Overactive Bladder Guidelines Released

Troy Brown

October 26, 2012

The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) have released a new clinical guideline on the diagnosis and treatment of nonneurogenic overactive bladder (OAB) in adults. It was published online October 23 in the Journal of Urology.

Elizabeth Ann Gormley, MD, a professor of surgery at Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, and colleagues served on an 11-member multidisciplinary panel that was convened by the AUA and the SUFU. The guideline was based on a systematic review and data extraction conducted by the Agency for Healthcare Research and Quality.

Howard Goldman, MD, a urologist in the section of female pelvic medicine and reconstructive surgery in the Glickman Urological and Kidney Institute at the Cleveland Clinic in Ohio, commented on the guideline in a telephone interview with Medscape Medical News.

"They did a very nice, complete job of really laying out what overactive bladder is, how to do an appropriate evaluation, what's necessary, what's not necessary. It'll make the diagnosis a lot clearer, so that hopefully patients who have overactive bladder will be more likely to be appropriately diagnosed," Dr. Goldman said.

"Hopefully it will make physicians recognize that for the initial evaluation, you don't need much besides a good history, physical exam, and urinalysis. You don't have to resort to expensive testing and things like that. It should save money in the long run," Dr. Goldman noted.

Recommendations

Approach to Diagnosis

A thorough history, physical exam, and urinalysis should be done initially. If necessary, a urine culture and/or postvoid residual assessment can be done, as well as collection of bladder diaries and/or symptom questionnaires. Urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound are not necessary in the initial workup for uncomplicated patients, and should be reserved for refractory or otherwise complicated cases. Urine cytology is not recommended in the absence of hematuria when the patient responds to therapy.

Treatment

Some patients and caregivers may choose no treatment at all. Behavioral therapies (eg, bladder training, bladder control strategies, pelvic floor muscle training, fluid management) and education should be offered first. Limited data suggest that starting antimuscarinic therapies at the same time as behavior therapies may prove clinically beneficial.

Second-Line Treatments: Antimuscarinics

Antimuscarinics should be offered as second-line therapy. Extended-release preparations should be used instead of immediate-release preparations when possible, to limit dry mouth. Transdermal oxybutynin (patch or gel) can also be used. Antimuscarinics should not be used by patients with narrow-angle glaucoma without the approval of the treating ophthalmologist. Extreme caution should be exercised when using antimuscarinics in patients with impaired gastric emptying or who have a history of urinary retention.

Attempts should be made to manage constipation and dry mouth before discontinuing antimuscarinics because of adverse effects. This may include "bowel management, fluid management, dose modification or alternative anti-muscarinics," the authors write.

Caution should be used when prescribing antimuscarinics in frail patients or those who are taking other medications that have anticholinergic properties.

Patients who do not respond to behavioral and medical therapy should have an evaluation by an appropriate specialist if they desire further treatment.

Third-Line Treatments

FDA-Approved: Neuromodulation Therapies

Sacral neuromodulation can be offered as third-line treatment to carefully selected patients with severe refractory OAB symptoms or "patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure."

Another approved treatment which the panel offers as third-line treatment, is peripheral tibial nerve stimulation (PTNS) using an acupuncture needle, which has been tested against sham-PTNS. "PTNS can benefit...patients with moderately severe baseline incontinence and frequency and willingness to comply with the PTNS protocol as well as those having resources allowing for frequent office visits for on-going treatment," the authors write.

Non–FDA Approved: Intradetrusor Injection of OnabotulinumtoxinA

Intradetrusor onabotulinumtoxinA may be offered 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 [postvoid residual] evaluation and able and willing to perform self-catheterization, if necessary."

Additional Treatments

Except as a last resort, indwelling catheters are not recommended for management of OAB because of the unfavorable risk-benefit balance.

Follow-Up

The patient should be followed up by the clinician to evaluate compliance, efficacy, adverse effects, and the possible use of alternative treatments.

When First- and Second-Line Treatments Do Not Work

Dr. Goldman explained that the guidelines will be particularly helpful for those physicians who are not sure what to do after first- and second-line treatments have been unsuccessful. "For patients who don't respond to traditional behavioral therapies or exercises, there's now clear guidance for what comes next," said Dr. Goldman.

Dr. Goldman said that in his practice, he offers PTNS earlier in the treatment process than the guideline recommends. "If patients don't respond to education and behavior therapies, I offer that alongside and at the same time as medication...so they can either have medication, or they can have PTNS," Dr. Goldman explained.

"An entirely new class of medication was just brought out this week that...calms the bladder down through a different mechanism than all the other medications that are listed there. As we go forward, there's going to be a whole new class of medications that appear to do the same things, but have different side effects," said Dr. Goldman. This will give patients more options, he noted.

"The panel recognizes that much additional research is needed in OAB including epidemiologic, basic science, translational and clinical research," the authors write.

The committee was funded by the AUA and the SUFU. The authors have a variety of relationships including receipt of research funding, lecturing, and consulting for pharmaceutical and medical equipment companies. A complete list can be found in the article. Dr. Goldman has done speaking and consulting for Allergan, Medtronic, and Pfizer and speaking for Astellas.

J Urol. Published online October 23, 2012. Abstract

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