الفهرس 
urinary bladder Innervation of theOnly 14 pages are availabe for public view
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Abstract
Overactive bladder is characterized by symptoms of frequency, urgency, nocturia with or without urge incontinence in absence of infection or other pathology. It is highly prevalent disorder that impacts the lives of millions of people worldwide. The symptoms of overactive bladder are associated with significant social, psychological, occupational, physical and sexual problems.
For management of overactive bladder, first of all the diagnosis of overactive bladder must be established by history taking and initial assessment of patient’s complaint, questionnaire, physical examination, voiding diary, pad test, laboratory investigations, urodynamic studies, radiological examination and cystoscopy.
Overactive bladder often remains a therapeutic problem, despite of the optimal use of conservative treatment; behavioral therapy which includes patient education about lower urinary tract, fluid restriction, timed voiding, bladder drill and pelvic floor physiotherapy , medical treatment, neuromodulation which, has been confirmed as a valuable addition to the therapeutic modalities in the last decade and lastly surgical treatment.
Medical treatment by oral anticholinergic drugs remain an easy and cheap method of treatment unless complications occur or poor patient compliance that hinders the therapeutic effect, in which cases shift to transdermal therapy or intravesical therapy could be an alternative methods for treatment.
The majority of oral drugs used for treatment of overactive bladder reduce involuntary contractions of detrusor muscles by blocking muscarinic receptors ( anticholinergic therapy). Oral drugs like, Tolterodine (2mg twice daily), Tolterodine ER(4mg once daily), Trospium chloride (20mg twice daily). Darifenacin (up to 15mg once daily), Solifenacin (5mg once daily) and Oxybutynin chloride(immediate release 5mg t.d.s or extended release 10mg twice daily) are of great help in controlling the symptoms of overactive bladder.
Although most anticholinergic drugs have demonstrated a good efficacy for treatment of overactive bladder (40-60% improvement), the problem remains that more than 50% of patients will stop treatment because they cannot tolerate their side effects (dry mouth, blurred vision, dizziness, somnolence and constipation).
One of the recent addition to overactive bladder drug therapies is the development of transdermal drug delivery system (Oxybutynin TDS), this method allows drug absorption to occur directly across the skin, bypassing liver metabolism resulting in high therapeutic plasma drug concentration with low tolerable dose, avoiding side effects and reduce the chance of patient stopping oral medication.
Other method of treatment, is intravesical therapy in which a drug (e.g. Oxybutynin ) is delivered directly into the bladder acting locally on the bladder wall, completely bypassing gut metabolism and avoiding side effects of oral drugs. Although a promising and effective method, intravesical therapy is not widely used because it requires repeated catheterization which is troublesome and mostly unaccepted by the patients.
Local injection of botulinum toxin into the detrusor may be an appropriate treatment for many patients with overactive bladder, particularly those who have not responded to or have tolerability problems with drug therapy.
Neuromodulation has made its way to the top of the list of options when the previous measures fail. The current techniques of neuromodulation are: anogenital electrical stimulation, Transcutaneous electrical nerve stimulation, percutaneous posterior tibial nerve stimulation, sacral nerve neuromodulation, and magnetic stimulation.
Surgical options to manage refractory overactive bladder are considered lastly after failure of the previously mentioned treatment methods. Denervation of the overactive detrusor muscle has been tried for more than 50 years with varying success. Surgical or chemical denervation can be used at central or peripheral level to interrupt motor and/or sensory pathways. Central denervation involves sacral roots S3 and S4 that have parasympathetic fibers and somatic fibers supplying the bladder and pelvic floor muscles. The hope is to develop a new technique that allows selective denervation of the motor nerves of the detrusor muscle without compromising the bladder sensation and without affection of other pelvic organs that are innervated by these nerves. Peripheral denervation can be performed by perivesical dissection of the pelvic nerves through an abdominal or transvaginal approach or by intervention on the detrusor muscle itself.
For many years augmentation enterocystoplasty was the only option when conservative measures failed to control the overactive bladder symptoms. Long-term outcomes are good with substantive patient satisfaction. However, the morbidity of the surgical procedure and attendant risks (metabolic disorders, perforation, recurrent infection, stone formation and malignancies) place enterocystoplasty near the bottom of the options. Recently tissue bio-engineering raises the hope for possibilities in the future to augment bladder capacity and improve bladder and urethral functions
Urinary diversion is last option when the bladder and urethra are so compromised that reconstruction in not possible