patient assessment: overactive bladder

Introduction
Case Study: AB is fifty-eight and has taught 5th grade in the Philadelphia public school system for the past thirty years. She is very distressed. She has lived with urinary urgency and frequency for more than six 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 actually 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, couldn't get them in the lock, and 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.

Patients with overactive bladder (OAB) tend not to tell their health care providers about their symptoms and "episodes" and their health care providers do not ask about urinary control problems, at least as a matter of routine or as part of an overall health assessment. OAB is quite common but only one out of four women (13% to 54%) with symptoms of OAB with urinary incontinence (UI) seeks clinical help.^1,2,3 OAB is both under-diagnosed and under-treated, partly due to the "stigma" attached to bladder control problems and partly due to the rampant misconceptions that exist among patients that inhibit them from seeking care. ⁴ Women are especially hesitant to bring up the subject and prefer that their health care providers initiate a conversation about OAB. Consequently, health care providers need good information about the best methods for assessing patients for OAB and for communicating with their patients about urinary symptoms.

Assessment and Screening
The widespread stigma around patients discussing urinary incontinence places a greater burden on nurses to introduce the topic of bladder control. Nurses understand the best ways to initiate a dialogue with patients, put them at ease, and encourage them to talk about symptoms, related issues and lifestyle changes. They can offer significant help to their patients in overcoming their reluctance to discuss such bladder control problems as OAB. After all, in a recent poll, nurses were named the health care professionals most trusted by the public.
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As part of a routine general health assessment, nurses should include questions about OAB, bladder control and voiding habits. A minimal investment of time is required by the health care provider when they use a screener or questionnaire that is appropriate in most clinical settings.⁵ Most such questionnaires are self-administered and can be completed in the waiting room prior to a medical visit. Office nurses, medical technicians or assistants can be trained to distribute and help patients fill in the questionnaires as part of the intake procedure. Table 1 lists commonly asked questions to help providers determine symptoms of OAB. ⁶

Patient History
A good place to begin any assessment of patients suspected of having OAB is to determine which symptom(s) are most bothersome to the patient. This information will guide the provider in recommending a therapy and measuring the patient's response to it. Focusing on symptoms allows the provider to bypass invasive and costly tests that often must be done by a specialist or by a teriary medical center and that can be stressful for patients.

The patient history should include details about all OAB symptoms including when they began, their duration, specific characteristics and how they have progessed. When questioned, many patients can recount the specific situations that "triggered" their wetting episodes and describe them in detail similar to our case study above.⁷ Triggers can be auditory or visual and some common triggers are running water, seeing a bathroom sign, having hands in water as when washing dishes, stress or anxiety, sudden exposure to cold when exiting from a warm environment and "key in the lock" or "garage door syndrome", all of which can bring about a sudden feeling of urgency with leakage of urine. Other problems may include urinary frequency, lower urinary tract symptoms (LUTS) including post void dribbling, nocturnal enuresis, hesitancy or weak stream and straining while voiding.⁸

As part of the patient history, the intake protocol should include questions about self-care, which ways a patient might hide or accommodate his symptoms and whether the patient has altered her lifestyle in response to bladder control problems.⁷ For example, some patients memorize the locations of available toilets and plan their route or daily activities so they are always near facilities, a practice known as "toilet mapping".

In addition, patients should be asked about any medical problems or illnesses that may precipitate an episode of OAB or transient urinary incontinence (See Table 2.) This should be accompanied by a discussion of any drugs the patient may be taking, both prescription and over the counter varieties (OTC). See Table 3.

