OVERACTIVE BLADDER/FOOT PROBLEMS
From the 50th annual Postgraduate Symposium Family Medicine Update, sponsored by the San Diego Academy of
Family Physicians
| OVERACTIVE BLADDER —Charles W. Nager, MD, Professor of Clinical Reproductive Medicine, and Director, Division
of Urogynecology, University of California, San Diego, School of Medicine
|
| Overactive bladder: common; defined in 2002 as urgency (sudden compelling desire to pass urine, which is difficult to defer)
with or without urge incontinence, usually with frequency (voiding >q2h during day) and nocturia (voiding >1 time
at night), in absence of pathologic or metabolic factors that would explain these symptoms (eg, bladder infection); more
common in elderly
|
| Etiology: unclear; role of brain to suppress coordinated voiding mechanism; neurogenic—loop in brain from cerebral cortex
to pontine micturition center suppresses micturition; in certain conditions (often associated with aging), dislearning or
dematuration of loop causes less control; myogenic—aging bladder becomes more excitable; self-propagated electrical
nerve impulses in bladder spread rapidly through gap junctions in smooth muscle, causing hyperexcitable bladder and
loss of control
|
| Pathophysiology: involuntary detrusor (smooth muscle of bladder) contractions during filling phase associated with urgency;
reduced functional bladder capacity results in urinary frequency; urge incontinence occurs if bladder pressure overcomes
sphincteric outflow resistance in urethra; women have less sphincteric outflow resistance (urge incontinence with overactive
bladder more likely in women than men)
|
| Spectrum of overactive bladder: symptoms of urgency, frequency, and nocturia (associated in some patients with urge incontinence);
stress incontinence (loss of urine with, eg, coughing, sneezing, laughing); mixed incontinence; many patients
may have urgency, frequency, and nocturia without true urge incontinence; overactive bladder—increases with age; similar
rates in men and women; present in nearly 33% of elderly patients, ≈16.6% of overall population; urinary
incontinence—≈33% stress; ≈33% urge; ≈33% mixed; stress incontinence patients tend to be younger; urge and mixed incontinence
patients tend to be older; most expenditures attributable to routine care (eg, protective pads)
|
| Behavior modification: effective therapy; improves awareness of bladder and understanding; education; reinforcement;
pelvic floor exercises (eg, Kegel) cause relaxation of bladder; fluid and diet modification—for patients with nocturia,
advise reducing fluids 2 hr before bedtime; adjust timing of diuretic (recommend taking 6-8 hr before bedtime); diary
of 24-hr fluid intake helpful; restrict fluid intake in patients with polyuria (urine production >2800 mL/day); caffeine,
alcohol, and nicotine stimulate bladder; fixed-schedule voiding—advise patients to void q1h for 1 wk; increase interval
time by 15 min every week; goal to void q3h; teaches patient to function at higher bladder capacity; prompted
voiding—set reminders for patients to void q2h; effective
|
 | Pelvic floor muscle rehabilitation: when urge occurs, patients should sit, relax, and perform 5 to 10 pelvic floor muscle
contractions and wait until urge subsides, then walk slowly to restroom to prevent urinary leakage; patient’s ability to
isolate and contract pelvic floor muscles can be determined during pelvic examination (teach patient to relax abdominal
wall and tighten pelvic floor); if patient cannot contract pelvic floor muscles, biofeedback (taught by, eg, nurse or
physical therapist) can help patient activate muscles; biofeedback programs effective for urge, stress, and fecal incontinence;
muscle training helps develop muscles; electrical stimulation of pelvic floor—electrodes inserted into vagina
provide electrical stimulation to cause contraction of pelvic floor; effective for activating muscles, especially in patients
who have difficulty with pelvic floor exercises; effective for overactive bladder; combination of antimuscarinic
therapy and behavioral therapy more effective than antimuscarinic therapy alone (84% vs 75%)
|
| Problems with behavioral therapy: time and labor intensive; requires patient and caregiver motivation; success dependent
on intensity of treatment
|
| Innervation of lower urinary tract: through sacral nerve route (S2 -S4 ); bladder innervation through pelvic nerves; control
of inhibition of bladder parasympathetic; pudendal nerves strengthen external urethral sphincter and muscles of pelvic
floor; inhibitory reaction to bladder sympathetic; pelvic nerves come in through acetylcholine receptors; muscarinic receptors
