Best Treatment for Overactive Bladder
The best treatment for overactive bladder (OAB) is to start with behavioral therapies as first-line treatment, followed by pharmacologic options such as beta-3 adrenergic agonists (mirabegron) or antimuscarinic medications if behavioral approaches are insufficient. 1, 2
First-Line Treatment: Behavioral Therapies
Behavioral therapies should be offered as the initial treatment for all patients with OAB due to their excellent safety profile and effectiveness:
- Bladder training with timed voiding and gradual extension of voiding intervals is recommended for all OAB patients 3, 1, 2
- Pelvic floor muscle training to improve urge suppression techniques 1, 2
- Fluid management, including optimizing timing and volume of fluid intake throughout the day 3, 1
- Dietary modifications to reduce bladder irritants (caffeine, alcohol, spicy foods) 3, 1
- Weight loss for obese patients - a relatively minor weight loss of 8% in obese women can reduce urgency urinary incontinence episodes by 42% 3, 2
Evidence shows that behavioral treatments are generally either equivalent to or superior to medications in terms of reducing incontinence episodes, improving frequency, and improving quality of life 3, 4.
Second-Line Treatment: Pharmacologic Options
If behavioral therapies alone are insufficient after 2-4 weeks of consistent implementation, pharmacologic options should be considered:
Beta-3 Adrenergic Agonists
- Mirabegron is preferred over antimuscarinic medications due to lower cognitive risk 1, 2, 5
- Starting dose: 25 mg once daily, may increase to 50 mg once daily after 4-8 weeks if needed 5
- Dose adjustments required for renal and hepatic impairment 5
Antimuscarinic Medications
- Options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium 3, 6
- Common side effects include dry mouth, constipation, dry eyes, blurred vision, and cognitive impairment 3
- Contraindicated in narrow-angle glaucoma unless approved by ophthalmologist 3
- Use with extreme caution in patients with impaired gastric emptying or history of urinary retention 3
- Transdermal oxybutynin may be offered if dry mouth is a concern with oral antimuscarinic medications 3
Combination Therapy
- Behavioral therapies may be combined with pharmacologic treatments for better outcomes 3, 2
- For patients with both BPH and OAB symptoms, combination therapy with an alpha blocker and either an antimuscarinic medication or a beta-3 agonist is recommended 7
Treatment Considerations and Monitoring
- Post-void residual (PVR) measurement is recommended before starting antimuscarinic medications, especially in patients with risk factors for urinary retention 3, 2
- A PVR greater than 250-300mL warrants caution when using antimuscarinic medications 2, 7
- Most patients experience significant symptom reduction rather than complete resolution with treatment 3, 2
- Follow-up should be scheduled 2-4 weeks after initiating treatment to assess efficacy and side effects 3