What is the best approach for treating bladder spasms?

Treatment of Bladder Spasms

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

First-Line Treatment: Behavioral Modifications

• Bladder Training Program:

  • Implement timed voiding schedule based on patient's bladder diary
  • Start with short intervals (1-2 hours) and gradually increase as control improves
  • Include prompted voiding and assessment of urinary frequency and volume 1

• Pelvic Floor Muscle Training (PFMT):

  • Teach proper pelvic floor muscle contraction techniques
  • Recommend regular practice sessions
  • Consider EMG biofeedback to help visualize and improve muscle control 1

• Lifestyle Modifications:

  • Apply local heat or cold over the bladder or perineum for symptomatic relief 1
  • Reduce fluid intake by approximately 25%
  • Eliminate or significantly reduce caffeine intake
  • Encourage weight loss in obese patients (even 8% weight loss can reduce incontinence episodes by up to 47%) 1

Second-Line Treatment: Pharmacologic Therapy

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

  • Mirabegron: Start at 25mg daily with food
  • Shows effectiveness within 8 weeks at 25mg dose and within 4 weeks at 50mg dose
  • Preferred in elderly patients due to lower risk of cognitive side effects 1
  • Monitor for adverse effects such as hypertension, headache, and nasopharyngitis

• Antimuscarinic Medications:

  • Oxybutynin: FDA-approved for bladder instability; exerts direct antispasmodic effect on smooth muscle and inhibits muscarinic action of acetylcholine 2
    • Starting dose: 5 mg 2-3 times daily
    • Increases bladder capacity and diminishes frequency of uninhibited detrusor contractions 2
  • Alternative antimuscarinics: solifenacin, darifenacin, fesoterodine, tolterodine, or trospium
  • Use with caution in elderly patients due to risk of cognitive impairment 1
  • Common side effects include dry mouth, blurred vision, and constipation

• Combination Therapy:

  • Consider combination of antimuscarinic plus beta-3 adrenergic receptor agonist for patients failing monotherapy
  • Superior efficacy in reducing incontinence episodes and micturitions, though adverse events may increase slightly 1

Third-Line Treatments for Refractory Cases

• Neuromodulation Therapies:

  • Sacral neuromodulation (SNS): Appropriate for severe refractory OAB symptoms in patients willing to undergo surgical procedure 3
  • Peripheral tibial nerve stimulation (PTNS): Typically applied for 30 minutes once weekly for 12 weeks 3
  • Transcutaneous electrical stimulation of the foot: May provide relief from postoperative bladder spasms 4

• Intradetrusor OnabotulinumtoxinA Injections:

  • Consider for patients who have failed behavioral and pharmacologic therapy
  • Patient must be willing and able to return for post-void residual evaluations and perform self-catheterization if necessary 3
  • Note: May not be FDA-approved for non-neurogenic OAB 3

• Intravesical Medications:

  • Dimethyl sulfoxide (DMSO), Heparin, or Lidocaine can be used in patients who fail oral therapy 1

• Other Options for Specific Cases:

  • Lumbar sympathetic blockade: May be useful for malignancy-related bladder spasms 5
  • For men with concomitant BPH and bladder spasms: Consider alpha blockers, possibly in combination with antimuscarinic agents 1

Special Considerations

• Indwelling catheters are not recommended for management of bladder spasms except as a last resort due to high risk of UTIs, urethral erosion, and urolithiasis 3
• If catheterization is necessary, intermittent catheterization is preferred over indwelling catheters 1
• For post-operative bladder spasms (e.g., after prostate surgery), antimuscarinic medications like tolterodine can be effective (2 mg twice daily) 6
• For patients with incomplete bladder emptying, teach proper self-catheterization technique 1

When to Refer

• Refer patients who are refractory to behavioral and pharmacologic therapy to a urologist for specialized management
• Consider referral for third-line treatments such as intradetrusor onabotulinumtoxin injections, PTNS, or SNS 1