(eg, M3 ) in bladder; nicotinic receptors of pudendal nerve and α receptors cause contraction of urethra; sympathetic
stimulation causes relaxation of smooth muscle (ie, urinary retention); cholinergic stimulation responsible for
voiding by causing contraction of smooth muscle
|
| Muscarinic receptors: bladder filled with M2 and M3 receptors; M3 receptors most active; M1 receptors found in brain,
M2 in cardiac muscle and bladder, M3 in bladder; drugs aimed at affecting bladder, but not brain and heart; M3 receptors
found in salivary glands (difficult to avoid dry mouth and constipation with drugs)
|
| Oxybutynin: undergoes considerable first-pass metabolism; mostly active at M3 and M1 receptors; some direct smooth
muscle relaxant properties; metabolized to N-desethyloxybutynin (N-Deo; causes side effects); available in immediate-
and extended-release forms and transdermal application (Oxytrol); side effects can be reduced by bypassing first-pass
metabolism in liver (ie, applying Oxytrol on abdomen, hip, or buttocks); steady-state plasma concentrations—
immediate-release oxybutynin resulted in side effect of dry mouth, due to high levels of N-Deo; extended-release oxybutynin
associated with more stable plasma drug levels, with relatively high levels of N-Deo; transdermal oxybutynin associated
with reasonable plasma drug levels with lower levels of N-Deo and reduced side effects (good for patients
particularly sensitive to side effects)
|
| Other drugs: tolterodine (Detrol)—nonselective antimuscarinic drug; side effects include dry mouth; as shown in randomized
trials, effective for urinary incontinence; solifenacin (Vesicare)—moderately selective at M3 receptor; good
for avoiding side effects associated with M1 -receptor selectivity (eg, cognitive effects); trospium—quaternary amine;
low penetration across blood-brain barrier, so fewer cognitive effects; good for patients being treated with polypharmacy
(not metabolized via cytochrome P [CYP]450 ); 20 mg bid; oxybutynin, solifenacin, and darifenacin may be better choices
when concerned with cardiac side effects
|
| Efficacy of drugs: reduction of urge incontinence—56% to 71%; 30% with placebo (diary often used as outcome measure;
act of keeping diary effective therapy); no good data that one drug more effective than another; reduction in frequency
over 24 hr—17% to 30%; tolerability—common side effects included constipation and dry mouth (lower rates
seen with transdermal oxybutynin)
|
| Sacral nerve stimulation (InterStim therapy): neuromodulation system; for refractory urge incontinence; implantable electrode
placed percutaneously at S3 and attached to external pacemaker for 1 to 2 wk; if patient undergoes dramatic improvement,
implantable pacemaker placed in flank to provide constant low-grade electrical stimulation to nerve; effective in some
patients; stimulation of sacral nerves “modulates” neural reflexes that influence bladder and improve control; 45% dry; 70%
significantly improved; 64% reduction in voids per day; >50% improvement in voided volume
|
| Botulinum toxin type A (Botox) injection: new therapy; 100 to 200 U of Botox A cystoscopically injected into bladder at
20 to 30 sites; performed under local anesthesia; well tolerated; problems include elevated postvoid residuals; rate of urinary
retention (>200 mL) ≈40%; lasts 6 to 9 mo
|
| True or false: all patients with overactive bladder have urge incontinence—false; patients with overactive bladder symptoms
more likely than normal subjects to have involuntary detrusor contractions during filling phase of urodynamic
studies—true; behavior modification (eg, bladder retraining) ineffective for overactive bladder—false; some newer anticholinergic
(antimuscarinic) drugs unequivocally more effective than older drugs—false; neuromodulation therapy can
be effective for patients with refractory urge incontinence—true
|
| LIMP IN, DANCE OUT: FOOT PROBLEMS —Richard M. Green, DPM, Clinical Instructor, University of California,
San Diego, School of Medicine, and Director, Scripps Mercy Podiatry Clinic, San Diego
|
| Introduction: ≈80% of foot and leg complaints at least partially associated with biomechanical or mechanical dysfunction;
abnormal foot with biomechanic problem may have digital contractures, corns, calluses, prominent metatarsal heads,
aching, and cramping; consider biomechanics in patients with abnormal wearing on shoes and in patients with frequent
injuries
|
| Foot types: high arch—rigid or flexible; rule out neurovascular disease (common with neurologic problems); low arch—
rigid or flexible; normal feet; flexible flat feet function differently from rigid flat feet and cause different problems
