Title: Assessment of the Patient With an Overactive Bladder
Abstract: AB is 58 years old and has taught fifth grade in the Philadelphia public school system for the past 30 years. She is distressed. She has lived with urinary urgency and frequency for more than 6 years, but it has been getting worse since her doctor prescribed a diuretic for her high blood pressure. Lately, the urge is so strong she feels she won't make it to the toilet unless she runs. When teaching, she is unable to leave her classroom and frequently doesn't have enough time between classes to go to the bathroom. The other day, AB had a “urinary accident.” Driving home from school, she got a strong urge. She parked the car in the garage, grabbed her shopping bags, and rushed to the door. She fumbled with her keys and couldn't get them in the lock; the urge was so strong that she completely “lost it.” AB wet through her pants. She was so glad she was home and not at school. She has started wearing an ultra thick pad in her underwear as a safeguard against unexpected episodes. During her last routine visit with her doctor, she was asked about her blood pressure but not about possible bladder problems, and she didn't bring up the subject. The above case study is a typical scenario of a woman suffering from overactive bladder (OAB). Patients tend not to report symptoms, and healthcare providers do not routinely ask patients about bladder control problems as part of an overall health assessment. Despite the high prevalence of OAB, it is consistently underdiagnosed and undertreated, because only 1 out of 4 women (13% to 54%) with symptoms of OAB with urinary incontinence (UI) seeks clinical help.1–3 A contributing factor is the “stigma” surrounding bladder control problems and the fact that patients have many misconceptions about these conditions, thus preventing them from seeking care.4 Patients, particularly women, would prefer that healthcare providers initiate the topic of OAB; therefore, there is a need for improved understanding of the assessment of OAB and increased patient-provider communication about this condition. Individualized Assessment and Screening Because of the widespread taboo of OAB, it is important that nurses take every opportunity to raise the subject of bladder control with their patients. Nurses were recently named the number one healthcare professional trusted by the public. They are experts at initiating a dialogue with patients, putting them at ease, and encouraging discussion of symptoms, related issues, and lifestyle changes. Nurses can assist patients in overcoming their reluctance to discuss a bladder control problem, such as OAB. Questions about OAB, bladder control, and voiding habits should be part of an overall assessment of the patient's general health; a “screener” or “questionnaire” can be used in most clinical settings and requires minimal time.5 Questionnaires or screeners can be self-administered and completed before scheduled medical visits, in a waiting room or while waiting for a healthcare provider in an examination room. Based on their credentials and positions, most clinical staff (ie, office nurse, medical technician, or assistant) can be trained in distributing and completing these questionnaires. The OAB-q shown in Figure 1 is an OAB-specific screener that can also be used by healthcare providers in detecting symptoms of OAB.6FIGURE 1: OAB-q.History When evaluating the patient with OAB, determining the most bothersome symptom(s) to the patient may be especially important in guiding therapy and determining a response. A symptoms-based approach to OAB bypasses the need for invasive and expensive investigations that require referral to a specialist or tertiary medical center—healthcare settings that many patients, particularly older individuals, find distressing. The history should determine the onset, duration, characteristics, and progression of the OAB symptoms. Many patients will report situational antecedents or “triggers” similar to those described in the case study.7 Common triggers or activities that may bring on sudden urgency and urine leakage include hearing running water, seeing a bathroom sign, washing dishes or clothes, anxiety or stressful situations, exposure to cold (eg, leaving a warm house to go out into the cold), and “key in the lock” or “garage-door syndrome.” In addition to urgency symptoms, frequency and UI lower urinary tract symptoms (LUTS) may be present that include postvoid dribbling, nocturnal enuresis, straining to void, and hesitancy and weak stream.8 Most patients will continue to alter their lifestyle and develop elaborate self-care practices to hide or accommodate their symptoms, and these should be explored when taking their history.7 A common practice reported is “toilet mapping,” which is when the person will habitually look for toilet locations and plan daily activities, such as traveling and shopping, based on knowing where toilets can be easily reached. The history should include a review of medical problems and/or illnesses, because these can precipitate an onset of OAB and transient UI (Table 1). A current drug review is performed and includes a review of over-the-counter medications (OTC) (Table 2).TABLE 1: Medical Conditions That May Be Involved in Transient