Everything you need to know about Overactive Bladder Syndrome (OBS)

Urination is a normal part of a healthy, functioning body, but for some people an active bladder becomes an overactive bladder.

Our bladder is similar to a balloon, as the bladder fills up, the walls stretch to accommodate the extra fluid, and we start to be aware of the feeling that we need to pass urine, but we are usually able to hold on. However, this is not the case for some people, and they are not able to hold on; when they feel the urge to pass urine, they can’t wait.

What is overactive bladder syndrome?

An overactive bladder is where a person regularly experiences a sudden and compelling urge or desire to pass urine. This sensation is often quite difficult to ignore. It can happen at any time during the day or night, often without any warning.

Most of the time the muscles in the bladder wall are relaxed, soft and stretchy. They only tighten and squeeze when the person is at the toilet and passing urine and relax again once the bladder is empty. When the bladder is overactive the muscles in the bladder wall tighten suddenly at any stage of bladder filling, usually before the bladder is full. This sudden tightening of the bladder wall muscles sends an unexpected signal to the brain saying that it wants to empty immediately. This sensation is called urgency, because the need to use the toilet is urgent.

If you have an overactive bladder, you may need to go often during the day and might get up a lot at night to urinate as well. Urinary incontinence – this is where you leak urine – can also be an unwanted side effect of an overactive bladder.

What causes overactive bladder syndrome?

In most cases, the cause of an overactive bladder is not known.

However, there are certain risk factors that can increase your chance of getting overactive bladder syndrome, including:

• Changes to your hormone levels – Bladder tissue is responsive to oestrogen levels; a drop in its production combined with an overall loss of muscle tone associated with ageing may lead to a weakened bladder.
• Weak pelvic muscles – This can lead to bladder leaks and an overactive bladder. Your pelvic floor muscles are vital to maintaining urinary continence. Over your lifetime, they may become weakened as a result of pregnancy and childbirth, menopause, genetic factors, or even weight gain. Also following pelvic surgery for cancer, incontinence or prolapse.

Overactive bladder can, in more rare cases, be caused by:

• Neurological diseases, including Multiple Sclerosis (MS) Parkinson’s Disease and Spina Bifida, or those who have suffered a stroke may also develop an overactive bladder.
• Injuries to the spinal nerves from slipped discs, surgery or trauma.

The type and quantity of fluid that you drink can also influence your symptoms. Not drinking enough fluids can cause distress on the bladder and worsen OBS symptoms.

There are a number of drinks that may irritate the bladder such as:

• Tea or coffee, whether decaffeinated or not.
• Carbonated drinks.
• Drinks containing aspartame – This is an artificial sweetener found in diet drinks.
• Hot chocolate.
• Green tea.
• Alcohol.
• Blackcurrant juice.
• Citrus fruit juice.

Some foods also irritate the bladder, such as tomatoes and spicy food, so limiting the intake of these fluids and foods may help. Some medications may also be associated with an overactive bladder; in this case speak to your GP.

Although not specifically a cause of overactive bladder syndrome, anxiety can make the problem worse.

Overactive bladder syndrome may co-exist with stress urinary incontinence, which is the leakage of small drops of urine when coughing and sneezing.

Also, an overactive bladder can sometimes be an indicator of other diseases or conditions, such as:

• Diabetes mellitus.
• Urinary tract infection.
• Pressure on the bladder from an enlarged uterus or ovarian cyst.
• Local disease in the bladder, such as an ulcer.

Who is at risk of OBS?

Overactive bladder syndrome is common, and can affect people of all ages, including children and the elderly. It does occur in greater frequency amongst the elderly, about 20–30% of people at retirement age, but it can also happen in young men and women.

Population-based studies have estimated the prevalence of overactive bladder syndrome (OBS) at 7–27% in men and 9–47% in women. It is the most common bladder symptom as you age. In the United Kingdom 17% of the adult population have some degree of overactive bladder symptoms, which is about 5.15 million sufferers in the UK.

Some children are born with problems affecting their kidneys, bladder, ureters (the tubes that connect the kidneys to the bladder) or urethra (the tube from the bladder that the urine comes out of). Although these problems are quite rare, these children may be at risk of OBS.

