What are the symptoms and treatment options for overactive bladder?

Symptoms and Treatment of Overactive Bladder

Overactive bladder (OAB) is characterized by urinary urgency, frequency, and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. 1, 2

Key Symptoms

• Urgency: The hallmark symptom of OAB, defined as a sudden, compelling desire to pass urine that is difficult to defer 1, 2
• Frequency: Typically more than seven micturition episodes during waking hours, though this varies based on fluid intake, sleep patterns, and comorbidities 2
• Nocturia: Interruption of sleep one or more times because of the need to void 1, 2
• Urgency urinary incontinence: Involuntary leakage of urine associated with a sudden compelling desire to void (may or may not be present) 1, 2

Diagnosis

• OAB is a diagnosis of exclusion requiring careful history, physical examination, and urinalysis to rule out other conditions 1, 2
• When both daytime and nighttime urinary frequency and urgency (with or without urgency incontinence) are self-reported as bothersome, the patient may be diagnosed with OAB 1
• Useful diagnostic tools include:
  • Voiding diary to document intake and voiding patterns 1
  • Post-void residual measurement in patients with obstructive symptoms, history of incontinence or prostatic surgery, and neurologic diagnoses 1
  • Validated symptom questionnaires to quantify bladder symptoms and treatment response 1

Differential Diagnosis

• Urinary tract infection (requires urinalysis to exclude) 2
• Nocturnal polyuria (characterized by normal or large volume nocturnal voids, unlike the small volume voids in OAB) 1
• Polydipsia-related frequency (distinguished using frequency-volume charts) 1
• Interstitial cystitis/bladder pain syndrome (shares frequency and urgency with OAB but includes bladder/pelvic pain) 1

Treatment Algorithm

First-Line: Behavioral Therapies

• All patients with OAB should be offered behavioral therapies as first-line treatment 1
• Behavioral approaches include:
  • Bladder training and delayed voiding 1
  • Pelvic floor muscle training for urge suppression 1
  • Fluid management (25% reduction in fluid intake can reduce frequency and urgency) 1
  • Caffeine reduction 1
  • Weight loss (8% weight loss in obese women can reduce urgency incontinence episodes by 42%) 1

Second-Line: Pharmacotherapy

• If symptoms persist despite behavioral therapies, offer oral medications:
  • Antimuscarinic medications (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium) 1, 3
  • Beta-3 adrenergic agonists (mirabegron) 1, 4
• When prescribing antimuscarinics:
  • Counsel patients about potential side effects (dry mouth, constipation, dry eyes, blurred vision) 1
  • Use with caution in patients with PVR 250-300 mL 1
  • Discuss potential risk for developing dementia and cognitive impairment 1
• Transdermal system (TDS) preparations of oxybutynin may be offered if dry mouth is a concern with oral antimuscarinics 1

Combination Approaches

• Behavioral therapies may be combined with antimuscarinic therapies for potentially additive effects 1
• For patients with inadequate response to monotherapy, clinicians may combine behavioral therapy, pharmacotherapy, and/or minimally invasive therapies 1

Third-Line: Minimally Invasive Therapies

For patients who fail behavioral and pharmacologic interventions:

• Intradetrusor onabotulinumtoxinA injections 1, 5
• Peripheral tibial nerve stimulation (PTNS) 1
• Sacral neuromodulation (SNS) 1, 6

Management of Incontinence

• Discuss incontinence management strategies (liners, pads, diapers, barrier creams, external catheters, absorbent protective underwear) with all patients who have urgency urinary incontinence 1

Special Considerations

OAB with BPH in Men

• Offer monotherapy with antimuscarinic medications or beta-3 agonists, or combination therapy with an alpha blocker and an antimuscarinic medication or beta-3 agonist 1
• Antimuscarinics and beta-3 agonists are effective as monotherapy and do not appear to significantly increase risk of urinary retention 1

Common Pitfalls

• Failure to distinguish between mixed urinary incontinence and pure OAB can lead to inappropriate treatment 2
• Inadequate follow-up to assess treatment efficacy and manage adverse events 2
• Using nutraceuticals, vitamins, supplements, or herbal remedies which have insufficient evidence to support their use in OAB treatment 1

Remember that OAB symptoms are rarely cured completely, but the burden on quality of life can often be significantly improved with appropriate treatment 1, 7.