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PostPosted: 08 Oct 2014 02:25 
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Overactive bladder syndrome

Overactive bladder syndrome (OBS) is a urological condition related to problems with urination, and sits in a spectrum of urinary incontinence, including the following:

Stress incontinence, which occurs when the bladder is under extra sudden pressure (cough, sneeze, heavy lifting, laughter).

Urge incontinence, when the urge to urinate is sudden and intense, and delay in going to the toilet cannot be countenanced. Stress incontinence and urge incontinence account for 90% of cases of urinary incontinence

Mixed incontinence, where symptoms of both stress and urge incontinence are experienced.

Overactive bladder syndrome, where there is urgency that may (wet OBS) or may not (dry OBS) be accompanied by incontinence.
OBS is sometimes referred to as irritable bladder or detrusor instability.

Overflow incontinence, where there is chronic urinary retention

Total incontinence, where urinary incontinence is severe and continuous

Prevalence

Between one in two and one in six adults in the US and Europe have OBS, and the prevalence increases with age.
The American Urological Society has reported that rates in men range between 7 and 27%, and between 9 and 43% in women.
Urge incontinence is higher in women that in men. As many as 39% of those with OBS symptoms are symptom-free within the year, but, for most, symptoms persist for several years.

Causes
The symptoms of OBS are caused by the detrusor sending the message to the brain that the bladder is in urgent need of being emptied when it is not.
What causes the detrusor to contract in the absence of a full bladder is not fully understood.

DIAGNOSIS AND MANAGEMENT TO FOLLOW.

G Mohan.


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PostPosted: 08 Oct 2014 02:48 
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Diagnosis (including signs and symptoms)

Lower urinary tract symptoms include problems with storing urine (urgent or frequent need to go to the toilet), problems with passing urine (a slow stream, straining, or stop and start) and problems after having passed urine (continuing to pass a few drops after you think you have finished, or feeling that you have incompletely emptied your bladder).

OBS diagnosis is made primarily by ruling out other causes of hyperactivity, such as infection or tumour.
Symptoms of OBS worsen at times of stress, and are made worse by caffeine and alcohol.

Symptoms may present as a complication of nerve- or brain-related disease, or if there is a urinary infection or a stone in the bladder, but in these cases it is not referred to as OBS, as there is a known cause.

Management

Treatments for OBS include nonpharmacological, lifestyle measures (moderate caffeine and alcohol intake, but continuing to drink 2 litres of fluid per day), bladder training (also known as bladder drill, effective in up to half of cases), medication (instead of or in addition to bladder training) and pelvic floor exercises.

Antimuscarinics (also called anticholinergics) (including fesoterodine, tolterodine, darifenacin, hyoscyamine, oxybutynin, trospium chloride, propiverine and solifenacin) may help.
Muscarinic receptors play a role in the contraction of urinary smooth muscle and stimulation of salivary secretion.
Antimuscarinics are competitive antagonists of the binding of acetylcholine to muscarinic receptors, and act by blocking certain nerve impulses to the bladder, which cause it to contract.

Although symptoms may recur after a course of medication has ended (a typical person with an overactive bladder may urinate 12 times per day, and medication may reduce this number to 2-3), using in conjunction with bladder training may mean that symptoms do not recur.

G Mohan.


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PostPosted: 14 Oct 2014 02:55 
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Overactive bladder syndrome is not uncommon..
Symptoms include an urgent feeling to go to the toilet, going to the toilet frequently, and sometimes leaking urine before you can get to the toilet (urge incontinence). Treatment with bladder training often cures the problem. Sometimes medication may be advised in addition to bladder training to relax the bladder


Understanding urine and the bladder
The kidneys make urine all the time. A trickle of urine is constantly passing to the bladder down the ureters (the tubes from the kidneys to the bladder). You make different amounts of urine depending on how much you drink, eat and sweat.

The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine (the urethra) is normally kept closed. This is helped by the muscles beneath the bladder that sweep around the urethra (the pelvic floor muscles).

