David Horovitz, MD is a board‑certified urologist and co‑founder of the Bakersfield Institute of Advanced Urology who has spent more than a decade helping Central Valley patients manage urinary‑tract and men’s‑health disorders through evidence‑based, minimally invasive care. Trained in endourology and robotic surgery at the University of Rochester Medical Center and certified in both Canada and the United States, Dr. Horovitz pairs surgical expertise with a patient‑first philosophy—regularly lecturing on topics such as overactive bladder, kidney‑stone disease, and prostate health.
Overactive bladder (OAB) is a condition which causes frequent, uncontrollable urges to urinate. It is defined by the International Urogynecological Association and the International Continence Society as “urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.” OAB may have a profound negative affect on one’s physical and psychosocial quality of life. The condition may significantly restrict a person’s activities and cause them to isolate themselves from others, especially when there otherwise would not be a bathroom in close proximity. It can deter one’s ability and willingness to travel, perform their work activities and engage in social situations.
Under normal circumstances, the kidneys filter blood to form urine which then passes down the ureters for storage in the bladder. As the bladder fills, the brain receives signals which trigger voluntary micturition, the act of passing the urine out of your bladder. In order for this to occur, the pelvic floor muscles and the urethra muscles relax while the bladder muscles contract. Urgency urinary incontinence, which is related to OAB, occurs when the bladder muscles contract involuntarily even before the bladder is full, leading to unwanted urinary leakage.
The exact cause of OAB is largely unknown but involves a complex interplay of neuronal and muscle physiology. The onset of OAB is generally idiopathic (unknown) although several factors may contribute including older age, female gender, obesity, smoking and bladder outlet obstruction. It is essential for a physician to differentiate OAB from other similar conditions such as urinary tract infection, neurogenic bladder, cystocele, stress urinary incontinence and interstitial cystitis. Some of these conditions may coexist with OAB so taking a complete medical history and performing a proper physical examination while utilizing other adjunctive tests are crucial for proper diagnosis and treatment.
It is often helpful for patients to keep a bladder diary in order to document their voiding times, volumes, and urgency episodes, in order to identify the patterns of frequency and urgency. After this, the doctor may conduct a urinalysis to rule out UTIs, hematuria, and glucosuria. Physicians may also order imaging studies when indicated, such as computer tomography (CT) of the abdomen and pelvis, renal and bladder ultrasound or magnetic resonance imaging (MRI).
Cystoscopy may be recommended by your physician, especially if you do not respond to first-line therapy. Here, a specialized, miniature fiberoptic telescope is inserted through the urethra into the bladder, allowing for a direct visual examination of your lower urinary tract. This test allows your physician to determine if there are structural factors which may be causing or contributing to your symptoms such as bladder tumors, bladder stones, ulcers or diverticulae. Often, your physician will also perform a gynecological examination (in female patients) in order to obtain additional related information, such as the presence or absence of a cystocele or rectocele, stress urinary incontinence and pelvic floor tenderness. A digital rectal examination is a crucial part of the workup for males with bothersome lower urinary tract symptoms, which, in conjunction with a blood test called PSA is often utilized to screen for prostate cancer.
Urodynamic testing is another popular test that helps in the diagnosis of OAB and understanding how your bladder functions. First, your urinary flow rate is studied and a determination is made of how much urine is left in your bladder after voiding. Next, specialized catheters equipped with pressure transducers are inserted into your bladder and rectum and electromyography probes are placed on your perineum. Your bladder is then filled with saline (simulating urine filling by your kidneys), and information is recorded about your bladder sensation, capacity, compliance (elasticity), presence of uninhibited contractions and the presence of leak with increased abdominal pressure. Once your bladder is full, you are given permission to void so that information may be obtained about how your bladder pressures relate to your urine flow and whether or not your abdominal and pelvic muscles properly relax during this process.
After concluding that a patient has OAB, urologists will often begin treatment by recommending behavioral modification. Patients are advised to cut back or avoid substances which can trigger bladder symptoms such as coffee, tea, alcohol, spicy and acidic foods and tobacco. One may be instructed to keep a voiding diary, perform timed voiding, engage in pelvic floor physiotherapy and perform various urge inhibition techniques. It is also important to maintain bowel regularity by increasing fiber intake, engaging in physical activity and staying hydrated as bladder dysfunction is often related to concomitant bowel dysfunction.
If conservative management is ineffective, medical intervention may be warranted which involves administering antimuscarinics such as oxybutynin and tolterodine or beta-3 agonists like mirabegron. Patients should be properly counseled on the side effect profiles of these medications. For anticholinergic medications specifically, a discussion should ensue regarding the potential risk for developing dementia and cognitive impairment and alternatives should be sought in patients who have narrow-angle glaucoma, impaired gastric emptying or urinary retention. Finally, third-line therapy may be offered including bladder botox injections, sacral neuromodulation or percutaneous tibial nerve stimulation.