What is the treatment of choice for overactive bladder?

Treatment of Choice for Overactive Bladder

Behavioral therapies should be offered as first-line treatment to all patients with overactive bladder, followed by pharmacological therapy with beta-3 adrenergic agonists or antimuscarinics as second-line options when behavioral approaches are insufficient. 1, 2

First-Line Treatment: Behavioral Therapies

• Bladder training, including timed voiding and gradual extension of voiding intervals, is recommended as the initial approach due to its effectiveness and excellent safety profile 1
• Pelvic floor muscle training to improve urge suppression techniques should be implemented to help patients manage urgency symptoms 1, 2
• Fluid management with a 25% reduction in fluid intake can reduce frequency and urgency symptoms 1, 3
• Weight loss for obese patients should be encouraged, as an 8% weight loss can reduce urgency urinary incontinence episodes by 42% 1, 2
• Caffeine reduction has been shown to reduce voiding frequency and should be included in the management plan 1

Behavioral therapies are recommended first because they are risk-free, tailored interventions that have been shown to be as effective as antimuscarinic medications in reducing symptom levels 1. While most patients do not experience complete symptom resolution, significant reductions in symptoms and improvements in quality of life are common 1.

Second-Line Treatment: Pharmacological Options

When behavioral therapies alone are insufficient, medication should be added:

Beta-3 Adrenergic Agonists (Preferred)

• Mirabegron is recommended as the first pharmacological option due to its efficacy and lower risk of cognitive effects compared to antimuscarinics 1, 4
• Starting dose is 25 mg orally once daily, which can be increased to 50 mg after 4-8 weeks if needed 5
• FDA-approved for treatment of OAB in adults with symptoms of urge urinary incontinence, urgency, and urinary frequency 5

Antimuscarinic Medications (Alternative)

• Options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium 1, 6
• Should be used with extreme caution in patients with narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention 1
• Transdermal system (TDS) preparations of oxybutynin may be offered if dry mouth is a concern with oral antimuscarinics 1
• Clinicians should discuss the potential risk for developing dementia and cognitive impairment with patients taking antimuscarinic medications 1

Combination Approaches

• Behavioral therapies may be combined with pharmacological treatments for potentially better outcomes than either approach alone 1
• When combining therapies, monitor improvement of symptoms carefully; if no improvement is noted, discontinue one or both therapies and pursue other treatments 1

Special Considerations and Monitoring

• Post-void residual (PVR) should be assessed in patients with obstructive symptoms, history of incontinence or prostatic surgery, or neurologic diagnoses 1
• Antimuscarinics should be used with caution in patients with PVR greater than 250-300 mL 1, 2
• Evaluate treatment efficacy after 4-8 weeks of therapy 4
• For patients who remain refractory to behavioral and medical therapy, referral to an appropriate specialist is recommended 1

Common Pitfalls to Avoid

• Failing to assess for contraindications before prescribing antimuscarinics 4
• Not considering drug interactions, particularly in elderly patients taking multiple medications 4
• Continuing ineffective therapy without considering alternatives 4
• Discontinuing behavioral therapies when starting medications 1, 2

The treatment of overactive bladder should follow a stepwise approach, starting with the least invasive options (behavioral therapies) before progressing to pharmacological treatments, with beta-3 agonists preferred over antimuscarinics due to their better side effect profile 1, 2, 4.