Microsoft word - santoso et al pdf

Basic Research Journal of Medicine and Clinical Sciences ISSN 2315-6864 Vol. 2(6) pp. 66-71 August 2013
Available online http//
Copyright 2013 Basic Research Journal


Current management of overactive bladder: Insight
from developing country
Dwi Ngestiningsih1,2, Santoso1, Rejeki Andayani Rahayu2
1Dept of Biochemistry Faculty of Medicine Diponegoro University Semarang, Indonesia. 2Division Geriatry Dept of Internal Medicine Faculty of Medicine Diponegoro University Semarang, Indonesia. *Corresponding author email: [email protected]; Tel: +62-821-330-10495 Overactive bladder (OAB) is a chronic, debilitating and highly prevalent condition occurred in all age,
especially among elderly affecting quality of life such as socioeconomic, psychological, occupational,
domestic, physical and sexual functioning. The management of OAB can be nonpharmacologic
interventions, pharmacologic interventions or combination of both. There are several substances
involving smooth muscle relaxants, tricyclic antidepressants herbal medicine that can be used to
encourage this OAB but still uncovered, this is a challenge for clinicians to investigate further
regarding herbal medicine for OAB in order to suppress cost of OAB management because herbal
medicine especially in Indonesia is cheaper than synthetic substances. The successful of management
of OAB is influenced by many factors, especially from developing country such as Indonesia is the
compliance of patients. The comprehensive and better understanding of this disorder is needed in
order to manage OAB comprehensively. This article discuss about the comprehensive approach for
managing OAB based on the clinical experience among developing country.

Keyword: Overactive bladder. Elderly, herbal medicine


Overactive bladder (OAB) defined as urgency with or
2008; Kirby et al., 2006; Dalyana, 2006; Mullins and without urge incontinence which is usually featured with Subak, 2005; Tapia et al., 2013; Thomas and Culley, frequency and nocturia in the absence of other pathologic or metabolic conditions that might explain the symptoms There is a few number of studies regarding the is a chronic, debilitating and highly prevalent condition socioeconomic impact related with OAB. In United occurred in all age. Its incidence is increased among Kingdom annual cost of National Health Service (NHS) elderly (MacDiarmid, 2008, Kirby et al., 2006; Dalyana, in order to cure the symptoms of urinary tract related disorders is approximately 536 million poundsterling, in In more than six European countries, it was noticed that adition, out of pocket fee from patients arround 207 this condition affects approximately 17.000 people aged million poundsterling for pampers and other services 40 years. In addition, it was reported that 16,9% women (Kirby et al., 2006; Tapia et al., 2013). and 16% men above 18 years also suffered from OAB In US, the total costs associated with overactive (Dalyana, 2006). The severity and nature of the bladder were estimated at US$ 12 billion. These condition’s symptoms may be determined by gender (eg, expenses comprise indirect costs such as lost OAB without urge incontinence is more common in men productivity, and direct costs, involving diagnosis, treatment, and routine care (Mullins and Subak, 2005). Epidemiological studies demonstrated that there is correlation between incidence of OAB with quality of life interventions, pharmacologic interventions or combination such as socioeconomy, psychological, occupational, domestic, physical and sexual functioning (MacDiarmid, include ”bladder retraining” which generally consists of patient education, scheduled voiding, and urge- happened when its volume is not full enough. As suppression techniques (Ouslander, 2004; Sandhu et al., consequence, the patient complains urge and unable to A range of drugs have been used in the past for the The symptoms of OAB are usually related to management of OAB from smooth muscle relaxants to unidentified causes involuntary contraction of detrusor tricyclic antidepressants (Staskin, 2005; Pranarka, 2006). muscle defined as detrusor hyperactivity (Andersson and The successful of management of OAB is influenced by Wein, 2004; Erdem and Chu, 2006; Gormley, 2008). a lot of factors. One of important factor, especially from There are two theory related to detrusor hyperactivity, developing country such as Indonesia is the compliance first is the myogenic theory. This theory depicts that the of patients. Shyness and also false paradigm that urinary increase of detrusor muscle excitability result increase of related problem is normal for elderly are two of reasons involuntary pressure of the bladder. Second theory is the for them to not seek medical help (Pranarka, 2006; neurogenic theory that explain that in OAB, there is impairment of central inhibitory tract or pheripheral Despite the considerable impact this condition has on afferent terminal sensitization affect on primitive urination patient’s quality of life, OAB remains underrecognized reflexes which is stimulate overactivity of detrussor and undertreated as a result of patient embarrassment and reluctance to seek medical help, as well as a lack of In OAB, it is believe that detrusor muscle hyperactivity proactive questioning by physicians (Pranarka, 2006; causes lack of inhibitory