Overactive Bladder

Overactive bladder is a disease which can result from several different etiologies but is primarily characterized by a hyperactive bladder wherein affected individuals feel a frequent urge to urinate and may also experience spontaneous urine loss.

Antimuscarinics are the traditional first-line therapy for treatment.  Any antimuscarinic should be tried for at least two weeks to allow for time for symptoms to improve prior to making any changes to therapy.

Refractory overactive bladder disease is characterized by nonresponsive disease despite treatment at maximum tolerable doses for a minimum of four weeks.

Sites of action of antimuscarinics:

  • Oxybutynin and tolterodine:  Nonselective (M1-M5) muscarinic antagonists (cross blood brain barrier)
  • Trospium: Nonselective (M1-M5) muscarinic antagonists (doesn’t cross blood brain barrier)
    • Good choice for patients whom have experienced cognition issues associated with other antimuscarinics
    • Solifenacin and darifenacin:  M3 selective antagonist
      • M3 selective antagonists are good choices for patients whom have experienced cognition issues associated with other antimuscarinics
      • M3 selective antagonists are more likely to cause constipation
      • Darifenecin should be avoided in patients with hepatic disorders
      • Fesoterodine:  moderately selective antagonist (primarily at M2 and M3)

Patients whom have experienced cognition issues related to the use of antimuscarinics

Additional therapies (many of which are used off-label for this indication in the US):

  • Tricyclic antidepressants (i.e. imipramine and amitriptyline)
  • Botulinum toxin injections (particularly for patients with bladder hyperactivity associated with spinal cord injuries or neurological disorders such as multiple sclerosis)
  • Vaginally administered estrogen products

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