There are over 38 million people in the United States who report symptoms of Overactive Bladder (OAB). Many of those people have symptoms that are severe and have an enormous impact on their lives. However, only a fraction of people ever receive any kind of care for their bladder problems. One of the greatest barriers to care for Overactive Bladder is that most patients wait months or years before ever seeking any help. Why?

I think there are a number of reasons for this. Maybe you have relatively mild symptoms and simply don’t feel that OAB is bothersome enough to go to the trouble of seeking help. This may be a very reasonable decision for some to make. Or you may be bothered by your symptoms but you are not aware of what treatment options are available. This is why it is so important that we work to inform our community about options for Overactive Bladder. But I am willing to be that at least some of you have not sought help for OAB because you are worried about having to endure expensive or invasive testing to diagnose and treat Overactive Bladder. This last group of you is my intended audience in today’s post. I hope that you may be reassured to know exactly what is (and isn’t) involved in most evaluations for OAB.

A quick refresher on Overactive Bladder may be helpful if you are new to The OAB Clinic Blog and patient information portal. OAB is a syndrome characterized by symptoms that include frequent urination, urgent urination and (in some people) urinary leakage (incontinence). While there are numerous theories about factors that can contribute to Overactive Bladder, no one component appears fully adequate to explain why some people develop these symptoms while others do not. Though we have several types of therapy for OAB, we do not currently have a cure for it. This is a chronic syndrome that may require lifetime therapy for many.

In discussing the evaluation for someone suspected of having OAB, I think it is educational to remember that Overactive Bladder is not the only urologic problem that can cause frequent or urgent urination. So, much of my evaluation is focused on making sure that there is not a different issue causing your symptoms. After years of working with OAB patients, I find that obtaining a thorough patient history can often provide most of the information that I really need. Even before the visit, I like to review what previous pelvic surgeries someone may have had or what other medical issues they are also dealing with. If your urinary symptoms started right after a hysterectomy or an incontinence procedure, this can provide to me a valuable clue about a potential cause for your symptoms other than OAB. Do you have a history of Urinary Tract Infections? Are there previous urine tests that show blood in your urine or do you see blood in your own urine? A medical history and a review of your symptoms can point to a “bladder warning sign” that may need a closer investigation.

A history of symptoms is also useful in establishing how severe your symptoms are and suggesting how you and I can best approach your therapy. If you have very mild symptoms, you may be more interested in focusing of behavioral therapies and avoiding medications altogether. If your symptoms are more severe, you may be more interested in medications or even advanced therapies (if medications and behavioral therapies do not properly control your symptoms). Taking your history is also a time when I can learn more about any behaviors or other medical conditions (or medications) which may have an impact on your bladder symptoms. For many patients who have a history within our health system, I am able to review much of this history before your appointment even begins.

At some point in the evaluation, a physical exam is also very critical. In particular, I am looking for any abnormalities of your urinary tract that could lead to similar symptoms. Again, the focus is often on checking to be sure that there are no other bladder issues that could be the source of your symptoms. Typically, I also check an office urine test to screen for evidence of blood in the urine or infection. Many people routinely have these test performed when they see a primary care physician and I often rely on those prior tests if you are making a “virtual visit”. So much has changed in our world in response to the COVID-19 pandemic. Among those changes is the rise of virtual visits as part of telehealth services. Our approach to OAB visits has adapted to this “new normal” and I find that I am increasingly comfortable waiting until a second or even third visit for many patients before we are able to do a full physical exam. This has meant that I can provide OAB care in an increasingly safe and convenient manner for patients from around our region, and even beyond.

And that’s it!! You’ve just heard everything that is “required” for the initial diagnosis of Overactive Bladder. I think many patients are surprised that the appropriate, early evaluation of OAB should not involve complex, invasive testing for most patients. The more extensive testing is only required for patients that have complicated symptoms or a complicated history, which most do not. Urine cultures may be obtained to more definitively look for infection, though usually only if there is an indication of infection on an office urine test or if a patient reports symptoms of a UTI. I often will use a portable bladder ultrasound to scan the bladder and estimate how much urine is left behind after you are done urinating. This is likely only truly necessary in people who are reporting difficulty emptying their bladder. However, in practice, this is done routinely by most urologists treating OAB because it is extremely quick and causes no pain or discomfort for you. A bladder diary is considered an optional test, though I use bladder diaries extensively and find them to be one of the most (if not the most) useful tools I have to diagnose and manage OAB. In any bladder diary, you are asked to record the number of times that you urinate per day. In my bladder diary, I additionally ask that you record the volume of each void (we provide a measuring “hat”), how much liquid you drink, any times that you leak urine and what you were doing when any bladder leakage occurred. I cannot think of a test that I use which is able to give me more information, with less cost and discomfort, than a bladder diary.