contraction, as a result urgency of urination. The weakness of detrusor muscle causes A better understanding of the negative effects of urinary uncomplete emptying of the bladder and increase symptoms on the economic outcomes and quality of life frequency of mixturition (Sandhu et al., 2006; Erdem and of patients with OAB as well the comprehensive treatment strategies is important in order to optimize There are several factors which influence of incidence treatment of potential pharmacologic therapies and the OAB. They are classified into two categories. First of all utilization of outcomes data together with clinical systemic factors involving metabolic status such as assessment to determine the true strengths and Diabetes, medication or substances causing increase of limitations of the class of medication (Thomas and Culley, urine production such as diuretics, caffeine, alcohol, and neurological abnormalities resulted in damage of nerves Despite the importance of objective assessment as well that control urination such as stroke, infection or injury of subjective in the management of OAB, few studies brain or spinal cord, multiple sclerosis, and heavy metal include subjective assessment as a primary end point. intoxications. Second category is lower urinary tract such Future studies with a greater emphasis on subjective as infection, inflammation, malignancy, abnormalities or assessment using instruments that have undergone conditions causing urinary flow obstruction such as validation studies, such as OAB questionnaires, are benign prostate hyperplasia, urinary tract stones(Sandhu needed in order to gain a better understanding related to OAB for optimizing management of OAB, particularly among elderly patients (Thomas and Culley, 2008). Diagnosis of OAB
Pathophysiology of OAB
The diagnosis of OAB is recognized from history taking, complete physical examination especially on the The two functions of the bladder are to store and void abdomen and genital and Neurology examination for urine. The process of micturition involves neural circuits identification of sensory problems (Kirby et al., 2006; in the brain and spinal cord that coordinate the anatomic Tapia et al., 2013; Sandhu et al., 2006). components of the lower urinary tract (Andersson and Overactive bladder symptoms include feeling always Wein, 2004). However, the direct connection and want urination, Have experienced urinary urgency, contribution of these elements are not completely frequency, and nocturia (Tapia et al., 2013; Sandhu et al., Normally, as bladder volume increases, involuntary Overactive bladder without urgency incontinence contraction of the detrusor muscle are often associated overactive bladder, often called dry which is about about with overactive volume f urine voided, and the experience two-thirds of patients with these disorders. Whereas if the of each urination (Tapia et al., 2013; Andersson and urinary urgency, it is often referred to as overactive Among OAB patients, their bladder transmit false Physical examintation is important in order to determine impulses to the brain, resulted in immature contraction the cause of OAB such as assessment of pelvic floor for women to identify stress incontinence, palpation of This exercise takes several weeks. During this training suprapubic region for determining bladder enlargement exercise the bladder should be recorded in a note to and mass, digital rectal examination in men should be monitor the progression. After a few months usually considered to assess the size and consistency of the patient will have normal sense of wanting to urinate or go Laboratory examination from urine sample to check for The successful of bladder training may be depend on infection, glucose levels and urodynamic tests, to see the the support of the doctors, nurses or coaches and also function of the bladder and the ability of his emptying the intake of enough water (Ouslander, 2004; Sandhu et completely, uroflowmetry, the measurement of residual al., 2006; Sussman, 2007; Thomas and Culley, 2008). urine. Are important as routine examination (Dalyana, Pelvic floor exercises is the main approach for stress 2006; Tapia et al., 2013; Sandhu et al., 2006). incontinence. This exercise includes exercise to Additional laboratory examination such as cystometry strengthen muscles surrounded the lower part of the to measure bladder pressure during charge. This bladder, uterus and rectum and also suppresion the procedure can identify the presence of involunter muscle pelvic ground when sitting from lying to standing. It contraction that can indicate the level of pressure which remains unclear whether pelvic floor exercises can help is someone feel like urinating and can measure the urinary urgency without stress incontinence. However, pressure needed for bladder emptying, Electromyography pelvic floor exercises can help if it is done in conjunction to determine the coordination of nerve impulses in the with bladder training (Ouslander, 2004; Sandhu et al., muscles of the bladder and urine sphincter, urodynamics video using x-ray or ultrasound waves to get a picture of Another approach is usage of absorbent pad, the bladder during charging and discharging. This test is acupuncture and electrical stimulation. Patient may need usually combined with the cystometry and cystoscopy.
