Behind the Counter: Medications vs. surgery for overactive bladder

Before starting any medication, healthcare professionals should recommend behavioral therapies for people with OAB. People can try these on their own or in combination with medications.

Some behavioral therapies include:

• fluid restriction and timing of fluid intake
• avoidance of bladder stimulants
• bladder control strategies
• pelvic floor therapy
• biofeedback training

According to American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction guidelines from 2019, these behavioral therapies are typically “first-line” options for non-neurogenic OAB. Oral medications are “second-line” treatments, though doctors may prescribe them initially for combined use with first-line behavioral therapy.

The primary initial medication class is anticholinergics, also known as antimuscarinics. Anticholinergics are generally available as immediate-release (IR) or extended-release (ER) formulations. So, dosing strategies can vary from once daily for ER formulations to several times daily for IR formulations.

There are about six different medications, most of which are available in IR and ER formulations, as well as different doses. Pills are available, as are transdermal patches that a person puts on their skin.

The most common anticholinergic medications include:

• oxybutynin (Oxytrol)
• darifenacin (Enablex)
• solifenacin (VESIcare)
• tolterodine (Detrol)
• fesoterodine (Toviaz)
• trospium chloride (Sanctura)

The most common side effects of anticholinergic medications are dry mouth and constipation. Most people experience some degree of these side effects, so doctors should let individuals know about them. They may also consider proactive approaches, such as an improved bowel regimen, to combat the side effects.

Healthcare professionals should not prescribe anticholinergics to people with narrow-angle glaucoma.

Some additional but less common side effects include:

• dry eyes
• dizziness
• difficulty voiding or urinary retention
• changes in mental status
• fatigue
• drowsiness
• blurry vision

Most of these side effects are mild and tolerable. However, if they become severe or bothersome, a doctor will have information about changing the dosage or changing the medication to a similar, alternative anticholinergic. If a person cannot tolerate anticholinergic medications, doctors may consider a beta-3 adrenergic agonist called mirabegron (Myrbetriq).

For postmenopausal females with OAB, vaginal estrogen hormone therapies may have a role, but only in certain situations.

Estrogens do have a role in the function of the urinary tract, though the use of estrogen replacement therapy in the management of OAB in postmenopausal females remains controversial for several reasons. Therefore, this question requires a very individualized approach that is best addressed between an individual and their doctor.

Vaginal estrogen cream can be beneficial in some instances. For example, it may help when vaginal atrophy and dryness contribute to urinary symptoms, particularly if the person is experiencing recurrent urinary tract infections (UTIs) alongside OAB. Treatment with vaginal estrogen cream may also be effective for some people with mild stress urinary incontinence, such as leakage that occurs with coughing or laughing.

However, for most females with OAB — particularly those who are premenopausal — hormone therapy is a treatment with limited efficacy.

In addition to anticholinergics, another second-line therapy includes (Myrbetriq). The Food and Drug Administration (FDA) approved this drug for the management of OAB in 2012.

Myrbetriq has fewer side effects with a similar efficacy to anticholinergics. Therefore, switching to Myrbetriq can be helpful if a person cannot tolerate the side effects of anticholinergics.

Some side effects of Myrbetriq include:

• hypertension
• sinus pressure
• a sore throat
• difficulty voiding

People may wish to combine Myrbetriq with anticholinergic medications for additional efficacy.

Intradetrusor onabotulinumtoxinA (BTX-A), also known as Botox, is a third-line treatment for OAB. In certain individuals who have not seen success with first- and second-line treatments, healthcare professionals may consider BTX-A.

People receive BTX-A during cystoscopy, which is an outpatient, minimally invasive surgical procedure. A urologist will use a tiny camera that evaluates the internal lining of the bladder. They will then inject the BTX-A throughout the bladder with a long needle using the camera guidance.

This is a well-tolerated procedure, and urologists will sometimes perform it while people are awake and under local anesthesia.

That said, there may be mild discomfort during the procedure and immediately after, with minor risks of blood in the urine and UTIs. Also, some individuals can go into urinary retention and may require intermittent catheterization afterward.

The treatment begins to work in about 1–2 weeks. However, it is not a permanent effect. A urologist will need to repeat the injections about every 6–12 months, with the average time for effect being 7.5 months.

Nerve stimulation, or neuromodulation, is a treatment in which healthcare professionals place electrodes adjacent to nerves, and electrical stimulation of the nerves improves bladder function. It is most effective for people with non-neurogenic OAB and if first- and second-line treatments do not work.

There are two types of neuromodulation: sacral neuromodulation and peripheral tibial nerve stimulation (PTNS).

During sacral neuromodulation, a surgeon will implant electrodes next to the S3 sacral nerve roots in the lower back. It is an outpatient, minor surgical procedure to place temporary leads at the nerve root.

A trial period helps determine the response. If a person sees at least 50% improvement, the surgeon can implant a permanent pulse generator as a long-term treatment for medication-refractory OAB.

PTNS is a newer, alternative form of neuromodulation. Doctors perform it in an office setting, typically once or twice per week. During the procedure, the doctor will place a needle alongside the posterior tibial nerve in the leg, which creates feedback to the spinal nerves.

The mechanism is not entirely understood, but the nerve impulses create short-term improvements in OAB with overall mixed results. It has minimal side effects but requires frequent office visits. Researchers are studying new options using implantable leads for PTNS in clinical trials.

Beyond bladder injections and nerve stimulation, less common surgical options are more involved and can be risky.

There are two major abdominal and bladder surgeries for end stage, severe, refractory, and complicated OAB: augmentation cystoplasty and urinary diversion.

Augmentation cystoplasty is more effective for neurogenic OAB than for non-neurogenic OAB. During augmentation cystoplasty, a surgeon will patch a segment of small intestine onto the bladder. This increases bladder compliance and volume.

In the most refractory of cases, surgeons can completely bypass the bladder with urinary diversion. During urinary diversion, they disconnect a segment of small intestine and fashion it into a channel. This connects the ureters from each kidney on the backend of the channel out to the skin, where the surgeon can place an ostomy appliance to collect the urine. This procedure is called an ileal conduit.

These two surgical options are major open abdominal procedures that include intestinal surgery and require multiple-day hospitalizations. Complications from these surgeries can be more severe and include:

• bleeding
• infection
• re-operation
• blood clots
• kidney damage
• intestinal obstruction

R. Matthew Coward, M.D., FACS, is an associate professor of urology and a clinical associate professor of obstetrics and gynecology at the University of North Carolina. He has been named one of the “Best Doctors in America” and is a “Castle Connolly Top Doctor.” Dr. Coward has published more than 70 peer reviewed scientific articles and book chapters.