OAB & Urgency Urinary Incontinence
Overactive bladder (OAB) and urgency urinary incontinence (UUI) are managed along a stepwise pathway: behavioral and lifestyle modifications first, then pharmacotherapy, then office-based procedures, then implantable neuromodulation, with bladder augmentation reserved for refractory neurogenic or idiopathic disease. Reconstructive urologists are typically involved at the procedural and surgical end of this pathway.
10 of 10 treatments
| Treatment | Category | Notes |
|---|---|---|
| Behavioral Therapy | Behavioral | Bladder training (progressive voiding intervals), urgency suppression techniques, timed voiding, fluid and dietary modification (caffeine, alcohol, acidic foods), and bowel management. First-line for all OAB/UUI. Effective in isolation or combined with pharmacotherapy; best delivered with a specialized continence nurse or physiotherapist. |
| Pelvic Floor Physical Therapy | Behavioral | Canonical PFPT program for OAB/UUI: urge suppression, bladder training, relaxation of overactive pelvic floor when present, and coordination training. Use strengthening only when the phenotype is hypotonic; down-training/manual work may be needed when urgency is driven by guarding or pain. |
| Anticholinergics | Pharmacological | Competitive muscarinic receptor antagonists (oxybutynin, tolterodine, solifenacin, darifenacin, fesoterodine, trospium). Reduce detrusor overactivity and urgency episode frequency. First-line pharmacotherapy. Dry mouth and constipation are the primary tolerability barriers; extended-release formulations and M3-selective agents (solifenacin, darifenacin) have better tolerability profiles. Avoid in cognitive impairment — CNS-penetrant agents (tertiary amines) increase dementia risk. |
| Beta-3 Agonists (Mirabegron / Vibegron) | Pharmacological | Selective beta-3 adrenoceptor agonists promote bladder relaxation during filling without inhibiting voiding. Mirabegron (Myrbetriq) and vibegron (Gemtesa) are FDA-approved for OAB. Comparable efficacy to anticholinergics with superior tolerability — no dry mouth and no anticholinergic cognitive burden. Mirabegron can raise blood pressure; vibegron has minimal blood-pressure signal. Preferred in elderly patients or those intolerant of anticholinergics. |
| Combination Anticholinergic + Beta-3 | Pharmacological | Combination therapy pairs a beta-3 agonist with an antimuscarinic, most commonly mirabegron + solifenacin in the BESIDE / SYNERGY evidence base. It can improve urgency and UUI when monotherapy is inadequate, but constipation, dry mouth, retention risk, cost, and PVR monitoring still matter. |
| Intradetrusor OnabotulinumtoxinA | Procedural | Cystoscopic injection of 100 U onabotulinumtoxinA into the detrusor (20 sites, sparing trigone). FDA-approved for OAB and neurogenic detrusor overactivity (NDO). Reduction in urgency incontinence episodes ~50–60%; complete resolution in ~30%. Effect duration 6–12 months; repeat injections required. Risk of urinary retention (~6% in OAB, higher in NDO) and UTI. Patients should be counseled on and capable of intermittent catheterization. |
| Sacral Neuromodulation (SNM) | Procedural | Electrical stimulation of the S3 sacral nerve root via a tined lead and implantable pulse generator (InterStim II/Micro/X — Medtronic; Axonics r-SNM/F15/R20). FDA-approved for OAB, UUI, urgency-frequency, and non-obstructive urinary retention. Staged trial (percutaneous nerve evaluation or staged implant) required before permanent implant. Durable 50–80% improvement sustained >5 years. MRI-conditional with current-generation devices. |
| Percutaneous Tibial Nerve Stimulation (PTNS) | Procedural | Retrograde stimulation of the sacral plexus via a needle electrode at the medial ankle (Urgent PC, NURO). 12-week weekly office treatment protocol; maintenance sessions required every 3–4 weeks. FDA-cleared for OAB. Comparable efficacy to anticholinergics in ORBIT and SUmiT trials; no systemic side effects. Wearable and implantable PTNS devices (eCoin, Revi) emerging as home-use alternatives. |
| Implantable Tibial Nerve Stimulation (eCoin / Revi) | Procedural | eCoin (Valencia Technologies) is a titanium disc implanted subdermally near the posterior tibial nerve, activated by an external wearable. Revi (BlueWind Medical) is a wireless implanted tibial nerve stimulator. Both eliminate need for in-office visits. Emerging alternatives to in-office PTNS for maintenance therapy; FDA de novo clearance for eCoin (2023). |
| Bladder Augmentation (Enterocystoplasty) | Surgical | Detubularized bowel segment (ileum most common) incorporated into the bivalved bladder to increase compliance and capacity. Reserved for refractory neurogenic detrusor overactivity (NDO) — typically spinal cord injury, spina bifida, radiation-induced contracted bladder — after failure of all pharmacologic and neuromodulation options. Requires lifelong CIC; risks include mucus production, UTI, metabolic acidosis, and rare malignant transformation after >10 years. |