IDIOPATHIC OVERACTIVE BLADDER

Idiopathic overactive bladder

« Perineo-sphincter rehabilitation works perfectly well. »

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While it affects 14% of the French population, non-neurological bladder hyperactivity remains insufficiently treated. Based on this observation, the French Association of Urology (AFU) has dedicated its latest report to this pathology in which it reviews the symptoms, diagnosis and the many treatments that have proved useful in this condition.

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The report was presented at the 114th AFU congress held this year in virtual format. The writers insist on the role of the general doctor in the detection of overactive bladder, which is not always mentioned by the affected patients, as this disorder is often experienced as a shame and a fatality. The use of the bladder calendar is presented as a « major factor in the diagnosis ».

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« Our goal is to raise awareness of this taboo disease, especially since there are now effective treatments for almost all types of overactive bladder, including the most severe », said Professor Xavier Gamé (Rangueil University Hospital, Toulouse), co-author of the report.

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Underestimated impacts

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Overactive bladder is caused by involuntary contractions of the detrusor, the muscle of the bladder, causing an urgent need to urinate (urguria) frequently, day and night (nocturia). It can be combined with urinary incontinence. The AFU report is devoted to idiopathic bladder hyperactivity, of non-neurological origin.

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Non-neurological overactive bladder is common, affecting 14% of the French population, nearly as much men as women. Its frequency increases with age. A tier of the over 75 years old are concerned. However, many people avoid consulting, convinced that this disorder is normal and an inevitable consequence of aging.

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« For the elderly, having an overactive bladder and urine leakage is experienced as a fatality », said Pr Véronique Phé (La pitié Salpêtrière Hospital, AP-HP, Paris), also author of the report, during an online press conference. The conviction that there is no way to relieve this disorder also increases the lack of willingness to talk about it.

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Yet OAB can be very disabling, « Its impact is probably underestimated », says the urologist. « It's a chronic disease with physical, psychological, social or economic repercussions. The impact on life quality is higher than those caused by diabetes or high blood pressure ».

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Digital urinary calendar

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It is considered normal to go to the bathroom four or five times a day to urinate or to get up from time to time at night to satisfy this need. « There is no urinary limit »to define an overactive bladder, says Pr Phé « As soon as the frequency of day and night urination becomes uncomfortable, it is necessary to consult a specialist ».

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On his side, the general doctor must think about questioning his patients, believe the authors. When a patient says that he or she often needs to find a toilet in an emergency, an investigation should be made for urgency, based first on the three-day urinary calendar, before proceeding to a more detailed evaluation.

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The urinary calendar can be used to look for a urinary disorder by indicating the frequency of urination, the quantity of urine eliminated or the quantity of drink absorbed. Developed in collaboration with the AFU, an application with a digital voiding calendar, called Uroquest, can be used. It is now available on download platforms.

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If urinary emergencies are suspected, evaluation continues with an urologist to « exclude local urologic disease, such as infection, bladder tumor, urinary stone or other urologic pathology ». Several tests may then be performed (ECBU, cystoscopy, ultrasound...) to try to « understand the pathophysiological mechanisms and guide the therapeutic strategy ».

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If performed with the help of a health professional, this rehabilitation is related to an improvement or recovery of the urinary emergency in three-quarters of the cases. By reinforcing the perineum, « you reacquire the perineo-inhibitory detrusor reflex », which allows the bladder sphincter to contract when the urge to urinate is felt.

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In case of failure, hormone replacement therapy may be offered in postmenopausal women, giving preference to the local way. Medical treatments also include anticholinergics and beta-3 activators, with « similar efficiency » on the different symptoms of hyperactivity, said Pr Gamé.

 

Link to download the urinary calendar:

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https://www.urofrance.org/fileadmin/medias/scores/catalogue-mictionnel.pdf 

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Neuromodulation and botulinum toxin

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When overactive bladder is resistant to these drug treatments, there are still three possible treatments: stimulation of the tibial nerve, neuromodulation of the sacral nerve and botulinum toxin injections.

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Stimulation of the tibial nerve is a non-invasive method, « which could probably become a primary treatment », says the urologist. Geriatricians tend to prefer it. It involves applying two electrodes to the ankle. With 20 minutes of stimulation per day, the success rate reaches 32 to 87% according to the documentation.

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Sacral nerve neuromodulation, on the other hand, involves surgical intervention to implant an electrode in contact with the sacral nerve in the area of the sacrum. Stimulation is performed using an external stimulator. If the method is successful, the device is implanted under the skin. This treatment improves urguria in 60 to 70% of implanted patients.

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Finally, botulinum toxin A (Botox®, Allergan) appears as an alternative to neuromodulation of the sacral nerve or as a complement for patients who are not sufficiently helped. The toxin is injected by endoscopy, under local or general anesthesia, and uniformly spread in the bladder tissue over 10 to 20 injection spots.

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Botulinum toxin is indicated as secondary therapy for the treatment of idiopathic hyperactivity combined with symptoms including at least three episodes of urinary incontinence, with urgency over three days, and a voiding rate higher than or equal to eight per day.

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However, this technique is associated with a risk of retention, between 5 and 10%, in the two months following the injection, which implies preparing the patient for the eventuality of self-catheterization in order to be able to empty his bladder.

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Other treatments are currently under evaluation, such as radiofrequency or laser, which are supposed to help regenerate the pelvic floor.

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Idiopathic overactive bladder: « perineo-sphincter rehabilitation works very well » - Medscape - Dec 1, 2020.

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https://www.urofrance.org/publications-livres/publications-scientifiques/rapports-du-congres.html