Activity Transcript

Ekene Enemchukwu, MD, MPH: Hi. Hello, I'm Ekene Enemchukwu. I'm an assistant professor of urology and obstetrics and gynecology, urogynecology by courtesy at Stanford School of Medicine in Palo Alto, California. Welcome to this program titled "Overactive Bladder Patient Journey: Closing the Loop on Long-Term Care."

Joining me today is Dr Diane Newman, who is an adjunct professor of urology and surgery at University of Pennsylvania in Philadelphia, Pennsylvania. Welcome, Diane.

Diane Newman, DNP, FAAN, BCB-PMD: Thanks for having me.

Dr Enemchukwu: We'll be going over the burden of OAB, particularly in different patient populations, and we'll really focus mostly on older patients. We'll also discuss some factors contributing to diagnostic delays, how to address patient needs in care plans, and then also in selecting treatment.

But first, let's start with a definition of OAB. Overactive bladder is a symptom complex that's characterized by bothersome urgency, which is a sudden and compelling desire to pass urine which is difficult to defer. It's often associated with urgency incontinence, as well, which is an involuntary loss of urine associated with urgency. It's also often associated with urinary frequency, which is going to the bathroom for greater than 8 times per 24-hour period. It's also often associated with nocturia, which is getting up to go to the bathroom 2 or more times at night. And this is all in the absence of urinary tract infections or other pathology.

Now when we look at the prevalence of overactive bladder, we can see that it's about 16% in men, about 17% in women, so roughly equal in terms of prevalence in terms of men and women. That prevalence increases with age. And so to put it in a little bit of perspective, OAB is a more prevalent condition than heart disease. We're talking about a pretty common condition.

OAB with urgency incontinence increases more sharply with age among women. OAB without urgency incontinence is more prevalent among men. This may be in men associated with an enlarged prostate, but understand that men can have OAB without an enlarged prostate. It's really important that although we may prescribe an ɑ-blocker, it may not always be the answer. It's often more complex and warrants further evaluation.

In terms of race and ethnicity, there've been a number of studies looking at OAB prevalence. These studies consistently demonstrate a higher rate of OAB in African American and Hispanic patients. In fact, there's some recent data showing higher rates of detrusor overactivity on neurodynamics in minority populations. However, there's also some other data that shows that race and ethnicity may be serving as a proxy for other risk factors. And so we have some data showing that there are higher rates of reported urge urinary incontinence in patients with low socioeconomic status, and that certain social determinants of health are associated with overactive bladder in urge urinary incontinence. This is more likely to be a multifactorial association, and further studies are really needed to determine causality.

I think it's important to really emphasize, again, that OAB is problematic in older individuals. In a national sample of over 2000 women aged 50 to 80, about half of those patients reported urinary incontinence in the past year; 41% described their leakage as problematic.

And so, I think we'll ask Diane here to talk a little bit more about the burden of OAB and how it affects patients.

Dr. Newman: Thank you so much. You know, that last slide that you showed was a survey of aging women and it shows that, yes, these women have these complaints, but they don't come forward. And that's what's so very disturbing about this. There is bother and research has shown that women are very bothered by overactive bladder symptoms. Men may be not as much, but they're almost equal. The strongest predictors of bother is that symptom that you discussed, urinary urgency. They'll go more frequently and they may have to get up at night to urinate. There is quite a bit of bother with this.

I've been practicing for a long time, and I think that why I love my practice, is the fact that I see the change in the treatments that we have, how it improves individuals of their quality of life. Because overactive bladder has a significant impact on daily life. Women, especially, report anxiety and depression. If they have nocturia, they're going to have sleep disturbance and they report a worse quality of sleep. But it does impact everything, such as interference with daily activities. They're less physically active because maybe that activity causes urine leakage. There is an issue with intimacy and sexual activity. They have low self-esteem. And the 1 thing that comes up all the time is stigmatization of these symptoms and the embarrassment that people report.

Now there is a disease progression here, and we're talking about overactive bladder in the older adult. And what happens is that in the early stages, they cope with it. And I'll show you in a minute some of the coping strategies. Especially if they're working, they may be depressed or anxious over having maybe not being able to access the bathroom. And then we do see this trajectory in the older population with moving into we call step care: assisted living and possibly even long-term care.

