AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | Advanced Management Options for Refractory Overactive Bladder INTRODUCTION Overactive Bladder Syndrome is a chronic and disabling condition that affects millions of patients globally. The International Continence Society (ICS) defines overactive bladder syndrome as a urinary urgency that can occur with or without incontinence and is associated with high frequency during the day and nocturia. 1 For urgency to be characterised as overactive bladder syndrome, there must be no proven infection or obvious pathology. In addition, OAB is often associated with anxiety from fear of leakage and pain. 1 In these patients, the sight of urgency is often the perineum or the base of the penis or vagina/urethra. 1 The definition and management of OAB are continuously evolving, and more advanced treatment approaches are emerging. In light of these advances, the purpose of this review was to provide an update on the advanced management of OAB. The review starts with a background of OAB, focusing on epidemiology, aetiology and symptoms, followed by an overview of the literature on the management of OAB. Across sub-Saharan Africa (SSA), where a large proportion of mEpidemiology of Overactive Bladder Syndrome A study that was conducted in the United Kingdom with a sample size of 19000 found that the prevalence of OAB was 11.8%. 2 Another study that was conducted in the United States National Overactive Bladder Evaluation (NOBLE) found a prevalence of 16%. 3 According to the United States study, OAB affects about 33 million women worldwide. OAB affects both men and women. 3 Both the United Kingdom and the United States studies found no differences in prevalence rates between men and women; however, in the United Kingdom study, differences were observed in symptoms between women and men. For example, in the United Kingdom study, storage symptoms were more common in women. 2 Another prevalence study of OAB in 6005 patients in Eastern Europe found a prevalence of 39.5% in women and 26.8% in men. 4 The Polish study found a significantly higher prevalence in women and a positive association between the prevalence of OAB increased and age. 4 OAB is more common in patients in their 40s, although it still occurs in children and young adults, and symptoms worsen with age. 5 The aetiology of OAB is attributed to a number of causal factors. First, there is the myogenic hypothesis, which attributes OAB to dysfunction of the detrusor smooth muscle that results in spontaneous contractions. 6 Secondly, the neurogenic hypothesis attributes OAB to the dysfunction of the central and or peripheral nervous control of the bladder. 6 One of the defining features of DO is the degeneration of nerve fibres within the bladder wall. A third hypothesis attributes OAB to the release of mediators such as ATP by the urothelium during bladder filling. 7 There is also a range of pathophysiological factors that are associated with OAB and DO, which alter bladder smooth muscle, neuronal and urothelial functions. 8 These factors include ageing, bladder outlet obstruction (BOO), obesity, psychological stress and undetected low-level bacterial infections. 8 SYMPTOMS AND DIAGNOSIS OF OAB The hallmark symptom of OAB is urgency in the absence of urinary tract infection, metabolic disorders that affect urination, or urinary stress incontinence. 9 While incontinence is sometimes present, it occurs in a third of the patients. 9 Incontinence that is due to OAB must be differentiated from incontinence associated with failure of the urethra and pelvic floor to withstand abdominal pressure as it is not associated with urgency. 9 The assessment and diagnosis should include investigations of patient characteristics such as the demographics, clinical history, including current medication and previous surgeries, and a physical examination. 10 It is crucial to understand which drugs are taken by the patient as medications such as Beta-blockers, anti-Parkinson agents, diuretics, and neuroleptics may cause incontinence. 10 A detailed urinary history should be taken, and the examining clinician should do a primary evaluation for urinary tract disorders to exclude other disorders that also cause urinary incontinence, such as diabetes, recurrent urinary tract infections, urinary bladder calculi, and bladder tumours. 10 The physical examination must also include laboratory and radiological investigations. Urine analysis, urinary culture, blood for glycated haemoglobin (HbA1C), electrolytes, and levels of creatinine to assess kidney functioning. 10 Radiology tests can be used to measure post-void residual urine, which should be less than 50ml and can also be done using ultrasound or a catheter. 10 Lastly, whenever possible, a uroflowmetry must be performed before and after the post- void residual urine test. 10 MANAGEMENT OF OAB Overactive bladder syndrome can be managed with a pharmacological or a non-pharmacological approach. The non-pharmacological approach entails education, lifestyle changes, bladder training and behavioural therapy. Education efforts should be focused on teaching the patients about OAB and assisting them with developing strategies to manage urgency and incontinence. The long duration of the treatment should also be explained to the patients. 11 Lifestyle changes such as smoking cessation, weight loss, dietary changes, exercise and bowel regulation are cited in various studies and recommendations on the management of OAB. 9, 12-14 However, these are based on expert opinions as there is a lack of clinical trials. 11, 14 Bladder training is a crucial component in the management of OAB. Bladder training entails developing the patient’s control over urination by urinating at regular intervals, starting with urination at 30 minutes until reaching 3-4 hours intervals. 9, 11, 13, 15 This can be aided by using a micturition calendar to increase patient compliance and sustain motivation through visual feedback. 13, 16 Dr KAMolefi, Z Abdool Department of Obstetrics and Gynaecology, Urogynaecology Unit, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa CORRESPONDENCE: Dr KA Molefi| Email: drmolefi@icloud.com Advanced management options for refractory overactive bladder African J urnal of Obst trics and Gynaecology | Volume 2 | Issue 1 | 2024 | 11