Female Pelvic Medicine & Reconstructive Surgery:
In March 2012, the American Urologic Association and the Society of Urodynamics and Female Urology published a guideline document, “Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults.“1 A panel of 10 urologists and a behavioral psychologist created the peer-reviewed document. The primary source of evidence for this guideline was the Agency of Healthcare Research and Quality report, “Treatment of Overactive Bladder in Women,” published in 2009.2 They also included data for male patients, studies that focused on nocturia, neuromodulation, and intradetrusor onabotulinumtoxinA.
There are 22 guideline statements that summarize the review. The evidence for each statement is graded by the Vanderbilt Evidence-based Practice Center. Fourteen of the 22 statements are based on “expert opinion” or “clinical principle.” No guideline statement received grade A evidence.
There have been a few new advances in the treatment of non-neurogenic overactive bladder (OAB) that are not included in these guidelines. The oxybutynin transdermal patch (Oxytrol) has been approved for over-the-counter sale in the United States.3 This may be particularly helpful for patients who have experienced dry mouth with oral antimuscarinic medicines.
In 2012, the Food and Drug Administration approved the beta-3 agonist mirabegron for the treatment of overactive bladder.4 This is another option for the medical treatment for non-neurogenic overactive bladder. It is not an anti-muscarinic medication so it may help patients who cannot tolerate anticholinergic medications. Most patients taking the medication do have a small rise in mean heart rate and blood pressure. It would likely be considered a third-line treatment because there is limited long-term data available on its use.
In January 2013, the FDA approved intradetrusor onabotulinumtoxinA for treatment of non-neurogenic OAB in patients who have an inadequate response to or are intolerant of anticholinergic medication.5 This approval occurred after the publication of the “ABC trial” which compared the anticholinergic medications solifenacin and trospium with intradetrusor onabotulinumtoxinA treatment in women with non-neurogenic OAB.6 The women treated with intradetrusor onabotulinumtoxinA had a higher rate of complete resolution of their OAB symptoms (27% vs. 13%) but they also had a higher rate of urinary retention requiring the use of a catheter two months after treatment (5% vs. 0%). The mean reduction of urge urinary incontinence episodes and quality of life scores were the same in both treatment groups. The dose of intradetrusor onabotulinumtoxinA for patients with non-neurogenic OAB is 100 units.
Practitioners who treat OAB will find these guidelines practical and helpful. Another excellent resource is www.OABCentral.org, which is available as a link on the AUGS website. This website has educational tools for patients and clinicians. It also has reviews of new studies as they become available.
1. Gormley AE, Lightner DJ, Burgio LT et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline. © 2012 by the American Urological Association.
2. Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187 (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-1). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2009; .
3. FDA News Release, Jan 25, 2013. FDA approves over-the-counter Oxytrol for Women to treat overactive bladder.
4. FDA News Release, June 28, 2012. FDA approves Myrbetriq for overactive bladder.
5. FDA News Release, Jan 18, 2013. FDA approves Botox to treat overactive bladder.
6. Visco AG, Brubaker L, Richter HE, et al. Pelvic Floor Disorders Network. Anticholinergic therapy vs. onabotulinumtoxinA for urgency urinary incontinence. N Engl J Med. 2012; 367:(19): 1803–1813.