|
| Pediatric foot problems: congenital or biomechanical; most problems biomechanically induced, but many foot problems inherited;
all low arches not pathologic; flat feet—95% of time, children outgrow flat feet; 5% of time, abnormal foot function
and pain develop in adulthood (5% of these children require surgery for eg, tendon balancing); check whether leg
medial to heel (significant problem; treatment necessary); patients do not outgrow significant structural deformities; treatment
mostly conservative (eg, casting for young infants, heel cups or orthotics for older children)
|
| Adult acquired flat foot: posterior tibial tendon dysfunction; posterior tibial tendon broadens and elongates; usually occurs in
overweight patients >50 yr of age with flat feet; more common in women; gradual foot collapse; one foot markedly flatter than
other; patients unable to perform independent toe raise on one leg (ie, cannot raise heel off ground); patients may have “too
many toes” sign (heel medial to leg; significant problem); conservative treatment—for older patients who are not surgical
candidates, consider orthotics and shoe modification (eg, wedging, rocker-bottom shoes); Richie brace with custom-made
orthotic may be helpful; surgery—consider when conservative treatment unsuccessful and activities of daily living limited;
soft tissue procedures and “reefing up” of posterior tibial tendon or transferring anterior tibial tendon usually ineffective; patients
usually require rear foot fusions (triple arthrodesis most common)
|
| Neuromas: worsen with narrow shoes or high heels; usually associated with biomechanically abnormal foot (typically, flat
foot with excessive pronation and hammering of toes); patient may have traumatic neuroma or anatomic variation; patient
usually complains of burning tingling pain that radiates to toes; sensation of walking on rolled-up sock or something
in shoe; patient must stop to massage foot; physical examination—pain in interspace distal to metatarsal heads; joint
moves with no pain; palpate capsule; no pain with weight-bearing on metatarsal heads; pain and Mulder’s click (pathognomonic)
with medial and lateral squeezing and compressing; management—conservative treatment (eg, strapping and
metatarsal pads); 1 to 2 injections of steroids helpful (improvement of symptoms may be diagnostic); magnetic resonance
imaging (MRI) or ultrasonography insufficient for diagnosis; if symptoms persist, consider excision (outpatient procedure
under local anesthesia; minimal downtime)
|
| Heel pain: incidence increasing; check for heel bursitis, tarsal tunnel syndrome, or entrapment of medial branch of lateral
calcaneal nerve; apophysitis—common in children 11 to 13 yr of age; pain with squeezing pressure at posterior aspect
of heel; no pain with plantar pressure; relieved by rest; children usually have underlying structural foot problem; x-ray
shows normal apophysis; posterior heel pain—enthesopathies; Achilles’ insertions; retrocalcaneal bursal pain; usually
related to biomechanically abnormal foot; improves with casting or anti-inflammatory agents, but pain returns in 2
to 3 mo unless underlying structural problem addressed; stress fractures and bone tumors in os calcis rare
|
| Plantar fasciitis: heel spur syndrome; common; spur not source of problem; enthesopathy; inflammation of fascia attachment
at heel; poststatic dyskinesia; point tenderness at inferior insertion of os calcis; not sore with squeezing pressure;
not associated with edema or erythema; symptoms decrease with higher heel; seen in high-arched and low-arched feet;
commonly in overweight women >50 yr of age; conservative treatment—strapping; over-the-counter and custom
orthotics; oral nonsteroidal anti-inflammatory drugs (1-2 injections for more severe cases); stretching; ice; physical
therapy; surgery—necessary in <5% of cases; open procedures; endoscopic partial fasciotomy; multiple stab incision
osteotomy, extracorporeal shock wave therapy
|
| Hyperkeratotic lesions: lesions on bottom of foot cannot be diagnosed unless callus reduced (lesion under callus); multiple
lesions on toes likely due to digital deformities (eg, contracted toes); be concerned with diabetes and ulcers; many
treatments for warts; padding and reducing corns and calluses helpful; conservative treatment for patients not candidates
for surgery; soft corns—often misdiagnosed as athlete’s foot; recur in spite of padding and trimming; require surgery;
consider obtaining culture of lesions and performing biopsy on ulcers; verrucoid carcinoma malignant and presents as
