder retraining and pelvic floor rehabilitation.
- Medications can also be prescribed in primary care if required.
- For those in whom medication is ineffective or contraindicated there are further, relatively minimally invasive therapies from specialist clinics.
Jane Simpson is a registered nurse, Continence Nurse Specialist and author of The Pelvic Floor Bible
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For more detail on managing incontinence and pelvic floor rehabilitation in women see our Nursing in Practice 365 CPD module Pelvic floor dysfunction and urinary incontinence in women CPD Points – Nursing In Practice 365
