AUA releases 2019 Update to its Overactive Bladder Clinical Practice Guideline
The American Urological Association (AUA) has released updates to its Diagnosis and Treatment of Overactive Bladder (Non-neurogenic) in Adults Clinical Guideline, jointly released by the AUA and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). This amendment is the product of the AUA's literature review process, whereby an additional systematic review is conducted to maintain guideline currency with newly published and relevant literature.
Overactive bladder is characterized by urinary symptoms including urgency, frequency, and nocturia, with or without urge incontinence. The prevalence and severity of symptoms increase with age, and most patients have symptoms for years.
Key Guideline Statements
1. The clinician should engage in a diagnostic process to document symptoms and signs that characterize OAB and exclude other disorders that could be the cause of the patient's symptoms; the minimum requirements for this process are a careful history, physical exam, and urinalysis. Clinical Principle
2. In some patients, additional procedures and measures may be necessary to validate an OAB diagnosis, exclude other disorders and fully inform the treatment plan. At the clinician's discretion, a urine culture and/or post-void residual assessment may be performed and information from bladder diaries and/or symptom questionnaires may be obtained. Clinical Principle
3. Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not be used in the initial workup of the uncomplicated patient. Clinical Principle
4. OAB is not a disease; it is a symptom complex that generally is not a life-threatening condition. After assessment has been performed to exclude conditions requiring treatment and counseling, no treatment is an acceptable choice made by some patients and caregivers. Expert Opinion
5. Clinicians should provide education to patients regarding normal lower urinary tract function, what is known about OAB, the benefits versus 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. Clinical Principle
First-Line Treatments: Behavioral Therapies
6. Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) as first line therapy to all patients with OAB. Standard (Evidence Strength Grade B)
7. Behavioral therapies may be combined with pharmacologic management. Recommendation (Evidence Strength Grade C)
Second-Line Treatments: Pharmacologic Management
8. Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as second-line therapy. Standard (Evidence Strength Grade B)
9. If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth. Standard (Evidence Strength Grade B)
10. Transdermal (TDS) oxybutynin (patch or gel) may be offered. Recommendation (Evidence Strength Grade C)
11. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a β3-adrenoceptor agonist may be tried. Clinical Principle
12. Clinicians may consider combination therapy with an anti-muscarinic and β3-adrenoceptor agonist for patients refractory to monotherapy with either anti-muscarinics or β3-adrenoceptor agonists. Option (Evidence Strength Grade B)
13. Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention. Clinical Principle
14. Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic therapy. Management may include bowel management, fluid management, dose modification or alternative anti-muscarinics. Clinical Principle
15. Clinicians must use caution in prescribing antimuscarinics in patients who are using other medications with anticholinergic properties. Expert Opinion
16. Clinicians should use caution in prescribing anti-muscarinics or β3-adrenoceptor agonists in the frail OAB patient. Clinical Principle
17. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. Expert Opinion
Third-Line Treatments: PTNS and Neuromodulation
18. Clinicians may offer intradetrusor onabotulinumtoxinA (100U) as third-line treatment in the carefully-selected and thoroughly-counselled patient who has been refractory to first- and second-line OAB treatments. The patient must be able and willing to return for frequent post-void residual evaluation and able and willing to perform self-catheterization if necessary. Standard (Evidence Strength Grade B)
19. Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected patient population. Recommendation (Evidence Strength Grade C)
20. Clinicians may offer sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure. Recommendation (Evidence Strength Grade C)
21. Practitioners and patients should persist with new treatments for an adequate trial in order to determine whether the therapy is efficacious and tolerable. Combination therapeutic approaches should be assembled methodically, with the addition of new therapies occurring only when the relative efficacy of the preceding therapy is known. Therapies that do not demonstrate efficacy after an adequate trial should be ceased. Expert Opinion
Fourth-Line Treatments: Augmentation Cystoplasty and Urinary Diversion
22. In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB patients may be considered. Expert Opinion
23. Indwelling catheters (including transurethral, suprapubic, etc.) are not recommended as a management strategy for OAB because of the adverse risk/benefit balance except as a last resort in selected patients. Expert Opinion
24. The clinician should offer to follow up with the patient to assess compliance, efficacy, side effects and possible alternative treatments. Expert Opinion
The Diagnosis and Treatment of Overactive Bladder (Non-neurogenic) in Adults was amended as follows:
- Guideline Statement 12 was modified based upon a 2018 literature review, which uncovered a number of studies looking at combination therapy for the treatment of Overactive Bladder (OAB). These studies demonstrated improved efficacy with combination therapy without any significant effect on patient safety when compared to monotherapy.
- Statement 12: Clinicians may consider combination therapy with an anti-muscarinic and β3-andrenoceptor agonist for patient refractory to monotherapy with either anti-muscarinics or β3-andrenoceptor agonists. (Option; Evidence Strength: Grade B)
- Guideline Statement 22 was re-categorized from "Additional Treatments" to "Fourth-Line Treatment." No changes have been made to the text or associated discussion of this statement.
- Statement 22: In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB patients may be considered. (Expert Opinion)
"This clinical framework for OAB does not require every patient go through each line of treatment in order, as there are many factors to consider when working with a patient to select the best treatment option," said Sandip Prasan Vasavada, MD, guideline panel member and professor of surgery and urology at the Cleveland Clinic Foundation in Cleveland, Ohio. "This latest amendment to the guideline reflects recently published studies, including the success of using combination therapy to treat OAB and we are confident it is fully aligned with the latest science on treatments for patients with overactive bladder."
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Unabridged version of this Guideline [pdf]