One of the things that's very important is that, yes, overactive bladder does impact quality of life, but it also causes other medical morbidities. We know that moderate to severe OAB symptoms are associated with frequent falls. They're trying to get to the toilet, they rush there because of that urgency and that fear of having incontinence. So there is quite a bit of association with falls. And you and I know that with falls, what happens with that breaking a bone, such as the hip, and then that trajectory as far as immobility and even mortality is increased.

And there's been quite a bit of data on this. There was a 2018 systematic review of 15 studies that showed that a portion of patients with OAB experience at least 1 fall over the year. Look at that, 18.9% to 50%. And then those recurrent and serious falls increase with individuals OAB, but it is a higher risk, 1.3 to 2.2 times more often seen in individuals OAB. And of course, this is in that older population. There's also a study that was done in long-term-care residents that 36% of falls, again, occurred while attempted to go to the bathroom. Because not just those individuals living at home, but it's also those that may be in a long-term-care facility.

The cost is something that we're all concerned about, especially government insurers, such as Medicare and Medicaid. But it also has an impact on work productivity. Higher unemployment, lower work productivity. I think about that all the time in the checkout counter. What do people do if they have OAB and they're checking out your groceries? I don't see anybody rushing to the bathroom, but I'm sure a lot of those women do have OAB. It has increased medical absenteeism. And then, of course, the cost of absorbent products, which can be in the billions. As far as total cost, we're looking at those individuals who may be need more care, but also those living in the community. There's direct and indirect costs that, again, run into the billions of dollars.

But, as I said before, I've been practicing since the '80s in this field, and those numbers have not changed as far as those who seek treatment. Few individuals, especially women, seek care for overactive bladder even though we have lots of treatments. Why do they delay it? Again, that stigmatization around this condition. Us providers are not very good about asking patients about symptoms. You see this comes up a lot in the primary care literature. A lot of individuals think it's part of aging, so, hey, the problem isn't that important, I'll deal with it. There's lack of maybe access to care. We talked about diversity as far as different populations that we treat and, of course, insurance complexities. Maybe the treatment that we, as providers, feel is important for that patient, or what that patient needs, insurers may not be covering it.

But the strongest predictors of treatment seeking though is, again, that older individual and the degree of bother. I'm sure that both of us can talk about patients who, when we ask them how long they've had the problem, it's years. It's not something that has just occurred in the past few weeks or months. It's something they’ve lived with for years and something triggered them to seek help.

Why women don't seek treatment, we are not quite clear on, but the point is they live with it years by self-management. They right away go buy pads. I have many patients who tell me they don't go on trips. They've recently retired, their spouse wants them to travel. I have 1 patient recently travel around the world. She said, "Diane, I can't because I don't know if I'm going to get the pads I need." They stop drinking. They think if they don't drink, they're not going to have OAB symptoms. They avoid exercising because exercise may trigger those symptoms. They start that what we call toilet mapping going more frequently, where their whole day is structured around knowing where the access to the bathroom is. They'll go to the mall, they'll go in the entrance where there's a toilet there so they can go before they start shopping. They stop there on their way out.

But tell me a little bit more about how we can manage OAB. Where do you see some of these gaps?

Dr. Enemchukwu: Yeah, I think a lot of the points you make are so important. I think, certainly, when they come in, we need to be ready to treat them. And the American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) have come out with guidelines to give us a framework for how to treat these patients. And again, they emphasize that it's a framework. It's not meant to be a rigid clinical pathway where patients need to go through step o1ne, step 2, step 3. And so when they talk about that framework, the first line involves a lot of behavioral therapy. That's going to be evaluating the patient's fluid intake. They might be drinking too much, they may be drinking too little, they may be drinking too much caffeine, too much carbonated fluid. So really identifying bad habits. They're identifying bladder irritants.

We also talk about weight loss. If patients are overweight, certainly, counseling them on ways to lose weight are going to impact their overall health. They're also going to positively impact their bladder health. I do also caution physicians to not say, just go lose weight and don't help the patient otherwise. Because again, Diane just talked about that catch-22, where being obese can sometimes worsen your symptoms and make it difficult to exercise and do the things that are going to help. In addition to really encouraging them to lose weight, also arm them with other tools to help with their symptoms.

