What are the treatment options for overactive bladder?

Treatment Options for Overactive Bladder

Behavioral therapies should be offered as first-line treatment to all patients with overactive bladder (OAB), followed by pharmacotherapy as second-line treatment, and minimally invasive procedures as third-line options for refractory cases. 1, 2

First-Line Treatment: Behavioral Therapies

Behavioral therapies are recommended as initial treatment due to their effectiveness and lack of side effects:

• Bladder training: Timed voiding, urgency suppression techniques
• Pelvic floor muscle training: Exercises to improve urge control
• Fluid management: Reducing fluid intake by 25% can decrease frequency and urgency
• Dietary modifications: Avoiding bladder irritants (caffeine, alcohol)
• Weight loss: For obese patients, even 8% weight reduction can reduce incontinence episodes by up to 47% 1

These behavioral approaches are as effective as antimuscarinic medications in reducing symptom levels and improving quality of life 1.

Second-Line Treatment: Pharmacotherapy

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

Preferred First-Line Pharmacologic Options:

• Beta-3 adrenergic agonists (mirabegron, vibegron): Preferred due to lower risk of cognitive side effects, especially in older adults 2, 3
  • Starting dose: 25 mg once daily
  • May increase to 50 mg once daily after 4-8 weeks if needed

Alternative Pharmacologic Options:

• Antimuscarinic medications 1:
  • Darifenacin
  • Fesoterodine
  • Oxybutynin (oral or transdermal)
  • Solifenacin
  • Tolterodine 4
  • Trospium

Important: Antimuscarinic medications are contraindicated in patients with narrow-angle glaucoma unless approved by an ophthalmologist 1. Use caution in elderly patients due to risk of cognitive effects 2.

If one medication is ineffective or causes intolerable side effects, clinicians should consider:

1. Dose modification
2. Switching to a different antimuscarinic
3. Switching to a beta-3 adrenergic agonist 1

Third-Line Treatment: Minimally Invasive Procedures

For patients with moderate to severe symptoms who fail to respond adequately to behavioral and pharmacologic treatments, consider 1, 2:

• Intradetrusor onabotulinumtoxinA injections (100 U)
• Sacral neuromodulation (SNS)
• Peripheral tibial nerve stimulation (PTNS)

Note: Patients must be willing to perform clean intermittent self-catheterization if considering botulinum toxin injections, and must be able to make frequent office visits if considering PTNS 1.

Fourth-Line Treatment: Invasive Therapies

For severe, refractory cases, surgical options may include:

• Urinary diversion
• Bladder augmentation cystoplasty 2

Special Considerations

• Renal impairment: Adjust medication dosages accordingly. For mirabegron, patients with eGFR 15-29 mL/min/1.73m² should not exceed 25 mg daily 3
• Hepatic impairment: Adjust medication dosages. Mirabegron should be limited to 25 mg daily in moderate hepatic impairment and is not recommended in severe impairment 3
• Men with BPH and OAB: Consider combination therapy with an alpha-blocker and an antimuscarinic 2

Monitoring and Assessment

• Track frequency of urination, urgency episodes, and incontinence episodes
• Monitor for signs of urinary retention, especially in at-risk patients
• Obtain post-void residual if symptoms worsen or do not improve adequately 2

Most OAB cases are not cured but can be effectively managed with significant symptom reduction and improved quality of life through a comprehensive treatment approach 2, 5.