Overactive Bladder Treatment & Management
- Author: Pamela I Ellsworth, MD, FACS; Chief Editor: Edward David Kim, MD, FACS more...
Surgical Therapy
Augmentation cystoplasty is rarely necessary in idiopathic OAB. However, it may be used in individuals with refractory neurogenic OAB, particularly in those with poor compliance. In this reconstructive procedure, a segment of the bowel is removed and used to replace a portion of the bladder.
Neuromodulation (sacral nerve stimulation; InterStim, Medtronic, Minneapolis, Minn) is a new technique that is FDA approved for the management of OAB and UUI. It requires the surgical implantation of a small device at the level of the S3. Typically, an external stimulator is placed, and, if the patient experiences a 50% or greater reduction in his or her symptoms, a permanent internalized stimulator is placed.
Urgent PC is an office-based method of neuromodulation, using percutaneous tibial nerve stimulation. Typically, twelve 30-minute sessions are performed, followed by a maintenance regimen. Urgent PC is approved by the FDA.
Go to Pubovaginal Sling, Injectable Bulking Agents for Incontinence, and Surgical Treatment of Urinary Incontinence for complete information on these topics.
Investigational Therapies
Among other investigational therapies, neurokinin receptor antagonists, alpha-adrenoceptor antagonists, nerve growth factor inhibitors, gene therapy, and stem cell–based therapies are of considerable interest. The future development of new modalities in OAB treatment appears promising.[69, 70, 71, 72, 73]
Detrusor injections of botulinum neurotoxin type A are currently under investigation for the treatment of idiopathic OAB and neurogenic OAB. Most of the effects of botulinum toxin are thought to be the result of inhibition of the release of acetylcholine from the presynaptic nerve terminal, which prevents stimulation of the detrusor muscle.
Review of the clinical data shows a profound effect of botulinum toxin on involuntary detrusor contractions and elevated detrusor pressures. Botulinum neurotoxin type A may also affect other neurotransmitters, such as sensory/afferent neurotransmitters.[74] The number of injection sites is typically 20-30, and the dose used varies (100-300 U is common). Repeat injections are needed.
A study by Khan et al looked at the impact on quality of life with long-term detrusor injections of botulinum neurotoxin type A for multiple sclerosis–neurogenic OAB.[74] In a prospective study involving 137 patients from 2002-2009 treated with repeated detrusor injections of botulinum neurotoxin type A, the authors noted that before treatment 83% of the patients were incontinent; 4 weeks after the first treatment, 76% were completely dry. The efficacy was sustained with repeat injections. The median interval between retreatments remained constant at 12-13 months. Furthermore, considerable improvement was noted in the mean urogenital distress inventory and incontinence impact questionnaire 7 scores initially and after subsequent treatments.
Approach Considerations
Once diagnosed, overactive bladder (OAB) can be managed with several different methods.[23, 24, 25, 26, 27] If a specific cause of OAB symptoms is identified, it should be treated appropriately; for example, urinary tract infection (UTI) should be treated with antibiotics; similarly, atrophic urethritis can be treated with topical application of estrogen vaginal cream.
The choice of a particular treatment depends on the severity of the symptoms and the extent that the symptoms interfere with the patient’s lifestyle.[28] The 3 main approaches to treatment include pharmacotherapy,[29] behavioral therapy, and surgery.
A combined treatment approach using behavioral and pharmaceutical interventions is effective in most patients with OAB. Several drugs that have been proven safe and efficacious in clinical trials have been recently approved for the treatment of OAB. Behavioral interventions, such as limiting bladder irritants (eg, caffeine, alcohol), bladder training, and urgency suppression techniques, including pelvic floor muscle exercises, should be part of every treatment plan.
Surgery is rarely used to treat OAB and is reserved for patients in whom pharmacologic and behavioral therapy fail. Various surgical options are available, including sacral nerve neuromodulation and, rarely, bladder augmentation. Cystoscopic detrusor injection with botulinum toxin A is currently undergoing investigation for neurogenic detrusor overactivity, and clinical trials also are ongoing for idiopathic detrusor overactivity. Percutaneous tibial nerve stimulation is a minimally invasive option for patients in whom pharmacologic therapy fails or is contraindicated.
Consultation with a pelvic floor physical therapist may be helpful.
