Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians
Overview:
Overactive bladder (OAB) is a symptom-based syndrome characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of UTI or other overt pathology (ICS, 2002). It affects approximately 30% of adults over 40 and becomes increasingly prevalent with age (Hsu et al., 2019).
Etiology and Pathophysiology
While detrusor overactivity is the urodynamic correlate in many cases, OAB can also occur due to:
- Neurological disorders (e.g., MS, Parkinson’s)
- Impaired bladder compliance
- Pelvic floor dysfunction (hypertonic or hypotonic)
- Psychological factors (e.g., anxiety, trauma history)
- Iatrogenic causes (e.g., medications, radiation)
Notably, Fontaine et al. (2021) emphasized that detrusor overactivity is not present in all OAB cases, necessitating a broader diagnostic lens.
Initial Management: First-Line Conservative Interventions
According to current guidelines and high-quality randomized trials, behavioral and physiotherapeutic interventions are the cornerstone of initial management.
1. Bladder Retraining:
Evidence supports scheduled voiding with progressive delay intervals, combined with urge suppression strategies (Scaldazza et al., 2017). Techniques include reverse Kegels, diaphragmatic breathing, sensory distraction, and pelvic floor relaxation.
2. Pelvic Floor Physiotherapy:
Pelvic health physiotherapists assess and rehabilitate both hypertonic and hypotonic pelvic floors. Contrary to popular assumptions, many OAB patients present with tight pelvic floor musculature that exacerbates urgency/frequency symptoms.
3. Lifestyle Modifications:
- Elimination of bladder irritants (e.g., caffeine, alcohol, acidic foods)
- Managing constipation
- Fluid management and pre-bedtime voiding
- Supine leg elevation in patients with peripheral edema
These non-invasive measures have high patient adherence and low adverse event profiles, making them ideal first-line strategies, particularly in older adults or those with polypharmacy concerns.
Pharmacological Interventions
If conservative measures prove insufficient, consider the following pharmacologic options:
Anticholinergics (e.g., oxybutynin, solifenacin): Effective but associated with dry mouth, constipation, and cognitive risk, especially in the elderly (Welk & McArthur, 2020).
β3-Adrenergic Agonists (e.g., mirabegron): Similar efficacy with improved CNS safety profile; preferred in patients at risk for anticholinergic burden (Yamaguchi et al., 2014).
Medication adherence is often suboptimal due to side effects, with >50% discontinuing within 6 months (Benner et al., 2010). Combination therapy with behavioral interventions improves outcomes.
Advanced Options for Refractory Cases
If pharmacological and behavioral therapies fail:
Percutaneous Tibial Nerve Stimulation (PTNS): Effective for OAB symptom reduction with a favorable safety profile (Keller et al., 2017).
Botulinum Toxin A Injections: FDA-approved for refractory OAB but requires intermittent self-catheterization in some patients.
Sacral Neuromodulation: Considered in severe cases with mixed incontinence or when other modalities fail.
Referral Recommendations
Refer patients for pelvic floor physiotherapy when:
- Symptoms persist despite lifestyle changes
- Pelvic floor dysfunction is suspected (e.g., concomitant pelvic pain, constipation)
- Pharmacologic therapy is contraindicated or declined
- Patients prefer non-invasive, functional approaches
Conclusion for Clinical Practice
OAB is a multifactorial condition with a significant impact on quality of life. Evidence-based management emphasizes a stepwise approach beginning with behavioral therapy and physiotherapy, progressing to pharmacological and neuromodulation therapies as needed. Collaborative care involving physiotherapists, urologists, and family physicians ensures optimal outcomes.
Key References
Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x
Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034
Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4
Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387
Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719
Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040
Yamaguchi, O., Marui, E., Kakizaki, H., Homma, Y., Igawa, Y., Takeda, M., & Ohkawa, S. (2014). Mirabegron 50 mg for OAB in Japanese patients: A phase III trial. BJU International, 113(6), 951–960. https://doi.org/10.1111/bju.12649
