Curr Bladder Dysfunct Rep (2014) 9:48–51
DOI 10.1007/s11884-013-0218-3
OVERACTIVE BLADDER (U LEE, SECTION EDITOR)
History of the Term “Overactive Bladder”
Diana Cardona-Grau & Sara Spettel
Published online: 30 November 2013
# Springer Science+Business Media New York 2013
Abstract The history of the term overactive bladder touches
many of the favorite controversies in urology; standardization
of often subjective symptoms, the distinction between normal
and disease, the role of industry, and the significance of a
finding on urodynamic studies versus a patient’s chief com-
plaint. This review explores the evolution of the term overac-
tive bladder, from its popularization by Drs. Abrams and Wein
in 1997 to the formalization by the ICS in 2002. We discuss
the rationale for the use of the term over others, particularly
the transition from multiple urodynamics based definitions to
a symptoms-based definition and the arguments supporting as
well as criticizing the shift. Lastly, we explore the history of
pharmaceutical involvement surrounding the use of this term.
The term overactive bladder is only 15 years old, but its
invention and history drastically changed the way we discuss
and treat voiding dysfunction, and its definition or perhaps,
inevitable successor, could very well do the same in years to
come.
Keywords Overactive bladder . History . Terminology .
Urodynamic . Pharmaceutical . OAB
Introduction: The Conference Title
The history of the term overactive bladder touches many of
the favorite controversies in urology; standardization of often
S. Spettel (*)
Urologic Consultants, P.C., 9135 SW Barnes Rd, Ste 663, Portland,
OR 97225, USA
e-mail: spettel@portlandurology.com
D. Cardona-Grau
Department of Surgery, Division of Urology, Albany Medical Center,
23 Hackett Blvd MC 208, Albany, NY 12208, USA
e-mail: cardond@mail.amc.edu
subjective symptoms, the distinction between normal and
disease, the role of industry, and the significance of
urodynamic testing versus a patient’s chief complaint. The
term overactive bladder (OAB) was not in common use until
15 years ago, it was famously introduced in 1997 by Drs. Paul
Abrams and Alan Wein when they co-chaired a 1997 consen-
sus conference titled, “The Overactive Bladder: From Basic
Science to Clinical Management.” One of the key goals of the
conference was to develop a symptom-based definition of
troublesome lower urinary tract symptoms, without need for
urodynamic studies [1]. The conference title and subsequent
proceedings introduced the term OAB into widespread use.
The exact definition underwent revisions and was later stan-
dardized by the International Continence Society (ICS) in
1999 and finally formalized in 2002 as: “urgency, with or
without urge incontinence, usually with frequency and
nocturia in the absence of an underlying metabolic or patho-
logic condition” [2].
Even before the formalization process, the term overactive
bladder and abbreviation OAB quickly made its way into the
peer literature and medical vocabulary. As Abrams writes of
the 1999 ICS subcommittee discussions, “it became clear that
the introduction of overactive bladder had acquired an ‘un-
stoppable’ momentum” [3].
Prior to the consensus conference, the terms to describe
urge and urge incontinence symptoms were based on findings
on urodynamic study. By creating a definition based on symp-
toms, the term OAB changed the landscape of urinary symp-
toms, and continues to be a source of debate for urologists to
this day.
Movement Away from Urodynamic Basis
Prior to the introduction of overactive bladder, the two terms
used to classify conditions were unstable bladder/detrusor
Curr Bladder Dysfunct Rep (2014) 9:48–51
instability and detrusor hyperreflexia. The instability termi-
nology is attributed to Patrick Bates of England of the “blad-
der is an unreliable witness” fame, while many Scandinavian
researchers used hyperreflexia. As a compromise, these were
standardized as separate entities with unstable bladder/
detrusor instability used to describe patients with involuntary
detrusor contractions seen on urodynamic studies without
obvious etiology, while detrusor hyperreflexia referred to
patients with a neurologic etiology. The term overactive
detrusor w as used as the generic, overarching term but was
still based on urodynamic findings.