Symptoms of overactive bladder syndrome

The number of times people usually have to pass urine each day is very varied.

Most people pass urine 6–8 times per day, but anywhere between 4–10 times per day can also be normal if you are healthy and happy with the number of times that you visit the toilet. However, people with an overactive bladder tend to pass urine more often than they would expect during the daytime and several times during the night. Your need to pass urine may be triggered by a sudden change of position, or even by the sound of running water.

Symptoms of overactive bladder syndrome include:

• Urgency – Having to rush to the toilet to pass urine. If your bladder squeezes (contracts) without any warning it can give you an urgent need to pass urine; that is, ‘when you have to go, you have to go’. This gives you a little or no time to get to the toilet. This is called urinary urgency.
• Frequency – Need to pass urine frequently during the day. If you have urinary urgency, this means that you need to pass urine often and more frequently than usual and in small volumes. Normal urine frequency depends on how much you drink in a day and the types of fluid you drink. You may also pass urine more frequently if you are taking certain medications such as diuretics.
• Nocturia – Waking up to pass urine during the night. An overactive bladder can also cause you to get up more than twice per night to pass urine. During your sleep time you should have 6–8 hours of uninterrupted sleep and sometimes disturbed nights can be the main problem of an overactive bladder. Urinary tract problems other than an overactive bladder can also cause nocturia, so this symptom may persist even if other overactive bladder issues respond to treatment.
• Urge incontinence – Leakage of urine because of not making it to the toilet in time. If the need to pass urine is so intense that you cannot hold on to it, it can lead to involuntary leakage of urine which is called urge urinary incontinence.

Complications of overactive bladder syndrome

Symptoms of overactive bladder syndrome can have a significant effect on your daily life. It is a chronic condition with symptoms that can disrupt your normal activities during the day and disrupt your sleep at night. The inconvenience of the symptoms can feel like an embarrassing condition to have, and can lead to discomfort, depression and emotional distress.

Urinary urgency, frequent urination and/or chronic fatigue due to sleep disruption can interfere with your work and daily routines. It can also lead to lower productivity at work and at home when you have to interrupt what you are doing to use the toilet.

Chronic fatigue and lack of energy may worsen other OBS complications. Each time the urge to urinate interrupts your night you may have to struggle to return to the deep and most restful stages of sleep. This can lead to fatigue.

A lower quality of life can have emotional effects on people with an overactive bladder. Sufferers’ social lives and interactions can be impacted; many avoid leaving the house or refuse social events out of fear of a flare-up in symptoms or from the discomfort or embarrassment of needing to find and use the toilet. This can lead to depression and, in some cases, agoraphobia, which is a fear of being in situations where escape might be difficult or that help wouldn’t be available if things go wrong.

The risk of falls and fractures is significantly increased in older adults largely because people with OBS may rush to the toilet risking accidents in their hurry.

How is overactive bladder syndrome diagnosed?

If you are experiencing any or all of the symptoms outlined above, speak to your GP in the first instance. They will ask you questions about your problem and your general health, examine you and may perform an internal examination. Your GP will take a urine sample to test for infection.

You may also have a flow test and post-flow ultrasound test, which involves passing urine in a special machine to measure the strength of your flow and to check whether you empty your bladder completely.

You will be asked to complete a three-day Bladder Diary to record the times and frequency that you pass urine and the volumes of urine that you pass.

The results of these tests and your bladder diary will help your GP to diagnose whether you have OBS, which is treatable, and helps to indicate initial treatment.

Can overactive bladder syndrome be prevented?

Whilst you may not be able to prevent OBS, there are some general lifestyle strategies which may help. Being thirsty is often a guide that your body needs water. Drinking less does result in a reduction in the amount of urine produced, but the urine can then become highly concentrated which can further aggravate symptoms, needing more frequent visits to the toilet.

Not drinking enough water can also cause constipation. Remember that food also contains water, particularly fruits and vegetables. Aim to drink about 1.5 litres of fluid a day, adjusting the amount you drink according to your need, and spreading drinks throughout the day.

If you are getting up at night to pass urine, then try to reduce your fluid intake in the evening, four hours before going to bed. Avoid caffeine and alcohol before going to bed. If you feel thirsty or need to take medications, then you can have small sips of water.

