Editor: Christopher M. Zahn, MD
Overactive bladder (OAB) is defined 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 of the pelvic support, urethral mobility, and provoked incontinence), urinalysis, and post void residual. Multichannel urodynamic studies should be reserved for complex cases in which an initial office diagnosis is unclear.
Initial treatment involves non-invasive lifestyle and behavior modifications. These include physical therapy with or without biofeedback, bladder training, and dietary modifications, including fluid restriction, avoidance of caffeine, and weight loss. Timed voids may also decrease episodes of incontinence.
First-line pharmacologic treatment is anti-muscarinic medications. It is reasonable to start with these agents in well-counseled patients who decline behavior or lifestyle modifications. These medications increase the storage capacity of the bladder and reduce urgency symptoms. Common 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.
Additional treatments have been described for OAB. Botulinum Toxin A injections have shown promise, but overtreatment can lead to urinary retention. Acupuncture has been effective. Mirabegron is a relatively new pharmacological agent with side effect profile similar to placebo. 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.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 155: Urinary Incontinence in Women. Obstet Gynecol. 2015 Nov;126(5):e66-81. doi: 10.1097/AOG.0000000000001148..
Olivera C, Meriwether K, El-Nashar S, et al. Nonantimuscarinic treatment for overactive bladder: a systematic review. Am Obstet Gynecol 2016;215:34-57.
Initial Approval: January 2017; Revised 1/2018.
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