Go to Pubovaginal Sling, Injectable Bulking Agents for Incontinence, and Surgical Treatment of Urinary Incontinence for complete information on these topics.
Pharmacologic Therapy
Anticholinergics
Anticholinergic agents are currently the first-line therapy for OAB.[30, 31, 32, 33] These agents are thought to exhibit their primary action by inhibiting involuntary detrusor muscle contractions (at the level of the efferent pathway), but identification of muscarinic receptors in the urothelium/suburothelium suggests that they may also affect the afferent sensory pathway. The goals of therapy with anticholinergic agents are to prevent inappropriate detrusor contractions and to maintain normal bladder function, while minimizing adverse effects.
The duration of treatment is controversial, although many physicians would argue that OAB is a chronic condition with symptom severity that may vary over time. A prospective randomized, open-label, multicenter trial was held to evaluate symptom change and retreatment rate after discontinuation of the antimuscarinic Tolterodine (extended-release, 4 mg) in known responders. The authors noted that after cessation of treatment, 65% of the patients requested retreatment and 62% experienced symptom relapse. Symptom duration and baseline health-related quality of life (HRQol) were risk factors for retreatment according to univariate analysis. However, HRQol was the only independent risk factor. This article serves to highlight both the importance of patient education when managing those with OAB and the significant potential need for long-term anticholinergic therapy.[34]
Oxybutynin and tolterodine are the more commonly used anticholinergics in OAB treatment. Oxybutynin (Ditropan) was among the first anticholinergic agents to be used to treat detrusor overactivity; its efficacy in treating OAB is well documented.[35] However, the effects of oxybutynin are not tissue-specific, and studies have shown that oxybutynin has a greater inhibitory effect on salivation than on bladder contraction, resulting in a high incidence of dry mouth.
Tolterodine (Detrol, Detrol LA) is the first major drug to address the problems of treatment tolerability.[36] Unlike oxybutynin, tolterodine has a greater inhibitory effect on bladder contraction than on salivation. Therefore, it has fewer side effects (eg, dryness of mouth), but with comparable efficacy.[37, 38]
A long-acting, extended-release formulation of oxybutynin (Ditropan XL), which is associated with fewer adverse effects than its immediate-release predecessor, and efficacy that is comparable to the agents above, is also currently available.[39, 40, 41]
A study of 148 men aged 42-88 years with persistent OAB symptoms while receiving alpha-blocker therapy for bladder outlet obstruction found that behavioral and antimuscarinic therapy are effective in reducing these symptoms when added to alpha-blocker treatment. The study concluded that behavioral therapy is at least as effective as antimuscarinic therapy.[42]
Other anticholinergic agents used to treat OAB include trospium chloride (Sanctura),[43, 44] propiverine hydrochloride (approved in Europe not in the United States), solifenacin (Vesicare),[45, 46, 47, 48] darifenacin (Enablex),[49] and oxybutynin patch (Oxytrol). More recently, fesoterodine (Toviaz) has been approved by the FDA.
No head-to-head trials of these agents have assessed efficacy and side effects. The available literature suggests that these agents are clinically similar and that none appears to offer a major distinct advantage over the others. However, slight differences in these agents may be clinically useful in drug selection. Recently, 2 placebo-controlled, comparative studies between tolterodine (Detrol LA) 4 mg and fesoterodine 8 mg have been performed, demonstrating a statistically significant greater reduction in UUI episodes with fesoterodine 8 mg compared with tolterodine 4 mg.[50]
Darifenacin has the most selective M3 activity and has shown the greatest degree of safety with respect to lack of impact on cognitive function, which suggests that it may offer a slight advantage in elderly patients. It is available in 2 formulations.
Trospium is a large-molecule quaternary amine with minimal central nervous system (CNS) penetration. It has a unique liver metabolic pathway, making it the most suitable for patients receiving multiple drugs with cytochrome P-450 (CYP-450) utilization.
The patch version of oxybutynin has minimal dry mouth or constipation adverse effects but is available in only a single, relatively small dosage and may irritate the skin. A gel formulation of oxybutynin is now available that delivers 5 mg of oxybutynin and is not associated with the skin irritation of the patch.
