What are the treatment options for overactive bladder?

Treatment Options for Overactive Bladder

The treatment of overactive bladder (OAB) should follow a comprehensive approach that includes behavioral therapies as first-line treatment for all patients, followed by pharmacotherapy with beta-3 agonists preferred over antimuscarinics due to cognitive safety concerns, and progressing to minimally invasive therapies for refractory cases. 1

Initial Evaluation and Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Obtain medical history focusing on urinary urgency, frequency, and urgency incontinence
• Perform physical examination
• Conduct urinalysis to exclude infection and hematuria 1

Treatment Algorithm

First-Line: Behavioral Therapies

Behavioral therapies should be offered to ALL patients with OAB due to their excellent safety profile and lack of side effects:

• Bladder training techniques:

  • Timed voiding
  • Urgency suppression techniques
  • Delayed voiding strategies

• Lifestyle modifications:

  • Fluid management (optimizing timing and volume)
  • Caffeine reduction
  • Alcohol reduction
  • Physical activity/exercise
  • Dietary modifications (avoiding bladder irritants)
  • Weight loss if applicable 1

• Pelvic floor muscle training:

  • Can be provided by specialized healthcare professionals
  • May include biofeedback techniques 1

Second-Line: Pharmacotherapy

If behavioral therapies alone are insufficient, medication should be added:

1. Beta-3 adrenergic agonists (preferred first choice):

   • Mirabegron (MYRBETRIQ): Starting dose 25mg once daily, may increase to 50mg after 4-8 weeks if needed 2
   • Better cognitive safety profile than antimuscarinics 1

2. Antimuscarinic medications (use with caution):

   • Options include oxybutynin, tolterodine, solifenacin, darifenacin, trospium
   • Oxybutynin has demonstrated significant clinical improvement in controlled studies 3
   • CAUTION: Antimuscarinics are associated with increased risk of dementia and cognitive impairment, particularly with cumulative and long-term use 1
   • Use with extreme caution in older adults or those with pre-existing cognitive concerns

Third-Line: Minimally Invasive Therapies

For patients who fail to respond adequately to behavioral and pharmacologic therapies:

• Botulinum toxin (Botox) bladder injections
• Sacral neuromodulation
• Percutaneous tibial nerve stimulation 1

Fourth-Line: Invasive Therapies

Reserved for severe, refractory cases:

• Urinary diversion
• Bladder augmentation cystoplasty 1

Combination Approaches

For patients with inadequate response to monotherapy, clinicians may combine multiple approaches:

• Behavioral therapy + pharmacotherapy
• Different classes of medications (beta-3 agonist + antimuscarinic)
• Behavioral therapy + minimally invasive therapy 1

When combining therapies, add one intervention at a time to determine individual impact of each therapy on symptoms.

Important Clinical Considerations

Antimuscarinic Cognitive Risks

• Strong evidence suggests association between antimuscarinic medications and increased risk of dementia
• Risk appears cumulative and dose-dependent
• Beta-3 agonists are typically preferred before antimuscarinic medications due to this risk 1

Incontinence Management

For patients with urgency urinary incontinence, discuss management strategies:

• Pads, liners
• Absorbent underwear
• Barrier creams
• External catheters when appropriate 1

Ineffective Treatments

Counsel patients that there is insufficient evidence to support:

• Nutraceuticals
• Vitamins
• Supplements
• Herbal remedies 1

Monitoring and Follow-up

• Assess treatment success and adverse events 2-4 weeks after initiating therapy
• If treatment is successful, annual follow-up is appropriate
• If treatment fails, reassess and consider alternative or additional therapies 1

Remember that OAB is typically not cured but managed, with the goal being symptom reduction and quality of life improvement. The treatment approach should prioritize safety while effectively addressing the patient's symptoms.