What are the treatment options for overactive bladder?

Treatment Options for Overactive Bladder

All patients with overactive bladder should begin with behavioral therapies as first-line treatment, followed by beta-3 adrenergic agonists (mirabegron) as the preferred pharmacologic option if behavioral measures fail, with antimuscarinic medications reserved as alternatives when beta-3 agonists are contraindicated or ineffective. 1, 2, 3

Initial Evaluation

Before initiating treatment, complete the following assessment:

• Obtain a comprehensive medical history focusing specifically on urgency symptoms, frequency patterns, nocturia episodes, and presence of urge incontinence 1
• Perform a physical examination to identify contributing factors including pelvic organ prolapse in women, enlarged prostate in men, and neurologic abnormalities 1, 2
• Conduct urinalysis to exclude urinary tract infection and microhematuria 1, 3
• Measure post-void residual in patients with emptying symptoms, history of urinary retention, enlarged prostate, neurologic disorders, prior incontinence or prostate surgery, or long-standing diabetes 1, 2
• Consider symptom questionnaires and 24-72 hour voiding diaries to quantify symptom burden and establish baseline for treatment monitoring 1

First-Line Treatment: Behavioral Therapies

Offer behavioral therapies to all patients regardless of symptom severity due to their excellent safety profile and absence of drug interactions. 1, 2, 3

Specific Behavioral Interventions:

• Timed voiding and urgency suppression techniques to retrain bladder function 1, 3
• Fluid management with optimization of timing (reduce evening intake) and total volume 2, 3
• Bladder irritant avoidance including caffeine and alcohol 1, 3
• Pelvic floor muscle training for improved urge control 2, 3
• Weight loss for obese patients with a goal of 8% weight reduction to decrease urgency incontinence episodes 3

Optimize Contributing Comorbidities:

• Treat benign prostatic hyperplasia in men with concomitant lower urinary tract symptoms 1, 3
• Manage constipation which can exacerbate bladder symptoms 1, 3
• Address genitourinary syndrome of menopause with appropriate hormone therapy 1, 3
• Optimize diabetes control in patients with long-standing disease 1, 3
• Review and adjust diuretic timing to minimize nocturia 1, 3

Second-Line Treatment: Pharmacologic Therapy

If behavioral therapies provide inadequate symptom control after 8-12 weeks, initiate pharmacologic treatment. 2, 3, 4

Preferred Pharmacologic Option:

• Beta-3 adrenergic agonist (mirabegron) is the preferred medication due to lower cognitive risk compared to antimuscarinics, particularly important in elderly patients 2, 3, 4
• Mirabegron dosing: Start 25 mg orally once daily, increase to 50 mg once daily after 4-8 weeks if needed 5
• Dose adjustment for renal impairment: Maximum 25 mg daily if eGFR 15-29 mL/min/1.73 m²; not recommended if eGFR <15 mL/min/1.73 m² 5
• Dose adjustment for hepatic impairment: Maximum 25 mg daily for Child-Pugh Class B; not recommended for Child-Pugh Class C 5

Alternative Pharmacologic Options:

Antimuscarinic medications (tolterodine, oxybutynin, solifenacin, fesoterodine, darifenacin, trospium) are alternatives but require caution: 2, 3, 4, 6

• Use with extreme caution in elderly patients due to cognitive impairment risk 2
• Contraindications include: narrow-angle glaucoma, impaired gastric emptying, history of urinary retention 3, 4
• Exercise caution if post-void residual >250-300 mL 4

Combination Therapy:

• Consider combining an antimuscarinic with a beta-3 agonist if monotherapy provides inadequate symptom control 2, 4
• Continue behavioral therapies alongside pharmacologic treatment for optimal outcomes 4

Treatment Monitoring:

• Allow 8-12 weeks to assess medication efficacy before switching agents 2, 3
• If inadequate response or intolerable side effects occur: modify dose, switch to different antimuscarinic, or switch to beta-3 agonist 4
• Schedule annual follow-up to assess treatment efficacy and detect symptom changes 2, 3

Third-Line Treatment: Minimally Invasive Therapies

For patients who fail behavioral and pharmacologic interventions after adequate trials, refer to urology specialist for consideration of: 2, 3, 4

• Intradetrusor onabotulinumtoxinA injection (100 units) - patients must be willing and able to perform clean intermittent self-catheterization if urinary retention develops 2, 3, 4
• Sacral neuromodulation for patients who cannot or will not perform self-catheterization 3, 4
• Peripheral tibial nerve stimulation - requires frequent office visits for treatment sessions 3, 4

Incontinence Management Strategies

Throughout all treatment phases, discuss absorbent products and coping strategies: 1, 3, 4

• Absorbent products (pads, liners, absorbent underwear) to manage leakage 1, 3
• Barrier creams to prevent urine dermatitis 1, 3
• External collection devices as appropriate 3, 4

Important Caveats:

• Most patients experience significant symptom reduction rather than complete resolution - set realistic expectations 3
• Success of behavioral therapies depends heavily on patient adherence - provide education and ongoing support 3, 4
• Telemedicine may be used for initial evaluation but in-office visit with physical examination and PVR measurement is required if symptoms persist after initial treatment 1