What are the treatment options for overactive bladder and incontinence?

Treatment Options for Overactive Bladder and Incontinence

Start all patients immediately with behavioral therapies (bladder training, fluid management, dietary modifications), and if pharmacotherapy is needed, prescribe mirabegron 25-50 mg daily as the preferred first-line medication over antimuscarinics due to significantly lower cognitive impairment risk. 1, 2

First-Line Treatment: Behavioral Therapies (Start Immediately for All Patients)

Behavioral interventions should be initiated in every patient with overactive bladder and incontinence because they have zero cognitive risk, no drug interactions, and effectiveness equal to antimuscarinics. 1

Core Behavioral Interventions:

• Bladder training and delayed voiding: Practice postponing urination when urgency occurs, gradually extending intervals between voids to retrain the bladder 1

• Fluid management: Reduce total daily fluid intake by approximately 25%, with particular attention to evening fluid restriction to decrease frequency and urgency 1, 3

• Bladder irritant avoidance: Eliminate or reduce caffeine and alcohol consumption, as these directly irritate the bladder 1

• Pelvic floor muscle training: Perform strengthening exercises for urge suppression and improved bladder control 1, 3

• Urgency suppression techniques: Stop, sit down, perform pelvic floor muscle contractions, use distraction or relaxation techniques, and wait for urgency to pass before walking calmly to the bathroom 1

• Weight loss: Even 8% reduction in obese patients decreases urgency incontinence episodes by 42% 1

Second-Line Treatment: Pharmacologic Management

Preferred Medication: Beta-3 Adrenergic Agonist

Mirabegron 25-50 mg daily is the strongly preferred pharmacologic option over antimuscarinics because it has no cognitive impairment risk—a critical advantage especially in elderly patients and those with dementia. 1, 2

• Start mirabegron at 25 mg orally once daily 4
• If inadequate response after 4-8 weeks, increase to maximum dose of 50 mg daily 4
• Mirabegron requires blood pressure monitoring, especially during initial treatment, and is contraindicated in severe uncontrolled hypertension 2
• Mirabegron has no impact on cognitive function, making it essential for geriatric patients and those with dementia 2

Alternative: Antimuscarinic Medications (Use with Caution)

Antimuscarinics should only be considered when beta-3 agonists fail or are contraindicated, and must be used with extreme caution in patients with cognitive impairment risk, narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention. 1

Available antimuscarinics include: darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium—no single antimuscarinic shows superior efficacy over others 1

Critical Contraindications and Precautions for Antimuscarinics:

• Narrow-angle glaucoma 1
• Impaired gastric emptying 1
• History of urinary retention 1
• Post-void residual >250-300 mL 1
• Cognitive impairment or dementia (relative contraindication) 1, 2

Combination Therapy for Inadequate Response

If monotherapy with either mirabegron or an antimuscarinic provides inadequate symptom control, combination therapy with solifenacin plus mirabegron 50 mg is statistically superior to either monotherapy alone for decreasing incontinence episodes and micturitions. 5

• The SYNERGY II trial demonstrated combination solifenacin 5 mg plus mirabegron 50 mg was superior to either monotherapy for reducing incontinence episodes (p<0.001 vs mirabegron; p=0.002 vs solifenacin) and micturitions (p<0.001 vs mirabegron; p=0.004 vs solifenacin) 5
• Adverse events including dry mouth, constipation, and urinary retention were slightly increased in combination therapy groups 5

Essential Pre-Treatment Assessment

Measure post-void residual (PVR) before starting any pharmacotherapy in patients with emptying symptoms, history of retention, enlarged prostate, neurologic disorders, prior incontinence/prostate surgery, or long-standing diabetes. 1, 2

• Post-void residual >250-300 mL warrants extreme caution when prescribing antimuscarinics or beta-3 agonists 1
• Urinalysis should be conducted to exclude infection and microhematuria 1, 3

Treatment Monitoring and Adjustment Algorithm

Allow 8-12 weeks to assess efficacy before changing therapy—this is an adequate trial period to determine whether the treatment is working. 1

If Inadequate Response or Intolerable Side Effects Occur:

1. First option: Modify the dose of current medication 1
2. Second option: Switch to a different antimuscarinic (if currently on antimuscarinic) 1
3. Third option: Switch to beta-3 agonist (if currently on antimuscarinic) 1
4. Fourth option: Add combination therapy (antimuscarinic + beta-3 agonist) 5, 1

Behavioral therapies may be combined with pharmacologic management simultaneously to optimize symptom control—initiating both together may improve outcomes including frequency, voided volume, incontinence, and symptom distress. 1

Third-Line Treatment for Refractory Cases

For patients who fail behavioral therapies and pharmacologic management, three advanced interventions are available: intradetrusor onabotulinumtoxinA injection, peripheral tibial nerve stimulation (PTNS), and sacral neuromodulation (SNS). 5, 1, 2

Intradetrusor OnabotulinumtoxinA (100 U):

• Patients must be willing and able to perform clean intermittent self-catheterization if urinary retention develops 1, 2
• Requires frequent post-void residual evaluation 3

Peripheral Tibial Nerve Stimulation (PTNS):

• Benefits carefully selected patients with moderately severe baseline incontinence and frequency 5
• Requires frequent office visits for treatment sessions 5, 1, 2
• Treatment effects are only maintained as long as therapy continues 5

Sacral Neuromodulation (SNS):

• The InSite trial demonstrated SNS effectiveness in patients with less severe symptoms (mean 11.2 voids/day, mean 2.4 incontinence episodes/day) 5
• Patients must have cognitive capacity to use the remote control to optimize device function 5
• Diagnostic MRI below the head is contraindicated with the device implanted 5

Incontinence Management Strategies

Absorbent products (pads, liners, absorbent underwear), barrier creams to prevent urine dermatitis, and external collection devices should be discussed as symptom management strategies—but these manage symptoms without treating the underlying condition and should be used alongside, not instead of, active treatment. 1, 3

Common Pitfalls to Avoid

Many patients present for second- or third-line treatments without ever having undergone comprehensive evaluation (completion of voiding diary) or adequate first-line trial of behavioral therapy—always ensure behavioral therapies have been properly attempted before escalating treatment. 5

• Short medication trials without adequate duration (less than 8-12 weeks) are inadequate to assess efficacy 5, 1
• Lack of dose modification or supportive management for commonly associated side effects leads to premature treatment abandonment 5
• Therapies that do not demonstrate efficacy after an adequate trial should be ceased rather than continued indefinitely 5

Annual Follow-Up

Annual follow-up is recommended to assess treatment efficacy and detect any changes in symptoms. 1, 3