What is an Overactive Bladder?

When urinary urgency happens even without the presence of urinary incontinent, the condition is called overactive bladder. This usually happens frequently or at night (Nocturia). Overactive bladder is more appropriately described as symptom syndrome, it is usually a symptom of an underlying condition rather that a separate disease itself. And it is a syndrome, in a sense that the condition is a combination of different symptoms.

Overactive Bladder: Who are the ones most affected?

This is a common condition that affects over 17% of women and men older than 40 years old.

Overactive Bladder Signs and Symptoms

You might have an overactive bladder if you experience the following symptoms:

Urinary urgency

This is a cardinal symptom of overactive bladder. Urinary urgency is defined as the sudden, strong urge to urinate that is hard to defer.

Urinary frequency

This is another symptom of overactive bladder. Urinary frequency is defined as urination of more than eight times a day.

Nocturia

Nocturia is defined as urination at night, prompting the individual to wake up more than once just to urinate.

Urge Incontinence

1. This is the involuntary passage of urine (for no external reason) while having the feeling or urge to urinate.
2. Overactive Bladder and its Impacts
3. One’s quality of life is most affected by this condition; daily living and the different domains in life are significantly affected by an overactive bladder. These includes the following impacts

Self-esteem

This is the first domain usually affected by an overactive bladder. People with this condition become shy, feel guilty and fearful. They often perceive themselves as a burden to their friends and family. For this they may prevent themselves from social gatherings and interactions.

Socialization

The social aspect of a person with an overactive bladder is also greatly affected. Patients fear of losing control during social gatherings, and also of the odor of the urine when involuntary passage happens. Travel plans become limited only to area with nearby bathrroms.

Physical activity

Having this condition can limit one’s physical activity. Individuals may not be able to perform certain tasks or complete them because of the condition

Sexual function

Intimate relationships can also be affected by an overactive bladder. Patients with overactive bladder avoid sexual contact and intimate activities due to the fear of passing out and the odor of the urine.

Overactive Bladder Causes

The exact mechanism why overactive bladder happens remains to be elusive from experts and medical science. However, several theories have been proposed on the causes of an overactive bladder. These theories are the following:

The Myogenic Theory

The myogenic theory proposes that an overactive bladder happens as a result of partial loss of nerves in the bladder. This may be due to the following:

1. Outlet obstruction in the bladder
2. Increased pressure within the urinary bladder

This then leads to the alteration of the smooth muscles in the bladder, causing them to be more excitable. The increase in the bladder’s smooth muscle excitability causes micromotions of the detrusor muscle, this increase bladder pressure pushing urine out of the body.

Suprapontine Inhibition

The suprapontine area is proposed to exert an action on the voluntary control of urination. MRI studies done on the suprapontine area indicate it has a participation in the control of urination, and individuals with damages on this area are seen to have voiding problems.

Acetylcholine from Urothelium

More recently, urothelium is discovered to be a factor in the development of an overactive bladder. The urothelium is a layer of epithelial tissue in the bladder and it may release greater amounts of acetylcholine. The increase in acetylcholine then triggers the activity of the brain and spinal cord, thereby giving the feeling of urinary urgency.

Other theorized causes of overactive bladder include:

1. Damaged spinal cord and axonal pathways
2. Loss of inhibition in the peripheries
3. Increased afferent input in the lower urinary tract
4. Cerebrovascular accident (stroke)
5. Spinal Cord Injury (SCI)
6. Multiple Sclerosis
7. Neuropathies (diabetic neuropathy most commonly)
8. Lesions in the brain especially on the suprapontine areas

Overactive Bladder Treatment

Overactive bladder therapy is treated with multiple approaches, but the first line treatment includes pharmacologic and behavioral therapy.

Pharmacologic Approach

Antimuscarinic agents

Pharmacologic therapy still remains to be the mainstay treatment of overactive bladder. The actions of antimuscarinic agents are:

1. Inhibits acetylcholine from binding to the muscarinic receptors in the bladder preventing the reaction of bladder emptying (which leads to urination and a better bladder capacity.
2. Inhibit sensory signals in the urothelium, decreasing signals to the brain and causing the brain to inhibit the voiding.

Five receptors are found all over the body, two of them are situated in the bladder, M2 and M3.

