Overactive bladder is a pattern of sudden, hard to delay urges to urinate, usually with frequent trips by day and at night, with or without leaking. It is diagnosed after ruling out infection, blood in the urine and other causes, and it is very common in older adults.
Key symptoms
- Sudden, strong urge to urinate that is hard to hold
- Urinating more than 8 times a day
- Waking up at night to urinate (nocturia)
- Leaking on the way to the toilet (urge incontinence)
What you find on exam
- Abdominal exam for a distended, palpable bladder
- Pelvic exam in women for prolapse and vaginal atrophy
- Rectal exam in men for prostate size and stool impaction
- Brief neuro exam: leg strength, sensation and reflexes
Tests
- Urinalysis and urine culture to rule out infection and blood
- Post-void residual with a bladder scan
- Bladder diary for 3 days: fluids, voids and leaks
- Urodynamic testing only in complex or unclear cases
Treatment basics
- Bladder training with timed voiding and urge suppression
- Pelvic floor muscle exercises; cut caffeine and alcohol and limit evening fluids
- Beta-3 agonist such as mirabegron or vibegron
- Antimuscarinic such as oxybutynin, used with care in older adults because of confusion risk
- Refractory cases: onabotulinumtoxinA bladder injections or nerve stimulation
Red flags
- Blood in the urine, which needs a full workup
- Large post-void residual or retention, which points to obstruction
- New urinary symptoms with back pain, leg weakness or saddle numbness
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.