Fesoterodine is the newest anticholinergic available for OAB. It shares the same active metabolite as tolterodine, 5-HMT; however, fesoterodine is efficiently and extensively metabolized to 5-HMT via ubiquitous esterases and thus does not have the pharmacokinetic variability associated with tolterodine. Furthermore, head-to-head studies have demonstrated superiority of the 8-mg dose of fesoterodine compared with tolterodine (Detrol LA) 4 mg in the reduction of UUI episodes.
Although efficacious, anticholinergic agents cause frequent side effects such as dry mouth, constipation, blurred vision, and drowsiness. These effects are dose-related and can severely limit tolerability, especially in elderly patients. Anticholinergics may also produce confusion, especially in elderly patients with pre-existing dementia.
Anticholinergics are contraindicated in patients with urinary retention, gastric retention, and untreated narrow-angle glaucoma. They should be used with caution in patients with clinically significant bladder outlet obstruction, decreased gastrointestinal motility, treated narrow angle glaucoma, and myasthenia gravis. More recently, cases of angioedema of the face, lips, tongue and/or pharynx have been reported with several of these agents, and patients should be counseled if they experience swelling to seek care immediately.
Various attempts have been made to improve the organ selectivity of these drugs to overcome their adverse effects. These include the development of new antimuscarinic agents with structural modifications[51, 52] and the use of innovative drug-delivery methods.
The advancement in the drug-delivery systems extends to the long-term therapeutic efficacy, with improved tolerability and patient compliance; however, future prospective therapies are aimed at novel targets with novel mechanisms of action, including beta3-adrenoceptor agonists, K+ channel openers, 5-HT modulators,[53] and botulinum toxin.[2] These prospective therapies are currently at different stages of clinical development.
Tricyclic antidepressants
Tricyclic antidepressants such as imipramine and doxepin have also been used to treat OAB. These block the reuptake of noradrenaline and serotonin. However, whether this mechanism mediates its beneficial effects on bladder hyperactivity is unclear. These agents have been associated with cardiac dysrhythmias and mental status changes and thus should be used with caution in elderly patients. Tricyclic antidepressants are not recognized as first-line therapy for the treatment of overactive bladder.
Capsaicin
Capsaicin is an extract from Mexican red peppers. It has been investigated for intravesical administration in OAB. A similar agent, resiniferatoxin, has also been investigated.
Behavioral Therapy
Behavioral therapy, also called behavioral modification, is a treatment approach that aims to alter an individual’s actions or environment to improve bladder control. Components of behavioral therapy include (1) education, (2) dietary and lifestyle modification (see Dietary Measures), (3) bladder training, (4) pelvic floor muscle therapy (PFMT), and (5) self-monitoring with bladder or voiding diaries.[54]
Bladder training
Bladder training involves a program of patient education and a scheduled voiding regimen, which is progressively increased. The goals of bladder training are to normalize urinary frequency, to improve control over bladder urgency, to increase bladder capacity, to decrease incontinence episodes, to prolong voiding intervals, and to improve the patient’s confidence in bladder control. Occasionally, it is used in conjunction with electrical stimulation and biofeedback therapy (see below).
The mechanism by which bladder training works is not fully identified; however, theories include improved cortical inhibition over detrusor contractions, improved cortical facilitation of urethral closure during bladder filling, improved central modulation of sensory afferent impulses, changes in behavior due to improved awareness of lower urinary tract function, and increased reserve capacity of the lower urinary tract.
A program of bladder retraining involves becoming aware of patterns of incontinence episodes and relearning skills necessary for storage and proper emptying of the bladder. Bladder retraining alone is successful in 75% of patients treated for urge incontinence.
Bladder retraining involves developing a schedule of when the patient should try to urinate; the patient should then try to consciously delay urination between these times. One method is to urinate at definite intervals (eg, 30 min); then, as the patient becomes skilled at waiting, the time intervals are gradually increased by one half hour until the individual is urinating every 3-4 hours.
Because the desired level of bladder control may take months to achieve, the patient needs to be highly motivated. Furthermore, bladder training may be effective in the short term, but, because of the extensive effort required, its efficacy may reduce over the long term.
