What are the treatment options for Overactive Bladder (OAB)?

Treatment Options for Overactive Bladder (OAB)

Behavioral therapies should be offered as first-line treatment to all patients with OAB, followed by pharmacologic options such as beta-3 agonists or antimuscarinics when needed, with combination therapy for refractory cases. 1

Initial Evaluation

When evaluating a patient with OAB symptoms:

• Obtain a comprehensive medical history focusing on:

  • Duration and severity of urgency, frequency, and incontinence episodes
  • Impact on quality of life
  • Previous treatments and their effectiveness
  • Comorbidities that may affect OAB (BPH, diabetes, neurological conditions)

• Physical examination should include:

  • Abdominal exam to assess for bladder distention
  • Pelvic/genital exam to identify prolapse or atrophy
  • Neurological assessment if neurogenic causes are suspected

• Laboratory testing:

  • Urinalysis to exclude infection and hematuria
  • Post-void residual measurement in patients with:
    • Emptying symptoms
    • History of urinary retention
    • Neurological disorders
    • Prior prostate or incontinence surgery
    • Long-standing diabetes

Treatment Algorithm

Step 1: Behavioral Therapies (First-Line for All Patients)

Behavioral therapies offer excellent safety profiles with few adverse effects and should be offered to all patients 1:

• Bladder training:

  • Scheduled voiding with progressive increases in voiding intervals
  • Urge suppression techniques

• Lifestyle modifications:

  • Fluid management (moderate reduction in overall intake)
  • Caffeine reduction
  • Weight loss for overweight/obese patients
  • Physical activity/exercise
  • Dietary modifications (reduce bladder irritants)

• Pelvic floor muscle training:

  • Supervised exercises to strengthen pelvic floor muscles
  • May include biofeedback techniques

Important note: While dietary modifications are commonly recommended, a recent systematic review found inconsistent evidence regarding the association between potential bladder irritants (alcohol, spicy foods, chocolate, artificial sweeteners, caffeinated/carbonated beverages, and high-acid foods) and OAB symptoms 2. Nevertheless, individual patients may still benefit from identifying and avoiding specific triggers.

Step 2: Pharmacologic Therapy (When Behavioral Therapies Are Insufficient)

If behavioral therapies alone are inadequate:

• Beta-3 adrenergic agonists (e.g., mirabegron):

  • Starting dose: 25 mg once daily
  • May increase to 50 mg once daily after 4-8 weeks if needed 3
  • Preferred first-line pharmacologic option due to lower risk of cognitive effects 1

• Antimuscarinic medications:

  • Options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium
  • Use with extreme caution due to potential cognitive risks:
    • Evidence suggests association with incident dementia
    • Risk may be cumulative and dose-dependent 1
  • Consider transdermal oxybutynin if dry mouth is a concern 1

Step 3: Combination Therapy for Refractory Cases

For patients with inadequate response to monotherapy:

• Combine behavioral therapy with pharmacologic therapy
• Consider combination of beta-3 agonist and antimuscarinic
• Monitor improvement carefully and discontinue ineffective therapies 1

Step 4: Minimally Invasive Therapies

For patients who fail conservative and pharmacologic options:

• Botulinum toxin A bladder injections
• Sacral neuromodulation
• Percutaneous tibial nerve stimulation

Special Considerations

Medication Adjustments for Special Populations

• Renal impairment:

  • For eGFR 30-89 mL/min/1.73m²: Mirabegron 25-50 mg daily
  • For eGFR 15-29 mL/min/1.73m²: Mirabegron 25 mg daily maximum
  • For eGFR <15 mL/min/1.73m²: Mirabegron not recommended 3

• Hepatic impairment:

  • Mild impairment (Child-Pugh A): Mirabegron 25-50 mg daily
  • Moderate impairment (Child-Pugh B): Mirabegron 25 mg daily maximum
  • Severe impairment (Child-Pugh C): Mirabegron not recommended 3

Incontinence Management Strategies

For patients with urgency urinary incontinence, discuss management options:

• Absorbent products (pads, liners, protective underwear)
• Barrier creams to protect skin
• External collection devices when appropriate 1

Common Pitfalls to Avoid

1. Skipping behavioral therapy: Don't bypass behavioral interventions, as they have similar efficacy to medications with minimal risk 1, 4.

2. Overreliance on antimuscarinic medications: Be cautious with these medications due to potential cognitive effects, especially in older adults 1.

3. Recommending unproven supplements: There is insufficient evidence to support nutraceuticals, vitamins, supplements, or herbal remedies for OAB 1.

4. Failing to monitor treatment response: Regularly assess symptom improvement and adjust therapy accordingly.

5. Introducing multiple therapies simultaneously: When combining therapies, add one at a time to determine individual impact 1.

By following this evidence-based approach to OAB management, clinicians can help patients achieve significant improvement in symptoms and quality of life while minimizing risks.