Bowel function can also play a role in OAB, especially constipation that causes fecal straining, and should be part of the patient history. Any other associated medical conditions should also be noted; for example, neurologic diseases, BPH, previous pelvic injury or such surgeries as hysterectomy or those for stress UI, and any previous pelvic trauma or radiation therapy. If the patient has already received treatments for OAB, these should be noted along with outcomes.⁹

Physical examination of the patient

A physical exam to investigate OAB symptoms includes four components:

General
Abdominal
Genital
Pelvic in women and rectal in men

General Exam
The clinician should evaluate the patient in a general way for such problems as lower extremity edema that may contribute to increased renal perfusion when the patient is lying down. This alone may explain symptoms of nocturia and nocturnal enuresis.

Abdominal Exam
Palpation of the abdomen can help detect bowel sounds, mases and suprapubic fullness.⁸ Decreased bowel sounds (fewer than three per minute) indicate decreased motility while prolonged gurgling sounds may indicate diarrhea. In elderly patients, abdominal masses may be an indication of hard stool in the colon and possible fecal impaction. It may be possible to palpate the bladder if it distends above symphysis pubis or contains more than 150 ml of urine but there are better methods than palpation for determining an abnormal post-void residual (PVR).⁸

Genital Exam
It is important to make a careful inspection of the skin in the perineal and gluteal areas and assess its integrity since OAB and urinary incontinence may cause dermatitis and a bacteria or fungal rash. Also, urine leakage may cause the clothing to be damp or wet and give off a characteristic odor of urine. These signs and any actual urine leakage from the perineum are important to note.

Constant wetness creates special problems for women. Excoriations and macerations of the vulva may occur and should be noted. At the same time, the vulva should be examined for signs of hypoestrogenism and of urogenital atrophy, especially atrophy of the vulvar skin, agglutination of the labia minora or a urethral caruncle. Vulvar atrophy appears as shrunken areas with dry, pale, inflamed mucosa or with red, petechial and ecchymotic areas that bleed easily.

A genital exam in men is done to evaluate the condition of the external perineal skin and to detect any abnormalities in the glans penis or foreskin. Phimosis can occur in uncircumcised men when the orifice of the foreskin is too narrow to allow retraction of the foreskin over the glans. Palpation of each testis and epididymis is done to rule out masses and the size, shape, consistency, and tenderness of any found should be noted.

Female Pelvic Exam
The pelvic exam is done to determine the presence of pelvic organ prolapse (POP), other vaginal abnormalities, and the condition of the pelvic floor muscle (PFM)⁵.

POP may include:

Urethrocele, the descent of the lower urethra into the vagina
Cystocele, the descent of the anterior vaginal wall and bladder into the vagina
Uterine prolapse when the uterus and cervix descend into the vagina
Vaginal vault prolapse when the walls of the vagina descend and fall out of the vagina
Rectocele, the protrusion of the posterior vaginal wall and rectum into the vagina.⁸

A helpful system for grading prolapse is the "Baden-Walker Halfway" categories:

Grade 0: no prolapse

Grade 1: vaginal segment descends halfway to the hymen

Grade 2: vaginal segment descends to the hymen

Grade 3: vaginal segment descends halfway outside the hymen

Grade 4: pelvic organs protrude completely outside the body without Valsalva (referred to as a procendentia).

The pelvic exam should include a strength assessment 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 Ask the patient to pull her vaginal muscles in and upward in short, fast contractions ("flicks") and in long, sustained contractions. The observer notes which other muscles contract at the same time, specifically the gluteal, abdominal or thigh muscles. There are several rating scales for PFM assessment.^11-15 This author has developed a scale that includes various components of PFM assessment (pressure, duration and alteration in position) and provides documentation for insurance requirements (See Table 4).

Anorectal Exam
The clinician does a rectal exam to assess for rectal sphincter tone and sensation, and to determine the presence of fecal impaction. Begin with visual inspection of the perianal area and note any ulcers, inflammation, rashes, excoriations or lumps. Inspect the anus for external hemorrhoids and fecal staining. Have the patient relax and contract the anal sphincter and "bear down" as if having a bowel movement. This allows assessment of the anus for tone, strength and symmetry of the anal sphincter and identification of any defects in the sphincter mechanism.¹⁰ An evaluation of anal sphincter contraction and tone can also provide an opportunity to assess the PFM, and both men and women can learn PFM exercises during this part of the rectal exam. The distal external sphincter can be felt just inside the anal canal while the puborectalis portion of the levator ani muscle is palpated 2.5 to 4 centimeters past the anal verge.¹⁰

A digital rectal exam (DRE) in men includes palpation of the prostate and notation of its size, consistency (typically "rubbery") and contour.

