First-line treatments:
Clinicians should offer 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. Standard (Evidence Strength Grade B)
Behavioral therapies may be combined with pharmacologic management. Recommendation (Evidence Strength Grade C)
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Second-line treatments:
Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as second-line therapy. Standard (Evidence Strength Grade B)
If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth. Standard (Evidence Strength Grade B)
Transdermal (TDS) oxybutynin (patch [now available to women aged 18 years and older without a prescription]* or gel) may be offered. Recommendation (Evidence Strength Grade C)
If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one antimuscarinic medication, then a dose modification or a different antimuscarinic medication or a β3-adrenoceptor agonist may be tried. Clinical Principle
Clinicians should not use antimuscarinics in patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should use antimuscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention. Clinical Principle
Clinicians should manage constipation and dry mouth before abandoning effective antimuscarinic therapy. Management may include bowel management, fluid management, dose modification or alternative antimuscarinics. Clinical Principle
Clinicians must use caution in prescribing antimuscarinics in patients who are using other medications with anti-cholinergic properties. Expert Opinion
Clinicians should use caution in prescribing antimuscarinics or β3-adrenoceptor agonists in the frail overactive bladder patient. Clinical Principle
Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. Expert Opinion
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Third-line treatments:
Clinicians may offer 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 (Evidence Strength Grade B C)
Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected patient population. Recommendation (Evidence Strength Grade C)
Clinicians may offer 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. Recommendation (Evidence Strength Grade C)
Practitioners and patients should persist with new treatments for an adequate trial in order to determine whether the therapy is efficacious and tolerable. Combination therapeutic approaches should be assembled methodically, with the addition of new therapies occurring only when the relative efficacy of the preceding therapy is known. Therapies that do not demonstrate efficacy after an adequate trial should be ceased. Expert Opinion
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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. Expert Opinion
In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated overactive bladder patients may be considered. Expert Opinion
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Follow-up:
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