If you suffer from constipation, this can increase pressure on the bladder and be an irritant. Increased dietary fibre can help with constipation. Eating healthily can help with maintaining a healthy weight, which helps reduce symptoms of an overactive bladder and incontinence. It has been demonstrated that a 5–10% weight loss can help.

Make getting to the toilet as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Bladder and Bowel UK also have a Just Can’t Wait card / App, which helps give access to toilets not normally accessible by the public. Although access is not guaranteed, the cards are widely accepted and acknowledged.

Doing exercises to strengthen your pelvic floor, also known as Kegel exercises, might help you with training your bladder and increasing the time between visits to the toilet.

Treatment for overactive bladder syndrome

For many people with overactive bladder syndrome, emptying the bladder frequently becomes a habit and the bladder has to be trained to overcome this pattern. Bladder training, which is a form of behavioural therapy, is considered an important part of any OBS treatment programme. The purpose of bladder training is to help you to regain control of your overactive bladder by suppressing its contractions.

Instead of rushing to the toilet as soon as you get the urge to pass urine, it is important to try to hold on. If you have difficulty doing this, try to distract yourself by doing something else such as sitting on your feet, crossing your legs or sitting on a rolled-up towel. You should aim gradually to increase the capacity of your bladder and the time interval between passing urine.

Start by passing urine every hour on the hour whether you need to go or not from when you get up in the morning until you go to bed at night. Try hard not to pass urine outside your set times. Practise this for 3-4 days. When you feel you have mastered this, gradually increase the time between passing urine.

It is helpful to carry out pelvic floor exercises to help you suppress your urgency feeling, for example when getting up from a sitting position, when hearing running water or putting the key in the door. It is important to note that bladder training takes time and needs your full commitment as it can take up to three months to show any benefit.

There are various overactive bladder medications that you may be prescribed. These are called anticholinergics or Beta 3 agonists. They work by blocking certain nerve impulses to the bladder which stops it from contracting when it should not contract, and improve symptoms in some cases, but not all.

A common plan is to try a course of medication for six weeks. If it is helpful, you may be advised to continue for up to six months or so and then stop the medication to see how symptoms are without the medication. However, if you combine a course of medication with bladder training, the long-term outlook may be better and symptoms may be less likely to return when you stop the medication.

Botox has been licensed (approved) for the treatment of overactive bladder syndrome in the UK in patients where medication has failed. The treatment involves injecting botulinum toxin A into the inside of your bladder via a small telescope.

This treatment has the effect of damping down the abnormal contractions of the bladder. However, it may also damp down the normal contractions so that your bladder is not able to empty fully. To address this side effect, about 10–20% of people who have the Botox procedure will need to insert a catheter (a small tube) into their bladder in order to empty it. This treatment is not routinely funded by the NHS and needs exceptional funding by the Primary Care Trust (PCT).

If the above treatments are not successful, surgery is sometimes suggested to treat OBS. This will be discussed with you by your consultant and would only be done after you have had a urodynamics test to prove bladder overactivity.

Surgery options can include:

• Sacral nerve stimulation – This is a procedure where a small device is implanted under the skin of the buttock to send a burst of electrical signals to the nerves that control the bladder. It works like a pacemaker to the bladder.
• Augmentation cystoplasty – In this operation, a small piece of bowel from the small or large intestine is added to the wall of the bladder to increase the size of the bladder. However, not all people can pass urine normally after this operation. You may need to insert a catheter (a small tube) into your bladder in order to empty it.
• Urinary diversion – In this operation, the ureters, that is the tubes from the kidneys to the bladder, are routed directly to a pouch made from a piece of a small intestine that opens to the outside of your body. The urine is collected into a bag. This procedure is only done if all other options have failed to treat your overactive bladder syndrome.

Final thoughts

Overactive bladder is a very common problem, but there are many different treatments available and strategies that you can use to help you to cope with the inconvenience.

For additional help, advice and support there are a number of sources available:

• Bowel and Bladder UK.
• Bladder Health UK 0121 702 0820.
• Continence Foundation.
• The Urology Foundation.