Pelvic floor muscle therapy
PFMT involves exercises designed to improve the function of the pelvic floor muscles. The rationale for use of PFMT in urgency urinary incontinence and OAB is that contraction of the muscles can reflexively or voluntarily inhibit contraction of the detrusor muscle. PFMT is defined as any program of repeated voluntary pelvic floor muscle contractions (VPFMC) taught by a healthcare professional.[55]
Regular daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful in younger women. PFM exercises should be performed 30-80 times daily for at least 8 weeks. The principle behind PFM exercises is to strengthen the muscles of the pelvic floor, thereby improving function of the urethral sphincter. The success of PFM exercises depends on proper technique and adherence to a regular exercise program. These exercises have limited value in elderly patients and in patients with poor mobility.
Another approach is to use vaginal cones to strengthen the muscles of the pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. The woman contracts the pelvic floor muscles in an effort to hold the device in place. The contraction should be held for up to 15 minutes and should be performed twice daily. Within 4-6 weeks, symptoms improve in about 70% of women who try this method.
Biofeedback-assisted therapy
Biofeedback is a method of positive reinforcement in which electrodes are placed on patient’s abdomen and the anal area. Biofeedback-assisted behavioral therapy uses biofeedback to teach patients how to control normal physiologic responses of the bladder and pelvic floor muscles that mediate incontinence. Used in conjunction with PFM exercises, biofeedback helps patients gain awareness and control of the pelvic muscles.
Early biofeedback for OAB consisted of bladder-pressure biofeedback.[56, 57] Feedback of pelvic floor’s muscular activity was subsequently added.[58] Bladder-pressure biofeedback was not widely adopted because of the need for catheterization during each training session. Biofeedback is most commonly used to teach individuals to identify and contract their pelvic floor muscles.
Some therapists place a sensor in the vagina (in women) or in the anus (in men) to assess contraction of the pelvic floor muscles. A monitor displays a graph that shows which muscles are contracting and which are at rest. The therapist can help the patient identify the correct muscles for performing Kegel exercises. About 75% of people who use biofeedback to enhance performance of Kegel exercises report symptom improvement, with 15% considered cured.
Pelvic floor electrical stimulation
Pelvic floor electrical stimulation involves the use of mild electrical pulses to elicit contractions in a specific group of muscles. The current may be delivered using an anal or vaginal probe. Pelvic floor electrical stimulation should be performed in conjunction with PFM exercises. The electrical stimulation therapy may be performed at the clinic or at home. A treatment session usually last 20 minutes and may be performed every 1-4 days. Some clinical studies have shown promising results in treating urge incontinence with electrical stimulation.
Recommendations
In 1989, the Consensus Conference on urinary incontinence in adults recommended that the least invasive or dangerous procedure should be tried first.[59] In its guidelines for urinary incontinence in adults, the Agency for Health Care Policy and Research recommended behavioral therapy as a first-line therapy for incontinence.[60] Most recently, the Third International Consultation on Incontinence in June 2004 recommended behavioral therapy as a first-line therapy for incontinence.[55]
Success rates
When behavioral therapy was compared with drug therapy in an outpatient geriatric medicine clinic, behavioral therapy yielded a mean 80.7% reduction in incontinence episodes.[61] Behavioral therapy was significantly more effective than oxybutynin given at a dosage of 2.5 mg/day to 5 mg 3 times per day (mean reduction in incontinence episodes. 68.3%). Both therapies were better than placebo (mean reduction, 39.4%). In addition, patient-perceived improvement was also greatest among those treated with behavioral therapy.
In a randomized clinical trial of bladder training, Fantl et al observed that episodes of incontinence decreased by a mean of 57% in women aged 55 years and older who underwent bladder training compared with little improvement in a no-treatment control group.[62]
Burgio et al demonstrated an added benefit of combining drug and behavioral therapy in a stepped program. Individuals who were not completely continent or unsatisfied with monotherapy (behavioral therapy or oxybutynin) were offered combination therapy.[63] When behavioral or oxybutynin therapy was changed to a combined strategy, substantial improvements were noted.
