What are alternative treatments for urinary urgency in women besides Myrbetriq (mirabegron), oxybutynin, and Trospium?

Alternative Treatments for Urinary Urgency in Women

Bladder training should be used as first-line treatment for urinary urgency in women, followed by pelvic floor muscle training and weight loss with exercise for obese patients, before considering pharmacologic alternatives to mirabegron, oxybutynin, and trospium. 1

Non-Pharmacologic Options (First-Line)

1. Bladder Training

   • Involves scheduled voiding and gradually extending time between voids
   • Strong recommendation with moderate-quality evidence 1
   • Should be attempted before any pharmacologic therapy

2. Pelvic Floor Muscle Training (PFMT)

   • Particularly effective for mixed urinary incontinence when combined with bladder training
   • Strong recommendation with moderate-quality evidence 1
   • Low-quality evidence shows PFMT plus bladder training improved UI more than tolterodine alone 2

3. Weight Loss and Exercise

   • Strongly recommended for obese patients with UI
   • Strong recommendation with moderate-quality evidence 1

Alternative Pharmacologic Options

If bladder training fails and alternatives to mirabegron, oxybutynin, and trospium are needed, consider:

1. Solifenacin

   • Lowest risk for discontinuation due to adverse effects among antimuscarinics 2, 1
   • Achieves continence more than placebo (NNTB, 10) 2
   • Better tolerated than immediate-release oxybutynin 1
   • High-quality evidence shows that higher doses (10 mg/d vs. 5 mg/d) did not decrease UI frequency but increased adverse effects 2

2. Darifenacin

   • Risk for discontinuation due to adverse effects similar to placebo 2, 1
   • May reduce systemic side effects 1
   • High-quality evidence supports efficacy 2

3. Tolterodine

   • Better side effect profile than oxybutynin 1
   • High-quality evidence showed tolterodine achieved continence (NNTB, 12) and improved UI (NNTB, 10) more than placebo 2
   • Risk for discontinuation due to adverse effects similar to placebo 2

4. Fesoterodine

   • Higher rates of adverse effects than tolterodine 1
   • Dry mouth and constipation are common side effects 1
   • Discontinuation due to adverse effects was higher with fesoterodine than tolterodine (NNTH, 58) 2

Advanced Therapeutic Options

For patients with severe refractory symptoms who fail pharmacologic therapy:

1. Sacral Neuromodulation (SNS)

   • Recommended for patients with severe refractory symptoms willing to undergo a surgical procedure
   • Moderate-strength evidence 1

2. Peripheral Tibial Nerve Stimulation (PTNS)

   • Alternative third-line treatment
   • Low-strength evidence 1

3. OnabotulinumtoxinA Injections

   • For patients with severe refractory symptoms
   • Requires counseling about potential need for self-catheterization
   • Moderate-strength evidence 1

Special Considerations

• Elderly patients: Avoid high doses of antimuscarinics due to increased risk of cognitive side effects 1
• Cognitive concerns: Consider medications with lower blood-brain barrier penetration 1
• Constipation: Choose antimuscarinic with lower constipation risk 1
• Dry mouth: Ensure adequate hydration, sugar-free gum/candy, or consider transdermal formulations 1

Comparative Effectiveness

• Pooled analyses showed that among drugs for urgency UI, continence was restored in 107 per 1000 women with solifenacin, 114 with trospium, and 130 with fesoterodine 3
• Discontinuation rates due to adverse effects were 13 per 1000 with solifenacin, 18 with trospium, and 31 with fesoterodine 3
• Combination therapy with mirabegron added to solifenacin may be considered for patients with inadequate response to monotherapy 4

Common Pitfalls and Caveats

• Don't overlook potential infectious causes in women with persistent symptoms 1
• Don't start antimuscarinic therapy without measuring post-void residual volume to minimize urinary retention risk 1
• Don't ignore fluid intake modification as a simple but effective intervention 1
• Discontinue medication if serious adverse effects occur (QT interval prolongation, tachycardia, anaphylactic reactions) 1
• Antimuscarinic side effects include dry mouth, constipation, and blurred vision; consider these when selecting therapy 2