Neurologic Exam
Four components comprise a focused neurological examination^8,9,10:

Mental Status
Sensory function
Motor function
Reflex Integrity

Observe the patient while rising from a chair and walking into the exam room as a measure of mobility. The way a patient manipulates clothing is a good measure of fine motor skills and manual dexterity. During conversation, the patient's mood, affect, orientation, speech pattern, memory and comprehension can provide clues to his mental status. Stimulation of the anal reflex (S2-5) and bulbocavernosus (S2-4) can be used to evaluate the sacral nerve root reflexes. Relevant dermatomes include L1 (labia majora), L1-2 (labia minora), and S3-5 (perineum and perianal skin).

Patient Bladder diary
An important part of intial screening for OAB is the patient's three day bladder diary. This simple and practical method of daily self-monitoring is the best way to obtain information on voiding behavior.¹⁶ The bladder diary should be examined for voiding patterns including daytime and nighttime patterns, frequency of urination, the association between leakage and urgency or the ingestion of caffeinated beverages, when incontinent episodes occur and their circumstances (during the night, cold temperature or on the way to the bathroom) and the type and amount of liquids ingested previously. In addition, the diary may show that the patient is making trips to the bathroom before feeling the need as a way to head off incontinence episodes ("defensive voiding").

Measurement of the urine volume is helpful in assessing the functional and maximal capacity of the bladder; both daytime and nocturnal urine volumes should be recorded as part of a Frequency Volume Record. It may also be helpful in quantifying urine leakage to have the patient record the type and quantity of absorbent incontinence pads used in a specified period of time.⁸ An actual "pad test" is an accurate way to determine the amount of urine leakage and can provide a more objective result.

Besides being useful for assessment, a bladder diary can be therapeutic for the patient and the act of keeping it can constitute a "behavioral intervention". Unfortunately, patient compliance is often low in spite of its value. Younger patients with families and full time jobs are less likely to take the time to keep a diary but older, retired men and women with more severe symptoms may have more time and motivation to comply.

Urologic Testing
Urinary tract infections are one of the transient causes of OAB and a Dipstick urinalysis is the easiest way to measure nitrites, leukocytes, red blood cells and glucose.⁵ Obtaining a post-void residual urine volume (PVR) is the best way to measure incomplete bladder emptying but is necessary only in patients that have experienced recurrent urinary tract infections (UTIs), have severe POP, prostate nodules or history of BPH, or in those who report difficulty emptying the bladder. A normal residual urine volume is 50-75 cc but in patients older than sixty-five, anything over 200 cc should probably be considered abnormal.

When to refer patients to a specialist for testing
The need for further testing with urodynamics should be related to the severity and duration of the patient's symptoms and the clinical setting. Complex urodynamics tests such as cystoscopy, cystometrogram (CMG), uroflow, urethral pressure profile (UPP), voiding pressures and electromygram can help ensure a correct diagnosis and provide a more accurate functional assessment of the urinary bladder and urethra. The CMG is a test that measures bladder capacity and can assess the stability of the detrusor muscle, instability of which is common in patients with OAB and urge UI. The UPP is used to measure urethral sphincter damage and the uroflow is useful in ruling out bladder outlet obstruction in men.

Patients should be referred to a specialist under the following conditions:

Uncertain diagnosis, especially if unable to develop a successful management plan.
Failure to respond to conservative treatments after a reasonable trial period.
Hematuria when no infection is found.
POP beyond the hymen (Grade 3 or higher).
Abnormal post-void residual volume.
Prostate nodule or enlargement.
Any neurologic condition that may cause neurogenic bladder.

