From the Guidelines
Underactive bladder treatment should prioritize a combination of behavioral modifications, medication, and intermittent catheterization, as there is no single effective treatment, as noted in the most recent guideline 1.
Treatment Approach
Treatment of underactive bladder typically begins with behavioral modifications, including:
- Timed voiding
- Double voiding (urinating, waiting a few minutes, then trying again)
- Pelvic floor exercises These methods aim to improve bladder emptying and reduce symptoms.
Medication Options
For medication options, alpha-blockers like tamsulosin (0.4mg daily) can help by reducing outlet resistance, as discussed in 1. However, the effectiveness of muscarinic and cholinergic agonists like bethanechol is limited, and their use is not widely recommended.
Intermittent Catheterization
Clean intermittent catheterization is often necessary when retention is significant, performed 4-6 times daily using sterile technique. This approach helps to ensure complete bladder emptying and prevent complications.
Surgical Options
For severe cases unresponsive to conservative measures, surgical options like sacral neuromodulation or reduction cystoplasty may be considered, as mentioned in 1. However, these options are typically reserved for patients who have failed other treatments and have significant symptoms.
Underlying Causes
Underactive bladder often results from neurological disorders (multiple sclerosis, diabetes, Parkinson's), prolonged bladder overdistension, or aging-related detrusor muscle deterioration. A comprehensive treatment plan should take into account the underlying cause of the condition and the patient's specific symptoms and needs.
Treatment Challenges
Unlike overactive bladder, which receives more attention, underactive bladder remains challenging to treat, with many patients requiring a combination of approaches tailored to their specific symptoms and underlying causes, as noted in 1 and 1.
From the Research
Definition and Diagnosis of Underactive Bladder
- Underactive bladder (UAB) is defined by the International Continence Society as a symptom complex characterized by a slow urinary stream, hesitancy, and straining to void, with or without a feeling of incomplete bladder emptying sometimes with storage symptoms 2.
- The exact etiology and pathophysiology for developing UAB is unknown, though it is likely a multifactorial process with contributory neurogenic, cardiovascular, and idiopathic causes 2.
- Diagnosis of UAB requires a pressure-flow study, and treatment alternatives are generally based on the evacuation of the lower urinary tract, independent of the etiology 3.
Treatment Options for Underactive Bladder
- Management options for females with UAB remain limited, with clean intermittent catheterization being the most commonly used 2.
- No pharmacotherapies have consistently been proven to be beneficial, but neuromodulation has had the most promising results in terms of symptom improvement 2.
- Other treatment options include alpha-blockers, cholinesterase inhibitors, muscarinic agonists, prostaglandin E2, and acotiamide, as well as surgical treatments such as sacral nerve stimulation-electrical stimulation and injections into the external sphincter 3.
- Newer technologies such as stem-cell therapy and gene therapy require more evidence before widespread use 2, 4.
Comparison with Other Conditions
- Underactive bladder is distinct from overactive bladder, which is characterized by urgency with or without urgency incontinence, usually with frequency and nocturia 5.
- Treatment options for overactive bladder, such as bladder training and anticholinergic drugs, may not be effective for underactive bladder 5, 6.
- Further research is needed to develop targeted therapeutic interventions for underactive bladder based on its unique pathophysiologic mechanisms 2, 4.