Patients with overactive bladder ty...

Patients with overactive bladder typically have a variety of symptoms that may include urinary entreaty and frequency, nocturia, and beg incontinence. The condition is commonly encountered and affects an estimated 30 to 40 percent of characters 75 years of age or older Patients with symptoms of overactive bladder many times withdraw from their usual social activities, are more likely to be lowered and may suffer from drowse disruption because of nocturia. Ouslander provides a review of the diagnostic work-up and treatment of overactive bladder.

Urination is a compages process, involving the higher cortex of the brain, the brainstem, afferent and efferent neural pathways, and various anatomic makes of the lower urinary tract. enigmas in any of these areas can lead to bladder dysfunction; the review includes a detailed table of conditions that may be implicated in overactive bladder. Overactive bladder has a multifactorial etiology in greatest in number persons. The author states that a targeted diagnostic evaluation of patients with symptoms of overactive bladder is required. All older men should be questioned about symptoms of benign prostatic hypertrophy Patient diaries may provide helpful details regarding commonness of urination, voiding volumes, pattern of voiding, and lifestyle factors that may contribute to symptoms. All patients should have focused genitourinary, pelvic, and rectal examinations, and a clean-catch urine specimen should be checked for hematuria and infection.

Sterile in-and-out catheterization can be used to check for the mien of post-void residual urine, and this proceeding should be considered in patients at risk for urinary retention (such as those with diabetes, benign prostatic hypertrophy or spinal cord injury). Alternatively, ultrasonography provides a noninvasive way to measure post-void bladder turns Cystoscopy should be targeted to patients with unexplained hematuria, renewed urinary tract infections, or risk factors for bladder cancer. Urodynamic testing is relatively more manifold and invasive, and the author notes that its part in the diagnostic work-up of overactive bladder is controversial. He proposes targeting this procedure to patients who have failed initial therapy or those with nonspe-cific symptoms and an unclear etiology of overactive bladder.

The multifactorial causes of bladder dysfunction typically necessitate a multimodal approach to treatment that includes behavioral and pharmacologic interventions. All patients should be educated to limit caffeine intake (and other diuretics, when possible), avoid constipation, and plan fluid intake to minimize social disruptions and be dead disturbance. Pelvic-muscle floor exercises and "bladder training" are more likely to be effective in cognitively intact, motivated patients whose primary vexed question is incontinence.

Anticholinergic medications are the main-stay of remedy therapy for overactive bladder. The chief puzzles occurring with these medications are side drifts and incomplete efficacy. The most numerous common side effect is parched mouth, and constipation, gastroesophageal ebb blurred vision, urinary retention, and cognitive riddles also may occur. Of the many agents available, oxybutynin and tolterodine have the greatest in quantity evidence for clinical efficacy. Generic immediate-release oxybutynin may work best in patients who sole need short-term control such as during social situations or at night to decrease nocturia. The once-daily con-trolled-release form of oxybutynin has fewer reported side imports and similar efficacy. Tolterodine is also available in short-acting and long-acting formulations, with similar efficacy and side imports com-pared with oxybutynin.

Older men with prostatic hypertrophy may benefit from alpha-blocker medications and should be watched for urinary retention if anticholinergic unsalable articles are employed. Nocturia related to book over-load (e.g., venous insufficiency, congestive heart failure with peripheral edema) may be improved at one dose of a diuretic taken in the late afternoon or from nighttime use of desmopressin in children. The review discusses a number of investigational medications, which may have promise for treatment of overactive bladder.

BILL ZEPF MD

Ouslander JG Management of overactive bladder. N Engl J M February 19 2004;350:786-99

COPYRIGHT 2004 American Academy of Family Physicians

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