Overactive bladder (OAB) syndrome is a chronic condition that affects both men and women, which can have a significant impact on an individual’s physical, psychological, social and financial quality of life (QoL) (Scarneciu et al, 2021). It has been identified that the syndrome is more common in those aged over 40, but it can also affect children and young people (Scarneciu et al, 2021). Studies show that OAB affects 12% of both men and women, with the incidence increasing with advancing age, as 70– 80% of people by the age of 80 show more severe symptoms (International Continence Society [ICS], 2013).  

Overactive bladder syndrome is defined as ‘urinary urgency, usually accompanied by frequency and nocturia, with or without urinary urge incontinence, in the absence of urinary tract infection or other obvious pathology’ (Araklitis et al, 2020). Many individuals will present with a combination of symptoms with varying severity (Table 1). The main element that characterises OAB is urgency. However, this can be accompanied with frequency, nocturia and urge incontinence, which are considered the most exasperating of symptoms (Robinson and Cardozo, 2019). It has been estimated that urgency incontinence or OAB wet is more common in women, while urgency and frequency (OAB dry) is more common in men (Scarneciu et al, 2021). As identified, the condition is extremely common.  

Table 1. Presenting symptoms and definitions of overactive bladder syndrome  

Symptoms associated with OAB syndrome have far reaching effects on individuals’ QoL, including:  
  • Frequent sleep disorders and sleep disruption due to waking at night numerous times to void. There is a correlation that due to sleep disorders, individuals with OAB have a much higher risk of fractures or fall-related injuries (Lightner et al, 2019; Burkhard et al, 2020)  
  • Association between OAB and anxiety and depression (Lai et al, 2016)  
  • Due to fear of not reaching the toilet in time or needing to go frequently, there is a reduction of physical activity, social interactions and work opportunities. This in turn leads to isolation and avoidance of situations whereby urinary accidents can occur (Scarneciu et al, 2021)  
  • Loss of self-esteem, which can have a negative impact on sexuality and relationships and result in a reduction in sexual activity (Scrivens, 2022)  
  • An economic burden, with loss of work capacity, washing facilities, management/treatment options (Scarneciu et al, 2021). 
The pathophysiology of OAB is poorly understood and there are several underlying mechanisms that can incite symptoms. Peyronnet et al (2019) challenge the assumed rational that OAB is solely caused by detrusor muscle overactivity, as individuals presenting with OAB do not always show detrusor overactivity on further investigations, i.e. urodynamics. This highlights that other possible underlying mechanisms might be contributing factors.  

Table 2. Contributory risk factors for OAB (adapted from Scarneciu et al, 2019; Hutchinson et al, 2020) 

RISK FACTORS FOR OAB  


There are numerous risk factors which could contribute to an individual presenting with symptoms of OAB (Table 2). 

To identify the underlying cause and start an individual treatment pathway, it is imperative to undertake a comprehensive initial assessment, which includes understanding the patient’s experience and how OAB is affecting their QoL.  
 

