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For patients with symptoms of idiopathic and neurogenic overactive bladder (OAB), challenges facing the clinician include determining what they hope to gain from treatment. The answers can help formulate a treatment plan that patients find acceptable, increasing adherence, and circumvent treatment failure.

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In shared decision making, clinicians and patients share the best available evidence when making decisions, and patients are supported to consider options to achieve informed preferences.1,2 Patients should be proactive in describing concerns and preferences in choosing treatment and the physician should elicit this information from the patient and consider it, integrating good communication skills and using patient decision support tools.1

For either idiopathic OAB or neurogenic detrusor overactivity (NDO), eliciting patient feedback and sharing the best available evidence when describing relevant options are important in achieving patient satisfaction (see Patient-Clinician Video A with Dr. Nitti).


OAB is defined as urgency, with or without urgency urinary incontinence (UUI), usually with frequency and nocturia, in the absence of pathologic or metabolic conditions that might explain these symptoms.3 Evaluation of urinary incontinence (UI) should include a history to delineate other causes (Table 1).

The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine, & Urogenital Reconstruction (SUFU) guideline offers a diagnosis and treatment algorithm for non-neurogenic OAB in adults.4 Minimum requirements are a history, examination, and urinalysis. To confirm a diagnosis of OAB and exclude other disorders, a urine culture, postvoid residual volume, and bladder diaries may be necessary. In the uncomplicated patient, urodynamics, cystoscopy, and renal/bladder ultrasound should not be used initially.

First-Line Treatments for OAB

Behavioral therapy. This approach has reduced the frequency of incontinence by 50% to 80%5,6 in both men7 and women.6 It may comprise bladder training, incremental voiding schedules, dietary modification, and/or pelvic floor muscle training.

Weight loss can also improve UI.8 A 6-month program that resulted in a weight loss of 8.0% in obese women reduced overall incontinence episodes by 47% vs. 28% in the control group. UUI episodes were reduced by 42% and 26%, respectively.

The combination of behavioral therapy plus antimuscarinics has also been explored. In elderly women, behavioral therapy alone reduced UI by 58% vs. 89% when behavioral therapy was combined with oxybutynin. In contrast, oxybutynin alone reduced UI by 73%, vs. 84% when oxybutynin was combined with behavioral therapy.9 Tolterodine combined with behavioral therapy resulted in a greater decrease in UI and patient satisfaction than behavioral therapy alone.10

Antimuscarinics alone, as well as antimuscarinics plus behavioral therapy, were more effective than behavioral therapy alone. However, it is unclear if antimuscarinics plus behavioral therapy are more effective than antimuscarinics alone.11 One challenge noted with behavioral therapy is adherence appears to diminish over time.12