The International Continence Society (ICS) recommends that PFMT be offered as a first-line therapy to all women with stress, urge, or mixed urinary incontinence. Different techniques of PFMT are described in the literature. They vary in the training schedule; the frequency, force, and duration of contractions of the pelvic floor muscle; and the use of adjuncts, such as biofeedback, electronic prompting devices, and intravaginal pressure-monitoring devices.[64]
Patients seem to benefit most from a PFMT program that provides intensive supervision. Most patients do not appear to have any posttreatment benefit from biofeedback-assisted PFMT.[65] However, for individuals who have trouble identifying and contracting the pelvic floor muscles, biofeedback may be useful. PFMT has been effective in women of all ages.[66]
Biofeedback-assisted behavioral training has been effective in treating urgency urinary incontinence, with 76-86% mean reductions in episodes of urgency urinary incontinence.[58, 67, 68] However, biofeedback is not necessary for everyone.
Burgio et al evaluated biofeedback, verbal feedback based on vaginal palpation, and use of a self-help booklet about PFMT in a first-time behavioral therapy program in community-dwelling women aged 55-92 years.[66] All achieved similar reductions in episodes of urgency incontinence. However, the groups differed significantly regarding patient satisfaction: complete satisfaction with treatment was reported by 75% of the biofeedback group, 85.5% of the verbal feedback group, and 55.7% of the self-help booklet group.
Limitations
Behavioral therapy relies on the active participation of an involved and motivated patient. In addition, it requires a practitioner who is well trained in such therapy. Behavioral therapy does not produce any permanent changes in bladder function (eg, decreased detrusor overactivity as measured on urodynamic studies). Therefore, regular adherence and long-term compliance are needed.
Dietary Measures
Eliminate dietary caffeine (in those with urge incontinence) and encourage adequate dietary fiber. Some have suggested that the avoidance of certain foods and beverages (eg, alcohol, spicy foods, nuts, chocolate, high-potassium foods, carbonated and caffeinated beverages) may improve the symptoms of OAB in some cases. Consider showing such a table to the patient to see if any foods on the list elicit a particular response by having the patient systematically try eliminating one at a time and seeing if there is any improvement in his or her symptoms. Adequate fluid intake is important because many persons with OAB restrict fluids in hopes of voiding less; however, concentrated urine may act as a bladder irritant.
Management of Chronic Incontinence
Although management approaches such as medical therapy, pelvic muscle exercises, and bladder training improve continence in most patients, some never achieve complete dryness. Treatment failures are sometimes due to concurrent use of necessary medications such as diuretics (water pills that increase urination), which can cause incontinence; restricted mobility; and other causes. Other patients may have dementia or other physical impairments that keep them from being able to perform pelvic muscle exercises or to retrain their bladders. Many are treated in long-term care facilities or at home.
The following recommendations can help keep persons with chronic incontinence improve symptoms and reduce their cost of care:
- Scheduled toileting - Take the patient to the toilet every 2-4 hours or according to his or her toilet habits.
- Prompted voiding - Check for dryness and encourage use of the toilet.
- Improved access to toilets - Use equipment such as canes, walkers, wheelchairs, and devices that raise the seating level of toilets to facilitate toileting. Clear a well-lit path to the toilet. Bedside commodes and urinals may be appropriate.
- Managing fluids and diet - Eliminate dietary caffeine (for those with urge incontinence) and encourage adequate fiber in the diet. Modify fluid intake. Reduce volume overload (for nocturia).
- Disposable absorbent pads or garments - Use these to keep patients dry.
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-78. [Medline].
Woodhouse JB, Patki P, Patil K, Shah J. Botulinum toxin and the overactive bladder. Br J Hosp Med (Lond). Sep 2006;67(9):460-4. [Medline].
Wein AJ, Rackley RR. Overactive bladder: a better understanding of pathophysiology, diagnosis and management. J Urol. Mar 2006;175(3 Pt 2):S5-10. [Medline].
Morrison J, Steers WD, Brading AF, et al. Neurophysiology and neuropharmacology. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. 2nd ed. Plymouth, England: Health Publications; 2002:86-163.
Yoshimura N, Chancellor MB. Current and future pharmacological treatment for overactive bladder. J Urol. Nov 2002;168(5):1897-913. [Medline].
de Groat WC. The urothelium in overactive bladder: passive bystander or active participant?. Urology. Dec 2004;64(6 Suppl 1):7-11. [Medline].
Andersson KE, Hedlund P. Pharmacologic perspective on the physiology of the lower urinary tract. Urology. Nov 2002;60(5 Suppl 1):13-20; discussion 20-1. [Medline].