Smoking cessation, definitely important. Lots of health benefits there. I don't think anyone will argue at that. Constipation management, I think, is one that we don't talk enough about. If a patient is having bowel dysfunction, it's not unreasonable to think that it may be causing some of their urinary dysfunction, as well, so managing that, I tell my patients, "We need to optimize your pelvic floor, and part of that is to optimize your bowel so that we can make your bladder better." Bladder training with urge suppression, pelvic muscle training, those are things that we can review with the patient there in the office or refer them to a formal pelvic floor physical therapist, if they have that available to them, to help them learn those strategies. I often tell my patients that first line of behavioral therapy, that's really the foundation to therapy. We can really optimize this. Then everything else that we may need to go to in the future will work that much better.

For second-line therapies, the guidelines mentioned medication. We have 8 medications. Oral medications are available to us now. Six of them fall into the category of antimuscarinics, and 2 fall into β₃ agonists. With the antimuscarinics, because these all work on the M3 receptor, they all have similar side effects of constipation, dry mouth, and can cause cognitive dysfunction. Now when we look at these, they're not all completely created equal. Certainly, the studies show, that they are probably equally effective. But in terms of side effects, our extended-release formulations are a little bit better in terms of dry mouth, maybe constipation. We know that trospium, which is a quaternary amine, is a little bit of a larger molecule and has some other features that cause it to probably be less likely to cross the blood-brain barrier. There are some little differences there.

We talk about β₃ agonists. Mirabegron has the potential side effect of hypertension. Vibegron, which is probably a more selective β₃ agonist, does not have that potential side effect or that label. When we look at combination therapy, it's interesting. We can actually add antimuscarinics to β₃ agonist. And there's data to show that there's an additive effect there. There's some benefit there, as well. But again, it's really important to look at the patient's overall medications, look at the overall patient, make sure that this isn't going to cause any undue side effects to that patient.

And finally, third-line therapies. These are often offered to the patient if they have failed first-line therapies, not great candidate for second-line therapies, or failed the second-line therapy or just intolerant of medications. And so these are often offered in the office. They include intradetrusor onabotulinumtoxinA, which is given cystoscopically in the office under a local anesthetic. There's peripheral tibial nerve stimulation, which is also offered in the office, weekly therapy over 12 weeks. And there's sacral nerve stimulation, which the first step in that therapy can also be offered in the office.

With so many therapies, you would think there's so many therapies we find something that works for the patient. But a lot of the time, what we also think we see is a noncompliant patient. But Diane brought up a couple of barriers that patients go through, really below the surface. OAB is a chronic condition with many barriers to therapy success. It's really important that we try to find those barriers for our patients so that we can give them the best chances of being successful.

What are some of those barriers? That's going to be high out-of-pocket costs, side effects, lack of therapy efficacy. There can be time constraints. Patients sometimes just have unrealistic expectations for what the therapies are supposed to do, and they stop it prematurely because of that. There can also be treatment fatigue. And so it's important that we're checking in with the patient. There's lack of knowledge. Sometimes the patient just doesn't understand. Sometimes it's the patient versus the provider's perspective are different. The patient's goals are different from what the provider thinks the patient's goals are. And so communication there is important.

And then we talked a little bit earlier about unmet social needs, lack of access. Sometimes there's not great relationships with the provider. There may be embarrassment, poor past experiences. There could be some mistrust with the system, insurance complexity, as Diane mentioned. And then it can go as far as food insecurity, financial stress, food deserts, and lack of stable housing that can make it impossible for the patients to even fill the prescription that you just wrote or to cut out any of the bladder irritants that may be contributing to their symptoms.

As I mentioned earlier, we have data that shows that there's higher rates of reported urge urinary incontinence in low-socioeconomic-status patients and that certain social determinants of health are associated with OAB and urge urinary incontinence. We also have data that shows that mental disorders, such as depression and anxiety, have been associated with urinary incontinence. And likely, this is related to changes in maybe neurotransmitter function, which could affect bladder regulation. In terms of access, we also know that commercially insured racial and ethnic minorities with overactive bladder are less likely to undergo third-line therapies for OAB. Still don't fully understand why that is. Access is probably multifactorial as we talked about earlier. But what we do know is that it is a complex issue that can be addressed by educating and increasing awareness among our providers to try to identify these barriers and arm patients with individualized resources

In terms of unmet social needs, it's more complex than even what I just talked about. Diane, can you talk a little bit about some of the unmet needs with older patients?

