Can hydroxyzine be used to treat overactive bladder?

Hydroxyzine for Overactive Bladder: Not Recommended

Hydroxyzine is not recommended for the treatment of overactive bladder as it is not included in any current clinical guidelines for OAB management.

First-Line Treatment Options for OAB

Behavioral Therapies

• Behavioral therapies should be offered as first-line treatment for all OAB patients 1
• These include:
  • Bladder training
  • Bladder control strategies
  • Pelvic floor muscle training
  • Fluid management
  • Weight loss (for obese patients)

Second-Line Treatment Options

If behavioral therapies are insufficient, pharmacologic options should be considered:

1. Beta-3 adrenergic agonists (preferred first-line pharmacologic treatment):

   • Mirabegron
   • Vibegron
   • Lower risk of cognitive side effects, especially important in older adults 2

2. Antimuscarinic medications (alphabetical order, no hierarchy implied):

   • Darifenacin
   • Fesoterodine
   • Oxybutynin
   • Solifenacin
   • Tolterodine
   • Trospium 1

Important Cautions with Antimuscarinic Medications

Antimuscarinic medications should be used with extreme caution in:

• Patients with narrow-angle glaucoma
• Patients with impaired gastric emptying
• Patients with history of urinary retention 1
• Patients at risk for cognitive impairment or dementia 1

Treatment Algorithm for OAB

1. Start with behavioral therapies (8-12 weeks trial)
2. If inadequate response, add pharmacologic therapy:
   • Beta-3 agonists preferred as initial pharmacologic therapy
   • Antimuscarinic medications as alternative options
3. If one medication is ineffective or causes unacceptable side effects:
   • Try dose modification
   • Switch to a different antimuscarinic medication
   • Switch to a beta-3 adrenergic agonist 1
4. For refractory cases:
   • Consider minimally invasive procedures:
     • Sacral neuromodulation
     • Tibial nerve stimulation
     • Intradetrusor botulinum toxin injection 1

Why Hydroxyzine is Not Recommended

Hydroxyzine, an antihistamine with anticholinergic properties, is notably absent from all major guidelines for OAB treatment 1. While it has anticholinergic effects that might theoretically affect bladder function, it is not FDA-approved for OAB and lacks clinical evidence supporting its use for this indication.

The AUA/SUFU guidelines specifically list the approved antimuscarinic medications for OAB, and hydroxyzine is not among them 1. Instead, the guidelines recommend specific antimuscarinic agents (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium) or beta-3 adrenergic agonists.

Potential Pitfalls in OAB Management

• Cognitive effects: Antimuscarinic medications are associated with increased risk of dementia and cognitive impairment, which may be cumulative and dose-dependent 1
• Inadequate trial duration: Behavioral therapies require 8-12 weeks for proper evaluation 1
• Failure to measure post-void residual: Important before starting antimuscarinic therapy in patients at risk for urinary retention 1
• Overreliance on pharmacologic therapy: Behavioral therapies are equally effective as antimuscarinic medications for symptom reduction 1

In conclusion, clinicians should follow established treatment algorithms for OAB that begin with behavioral therapies and progress to evidence-based pharmacologic options when necessary. Hydroxyzine is not supported by evidence or guidelines for OAB treatment.