DuBeau CE. Interpreting the effect of common medical conditions on voiding dysfunction in the elderly. Urol Clin North Am. Feb 1996;23(1):11-8. [Medline].
Miller SW. Management and treatment of overactive bladder in the elderly. J Am Soc Consult Pharm. 1999;14(Suppl 4):S1-S11.
Shah D, Badlani G. Treatment of overactive bladder and incontinence in the elderly. Rev Urol. 2002;4 Suppl 4:S38-43. [Medline]. [Full Text].
Staskin DR. Overactive bladder in the elderly: a guide to pharmacological management. Drugs Aging. 2005;22(12):1013-28. [Medline].
Stoddart H, Donovan J, Whitley E, Sharp D, Harvey I. Urinary incontinence in older people in the community: a neglected problem?. Br J Gen Pract. Jul 2001;51(468):548-52. [Medline]. [Full Text].
Voytas J. The role of geriatricians and family practitioners in the treatment of overactive bladder and incontinence. Rev Urol. 2002;4 Suppl 4:S44-9. [Medline]. [Full Text].
Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Corey R, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. May 2003;20(6):327-36. [Medline].
Milsom I, Abrams P, Cardozo L, Roberts RG, Thüroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. Jun 2001;87(9):760-6. [Medline].
Abrams P, Kelleher CJ, Kerr LA, Rogers RG. Overactive bladder significantly affects quality of life. Am J Manag Care. Jul 2000;6(11 Suppl):S580-90. [Medline].
Davila GW, Neimark M. The overactive bladder: prevalence and effects on quality of life. Clin Obstet Gynecol. Mar 2002;45(1):173-81. [Medline].
Hu TW, Wagner TH, Bentkover JD, LeBlanc K, Piancentini A, Stewart WF, et al. Estimated economic costs of overactive bladder in the United States. Urology. Jun 2003;61(6):1123-8. [Medline].
Liberman JN, Hunt TL, Stewart WF, Wein A, Zhou Z, Herzog AR, et al. Health-related quality of life among adults with symptoms of overactive bladder: results from a U.S. community-based survey. Urology. Jun 2001;57(6):1044-50. [Medline].
Bailey KL, Torigoe Y, Zhou S, et al. Overactive bladder cost of illness: Analysis of Medi-Cal claims. Presented at the International Society for Pharmacoeconomics and Outcomes Research 5th Annual International meeting,. Arlington, VA. May 21-24, 2000.
Brown JS, Vittinghoff E, Wyman JF, Stone KL, Nevitt MC, Ensrud KE, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc. Jul 2000;48(7):721-5. [Medline].
Weiss JP, Blaivas JG, Bliwise DL, Dmochowski RR, Dubeau CE, Lowe FC, et al. The evaluation and treatment of nocturia: a consensus statement. BJU Int. Jul 2011;108(1):6-21. [Medline].
Dmochowski RR. Treatment of the overactive bladder: where we stand in 2003. Rev Urol. 2003;5 Suppl 8:S11-7. [Medline]. [Full Text].
Kirby M, Artibani W, Cardozo L, Chapple C, Diaz DC, De Ridder D, et al. Overactive bladder: The importance of new guidance. Int J Clin Pract. Oct 2006;60(10):1263-71. [Medline].
Lai HH, Boone TB, Appell RA. Selecting a medical therapy for overactive bladder. Rev Urol. 2002;4 Suppl 4:S28-37. [Medline]. [Full Text].
Lee M, Weberski J. Options for treatment of overactive bladder. J Am Pharm Assoc. July 2005;(;(Suppl):S1-S15.
Ouslander JG. Management of overactive bladder. N Engl J Med. Feb 19 2004;350(8):786-99. [Medline].
[Best Evidence] Alhasso AA, McKinlay J, Patrick K, Stewart L. Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults. Cochrane Database Syst Rev. Oct 18 2006;CD003193. [Medline].
Lackner TE. Pharmacotherapy of urinary incontinence. J Am Med Dir Assoc. Jan-Feb 2002;3(1 Suppl):S16-24. [Medline].
Herbison P, Hay-Smith J, Ellis G, Moore K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. BMJ. Apr 19 2003;326(7394):841-4. [Medline]. [Full Text].
Lepor H. A comparison of anticholinergic therapies in the treatment of overactive bladder. Rev Urol. Fall 2001;3(4):209. [Medline]. [Full Text].
