Bladder training

OVERACTIVE bladder (OAB) is characterised by involuntary contractions of the detrusor muscle while the bladder fills with urine. Normally, that muscle remains relaxed during bladder filling and contracts only when the bladder needs to be emptied, according to Uncovering Overactive Bladder, A Guide for Nurse. 

In people with OAB, the detrusor muscle contracts prematurely, giving rise to the characteristic symptoms of frequency (eight or more visits to the toilet every 24 hours), urgency (sudden, strong desire to urinate) and urge incontinence (sudden and involuntary loss of urine).  

Most healthy adults feel the desire to empty their bladder when it is about half its physiologic capacity. However, the desire to void is suppressed by the cerebral cortex until a suitable time and place. How often the bladder needs to be emptied varies between individuals. However, urinating more than eight times over 24 hours is generally considered to be abnormal. 

The incidence of OAB increases with age. However, the disorder is not necessarily an inevitable consequence of ageing. 

In the majority of cases, the underlying cause of OAB is unknown. In some patients, the cause may be neurological, such as stroke, multiple sclerosis, Alzheimer’s disease or Parkinson’s disease. Some medications, too, may cause incontinence, such as diuretics, anti-depressants, anti-hypertensives, hypnotics, narcotics, sedatives, sleep aids, cold remedies and analgesics. 

OAB symptoms may cause sleep disturbances, depression and reduction in sexual activity and social interaction.  

Generally, OAB is under-diagnosed and under-treated due to lack of awareness (on the part of the public and of healthcare professionals), reluctance on the part of patients due to embarrassment, cultural barriers and lack of a conducive setting to discuss the matter.  

Patients often limit, restrict and tailor their activities according to their continence needs. They may also try other ways of coping, such as reducing fluid intake, wearing dark and baggy clothing, and toilet mapping. 

Patients with OAB and other common types of urinary incontinence, most notably stress incontinence, may present with similar symptoms. However, these conditions respond to different treatment regimens. To successfully manage a patient with OAB, it is essential to differentiate individuals with overactive bladder from other bladder control problems. 

Many patients with OAB can be diagnosed and treated. As a general guide, a patient suspected of having OAB should be considered for referral if: 

their symptoms do not respond to initial treatment within two to three months 

they have hematuria (blood in urine) without infection or urinalysis 

their symptoms are suggestive of poor bladder emptying, such as hesitancy, poor stream and terminal dribbling 

there is evidence of unexplained neurological or metabolic disease, such as diabetes and renal failure. 

Bladder training is also helpful for people with OAB. 

In bladder training, the patient is advised to keep a strict schedule of voiding. The patient must have an understanding of how the brain possesses control over the bladder and not the bladder controlling the brain. The patient also needs to understand how urge comes with bladder filling, as it can be felt even if the bladder is not completely filled. Urges are reminders, not commands. 

Continence is a learned behaviour. With the strict instructed voiding patterns, patients are eventually capable of increasing their bladder capacity through the strengthening of bladder muscles. 

For some people, bladder training alone is not enough, so drug treatment is sought. 

The diet and fluid intake of the patient should also be reviewed. Some patients will try to reduce the risk of leakage by restricting their fluid intake but drinking too little results in concentrated urine, which can irritate the bladder. Hence, patients are encouraged to drink adequate volumes of fluids. They are also encouraged to reduce their consumption of caffeine, carbonated soft drinks and alcoholic drinks, as they act as bladder irritants. 

Surgery is reserved for patients with severe symptoms that do not respond to treatment.