What are the treatment options for bladder spasms?

Treatment Options for Bladder Spasms

Bladder spasms should be treated using a stepwise approach starting with behavioral modifications, followed by pharmacologic therapy with antimuscarinic medications or beta-3 adrenergic receptor agonists, and progressing to more invasive options for refractory cases. 1, 2

First-Line Treatments: Behavioral Modifications

Behavioral modifications should be implemented for all patients with bladder spasms:

• Bladder training: Establish a timed voiding schedule based on the patient's bladder diary, starting with short intervals (1-2 hours) and gradually increasing as control improves 2
• Pelvic floor muscle exercises: Teach proper contraction techniques to help control urgency 2
• Fluid management:
  • Reduce fluid intake by approximately 25% 2
  • Eliminate or significantly reduce caffeine intake 2
  • Avoid bladder irritants such as coffee, citrus products, spicy foods, and tomatoes 2, 3
• Application of local heat or cold over the bladder or perineum 1
• Weight loss for obese patients (even 8% weight loss can reduce incontinence episodes by up to 47%) 2

Second-Line Treatments: Pharmacologic Therapy

If behavioral modifications provide inadequate relief, pharmacologic therapy should be initiated:

Beta-3 Adrenergic Receptor Agonists (Preferred First-Line Medication)

• Mirabegron: Start at 25mg daily with food; effectiveness seen within 8 weeks 2, 4
  • Preferred in elderly patients due to lower risk of cognitive side effects 2
  • Monitor for adverse effects including hypertension, headache, and nasopharyngitis 2

Antimuscarinic Medications

• Oxybutynin: Start at 5mg 2-3 times daily (2.5mg 2-3 times daily in frail elderly) 2, 5
  • Use with caution in elderly due to risk of cognitive impairment 2, 5
  • Effective half-life of approximately 2-3 hours (5 hours in elderly) 5
• Alternative antimuscarinics: Solifenacin, darifenacin, fesoterodine, tolterodine, or trospium 2
  • Tolterodine (2mg twice daily) has shown effectiveness for catheter-induced bladder spasms after prostate surgery 6

Combination Therapy

• Consider combination therapy with an antimuscarinic plus beta-3 adrenergic receptor agonist for patients who fail to achieve adequate symptom relief with monotherapy 2

Third-Line Treatments: Intravesical Therapies

For patients who fail behavioral and oral pharmacologic therapy:

• Intravesical medications:
  • Dimethyl sulfoxide (DMSO) 1, 7
  • Heparin 1
  • Lidocaine 1, 7
  • Oxybutynin 7

Fourth-Line Treatments: Neuromodulation and Advanced Therapies

For refractory cases:

• Neuromodulation therapies:

  • Sacral neuromodulation (SNS) 2, 7
  • Peripheral tibial nerve stimulation (PTNS) 2
  • Transcutaneous electrical stimulation of the foot (has shown promise in reducing postoperative bladder spasms) 8

• Intradetrusor onabotulinumtoxinA injections 2

• Lumbar sympathetic blockade at L4 (may be useful for malignancy-related bladder spasms) 9

Special Considerations

For Men with Benign Prostatic Hyperplasia (BPH)

• Alpha blockers are typically the initial therapy 2
• For men with concomitant BPH and bladder spasms, consider combination of alpha-blocker and antimuscarinic 2
• For prostate size >30cc, consider adding 5-alpha reductase inhibitors (5ARIs) 2

For Patients with Interstitial Cystitis/Bladder Pain Syndrome

• Consider additional medications:
  • Amitriptyline 1, 7
  • Hydroxyzine 1, 7
  • Pentosan polysulfate 1, 7
  • Cimetidine 1
• For Hunner's lesions, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1

For Patients with Neurogenic Detrusor Overactivity

• Mirabegron is indicated for pediatric patients aged 3 years and older weighing 35 kg or more 4

Important Cautions and Considerations

• Anticholinergic medications may alter the absorption of concomitantly administered drugs due to effects on gastrointestinal motility 5
• Use caution when combining anticholinergic agents with CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, erythromycin) as they may increase oxybutynin concentrations 5
• For catheter-related bladder spasms, antimuscarinic medications can provide significant relief 6
• Pain management should be considered as a component of treatment but does not constitute sufficient treatment alone 1