ASSESSMENT  


As diagnosis of OAB is based on symptoms, taking a detailed comprehensive history is extremely important. It has long been identified that the assessment of continence problems should be undertaken by an experienced professional (McClurg et al, 2013), in line with recommended minimum standards (United Kingdom Continence Society [UKCS], 2015).  
Basic continence assessment should consist of the following components (Yates, 2019):  
  • Type of continence problem, i.e. main complaints of urgency/ frequency/nocturia etc identify the differential diagnosis  
  • Information about the onset, duration, current presentation and severity of the symptoms and whether related to a specific event/condition. This information can be gathered via numerous validated symptom profiles, such as the International Consultation on Incontinence Questionnaire Overactive bladder (ICIQ-OAB; https://iciq.net/iciq-oab). However, these are not well known or used in general nursing (Scarneciu, 2021)  
  • Impact of symptoms on current QoL (again not currently commonly incorporated in basic QoL assessments) should be advocated to see patient-reported outcomes of improvement after treatment initiated (National Institute for Health and Care Excellence [NICE], 2019)  
  • How individuals are currently managing symptoms  
  • Identification of any presenting red flags, e.g. associated pain or haematuria (blood in urine) that may require onward referral to a specialist (Scrivens, 2022)  
  • Complete medical, surgical, obstetric (parity, weight of baby, type of delivery), neurological and mental health history. Also history of stress incontinence may lead to OAB (Willis-Gray et al 2016)  
  • Details of any allergies, smoking status, mobility, dexterity, and cognitive, body mass index (BMI) or social issues 
  • Details of all medication, including over-the-counter medication, herbal remedies and recreational drug use (Table 3). Professionals should also be aware of increased comorbidities and polypharmacy in certain individuals which can contribute to OAB.  
Assessment findings should be supported by basic investigations, which include (Yates, 2019; Colley, 2020):  
  • A completed 24-hour three-day bladder diary, which should include individuals’ fluid intake and type of fluid, voided volumes, frequency of voiding, frequency of urinary leakage and amount of leakage. This diary can help to identify any associated triggers for intervention, e.g. excessive drinking or too little fluid intake and any bladder irritants, e.g. caffeine, alcohol  
  • Dipstick urinalysis — this is used in an initial continence assessment as a screening rather than diagnostic test. It helps to rule out numerous abnormalities, e.g. renal problems, haematuria (blood in the urine), or other constituents in the blood, such as glucose (indicating potential diabetes) and protein. It is also a good indicator of an individual’s hydration state. However, a diagnosis of urinary tract infection (UTI) should be based on the patient’s symptoms, not on dipstick urine testing (Public Health England [PHE], 2019a; 2019b)  
  • Post-void residual (PVR) urine bladder scans — if presenting with symptoms of poor flow, feelings of incomplete emptying and recurrent UTIs, or have an underlying neuropathy. There are two methods of assessing PRV urine volume: sterile urethral in/out catheterisation (a direct measurement of urine volume) and bladder ultrasound scanning (an indirect estimation of urine volume). Both of these investigations require a competent skilled professional trained in these procedures for implementation and interpretation of results. There is no clear consensus regarding the constitution of a normal or abnormal PVR urine volume with regards to retention. Volumes of 100–150ml are usually considered significant, but this will depend on total bladder capacity (Yates, 2021a)  
  • Physical examinations (vaginal/rectal/abdominal/neurological), if required, but only performed by a competent professional. However, while most registered healthcare professionals may not have the required skills or competency to undertake all of these examinations, they may well have the skills to do some of the most basic ones, such as a visual examination of the perineum area to identify abnormalities such as skin excoriation, atrophic vaginitis, visual prolapses, visual urinary leakage or alterations to female genitalia which may indicate female genital mutilation (Yates, 2021a).  

Table 3. Medications that may affect continence (adapted from the Royal College of Nursing [RCN], 2016; British National Formulary [BNF], 2022)

TREATMENT  


Treatment options come in two forms — initial first-line treatments or non-pharmacological conservative therapies, which are based on behavioural lifestyle changes and carry little risk, and second-line pharmacological treatments.  
 

First-line, conservative therapies  


Lifestyle interventions that can be offered as treatment options for individuals with OAB syndrome include (Herbert, 2019; Burkhard et al, 2020):  
  • Fluid advice — amount and type and avoidance of bladder irritants  
  • Weight loss  
  • Smoking cessation  
  • Timed voiding  
  • Urge suppression techniques  
  • Pelvic floor rehabilitation  
  • Bladder retraining.  
These will now be discussed in more detail.  

It is important to discuss fluid intake with individuals. The general consensus is that an average healthy adult needs a daily fluid intake of approximately 1.5–2 litres in 24 hours to replace natural loss. Maintaining appropriate fluid intake is vital to individuals with OAB, as low fluid intake may contribute to dehydration which leads to bladder urgency and frequency, although increased fluid can, of course, increase voiding problems (Yates, 2021b). The best form of fluid to advise is water, although some diluted squash or decaffeinated drinks can be alternatives. It is usual to advise individuals to decrease caffeine intake, as experts agree that it may have a stimulant effect on the bladder and exacerbate urgency, frequency and nocturnal voiding (Burkhard et al, 2020). Caffeine is mainly found in coffee, tea, drinking chocolate, cola and other carbonated drinks. Restricting fluids about two hours before bedtime may reduce nocturia.  

Weight loss has been shown to reduce the symptoms of OAB and incontinence and discussion with individuals and correct signposting to appropriate services for help could be beneficial (Scrivens, 2022). Smoking is another behaviour that can contribute to OAB, as nicotine has been shown to irritate the bladder (Madhu et al, 2015).  