Overactive Bladder With Urinary IncontinenceTABLE 2: Medications That Can Affect Bladder FunctionThe history should include a review of bowel function, specifically the occurrence of constipation, fecal staining, and fecal incontinence. The history should note any associated medical conditions (eg, neurologic disease or benign prostatic hyperplasia [BPH]), previous pelvic injury or surgery (eg, hysterectomy or surgery for stress UI), and previous pelvic radiation therapy or trauma. Finally, the history should include previous treatment or management of OAB symptoms, including outcomes.9 Physical Examination All patients identified as having bothersome OAB symptoms should undergo a limited physical examination to include general, abdominal, genital, pelvic in women, and rectal. General The first part of the physical examination is a general examination to detect conditions, such as lower extremity edema, that may contribute to increased renal perfusion while recumbent, causing nocturia and nocturnal enuresis. Abdomen An abdominal examination is performed to detect the presence of bowel sounds, masses, and suprapubic bladder fullness.8 Sluggish bowel sounds, 3 or fewer/minute, indicate decreased motility, whereas prolonged gurgling sounds may result from increased motility seen with diarrhea. In the elderly patient, masses may result from hard stool in the colon, indicating possible fecal impaction. A distended bladder may rise above the symphysis pubis, and it may be possible to palpate or percuss the bladder if it contains 150 mL or more of urine. Palpation, however, is not the most accurate method for determining an abnormal postvoid residual (PVR).8 Genitalia Assessment and inspection of the external perineal skin and gluteal area is important, because OAB with UI can cause redness (dermatitis) and rash (bacterial or fungal). Be alert to the signs of urine leakage by noting wet clothing or the odor of urine on the patient or urine leakage on the perineum. In women, excoriations and maceration of the vulva may occur with constant wetness or may be secondary to infection. Observe the vulva for signs of hypoestrogenism or urogenital atrophy, such as atrophy of the vulvar skin and labia minora, or a urethral carbuncle. In women with atrophy, the vulvar and urethral area appears atrophic and the vaginal mucosa looks dry, pale, and inflamed; may be red, petechial, or ecchymotic; and may easily bleed. In men, a genital examination is performed to evaluate external perineal skin condition, to detect abnormalities of the foreskin and glans penis. In uncircumcised men, a condition called phimosis can be present if the orifice of the foreskin is constricted, preventing retraction of the foreskin over the glans. Each testis and epididymis should be palpated to determine the presence of an abnormal mass, while noting the size, shape, consistency, and tenderness. Pelvic Examination in Women In women, a comprehensive pelvic examination to determine the presence of pelvic organ prolapse (POP), vaginal abnormalities, and pelvic floor muscle (PFM) assessment is indicated.5 The descriptions of the various terminology for POP include: urethrocele—descent of the lower part of the urethra into the vagina, cystocele—descent of the anterior vaginal wall and the bladder behind it, uterine prolapse—descent of the uterus and cervix into the vagina, vaginal vault prolapse—the walls of the vagina fall out of the vagina, and rectocele—protrusion of the posterior vaginal wall and the rectum behind it.8 Most clinicians use the Baden-Walker Halfway system to grade the prolapse: Grade 0: no prolapse, Grade 1: vaginal segment descends halfway to the hymen, Grade 2: descent to the hymen, Grade 3: descent halfway outside the hymen, and Grade 4: maximum possible descent (when the pelvic organs protrude completely outside the body without Valsalva, referred to as a procendentia). The examination should determine the strength of the PFM, specifically the muscular attachments along the pubic arch and the insertion of the levator ani (just superior to the hymeneal ring) and coccygeus muscles.8,10 The patient is asked to tighten or pull in and upward with her vaginal muscles in short fast contractions called “flicks” and in long sustained contractions. The examiner notes through observation whether accessory muscles (such as gluteal, abdominal, and thigh) also contract. To measure the strength of the PFM, several experts have developed rating scales for PFM assessment.11–15 The author has developed a scale that is useful in practice because it notes various components of the PFM assessment (pressure, duration, and alteration in position) and provides documentation for insurance requirements (Figure 2).FIGURE 2: Clinical scale for grading digital evaluation of muscle strength. Adapted with permission from Newman DK. Managing and Treating Urinary Incontinence. Baltimore: Health Professions Press; 2002.Anorectal A rectal examination is performed to assess for fecal impaction, rectal sphincter tone, and sensation. Inspect the perianal areas for lumps, ulcers, inflammation, rashes, or excoriation and the anus, noting any fecal staining and external hemorrhoids. Assess the overall, tone, strength, and symmetry of the anal sphincter, and identify defects in the sphincter