The guideline offers recommendations for first-, second-, and third-line therapies for overactive bladder (OAB). It also mentions that after assessment has been performed to exclude conditions requiring treatment, no treatment is an acceptable choice made by some patients and caregivers.

The International Urogynaecological Association (IUGA) and International Continence Society (ICS) defines overactive bladder (OAB) as the presence of “urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence (UUI), in the absence of urinary tract infection (UTI) or other obvious pathology.”

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Recommendations for diagnosis of Overactive Bladder (OAB)- non-neurogenic in adults

The clinician should engage in a diagnostic process to document symptoms and signs that characterise OAB and exclude other disorders that could be the cause of the patient’s symptoms; the minimum requirements for this process are a careful history, physical exam, and urinalysis.

While taking the history, the clinician should assess the following:

• Bladder storage symptoms associated with OAB (e.g., urgency, urgency incontinence, frequency, nocturia)
• Other bladder storage problems (e.g., stress incontinence episodes)
• Bladder emptying (e.g., hesitancy, straining to void, prior history of urinary retention, force of stream, intermittency of stream)

As bladder function is related to amount and type of fluid intake, an inquiry into fluid intake habits should be also performed. Patients, who are not able to provide accurate intake and voiding information, should be encouraged to fill out a fluid diary. Current medication use and co-morbid conditions should also be reviewed.

Physical examination should include the following:

• An abdominal exam: Check for scars, masses, hernias, areas of tenderness and suprapubic distension
• Examine lower extremities for oedema
• A rectal/genitourinary exam: Check for pelvic floor disorders in females and prostatic pathology in males
• The Mini-Mental State Examination (MMSE): Use to assess patients who may be at risk for cognitive impairment

Urinalysis should be performed to rule out UTI and haematuria. A urine culture is not necessary unless there is indication of infection. If evidence of infection is detected, then a culture should be performed. If evidence of haematuria not associated with infection is found, then the patient should be referred for urologic evaluation.

In some patients, 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.

A urine culture may be performed in patients with irritative voiding symptoms, but without overt signs of infection, to completely exclude the presence of clinically significant bacteriuria.

Post-void residual (PVR) measurement is recommended in patients with obstructive symptoms, history of incontinence or prostatic surgery and neurologic diagnoses. PVR should be measured with an ultrasound bladder scanner (immediately after the patient voids) or by urethral catheterisation.

Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not be used in the initial workup of the uncomplicated patient.

For complicated patients or patients refractory to multiple OAB treatments, additional diagnostic tests should be selected based on patient history and presentation, and clinician judgment.

• Patients with haematuria should be referred for a urologic work up
• In patients with uncomplicated OAB without haematuria who respond to therapy- urine cytology is not recommended

OAB is not a disease; it is a symptom complex that generally is not a life-threatening condition. After assessment has been performed to exclude conditions requiring treatment and counseling, no treatment is an acceptable choice made by some patients and caregivers.

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Treatment recommendations for diagnosis of overactive bladder

First-line treatments: Behavioural therapies

Behavioural treatments are the recommended first-line treatments as they are effective in reducing symptom levels as are anti-muscarinic medications, and consist of many components that can be tailored to address individual patient needs. These include bladder training, bladder control strategies, pelvic floor muscle training and fluid management.

Behavioural may be used in combination with drugs to optimise patient symptom control and quality of life.

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Second-line treatments: Pharmacologic management

1. Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as second-line therapy.

Oral anti-muscarinics help to reduce symptoms, however, due to their side effect profile they are recommended as second-line therapy.

2. If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth.

The effects of antimuscarinics on salivary glands (such as dry mouth) are responsible for bothersome side effects; which ultimately lead to poor patient compliance. As anti-muscarinic therapy is generally long-term, optimising medication tolerability is important to obtaining patient compliance and ER formulations can help in this regard.

3. Transdermal (TDS) oxybutynin (patch or gel) may be offered.

In patients who are at risk of or who have experienced dry mouth with oral agents, transdermal preparations of oxybutynin are recommended instead of oral anti-muscarinics.

4. 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 β3-adrenoceptor agonist may be tried.

The panel advises that clinicians should not abandon anti-muscarinic therapy if trial of one medication appears to fail or produces an unacceptable adverse event profile. As per the panel, patients may experience better symptom control and/or a more acceptable adverse drug event profile with another anti-muscarinic. Dose modification may also help in achieving a better balance between efficacy and adverse drug events.

If required, patients may be switched to a β3-adrenoceptor agonist (e.g., mirabegron) as it has an efficacy profile that appears similar to the anti-muscarinics and has a relatively lower adverse event profile.

5. Clinicians may consider combination therapy with an anti-muscarinic and β3-adrenoceptor agonist for patients refractory to monotherapy with either anti-muscarinics or β3-adrenoceptor agonists.

Studies show that compared to monotherapy, combination therapy is associated with an improved efficacy without any significant effect on the safety profile.

6. Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention.

• Extreme caution is warranted when using anti-muscarinics in patients with narrow-angle glaucoma, impaired gastric emptying or a history of urinary retention
• A clearance from an ophthalmologist/gastroenterologist/urologist is necessary if the patient has glaucoma, is at risk for or has a history of gastric emptying problems or urinary retention respectively
• Anti-muscarinics are also contraindicated in patients using solid oral forms of potassium chloride

7. Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic therapy. Management may include bowel management, fluid management, dose modification or alternative anti-muscarinics.

The adverse effects associated with anti-muscarinic therapy should be proactively monitored and managed. Before initiating therapy, it is essential to educate patients regarding the various ways in which side effects can be managed.

8. Clinicians must use caution in prescribing anti-muscarinics in patients who are using other medications with anti-cholinergic properties.

The concurrent use of other medications with anti-cholinergic activity may potentiate the side effects of the anti-muscarinic class of OAB medications; hence, caution should be exercised when in such cases.

9. Clinicians should use caution in prescribing anti-muscarinics or β3-adrenoceptor agonists in the frail OAB patient.

The use of OAB medications may have a lower therapeutic index and a higher adverse drug event profile in frail patients. Frail patients include those with mobility deficits, weight loss and weakness without medical cause and who may have cognitive deficits.

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Third-line treatment: PTNS and neuromodulation

Intradetrusor onabotulinumtoxinA (100U), peripheral tibial nerve stimulation (PTNS) and sacral neuromodulation (SNS) are the third line treatment options recommended by the guideline.