What is the first line treatment for bladder spasms (detrusor overactivity)?

From the Guidelines

Behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training, and fluid management, should be offered as first-line therapy to all patients with bladder spasms, as they are as effective in reducing symptom levels as anti-muscarinic medications. According to the AUA/SUFU guideline 1, these therapies are considered first-line treatments because they are risk-free and can be tailored to improve individual symptoms. For patients who require additional treatment, anticholinergic medications such as oxybutynin (Ditropan) can be considered, starting at 5 mg orally two to three times daily. However, the most recent and highest quality study 1 prioritizes behavioral therapies as the initial approach.

Some key points to consider when implementing behavioral therapies include:

• Bladder training to help the patient regain control over their bladder
• Pelvic floor muscle training to strengthen the muscles that support the bladder
• Fluid management to avoid excessive fluid intake, especially before bedtime
• Avoiding bladder irritants such as caffeine, alcohol, spicy foods, and acidic beverages

It's essential to note that while anticholinergic medications like oxybutynin can be effective, they may cause significant side effects like dry mouth or constipation. In such cases, alternatives like tolterodine (Detrol) 2 mg twice daily or solifenacin (VESIcare) 5 mg once daily can be considered. Patients should expect gradual improvement over 1-2 weeks of consistent treatment and should contact their healthcare provider if symptoms worsen or don't improve after two weeks of treatment. The AUA/SUFU guideline 1 and the European Association of Urology guidelines 1 support the use of behavioral therapies as a first-line approach for managing bladder spasms.

From the FDA Drug Label

The patient should be observed for at least 30 minutes post-injection. Patients should be considered for re-injection when the clinical effect of the previous injection diminishes (median time to qualification for re-treatment in the double-blind, placebo-controlled clinical studies was 295-337 days [42-48 weeks] for BOTOX 200 Units), but no sooner than 12 weeks from the prior bladder injection.

The FDA drug label does not answer the question.

From the Research

Bladder Spasm First Line Treatment

• The first line treatment for overactive bladder syndrome, which is characterized by unstable bladder contractions, includes conservative measures such as weight reduction, decrease in exposure to bladder stimulants, fluid optimisation, and pelvic floor exercises 2.
• Pharmacological treatments for overactive bladder include anticholinergic medications such as oxybutynin and tolterodine 2, 3, 4, 5, 6.
• Tolterodine is a non-subtype selective antimuscarinic agent that has been shown to be effective in reducing symptoms of overactive bladder, including urinary frequency, urgency, and urge incontinence 3, 6.
• Compared to oxybutynin, tolterodine has been shown to have a similar efficacy but better tolerability, with fewer adverse events such as dry mouth 4, 6.
• Other anticholinergic agents, such as darifenacin, solifenacin, and trospium, have also been approved for the treatment of overactive bladder and have shown to be effective and well-tolerated 5.

Anticholinergic Medications

• Oxybutynin and tolterodine are commonly used anticholinergic medications for the treatment of overactive bladder 2, 3, 4, 5, 6.
• These medications work by blocking muscarinic receptors in the bladder wall and detrusor muscle, which helps to reduce unstable bladder contractions and symptoms of overactive bladder 3.
• The choice of anticholinergic medication may depend on the individual patient's response and tolerability to the medication, as well as the presence of any underlying medical conditions or concomitant medications 4, 5.