Overactive Bladder Guidelines

Updated: Dec 20, 2022
  • Author: Pamela I Ellsworth, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines Summary

The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) have released joint guidelines on the diagnosis and treatment of non-neurogenic overactive bladder (OAB) in adults. These guidelines have been endorsed by the American Urogynecologic Society (AUGS). [2]

The European Association of Urology (EAU) guidelines on the diagnosis and management of female non-neurogenic lower urinary tract symptoms includes recommendations for overactive bladder, stress incontinence and mixed urinary incontinence. [104]


The AUA/SUFU guidelines include the following recommendations for the diagnosis of OAB [2] :

  • The minimum requirements for the diagnostic process to document symptoms and signs that characterize OAB and exclude other disorders are a careful history, physical exam, and urinalysis. 
  • Additional procedures and measures may be necessary to validate an OAB diagnosis, exclude other disorders, and fully inform the treatment plan. At the clinician's discretion, a urine culture and/or post-void residual assessment may be performed and information from bladder diaries and/or symptom questionnaires may be obtained. 
  • Urodynamics, cystoscopy, and diagnostic kidneys and bladder ultrasound should not be used in the initial workup of the uncomplicated OAB.
  • After assessment has been performed to exclude conditions requiring treatment and counseling, no treatment is an acceptable patient choice.
  • Patient education should include normal lower urinary tract function, what is known about OAB, the benefits versus risks/burdens of the available treatment alternatives, and the fact that achieving acceptable symptom control may require trials of multiple therapeutic options.

The EAU recommendations are in concurrence with the AUA/SUFU guidelines. [104]


The AUA/SUFU guidelines include the following key recommendations for the treatment of OAB [2] :

  • First-line treatment for all patients with OAB are behavioral therapies (eg, bladder training, bladder control strategies, pelvic floor muscle training, fluid management). 
  • Behavioral therapies may be combined with pharmacologic management.
  • Oral anti-muscarinics or oral beta-3 adrenoceptor agonists should be offered as second-line therapy.
  • Transdermal (TDS) oxybutynin (patch or gel) may be offered as second-line therapy.
  • If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a beta-3 adrenoceptor agonist may be tried.
  • Combination therapy with an anti-muscarinic and a beta-3 adrenoceptor agonist for OAB refractory to monotherapy with either anti-muscarinics or beta-3 adrenoceptor agonists can be considered.
  • Anti-muscarinics should not be given to patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should be used with extreme caution in patients with impaired gastric emptying or a history of urinary retention. 
  • Before abandoning effective anti-muscarinic therapy because of constipation and dry mouth, those adverse effects should be addressed with bowel management, fluid management, dose modification, or alternative anti-muscarinics.
  • Caution is needed when prescribing anti-muscarinics in patients who are using other medications with anticholinergic properties. 
  • Intradetrusor onabotulinumtoxinA (100U) is a third-line treatment in carefully selected and thoroughly counseled patients with OAB that has proved refractory to first- and second-line OAB treatments. These patients must be able and willing to return for frequent post-void residual evaluation and able and willing to perform self-catheterization if necessary.
  • Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in carefully selected patients.
  • Clinicians may offer sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure. 
  • In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB may be considered. 

The EAU guidelines are in general agreement with AUA/SUFU treatment recommendations but include a caution for use of long-term anticholinergic treatment in elderly women, particularly those at risk for or with cognitive dysfunction. The EAU guidelines also include the following strong recommendations for life style interventions [104] :

  • Overweight and obese adults should be encouraged to lose weight and maintain weight loss.
  • Adults with OAB should be informed that reducing caffeine intake may improve symptoms of urgency and frequency, but not incontinence.
  • Smoking cessation strategies for patients who smoke