Dr Newman: Yeah. You really did a nice review of all the things that can impact care and maybe why these individuals are not coming forward. And then you get into the aging adult. And what we have found is that there's so many more additional things that we have to think about. The mobility of that individual. I mean, is mobility one of the reasons why they're at risk for falls in addition to their overactive bladder symptoms. Cognitive function. And I'm not talking about someone that's necessarily with dementia, but someone that's forgetful that that can be really a problem. Manual dexterity. I mean, I did a lot of work in actually home care for years, watching individuals try to manipulate clothes, to go to the bathroom. It's really been both men and women having problems with that. Poor upper- and lower-extremity strength. Can they lift themselves up from a chair to walk to the bathroom? Visual problems. And then we see more neurologic conditions in this population: Parkinson's, stroke. And then, of course, polypharmacy. That is such a problem with the aging adult. And so many drugs interact that there's a concern, especially with a burden of anticholinergic medications. It's not just necessarily overactive bladder medications.

Older adults are a heterogeneous group, but unmet needs will differ depending on where they live. Are they community dwelling? I am seeing, and I'm sure you are seeing, many, many more older individuals working. I have 90-year-olds still working at least part-time. And some individuals who need to work in their 60s and 70s. Can they void at will? That's a British term that Occupational Safety and Health Association (OSHA) uses actually. Are you in a job where you can really access the bathroom? Do you have bathroom breaks? In factories, do they have enough stalls for the number of women working? In the long-term-care resident, they may need just a little bit of assistance to get to the bathroom. Do you have staff to help them? And then frailty is a really whole other area in older adults. And we're seeing much more frail individuals as they age because of the fact that we're living longer. There's a lot of things you've got to think about in that older adult patient.

Dr Enemchukwu: Agreed, agreed. And this really leads me to what we should be thinking about when we're managing OAB. Should we be looking at the whole patient and consider their goals and expectations? Obviously, that's a rhetorical question. Yes, we should. But just curious for you, Diane, are there any particular tools that you use when you're talking about goals and expectations for patients? Or is just part of your assessment when you're talking to them?

Dr Newman: Well, I tried to find out what do they want from the outcome. Because you did a great review of the AUA/SUFU guidelines, and we have first-, second-, and third-line treatments, but what do they want from it? If they want to go to a wedding in a week and not have to worry about leakage, I may not start a behavioral therapy because that's going to take weeks. I may prescribe a medication. And sometimes I will listen to a history and maybe I listen to a lot of incontinence and I think, well, that's terrible. But really, what that individual is worried about is getting up at night and falling. You really have to determine, you listen to them, you listen to their symptoms, but what is their goal and what do they want from their treatment? It can be like, it's detective work. Sometimes it can be very difficult to figure that out especially in the older adult. Sometimes these older adults bring a family member. They live with their child and the child may have different goals than the parent does. Sometimes it can be really difficult.

You have presented some of this as far as identifying barriers and facilitators to improve engagement and adherence. And I think that all of us clinicians need that. Can you go over a little bit of that for us?

Dr Enemchukwu: Yes, absolutely. I think I agree with everything that you've said and I think it summarizes it to say that certainly, discussing therapeutic goals and personal barriers are going to be very important here, discussing the importance of behavioral therapies as the foundation of OAB. But again, I like your point about individualizing it. We can't just throw the whole kitchen sink at every single patient that comes in. We really got to listen to the patient, tailor it, and individualize what they need. If they're going to a wedding next week, you can give them some hints. "Hey, if you go drink a bunch of champagne at the wedding, you're probably going to be in the bathroom a lot. Maybe try to avoid that and drink a little bit more water or something else to try to manage that."

You want to review their medications. And you talked a lot about polypharmacy, and that's so important. There's even data that show that there are patients who have dementia, for example, that go in and they fill prescriptions for anticholinergic medications because they're not aware, and we'll talk a little bit more about that later. And we don't want to be the ones prescribing that medication if patient shouldn't be on it. And then comorbidities when we're recommending medications, as well, that's really important.