Timed voiding and urge suppression (when the individual is encouraged to use techniques, e.g. holding on, standing or sitting still to delay voiding), with bladder retraining, which consists of a scheduled voiding regimen with gradual adjusted voiding intervals (Herbert, 2019), aim to:  
  • Improve bladder urgency, frequency, time between voids  
  • Increase bladder capacity  
  • Reduce incontinence episodes (Herbert, 2019).  
Bladder retraining is recommended for at least six weeks (Herbert, 2019; NICE, 2019). Within clinical practice, all these techniques identified above, i.e. urge suppression, timed voiding, bladder retraining are usually employed to assist treating OAB combined with pelvic floor training to help individuals contract their muscles for longer periods and potentially safely reach a toilet. A combination of all usually produces optimal results and better patient outcomes (Scarneciu et al, 2021).  
 

Second-line treatments — medication  


Pharmacological therapies should only be initiated following a trial of non-pharmacological management and can often be used as an add-on to these therapies. Table 4 outlines drugs used to manage OAB. 
 

Table 4. Summary of medication used in OAB problems (adapted from Burkhard et al, 2020) 

REFERRAL ONWARDS  


If individual patients do not respond to conservative first-line plus instigation of second-line drug therapy, referral to secondary services may be appropriate. Patients can then be assessed for further treatments that may include botulinum toxin, percutaneous posterior tibial nerve stimulation, or sacral nerve stimulation. However, these treatments may not be available everywhere.  

CONCLUSION  


Overactive bladder syndrome is a highly prevalent disabling condition which affects individual QoL. It is diagnosed by its presenting symptoms made in the absence of other pathologies. Healthcare professionals can make a difference to an individual’s QoL with conservative first-line therapies. If these interventions do not produce the expected change in symptoms, they can be supported by introducing second-line pharmacology. It is important to review the symptom presentation and, if still bothersome, referral onwards may be appropriate. 

Case report  


Mrs Y was aged 54, with a BMI of 28, and a smoker (10 cigarettes per day). At her first assessment, she was given a QoL questionnaire and bladder diary to complete. She was referred to the bladder/bowel service with symptoms of bladder urgency. Her completed bladder diary showed frequency of voiding 17 times in 24 hours (including x3 nocte). Her maximum bladder capacity was 320mls, with a minimum of 40mls. Symptoms of urge urinary incontinence occurred four times daily — very wet — and Mrs Y purchased pad products for protection. She rated her QoL score as 0 (on a scale of 0–5, where 0 = poor quality of life), indicating that her incontinence was having a great impact on her life. She had given up her job due to symptoms and was having no social life as she was too scared to go out in case of leakage.  

Her past medical history included having two children (one weighed over 8lb at birth and she needed to have stitches due to tear), and she was now post-menopausal. She was on no medication. Her fluid intake was poor, less than 1 litre due to worry about leakage. Her bowels opened on alternate days, type 3 on the Bristol stool chart. A urinalysis detected no abnormality, and a post void bladder scan showed it was essentially empty.  
 

Initial plan  


Mrs Y was advised to drink less coffee or change to decaffeinated, and generally increase her fluid intake, with mainly water if possible. She was also given advice with regards to diet and referred to a dietician. Smoking cessation information was also given.  

She was then reviewed after eight weeks. Her symptoms had improved but she was still leaking twice daily — frequency reduced to 11 times in 24 hours, but urgency still remained an issue.  

At this second visit (eight-week review, a pelvic floor examination took place and initial bladder retraining and pelvic floor rehabilitation was commenced. Mrs Y was currently losing weight.  

At her third visit (12 weeks later), Mrs Y’s symptoms had much improved, with her reporting that frequency was now nine times in 24 hours (including x1 nocte), and that she was able to get to the toilet as she had better control. There had only been one episode of leakage in the past month, and she was not having to purchase pad protection any more. She had also been able to increase social activities, as was no longer worried about leakage. Mrs Y was happy with the outcome and now rated her QoL as 5 on the questionnaire. She was discharged with contact details of the bladder and bowel service. 
Ann Yates is director of continence services, Cardiff and Vale University Health Board 
This piece was first published in the Journal of Community Nursing. To cite this article use: Yates A (2023) Overactive bladder syndrome: what community nurses should know. J Community Nurs 37(1): 31–36

References

Araklitis G, Baines G, Da Silva AS, Robinson D, Cardozo L (2020) Recent advances in managing overactive bladder. F1000Res Sep 11;9:F1000 Faculty Rev-1125  

