[The medical treatment of overactive bladder]

Overactive bladder, very frequent in neurological disorders, leads to very distressing symptoms such as urgency, frequency and incontinence which may dramatically impair the patient's quality of life. The medical approach is essentially pharmacological but the management of the nociceptive factors must not be neglected. In the mild urinary dysfunctions, bladder training can be advised. The pharmacological treatment aims at reducing the parasympathetic activity or at deafferenting the bladder. The antimuscarinic agents are an essential part of the treatment. Oxybutynin is the most widely used medication but recent agents like tolterodin have a better tolerability. Other drugs can also be used such as desmopressin, flavoxate. New molecules are under experiment (darifenacin). In case of troublesome side-effects or resistance to oral medications, local treatments are considered. Intravesical oxybutynin has been tried but has a short-lived efficacy. Intravesical instillation of capsaicine or resiniferatoxin blocks C-fibres afferents and leads to clinical and urodynamic improvement. Recently, injections of botulinum-A toxin in the detrusor have been advocated aiming at blocking the transmission of parasympathetic impulse. The first studies report encouraging results. All these local treatments resulting in bladder paresis are recommended for patients performing self-catheterization. Should these treatments fail, other therapeutic approaches are considered such as intrathecal treatment, neuromodulation, before deciding on neurosurgical or urosurgical procedures.