What is the treatment for bladder spasm?

Treatment of Bladder Spasm

Behavioral therapies should be offered as first-line treatment for bladder spasms, including bladder training, pelvic floor muscle training, and fluid management, with oral anticholinergics (particularly oxybutynin) as second-line pharmacologic therapy when behavioral interventions alone are insufficient. 1, 2

First-Line: Behavioral Interventions

Start with non-pharmacologic approaches as they are risk-free and as effective as antimuscarinic medications for symptom reduction: 1

• Bladder training and delayed voiding techniques to improve bladder capacity and reduce frequency/urgency 1, 2, 3
• Pelvic floor muscle training to enhance voluntary control over bladder function 1, 2, 3
• Fluid management with 25% reduction in total daily intake to decrease voiding frequency 1, 2, 3
• Avoidance of bladder irritants including caffeine, alcohol, and spicy foods 2, 3
• Application of heat or cold over the bladder or perineum to alleviate trigger points 2, 3

Weight loss of just 8% in obese patients reduces urgency incontinence episodes by 42% versus 26% in controls. 1

Second-Line: Pharmacologic Management

If symptoms remain bothersome after 8-12 weeks of behavioral therapy, add anticholinergic medications: 1, 2

Preferred Anticholinergic Options

• Oxybutynin is the first-line pharmacologic choice: 5 mg 2-3 times daily, titrated as needed 2, 3, 4
• Alternative oral anticholinergics (if oxybutynin not tolerated): darifenacin, fesoterodine, solifenacin, tolterodine, or trospium 1, 2, 3
• Solifenacin has the lowest risk for discontinuation due to adverse effects among anticholinergics 2
• Transdermal oxybutynin may be offered if dry mouth is a concern with oral formulations 1

Combination Therapy

Behavioral therapies may be combined with anticholinergics for enhanced efficacy, though evidence is limited (Grade C). 1 Add therapies one at a time methodically when assembling combination approaches. 1, 2

Managing Anticholinergic Side Effects

Common side effects include dry mouth, constipation, dry eyes, blurred vision, and cognitive impairment: 1, 2, 3

• Switch to lower dose, extended-release formulations, or transdermal delivery systems 2
• If inadequate symptom control or unacceptable adverse events occur with one anticholinergic, try dose modification or switch to a different anticholinergic or beta-3 adrenoceptor agonist (mirabegron) 1

Critical Contraindications

Do not use anticholinergics in: 1, 2, 3

• Narrow-angle glaucoma (unless approved by ophthalmologist)
• Impaired gastric emptying
• History of urinary retention
• Post-void residual (PVR) >250-300 mL (use with extreme caution)

Third-Line: Advanced Interventions

For severe refractory symptoms after adequate trial (8-12 weeks) of first- and second-line therapies: 1

Intradetrusor OnabotulinumtoxinA

• FDA-approved dose: 100 units for carefully selected, thoroughly counseled patients 1, 5
• Patients must be willing and able to perform self-catheterization if urinary retention develops 1
• Requires frequent post-void residual monitoring 1
• Effects diminish over time; repeat injections likely necessary 1
• Lower adverse event rates at 100 U compared to 200 U doses 1

Neuromodulation Options

• Sacral neuromodulation (SNS) for severe refractory symptoms in patients willing to undergo surgical procedure 1, 2
• Peripheral tibial nerve stimulation (PTNS) for carefully selected patients who can make frequent office visits 1, 2

Special Clinical Scenarios

Post-Surgical Bladder Spasm (Catheter-Related)

For bladder spasms caused by indwelling catheters after prostate operations, tolterodine 2 mg twice daily provides rapid relief: 54.9% total alleviation and 36.6% partial alleviation after 72 hours. 6

Malignancy-Related Bladder Spasm

For cancer-related bladder spasms refractory to standard treatments, lumbar sympathetic blockade at L4 with 10 mL of 0.25% bupivacaine may provide relief for up to 2 months. 7

Neurogenic Bladder with Severe Spasm

For tetraplegic patients with severe, protracted bladder spasms and autonomic dysreflexia unresponsive to nifedipine, diazepam, and paracetamol, intrathecal baclofen bolus via implanted pump produces prompt relief. 8

Monitoring and Follow-Up

• Allow adequate trial periods of 8-12 weeks to determine efficacy before changing therapies 2, 3
• Measure post-void residual in patients at risk for urinary retention, particularly before and after botulinum toxin therapy 2
• Educate patients that treatment effects are maintained only as long as therapy is continued 2
• Periodically reassess efficacy and stop ineffective treatments 3

Common Pitfalls to Avoid

• Do not abandon anticholinergic therapy after failure of just one medication; try dose modification or alternative agents first 1
• Do not combine multiple anticholinergics together (no supporting literature) 1
• Do not use urodynamics, cystoscopy, or diagnostic ultrasound in initial workup of uncomplicated patients 1
• Ensure patients understand the need for self-catheterization before proceeding with botulinum toxin therapy 1