Guideline for Overactive Bladder in Females

Saswata Chakraborty ¹*, Mark Rogers ²

1,2. Department of Urology, Scunthorpe General Hospital, North Lincolnshire and Goole NHS Foundation Trust Cliff Gardens, Scunthorpe North Lincolnshire, DN15 7BH, United Kingdom.

     
Corresponding Author: Saswata Chakraborty, Department of Urology, Scunthorpe General Hospital, North Lincolnshire and Goole NHS Foundation Trust Cliff Gardens, Scunthorpe North Lincolnshire, DN15 7BH, United Kingdom.

Copy Right: © 2023 Saswata Chakraborty, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 16, 2023

Published Date: April 01, 2023

Guideline for Referral to Secondary Care Continence Clinic. Primary Care (GP) to carry out:-

1. Initial assessment:

• Full history and examination.
• Rule out red flag symptoms as below.
• Bladder diary for a minimum of 3 days.
• Treat confirmed UTI, Treat vaginal atrophy.

Conservative Management

• Lifestyle Interventions- e.g reduce weight if BMI>30, reduce/stop caffeine intake, modify fluid intake.
• Review medications (e.g., diuretics/anti-hypertensives)
• Manage constipation.
• Bladder training for 12 weeks (see Appendix 1)
• Smoking cessation.
• Supervised pelvic floor muscle training for at least 3 months.
• Consider medical/medication causes if nocturia present in elderly women, as less likely to be caused by OAB.

2. Pharmacological Treatment-

Before starting OAB Drugs discuss with the patient:

• Likelihood of success and associated common side effects such as dry mouth and constipation.
• Adverse effects may indicate that treatment is starting to have an effect.
• Full benefits may not be seen until they have taken the treatment for 4 weeks (Use for 12 weeks if combined with bladder training &/or pelvic floor exercises).

Consider the bladder training programme in combination with an OAB drug if the frequency is a troublesome symptom.

Choosing OAB Drugs

1. First-Line Treatment (antimuscarinic) – Generic Solifenacin 5-10 mg daily. Not recommended in elderly, dementia, anticholinergic burden score ≥3 Contraindications: Patient with narrow-angle glaucoma, Sjogren syndrome, significant bladder outflow obstruction or urinary retention, severe ulcerative colitis, toxic megacolon, gastrointestinal obstruction, and Myasthenia Gravis.

NOTE: Little evidence to justify a switch to another antimuscarinic if one has failed.

2. Second Line (Beta agonist): Mirabegron 50 mg daily, if no satisfactory response to antimuscarinic OR antimuscarinic not suitable or contra-indicated. Contraindications: Contra-indicated in severe uncontrolled hypertension (systolic ≥180 mmHg or diastolic ≥ 110 mmHg). Refer BNF.

Cautions: Caution in patients with stage 2 hypertension (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥ 100 mm Hg), History of QT-interval prolongation. Blood Pressure to be measured before starting and regularly monitored (MHRA October 2015)

3. Mirabegron 25 mg daily if hepatic or renal impairment.

Review

• Offer face to face or telephone review 4 weeks after the start of new OAB drug treatment or before 4 weeks if adverse events of OAB drug are intolerable, and until stable
• Review patients on long term treatment annually or every 6 months if over 75 years if treatment is effective and well-tolerated, do not change the dose or the drug

3. Referral to Secondary care

For Urodynamics and/or Intradetrussor Botulinum Toxin injections, if Second-line drug therapy fails.

The patient does not want to try another drug after first-line medication/Bladder training/pelvic floor muscle training have failed.

Also, consider referral if the following were noticed during the initial assessments (RED FLAGS)

• Presence of haematuria.
• Visible prolapse.
• Clinically benign pelvic mass.
• Suspected neurological disease.
• Recurrent UTI.
• Persistent bladder/urethral pain.
• Symptoms of voiding difficulty.
• Suspected urogenital fistulae.
• Associated faecal incontinence.
• Palpable bladder on bimanual or abdominal examination after voiding.
• Previous continence surgery.
• Previous pelvic cancer surgery.
• Previous pelvic radiation therapy.

Frequency Volume Chart patterns

Voided volume – Normal (1500-2000ml /24hrs) ; Frequency - Normal( 5-8 voids in 24hrs) Normal volume per void – 300ml - 500ml ; Normal frequency at night 1-2 times.

