What are the treatment options for overactive bladder (OAB)?

Overactive Bladder Treatment

Treatment for overactive bladder should begin with behavioral therapies offered to all patients, followed by pharmacologic options with beta-3 agonists (mirabegron) preferred over antimuscarinics due to lower cognitive risk, and progressing to minimally invasive procedures like botulinum toxin injections or neuromodulation for refractory cases. 1, 2, 3

Initial Evaluation

Before initiating treatment, complete the following assessment:

• Obtain comprehensive medical history focusing on urgency, frequency, nocturia, and incontinence episodes 1, 4
• Perform physical examination to identify pelvic organ prolapse, enlarged prostate, or genitourinary syndrome of menopause 1, 4
• Conduct urinalysis to exclude infection and microhematuria 1
• Measure post-void residual in patients with emptying symptoms, history of retention, neurologic disorders, prior incontinence/prostate surgery, or long-standing diabetes 1, 3

Treatment Framework: Shared Decision-Making Model

The 2024 AUA/SUFU guidelines have moved away from strict stepwise progression and now emphasize selecting treatments from multiple categories simultaneously based on patient preferences, rather than forcing sequential "step therapy." 1 This allows patients to choose from a menu of options regardless of invasiveness.

First-Line: Behavioral Therapies

Offer behavioral therapies to all patients as they have excellent safety profiles and no drug interactions: 2, 3

• Timed voiding with gradual extension of voiding intervals 4
• Urgency suppression techniques using pelvic floor muscle training 2, 4
• Fluid management: optimize timing and volume, reduce evening intake to decrease nocturia 2, 3
• Avoid bladder irritants: reduce caffeine and alcohol (though evidence for specific irritants remains inconsistent) 1, 5
• Weight loss: 8% reduction can decrease urgency incontinence episodes by 42% in obese patients 4

Second-Line: Pharmacologic Therapies

Beta-3 Adrenergic Agonists (Preferred)

Mirabegron is the preferred pharmacologic option due to lower cognitive impairment risk compared to antimuscarinics: 2, 3

• Starting dose: 25 mg orally once daily 6
• Maximum dose: 50 mg orally once daily after 4-8 weeks if needed 6
• Efficacy timeline: 25 mg effective within 8 weeks; 50 mg effective within 4 weeks 6
• Dose adjustments for renal impairment: Maximum 25 mg daily if eGFR 15-29 mL/min/1.73 m²; not recommended if eGFR <15 or dialysis 6
• Dose adjustments for hepatic impairment: Maximum 25 mg daily for Child-Pugh Class B; not recommended for Class C 6

Antimuscarinic Medications (Alternative)

Options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium 1, 3

Use with extreme caution in: 3, 4

• Patients with cognitive impairment risk (especially geriatric patients) 2
• Narrow-angle glaucoma 3
• Impaired gastric emptying 3
• History of urinary retention 3
• Post-void residual >250-300 mL 3

Treatment Optimization

• Allow 8-12 weeks to assess efficacy before changing therapies 2
• If inadequate response or adverse events occur, consider dose modification, switching to different antimuscarinic, or switching to beta-3 agonist 3
• Combination therapy (behavioral + pharmacologic, or antimuscarinic + beta-3 agonist) may provide superior outcomes 3, 4

Third-Line: Minimally Invasive Therapies

For patients refractory to behavioral and pharmacologic interventions after adequate trial periods: 2, 3

• Intradetrusor onabotulinumtoxinA (100 units): Patients must be willing and able to perform clean intermittent self-catheterization if needed and return for frequent post-void residual monitoring 2, 3
• Sacral neuromodulation (SNS) 3
• Peripheral tibial nerve stimulation (PTNS): Requires frequent office visits 3

Incontinence Management Strategies

These products help cope with incontinence but do not treat the underlying condition: 1, 3

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

Optimization of Comorbidities

Address contributing medical conditions: 1

• Benign prostatic hyperplasia 1
• Constipation 1
• Diuretic timing adjustment 1
• Diabetes mellitus control 1
• Genitourinary syndrome of menopause treatment 1
• Pelvic organ prolapse management 1

Fourth-Line: Invasive Therapies

Reserved for severe refractory cases with higher complication risks: 1

• Urinary diversion 1
• Bladder augmentation cystoplasty 1
• Indwelling urethral or suprapubic catheters (last resort) 1

Follow-Up and Monitoring

• Annual follow-up to assess treatment efficacy and symptom changes 2
• Most patients experience significant symptom reduction rather than complete resolution 4
• Symptom questionnaires (Bristol Female LUTS, LURN-SI-29) and 24-72 hour voiding diaries can assist in monitoring treatment response 1

Critical Pitfalls to Avoid

• Do not prescribe antimuscarinics to geriatric or frail patients without considering cognitive impairment risk—beta-3 agonists are safer 2
• Do not use antimuscarinics with post-void residual >250-300 mL without caution 3
• Do not abandon behavioral therapies when starting medications—combination approaches work better 4
• Do not change therapies before allowing adequate 8-12 week trial period 2