MacDiarmid SA. Overactive bladder: improving the efficacy of anticholinergics by dose escalation. Curr Urol Rep. Dec 2003;4(6):446-51. [Medline].
Nabi G, Cody JD, Ellis G, Herbison P, Hay-Smith J. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev. Oct 18 2006;CD003781. [Medline].
Lee YS, Choo MS, Lee JY, et al. Symptom change after discontinuation of successful antimuscarinic treatment in patients with overactive bladder symptoms: a randomised, multicentre trial. Int J Clin Pract. Sep 2011;65(9):997-1004. [Medline].
Tapp AJ, Cardozo LD, Versi E, Cooper D. The treatment of detrusor instability in post-menopausal women with oxybutynin chloride: a double blind placebo controlled study. Br J Obstet Gynaecol. Jun 1990;97(6):521-6. [Medline].
Roberts RG, Garely AD, Bavendam T. Safety and tolerability of tolterodine for the treatment of overactive bladder in adults. Am J Manag Care. Jul 2005;11(4 Suppl):S158-62. [Medline].
Abrams P. Evidence for the efficacy and safety of tolterodine in the treatment of overactive bladder. Expert Opin Pharmacother. Oct 2001;2(10):1685-701. [Medline].
Kanofsky JA, Nitti VW. Tolterodine for treatment of overactive bladder. Urol Clin North Am. Nov 2006;33(4):447-53, viii. [Medline].
Diokno AC, Appell RA, Sand PK, Dmochowski RR, Gburek BM, Klimberg IW, et al. Prospective, randomized, double-blind study of the efficacy and tolerability of the extended-release formulations of oxybutynin and tolterodine for overactive bladder: results of the OPERA trial. Mayo Clin Proc. Jun 2003;78(6):687-95. [Medline].
Gupta SK, Sathyan G. Pharmacokinetics of an oral once-a-day controlled-release oxybutynin formulation compared with immediate-release oxybutynin. J Clin Pharmacol. Mar 1999;39(3):289-96. [Medline].
Zinner NR, Mattiasson A, Stanton SL. Efficacy, safety, and tolerability of extended-release once-daily tolterodine treatment for overactive bladder in older versus younger patients. J Am Geriatr Soc. May 2002;50(5):799-807. [Medline].
Burgio KL, Goode PS, Johnson TM, et al. Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial. J Am Geriatr Soc. Dec 2011;59(12):2209-16. [Medline].
Staskin DR. Trospium chloride: Distinct among other anticholinergic agents available for the treatment of overactive bladder. Urol Clin North Am. Nov 2006;33(4):465-73, viii. [Medline].
Zinner NR. Trospium chloride: an anticholinergic quaternary ammonium compound for the treatment of overactive bladder. Expert Opin Pharmacother. Jul 2005;6(8):1409-20. [Medline].
Brunton S, Kuritzky L. Recent developments in the management of overactive bladder: focus on the efficacy and tolerability of once daily solifenacin succinate 5 mg. Curr Med Res Opin. Jan 2005;21(1):71-80. [Medline].
Kelleher CJ, Cardozo L, Chapple CR, Haab F, Ridder AM. Improved quality of life in patients with overactive bladder symptoms treated with solifenacin. BJU Int. Jan 2005;95(1):81-5. [Medline].
Maniscalco M, Singh-Franco D, Wolowich WR, Torres-Colón R. Solifenacin succinate for the treatment of symptoms of overactive bladder. Clin Ther. Sep 2006;28(9):1247-72. [Medline].
Wagg A, Wyndaele JJ, Sieber P. Efficacy and tolerability of solifenacin in elderly subjects with overactive bladder syndrome: a pooled analysis. Am J Geriatr Pharmacother. Mar 2006;4(1):14-24. [Medline].
Zinner N, Susset J, Gittelman M, Arguinzoniz M, Rekeda L, Haab F. Efficacy, tolerability and safety of darifenacin, an M(3) selective receptor antagonist: an investigation of warning time in patients with OAB. Int J Clin Pract. Jan 2006;60(1):119-26. [Medline].
Herschorn S, Swift S, Guan Z, et al. Comparison of fesoterodine and tolterodine extended release for the treatment of overactive bladder: a head-to-head placebo-controlled trial. BJU Int. Jan 2010;105(1):58-66. [Medline].
