Overactive Bladder Article
Howard Loomis
Overactive bladder (OAB) is a symptom complex that has become very common. Unfortunately, it is often overlooked since most patients who have problems in that area do not mention them to their doctors until they become advanced. The term “overactive bladder” is usually used to group together many different symptoms your patient may be experiencing, but we should seek clarification of these symptoms as follows:
• Urinary frequency is voiding eight or more times in a 24-hour period. The patient can postpone voiding until convenient to do so.
• Urinary urgency is defined as occurring suddenly and very difficult to postpone.
• Urinary incontinence is the involuntary leakage of urine
when control over the urinary sphincter is either lost or weakened.
I am going to confine my remarks to urinary urgency because I believe it is quite common in chiropractic patients who seldom mention the problem during routine visits. Many of your patients do not understand the relationship of structural and visceral problems and consequently don’t realize that you can help them with the problem of urinary urgency.
Certainly, many factors may be involved in the development of overactive bladder symptoms, but clearly, pelvic rotation has a direct effect on the muscles of the pelvic floor. Stimulation of the detrusor muscle (wall of the bladder), whether myogenic, neurogenic, or idiopathic in origin, can result in urinary frequency, urgency, or incontinence.
I am going to focus on urinary urgency and its relationship to pelvic rotation, and exclude conditions such as urinary incontinence and nocturia. It is also necessary to exclude urinary frequency because that may involve urinary tract infections, polyuria, and underlying neurologic abnormalities.
Let us look at why this very common syndrome is important to chiropractors and how they can spot the possibility of it existing in their patients who may not realize they can be helped.
Consider that 38% of the OAB cases reported in one study had begun within the past year, but the majority of patients have symptoms for years.
Donaldson MM, Thompson JR, Matthews RJ, Dallosso HM, McGrother CW. The natural history of overactive bladder and stress urinary incontinence in older women in the community: A three-year prospective cohort study. Neurourol Urodyn. 2006, 25(7):709-16.
And despite the high prevalence of OAB, a significant discrepancy is found between the number of affected individuals and those seeking treatment.
Meller LA, Lose G, Jergensen T. The prevalence and bothersomeness of lower tract symptoms in women 40-60 years of age. Acta ObstetGynecolScand. 2000 Apr. 79(4):298-305.
Structural Considerations
The pelvic floor is formed by the levator ani and coccygeus muscles, and it separates the pelvic cavity above from the perineal region below. Recall that the pelvic cavity is formed by the pelvic bones, which can and do rotate in response to lower extremity asymmetries.
In men, the bladder lies in front of the rectum and is supported by fibers of the levator ani and the prostate gland. In women, it lies hi front of the uterus, separated and supported by the levator ani and the upper paid of the vagina.
Netter, Frank H. (2014). Atlas of Human Anatomy including Student Consult Interactive Ancillaries and Guides. (6th edition, ed.). Philadelphia, Penn.: WB Saunders Co. pp. 346-348.
The Effect of Pelvic Rotation on OAB
Consider the possibility of pelvic rotation resulting from deficient unilateral body support as a cause of urinary urgency. Now, I know I’m “preaching to the choir” when I talk about pelvic rotation being caused by sacral subluxation, leg deficiency, and ankle pronation. However, I would like to point out a simple screening procedure that may point to the possibility that a patient may, in fact, be experiencing symptoms of urinary urgency.
Unlevel Pelvis When Sitting
Have the patient sit on a level surface and place your hands on top of the iliac crests. Notice if one is higher than the other and inquire whether the patient experiences symptoms involving not only the bladder, but also the bowel and uterus and ovaries or prostate. If so, you are well on your way to explaining the relevance of those symptoms to the pelvis becoming unlevel and the possible causes. My clinical experience suggested that an unlevel pelvis occurred in 20 to 30% of my patients when they were seated.
Unlevel Pelvis in Supine Position
The well-known Derifield leg check effectively identifies pelvic rotation of the innominate and its two articulations responsible for maintaining the body in an upright posture—namely the sacroiliac joint and the iliofemoral joint. Any pelvic rotation, using either joint as its fulcrum, will affect the pelvic floor and clearly will affect the filling and emptying of the bladder, as well as the other organs below the level of the umbilicus.
Normal Bladder Emptying
Normal bladders store urine at low pressure until it is full.
