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Presenting w/ OAB s/sx (urgency, frequency, nocturia, urge-incontinence)
Assess w/ hx,1 exam, UA w/micro to exclude other disorders [CP] - If dx unclear or more info needed: UCx, PVR, bladder diary, and/or sx questionnaire [CP]
- Not recommended for initial w/u in uncomplicated pts: urodynamics, cystoscopy, renal/bladder US. [CP]
Consider 1st-line options2 after pt education, risk/benefit counseling [CP] - Choosing to forego tx is a valid choice [EO]
- Behavior tx3 is 1st-line for OAB: [S/B] bladder training/delayed voiding, bladder control strategies, PFMT, fluid mgmt, diet changes, wt loss, etc. May combine w/ drug tx2 [C] if behavioral tx partially effective.
2nd-line options4 w/ active management of ADEs2,4,5,6,7 - Offer oral antimuscarinics5,8 or β3-adrenoceptor agonists (mirabegron) [S/B]. Transdermal oxybutynin patch/gel OTC8 may be offered. [R/C]
- If inadequate sx control2 and/or unacceptable ADE w/ 1 antimuscarinic:5,6 manage constipation/dry mouth,4 modify dose, or try a different antimuscarinic or a β3-adrenoceptor agonist (mirabegron). [CP]
- If refractory to behavioral and drug tx:2 eval by specialist if additional tx desired [EO]. Consider UCx, PVR, bladder diary/sx questionnaire, etc.
Footnotes 1 Urgency (sudden compelling desire to pass urine which is difficult to defer) is the hallmark sx of OAB. Hx: fluid intake, voids per day/night, diuretic/other med use, degree of bother, comorbid conditions, etc.
2 Acceptable sx control may require trials of multiple tx options [CP]. Persist w/ new tx for adequate trial to determine efficacy, tolerability; d/c tx if efficacy not demonstrated. Assemble combo tx methodically, adding new tx only when relative efficacy of preceding tx known [EO]. Appropriate duration: 8-12 wks for behavioral, 4-8 wks for pharmacologic tx.
3 Behavior tx (1st-line) [S/B] includes bladder training, bladder control strategies, PFMT, fluid mgmt. Behavioral tx may be combined w/ drug tx [C], including antimuscarinics or β3-adrenoceptor agonists (mirabegron). If inadequate sx control and/or unacceptable ADE w/ 1 antimuscarinic: manage constipation/dry mouth, modify dose, or try a different antimuscarinic or a β3-adrenoceptor agonist (mirabegron) [CP]. Before abandoning effective antimuscarinic tx: manage constipation, dry mouth, including bowel and fluid mgmt, dose modification or alternative antimuscarinic. [CP] If IR and ER formulations available, ER preferred d/t lower rates of dry mouth. [S/B]
4 If IR and ER formulations available, ER preferred d/t lower rates of dry mouth. [S/B]
5 Antimuscarinics (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium): don’t use if narrow-angle glaucoma (unless approved by pt’s ophthalmologist); use w/ extreme caution in pts w/ impaired gastric emptying or urinary retention hx [CP]; if PVR >250-300 mL, use w/ caution. If obstructive voiding sx appear on antimuscarinic tx, monitor PVR.
6 Before abandoning effective antimuscarinic tx: manage constipation, dry mouth, including bowel and fluid mgmt, dose modification or alternative antimuscarinic. [CP]
7 PVR: measure w/ US bladder scanner immediately post void; if US scanner not available, use urethral cath.
8 Available to women ≥18 yo w/o prescription.
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OAB refractory to (or not a candidate for) behavioral and drug tx
If refractory9 to behavioral10 and drug tx:11 specialist eval if additional tx desired [EO]. Consider UCx, PVR, bladder diary/sx questionnaire, etc. Offer 3rd-line tx to carefully selected, thoroughly-counseled pts w/ mod-severe sx refractory9 to behavior modification10 and drug tx11 (or who are not candidates for these tx) - Intradetrusor onabotulinumtoxinA (100U) in pts willing/able to return for freq PVRs and self-cath if needed [S-O/B-C]
- Peripheral tibial nerve stimulation [R/C]
- Sacral neuromodulation in pts w/ severe refractory OAB, or if pt not a candidate for 2nd-line drug tx and is willing to undergo surgery [R/C]
- If severe, refractory, complicated OAB: in extremely rare cases, consider augmentation cystoplasty or urinary diversion [EO]
- Not recommended: indwelling cath (transurethral, suprapubic, etc) d/t adverse risk/benefit (except as last resort) [EO]
Footnotes 9 Acceptable sx control may require trials of multiple tx options [CP]. Persist w/ new tx for adequate trial to determine efficacy, tolerability; d/c tx if efficacy not demonstrated. Assemble combo tx methodically, adding new tx only when relative efficacy of preceding tx known [EO]. Appropriate duration: 8-12 wks for behavioral, 4-8 wks for pharmacologic tx.
10 Behavior tx (1st-line) [S/B] includes bladder training, bladder control strategies, PFMT, fluid mgmt. Behavioral tx may be combined w/ drug tx [C], including antimuscarinics or β3-adrenoceptor agonists (mirabegron). If inadequate sx control and/or unacceptable ADE w/ 1 antimuscarinic: manage constipation/dry mouth, modify dose, or try a different antimuscarinic or a β3-adrenoceptor agonist (mirabegron) [CP]. Before abandoning effective antimuscarinic tx: manage constipation, dry mouth, including bowel and fluid mgmt, dose modification or alternative antimuscarinic. [CP] If IR and ER formulations available, ER preferred d/t lower rates of dry mouth. [S/B]
11 If failure and/or ADE w/ 1 med: try at least 1 other med prior to considering 3rd-line tx.
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