Treatment of Overactive Bladder in Females
First-line treatment for overactive bladder (OAB) in females should be behavioral therapies, which are as effective as antimuscarinic medications but with no risk of adverse effects. 1
Initial Evaluation
- Comprehensive medical history focusing on bladder symptoms, including urgency, frequency, nocturia, and incontinence 1, 2
- Physical examination to identify contributing factors such as pelvic organ prolapse or genitourinary syndrome of menopause 1
- Urinalysis to exclude urinary tract infection and hematuria 1
- Post-void residual measurement in patients with risk factors (emptying symptoms, history of retention, neurologic disorders, prior incontinence surgery) 1
- Optional: symptom questionnaires and/or voiding diary to document baseline symptoms and monitor treatment response 1
Treatment Algorithm
First-Line: Behavioral Therapies
- Bladder training: timed voiding and gradual extension of voiding intervals 1, 3
- Pelvic floor muscle training to improve urge suppression techniques 1, 4
- Fluid management: optimizing timing and volume of fluid intake 1, 2
- Dietary modifications: reducing bladder irritants (caffeine, alcohol, carbonated beverages) 2, 5
- Weight loss for obese patients (8% weight loss can reduce urgency incontinence episodes by 42%) 1
Second-Line: Pharmacologic Therapies
When behavioral therapies are insufficient:
- Beta-3 adrenergic agonists (e.g., mirabegron) are preferred due to lower cognitive risk 2, 6
- Antimuscarinic medications (options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium) 1
- Combination of behavioral therapies with pharmacologic treatment may provide additional benefit 1
Third-Line: Specialist Referral for Advanced Therapies
For patients refractory to behavioral and pharmacologic therapies:
- Botulinum toxin injection into the bladder 1, 7
- Sacral neuromodulation 1, 7
- Percutaneous tibial nerve stimulation 1, 7
Special Considerations
- Antimuscarinic medications should be used with extreme caution in patients with narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention 1, 8
- Antimuscarinic medications should be avoided in patients with cognitive impairment risk 2, 8
- Post-void residual >250-300mL warrants caution when using antimuscarinic medications 1
- Transdermal oxybutynin may be considered if dry mouth is a concern with oral antimuscarinics 1
Treatment Efficacy and Expectations
- Most patients experience significant symptom reduction rather than complete resolution 1, 7
- Behavioral therapies are equivalent to or superior to medications for reducing incontinence episodes and improving quality of life 1, 3
- Combination of behavioral and pharmacologic therapies may provide better outcomes than either alone 1, 2
- Treatment success depends on patient adherence and engagement, particularly with behavioral interventions 2, 5