What medications help with overactive bladder?

Medications for Overactive Bladder

Anticholinergic medications are the second-line treatment for overactive bladder after behavioral therapies, with options including darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium, all showing similar efficacy but different side effect profiles. 1

Treatment Algorithm

First-Line Therapy

• Behavioral therapies should be offered to all patients with OAB before medication 1
  • Bladder training and delayed voiding 1
  • Pelvic floor muscle training 1
  • Fluid management (25% reduction in fluid intake) 1
  • Weight loss for obese patients (8% weight loss can reduce urgency incontinence by 42%) 1
  • Caffeine reduction 1

Second-Line Therapy: Antimuscarinic Medications

• Oral antimuscarinic options (alphabetically, no hierarchy implied) 1:
  • Darifenacin 1
  • Fesoterodine 1
  • Oxybutynin (immediate and extended release) 1, 2
  • Solifenacin 3
  • Tolterodine (immediate and extended release) 1, 4
  • Trospium 2

Beta-3 Adrenoceptor Agonist

• Mirabegron (25-50 mg once daily) for patients with OAB symptoms 5
  • Starting dose: 25 mg once daily 5
  • May increase to 50 mg once daily after 4-8 weeks if needed 5

Combination Therapy

• Behavioral therapies may be combined with antimuscarinic medications 1
• Alpha-blockers may be combined with antimuscarinic agents in men with both storage and voiding symptoms 1

Medication Selection Considerations

Antimuscarinic Medications

• All antimuscarinic medications have similar efficacy profiles 1, 2
• Common side effects include 1:
  • Dry mouth (most common) 4, 6
  • Constipation 1
  • Dry eyes and blurred vision 1
  • Dyspepsia 1
  • Urinary tract infection 1
  • Urinary retention 1
  • Impaired cognitive function 1

Special Considerations

• Transdermal oxybutynin may be offered if dry mouth is a concern with oral antimuscarinics 1, 2
• Trospium is appropriate for patients with pre-existing cognitive impairment 2
• Solifenacin may be suitable for elderly patients or those with pre-existing cognitive dysfunction 2
• Darifenacin is appropriate for patients with pre-existing cardiac concerns or cognitive dysfunction 2
• Mirabegron offers an alternative mechanism of action (beta-3 adrenoceptor agonist) for patients who cannot tolerate antimuscarinic side effects 5

Contraindications and Precautions

• Do not use antimuscarinic medications in patients with 1:

  • Narrow-angle glaucoma (unless approved by ophthalmologist) 1
  • Impaired gastric emptying (use with extreme caution) 1
  • History of urinary retention (use with extreme caution) 1
  • Patients using solid oral forms of potassium chloride 1

• Dose adjustments required for 5:

  • Renal impairment (for mirabegron) 5
  • Hepatic impairment (for mirabegron) 5

Efficacy Expectations

• Most patients experience significant symptom reduction but not complete relief 1
• Patients with more severe symptoms typically experience greater reductions 1
• Complete symptom relief is more likely in patients with relatively low baseline symptom levels 1
• Maximum treatment effects typically occur after 5-8 weeks of treatment 4

Common Pitfalls to Avoid

• Failure to try behavioral therapies first - these are as effective as medications with no risk 1
• Overlooking contraindications - especially narrow-angle glaucoma and urinary retention risk 1
• Not checking post-void residual (PVR) in patients at higher risk of urinary retention 1
• Setting unrealistic expectations - complete symptom resolution is uncommon 1
• Not addressing side effects promptly - dry mouth and other side effects are major reasons for discontinuation 4, 6
• Not considering drug interactions - especially with CYP450 inhibitors 7

Third-Line Treatments

• For patients who fail behavioral and medical therapy, referral to a specialist is recommended for consideration of 1:
  • Neuromodulation therapy 1
  • OnabotulinumtoxinA injections 1, 2