Evaluation and Treatment of Overactive Bladder in Women

Overactive bladder (OAB) is a symptom complex that includes urinary urgency, frequency, urgency incontinence, and nocturia. It is highly prevalent, affecting up to 12% of the adult population, and can significantly impact quality of life. The diagnosis of OAB is made by history, physical examination, and a urinalysis to rule out underlying infection or other concerning potential etiologies. The need for additional testing is based on the initial evaluation findings, and is recommended in cases of underlying urinary tract infection, microscopic hematuria, obstructive voiding symptoms, and symptoms refractory to previous treatments. Initial management includes behavioral modification with attention to total daily fluid intake, avoidance of bladder irritants, treatment of constipation, weight loss, timed voiding, urge-suppression techniques, and pelvic floor physical therapy. Options for oral medications include antimuscarinic agents and β adrenergic agents, and can be used following or in conjunction with behavioral treatment. For patients refractory to behavioral therapy and oral medications, consideration should be given to referral to a specialist (eg, a urologist or urogynecologist) for discussion of more advanced therapies such as sacral neuromodulation, percutaneous tibial nerve stimulation, and intradetrusor injection of onabotulinumtoxinA. These more advanced treatments have favorable efficacy compared with oral agents in randomized trials, although each has a unique risk/benefit profile and shared decision-making with the individual patient is crucial. Here, we review pertinent considerations in the clinical evaluation and management of OAB in women.