What are the treatment options for overactive bladder?

Overactive Bladder Treatment

Start all patients immediately with behavioral therapies (bladder training, fluid management, caffeine avoidance), then add mirabegron 25-50 mg daily as the preferred pharmacologic agent if symptoms persist after 8-12 weeks, reserving antimuscarinics as second-choice due to cognitive risks. 1, 2

First-Line Treatment: Behavioral Therapies (Start Immediately)

Behavioral interventions are as effective as medications for reducing symptoms but carry zero risk, making them mandatory initial therapy for all patients. 3

Core behavioral interventions include:

• Bladder training and delayed voiding: Practice postponing urination when urgency occurs, gradually extending intervals between voids to retrain bladder capacity 3, 1
• Fluid management: Reduce total daily fluid intake by 25%, which decreases frequency and urgency; restrict evening fluids specifically for nocturia 3, 1
• Caffeine and alcohol elimination: These directly irritate the bladder and worsen urgency 3, 2
• Pelvic floor muscle training: Strengthening exercises improve urge suppression and bladder control 3, 1
• Weight loss for obese patients: Even 8% weight reduction decreases urgency incontinence episodes by 42% versus 26% in controls 3, 1

The success of behavioral therapies depends heavily on patient adherence, so education and support are critical. 1 Most patients experience significant symptom reduction rather than complete cure. 3

Second-Line Treatment: Pharmacologic Management

Preferred Agent: Beta-3 Adrenergic Agonist

Mirabegron is the preferred pharmacologic option over antimuscarinics due to substantially lower cognitive risk. 1, 2

• Dosing: Start mirabegron 25 mg orally once daily; increase to 50 mg daily after 4-8 weeks if needed 4
• Efficacy: Similar symptom reduction to antimuscarinics but with more favorable adverse event profile 3

Alternative Agents: Antimuscarinics (Use with Caution)

Antimuscarinics are second-choice options when beta-3 agonists fail or are contraindicated. No single antimuscarinic shows superior efficacy over others. 3, 1

Available antimuscarinics include (alphabetical order, no hierarchy): darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium 3, 5

Critical contraindications and precautions:

• Absolute contraindication: Narrow-angle glaucoma unless approved by ophthalmologist 3
• Extreme caution required: Impaired gastric emptying, history of urinary retention, post-void residual >250-300 mL 3, 1
• Avoid in cognitive impairment: Antimuscarinics carry significant cognitive risk, particularly in elderly patients 1, 2
• Do not use with solid oral potassium chloride: Reduced gastric emptying increases potassium absorption risk 3

Common non-life-threatening side effects: Dry mouth, constipation, dry eyes, blurred vision, dyspepsia, UTI 3

Combination Therapy

Behavioral and pharmacologic therapies may be combined from the outset, as simultaneous initiation improves outcomes including frequency, voided volume, incontinence, and symptom distress. 3, 1

Treatment Adjustments for Inadequate Response

Allow 8-12 weeks to assess efficacy before changing therapy. 1, 2

If inadequate symptom control or unacceptable adverse events occur with one medication:

• Dose modification: Reduce dose or combine with behavioral techniques to balance efficacy and side effects 3
• Switch to different antimuscarinic: Patients experiencing failure or unacceptable side effects with one antimuscarinic may respond better to another, particularly when switching from immediate-release to sustained-release formulations 3
• Switch to beta-3 agonist: Mirabegron offers similar efficacy with relatively lower adverse event profile 3

Do not abandon antimuscarinic therapy after a single medication trial fails. 3

Essential Pre-Treatment Evaluation

Measure post-void residual (PVR) before starting antimuscarinics in high-risk patients:

• Concomitant emptying symptoms 1
• History of urinary retention 1
• Enlarged prostate 1
• Neurologic disorders 1
• Prior incontinence or prostate surgery 1
• Long-standing diabetes 1

PVR >250-300 mL warrants extreme caution when prescribing antimuscarinics or beta-3 agonists. 1

Third-Line Treatments (Specialist Referral Required)

Patients refractory to behavioral and pharmacologic therapy should be evaluated by a urologist if they desire additional treatment. 3

Advanced options include:

• Intradetrusor onabotulinumtoxinA injections: Patients must be willing to perform clean intermittent self-catheterization if urinary retention develops 3, 1
• Peripheral tibial nerve stimulation (PTNS): Requires frequent office visits for treatment sessions 3, 1
• Sacral neuromodulation (SNS): Implantable device for refractory cases 3, 1

These therapies present increasing risk that must be balanced against potential efficacy. 3

Incontinence Management Strategies

While treating the underlying condition, discuss symptom management products:

• Absorbent products (pads, liners, absorbent underwear) 1, 2
• Barrier creams to prevent urine dermatitis 1
• External collection devices 1

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

Monitoring and Follow-Up

• Annual follow-up to assess treatment efficacy and detect symptom changes 1, 2
• Most patients experience significant symptom reduction rather than complete resolution 1, 2

Common Pitfalls to Avoid

• Do not delay behavioral therapy: Start immediately—it's as effective as medications with zero risk 3
• Do not default to antimuscarinics: Mirabegron should be first pharmacologic choice due to lower cognitive risk 1, 2
• Do not abandon therapy prematurely: Allow 8-12 weeks before declaring treatment failure 1, 2
• Do not skip PVR measurement in high-risk patients: Failure to measure PVR before antimuscarinics risks acute urinary retention 1