OAB

Question 1

diagnosis

Answer 1

The clinician should engage in a diagnostic process to document symptoms and signs that characterize 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.

• 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.
• Urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound should not be used in the initial workup of the uncomplicated patient.
• 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.
• Clinicians should provide education to patients regarding normal lower urinary tract function, what is known about OAB, the benefits vs. risks/burdens of the available treatment alternatives, and the fact that acceptable symptom control may require trials of multiple therapeutic options before it is achieved.

Question 2

First line treatment

Answer 2

• Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) as first-line therapy to all patients with OAB.
• Behavioral therapies may be combined with pharmacologic management.

Question 3

Second line treatment

Answer 3

• Clinicians should offer oral anti-muscarinics, or ß-3 andrenoceptor agonists as second-line therapy.
• 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.
• Transdermal (TDS) oxybutynin (patch [now available to women ages 18 years and older without a prescription] or gel) may be offered.
• 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 ß3-andrenoceptor agonist may be tried.
• 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.
• 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.
• Clinicians must use caution in prescribing anti-muscarinics in patients who are using other medications with anti-cholinergic properties.
• Clinicians should use caution in prescribing anti-muscarinics or ß3-andrenoceptor agonists in the frail OAB patient.
• Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy

Question 4

Third line treatments

Answer 4

• Clinicians may offer intradetrusor onabotulinumtoxinA (100U) 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 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 a carefully selected patient population.
• 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.
• Practitioners and patients should persist with new treatments for an adequate trial in order to determine whether the therapy is efficacious and tolerable. Combination therapeutic approaches should be assembled methodically, with the addition of new therapies occurring only when the relative efficacy of the preceding therapy is known. Therapies that do not demonstrate efficacy after an adequate trial should be ceased

Question 5

Additional treatments

Answer 5

• Indwelling catheters (including transurethral, suprapubic, etc.) are not recommended as a management strategy for OAB because of the adverse risk/benefit balance except as a last resort in selected patients.
• In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB patients may be considered.

Question 6

Followup

Answer 6

• The clinician should offer follow up with the patient to assess compliance, efficacy, side effects and possible alternative treatments.

Question 7

Algorithm

Answer 7