What are the treatment options for overactive bladder?

Treatment Options for Overactive Bladder

Treatment of overactive bladder (OAB) should follow a personalized approach through shared decision-making, offering options from multiple treatment categories simultaneously rather than a strict stepwise progression. 1, 2

Initial Evaluation

• Comprehensive medical history focusing on bladder symptoms, physical examination, and urinalysis to exclude microhematuria and infection are essential components of the initial evaluation 1, 2
• Post-void residual measurement should be performed in patients with risk factors such as emptying symptoms, history of retention, neurologic disorders, prior incontinence surgery, enlarged prostate, or long-standing diabetes 1, 2
• Symptom questionnaires and voiding diaries may assist in diagnosis, exclude other disorders, assess symptom burden, and evaluate treatment response 1, 3

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, 3
• Specific behavioral interventions include:
  • Timed voiding and urgency suppression techniques 1, 2
  • Fluid management with optimization of timing and volume 2, 3
  • Avoidance of bladder irritants (caffeine, alcohol) 1, 2
  • Pelvic floor muscle training for improved urge control 2, 3
  • Weight loss for obese patients (goal of 8% weight loss can reduce urgency incontinence episodes by 42%) 3, 4

Incontinence Management Strategies

• Products to better cope with urinary incontinence include absorbent products (pads, liners), barrier creams, and collection devices 1, 2
• These strategies don't treat the underlying condition but reduce adverse consequences of incontinence 1, 5

Optimization of Comorbidities

• Treating conditions that affect OAB severity can improve symptoms, including:
  • BPH, constipation, diuretic use, obesity, diabetes mellitus 1, 2
  • Genitourinary syndrome of menopause, pelvic organ prolapse, tobacco abuse 1, 3

Pharmacologic Therapies

• Beta-3 adrenergic agonists (mirabegron) are preferred over antimuscarinics due to lower cognitive risk 2, 3
  • Starting dose: 25 mg once daily; may increase to 50 mg once daily after 4-8 weeks 6
  • Indicated for treatment of OAB with symptoms of urge urinary incontinence, urgency, and frequency 6
  • Dose adjustments needed for renal and hepatic impairment 6
• Antimuscarinic medications (tolterodine, oxybutynin, solifenacin, etc.) are alternative options 2, 7
  • Should be used with caution in patients with narrow-angle glaucoma, impaired gastric emptying, history of urinary retention, or cognitive impairment 2, 5
  • Post-void residual >250-300 mL warrants caution when using these medications 2, 5

Minimally Invasive Therapies

• For patients who fail behavioral and pharmacologic interventions:
  • Intradetrusor onabotulinumtoxinA injections (patients must be willing to perform self-catheterization if needed) 2, 5
  • Peripheral tibial nerve stimulation (requires frequent office visits) 2, 5
  • Sacral neuromodulation 2, 5

Invasive Therapies

• Reserved for refractory cases:
  • Urinary diversion 1, 8
  • Bladder augmentation cystoplasty 1, 8

Treatment Approach and Monitoring

• Allow adequate trial periods (8-12 weeks) to determine efficacy before changing therapies 5, 9
• Combination of behavioral and pharmacologic therapies may provide better outcomes than either alone 2, 3
• Most patients experience significant symptom reduction rather than complete resolution 3, 9
• Annual follow-up is recommended to assess treatment efficacy and detect any changes in symptoms 5, 8

Special Considerations

• For elderly patients, beta-3 adrenergic agonists are preferred over antimuscarinics due to lower risk of cognitive effects 2, 5
• For patients with inadequate symptom control on monotherapy, consider combination therapy with an antimuscarinic and beta-3 adrenoceptor agonist 5, 9
• The success of behavioral therapies depends heavily on patient acceptance, adherence, and compliance, emphasizing the importance of patient education and support 2, 10