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EDITOR
Sajjad Rahnama’i

CURRENT DEFINITION & EXPLANATORY NOTES
The overactive bladder syndrome (OAB) is defined as urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence [1,2]. This definition derives from the International Continence Society (ICS) Standardisation of Terminology of Lower Urinary Tract Symptoms [1] and the joint ICS and International Urogynecological Association (IUGA) report on the Terminology for Female Pelvic Floor Dysfunction [2].
The International Consultation on Incontinence Research Society (ICI-RS) proposed that the terminology is slightly rephrased as: "overactive bladder syndrome (OAB) is characterized by urinary urgency, with or without urgency urinary incontinence, usually with increased daytime frequency and nocturia, if there is no proven infection or other obvious pathology [3].


OLD DEFINITIONS
Previously, OAB symptoms were described as associated with the unstable bladder (A bladder contracting involuntarily during the filling phase of a cystometrogram) [4] also refferd to as detrusor hyperreflexia [5] (if neurological disease was present) or detrusor overactivity [5] (if the cause was unknown or non-neurogenic).
OAB has a symptom-based definition and a a widely used term. It is a pragmatic approach to categorizing a recognized group of patients, and is understood by the patients. However, expert opinion suggested several issues for which additional evidence should be sought [3]. Naming an organ (bladder) in the condition may suggest underlying mechanism, when contributory aspects may lie outside the bladder. No severity thresholds are set, which can cause uncertainty. Urgency is prominent in the definition, but may not be prominent in patients whose adaptive behavior reduces their propensity to urgency. OAB can co-exist with other common conditions, such as benign prostate enlargement (BPE), stress incontinence or nocturnal polyuria.


MECHANISMS
OAB occurs in both men and women. In some patients, it is accompanied by uncontrolled contractions of the detrusor muscle during bladder filling, called detrusor overactivity (DO). However, patients with OAB do not always present with DO. DO is detected in only about half of patients with OAB by conventional techniques. But up to 50% of patients presenting with DO on urodynamics do not complain of clinical symptoms [4,5]. The differences in the relationship between sensation and bladder activity may be indicative of different clinical states. However, it is more likely that we don’t understand the true nature of the clinical condition yet.
The only currently available tool to link OAB and DO is urodynamics. Nevertheless, DO and OAB share therapeutic options and, partially, common patho-physiological mechanisms [4,5].
The characteristic symptom of OAB is a sudden and strong sudden desire to void, that can not be postponed (urgency). In some patients, this can result in involuntary urine loss, which is called urgency urinary incontinence.
The term “increased daytime frequency” refers to a perception by the patient that he or she passes urine too often in the daytime. Some organisations attempt quantify an increased number of micturitions per day (e.g.more than 8 times a day), but there is limited normative data to underpin such statements at the current time. Increased daytime frequency can occur as a result of reduced functional bladder capacity. Increased daytime frequency may be partly caused by patients’ adaptation (‘coping mechanism’) to avoid leaking urine by maintaining a relatively low urinary volume in the bladder. Patients with OAB may deliberately try to keep their bladder as empty as possible to maintain continence, with consequent increase in urination frequency. Despite this adaptive coping mechanism, incontinence may still be a significant problem. Even a small increase in urgency and/or frequency can have a marked effect on the patient, depending upon when it occurs. Urgency incontinence is the most bothersome symptom of overactive bladder and is reported in around 20% of men and 40% of women with overactive bladder symptoms [6-8].
The diagnosis of OAB is made on the basis of symptoms alone. However, cystometry can be used to verify that uncontrolled contractions during bladder filling are responsible for the OAB symptoms.

THERAPIES
Recent large meta-analyses of the most widely used antimuscarinic drugs have clearly shown that these drugs provide a significant clinical benefit [9-12]. None of the commonly used antimuscarinic drugs (darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine, and trospium) are an ideal first-line treatment for all OAB/DO patients. Optimal treatment should be individualised, considering the patient’s comorbidities and concomitant medications and the pharmacologic profiles of different drugs [9]. Recently, Beta3 agonists have been successfully tested in patients with OAB [13,14]. These agents have been shown to bring significant improvements in incontinence episodes and micturition frequency. Urgency incontinence secondary to idiopathic DO may be treated by neuromodulation [15], percutaneous tibial nerve stimulation (PTNS) [16] or bladder augmentation [17]. Botulinium toxin injection can be used to treat idiopathic DO unresponsive to other therapies [18]. Botulinum toxin for detrusor injections is currently being used off-label for this indication.