The clinical conditions associated with the above defini-
tions whether caused by a neurologic etiology or not were
classified as motor urgency and motor urge incontinence.
Other terms used to describe detrusor hyperreflexia included
hypertonic, systolic, uninhibited, spastic, or automatic
detrusor. Urgency and urge incontinence without an involun-
tary contraction on UDS was referred to as “sensory urgency”
or “sensory urge incontinence” [4]. These terms have been
eliminated from the current definitions.
Urologists have long recognized that urodynamically based
diagnosis of the lower urinary tract symptoms posed several
challenges. Issues discussed at the 1997 consensus conference
were that urodynamic testing is a somewhat invasive and
complex test which requires a specialist, thus initial evaluation
for OAB symptoms was deemed unnecessary and not eco-
nomically feasible [5]. Furthermore, the sensitivity in detect-
ing involuntary detrusor contractions can be variable depend-
ing on how the study is performed and given that urodynamic
studies only capture one instance of filling and voiding, this
isolated study can differ from long-term ambulatory monitor-
ing [5]. The subsequent literature from the conference pro-
posed preserving detrusor overactivity or overactive detrusor
as a urodynamic-based definition that describes a particular
type of detrusor dysfunction during filling cystometry, how-
ever, observed the need for a symptom based definition, thus
the term overactive bladder.
Rationale for OAB
As stated by Dr. Wein, the impetus behind the term OAB was
to describe the “common condition in a manner that was
useful both for primary-care practitioners and specialists, that
could imply initial, non-invasive therapy without the need for
complicated, expensive, or invasive studies” [1].
The exact wording for the term overactive bladder was
largely based on Drs. Wein and Abram’s personal experience
using it with their own patients and in discussing with other
providers who found it easier to understand. As Abrams states,
“In the English language, "unstable" has connotations of
mental instability, and physicians talking about the unstable
bladder had always to be careful not to insult the sensibilities
49
of the patient” [3]. As mentioned, the term detrusor overac-
tivity was previously used by the ICS, and the term OAB was
informally used in publications as early as 1989 [6]. The
current ICS definitions keep detrusor overactivity as a separate
urodynamic finding from the symptom complex of overactive
bladder.
The original definition of OAB from the consensus con-
ference was “a medical condition referring to the symptoms of
frequency and urgency, with or without urge incontinence,
when appearing in the absence of local pathologic or meta-
bolic factors that would account for these symptoms” [7]. This
was further qualified with causing “profound impairment on
quality of life and not requiring incontinence for diagnosis
because roughly half of the people with overactive bladder do
not have incontinence” [7]. One of the longstanding discus-
sion points for the OAB definition is the question of whether
incontinence or “fear or leakage” fits into the definition.
The published definition in the 2002 ICS standardization
report is “urgency, with or without urge incontinence, usually
with frequency and nocturia in the absence of an underlying
metabolic or pathologic condition” [8••]. This definition in-
cluded the additional symptom of nocturia to the original
definition proposed in the consensus conference in 1997. In
this document, OAB is referred to as overactive bladder
syndrome with synonyms provided as urge syndrome and
urgency-frequency syndrome.
To complicate the history of terms, the definition of urgen-
cy, itself a key component of OAB, as well as incontinence,
which is not a component of the definition, have also under-
gone revisions during this time. Urgency was changed in the
2002 ICS definitions from “strong desire to void accompanied
by fear or leakage or pain” to “sudden, compelling desire to
pass urine that is difficult to defer.” Incontinence was revised
from “involuntary loss of urine that is a social or hygienic
problem” to “urinary incontinence is the complaint of any
involuntary leakage” whether bothersome or not [3].
