What are the treatment options for overactive bladder syndrome?

Treatment Options for Overactive Bladder Syndrome

The optimal treatment approach for overactive bladder syndrome (OAB) follows a stepwise algorithm beginning with behavioral therapies as first-line treatment, followed by pharmacologic options as second-line treatment, and progressing to more invasive procedures for refractory cases. 1, 2

Diagnosis and Clinical Presentation

• OAB is characterized by urinary urgency (a sudden, compelling desire to pass urine that is difficult to defer), often accompanied by frequency, nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. 3
• Diagnosis requires exclusion of other conditions through careful history, physical examination, and urinalysis. 3
• A voiding diary documenting intake and voiding patterns is a useful diagnostic tool. 3

First-Line Treatment: Behavioral Therapies

• Behavioral therapies should be offered to all patients with OAB due to their excellent safety profile and lack of drug interactions. 2, 1
• Specific behavioral interventions include:
  • Bladder training with timed voiding and gradual extension of voiding intervals 4, 5
  • Pelvic floor muscle training to improve urge suppression techniques 4, 5
  • Fluid management, including optimizing timing and volume of fluid intake 2, 5
  • Dietary modifications, such as avoiding bladder irritants (caffeine, alcohol, carbonated beverages) 2, 6
  • Weight loss for obese patients (goal of 8% weight loss can reduce urgency incontinence episodes by 42%) 4, 7

Second-Line Treatment: Pharmacologic Management

• If symptoms persist despite behavioral therapies, oral medications should be considered: 1, 2
• Beta-3 adrenergic agonists:
  • Mirabegron is indicated for OAB in adults with symptoms of urge urinary incontinence, urgency, and frequency 8
  • Starting dose is 25 mg once daily, which may be increased to 50 mg once daily after 4-8 weeks if needed 8
  • Preferred over antimuscarinics due to lower cognitive risk 4, 2
  • Efficacy is demonstrated within 4-8 weeks of treatment 8
• Antimuscarinic medications:
  • Options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium 4, 1
  • Should be used with caution in patients with narrow-angle glaucoma, impaired gastric emptying, history of urinary retention, or cognitive impairment 4, 2
  • Post-void residual greater than 250-300 mL warrants caution when using these medications 4, 1

Combination Therapy

• Behavioral therapies may be combined with pharmacologic management to optimize symptom control 1, 9
• Initiating behavioral and drug therapy simultaneously may improve outcomes, including frequency, voided volume, incontinence, and symptom distress 1, 9

Treatment Adjustments

• If inadequate symptom control or unacceptable adverse events occur with one antimuscarinic medication, consider:
  • Dose modification
  • Switching to a different antimuscarinic
  • Switching to a beta-3 adrenergic agonist 1
• For patients with both OAB and benign prostatic hyperplasia (BPH), consider:
  • Monotherapy with antimuscarinic medications or beta-3 agonists
  • Combination therapy with an alpha blocker and an antimuscarinic or beta-3 agonist 3

Third-Line Treatment: Advanced Therapies

For patients who fail behavioral and pharmacologic interventions, consider: 1, 7

• Intradetrusor onabotulinumtoxinA injections (patients must be willing to perform clean intermittent self-catheterization if needed) 1, 6
• Peripheral tibial nerve stimulation (PTNS) (requires frequent office visits) 1, 7
• Sacral neuromodulation (SNS) 1, 7

Treatment Expectations

• Most patients experience significant symptom reduction rather than complete resolution with treatment 4, 10
• Success depends on patient acceptance, adherence, and compliance, emphasizing the importance of patient education and support 2, 9

Special Considerations

• For patients with renal impairment, mirabegron dosing should be adjusted based on estimated GFR 8
• For patients with hepatic impairment, mirabegron dosing should be adjusted based on Child-Pugh classification 8
• Caution should be exercised when prescribing antimuscarinics or beta-3 adrenergic agonists to patients with post-void residual 250-300 mL 1, 3