From the Guidelines
Assessment and management of overactive bladder (OAB) should begin with a thorough evaluation including medical history, physical examination, urinalysis, and bladder diary to document voiding patterns and symptoms, as recommended by the AUA/SUFU guideline 1. The evaluation process is crucial for determining the presence of OAB and ruling out other potential causes of symptoms.
- A thorough medical history should be taken to identify any underlying medical conditions that may be contributing to OAB symptoms.
- A physical examination should be performed to assess for any abnormalities that may be related to OAB.
- Urinalysis should be obtained to rule out infection or other conditions that may be causing symptoms.
- A bladder diary should be kept to document voiding patterns and symptoms.
First-line treatment involves behavioral modifications such as fluid management, timed voiding, bladder training, and pelvic floor exercises, as stated in the AUA/SUFU guideline 1. These modifications can help to reduce symptoms of OAB and improve quality of life.
- Fluid management involves adjusting fluid intake to avoid excessive urine production.
- Timed voiding involves voiding at regular intervals to avoid urgency and frequency.
- Bladder training involves gradually increasing the time between voiding to improve bladder capacity.
- Pelvic floor exercises, such as Kegel exercises, can help to strengthen the muscles that support the bladder and improve bladder control.
For patients who don't respond adequately to these measures, anticholinergic medications like oxybutynin (5mg 2-3 times daily), solifenacin (5-10mg daily), tolterodine (2-4mg daily), or beta-3 adrenergic agonists such as mirabegron (25-50mg daily) can be prescribed, as suggested by the AUA/SUFU guideline 1.
- Anticholinergics work by blocking muscarinic receptors in the bladder, reducing detrusor muscle contractions, but may cause side effects like dry mouth, constipation, and cognitive issues, particularly in older adults.
- Mirabegron causes fewer anticholinergic side effects but may increase blood pressure.
For refractory cases, advanced options include botulinum toxin injections into the bladder (100-200 units, lasting 6-9 months), posterior tibial nerve stimulation (weekly 30-minute sessions for 12 weeks, then maintenance therapy), sacral neuromodulation, or surgical interventions like augmentation cystoplasty, as stated in the AUA/SUFU guideline 1. Treatment should be individualized based on symptom severity, comorbidities, and patient preferences, with regular follow-up to assess efficacy and adjust therapy as needed, as recommended by the AUA/SUFU guideline 1.
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. Mirabegron was evaluated in three, 12-week, double-blind, randomized, placebo-controlled, parallel group, multicenter clinical trials in patients with overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency (Studies 1,2, and 3) The co-primary efficacy endpoints in all 3 trials were (1) change from baseline to end of treatment (Week 12) in mean number of incontinence episodes per 24 hours and (2) change from baseline to end of treatment (Week 12) in mean number of micturitions per 24 hours, based on a 3-day micturition diary Tolterodine tartrate tablets were evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in four randomized, double-blind, placebo-controlled, 12-week studies.
Assessment and Management Options:
- Medications: Mirabegron and tolterodine are indicated for the treatment of overactive bladder (OAB) in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency.
- Key Considerations:
- Mirabegron should be administered with caution to patients taking muscarinic antagonist medications for the treatment of OAB and in BOO because of the risk of urinary retention.
- The efficacy of mirabegron was maintained through the 12-week treatment period.
- Tolterodine tartrate tablets were evaluated in four randomized, double-blind, placebo-controlled, 12-week studies.
- Efficacy Endpoints:
From the Research
Assessment of Overactive Bladder
- The assessment of overactive bladder (OAB) involves a targeted history and examination of the urogenital system to determine the burden of disease on the patient 4.
- A thorough clinical assessment and appropriate investigations are required for those with persistent symptoms following conservative therapy, including treatment of any underlying pathology 5.
- The diagnosis of OAB is one of exclusion, and it is essential to rule out any underlying conditions that may be contributing to the symptoms 4, 6.
Management Options for Overactive Bladder
- First-line treatment for OAB includes conservative measures such as lifestyle interventions, including weight reduction, decrease in exposure to bladder stimulants, fluid optimization, and pelvic floor exercises 4, 6, 7.
- Pharmacological treatments for OAB include anticholinergic medications such as oxybutynin, and antimuscarinic agents 5, 4, 8.
- For patients who are unresponsive to pharmacological treatment, minimally invasive procedures such as intravesical botulinum toxin A injections may be considered 4, 8.
- Sacral neuromodulation and other emerging treatments such as targeted secretion inhibitors, liposome integrated botulinum toxin A, and gene therapy may also be effective for some patients 8.
- In severe cases, reconstructive surgery or catheter insertion may be considered as a last resort 5, 6.
Lifestyle Interventions
- Lifestyle interventions, including fluid manipulation, weight reduction, and smoking cessation, may be beneficial in reducing OAB symptoms 7.
- Reducing fluid intake and caffeine consumption may improve OAB symptoms, although further clinical trials are needed to determine the optimal fluid intake and timing 7.