An interesting 2012 opinion poll of leading expects in
urinary incontinence and OAB highlights the continued vari-
ability of both the workup and definition of the symptom
complex [8••]. The article emphasizes that, “OAB is not
necessarily the same disease process in every patient but,
rather, a collection of symptoms that create bother caused by
one of many possible disease processes” [8••]. One of the
findings from the study was the continued perception of some
experts of OAB as a marketing term.
Pharmaceutical Involvement
As the authors of this review, we remember as residents a
well-known visiting professor mentioning off-hand that the
term OAB was originally a pharmaceutical invention- a story
both Drs. Wein and Abrams have refuted several times.
50
Abrams himself alludes to the often noted connection between
pharmaceuticals and OAB as he writes in the introduction to
the book “The Overactive Bladder: Evaluation and Manage-
ment,” “The overactive bladder is not a new disease or a term
invented for those willing to sell pills to patients” [9].
A 2012 editorial in European Urology editorial is one of the
more recent to criticize the pharmaceutical industry’s involve-
ment with marketing and research centered around the term
OAB. In this article, the authors observe that, “For pharma-
ceutical companies, OAB has undeniably proved lucrative—
the proverbial “goose that laid the golden egg’ [10•].
As the authors point out, the 1997 consensus conference
was supported by the company Pharma, as part of an educa-
tional grant, the same company that then introduced the drug
tolterodine. Dr. Abrams has stated in several of his publica-
tions that the company initially opposed the term. In response
to the 2012 editorial cited above he writes, “The company
objected to our idea because the drug that they intended to
bring to market would have been granted a licence for use in
patients with the diagnosis of "unstable bladder", which the
editorial rightly points out was the term accepted by the
regulators at that time. However we insisted on the use of
OAB, the company finally conceded” [8••].
As the editorial summarizes, whereas previous drugs had
been licensed for urodynamically confirmed bladder instabil-
ity, in 1998, the US Food and Drug Administration approved
tolterodine for the treatment of “symptoms of overactive
bladder.” As it states, “Multimillion-dollar promotional cam-
paigns (including direct-to-consumer advertising in some
countries) followed” [7].
One of the goals of the new term was to describe the
symptom complex in more accessible and readily understood
terms. Few would disagree that the introduction of the term
helped to increase awareness of the OAB symptoms, and
increased number of primary care physicians treating the
symptoms. The move away from urodynamic to symptoms
based-definition occurred at the same time as an increase in
number and prevalence of anticholinergic medications. An
“Illustrative quote” from the expert interviews above states,
“I am very sensitive to OAB being a dummied-down concept
to enhance the industry of antimuscarinics.”
One’s view of the pharmaceutical industry’s role in the
marketing of OAB has much to do with one’s view of the
industry and the positives and negatives the relationship im-
parts. As Abrams states, “Researchers should work with in-
dustry, and not for industry, remembering that our first respon-
sibilities are to science and to our patients” [11].
Indeed, as physicians we are both scientifically and clini-
cally inclined. As such, our scientific inclinations cry out for
strict definitions and objective criteria for almost any condition,
particularly when it comes to treatment. Clinically and practi-
cally, however, we treat patients and their symptoms and in
many conditions we do not have strict definitions and objective
Curr Bladder Dysfunct Rep (2014) 9:48–51
criteria. This sentiment is very accurately described by Abrams
when he writes “most medical conditions are not black or white
but have an element of grey” [11]. Thus, while some criticize
the definition of OAB for being vague and the lack of speci-
ficity, this reflects that grey area described by Dr. Abrams.
The Leaders
Many of the papers cited on the history of the term OAB have
the involvement of the two co-chairs of the conference, Drs.
Wein and Abrams two of the leading experts in our field.