foul-smelling lesion; epidemiology of melanoma—men and women 30 to 60 yr of age; more common in whites than
blacks and Asians; more common on torso in men (lower extremities in women)
|
| Ingrown toenails: toenail causes foreign body reaction; 98% of patients do not need antibiotics; do not inject end of toe
(provide anesthetic block at base of toe); avulse nail; partial matricectomy—necessary for recurrences; use disposable
nail splitter with Beaver blade handle; remove piece of nail; use curette to remove granulomatous tissue; apply polymyxin
B sulfate, neomycin, and bacitracin (eg, Neosporin) and bandage; advise patient to soak toe in warm water with
dilute povidone iodine (eg, Betadine)
|
| Charcot’s foot: collapsing neuropathic foot; usually in patients with diabetes; always in patients with neuropathy and adequate
circulation; foot becomes red, swollen, and hot, with no specific trauma; management—early x-rays negative; during
acute stages “you’re probably going to want to turf it”; immediate non-weight-bearing; bivalve cast; serial x-rays;
gradual return to weight-bearing; chronic cases may require extra-depth molded shoes, Plastazote inserts, and other padding;
consider bumpectomy in older patients; consider reconstruction of foot in younger patients with more severe deformity
(requires 1 yr of immobilization and non-weight-bearing)
|
| Questions and answers: removal of callus—use 10- or 20-blade or other sharp instrument to shave or scrape callus to see
underneath; not difficult; plantar warts do not hurt when pressed, but hurt when squeezed; capillary pinpoint bleeding
may occur
|
Suggested Reading
Abrams P et al: Muscarinic receptor antagonists for overactive bladder. BJU Int 100:987, 2007; Amarenco G et al: Urodynamic
effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder. J Urol 169:2210, 2003; Andersson
KE et al: Treating patients with overactive bladder syndrome with antimuscarinics: heart rate considerations. BJU Int
100:1007, 2007; Cardozo L: The overactive bladder syndrome: treating patients on an individual basis. BJU Int 99 Suppl
3:1, 2007; Choksi P et al: Charcot arthropathy. An often overlooked complication of diabetes mellitus. J Ark Med Soc
103:229, 2007; Flicek BF: Heel spurs and plantar fasciitis: an update on therapies. Adv Nurse Pract 14:61, 2006; Govier
FE et al: Percutaneous afferent neuromodulation for the refractory overactive bladder: results of a multicenter study. J Urol
165:1193, 2001; Hintermann B et al: Lengthening of the lateral column and reconstruction of the medial soft tissue for
treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int 20:622,
1999; Hyland MR et al: Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the
short-term management of plantar heel pain. J Orthop Sports Phys Ther 36:364, 2006; Kelishadi SS et al: Recalcitrant verrucous
lesion: verrucous hyperplasia or epithelioma cuniculatum (verrucous carcinoma). J Am Podiatr Med Assoc 96:148,
2006; Menz HB et al: Plantar pressures are higher under callused regions of the foot in older people. Clin Exp Dermatol
32:375, 2007; Paige NM et al: The top 10 things foot and ankle specialists wish every primary care physician knew. Mayo
Clin Proc 81:818, 2006; Smith CP et al: Single-institution experience in 110 patients with botulinum toxin A injection into
bladder or urethra. Urology 65:37, 2005; Zelent ME et al: Minimally invasive Morton's intermetatarsal neuroma decompression.
Foot Ankle Int 28:263, 2007; Zhang AY et al: Effects of combined pelvic floor muscle exercise and a support
group on urinary incontinence and quality of life of postprostatectomy patients. Oncol Nurs Forum 34:47, 2007.
Educational Objectives
| The goals of this program are to improve the management of overactive bladder and common foot problems. After
hearing and assimilating this program, the participant will be better able to:
|
| 1. Counsel patients about behavior modifications that can improve symptoms of overactive bladder.
|
| 2. Choose effective agents for overactive bladder, based on side effect profiles.
|
| 3. Recommend newer therapy for refractory urge incontinence.
|
| 4. Identify causes of common foot problems, such as structural abnormalities.
|
| 5. Recognize common foot problems, such as plantar fasciitis, based on clinical findings.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgments
Drs. Nager and Green spoke in San Diego, CA, at the 50th annual Postgraduate Symposium Family Medicine Update
2007, presented August 3-5, 2007, by the San Diego Academy of Family Physicians. The Audio-Digest Foundation thanks
the speakers and the San Diego Academy of Family Physicians for their cooperation in the production of this program.
|