mechanism by having the patient relax and contract the anal sphincter and “bear down” as if having a bowel movement.10 Assessment of the PFM can be performed by evaluating the anal sphincter contraction and tone; men and women can also be taught PFM exercises during the rectal examination. In the rectum, the distal external sphincter is felt just inside the anal canal. The puborectalis portion of the levator ani muscle can be palpated approximately 2.5 to 4 cm from the anal verge.10 In men, a digital rectal examination (DRE) should include an assessment of the size, consistency (usually “rubbery” in nature), and contour of the prostate. Neurologic A focused neurologic examination is divided into 4 parts: (1) mental status, (2) sensory function, (3) motor function, and (4) reflex integrity.8–10 The patient should be observed rising from a chair and walking into the examination room to determine mobility. Watching the patient manipulate clothing can assess fine motor skills and manual dexterity. Mental status should include assessment of mood, affect, orientation, speech pattern, memory, and comprehension. Test specific dermatomes for position, vibration, pinprick, light touch, and temperature. Relevant dermatomes include L1 (labia majora), L1-2 (labia minora), and S3–5 (perineum and perianal skin). Tests used to evaluate the sacral nerve root reflexes include stimulation of the anal reflex (S2–5) and bulbocavernosus (S2–4). Bladder Diary A 3-day bladder diary or log is an important part of the initial screening for OAB, because daily self-monitoring is a simple and practical method of obtaining information on voiding behavior.16 When reviewing the diary, the healthcare provider should attempt to determine voiding patterns during the day, during the night, frequency of urination, if urine leakage is associated with urgency or after the ingestion of a bladder irritant (such as caffeinated beverages), incontinent episodes, the events surrounding these episodes (on the way to the bathroom, during the night, and cold temperature trigger), and amount and type of liquid intake. The healthcare provider should determine if the patient is practicing “defensive voiding,” such as voiding before the onset of urgency to avoid an incontinent episode. The volume of voided urine can determine functional and maximal bladder capacity, and daily and nocturnal urine volumes and can be obtained using a frequency volume record. Many providers are interested in the patient noting the type and quantity of absorbent incontinence pads used and to quantify amount of urine leakage.8 An objective and accurate way to determine the amount of urine leakage is by performing a “pad test.” The act of keeping a diary can be therapeutic and a type of “behavioral intervention.” However, despite the value of this monitoring tool, patient compliance can be low. Young working women have busy lives and are less likely to comply; older retired men and women may have more severe OAB symptoms and have time to monitor their problem. Urologic Testing One of the transient causes of OAB is a UTI, so a dipstick urinalysis is necessary to determine the presence of nitrites, leukocytes, red blood cells, and glucose.5 Determining the presence of incomplete bladder emptying by obtaining a postvoid residual urine volume (PVR) is not necessary on all patients, except those with recurrent urinary tract infections, report difficulty emptying the bladder, severe POP, prostate nodules, and/or history of BPH. Normal range of residual urine is 50–75 mL. In patients 65 years or older, a PVR >200 mL is most likely abnormal. Indications for Specialized Testing and Referral to a Specialist The decision to perform urodynamics depends on the patient's presenting symptoms, severity of the OAB, length of time the patient has been experiencing the problem, and the clinical setting. Complex urodynamics are used to ensure the correct diagnosis and to determine the anatomic and functional status of the urinary bladder and urethra. These tests include cystoscopy, cystometrogram (CMG), uroflow, urethral pressure profile (UPP), voiding pressures, and electromyogram. A CMG determines bladder capacity and the presence of detrusor instability, which may be seen in patients with OAB and urge UI. To determine urethral sphincter damage, a UPP may be performed. In men, a uroflow is helpful to rule out bladder outlet obstruction. Referral to a specialist should be made on the basis of these criteria: uncertain diagnosis and inability to develop a reasonable management plan, failure to respond to an adequate trial of conservative treatments, hematuria without infection, severe (beyond the hymen) POP, abnormal PVR, prostate nodule/enlargement, and/or neurologic condition in which a component of neurogenic bladder is suspected. Conclusion Nurse healthcare providers need to be knowledgeable about assessment of OAB so that they can advise patients on treatment options. The first step is the detection of OAB through a symptom-based approach, followed by a history and examination.
Publication Year: 2005
Publication Date: 2005-05-01
Language: en
Type: article
Indexed In: ['crossref']
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Cited By Count: 3
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