Historically, management of overactive bladder (OAB) can be seen to have failed to fully address the needs of patients. A majority of patients with OAB report their symptoms have a significant impact on daily living and seek medical help. Yet in at least







one study (which, is, admittedly, more than 15 years old) only about 1/4 of those patients were receiving treatment at the time evaluated. Half of those patients who did not seek treatment believed that no treatment was available. Furthermore, we know that a significant number of people will fail to see satisfactory improvement with early therapies including behavioral changes and medications.  Few of these people are treated with more advanced therapies intended for those patients patients with these refractory symptoms.

A care pathway is a set of steps designed to effectively manage a patient’s journey from disease to health. It is essentially a “roadmap” of how we believe a patient should be diagnosed and treated for a given problem.

It provides a standard set of instructions as to how we should care for patients and should be based on the most current guidelines and evidence available. It would seem logical that an optimized patient care pathway for OAB should lead to better outcomes. Furthermore, illustrating the care pathway in a way patients can see and understand (we use a “roadmap”) can help patients to see what to expect as they undergo evaluation and treatment.

In developing our OAB Care Pathway, we first sought to define what the initial steps should be in evaluating patients thought to have OAB. The initial evaluation of OAB begins with a thorough, but otherwise simple evaluation including a history of symptoms and other medical problems, as well as a physical exam designed to identify any other conditions that may mimic OAB. It is clear that for most patients with OAB, expensive and invasive tests are not needed for the evaluation.

An OAB Care Pathway should define the appropriate therapies for treating OAB. This includes behavioral changes, oral and dermal medications, percutaneous tibial nerve stimulation, sacral neuromodulation, and botulinum toxin. An optimized pathway considers not just what treatments can be used but the ideal order for those treatments. In the case of OAB, you would not want to begin with a treatment such as sacral neuromodulation before trying a more conservative therapy such as behavioral changes or medications. Again, consultation with available guidelines is helpful in defining which therapies are appropriate and when they should be used.

It is important for patients to have an idea of how long they should expect before a treatment begins to work. We use “mile markers” along the way so that patients can anticipate how long before they may see improvement.

A care pathway does little good if patients are blocked from making progress by barriers such as treatment side effects, problems with insurance coverage, or need for more advanced testing. In The OAB Clinic, an OAB Navigator assigned to each patient serves as a guide along the journey. She can help patients get back on track by answering questions, helping to facilitate medication changes, or arranging ahead of time for any needed tests. This helps to decrease the need for frequent visits, eliminating many of the “stops” along the way.

In The OAB Clinic, a part of UT Erlanger Urology in Chattanooga, Tennessee, our use of an optimized Patient Care Pathway has helped to significantly reduce those patients who leave the road to bladder health because of confusion or frustration. We have seen the number of patients “lost” plummet from about 70% to about 7%. This means that more patients are able to reach their bladder goals. With our care pathway, we hope to continue to change the history of OAB for all.

Colin M. Goudelocke M.D.  FPMRS

The OAB Navigator at The OAB Clinic in Chattanooga, Tennessee, serves a very unique and important role in the care of our incontinence patients. But before we describe that role, it may be helpful to first describe the obstacles many of our Overactive Bladder (OAB) patients faced before the arrival of our navigator. Only by seeing how far we have come are we able to appreciate how critical a role the OAB Navigator plays in the success of our patients.

Not so long ago, the majority of our OAB patients were frustrated by the obstacles they faced in seeking and receiving treatment for their bladder symptoms. One example I use frequently is the patient who might come back to clinic several weeks after starting a new medication. Some of those patients might return to tell us that they had stopped the new treatment due to side effects – sometimes only days after starting it. Think of the frustration of sitting at home for weeks without any treatment, waiting for your appointment so that you can tell us that the treatment we prescribed made you worse, not better. And for this privilege you often paid yet another co-pay! This kind of wasteful back and forth was standard before our OAB Navigator.

