What is the initial therapy for overactive bladder?

Initial Therapy for Overactive Bladder

Behavioral therapies should be offered as first-line treatment to all patients with overactive bladder (OAB) before initiating pharmacologic therapy. 1, 2

Diagnostic Evaluation Before Treatment

Before initiating treatment, a proper diagnosis should be established:

1. Medical history focusing on:

   • Duration and severity of bladder symptoms
   • Presence of urgency, frequency, nocturia, and incontinence
   • Previous treatments and their effectiveness

2. Physical examination:

   • Abdominal exam to assess for bladder distention
   • Pelvic examination in women to evaluate for pelvic organ prolapse
   • Digital rectal examination in men to assess prostate
   • Lower extremity assessment for edema
   • Cognitive function assessment (impacts treatment options)

3. Basic testing:

   • Urinalysis to exclude infection and hematuria 1
   • Urine culture if urinalysis suggests infection 1
   • Post-void residual (PVR) assessment before starting medications 2

First-Line Treatment: Behavioral Therapies

Behavioral therapies are recommended as first-line treatment because they are risk-free, can be tailored to individual patients, and are as effective as antimuscarinic medications in reducing symptoms 1, 2:

1. Bladder training:

   • Establish normal voiding intervals with progressive scheduling
   • Delayed voiding techniques to gradually increase time between voids
   • Urgency suppression techniques

2. Pelvic floor muscle training:

   • Regular exercises to improve urinary control
   • Quick contractions to suppress urgency

3. Fluid management:

   • Reduce fluid intake by approximately 25% if experiencing frequency 2
   • Eliminate or significantly reduce bladder irritants (caffeine, alcohol) 2

4. Weight management:

   • Even modest weight loss (8%) can reduce incontinence episodes by up to 47% in obese patients 1, 2

5. Bladder diary:

   • Document voiding patterns, fluid intake, and symptoms to track progress 1, 2

Second-Line Treatment: Pharmacologic Options

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

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

   • Mirabegron (starting dose 25mg daily with food) 2, 3
   • Lower risk of cardiovascular and cognitive side effects compared to antimuscarinics 2
   • Demonstrated efficacy in reducing incontinence episodes and micturition frequency 3

2. Antimuscarinic medications (alternative options):

   • Solifenacin, darifenacin, fesoterodine, tolterodine, trospium 2, 4
   • Oxybutynin (starting dose 5mg 2-3 times daily) 2
   • Use with caution in elderly patients due to risk of cognitive impairment 2
   • Transdermal formulations have lower incidence of dry mouth 2

Treatment Algorithm

1. Start with comprehensive behavioral therapies for 4-8 weeks
2. If inadequate response, add pharmacologic therapy:
   • First choice: Beta-3 agonist (mirabegron)
   • Alternative: Antimuscarinic medication
3. If single agent is ineffective, consider combination therapy with beta-3 agonist and antimuscarinic 2
4. For treatment failures, refer to specialist for third-line therapies:
   • Botulinum toxin injections
   • Neuromodulation (sacral or tibial nerve stimulation)

Important Considerations and Pitfalls

• Post-void residual monitoring: Check PVR before initiating antimuscarinic therapy and if symptoms worsen; use with caution if PVR >250-300mL 1, 2
• Cognitive effects: Avoid antimuscarinic medications in elderly patients or those with cognitive impairment due to increased dementia risk 2
• Patient education: Essential component of treatment as it empowers patients to actively participate in their care 1, 2
• Realistic expectations: Most cases of OAB are not cured but symptoms can be significantly reduced with improved quality of life 5
• Comorbidity management: Address conditions that may worsen OAB symptoms (BPH, constipation, diabetes) 1, 2

The 2024 AUA/SUFU guidelines have moved away from strict step therapy, emphasizing shared decision-making to select the best therapy based on patient preferences and side effect tolerance 1. However, behavioral therapies remain the cornerstone of initial treatment due to their safety profile and comparable efficacy to medications.