British National Formulary (BNF) 78 (2022) Available online: www.bnf.org    

Burkhard FC, Bosch JLHR, Cruz F, et al (2020) Urinary Incontinence in Adults. EAU Guidelines. Presented at the EAU Annual Congress Amsterdam, 2020. Available online: https://uroweb.org/guideline/urinary-incontinence/   

Colley W (2020) Colley Model. Supporting the assessment of bladder symptoms in adults. Available online: www.continenceassessment.co.uk   

Drake MJ, Chapple C, Esen AA, et al (2016) Efficacy and safety of mirabegron add-on therapy to solifenacin incontinent overactive bladder patients with an inadequate response to initial 4-week solifenacin monotherapy: a randomised double blind multicentre phase 3b study (BESIDE). Eur Urol 70(1): 136–45  

Herbert J (2019) The conservative assessment and treatment of mixed urinary and anal incontinence in women: a multidisciplinary approach. Urology News 23(6). Available online: www.urologynews.uk.com   

Hutchinson A, Nesbitt A, Joshi A, Clubb A, Perera M (2020) Overactive bladder syndrome: management and treatment options. Aust J Gen Pract 49(9): 593–8  

International Continence Society Fact Sheets (2013) A background to urinary and faecal incontinence. Overactive Bladder. Available online: https://www.ics.org/folder/news-and-publications/ics-factsheets/d/ics-factsheets-2013-edition      

Lai HH, Shen B, Rawal A, Vetter J (2016) The relationship between depression and overactive bladder/urinary incontinence symptoms in the clinical OAB population. BMC Urol 16(1): 60  

Lightner DJ, Gomelsky A, Souter L, Vasavada SP (2019) Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU Guideline amendment 2019. J Urol 202(3): 558–63  

Madhu C, Enki D, Drake MJ, Hashim H (2015) The functional effects of cigarette smoking in women on the lower urinary tract. Urol Int 95(4): 478–82  

McClurg D, Jamieson K, Hagen S, Cheater F, Eustice S, Burke J (2013) Improving continence education for nurses. Nurs Times 109(4): 16–8  

National Institute for Health and Care Excellence (2019) Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline [NG123] NICE, London. Available online: www.nice.org.uk/guidance/ng123   

Peyronnet B, Mironska E, Chapple C, et al (2019) A comprehensive review of overactive bladder pathophysiology: on the way to tailored treatment. Eur Urol 75(6): 988–1000  

Public Health England (2019a) Diagnosis of urinary tract infections. Quick reference guide for primary care: for consultation and local adaptation. PHE, London  

Public Health England (2019b) Diagnosis of urinary tract infections (UTIs). Quick reference guide for primary care: Summary table. PHE, London  

Robinson D, Cardozo L (2019) Managing overactive bladder. Climacteric 22: 250–6  

Royal College of Nursing (2016) Medications. Causes of incontinence | Continence | RCN (rcni.com) 

Scarneciu I, Lupu S, Bratu OG, et al (2021) Overactive bladder: A review and update. Exp Ther Med 22(6): 1444  

Scrivens R (2022) Overactive bladder syndrome: an overview of diagnosis and management. Nurs Times [online] 118(6)  

Toozs-Hobson P, Robinson D (2019) Managing the symptoms of overactive bladder. Pharmaceutical Journal, 8 March. Available online: https://pharmaceutical-journal.com/article/ld/managing-the-symptoms-of-overactive-bladder   

United Kingdom Continence Society (2015) Minimum standards for continence care in the United Kingdom (revised 2nd edition). Report of the Continence Care steering group. Available online: www.ukcs.uk.net/wp-content/uploads/2016/04/15091716_Revised_Min_Standards_for_CC_in_UK.pdf     

Willis-Gray MG, Dieter AA, Geller EJ (2016) Evaluation and management of overactive bladder: Strategies for optimizing care. Res Rep Urol 8: 113–22  

Yates A (2019) Basic continence assessment: what community nurses should know. J Community Nurs 33(3): 52–5 

Yates A (2021a) Clinical Skills (part 2) Continence assessment and investigations. J Community Nurs 35(2): 30–7  

Yates A (2021b) Clinical Skills (part 3) Conservative therapies and treatments. J Community Nurs 35(4): 34–41 


Back to journal