to use diapers (absorbent pads) to protect clothing and Used to see abnormalities on lower urinary tract for when unable to urinate (Thomas and Culley, 2008; Oki et example a tumor or urinary tract stones, urinary bladder diary for 3 days to assess symptoms both before and Emmon and Otto demonstrated that among 85 women after the experimental treatment should be considered in with OAB treated with acupuncture for 4 weeks has a order to diagnose OAB (Sandhu et al., 2006; Tapia et al., meaningful effect for the improvement of OAB involving on bladder capacity, urgency, frequency and quality of life equivalently to pharmacological therapy and physical therapy or behavior changes (Ouslander, 2004; Emmons Management of OAB
A mild electrical pulse applied through the vagina or anus or use patches on the skin, can be used to stimulate approach is more effective and efficient. In general, the the nerves that control the bladder and sphincter management of OAB divided into two approaches, first is non pharmacological treatment involves the life style In addition, minor surgery in order to provide electrical changes, bladder training, and pelvic floor exercises and stimulation can be applied by attaching an electrical wire pharmacological treatment (Sandhu et al., 2006; near the coccyx. In this procedure there are two stages, Ouslander, 2004).
first the wire is placed and connected with a temporary Life style changes involve locate the easiest way for stimulator that can be taken for a few days. If his toilet, drink sufficient water, avoid caffeine due to its condition improves, it will proceed with the second step. diuretic effect. In some people the alcohol can worsen the Second the electric wire is placed close to the tail bone is symptoms of overactive bladder, especially when connected to the stimulator and permanent that is placed combined with caffeine (Ouslander, 2004; Sandhu et al., under the skin (Oki et al., 2006). Figure 1. There are several substances which can be used for Bladder training also called bladder drill has the treatment of OAB (Thomas and Culley, 2008; Andersson purpose to slow down the stretch the bladder so that it and Wein, 2004; Asimakopoulos et al., 2012; Staskin, can enlarge the volume of the bladder and the patient can remove the urine is only 5 – 6 times in 24 hours. At the same time will reduce the hyperactivity of the bladder muscles. The principle of this exercise is try to stifle and Antimuscarinic
refrain using several ways such as sitting on hard chairs, counting backwards from 100, doing some pelvic floor Drug commonly used is antimuscarinic which is also exercises (Ouslander, 2004; Sandhu et al., 2006; commonly referred to anticholinergic. Belonging to this Sussman, 2007; Thomas and Culley, 2008). group are: oxybutynin, tolterodine, trospium chloride,
Figure 1
. Electric Stimulator (Oki et al., 2006).
solifenacin and propiverine. These medications work by can improve patient compliance and in some patients way of block nerve impulses to bladder that will result in aged prefers to wear a 'patch' rather than a pill (Emmons the relaxation of the muscles of the bladder and will increase the capacity of the bladder (Oki et al., 2006; Ouslander, 2004; Hood and Andersson, 2013). These medicines may improve symptoms in some Tolterodine
cases. This improvement will vary on each individual. We recommend a try given the drug for a month or so, if it Tolterodine is an antagonist of muscarinic agent which is helps then the medication be continued for six months or available in the form of short-acting and long-acting. more then the medication is stopped and seen how Various clinical test showed that 2 mg or 4 mg per day existing symptoms without medication (Asimakopoulos et will be just as effective as administering oxybutynin 5 mg The side effects of this drug are frequent but only a light weight and can be tolerated. Frequent side effects are dry mouth, dry eyes, constipation and blurred vision Propiverine dan trospium
(Asimakopoulos et al., 2012, Hood and Andersson, The drug is effective for OAB and drug side effects are minimal compared to oxybutynin short-acting (Oki et al., 2006, Wagg and Cohen, 2002, Asimakopoulos et al., Oxybutynin
Oxybutynin is the non-selective antimuscarinic that have activity relaxing the muscles of the bladder and local Estrogen
