Overactive Bladder - Draft

Overview

Overactive bladder (OAB) syndrome is characterised by urgency, often with frequency and nocturia and sometimes leakage (urge incontinence). It is often but not always associated with detrusor muscle overactivity. It can be idiopathic or neurogenic. Strictly speaking, the term overactive bladder should be confined to cases where the condition is secondary to a known cause, whilst overactive bladder syndrome should be used in cases which are idiopathic. In practice the term is often used interchangeably. OAB can have a significant impact on quality of life. (1)

The BNSSG formulary team have developed a pathway for management of Over Active Bladder Syndrome in Adults in the guideline section below:

• Obstetrics, Gynaecology and Urinary-tract Disorders Guidelines (Remedy BNSSG ICB)

Assessment in Primary Care

• History and examination - exclude Red Flags

• Urine dipstick

• Frequency/volume chart (bladder diary) for 3 days - Input output chart.pdf

• Post-void residual – if symptoms suggestive of recurrent urinary tract infection (UTI) or voiding dysfunction - how is this requested from primary care?

• Effects on quality of life (ISIC -OAB) or more detailed quality of Life questionnaire can be used e.g. ICIQ-FLUTS or ICUQ-MLUTS - (I have included the link to the shortened version here as the longer versions advised in the formulary document seem a bit over the top and appear that they are mainly used for research purposes or in specialist settings.)

Who to Refer

Most patients with OAB can be managed in primary care and/or community care.

Secondary care referral is appropriate when appropriate lifestyle advice, bladder retraining and medical management has failed. This would include trying two different medications for a minimum of 4-6 weeks each. See pathway for details (2).

Red Flags

See Urology - USC (2WW) page

Consider other causes of urinary symptoms that may indicate that malignancy should be excluded (see link above for further details) such as:

• Visible haematuria - referral route depending on age and exclusion of other causes.

• Non- visible haematuria in patients aged 60 or over with either dysuria or raised white cell count on a blood test.

• Abdominal mass identified clinically or on imaging thought to arise from urinary tract. 

• Prostate feels malignant on digital rectal examination - features include asymmetry, irregularity, nodules and differences in texture e.g firm or hard. 

• Elevated age specific PSA in men with 10 year life expectancy. PSA test should be postponed for at least 1 month after treatment of UTI.

Before Referral

First Line: Conservative Measures

• Modify fluid intake if excessive or inadequate fluid consumption (aim for ~20ml/kg/day, it can be helpful to recommend reducing individual drinks by 25% i.e. fill a cup by ¾ rather than full)
• Reduce caffeine intake
• Weight loss if BMI >30kg/m2
• Smoking cessation
• Bladder re-training for a minimum of 6 weeks – ideally 12 weeks, supplemented by pelvic floor exercises - Consider self care such as the Bladder & Bowel Self Care App or referral to Bladder & Bowel Services.
• Female patients with vaginal atrophy should be offered transvaginal oestrogen - see Vaginal and vulval conditions (Remedy BNSSG ICB)
• NB: Pads and incontinence aids should only be used as a coping strategy and should not be offered as treatment. 

Second Line: Medical Management

To be commenced only if conservative measures have failed. Conservative measures should be encouraged to continue alongside medication. Consider the risk of anti-cholinergics, particularly in the frail/elderly.

Medication options include:

• Solifenacin
• Trospium
• Transdermal oxybutynin* - if oral medication not tolerated.
• Mirabegron

Tolterodine is not included at all. The pathway does say that tolterodine modified release is non-formulary but tolterodine standard release is blue on the formulary so not sure why not included in the pathway?

Vibegron is also not listed on the pathway but is on the formulary and NICE advise if other options are not tolerated. 1 Recommendations | Vibegron for treating symptoms of overactive bladder syndrome | Guidance | NICE

7.1 Bladder and urinary disorders (Remedy BNSSG ICB)

*Due to high anticholinergic burden, oral oxybutynin should be avoided in elderly or frail patients and alternatives considered.

Consider combination therapy with an anticholinergic plus mirabegron if individual medications fail to control
symptoms

For detailed  medication advice and flow diagram see the guideline in the link below:

• Obstetrics, Gynaecology and Urinary-tract Disorders Guidelines (Remedy BNSSG ICB)

Anti-cholinergic Burden

Consider using the ACB calculator to calculate risk and the options for reducing risk.

Referral

Community Bladder and Bowel Services

See the Bladder & Bowel Services page for advice on referral for bladder retraining and community support.

Secondary Care Referral

Secondary care referral if criteria are met should be via eRS to urology. These referrals will normally be triaged by the GPcare Urology service who will arrange review or onward referral to hospital services if required. 

Secondary care treatment options are summarised in the management guidelines (2).

Resources

References

(1) Overactive Bladder (Urinary Incontinence and Urge Incontinence)

(2) Obstetrics, Gynaecology and Urinary-tract Disorders Guidelines (Remedy BNSSG ICB)

Patient Resources

• CONfidence App -produced b NBT - an app to provide practical advice and self care tips and links to support people with bladder and bowel leakage including pelvic floor exercises.
• Male Pelvic Floor Exercises(pdf)
• Female Pelvic Floor Exercises (pdf)
  
  

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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