REFERENCES AND RESOURCES
1. Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., Van Kerrebroeck, P.E., Victor, A. & Wein, A. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 61, 37-49 (2003).
2.Haylen, B.T., de Ridder, D., Freeman, R.M., Swift, S.E., Berghmans, B., Lee, J., Monga, A., Petri, E., Rizk, D.E., Sand, P.K. & Schaer, G.N. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics 29, 4-20 (2010).
3. Do we need a new definition of the overactive bladder syndrome? ICI-RS 2013. Drake MJ. Neurourology and Urodynamics. 2014;33(5):622-4

4. International Continence Society (1980): Third report on the standardization of terminology of lower urinary tract function. Br J Urol 52:348.
5. Edward McGuire Bladder Instability and Stress lncont inence Neurourology and Urodynamics 7563-567 (1988)
6. Cerruto, M.A., Asimakopoulos, A.D., Artibani, W., Del Popolo, G., La Martina, M.,Carone, R. & Finazzi- Agrò, E. Insight into new potential targets for the treatment of overactive bladder and detrusor overactivity. Urologia Internationalis 89, 1-8 (2012).
7. Abrams, P., et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourology and Urodynamics 29, 213-240 (2010).
8. Van Kerrebroeck, P.E. A treatment algorithm for the overactive bladder. British Journal of Urology International 83 Suppl 2, 29-30 (1999).
9. Cardozo, L.D. & Stanton, S.L. Genuine stress incontinence and detrusor instability—a review of 200 patients. British Journal of Obstetrics and Gynaecology 87, 184-190 (1980).
10. Feneley, R.C., Shepherd, A.M., Powell, P.H. & Blannin, J. Urinary incontinence: prevalence and needs. British Journal of Urology 51, 493-496 (1979).
11.Thuroff, J.W., Abrams, P., Andersson, K.E., Artibani, W., Chapple, C.R., Drake, M.J., Hampel, C., Neisius, A., Schroder, A., Tubaro, A., EAU Guidelines on Urinary Incontinence, European Urology 387–400 ( 2011)
12. Chapple CR, Khullar V, Gabriel Z, et al. The effects of antimuscarinic treatments in overactive bladder: a systematic review and meta-analysis. Eur Urol 2005 Jul;48(1):5-26.
13. Chapple CR, Khullar V, Gabriel Z, et al. The effects of antimuscarinic treatments in overactive bladder: an update of a systematic review and meta-analysis. Eur Urol 2008;54(3):543-62.
14. McDonagh MS, Selover D, Santa J, et al. Drug class review: agents for overactive bladder. Final report. Update 4. Portland, Oregon: Oregon Health
15. Herschorn S, Barkin J, Castro-Diaz D, Frankel JM, et al A Phase III, Randomized, Double-blind, Parallel-group, Placebo-controlled, Multicentre Study to Assess the Efficacy and Safety of the β3Adrenoceptor Agonist, Mirabegron, in Patients With Symptoms of Overactive Bladder Urology. 2013 Jun 12.
16. Bridgeman MB, Friia NJ, Taft C, Shah M. Mirabegron: β3-Adrenergic Receptor Agonist for the Treatment of Overactive Bladder. Ann Pharmacother. 2013 Jul
17. Siddiqui NY, Wu JM, Amundsen CL. Efficacy and adverse events of sacral nerve stimulation for overactive bladder: A systematic review. Neurourol Urodyn. 2010;29 Suppl 1:S18-23. doi: 10.1002/nau.20786.
18. Biemans JM, van Balken MR Efficacy and effectiveness of percutaneous tibial nerve stimulation in the treatment of pelvic organ disorders: a systematic review.. Neuromodulation. 2013 Jan-Feb;16(1):25-33;

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