anesthesia. This dosage can be detached immediately (5 mg TID), off slow (5 or 10 mg O.D.) and transdermal Local vaginal preparations are more effective than oral patches (39 cm 2 patch in a dose of 36 mg per patch) estrogens, but existing data about its effectiveness that will release 2.4 mg oxybutynin per day for 3-4 days limited (Emmons and Otto, 2005, Hood and Andersson, Multicenter Study on Assessment of Transdermal Therapy in Overactive Bladder With Oxybutynin (MATRIX), has evaluated the effects of oxybutynin Antagonis Alpha-adrenergic
transdermal system (OXY-TDS; 3.9 mg/h) towards the quality of life and safety of the drug. On the research for 6 These agents are very useful in men with benign prostate months to adult patients including 699 2878 age 75 years or old. This study demonstrated that the OXY-TDS hypotension. The dose used is raised gradually to improves quality of life and can be well tolerated and overcome the effects of tolerance (Hood and Andersson, safe. OXY-TDS seems to constitute an ideal OAB therapy in the elderly. The granting of two times per week Imipramine
function in men with benign prostate obstruction (Kajiwara and Mutaguchi, 2008). Another herbal medicine An antidepressant effect of anticholinergic and tricyclic is Ganoderma lucidum is well tolerated and there is an with alpha-adrenergic. It may have the effect reflex improvement of symptoms of OAB. The recommended against Central bladder emptying so it is recommended dose of extract of Ganoderma lucidum is 6 mg in men to mix the urgency incontinence--stress. Its use should be with lower urinary tract symptoms (Noguchi et al., 2008). carefully because side effects of postural hypotension In addition, surgery approach can be considered when and cardiac conduction disturbances (Hood and pharmacological or changes of life style are failed in order to manage OAB (Gormley, 2008, Erdem and Chu, 2006). The aim of surgical treatment is to increase the ability of the filling of the bladder and reduce pressure on Darifanacin and solifenacin
the bladder. By Stimulation of the nervus Sacralis which is done by installing pacemaker under the skin of the A antimuscarinic future with selective receptor antagonist abdomen and connected by a small cable that is placed Action M3 and less systemic effect anticholinergic (Jha near the coccyx area sacralis. Modulation of nerve
impulses can improve the symptoms of OAB. Another surgery procedure is augmentation cystoplasty. This reconstruction procedure used to increase bladder Capsaicin and resiniferatoxin
capacity, by using a portion of the intestine to replace most of the bladder. On the procedure required a An promised intravesical agent to overcome the increase catheter to empty the bladder (Gormley, 2008). of reflexes of detrusor muscle in neurogenic bladder. CONCLUSION
Botulinum Toxin (Botox)
To sum up, OAB is multicausal condition influencing the There are some subtype botulinum toxin antigen which is activity of detrussor muscle result in the urgency and already known, namely: A, B, C1, D, E, F, and G. Types frequency of urination with consequence on patients A and B are used in urology. Botulinum toxin in action by quality of life involving psychological and socioeconomic way of inhibiting the release of acetylcholine from the problems. The comprehensive and better understanding nerve endings kolinergik interacting with the protein of this disorders is needed in order to manage OAB complex that is used to populate the acetylcholine vesicles. Effects of botulinum toxin was losing muscle contraction and muscle atrophy at the site of the injection. Chemical denervation are reversible and the regeneration Future Prospect and Suggestion
of the axon will occur within approximately 3-6 months. Administration of botulinum toxin in sufficient quantities Regarding pharmacological theurapeutic approach, there will inhibit the release of acetylcholine and other are several substances involving herbal medicine that neurotransmitters. The molecules cannot pass through can be used to encourage this OAB but still uncovered, the brain barrier so it has no effect on the CNS. The use this is a challenge for clinicians to investigate further of botulinum toxin is rising quickly, used to treat regarding herbal medicine for OAB in order to suppress neurogenic detrusor idiopathic overaktivitas and by cost of OAB management because herbal medicine means of the injection of (Sahai et al., 2007; MacDiarmid, especially in Indonesia is cheaper than synthetic Herbal medicine