As the authors of this review, we have found it somewhat
remarkable in reading through the discussions and criticisms
of the term OAB over the last 15 years to follow a basic
pattern: either Dr. Wein or Abrams will author a paper or
chapter about the term which is followed by responses critical
of the term. Alternatively, they will respond to an article
critical of the term, usually inviting the author to join them
at the next ICS symposium to hash out their ideas. Same
pattern, 15 years. One can almost hear Dr. Abrams sigh when
he writes, “if a better term emerges, then I would be the first to
support it. However, the term we have is OAB, and to imagine
that the term stops all scientific thinking is wrong” [12].
We believe the bottom line comes down to patient care and
the benefit to our patients, while OAB may not be the perfect
term; it gives both primary providers and patients treatment
options. It allows for some degree of classification and pro-
vides a diagnosis to what can be a frustrating and elusive
symptom complex. Over the course of 15 years the
term has been scrutinized extensively and undergone
revision but as Dr. Abrams points out- until better terms
arise, OAB is what we have.
Conclusions
The symptoms patients present with over the years, and for the
most part the underlying pathology, remain the same, but as
our understanding and treatment options improve, we develop
new terminology to classify and treat. The term overactive
bladder is only 15 years old, but its invention and history
drastically changed the way we discuss and treat voiding
dysfunction, and its definition or perhaps, inevitable succes-
sor, could very well do the same in years to come.
Compliance with Ethics Guidelines
Conflict of Interest Diana Cardona-Grau and Sara Spettel declare that
they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
Curr Bladder Dysfunct Rep (2014) 9:48–51
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Wein A. Symptom-based diagnosis of overactive bladder: an over-
view. Can Urol Assoc J = J Assoc Urol Can. 2011;5(5 Suppl 2):
S135–6.
2. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U,
et al. The standardisation of terminology of lower urinary tract
function: report from the Standardisation Sub-committee of the
International Continence Society. Am J Obstet Gynecol.
2002;187(1):116–26.
3. Abrams P. Describing bladder storage function: overactive bladder
syndrome and detrusor overactivity. Urology. 2003;62(5 Suppl 2):
28–37. discussion 40–22.
4. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff
JW. Definition of overactive bladder and epidemiology of
urinary incontinence. Urology. 1997;50(6A Suppl):4–14. dis-
cussion 15–17.
5. Wein AJ, Rovner ES. Definition and epidemiology of overactive
bladder. Urology. 2002;60(5, Supplement 1):7–12.
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6. Fall M, Ohlsson BL, Carlsson CA. The neurogenic overactive bladder.
Classification based on urodynamics. Br J Urol. 1989;64(4):368–73.
7. Abrams P, Wein AJ. Introduction: overactive bladder and its treat-
ments. Urology. 2000;55(5, Supplement 1):1–2.
8.•• Lee UJ, Scott VC, Rashid R, Behniwal A, Wein AJ, Maliski SL,
et al. Defining and managing overactive bladder: disagreement
among the experts. Urology. 2013;81(2):257–62. An interesting
opinion poll of experts in the field discusses the defintion and
workup of overactive bladder. Highlights the "art of medicine" even
in our ever increasingly standardized field.
9. Kreder KD, R. The overactive bladder evaluation and management.
In. 1st ed. Informa Healthcare; 2007, p. 438.
10.• Tikkinen KA, Auvinen A. Does the imprecise definition of overac-
tive bladder serve commercial rather than patient interests? Eur
Urol. 2012;61(4):746–8. discussion 749–750. One of the more
prominent critics of the role of industry in marketing and research
of overactive bladder discusses commericial interests. See also
response by Abrams and Wein below.
11. Abrams P, Wein A. Re: Kari A.O. Tikkinen, Anssi Auvinen. Does
the imprecise definition of overactive bladder serve commercial
rather than patient interests? Eur Urol 2012;61:746–8: the origin
of the term overactive bladder, industry, and patient care. Eur Urol.
2012;61(4):749–50.
12. Abrams P. Response to OAB, are we barking up the wrong tree? A
lesson from my dog. Neurourol Urodyn. 2011;30(8):1409. discus-
sion 1412–1404.