Overactive bladder Diagnosis and management First-line investigations Elicit a careful clinical history, perform a physical examination, and obtain a urinalysis in patients with suspected overactive bladder, in order to document suggestive symptoms and signs, and exclude alternative potential causes. B Renal and bladder ultrasound, urodynamic studies and cystoscopy Avoid obtaining diagnostic renal and bladder ultrasound, urodynamic studies, or cystoscopy as part of the initial evaluation of patients with uncomplicated overactive bladder. D Second-line investigations Q Are additional investigations required to confirm the diagnosis of overactive bladder and/or exclude other disorders? Yes Consider obtaining the following additional tests selectively, in patients in whom additional information is required to confirm the diagnosis of overactive bladder, and exclude other disorders: bladder diary urine culture post-void residual. C No General counseling Q Does diagnostic evaluation confirm the diagnosis of overactive bladder? No Consider alternative diagnoses. Yes Inform patients that overactive bladder is not a disease; it is a symptom complex that generally is not a life-threatening condition. E Educate patients regarding normal lower urinary tract function, what is known about overactive bladder, the benefits vs. risks/burdens of the available treatment alternatives, and the fact that acceptable symptom control may require trials of multiple therapeutic options before it is achieved. B First-line therapy Offer behavioral therapies (such as bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first-line therapy to all patients with overactive bladder. B Consider combining behavioral therapies with pharmacologic management, if behavioral therapies alone are partially effective. C Second-line therapy Q Does the patient experience adequate symptom relief with first-line therapy? Yes Schedule clinical follow-up to evaluate adherence to treatment, and assess efficacy and side effects of medications. E No Offer oral antimuscarinics or oral -3 adrenergic agonists as second-line therapy in patients with overactive bladder who do not respond to initial management. B Consider offering transdermal oxybutynin (patch or gel) as an alternative to oral agents in patients with overactive bladder who do not respond to initial management. C Use antimuscarinics and -3 adrenergic agonists with caution in patients who are frail. B Use antimuscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention. B Use antimuscarinics with caution in patients who are using other medications with anticholinergic properties. E Avoid antimuscarinics in patients with narrow-angle glaucoma, unless approved by the treating ophthalmologist. D Management of medication adverse effects Q Does the patient experience unacceptable side effects from antimuscarinic agents? Yes Consider one of the following options in patients who unexperience unacceptable adverse effects from antimuscarinic agents: modifying the dose of the current agent switching to a different antimuscarinic agent switching to a -3 adrenergic agonist. C Educate patients about the possible effects of medication on bowel function, and provide advice on the roles of adequate dietary fiber and fluid, psyllium-based fiber supplements and regular exercise in maintaining regular bowel habits. Educate patients about the risk of dry mouth with antimuscarinics, and provide advice on management strategies, such as oral lubricants, avoiding mouthwashes with alcohol, taking small sips of water, sucking on sugar-free hard candies and chewing sugar-free gum. No Management of nonresponse to treatment Q Does the patient experience adequate symptom relief with pharmacologic management? Yes Schedule clinical follow-up to evaluate adherence to treatment, and assess efficacy and side effects of medications. E No Ensure that each line of treatment has been tested for an adequate amount of time to determine whether the therapy is efficacious and tolerable. E Consider one of the following options in patients who experience inadequate symptom control with an antimuscarinic agent: modifying the dose of the current agent switching to a different antimuscarinic agent switching to a -3 adrenergic agonist. C Consider combination therapy with an antimuscarinic and a -3 adrenergic agonist for patients refractory to monotherapy with either antimuscarinics or -3 adrenergic agonists. C Nerve stimulation and neuromodulation Q Does the patient have severe symptoms refractory to first- and second-line therapies? Yes Consider offering peripheral tibial nerve stimulation as a third-line therapy in carefully selected patients who do not respond to first- and second-line therapies. C Consider offering sacral neuromodulation as third-line therapy in patients with severe symptoms that are refractory to first- and second-line therapies, or patients who are not candidates for second-line therapy, and are willing to undergo a surgical procedure. C Intradetrusor onabotulinumtoxin A Consider offering intradetrusor onabotulinumtoxin A injection as third-line therapy in carefully selected and thoroughly counseled patients who do not respond to first- and second-line therapies. Patients must be able and willing to return for frequent post-void residual evaluation, and be able and willing to perform self-catheterization if necessary. B Follow-up clinical assessment Schedule clinical follow-up to evaluate adherence to treatment, and assess efficacy and side effects of medications. E No Schedule clinical follow-up to evaluate adherence to treatment, and assess efficacy and side effects of medications. E