What are the treatment options for an overactive bladder?

Treatment of Overactive Bladder

Start all patients immediately with behavioral therapies combined with mirabegron 25-50 mg daily as the preferred pharmacologic agent, avoiding antimuscarinics in elderly or cognitively impaired patients due to dementia risk. 1, 2

Initial Evaluation Requirements

Before initiating treatment, complete the following assessment:

• Obtain urinalysis and urine culture to exclude urinary tract infection, the most common OAB mimicker 2
• Measure post-void residual (PVR) in patients with emptying symptoms, urinary retention history, enlarged prostate, neurologic disorders, prior incontinence/prostate surgery, or long-standing diabetes 1, 2
• Identify bladder outlet obstruction, particularly in men with enlarged prostate—PVR >250-300 mL suggests obstruction and contraindicates antimuscarinic use 1, 2

First-Line Treatment: Behavioral Therapies (Start Immediately)

Initiate these interventions in all patients due to excellent safety profile and zero drug interactions:

• Bladder training with delayed voiding: Practice postponing urination when urgency occurs, gradually extending intervals between voids—equally effective to antimuscarinics with zero cognitive risk 1
• Urgency suppression technique: Stop, sit down, perform pelvic floor contractions, use distraction/relaxation, wait for urgency to pass, then walk calmly to bathroom 1
• Fluid management: Reduce total daily fluid intake by 25%, with particular evening restriction to decrease frequency and urgency 1
• Eliminate bladder irritants: Remove caffeine and alcohol from diet 1, 3
• Weight loss in obese patients: Even 8% weight reduction decreases urgency incontinence episodes by 42% 1
• Pelvic floor muscle training for urge suppression and improved bladder control 1, 3

Second-Line Treatment: Pharmacologic Options

Preferred Agent: Beta-3 Adrenergic Agonist

Mirabegron is the preferred pharmacologic option over antimuscarinics due to significantly lower cognitive impairment risk, particularly critical in elderly patients. 1, 2

• Mirabegron dosing: Start 25 mg orally once daily, increase to maximum 50 mg daily after 4-8 weeks if needed 1, 4
• Dose adjustment for renal impairment: Maximum 25 mg daily if eGFR 15-29 mL/min/1.73 m²; not recommended if eGFR <15 or dialysis-dependent 4
• Dose adjustment for hepatic impairment: Maximum 25 mg daily for Child-Pugh Class B; not recommended for Class C 4

Alternative Agents: Antimuscarinics (Use with Extreme Caution)

Consider only when beta-3 agonists fail or are contraindicated:

• Available agents: Darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium—no single agent shows superior efficacy over others 1, 5
• Critical contraindications: Narrow-angle glaucoma, impaired gastric emptying, history of urinary retention, PVR >250-300 mL 1, 2
• Avoid in cognitive impairment: Antimuscarinics increase dementia risk; use beta-3 agonists instead 2

Treatment Optimization Strategy

• Allow 8-12 weeks to assess efficacy before declaring treatment failure 1, 3
• Combine behavioral and pharmacologic therapies simultaneously for superior outcomes including improved frequency, voided volume, incontinence, and symptom distress 1
• If inadequate response: Consider dose modification, switch to different antimuscarinic, or switch to beta-3 agonist 1
• Annual follow-up to assess treatment efficacy and detect symptom changes 1, 3

Third-Line Treatment for Refractory Cases

When behavioral and pharmacologic interventions fail after adequate trial:

• Intradetrusor onabotulinumtoxinA injections: Requires patient willingness to perform clean intermittent self-catheterization if needed 1, 3
• Peripheral tibial nerve stimulation (PTNS): Requires frequent office visits 1, 3
• Sacral neuromodulation (SNS): Surgical implantation option 1, 3

Optimize Contributing Comorbidities

Treating underlying conditions significantly improves OAB symptoms:

• Benign prostatic hyperplasia in men 2, 3
• Constipation management 2, 3
• Genitourinary syndrome of menopause treatment 2, 3
• Diabetes mellitus optimization 2, 3
• Pelvic organ prolapse repair 2, 3

Incontinence Management Products

While pursuing definitive treatment, provide symptom management:

• Absorbent products: Pads, liners, absorbent underwear 1, 3
• Barrier creams to prevent urine dermatitis 1, 3
• External collection devices 1

These products manage symptoms but do not treat underlying OAB—use alongside, not instead of, active treatment. 1

Critical Pitfalls to Avoid

• Never prescribe antimuscarinics to cognitively impaired patients—use mirabegron instead due to dementia risk 2
• Never ignore elevated PVR >250-300 mL—indicates possible bladder outlet obstruction requiring different treatment approach 1, 2
• Never declare treatment failure before 8-12 weeks—adequate trial period essential 1, 3
• Never use antimuscarinics in patients with narrow-angle glaucoma, impaired gastric emptying, or urinary retention history 1, 2