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Overactive Bladder

Author: Julie DeCesare, MD

Editor: Daniel Martingano, MD

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Overactive bladder (OAB) is defined by the International Continence Society (ICS) as “urinary urgency, typically accompanied by frequency and nocturia, with and without urge urinary incontinence, in the absence of urinary tract infection or other obvious pathology.” OAB impacts approximately 18 million women per year, and accounts for about 7% of all ambulatory visits made by women.

Normal micturition occurs when the smooth detrusor muscle contracts and triggers an automatic relaxation of the urethral sphincter muscles. In cases of overactive bladder, the detrusor muscle contracts when the bladder is not full, often randomly. This triggers the patient to feel the sudden urge to void with resultant episodic incontinence, although not all women with OAB will have actual urinary leakage. Most patients describe an overwhelming urge to void with difficulty getting to the bathroom in time. Frequency and nocturia are also common symptoms.

Initial evaluation of this condition includes complete history, bladder diary, physical exam including the assessment for pelvic organ prolapse, urethral mobility, and stress urinary incontinence (usually with a cough stress test), urinalysis, and post void residual. Multichannel urodynamic studies is performed by a urologist or urogynecologist and should be reserved for complex cases in which an initial office diagnosis remains unclear.

Initial treatment for OAB involves non-invasive lifestyle and behavior modifications. These include physical therapy with or without biofeedback, bladder training, keeping a bladder diary and dietary modifications, including fluid restriction, avoidance of caffeine, and weight loss. Timed voids are also recommended.

Pharmacologic interventions are broadly classified as anti-muscarinic, beta-adrenergic, and vaginal estrogen. These should be offered to patients who find behavior and lifestyle modifications either unacceptable or ineffective, with vaginal estrogen reserved for postmenopausal patients. Anti-muscarinic agents increase the storage capacity of the bladder and reduce urgency symptoms. Common anti-muscarinic agents include oxybutynin and tolterodine tartrate. Side effects are problematic and include dry mouth, constipation, and somnolence. Less common effects include nausea, dry eyes, and headache. These medications only have a minimal effect on the number of voiding episodes, which is one of the most bothersome symptoms. Mirabegron is a beta-adrenergic agent that improves both frequency of urination and incontinence. No significant side effects have been noted when compared to placebo. Vaginal estrogen has been shown to reduce frequency of voiding and may also be beneficial in combination with anti-muscarinics by correcting overlapping conditions of genitourinary syndrome.

Additional treatments have been described for OAB when these aforementioned medications are ineffective or contraindicated. Botulinum Toxin A injections have shown promise, but overtreatment can lead to urinary retention. Nerve modulators, including posterior tibial nerve stimulation and sacral neuromodulation, have also been shown to promote relief from OAB. Neuromodulation is an additional alternative for patients with recalcitrant urgency urinary incontinence who have not responded to other conservative measures. Desmopressin can be helpful particularly for nighttime frequency, although it can lead to hyponatremia. Sodium levels should be monitored with initiation and dose changes. Finally, mindfulness-based stress reduction techniques have shown promise in reducing incontinence episodes in small studies.


Further reading:

Al Hussein Al Awamlh B, Al Hussein Alawamlh O, Lee R, Lee UJ. Overactive Bladder: Clinical Updates in Women's Health Care Primary and Preventive Care Review. Obstet Gynecol. 2020 Jan;135(1):253. doi: 10.1097/AOG.0000000000003611. PMID: 31856122.

Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society. ACOG Practice Bulletin No. 155: Urinary Incontinence in Women.  Obstet Gynecol. 2015 Nov;126(5):e66-81. doi: 10.1097/AOG.0000000000001148.

Lightner DJ, Gomelsky A, Souter L, Vasavada SP. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment 2019. J Urol. 2019 Sep;202(3):558-563. doi: 10.1097/JU.0000000000000309. Epub 2019 Aug 8. PMID: 31039103.

 Initial Approval: January 2017; Revised January 2018; Reaffirmed June 2019; Revised March 2021; Revised November 2022


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