Guideline sources The following summarized guidelines for the evaluation and management of overactive bladder are prepared by our editorial team based on guidelines from the American Urological Association (AUA/SUFU 2019). 1 Pathway Overactive bladder Diagnosis and management Guidelines 1. Diagnostic investigations 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 https://web.pathway.md/diseases/rechbVZftk9hplMry 1/4 6/30/23, 1:25 AM Overactive bladder Pathway symptoms and signs, and exclude alternative potential causes. B Second-line investigations: 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 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 2. Medical management 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: 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 Show 5 more Management of nonresponse to treatment: 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 Show 2 more Management of medication adverse effects: 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 Show 2 more 3. Therapeutic procedures Urinary catheter placement: avoid indwelling catheters as a management strategy for overactive bladder because of the adverse risk/benefit balance, except as a last resort in selected patients. D Intradetrusor onabotulinumtoxin A: consider offering intradetrusor onabotulinumtoxin A injection as third-line therapy in carefully selected and thoroughly counseled patients who do not https://web.pathway.md/diseases/rechbVZftk9hplMry 2/4 6/30/23, 1:25 AM Overactive bladder Pathway 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 Nerve stimulation and neuromodulation: 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 4. Surgical interventions Augmentation cystoplasty: consider performing augmentation cystoplasty or urinary diversion in rare cases for the management of severe, refractory, complicated overactive bladder. E 5. Patient education General counseling: 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 6. Follow-up and surveillance Follow-up clinical assessment: schedule clinical follow-up to evaluate adherence to treatment, and assess efficacy and side effects of medications. E Clinical findings Symptoms Past medical history Constipation Cancer Declining cognitive function due to aging Diabetes mellitus Medications Feeling of incomplete bladder emptying Menopause Multiple sclerosis Nocturia Stroke UTI https://web.pathway.md/diseases/rechbVZftk9hplMry 3/4 6/30/23, 1:25 AM Overactive bladder Pathway Sudden urge to urinate that's difficult to control Rectal exam Urinary frequency Enlarged prostate Urinary incontinence Social history Alcohol consumption Excessive consumption of caffeine Imaging findings References 1. Lightner DJ, Gomelsky A, Souter L et al. Diagnosis and Treatment of Overactive Bladder Non- Neurogenic) in Adults: AUA/SUFU Guideline Amendment 2019. J Urol. 2019 Sep;202 3 558 563. Open 2. Gormley EA, Lightner DJ, Burgio KL et al. Diagnosis and treatment of overactive bladder (non- neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012 Dec;188 6 Suppl):2455 63. Open https://web.pathway.md/diseases/rechbVZftk9hplMry 4/4