From the Guidelines
Overactive bladder can be effectively managed through a combination of behavioral techniques and medications, with the most recent guidelines recommending a stepped approach starting with lifestyle modifications and behavioral therapies, as outlined in the 2024 AUA/SUFU guideline 1, 2. The treatment of overactive bladder (OAB) should prioritize a patient-centered approach, taking into account symptom severity, comorbidities, and medication side effect profiles.
Initial Management
- Start with lifestyle modifications including bladder training, timed voiding, pelvic floor exercises, and limiting caffeine, alcohol, and fluid intake before bedtime, as these measures have been shown to be effective in managing OAB symptoms 3.
- Behavioral therapies, such as fluid management, caffeine reduction, physical activity/exercise, dietary modifications, and mindfulness, offer patients with OAB some efficacy, excellent safety, and few if any adverse effects 3.
Pharmacologic Therapies
- If lifestyle modifications and behavioral therapies are insufficient, anticholinergic medications like oxybutynin (5mg 2-3 times daily), solifenacin (5-10mg once daily), or tolterodine (2-4mg daily) can help by blocking bladder muscle contractions 4.
- Beta-3 agonists such as mirabegron (25-50mg daily) offer an alternative with fewer side effects like dry mouth and constipation 1.
Minimally Invasive Therapies
- For patients with inadequate response to oral medications, botulinum toxin injections into the bladder (100-200 units) can provide relief for 6-9 months 2.
- Neuromodulation therapy through sacral nerve stimulation or posterior tibial nerve stimulation may benefit those with refractory symptoms, with high success rates, durable efficacy, and excellent patient satisfaction 2.
Treatment Approach
- Treatment should be individualized based on symptom severity, comorbidities, and medication side effect profiles, with a focus on patient preferences and values 2.
- Anticholinergics should be used cautiously in elderly patients due to potential cognitive effects, and alternative treatments should be considered when necessary 4.
- Most patients see improvement within 2-4 weeks of starting medication, but may need to try different options to find the optimal treatment, highlighting the importance of a stepped approach and ongoing patient assessment 4, 2.
From the FDA Drug Label
Mirabegron extended-release tablets are indicated for the treatment of OAB in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency. The recommended starting dosage of mirabegron extended-release tablets is 25 mg orally once daily. If needed, increase to the maximum dosage of mirabegron extended-release tablets 50 mg orally once daily after 4 to 8 weeks.
Treatment of Overactive Bladder: Mirabegron is indicated for the treatment of overactive bladder (OAB) in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency.
From the Research
Overactive Bladder Treatment Options
- First-line treatment for overactive bladder (OAB) includes conservative measures such as weight reduction, decrease in exposure to bladder stimulants, fluid optimisation, and pelvic floor exercises 8
- Behavioral therapy is recommended as a first choice for OAB management, with pharmacologic treatment as second-line treatment, and onabotulinumtoxinA, peripheral tibial nerve stimulation, and sacral nerve stimulation as third-line therapy for patients refractory or intolerant to first- and second-line treatments 9
Pharmacological Treatments
- Anticholinergic medications such as oxybutynin are used as pharmacological treatments for OAB 8
- β3-adrenoceptor agonists are also used as pharmacologic treatment for OAB 9, 10
Lifestyle Modifications
- Reducing fluid intake can improve OAB symptoms, with a general consensus that caffeine reduction may be beneficial 11
- Obesity, smoking, and consumption of carbonated drinks are risk factors for OAB, while there is less support for the contributory role of caffeine or the impact of caffeine reduction 12
Bladder Training
- Bladder training is widely prescribed as a first-line treatment for OAB, and may be more effective than anticholinergics on cure or improvement at the early phase 10
- Bladder training may reduce the number of incontinence episodes, and there may be fewer adverse events compared to anticholinergics 10
- The evidence for bladder training is mostly low or very-low certainty, and more well-designed trials are needed to reach a firm conclusion 10