The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) have released a new clinical guideline on the diagnosis and treatment of nonneurogenic overactive bladder (OAB) in adults. It was published online October 23 in the Journal of Urology.
Approach to Diagnosis
A thorough history, physical exam, and urinalysis should be done initially. If necessary, a urine culture and/or postvoid residual assessment can be done, as well as collection of bladder diaries and/or symptom questionnaires. Urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound are not necessary in the initial workup for uncomplicated patients, and should be reserved for refractory or otherwise complicated cases. Urine cytology is not recommended in the absence of hematuria when the patient responds to therapy.
Some patients and caregivers may choose no treatment at all. Behavioral therapies (eg, bladder training, bladder control strategies, pelvic floor muscle training, fluid management) and education should be offered first. Limited data suggest that starting antimuscarinic therapies at the same time as behavior therapies may prove clinically beneficial.
Second-Line Treatments: Antimuscarinics
Antimuscarinics should be offered as second-line therapy. Extended-release preparations should be used instead of immediate-release preparations when possible, to limit dry mouth. Transdermal oxybutynin (patch or gel) can also be used. Antimuscarinics should not be used by patients with narrow-angle glaucoma without the approval of the treating ophthalmologist. Extreme caution should be exercised when using antimuscarinics in patients with impaired gastric emptying or who have a history of urinary retention.
Attempts should be made to manage constipation and dry mouth before discontinuing antimuscarinics because of adverse effects. This may include “bowel management, fluid management, dose modification or alternative anti-muscarinics,” the authors write.
Caution should be used when prescribing antimuscarinics in frail patients or those who are taking other medications that have anticholinergic properties.
Patients who do not respond to behavioral and medical therapy should have an evaluation by an appropriate specialist if they desire further treatment.
FDA-Approved: Neuromodulation Therapies
Sacral neuromodulation can be offered as third-line treatment to carefully selected patients with severe refractory OAB symptoms or “patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure.”
Another approved treatment which the panel offers as third-line treatment, is peripheral tibial nerve stimulation (PTNS) using an acupuncture needle, which has been tested against sham-PTNS. “PTNS can benefit…patients with moderately severe baseline incontinence and frequency and willingness to comply with the PTNS protocol as well as those having resources allowing for frequent office visits for on-going treatment,” the authors write.
Non–FDA Approved: Intradetrusor Injection of OnabotulinumtoxinA
Intradetrusor onabotulinumtoxinA may be offered as “third-line treatment in the carefully selected and thoroughly counseled patient who has been refractory to first-and-second-line OAB treatments. The patient must be able and willing to return for frequent [postvoid residual] evaluation and able and willing to perform self-catheterization, if necessary.”
Except as a last resort, indwelling catheters are not recommended for management of OAB because of the unfavorable risk-benefit balance.
The patient should be followed up by the clinician to evaluate compliance, efficacy, adverse effects, and the possible use of alternative treatments.
J Urol. Published online October 23, 2012. Abstract