Currently and FDA approved antimuscarinic agents are as follows:

1. Ditropan (oxybutin extended release)
2. Detrol ( tolterodine tartate extended release)
3. Oxytrol (transdermal oxybutin)
4. Sanctura IR (trospium chloride immediate release)
5. Vesicare (Solifenacin)
6. Enablex (Daifenacin)
7. Toviaz (fesoterodine)
8. Gelnique (oxybutin chloride gel 10%)

Behavioral therapy

This is also employed but is seen most effective when done in conjunction with pharmacologic therapies. Behavioral therapy includes:

1. Education on normal urination habits and normal bladder function
2. Setting intervals even if the urge to urinate is not present
3. Avoidance of caffeine, acidic and spicy foods which may exacerbate the symptoms
4. Ample fluid intake- not too much or too little so the bladder would not be irritated

Overactive Bladder in Children

Overactive bladder can also occur in children but it is more physiologic than pathologic. For most cases, children are able to overcome an overactive bladder, certain studies have shown that almost 15% of the condition ceases after the age of 5.

Cause in Children

Among children, this can be a condition resulting from the immaturity of the nervous system. A child’s body still needs time to adjust or respond to the signals that regulate its function, and that includes urination.

Treatment  in Children

When the child is unable to overcome the condition, medications and bladder training usually follows. Other techniques to manage this may also include the following:

1. Caffeine free diet
2. Scheduling the time of urination even without the urge to do so
3. Learning how to relax the muscles during urination
4. Teaching the child to how to urinate properly, nut rushing and taking time to urinate

Overactive Bladder in men

Men are also equally affected by this condition. This usually happens to men above the age of 40. Overactive bladder can have a myriad of causes that are only particular to men. These may include:

1. Diverticulitis in the Bladder
2. Stones in the Bladder
3. Urinary Tract Infection

Treatment in Men

Overactive bladder can also be treated with a combination of medications and behavioral therapy.

Recent studies suggest that pelvic floor exercises can also be beneficial to men. pelvic floor exercises strengthens the muscles in the pelvis allowing the individual to gain more control on voiding. Pelvic floor exercises are usually done by females but recent studies reveal it is also beneficial to males as well.

Overactive Bladder Complications

Complications of overactive bladder include:

Ascending Urinary tract infections

This can result from prolonged exposure from the leaked urine. Ascending urinary tract infections usually begin in the lower parts of the urinary tract (possibly the urethra) and works its way up to the bladder and the ureters.

Skin Infections

This results from the exposure of the skin to the urine. Rashes in the perineal and anal area may cause significant discomfort to the individual.

Dehydration

This is possibly due to the frequent loss of fluids through urination

Depression

Individuals with overactive bladder may experience intense psychological problems, and this may lead to depression. Depression is usually rooted to the fact that the condition limits their physical and social capacities.

1. Disturbance in the sleep cycle
2. Fatigue
3. Insomnia

Extrapyramidal Definition

Extrapyramidal is a term that describes the neural network, which is a part of the motor system that is outside the pyramidal tracts in the medulla. Extra means outside, thereby extrapyramidal system arises outside the pyramids of the medulla.

Extrapyramidal System and Tract

The extrapyramidal system is responsible for

• The involuntary movements and reflexes of the motor system.
• The modulation of movements.
• Regulates and modulates the anterior horn cells of the spinal cord, thereby limiting the involuntary motor movements

The extrapyramidal system lies outside the motor cortex that passes through the corticobulbar and corticospinal tracts. The pyramidal system is responsible for the direct innervations of the motor neurons while the extrapyramidal system is only responsible for the regulation.

The extrapyramidal tract is mainly located on the reticular formation of the medulla and pons. It is also found in the spinal cord areas, which are responsible for locomotion, reflexes, postural control and complex movements. The extrapyramidal tracts are in turn regulated by the basal ganglia, nigrostriatal pathway, vestibular nuclei, sensory areas of the cerebral cortex and the cerebellum. These areas and regulatory sections are all parts of the extrapyramidal system. The extrapyramidal system regulates the motor activity even with the absence of direct innervations with the motor neurons.