Chapple CR, Yamanishi T, Chess-Williams R. Muscarinic receptor subtypes and management of the overactive bladder. Urology. Nov 2002;60(5 Suppl 1):82-8; discussion 88-9. [Medline].
Michel MC, Hegde SS. Treatment of the overactive bladder syndrome with muscarinic receptor antagonists: a matter of metabolites?. Naunyn Schmiedebergs Arch Pharmacol. Nov 2006;374(2):79-85. [Medline].
Dmochowski RR. Duloxetine: a summary of published clinical experience. Rev Urol. 2004;6 Suppl 3:S56-63. [Medline]. [Full Text].
Burgio KL. Influence of behavior modification on overactive bladder. Urology. Nov 2002;60(5 Suppl 1):72-6; discussion 77. [Medline].
Wilson PD, Berghmans B, Hagen S, et al. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence Management. Paris, France.: Health Publications; 2005:855-94.
Cardozo L, Stanton SL, Hafner J, Allan V. Biofeedback in the treatment of detrusor instability. Br J Urol. Jun 1978;50(4):250-4. [Medline].
Cardozo LD, Abrams PD, Stanton SL, Feneley RC. Idiopathic bladder instability treated by biofeedback. Br J Urol. Dec 1978;50(7):521-3. [Medline].
Burgio KL, Whitehead WE, Engel BT. Urinary incontinence in the elderly. Bladder-sphincter biofeedback and toileting skills training. Ann Intern Med. Oct 1985;103(4):507-15. [Medline].
Consensus conference. Urinary incontinence in adults. JAMA. May 12 1989;261(18):2685-90. [Medline].
Fantl JA, Newman DK, Colling J, et al. Urinary Incontinence in Adults: Acute and Chronic Management Clinical Practice Guidelines. No. 2, 1996 Update. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; March 1996.
Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA. Dec 16 1998;280(23):1995-2000. [Medline].
Fantl JA, Wyman JF, McClish DK, Harkins SW, Elswick RK, Taylor JR, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA. Feb 6 1991;265(5):609-13. [Medline].
Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc. Apr 2000;48(4):370-4. [Medline].
Wyman JF, Fantl JA, McClish DK, Bump RC. Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Continence Program for Women Research Group. Am J Obstet Gynecol. Oct 1998;179(4):999-1007. [Medline].
Wyman JF, Fantl JA. Bladder training in ambulatory care management of urinary incontinence. Urol Nurs. Sep 1991;11(3):11-7. [Medline].
Burgio KL, Goode PS, Locher JL, Umlauf MG, Roth DL, Richter HE, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA. Nov 13 2002;288(18):2293-9. [Medline].
Burton JR, Pearce KL, Burgio KL, Engel BT, Whitehead WE. Behavioral training for urinary incontinence in elderly ambulatory patients. J Am Geriatr Soc. Aug 1988;36(8):693-8. [Medline].
McDowell BJ, Burgio KL, Dombrowski M, Locher JL, Rodriguez E. An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients. J Am Geriatr Soc. Apr 1992;40(4):370-4. [Medline].
Andersson KE. New pharmacologic targets for the treatment of the overactive bladder: an update. Urology. Mar 2004;63(3 Suppl 1):32-41. [Medline].
Chancellor MB. New frontiers in the treatment of overactive bladder and incontinence. Rev Urol. 2002;4 Suppl 4:S50-6. [Medline]. [Full Text].
Epstein BJ, Gums JG, Molina E. Newer agents for the management of overactive bladder. Am Fam Physician. Dec 15 2006;74(12):2061-8. [Medline].
Monaghan C. Pharmacological treatment of urinary incontinence: Current and future management options. Clin Excell Nurse Pract. 2004;8(3):121-5.
Ng CK, Gonzalez RR, Te AE. Refractory overactive bladder in men: update on novel therapies. Curr Urol Rep. Nov 2006;7(6):456-61. [Medline].
Khan S, Game X, Kalsi V, Gonzales G, Panicker J, Elneil S, et al. Long-term effect on quality of life of repeat detrusor injections of botulinum neurotoxin-a for detrusor overactivity in patients with multiple sclerosis. J Urol. Apr 2011;185(4):1344-9. [Medline].
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