What are the treatment options for overactive bladder?

Treatment of Overactive Bladder

The optimal treatment for overactive bladder (OAB) should follow a personalized approach through shared decision-making between clinician and patient, selecting from multiple treatment categories based on the patient's needs, preferences, and side effect tolerance rather than strictly following a stepwise progression. 1

Initial Evaluation

• A comprehensive medical history focusing on bladder symptoms, physical examination, and urinalysis to exclude microhematuria and infection are essential components of the initial evaluation of patients with OAB 1, 2
• Telemedicine is a viable option for initial evaluation of OAB patients, with urinalysis obtained at a local laboratory 1
• Post-void residual measurement is indicated in patients with emptying symptoms, history of urinary retention, enlarged prostate, neurologic disorders, prior incontinence surgery, or long-standing diabetes 2

Treatment Categories

First-Line: Behavioral Therapies

• Behavioral therapies should be offered to all patients with OAB due to their excellent safety profile and lack of drug interactions 2
• These include:
  • Bladder training and timed voiding 2
  • Urgency suppression techniques 2
  • Fluid management with appropriate timing and potentially reducing fluid intake 2
  • Dietary modifications such as avoiding bladder irritants (caffeine, alcohol) 1, 2
  • Pelvic floor muscle training for urge suppression and improved control 2

Optimization of Comorbidities

• Treatment of conditions known to affect OAB severity should be addressed, including:
  • BPH, constipation, diuretic use, obesity, diabetes mellitus, genitourinary syndrome of menopause, pelvic organ prolapse, and tobacco use 1

Non-invasive Therapies

• Pelvic floor muscle training, biofeedback, transcutaneous tibial nerve stimulation, and electromagnetic therapy can be offered 1

Pharmacologic Therapies

• Beta-3 adrenergic agonists (e.g., mirabegron) are typically preferred over antimuscarinic medications due to their lower cognitive risk profile 2, 3

  • Starting dose of mirabegron is 25 mg orally once daily, which can be increased to 50 mg after 4-8 weeks if needed 3
  • Dose adjustments are required for patients with renal or hepatic impairment 3

• Antimuscarinic medications (e.g., tolterodine, darifenacin, fesoterodine, oxybutynin, solifenacin, trospium) are alternative options 2, 4

  • These should be used with caution in patients with narrow-angle glaucoma, impaired gastric emptying, history of urinary retention, or cognitive impairment 2
  • Post-void residual greater than 250-300 mL warrants caution when using antimuscarinics 2

• If inadequate symptom control or unacceptable adverse events occur with one medication, consider:

  • Dose modification 2
  • Switching to a different antimuscarinic 2
  • Switching to a beta-3 adrenergic agonist 2
  • Combination therapy with an antimuscarinic and beta-3 adrenergic agonist 5

Minimally Invasive Therapies (Third-Line Treatment)

For patients who fail behavioral and pharmacologic interventions:

• Intradetrusor onabotulinumtoxinA injections (patients must be willing to perform clean intermittent self-catheterization if needed) 2, 5
• Peripheral tibial nerve stimulation (requires frequent office visits) 2
• Sacral neuromodulation 2

Incontinence Management Strategies

• Absorbent products (pads, liners, absorbent underwear), barrier creams, and external collection devices can be discussed as management strategies for patients with urgency urinary incontinence 1, 2
• These strategies manage symptoms but do not treat the underlying condition 6

Special Considerations

Geriatric Patients

• Beta-3 adrenergic agonists are preferred in geriatric patients due to lower cognitive risk 5
• Antimuscarinic medications should be used with caution due to risk of cognitive impairment 5
• Annual follow-up is recommended to assess treatment efficacy and detect any changes in symptoms 5

Treatment Monitoring

• Allow adequate trial periods (8-12 weeks) to determine efficacy before changing therapies 2, 5
• Initiating behavioral and drug therapy simultaneously may improve outcomes in frequency, voided volume, and symptom distress 2

Treatment Algorithm

1. Begin with behavioral therapies and optimization of comorbidities for all patients
2. If inadequate response, add pharmacotherapy (preferably beta-3 agonist)
3. If still inadequate response, consider dose adjustment, medication switch, or combination therapy
4. For refractory cases, consider minimally invasive therapies
5. Throughout treatment, incontinence management strategies can be employed as needed