Conclusion
Nurse providers can play an important role in helping patients obtain OAB treatments by learning symptom-based OAB assessment and detection that includes patient history and examination.

References

Herzog AR, Fultz NH, Normolle DP, Brock BM, Diokno AC. Methods used to manage urinary incontinence by older adults in the community. J Am Geriatrics Society. 1998;37(4):339-47.
Kinchen, KS, Burgio, K, Diokno, AC, Fultz, NH, Bump, R, Obenchain, R. Factors associated with women's decisions to seek treatment for urinary incontinence. Journal Women's Health.2003;12(7):687-697.
Roberts, RO, Jacobsen, SJ, Rhodes, T, et al. Urinary incontinence in a community based cohort: prevalence and healthcare-seeking behavior. J Am Geriatrics Society 1998; 46:467-472.
Garcia, JA, Crocker, J, and Wyman, JF. Breaking the cycle of stigmatization. J Wound Ostomy Continence Nurs. 2005;32(1):38-52.
Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Continence Program for Women Research Group. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol Urodyn 1995;14:131-9.
Coyne K, Revick, D, Hunt, T, et al. Psychometric validation of an overactive bladder symptoms and health related quality of life questionnaire: The OAB-q. Qual Life Res. 2002; 11:563-574.
Newman, DK, and Wein, AJ. Overcoming Overactive Bladder. Los Angeles, California: New Harbinger, 2004.
Newman, DK. and Wein, AJ. Managing and Treating Urinary Incontinence. 2nd Edition; Baltimore, Maryland: Health Professions Press, 2008.
Newman DK, and Giovannini D. The overactive bladder: a nursing perspective. Am J Nurs 2002; 102(6):36-45.
Newman, DK. Pelvic Muscle Rehabilitation, Clinical Manual. The Prometheus Group: Dover, NH, 2003.
Bo, K, Finckenhagen, H. Vaginal palpation of pelvic floor muscle strength: inter-test reproducibility and comparison between palpation and vaginal squeeze pressure. Acta Obst Gynecol Scand. 2001; 80:883-887.
Brink, CA, Sampselle, CM, Wells, TJ, Diokno, AC, Gillis, GL. A digital test for pelvic muscle strength in older women with urinary incontinence. Nursing Research, 1989; 38(4), July/August: 196-199.
Brink, CA, Wells, J, Sampselle, CM, et al. Digital test for pelvic muscle strength in women with urinary incontinence Nursing Research 1994; 43:352-356.
Laycock J and Jerwood D. 2001.(?????) Pelvic floor assessment; the PERFECT scheme. Physiotherapy. 2001; 12: 631-642.
Worth, AM., Doughery, MC, McKey, PL. Development and testing of the circumvaginal muscles rating scale. Nursing Research. 1986; 35(3):166-168.
Sampselle, CM. Teaching women to use a voiding diary. Am J Nurs. 2003;103:62-64.

Table 1: Symptom assessment chart⁹

Do you frequently have strong, sudden urges to urinate?
Do you urinate more than 8 times in a 24-hour period?
Do you have uncontrollable urges to urinate that sometimes result in wetting accidents?
Do you leak urine on the way to the bathroom?
Do you frequently get up two or more times during the night to go to the bathroom?
Do you avoid places you think won't have a nearby restroom?
Do you go to the bathroom so often that it interferes with your activities?
Do you frequently limit your fluid intake when you're away from home so that you don't need to worry about finding a restroom?
When you're in an unfamiliar place, do you make sure you know where the restroom is?
Do you use absorbent pads to keep from wetting your clothes?

From Newman DK, Giovannini D. The overactive bladder: a nursing perspective. Am J Nurs 2002;102(6):36-45.