But many of you may have friends or family who have undergone much more invasive testing for their OAB symptoms than I have described so far. Why? Likely because some patients have a more complicated history or symptoms. Remember, the diagnosis of Overactive Bladder largely involves ruling out other concerning causes for the same symptoms. If those symptoms are straightforward and there is no previous history of pelvic surgery, radiation or neurologic damage, the simple steps above are all that are needed. But the more complicated the history and the more concerning the symptoms, the more likely that an invasive test may be required to safely exclude those other issues.

Looking inside of the bladder with a small, lighted scope through the urine tube you use to urinate (urethra) is called a cystoscopy (the scope is called a cystoscope). This can often be performed comfortably in the office with numbing gel applied to the urethra to minimize discomfort. It only takes about a minute. I do not routinely perform cystoscopy on Overactive Bladder patients. However, if you have blood in your urine that you can see or if you have enough blood in your urine seen under the microscope, I will usually recommend that you have a cystoscopy performed to check for concerning causes of your symptoms such as bladder stones or tumors. Blood in the urine often prompts an ultrasound or CT of the kidneys as well. Patients with previous pelvic surgeries, especially incontinence surgeries that used permanent materials, will often have cystoscopy as well if there is a suspicion that the materials may be seen inside of the bladder. Most incontinence procedures use some type of permanent material.

A second, invasive test that is sometimes performed in Overactive Bladder patients is a pressure test of the bladder called a urodynamic test. In urodynamic evaluation, the bladder is filled and the pressures are measured by small catheters. Like cystoscopy, urodynamic evaluation is not part of my routine evaluation of OAB and most patients will not have this done. This is most commonly performed in patients who have a neurologic injury that is likely to affect the bladder, such as spinal cord injury, multiple sclerosis or Parkinson disease. In these cases, a pressure test of the bladder gives important information about how the bladder stores and empties, as well as whether there is any risk to the kidneys from storage of urine at improperly high pressures. People who are unable to empty their bladders well, have a previous incontinence surgery or have a vaginal bulge that extends beyond the vaginal opening are all more likely to need a urodynamic evaluation at some point. This becomes even more likely if early therapies such as behavioral changes and medications are not helping with symptoms (or making them worse).

While urodynamic evaluations can be useful in some select individuals, it is reassuring to know that many common problems in OAB do not necessarily require a bladder pressure test. If your symptoms are not improving with behavioral therapies or a medication and you do not have a complicated history or symptoms, you do not automatically need to have urodynamic testing performed. Similarly, just because your symptoms are severe does not mean that you have to have this bladder pressure test. Finally, urodynamic evaluations are not the most effective or efficient way of identifying whether you have stress incontinence, urgency incontinence or both (mixed incontinence). A symptom history, physical exam and the bladder diary are all probably more accurate and certainly more cost-effective at distinguishing among these types of incontinence.

There are so many reasons why millions of men and women with Overactive Bladder are do not seek care. However, I believe that education is key in overcoming most of the obstacles. Patients who have mild symptoms often think their problems do not justify any treatment. But if you know what a profound impact very simple, easy behavioral changes can have on your symptoms, you may reconsider. I meet many people in my practice who avoided caring for their bladder out of embarrassment or even shame. I hope that we can educate our community about how common OAB really is and how men and women, young and old, of all walks of life, suffer from these symptoms. If you know how many of your friends and neighbors share the same bladder issues as you do, perhaps the stigma of incontinence might be decreased. And for those of you who don’t know what treatments are available or who don’t know where you can find a care provider to help, I hope that this blog and The OAB Clinic information portal can provide an education about all areas of pelvic and bladder health. Finally, if you are worried about what you will need to endure to finally begin treatment for your Overactive Bladder, know that you will most likely need nothing more than a medical history and physical exam to start your journey to find your better bladder.