overactive%20bladder
OVERACTIVE BLADDER
Treatment Guideline Chart

Overactive bladder is a syndrome characterized by urinary urgency with or without frequency, nocturia and urgency incontinence.

It is also known as bladder spasms, suggestive of underlying detrusor overactivity.

Incidence increases with age and more commonly affects women.

Overactive%20bladder Treatment

Principles of Therapy

  • Goals of treatment:
    • To reduce urinary urgency and frequency
    • To increase voided volume (bladder capacity)
    • To decrease urge incontinence (reduce leakage episodes
  • Before starting OAB drugs, the following should be monitored:
    • Coexisting conditions (eg poor bladder emptying, constipation, glaucoma)
    • Use of other existing medication affecting the total antimuscarinic load
    • Risk of adverse effects
  • Treatment should be individualized; consider the patient’s comorbidities, concomitant medications and pharmacological profiles of different drugs

Pharmacotherapy

Antimuscarinics

  • Anticholinergic agents that specifically block the muscarinic form of the cholinergic receptor
  • Recommended as first-line pharmacologic therapy for patients with OAB
  • Decrease the bladder tone and amplification of contractions of the urinary bladder, counteract the relaxation of the trigone and external sphincter responsiveness of the bladder wall muscle to stimulating nerve impulses
  • Should be offered in patients with spinal cord disease, symptoms of OAB, conditions affecting the brain and impaired bladder storage
  • Residual urine volume should be monitored in patients who are not using intermittent or indwelling catheterization after the start of antimuscarinic treatment
  • Extended-release (ER) preparations should be prescribed over intermediate-release (IR) because of lower rates of adverse effects of dry mouthIf there is inadequate symptom control or unacceptable adverse drug reaction to antimuscarinic drugs, patient can be shifted to another or different antimuscarinic medication or β3-adrenoreceptor agonists
  • Constipation and dry mouth should be managed before abandoning the antimuscarinic therapy
Darifenacin
  • ER form that elicits competitive muscarinic receptor antagonistic activity
  • Reduces smooth muscle contractions of the bladder
  • Indicated for symptoms of OAB  (eg urge incontinence, urgency, frequency)
Fesoterodine
  • Has similar muscarinic receptor affinity as Tolterodine but was shown to be superior to it
  • Based on the IMPACTA study, patients who were shifted from their previous anticholinergics to Fesoterodine had decreased incidence of dry mouth and constipation
Imidafenacin
  • Has greater affinity for M3 and M1 receptors
Oxybutynin
  • An M3, M1 specific receptor
  • Inhibits the action of acetylcholine on the smooth muscle with antispasmodic effect
  • Increases bladder capacity and decreases uninhibited contractions
  • Transdermal administration reduces occurrence of dry mouth
Propiverine
  • Has mixed mechanism of action in the treatment of symptoms associated with OAB
  • Blocks muscarinic receptors in the detrusor muscle and cellular calcium influx thereby diminishing muscle spasm
  • Generally tolerated with a lower incidence of dry mouth than that of Oxybutynin
  • Valuable option for adults with OAB associated with idiopathic and neurogenic detrusor overactivity and in men with storage lower urinary tract symptoms
  • Patients must be willing to return for frequent post-void residual evaluation and perform self-catheterization
Solifenacin
  • Competitive muscarinic receptor antagonist approved for the treatment of OAB symptoms
  • Has been shown to be effective in treating OAB symptoms in multiple sclerosis patients and significantly improved the frequency, urgency, volume voided, and number of pads used per 24 hours
    • Reduces micturition and urgency urinary incontinence episodes for 24 hours
Tolterodine
  • Non-specific competitive inhibitor muscarinic receptor antagonist for OAB
  • Anticholinergic receptor with selectivity to urinary bladder
  • Has high specificity for muscarinic receptors
Trospium
  • Non-specific quarternary ammonium compound that is excreted intact in the urine and is not dependent on cytochrome P450 system for its metabolism
  • Indicated for the treatment of OAB symptoms
β3-Adrenoreceptor Agonists

Mirabegron
  • First-in-class β3-adrenoreceptor agonists licensed for OAB treatment
  • Causes relaxation of detrusor smooth muscle by its agonist action at β3 receptors leading to increased storage capacity of bladder
  • Well-tolerated and effective in the treatment of urinary incontinence and frequency micturition
  • Has lower incidence of dry mouth as compared to other antimuscarinics
  • Recommended as an option only for people whom antimuscarinic drugs are contraindicated, clinically ineffective, or have unacceptable side effects
Vibegron
  • A phase III clinical trial conducted in Japan showed reduction in micturition in 24 hours, incontinent patients became dry and more than 40% of subjects exhibited resolution of nocturia
  • In the EMPOWUR study, participants were randomized to Vibegron, placebo, or Tolterodine
    • Participants on Vibegron had statistically significant reduction in urgency incontinence episodes
    • Vibegron-associated adverse events were mild and less frequent than those on Tolterodine
Botulinum toxin type A
  • A Food and Drug Administration-approved medication used for the treatment of urinary incontinence due to detrusor overactivity associated with neurologic conditions in adults who have inadequate response to anticholinergic drugs
  • In the study of Hobbs et al, botulinum toxin type A, was a successful treatment in males with idiopathic wet and dry OAB irrespective of detrusor overactivity
  • Intradetrusor onabotulinum toxin A (100U) may be given for carefully-selected and thoroughly-counseled patient who became refractory to first and second line treatments
  • Based on the study of Khan et al, there was a considerable improvement shown in the mean Urogenital Distress Inventory and Incontinence Impact Questionnaire
  • Patients must be willing to return for frequent post-void residual evaluation and perform self-catheterization
  • Monitor the upper urinary tract of patients who are judged to be at risk of renal complications (eg with high intravesical pressures on filling cystometry) during treatment with botulinum toxin type A

Non-Pharmacological Therapy

Lifestyle Changes
  • Fluid intake
    • Limiting fluid intake to 1-1.5 L per day is recommended
    • Eliminate alcohol and caffeine, particularly in the evening
  • Smoking cessation
    • Nicotine can irritate the bladder and cause bladder contraction and urgency
    • Coughing due to smoking may cause urinary leakage
  • Stress
    • To reduce stress, techniques such as meditation, yoga, breathing techniques and music relaxation may relieve symptoms
  • Diet
    • Foods such as tomato-based, highly spiced, fruits and fruit juices, frizzy drinks and foods containing chocolate, tea and coffee should be eliminated in the diet, as this can irritate and trigger OAB
    • Increase intake of dietary fiber as constipation can put pressure in an OAB
  • Exercise
    • Being obese and overweight might increase symptoms of OAB, as this increases the pressure on the bladder or other neurological conditions
    • Pelvic muscle floor should be considered in patients with lower urinary tract dysfunction due to multiple sclerosis or stroke and other neurological conditions where there is a potential voluntary contraction of the pelvic floor
  • Dry mouth
    • This is due to the adverse effect of the anticholinergic drugs
    • The patient is advised to sip water
  • Diuretics
    • Known cause of incontinence and should be avoided especially in the elderly, when possible
Products Used to Help Living with OAB
  • Portable urinals
    • Find the one that will fit inside the handbag or in the glove box of the car
  • Protective underwear or pads
    • Using or wearing a pad can help patients with leakage of urine, from mild, medium to heavy
  • Waterproof bedding
    • This is advised for those who experience nocturnal enuresis
Behavioral Therapy
  • Aims to increase interval between voiding, reduce episodes of urgency and nocturia, and prevent incontinence by training patients to control detrusor muscle contractions through pelvic muscle floor training


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