Extrapyramidal Disorder Symptoms and Signs

The extrapyramidal symptoms are a collection of side-effects that commonly occur with certain use of medications. These medications affect the extrapyramidal system leading to extrapyramidal side-effects or extra pyramidal symptoms. Since the extrapyramidal system is responsible for regulating the motor activity of neurons, the affectation of which leads to lack of regulation thereby causing movement disorders. These symptoms include:

• Akathisia. Akathisia is a condition of motor restlessness. Akathisia may involve urge to move constantly, inability to sit still, or feeling of shakiness or jitterness. The restless movements usually lead to exhaustion and may predispose to suicide because the patient may not be able to bear the severe akathisia.
• Acute Dystonic Reaction. Acute dystonic reaction involves muscular spasm of the neck known as torticollis. The patient experiences severe pain on the neck when trying to move it. The eyes may also be affected leading to oculogyric crisis. There is also spasm in the jaw and tongue. This happens because of lack of modulation of muscle contraction leading to over contraction and muscle spasms. Dystonia may be severely painful. Spasms of the tongue and jaw may also lead to drooling.
• Pseudoparkinsonism. Pseudoparkinsonism is a false Parkinsonism disorder caused by the intake of drugs. The true Parkinson’s disease involves the problems in the nigrostrial pathway. However, because of dopamine deficiency, there is dysregulation of the extrapyramidal system. The extrapyramidal system is responsible for skeletal muscle tone and posture. Affectation of which may result in bradykinesia or slow movements, lead-pipe rigidity, postural instability, mask like face, shuffling gait and resting tremor that are similar to true Parkinson’s disease.
• Tardive Dyskinesia. Tardive dyskinesia is asymmetrical and involuntary movement of muscles. Tardive dyskinesia is a chronic, irreversible condition and usually occurs after the long-term use of certain antipsychotic medications. Tardive dyskinesia may include lip smacking, fly-catching movement of the tongue, eye blinking, finger movements and arm and leg movements. Tardive dyskinesia is usually recognizable.

The Barnes Akathisia Rating Scale as well as the Simpson-Angus Scale measures the severity of the extrapyramidal symptoms.

Extrapyramidal Disorder Causes

The most common cause of extrapyramidal symptoms includes medication use such as:

• Antipsychotics – Antipsychotic medications such as haloperidol, thioridazine, and chlorpromazine are medications used to treat psychoses or schizophrenia. Antipsychotics are also used to manage symptoms of Alzheimer’s disease. The use of antipsychotics reduces the level of dopamine in the brain leading to extrapyramidal side-effects. Typical antipsychotics most commonly cause EPS than atypical antipsychotics.
• Antidopaminergic anti-emetics – This medication reduces the functioning of the dopaminergic neurons. An example of which is metoclopramide.
• Tricyclic antidepressants – Amoxapine, a tricyclic antidepressant drug also causes extrapyramidal symptoms.

Other causes of EPS may include cerebral palsy and brain damage that affects the extrapyramidal system. Extrapyramidal symptoms usually occur after the intake of the above medications in a few hours or even up to years of treatment.

Extrapyramidal Disorder Treatment

Treatment of extrapyramidal symptoms includes those that relieve the symptoms as well as reversing the effects of medications that cause the disorder. Treatments include:

Medications

Medications are the primary treatment of extrapyramidal symptoms. These include:

• Anticholinergic medications – Anticholinergic drugs are given to patients to reduce extrapyramidal symptoms, specifically pseudoparkinsonism and dystonia. Acetylcholine is responsible for muscle contraction; thereby inhibiting its binding to its receptor sites reduces muscle spasms and twitching. Anticholinergic medications may include benztropine or Cogentin.
• Dopaminergics – Dopaminergics are medications that increase the binding of dopamine to its receptor sites, thereby reversing the effects of decreased dopaminergic activity. These medications include diphenhydramine, or trihexophenidyl.
• Beta blockers – Beta blockers such as metoprolol are also given to reduce EPS.
• Benzodiazepines – Benzodiazepines such as valium may also be given to stabilize the nerve impulse transmission to reduce motor restlessness.
• Medication modification – Switching from typical antipsychotics to atypical antipsychotics is very essential for those needing continued treatment for psychosis. Atypical antipsychotics do not produce extrapyramidal symptoms and are as equally effective as the traditional neuroleptics. Atypical antipsychotics or neuroleptics include ziprasidone, aripiprazole, risperidone, olanzapine, clozapine and quetiapine. These medications do not result in the affectation of the nigrostriatal pathway. When medication modification is not possible, reducing the dose of typical neuroleptics is done.

Extrapyramidal Side Effects

In summary, extrapyramidal side-effects include symptoms occurring from the affectation of the regulation of the motor cortex activity leading to extrapyramidal symptoms such as

• akatishia
• dystonia
• dyskinesia and
• pseudoparkinsonism