What are the treatment options for overactive bladder?

Treatment Options for Overactive Bladder

The first-line treatment for overactive bladder (OAB) should be behavioral therapies, including bladder training, pelvic floor muscle training, and fluid management, as these are as effective as antimuscarinic medications but without the risk of adverse effects. 1

Treatment Algorithm

First-Line: Behavioral Therapies

1. Lifestyle Modifications

   • Weight loss (even 8% reduction can decrease incontinence episodes by up to 47%) 1
   • Establish timed voiding schedule based on bladder diary 1
   • Reduce fluid intake by approximately 25% 1
   • Eliminate or significantly reduce caffeine intake 1

2. Pelvic Floor Muscle Training

   • Regular exercises to strengthen pelvic floor muscles 1
   • No adverse effects reported in clinical studies 1

3. Bladder Training

   • Start with short voiding intervals (1-2 hours) and gradually increase as control improves 1
   • May be more effective than anticholinergics for symptom improvement 1

Second-Line: Pharmacological Options

If behavioral therapies fail after 4-8 weeks, proceed to medications:

1. Beta-3 Adrenergic Receptor Agonists

   • Mirabegron (preferred first-line medication, especially in elderly) 1, 2
     • Starting dose: 25 mg once daily 2
     • May increase to 50 mg once daily after 4-8 weeks if needed 2
     • Success defined as ≥50% reduction in UI episodes within 8 weeks 1
     • Dosage adjustments for renal impairment:
       • eGFR 30-89 mL/min: 25 mg (max 50 mg)
       • eGFR 15-29 mL/min: 25 mg (max 25 mg)
       • eGFR <15 mL/min: Not recommended 2
     • Dosage adjustments for hepatic impairment:
       • Child-Pugh Class A: 25 mg (max 50 mg)
       • Child-Pugh Class B: 25 mg (max 25 mg)
       • Child-Pugh Class C: Not recommended 2

2. Antimuscarinic Medications

   • Oxybutynin (5 mg twice daily is most cost-effective) 1

     • Use with caution if post-void residual 250-300 mL 1
     • For elderly (>65 years), start with 2.5 mg twice daily 1
     • Extended-release or transdermal formulations may reduce dry mouth 1

   • Tolterodine (alternative antimuscarinic) 3

     • Indicated for OAB with symptoms of urge incontinence, urgency, and frequency 3

   • Assess efficacy after 2-4 weeks 1

Third-Line: Advanced Therapies (for refractory cases)

1. Intradetrusor OnabotulinumtoxinA Injections 1

   • For patients who fail behavioral and pharmacologic therapy

2. Neuromodulation Therapies 1

   • Sacral neuromodulation (SNS) for patients willing to undergo surgery
   • Peripheral tibial nerve stimulation (PTNS) - typically 30 minutes weekly for 12 weeks

Management of Common Side Effects

• Dry mouth: Switch to extended-release oxybutynin or transdermal formulation 1
• Constipation: Increase fluid and fiber intake, consider stool softeners 1
• Urinary retention: Check post-void residual, reduce dose or discontinue if >200 mL 1

Special Considerations

• Elderly patients: Higher risk of cognitive side effects with antimuscarinics; consider mirabegron as first-line pharmacotherapy 1
• Annual follow-up is recommended to reassess symptoms and treatment efficacy 1
• Patient education is essential for treatment success, empowering active participation in care 1

Common Pitfalls to Avoid

1. Skipping behavioral therapies - These should always be tried first before medications
2. Not checking post-void residual in patients with obstructive symptoms or history of incontinence 1
3. Inadequate treatment duration - Allow 4-8 weeks to assess efficacy of medications 1, 2
4. Not addressing side effects promptly - Side effects are a major cause of treatment discontinuation
5. Overlooking comorbidities - Adjust medication choice and dosing based on renal/hepatic function 1, 2