What is the first‑line pharmacologic treatment and dosing for an adult with over‑active bladder (urgency, frequency, or urge incontinence)?

First-Line Pharmacologic Treatment for Overactive Bladder

For adults with overactive bladder, solifenacin 5 mg once daily is an appropriate first-line pharmacologic agent, taken with water and swallowed whole, with or without food. 1

Mandatory Behavioral Therapy Before or Alongside Medication

• All patients must initiate behavioral interventions—including bladder training, pelvic floor muscle training, fluid management, and weight loss if obese—before or concurrently with any pharmacologic therapy, as these non-drug approaches achieve efficacy comparable to antimuscarinic medications with minimal adverse effects. 2, 3
• A 25% reduction in fluid intake reduces frequency and urgency, and an 8% weight loss decreases urgency urinary incontinence episodes by 42% in obese patients. 3
• Behavioral therapies should be continued for 8–12 weeks to assess effectiveness before judging the need for medication escalation. 2

Solifenacin Dosing and Administration

• The recommended starting dose of solifenacin is 5 mg once daily; if well tolerated and symptom control is insufficient, the dose may be increased to 10 mg once daily. 1
• Solifenacin tablets should be taken with water and swallowed whole, and can be administered with or without food. 1
• Do not exceed 5 mg once daily in patients with severe renal impairment (creatinine clearance < 30 mL/min/1.73 m²), moderate hepatic impairment (Child-Pugh B), or when co-administered with strong CYP3A4 inhibitors such as ketoconazole. 1
• Do not use solifenacin in patients with severe hepatic impairment (Child-Pugh C). 1

Efficacy of Solifenacin

• Solifenacin demonstrates efficacy for all overactive bladder symptoms, including reduction in urinary incontinence episodes, decrease in urgency episodes, reduction in urinary frequency, and improvement in nocturia. 4
• When compared to immediate-release tolterodine, solifenacin shows statistically significant superiority for quality of life, patient-reported cure/improvement, leakage episodes in 24 hours, and urgency episodes in 24 hours, with lower risk of dry mouth. 5
• Solifenacin may be an adequate anticholinergic choice for elderly patients or those with pre-existing cognitive dysfunction. 6

Safety Considerations and Contraindications

• Solifenacin is contraindicated in patients with urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma. 1
• Use with extreme caution in patients with impaired gastric emptying, history of urinary retention, or narrow-angle glaucoma. 4
• Angioedema of the face, lips, tongue, and/or larynx has been reported with solifenacin, sometimes after the first dose; if upper airway involvement occurs, promptly discontinue solifenacin and ensure a patent airway. 1
• Solifenacin is contraindicated in patients with known or suspected hypersensitivity to solifenacin or its inactive ingredients, as anaphylactic reactions have been reported. 1

Common Adverse Effects

• Common side effects of antimuscarinics, including solifenacin, include dry mouth, constipation, dry eyes, blurred vision, dyspepsia, urinary tract infection, and urinary retention. 3
• Dry mouth is the most frequent complaint with antimuscarinic agents, and constipation should be monitored and managed proactively. 2

Alternative First-Line Pharmacologic Options

• Beta-3 adrenergic agonists (mirabegron or vibegron) are typically preferred before antimuscarinic medications due to their superior tolerability profile, lower incidence of dry mouth and constipation, and absence of cognitive risk concerns, particularly in elderly patients or those with cognitive concerns. 2
• Mirabegron 25 mg once daily is the starting dose, with efficacy demonstrated within 8 weeks and a superior tolerability profile compared to antimuscarinics. 2
• Mirabegron can be used safely in patients with narrow-angle glaucoma, history of urinary retention, or impaired gastric emptying, as it lacks anticholinergic effects. 2

Management of Inadequate Response or Intolerable Side Effects

• If solifenacin fails to provide adequate symptom relief or produces intolerable adverse effects, do not abandon antimuscarinic therapy; instead, switch to another antimuscarinic agent or change to a beta-3 agonist. 2
• Each pharmacologic trial should be continued for a minimum of 4–8 weeks before judging effectiveness or safety. 2
• Dose adjustment—such as reducing the daily dose—or reinforcing behavioral techniques can improve tolerability while preserving efficacy. 2

Combination Therapy for Refractory Symptoms

• For patients failing monotherapy, combining solifenacin 5 mg with mirabegron 50 mg is effective and statistically superior to either monotherapy for reducing incontinence episodes and micturitions, with moderate strength of evidence. 2, 3
• Adverse events such as dry mouth, constipation, and dyspepsia are slightly increased with combination therapy versus monotherapy. 2

Special Population Considerations

• In frail elderly patients (those with mobility limitations, unintended weight loss, weakness, or cognitive deficits), exercise heightened caution when prescribing either antimuscarinic drugs or beta-3 agonists due to a narrower therapeutic index and higher risk of adverse events; beta-3 agonists remain preferred because they do not increase cognitive impairment risk. 2
• In elderly men, assess post-void residual volume before starting solifenacin; if ≥ 250 mL (or maximum urinary flow rate < 10 mL/s), bladder outlet obstruction is likely, and an alpha-blocker should be used as first-line therapy rather than antimuscarinic or beta-3 agonist monotherapy. 2
• There is a potential risk for developing dementia and cognitive impairment with antimuscarinic medications, which may be cumulative and dose-dependent. 2

Common Pitfalls to Avoid

• Do not prescribe solifenacin without first offering or concurrently implementing behavioral therapies, as failing to optimize behavioral interventions is a common error. 2
• Do not discontinue antimuscarinic therapy after a single agent fails without first attempting another antimuscarinic or switching to a beta-3 agonist, as evidence supports the benefit of class switching in achieving symptom control. 2
• Do not use antimuscarinics in patients with contraindications such as narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention. 2
• Do not ignore cognitive risks when prescribing antimuscarinics, especially in elderly patients. 2

Realistic Expectations

• Most patients will not experience complete symptom relief but can expect significant reductions in symptoms and improvements in quality of life. 3
• Education on treatment efficacy, realistic expectations, and length of treatment should be provided upon initiation of antimuscarinic therapy, as continuation rates for anticholinergic therapy are low. 6