And so I think some good examples of baseline assessments, if you wanted to use a formal assessment, would be looking at social determinants of health. I'll share one of those that I like to use. Frailty assessment, which you talked about. Some people use the get up and go test, some people evaluate the patient based on how mobile they are, how well they're able to answer your questions, or if they have a family member with them that's answering all of their questions. There are a number of ways to look at that. There's also the Self-Assessment Goal Achievement, or the SAGA, which I like, which is a way for the patient to assess and list their goals and then to prioritize them on a scale of 1, not very important, to 5, very important. Simply to ask the patient, "What is your most bothersome symptom?" Sometimes it's hard, as you've mentioned, to nail that down. But really making the patient think about what it is that bothers them the most so that we can really try to laser focus their therapy. And then there's a Treatment Burden Questionnaire, which I like a lot and I use occasionally, which allows clinicians to really evaluate competing treatment burden. It makes sure that this is, again, high priority for the patient.

And so the one I like to use for social determinants of health would be the CMS Accountable Health Community standardized screening. And this one has 5 core domains. It looks, again, at housing instability, food insecurity, transportation difficulties, utilities assistance, interpersonal safety concerns. It's so important to get that baseline assessment. Other domains that are really important, again, and, Diane, you've mentioned this, is family and social supports. What's the patient education level? What's their employment or financial strain? I liked what you mentioned before about the person checking out the groceries at the grocery store. It's difficult to have OAB and hold that job, so then more likely to be unemployed and more likely to have the stress and anxiety, more likely to have the OAB. It's kind of this catch-22, and you want to try to help that patient so that they can hold down a job. And then finally, mental health and disability, which we've talked about already.

And so, I think for older patients, we have to be even more cognizant of other unique challenges that they may have. And so, Diane, what should we particularly think about among older patients?

Dr Newman: Well, you've mentioned a few, and I think the 1 is the comorbidities. We're going to see more and more individuals that have associated symptoms that may be neurologic in the basis and be affecting the bladder. Like I said, Parkinson's, stroke. Diabetes does affect the bladder. Their polypharmacy, what medications are they taking? Mobility is a big issue in the older adult, and their balance. A lot of times, I'll say, where is your bathroom? If the older adult's bathroom is upstairs next to their bedroom, but they're on the first floor their entire day, they may not be able to access it. And you're in California and I'm in Philly. Philly's really an old city. We have row houses where you have 3 stories. And really, the access to bathroom is a major problem for some of these older adults. Sometimes if I'm worried about mobility and balance, I actually do refer to physical therapy to help them get some of that strength back. Cognition is also an issue.

And you brought up the bowels. I mean, this is such an issue in actually older and younger patients. I ask about it all the time and I worry, adding, say, maybe an antimuscarinic overactive bladder medication that has a side effect of constipation if they're already having problems with constipation. You have to think about that. And the other, really, big concern, I think, sometimes we miss is the fact that they do restrict their fluid intake. The older adult does because they're so concerned about wetting. And the belief is, "If I don't drink, then I'm not going to have urine in my bladder, I'm not going to have overactive bladder, I'm not going to have urgency frequency." But actually, we see dehydration, especially in summer months when it's really hot.

There is really a pathway that we follow as far as assessment of an older male or female patient. And we do think about outside the box or outside the bladder, these other areas. And we need to do, really, a lot of active case finding in this population. As far as activities of daily living (ADL[s]), I always say, if they can dress themselves, then they should be able to manage toileting, especially based on their mobility. What type of examination may you do? I do my focus -- abdominal, genital, digital rectal examination -- but I also do some neurologic as far as I watch their gait. Are they able to pick up things? Are they, like I said, able to manage disrobing? And then I try to do diaries. I don't know what success you have with them, but they can be really helpful to determine what's going on when they're home. I want to know what your patterns are, I want to know what your problems are. And then any associated symptoms. Overactive bladder should not be painful. If they have hematuria, recurrent urinary tract infections (UTIs), recent pelvic surgery, women who have prolapse beyond the introitus, if you suspect any of these things, you may need referral.

But in that age group, in actually any age group, overactive bladder can be treated in that primary care environment. You want to come up with a diagnosis as far as do they have mixed symptoms, do they have stress and urgent continence with overactive bladder? And then as we know, we do move forward following the AUA guidelines, which has really given us a care pathway in this population that we can use.

Let's go into a little bit more about whether other considerations as far as polypharmacy, and I'm sure you're concerned about anticholinergic burden, and that's really the big issue, isn't it now, especially its impact on cognition in the older adult.

