Fear-Avoidance and Overactive Bladder: Toward a Mechanism-Informed Model of Care

Overactive bladder (OAB) is associated with substantial psychological burden, yet existing biopsychosocial frameworks acknowledge that psychological factors shape outcomes without explaining the cognitive and behavioral mechanisms through which that influence operates. This paper aimed to propose the fear-avoidance as a missing explanatory framework for OAB symptom maintenance, and to introduce a phenotyping model for clinical application.

We synthesized literature on fear-avoidance theory, cognitive appraisal and coping, and OAB epidemiology and psychosocial burden to construct a theoretical model linking urinary urgency to fear-avoidance mechanisms and developed a phenotyping framework distinguishing idiopathic and physiological OAB subtypes.

We propose that urinary urgency, characterized by unpredictability and difficulty deferring, functions as a potent stimulus for catastrophic threat appraisal, initiating a self-sustaining cycle of avoidance, hypervigilance, and perceived uncontrollability that perpetuates symptom burden independent of underlying pathology. We further distinguish two OAB subgroups: idiopathic OAB (iOAB), in which fear-avoidance functions as a primary, symptom-originating mechanism driven by maladaptive toileting behaviors and, in some cases, trauma-related hypervigilance; and physiological OAB (pOAB), in which an identifiable physiological cause (e.g., menopause, prostatectomy, radiation cystitis, neurogenic bladder) drives symptom onset while fear-avoidance operates as a secondary but clinically meaningful amplifier.

This distinction carries direct implications for treatment prioritization, positioning fear-avoidance-informed behavioral care as either a primary intervention or a necessary adjunct to medical management. The framework offers clinicians a testable, mechanism-informed model for understanding and addressing avoidance behavior across the OAB clinical spectrum, and provides direction for empirical research on OAB phenotyping and behavioral intervention.