As your bladder fills, nerve signals sent to your brain eventually trigger the need to urinate. The brain then returns signals that coordinate the relaxation of the pelvic floor muscles and the muscles of the urethra (urinary sphincter muscles) with the detrusor muscles of the bladder wall, which contract, pushing the urine out.
OAB and Involuntary Muscle Contractions
Overactive bladder occurs because the muscles of the bladder start to contract involuntarily even when the volume of urine in your bladder is low. This involuntary contraction creates the feeling of the urgent need to urinate. This may involve both the CNS and peripheral nervous system relaying sensory afferent signals horn the lower urinary tract, bladder, and sphincter.
Sympathetic and Parasympathetic Innervation
The bladder receives motor innervation horn both sympathetic fibers and parasympathetic fibers:
• Stimulation of sympathetic fibers h orn the superior and inferior hypogastric plexuses and nerves (T10-L4) relax the muscle and contract the sphincter (fight-or-flight response).
• Stimulation of parasympathetic fibers horn the sacral spinal nerves S2, S3, S4 contract the muscle and relax the sphincter. One might suspect a causal relationship to urinary urgency and pelvic misalignment.
Neurotransmitter Influences on the Bladder
Acetylcholine acts at neuromuscular junctions and is the predominant peripheral neurotransmitter responsible for detrusor contractions. It is released horn the parasympathetic nerve terminal and binds to receptors on the detrusor muscle.
Within the central nervous system, glutamate, serotonin, and
dopamine are involved in the storage of urine and emptying of the bladder. Glutamate is an excitatory neurotransmitter in pathways that control the lower urinary tract. Serotonin pathways facilitate urine storage. Dopamine pathways may have both inhibitory and excitatory effects on urination.
The Prevalence of Overactive Bladder
Two epidemiologic studies have assessed the prevalence of overactive bladder. One study used a computer-assisted telephone interview questionnaire to estimate the prevalence of OAB and its variation by sex, age, and other demographic factors. A sample of 5,204 adults who closely represented the US population by sex, age, and geographic regions was evaluated and 16.5% met the criteria for OAB. The prevalence of OAB was similar in women and men, at 16.9% and 16%, respectively. In both men and women, the prevalence of OAB increased with age.
Stewart WF, Van Rooyan JB, Cundiff GW, Abrams P, Herzog AR, Corey R, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003 May 20 (6): 327-36.
Another study (2001) collected data with a populationbased survey (conducted by telephone or direct interview) of 16,776 men and women aged 40 years or older horn the general population in Europe. The main outcome measures included the prevalence of urinary frequency (>8 micturitions per day), urinary urgency, and urgency incontinence.
Milsom I, Abrams P, Cardozo L, Roberts RG, Thuroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. B.JII Int. 2001 Jun 87 (9): 760-6
The overall prevalence of OAB symptoms was 16.6%. Frequency was the most common symptom (85%), followed by
urgency (54%), and urgency incontinence (36%). The prevalence of OAB increased with age, and rates in men and women were similar. Symptoms of urinary urgency and frequency were similar among both sexes, but urgency incontinence was more prevalent in women than in men. Men tend to develop OAB slightly later in life than women do, and women are more likely to develop urgency incontinence.
Others at risk to develop OAB are persons with insulindependent diabetes, persons older than 75 years, persons with arthritis, individuals on oral honnone-replacement therapy, and those with an increased BMI.
DuBeau CE. Interpreting the effect of common medical conditions on voiding dysfunction in the elderly. Urol Clin North Am. 1996 Feb 23(1): 11-8.
Conclusion
The occurrence of urinary urgency is probably quite high in chiropractic patients, especially among those within the demographic groups mentioned in the referenced studies. I hope that this article brings a better understanding of the possibilities the chiropractic profession has in treating sufferers of OAB.
Dr. Loomis has an extensive background in enzymes and enzyme supplements. He is the founder and president of the Food Enzyme Institute. His extensive knowledge of physiology, biochemistry, and enzymology has made him a sought-after speaker and a prolific writer. The Food Enzyme Institute offers seminars to healthcare practitioners around the country. Dr. Loomis published ENZYMES: The Key to Health in 1999. He also coauthored and published The Enzyme Advantage: For Healthcare Providers and People Who Care About Their Health in 2015, and The Enzyme Advantage for Women in 2016, with respected medical journalist Arnold Mann. Contact info: 6421 Enterprise Lane, Madison, WI53 719 customer service afoodenzymeinsiiiute.com. 800-662-2630.