Dr Enemchukwu: Absolutely, absolutely. We have a growing body of literature that just shows that the use of anticholinergic medications for greater than 3 months is associated with increased risk of dementia. I think that that's concerning, and that's a data point that I do share with all of my patients so that they can be informed and they can make a decision as to whether they want to try an anticholinergic or not. And we really need to think about that, again, in our frail patients and our elderly patients.

And so the other important piece of that is that the anticholinergic burden is associated with increased risk of falls and fractures. And you went over that, as well. We have that cohort study of long-term care residents, over 120,000 of them, and it shows that the healthcare resources are increased as you increase your anticholinergic burden in this population. We see more outpatient emergency room (ER) physician visit costs that, again, are increasing with anticholinergic burden. And those patients, once they have a fall or fracture, then the predicted annual costs are higher for them than their age-matched cohorts. Of course, we care about the individual patient, but we need to also be responsible, I think, as a healthcare society that we're being great stewards of our healthcare costs with patients and trying to prevent these bad outcomes as much as we can.

I think part of that involves leveraging our entire healthcare interprofessional team to reach this goal. It's very doable. Diane, what are the roles of various members of the interprofessional care team in identifying and addressing unmet needs and managing OAB for your patients?

Dr Newman: Yeah, you're right. We need an interprofessional team. And everybody plays a role. As a nurse practitioner, you're a physician, and we have physician assistants, we're prescribers, that's true. But we also assess, diagnose, and treat. They really are the key as far as identifying this condition and treating it. But the nurse, registered nurse is extremely important because in my practice, and I'm sure in yours, they really work with the patient on the phone. They hear about any complaints they have with what we prescribe. But also, they educate the patient on the condition and the different treatments. Pharmacists also play a role. A lot of absorbing products now, of course, are sold in pharmacies. And I do know that patients ask pharmacists about what is the best product for me. And of course, they're integral for drug management as far as what we prescribe. But we've mentioned the physical therapist and occupational therapist. When I did home care in Philadelphia for years, where I assessed individuals with urinary incontinence. I brought in occupational therapist to help me get people to the bathroom. I found them invaluable because they came up with really great ideas and assistive devices to use that really helped to get that individual more mobile. And then a physical therapist, especially mobility and helping that individual as far as maximizing what they're able to do. It's a team effort here, and I want to stress that. And in the older adult, I think the team is even bigger because you're seeing so many more problems with that population.

Dr Enemchukwu: Yeah, I couldn't agree more. And sometimes it feels a little overwhelming when you feel as if you need to do it all. But as the provider, you don't need to do it all, really, leveraging this other team. I love how you just broke that down.

I'd like to go ahead and summarize it a little bit. Again, OAB being a symptom complex characterized by bothersome urgency with or without urgency incontinence or nocturia in the absence of UTIs or other pathologies. I love how Diane really emphasized the fact that we need to be checking for these other potential conditions and make sure that we're not missing anything. The prevalence and burden certainly increase with age. And so, with our older population, we really need to be screening and looking for these symptoms. It's associated with worse overall quality of life and higher individual and societal costs.

Management treatment decisions -- we really need to consider the whole patient. Not every patient is the same. We need to try to tailor our therapies, screen for barriers, facilitators, try to engage the patients in their therapy. We have to consider costs. Everyone's insurance is a little bit different. We have unmet social needs that need to be considered. Comorbidities, polypharmacy, anticholinergic burden, these are all things that we should be thinking about. And specifically, in the older patient, we need to think about dehydration. I've got to say that’s something that I think is not emphasized enough and how that can contribute to these symptoms. Timing of their medications, talk about things like diuretics and when they're taking it and how that can contribute to things. There's living situation, their caregiver, life expectancy, mobility, disability. I think that these are all important things and I think that Diane did a great job of reviewing all of that.

And finally, use of interprofessional teams can really aid in identifying and addressing unmet needs, treatment selection, and overall management.

I really want to thank Diane, for this great discussion and great points that you brought up and reviewed with us today.

Dr Newman: Well, thank you for having me. But, yes, this is a really great discussion. I hope that our viewers and who listen to this understand that just because an individual is older, doesn't mean that we cannot treat their overactive bladder.

Dr Enemchukwu: Absolutely, agree 100%. And I want to thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation. Thanks so much.

This transcript has been edited for style and clarity.