Voided volume per void - Normal; Frequency - Increased : Suspect Polydipsia, Occasionally Diabetes Insipidus/Diabetes Mellitus.

Voided volume- reduced and consistently fixed in both Day and Night: Suspect reduced bladder capacity.

Voiding frequency increased with reduced and variable voided volume Day and Night with urgency and urge incontinence : Overactive bladder.

Early morning -Normal voided volume ; Daytime voided volume- Variable with no night time waking – Suspect Psychosomatic.

Voided volume-Normal; Frequency - Normal in the day time; Night time frequency increased with total Voided volume at night- 33% of 24h--- Consider Nocturnal Polyuria.

References

1. Chapple CR, Martinez-Garcia R, Selvaggi L, Toozs-Hobson P, Warnack W, Drogendijk T, Wright DM, Bolodeoku J. A Comparison of the Efficacy and Tolerability of Solifenacin Succinate and Extended Release Tolterodine at Treating Overactive Bladder Syndrome: Results of the STAR Trial, European Urology 2005; Volume 48, Issue 3: 464-470.

2. Chapple CR, Vik Khullar, Victor Nitti VW, Frankel J, Herschorn S, Kaper M, Blauwet MB, Siddiqui E. Efficacy of the β3-adrenoceptor Agonist Mirabegron for the Treatment of Overactive Bladder by Severity of Incontinence at Baseline: A Post Hoc Analysis of Pooled Data from Three Randomised Phase 3 Trials, European Urology 2015; Volume 67, Issue 1: 11-14.

3. Chapple CR, Kaplan SA, Mitcheson D, Klecka J, Cummings J, Drogendijk T, Dorrepaal C, Martin N. Randomized Double-blind, Active-controlled Phase 3 Study to Assess 12- Month Safety and Efficacy of Mirabegron, a β3-Adrenoceptor Agonist, in Overactive Bladder, European Urology, Volume 63, Issue 2, 2013, pp 296-305.

4. Castro-Diaz D, Chapple CR, Hakimi Z, Blauwet MB, Delgado-Herrera L, Lau W, Mujais S. The effect of mirabegron on patient-related outcomes in patients with overactive bladder: the results of post hoc correlation and responder analyses using pooled data from three randomized Phase III trials. Qual Life Res. 2015 Jul;24(7):1719-27.

5. Abrams P, Kelleher C, Staskin D, et al. Combination treatment with mirabegron and solifenacin in patients with overactive bladder: efficacy and safety results from a randomised, double-blind, dose-ranging, phase 2 study (Symphony). Eur Urol. 2015; 67(3): 577-588.

6. Abrams P, Kelleher C, Staskin D, et al. Combination treatment with mirabegron and solifenacin in patients with overactive bladder: exploratory responder analyses of efficacy and evaluation of patient-reported outcomes from a randomized, double- blind, factorial, dose-ranging, Phase II study (SYMPHONY) . World J Urol. 2017; 35(5): 827-838.

7. Herschorn S, Chapple CR, Abrams P, et al. Efficacy and safety of combinations of mirabegron and solifenacin compared with monotherapy and placebo in patients with overactive bladder (SYNERGY study). BJU Int. 2017; 120(4): 562-575.

8. Drake MJ, Chapple C, Esen AA, et al. Efficacy and Safety of Mirabegron Add-on Therapy to Solifenacin in Incontinent Overactive Bladder Patients with an Inadequate Response to Initial 4-Week Solifenacin Monotherapy: A Randomised Double-blind Multicentre Phase 3B Study (BESIDE). Eur Urol. 2016; 70(1): 136-45.

9. MacDiarmid S, Al-Shukri S, Barkin J, et al. Mirabegron as Add-On Treatment to Solifenacin in Patients with Incontinent Overactive Bladder and an Inadequate Response to Solifenacin Monotherapy. J Urol. 2016; 196(3): 809-18.

10. Robinson D, Kelleher C, Staskin D, et al. Patient-reported outcomes from SYNERGY, a randomized, double-blind, multicenter study evaluating combinations of mirabegron and solifenacin compared with monotherapy and placebo in OAB patients. Neurourol Urodyn. 2018; 37(1): 394-406.