Despite of synthetic substances, there are some herbal This study is based on the experience of clinical practice medicine used for the treatment of OAB. One of the most in Sub Division of Geriatry Dept of Internal Medicine, popular is a traditional Chinese medicine using Gosha- Faculty of Medicine Diponegoro University - Dr. Kariadi jinki-gan (Ogushi and Takahashi, 2007). Previous study Hospital Semarang Indonesia. We would like to thank to demonstrated that Goshi-jinki-gan ma be a new potential all people in Division of Geriatry Dept of Internal Medicine, therapeutic agent for OAB without deterioration of voiding Faculty of Medicine Diponegoro University - Dr. Kariadi Hospital Semarang Indonesia for the opportunity to carry Mullins CD, Subak LL (2005). New Perspectives on Overactive Bladder: this study in this hospital. Lastly we send our gratitude to Quality of Life Impact, Persistency, and Medication Treatment Costs. The American Journal Of Managed Care, 11. our team and staff of Dept of Biochemistry Faculty of Noguchi M, Kakuma T, Tomiyasu K, Kurita Y, Kukihara H, Konishi F, Medicine Diponegoro University, Semarang Indonesia. Kumamoto S, Shimizu K, Kondo R, Matsuoka K (2008). Effect of an extract of Ganoderma lucidum in men with lower urinary tract symptoms: a double-blind, placebo-controlled randomized and dose-ranging study. Asian J Androl, 10, 651-658. REFERENCES
Ogushi T, Takahashi S (2007). Effect of Chinese herbal medicine on Andersson KE, Wein AJ (2004). Pharmacology of the Lower Urinary Tract: Basis for Current and Future Treatments of Urinary Oki T, Toma-Okura A, Yamada S (2006). NEUROPHARMACOLOGY : Incontinence. Pharmacol Rev, 58, 581-631. Advantages for Transdermal over Oral Oxybutynin to Treat Asimakopoulos AD, Cerruto MA, Popolo GD, Martina ML, Artibani W, Overactive Bladder: Muscarinic Receptor Binding, Plasma Drug Carone R, Finazzi-Agrò E (2012). An Overview on Mixed Action Concentration, and Salivary Secretion. JPET, 316, 1137-1145. Drugs for the Treatment of Overactive Bladder and Detrusor Ouslander JG (2004). Management of Overactive Bladder. N Engl J Dalyana (2006). Overactive bladder. J. Indian Acad. Clin. Med. 7. Pranarka K (2006). Incontinence herbs treatment in Elderly: From Basic Emmons and Otto (2005). Acupuncture for Overactive Bladder. Obstet to Clinical Practice. The Symposium Of Incontinence. Semarang, Erdem N,Chu FM (2006). Management of Overactive Bladder And Urge Sahai A, Khan MS, Gregson N, Smith K, Dasgupta P (2007). Botulinum Urinary Incontinence In The Elderly Patient. Am. J. Med. 119, 29-36. toxin for detrusor overactivity and symptoms of overactive bladder: Gormley EA (2008). Overactive Bladder: Management And Treatment where we are now and where we are going. Nature Clinical Practice Options. The Masters in Urology Meeting. Semarang, Bermuda. Hood B, Andersson KE (2013). Common theme for drugs effective in Sandhu JS, Gupta A, Mohan V, Markan A, Sandhu P (2006). Approach overactive bladder treatment: Inhibition of afferent signaling from the to Overactive Bladder. JIACM, 7, 109-112. Staskin DR (2005). Overactive Bladder In The Elderly: A Guide to Jha S, Parsons M (2006). Treatment of overactive bladder in the aging Pharmacological Management. Drugs Aging, 22, 1013-1028. population: focus on darifenacin. Clin. Intervent in Aging, 1, 309-316. Sussman DO (2007). Overactive Blader: Treatment options in primary Kajiwara M, Mutaguchi K (2008). Clinical efficacy and tolerability of gosha-jinki-gan, Japanese traditional herbal medicine, in females with Tapia CI, Khalaf K, Berenson K, Globe D, Chancellor M, Carr LK (2013). Health-related quality of life and economic impact of urinary incontinence due to detrusor overactivity associated with a neurologic Kirby M, Artibani W, Cardozo L, Chapple C, Diaz C (2006). Overactive condition: a systematic review. BioMed Central, 11. Bladder: the Importance of the New Guidance. Int. J. Clin. Pract. 60, Thomas L, Culley EJ (2008). Overactive Bladder Disease: The Urge for Better Therapies. J. Manag. Care Pharm. 14, 381-386. Macdiarmid SA (2008). Maximizing the Treatment of Overactive Bladder Wagg A, Cohen M (2002). Medical Therapy For The Overactive Bladder In The Elderly. Age Ageing, 31, 241-246.


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