Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians Overview: Overactive bladder (OAB) is a symptom-based syndrome characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of UTI or other overt pathology (ICS, 2002). It affects approximately 30% of adults over 40 and becomes increasingly prevalent with age (Hsu et al., 2019). Etiology and Pathophysiology While detrusor overactivity is the urodynamic correlate in many cases, OAB can also occur due to: Neurological disorders (e.g., MS, Parkinson’s) Impaired bladder compliance Pelvic floor dysfunction (hypertonic or hypotonic) Psychological factors (e.g., anxiety, trauma history) Iatrogenic causes (e.g., medications, radiation) Notably, Fontaine et al. (2021) emphasized that detrusor overactivity is not present in all OAB cases, necessitating a broader diagnostic lens. Initial Management: First-Line Conservative Interventions According to current guidelines and high-quality randomized trials, behavioral and physiotherapeutic interventions are the cornerstone of initial management. 1. Bladder Retraining: Evidence supports scheduled voiding with progressive delay intervals, combined with urge suppression strategies (Scaldazza et al., 2017). Techniques include reverse Kegels, diaphragmatic breathing, sensory distraction, and pelvic floor relaxation. 2. Pelvic Floor Physiotherapy: Pelvic health physiotherapists assess and rehabilitate both hypertonic and hypotonic pelvic floors. Contrary to popular assumptions, many OAB patients present with tight pelvic floor musculature that exacerbates urgency/frequency symptoms. 3. Lifestyle Modifications: Elimination of bladder irritants (e.g., caffeine, alcohol, acidic foods) Managing constipation Fluid management and pre-bedtime voiding Supine leg elevation in patients with peripheral edema These non-invasive measures have high patient adherence and low adverse event profiles, making them ideal first-line strategies, particularly in older adults or those with polypharmacy concerns. Pharmacological Interventions If conservative measures prove insufficient, consider the following pharmacologic options: Anticholinergics (e.g., oxybutynin, solifenacin): Effective but associated with dry mouth, constipation, and cognitive risk, especially in the elderly (Welk & McArthur, 2020). β3-Adrenergic Agonists (e.g., mirabegron): Similar efficacy with improved CNS safety profile; preferred in patients at risk for anticholinergic burden (Yamaguchi et al., 2014). Medication adherence is often suboptimal due to side effects, with >50% discontinuing within 6 months (Benner et al., 2010). Combination therapy with behavioral interventions improves outcomes. Advanced Options for Refractory Cases If pharmacological and behavioral therapies fail: Percutaneous Tibial Nerve Stimulation (PTNS): Effective for OAB symptom reduction with a favorable safety profile (Keller et al., 2017). Botulinum Toxin A Injections: FDA-approved for refractory OAB but requires intermittent self-catheterization in some patients. Sacral Neuromodulation: Considered in severe cases with mixed incontinence or when other modalities fail. Referral Recommendations Refer patients for pelvic floor physiotherapy when: Symptoms persist despite lifestyle changes Pelvic floor dysfunction is suspected (e.g., concomitant pelvic pain, constipation) Pharmacologic therapy is contraindicated or declined Patients prefer non-invasive, functional approaches Conclusion for Clinical Practice OAB is a multifactorial condition with a significant impact on quality of life. Evidence-based management emphasizes a stepwise approach beginning with behavioral therapy and physiotherapy, progressing to pharmacological and neuromodulation therapies as needed. Collaborative care involving physiotherapists, urologists, and family physicians ensures optimal outcomes. Key References Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034 Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4 Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387 Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719 Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040 Yamaguchi, O., Marui, E., Kakizaki, H., Homma, Y., Igawa, Y., Takeda, M., & Ohkawa, S. (2014). Mirabegron 50 mg for OAB in Japanese patients: A phase III trial. BJU International, 113(6), 951–960. https://doi.org/10.1111/bju.12649
Understanding Overactive Bladder (OAB): A Guide to Regaining Control
As a pelvic health physiotherapist, I often meet patients who quietly suffer from sudden urges to urinate, frequent trips to the bathroom, or unexpected leakage. These symptoms may be signs of a condition called Overactive Bladder (OAB)—and the good news is, it’s treatable. What is Overactive Bladder? OAB is a condition where the bladder muscle (called the detrusor) contracts involuntarily, causing a sudden and powerful urge to urinate—even when the bladder isn’t full. People with OAB may: Feel urgent, frequent urges to urinate (8+ times per day) Leak urine before getting to the bathroom (urge incontinence) Wake up multiple times at night to urinate (nocturia) You are not alone—studies show that nearly 30% of adults over age 40 experience some form of OAB (Hsu et al., 2019). Why Does It Happen? There’s no single cause for OAB. Common contributors include: Age-related changes in bladder or nervous system Neurological conditions (e.g., stroke, multiple sclerosis) Tight or weak pelvic floor muscles Stress or anxiety Medications or bladder irritants (like caffeine or alcohol) Sometimes, the bladder muscle becomes overly sensitive or “trained” to signal urgency too often, even if it’s not truly full. Common Coping Strategies That Backfire Some people try to manage symptoms by: Toilet mapping (always knowing where the nearest washroom is) Fluid restriction “Just in case” urination These seem logical but can actually worsen symptoms by training the bladder to hold less and become more sensitive over time. What Actually Helps? 1. Bladder Retraining (with Physiotherapy Support) This is a proven method that helps you gradually increase the time between bathroom visits using: Scheduled voiding (e.g., every 90 minutes instead of every hour) Urge suppression techniques, like: Deep breathing Mental distraction Reverse Kegels (relaxing pelvic floor muscles) In a randomized controlled trial, behavioral therapies (like bladder training) improved urgency and leakage with minimal side effects, often matching or exceeding medication benefits (Scaldazza et al., 2017). 2. Pelvic Floor Physiotherapy As a physiotherapist, I assess whether your pelvic floor is: Too weak (needs strengthening) Too tight (needs relaxation) Both can contribute to OAB. A personalized program, often including biofeedback and exercises, can make a big difference. 3. Lifestyle Changes Hydrate smartly: Sip fluids throughout the day but reduce intake 2–3 hours before bedtime. Avoid bladder irritants: Caffeine, alcohol, spicy foods, and artificial sweeteners. Manage constipation and stress: Both can increase pressure on the bladder. 4. Medical Options (When Needed) When lifestyle changes aren’t enough, your doctor might recommend: Anticholinergic medications (e.g., oxybutynin) Beta-3 agonists like mirabegron—shown to have fewer cognitive side effects in older adults (Welk & McArthur, 2020). If medications don’t help, advanced options like tibial nerve stimulation or Botox injections into the bladder wall may be considered (Keller et al., 2017). Takeaway OAB is not a normal part of aging. It’s a treatable condition that responds well to physiotherapy, behavior change, and, if needed, medication. If you’re constantly searching for bathrooms, waking up at night, or feeling anxious about leaking—know that you can take control again. A pelvic health physiotherapist can be your first step toward regaining confidence and comfort. References Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034 Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4 Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387 Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719 Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040