Overactive bladder (OAB) is a prevalent symptom affecting quality of life, particularly in the aging population, characterized by urgency and urge incontinence. Treatment options range from first-line behavioral therapies to pharmacologic management with antimuscarinic agents, which are effective but may have side effects. For refractory cases, third-line treatments include onabotulinum toxin A injections or surgical options such as sacral neuromodulation.

1. Overactive Bladder
DR LAXMI SHRIKHANDE
DR ANIL SHRIKHANDE

2. ❑Overactive bladder (OAB) is not a disease; it is a
symptom; Patients with OAB do not complain of pain or
dysuria
❑Bladder storage symptoms have a severe impact on many areas
as regards the quality of life including health-related, social,
psychological and working functions
❑Overactive bladder (OAB) is highly prevalent and is
associated with considerable morbidity, especially in
aging population
OAB

3. OAB-Symptoms
Urgency
Frequent strong, sudden and
unpredictable desire to urinate
UrgeIncontinence
Involuntary urine loss associatedwith
sudden, strong desire to void
Eur.Ass.Gyn.Obs,1999

4. Inappropriate (involuntary, unpredictable)detrusor
contractionduringfilling phaseof micturition
Pathophysiology
PLoSONE2007; 2 (2):e195

5. SOLIACT

6. Overactive bladder: treatment options
First-line treatments:
❑Behavioral therapies (e.g. bladder training, bladder control
strategies, pelvic floor muscle training, fluid management) as
first-line therapy to all patients with overactive bladder.
❑Pharmacologic management.

7. 7
Mattiasson A. Urology. 2000;55(suppl 5a):12-13, Mattiasson A. Neuro Urodyn. 2001;20:403-404, Burgio et al. JAGS. 2000;48:370-374.
Drug therapy: becoming increasingly important & currently
mainstay in treatment for OAB
OAB: Pharmacotherapy
Antimuscarinic agents: Gold standard
Second-line treatments:

8. 8
Ideal muscarinic receptor antagonist
 Efficacious:
 Inhibits involuntary bladder contractions
 Does not adversely affect voluntary detrusor activity
 Organ selective:
 Preferentially affects bladder over other organs
 Minimal side effects
 Tolerable:
 Improves compliance

9. Choice of agent
 may not experience the full benefit of these drugs until after
4 weeks of treatment
 If the first choice is not effective or is poorly tolerated, it is
reasonable to offer another drug, preferably the least
expensive.
 should be counseled about the need for concurrent
behavioral therapy, because these drugs are more effective
in combination with behavioral therapy than with either
treatment modality alone.

10. Side effects
 Common adverse effects include constipation,
impaired cognition, sedation, and blurred vision.
 These agents should not be used in patients with
narrow angle glaucoma because they can increase
intraocular pressure.
 Extra caution in frail patients-cognitive function
 SR preparation preferred
 start with Lowest possible dose

11. Drugs
 Oxybutynin- side effects
 Tolterodine 4 mg OD
 Trospium 60 mg OD- safe in elderly as it doesn’t cross
blood brain barrier
 Darifenacin-frequency 7.5mg OD /15 mg
 Solifenacin-urgency 5mg OD / 10mg
 Mirabegron-50 mg OD
 Combination

12. Mirabegron-Beta 3 agonist
 USFDA approved in 2012
 A placebo controlled RCT found that patients taking once daily mirabegron
had 1.1 (−1.35 to −0.91) fewer daily episodes of urinary incontinence with
placebo, compared with 1.5 (−1.69 to −1.25) for 50 mg mirabegron, and 1.6
(−1.86 to −1.40) with 100 mg mirabegron, from a baseline of 2.4 episodes daily.
 Adverse effects were uncommon, with dry mouth and constipation reported in
less than 2% of all patients.
 In addition, a pooled phase III clinical trial showed no significant increase in
hypertension (<1 mm Hg) with mirabegron versus placebo.
 Dose- 50 mg ODX 8 weeks- 12 month
 Can be given in association with solifenacin 5 mg OD-urgency/nocturia
 Caution- renal impairment and HT

13. Third-line treatments:
❑ Intradetrusor onabotulinum toxin A (100 U) as third-line treatment in the carefully-selected
and thoroughly counseled; patient who has been refractory to first- and second-line
overactive bladder treatments. The patient must be able and willing to return for frequent
post-void residual evaluation and able and willing to perform self-catheterization if
necessary.
Standard Option
❑ Peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected
patient population.
❑ Sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient
population characterized
❑ By severe refractory overactive bladder symptoms or patients who are not candidates for
second-line therapy and are willing to undergo a surgical procedure.
Additional treatments:
❑ Indwelling catheters (including transurethral, suprapubic, etc.) are not recommended as a
management strategy for overactive bladder because of the adverse risk/benefit balance
except as a last resort in selected patients.
❑ In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory,
complicated overactive bladder patients may be considered.
Overactive bladder: treatment options

14. 1. Underreporting • Increase patient awareness
about OABasadisease
2. High discontinuation
rates with antimuscarinic
therapy
• Increase awareness
regarding OABmanagement
• Need anantimuscarinic
agent:
➢ Better efficacy
➢ Better persistencerates
➢ Goodsafety profile
➢ Integration with behavioural
therapy