From the Guidelines
Overactive bladder (OAB) should be managed with a stepped approach, starting with lifestyle modifications and behavioral therapies, followed by pharmacotherapy, and finally, minimally invasive treatments for those who do not respond to initial therapies, as recommended by the most recent guidelines 1.
Diagnosis and Initial Management
OAB is characterized by sudden urges to urinate that are difficult to control, often accompanied by frequent urination and nighttime awakening to urinate. The initial step in managing OAB involves lifestyle modifications including fluid management, bladder training, and pelvic floor exercises. Limiting caffeine, alcohol, and spicy foods, which can irritate the bladder, is also recommended.
Pharmacotherapy
For medication, first-line treatments include anticholinergics such as oxybutynin (5mg 2-3 times daily), solifenacin (5-10mg once daily), or tolterodine (2-4mg daily), as supported by earlier guidelines 1. Beta-3 adrenergic agonists like mirabegron (25-50mg daily) are alternatives with fewer side effects like dry mouth and constipation.
Advanced Therapies
For patients who do not respond to medications, advanced options include Botox injections into the bladder (100-200 units every 6-9 months), posterior tibial nerve stimulation (weekly 30-minute sessions for 12 weeks), or sacral neuromodulation, as recommended by the latest guideline 1. These treatments work by reducing inappropriate bladder muscle contractions or normalizing the neural pathways that control bladder function.
Importance of Patient-Centered Approach
It's crucial to rule out urinary tract infections, neurological conditions, or anatomical problems before starting treatment, as these may require different approaches. A patient-centered approach, considering individual preferences and values, is essential for crafting personalized treatment plans aligned with patient goals, potentially enhancing the effectiveness of OAB management 1.
Key Considerations
- The latest guideline from 2024 1 emphasizes the importance of offering sacral neuromodulation, tibial nerve stimulation, and/or intradetrusor botulinum toxin injection to patients with OAB who have an inadequate response to, or have experienced intolerable side effects from, pharmacotherapy or behavioral therapy.
- Behavioral therapies, including bladder training, bladder control strategies, pelvic floor muscle training, and fluid management, are recommended as first-line therapy for all patients with OAB, as they are effective in reducing symptom levels and are risk-free 1.
From the FDA Drug Label
Mirabegron was evaluated in three, 12-week, double-blind, randomized, placebo-controlled, parallel group, multicenter clinical trials in patients with overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency (Studies 1,2, and 3) Mirabegron extended-release tablets are indicated for the treatment of OAB in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency. The recommended starting dosage of mirabegron extended-release tablets is 25 mg orally once daily. If needed, increase to the maximum dosage of mirabegron extended-release tablets 50 mg orally once daily after 4 to 8 weeks.
Mirabegron is used to treat overactive bladder in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency. The recommended starting dose is 25 mg orally once daily, which can be increased to a maximum dose of 50 mg orally once daily after 4 to 8 weeks if needed 2, 2, 2.
From the Research
Definition and Symptoms of Overactive Bladder
- Overactive bladder (OAB) is a symptom-based syndrome characterized by the presence of urgency, which is defined as a sudden and compelling desire to void that cannot be postponed 3.
- OAB may significantly impact quality of life, and numerous treatment options exist, including behavioral therapies and traditional therapies such as pharmacological therapy and neuromodulation 3, 4.
Risk Factors for Overactive Bladder
- Initial evidence suggests that obesity, smoking, and consumption of carbonated drinks are risk factors for OAB 3.
- However, there is less support for the contributory role of caffeine or the impact of caffeine reduction 3, 5.
Treatment Options for Overactive Bladder
- Behavioral therapies, such as pelvic floor muscle rehabilitation, bladder training, and dietary modification, are considered the mainstay of treatment for urinary incontinence in general 3.
- First-line treatment comprises conservative measures including weight reduction, a decrease in exposure to bladder stimulants, fluid optimisation, and pelvic floor exercises 4.
- Pharmacological treatments for OAB include anticholinergic medications such as oxybutynin, and minimally invasive procedures such as intravesical botulinum toxin A injections may be recommended for patients unresponsive to pharmacological treatment 4.
Efficacy of Behavioral Therapies
- The evidence supporting bladder training and pelvic floor muscle training is more consistent, and a trend towards combining these therapies to treat OAB appears positive 3, 6.
- A randomized controlled trial found that bladder training, pelvic floor muscle training, and pelvic floor muscle training with biofeedback all showed significant improvement in symptoms reduction and quality of life improvement in female patients with OAB syndrome 6.