Table 2: Medical conditions that may be involved in transient OAB with UI

General	Metabolic conditions
UTI Dehydration (concentrated urine can irritate the bladder) Delirium / mental confusion Depression Fecal impaction Urinary retention Caffeine; alcohol, smoking Obesity	Hyperglycemia Congestive heart failure Parkinson's disease Neurologic conditions (e.g., multiple sclerosis, stroke) Venous insufficiency with edema Hypercalcemia

Newman, 2005; Voytas, 2002

Table 3 Medications that Affect Bladder Function

Medication

Effect

ACEI (Captopril, Lisinopril,
Enalapril)
Increased cough leading to stress UI

Alpha-adrenergic agonists Increase urethral resistance causing post-void dribbling, straining, hesitancy in urione flow

Alpha-receptor agonists (pseudoephreine, ephedrine) Urethral constriction, urinary retention (male)

Alpha-receptor antagonists (prazosin, terazosin, doxazocin) Urethral relaxation and decreases urethral resistance causing stress UI (females) with UI with cough, sneeze, or other activity

Anticholinergics (H1 antihistamines, antiparkinsonian agents) Urinary retention with symptoms of post-void dribbling, straining, hesitancy in urine flow, overflow incontinence, fecal impaction

Antidepressants, tricyclic Anticholinergic effect, alpha-receptor antagonist effect causing post-void dribbling, straining, hesitancy in urine flow

Antipsychotics, sedatives Act as sedative causing confusion, may relax destrusor muscle leading to urinary retention

Beta-receptor antagonists (propranolol, Metoprolol, Atenolol) Urinary retention

Calcium channel blockers (Verapamil, dilitiazem, nifedipine) Urinary retention, fecal impaction

Diuretics Increases urine production (plolyuroia) and volume leading to urgency and frequency

Methylxanthines (caffeine, Theophylline) Polyuria, bladder irritation

Neuroleptics (thioridazine, chlorpromazine) Anticholinergic effect, sedation

Other (caffeine and alcohol) Other (caffeine and alcohol) Act as diuretic leading to urgency and frequency, induces sedation

Opiods Urinary retention, fecal impaction, sedation, delirium

Sedative-hypnotics Sedation effect may relax detrusor muscle

Table 4 Clinical Scale for Grading Digital Evaluation of Muscle Strength

CHECK ONE		VAGINAL EXAM ϖ RECTAL EXAM ϖ
Scale	Grade	Description
None	0	No duration (number of seconds) of muscle contraction, pressure or strength, displacement
Trace	1/5	Slight but instant contraction: < 1 second
Weak	2/5	Weak contraction: with or without posterior elevation of fingers, held for > 1 second but < 3 seconds
Moderate	3/5	Moderate contraction: with or without posterior elevation of fingers, held for at least 4-6 seconds, repeated 3 times
Good	4/5	Strong contraction: with posterior elevation of fingers, held for at least 7-9 seconds, repeated 4-5 times
Strong	5/5	Unmistakably strong contraction with posterior elevation of fingers, held for at least 10 seconds, repeated 4-5 times

Usage of Accessory Muscle Groups

Abdominal	ϖ Yes	ϖ No
Gluteal	ϖ Yes	ϖ No
Thigh/Abdutor	ϖ Yes	ϖ No

Evaluation - Muscle Hypertonus/Spasm (Palpate the levators at the 4 and 8 o'clock position to determine if that reproduces any pain, discomfort or tenderness)

Circle One:	0	No pressure or pain associated with exam
	1	Comfortable pressure associated with exam
	2	Uncomfortable pressure associated with exam
	3	Moderate pain associated with exam, intensifies with contraction
	4	Severe pain associated with exam, unable to perform muscle contraction due to pain

[Adapted with permission from Newman, DK. & Wein, AJ (2008) Managing and Treating Urinary Incontinence, 2nd Edition; Baltimore: Health Professions Press]

Posted June 2008