When a certain amount of urine is in the bladder, you become aware that the bladder is getting full. When you go to the toilet to pass urine, the bladder muscle contracts (squeezes), and the urethra and pelvic floor muscles relax.

Complex nerve messages are sent between the brain, the bladder, and the pelvic floor muscles. These tell you how full your bladder is, and tell the right muscles to contract or relax at the right time.

What is overactive bladder syndrome?
An overactive bladder is when the bladder contracts suddenly without you having control, and when the bladder is not full. Overactive bladder syndrome is a common condition where no cause can be found for the repeated and uncontrolled bladder contractions. (For example, it is not due to a urine infection or an enlarged prostate gland.)

Overactive bladder syndrome is sometimes called an irritable bladder or detrusor instability. (Detrusor is the medical name for the bladder muscle.)

Symptoms include:
Urgency. This means that you get a sudden urgent desire to pass urine. You are not able to put off going to the toilet.
Frequency. This means going to the toilet often - more than seven times a day. In many cases it is a lot more than seven times a day.
Nocturia. This means waking to go to the toilet more than once at night.
Urge incontinence occurs in some cases. This is a leaking of urine before you can get to the toilet when you have a feeling of urgency.

What can you do about it follows: Pelvic floor exercises:http://tnmgc.com/discus/viewtopic.php?f=23&t=572

Perhaps Badri, can convert this leaflet as patient info in the front page, please.

Dr G Mohan.


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PostPosted: 19 Oct 2014 12:55 
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Hi Mohan
When I read your article on over active bladder, my thoughts went back to one of my patients who was suffering from frequency of urine. He was under my treatment for hypertension for some years. He was not a diabetic. While on my treatment, he developed frequency of urine and he first saw a urologist who after initial routine examination of blood and urine, ordered for an ultrasound examination of the lower abdomen. He found his prostate normal and no other abnormalities either. But empirically he gave him tamsulocin 0.4 mg at bed time. Even after two weeks’ treatment he did not get any relief and the urologist this time thought it might be due to some central nervous system problem and hence he was referred to a neurologist. At this stage, he came to me asking for my opinion. While on examination he told me that for some months he had noted some swelling in the scrotum on one side. To my surprise he had a huge indirect inguinal hernia and a hydrocele on the same side. I wrote for an ultrasound examination of scrotum and hernia. The ultra-sonogram revealed that in addition to a simple hydrocele and inguinal hernia he had his bladder herniating to the hernia sac and thereby reducing the volume of the urinary bladder. Now I knew what the cause of his frequency of urine was. With this picture I referred him to my surgical colleague for hernia repair. After this his symptom also disappeared for good. And he was saved from an enormous (physical, mental and financial) burden of a neurological investigations.
This again shows that in our busy practice we don’t conduct a full relevant examination of the patient. Who knows I also would have missed this case unless patient gave me a clue regarding the presence of a swelling in the scrotum. The first radiologist also missed this probably at that time he did not have bladder herniation. So I must say that an element of luck was with the patient. I hope you agree.

UA Mohammed


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PostPosted: 20 Oct 2014 00:11 
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Hi Mohammed,

What a clever physician you are! I hope you have passed on some of your experience and thoughts to the junior doctors.

I totally agree with you that we doctors do not examine a patient thoroughly. Particularly if you are a specialist, you tend to examine only the area pertaining to your speciality. Students must be taught that a quick general examination of a patient must become part of their routine irrespective of what speciality they belong to. Of course you must explain to the patient why you are examining his pulse or BP when he came to you for a joint pain or a ear infection! Most patients will be more than happy that you are so thorough with your examination.

Badri.


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PostPosted: 20 Oct 2014 09:18 
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Thank you Badri
But I still think that if the patient was not forthcoming about his having a swelling in the scrotum I would not have made this diagnosis. It reminds me my teacher Prof K R who used to tell us to listen to the patient carefully he would tell you the diagnosis, much more than the investigations you do. That is why even these days we miss the diagnosis of angina because we solely depend upon the ECG, not what the patient says.

UA Mohammed


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