Today, that patient with intolerable side effects (and every other patient) receives a phone call about a week later from the navigator. If a different medication is needed or questions about side effects need to be answered, this is usually handled over the phone without the need for another visit (and another co-pay!). After 3-4 weeks, another phone call assesses how patients are responding to therapy. If changes need to be made, this can be done, again, by phone. It also allows us to anticipate your needs at the next visit, scheduling additional time or testing as needed.

The use of an OAB Navigator, has allowed us at The OAB Clinic to minimize the number of visits needed for you to reach your bladder goals. Through the navigator, we try to answer your questions when you have them, not weeks later at your next visit. OAB patients calling in with questions or concerns can directly reach the navigator, their own personal “concierge” through the journey to bladder health. Finally, the navigator allows us to anticipate your needs before your visit, so we can be prepared before you come. In one phrase: it allows us to be proactive not reactive.

Our OAB Navigator is one of the many ways we are striving at The OAB Clinic to provide the very best care for urinary incontinence. As a part of UT Erlanger Urology in Chattanooga, Tennessee, we are able to provide all of the resources that may be needed to care for urinary incontinence, no matter how complex. Please visit us or call at (423) 778-4OAB (4622) if we can help.

Colin M. Goudelocke, M.D.  FPMRS

These three simple and quick incontinence questions, based on the 3IQ incontinence questionnaire, can be very useful in helping you determine what type of incontinence you may be experiencing.

1. During the last 3 months, have you leaked urine (even a small amount)?

Urinary incontinence can be determined by simply asking someone if they ever experience urine leakage that is unintentional. Yet this ignores the fact that it is possible to experience occasional urinary leakage that may be infrequent enough that it is not bothersome. It may be more helpful to describe urinary incontinence as “the involuntary loss of urine” that poses a “social or hygienic problem”. For many patients with urine leakage, incontinence does represent a severe and bothersome stress that has social, financial and psychological consequences.

2. During what kinds of situations did you leak urine?

Beyond simply determining if urine leakage is bothersome, it is important to determine what type of incontinence you are experiencing. Urine leakage can occur in association with physical activity including coughing, sneezing, laughing, exercise or bending over. This is often referred to as Stress Incontinence. The “stress” refers to the increase in the pressure in your abdomen that results in the leakage.

In other patients, a sense of urgency (a sudden urge to urinate that is difficult to postpone) accompanies urinary leakage. Patients with Urgency Incontinence will often urinate frequently and urgently as well, trying to prevent urinary leakage.

Finally, patients may also experience loss of urine without either any exertion or sense of urgency.

3. During what kinds of situations did you leak urine most often?

While we generally describe urinary incontinence as being either Stress Incontinence or Urgency Incontinence, this does not mean that all patients will have either Urgency Incontinence OR Stress Incontinence. In fact, about 40% of patients (and the number may be much higher) with incontinence will experience both Stress Incontinence AND Urgency Incontinence to some degree. This is usually referred to as Mixed Incontinence.

But for many patients, it is useful to determine if either Stress Incontinence or Urgency Incontinence predominates, even if they experience both types. This allows us to focus on what is the more bothersome form of incontinence. It is not unusual for a patient to see improvement in one type of incontinence, only to realize that they have relatively little bother from the other type and do not need further therapy.

In those patients who do not find a connection between urine leakage and either coughing, sneezing, etc, or urgency, there may be another cause of incontinence (neurologic injury, fistula, etc) that needs to be investigated by a specialist in the field.

With three simple questions, patients can often, reliably, identify they type of incontinence they are experiencing. This is useful in guiding both an evaluation of the urine leakage as well as possible therapies available.

At The Overactive Bladder Clinic a part of UT Erlanger Urology in Chattanooga, Tennessee, we specialize in the evaluation and treatment of all forms of urinary incontinence. For more information, contact us at 423-778-4OAB (4622).

Colin M. Goudelocke, M.D.  FPMRS