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  • Review Article
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Management of overactive bladder

Nature Reviews Urology volume 7, pages 572–582 (2010)Cite this article

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Abstract

Many people are affected by urinary urgency, which can be highly bothersome. Urgency is the cornerstone symptom of overactive bladder (OAB), commonly occurring in conjunction with urinary frequency and nocturia. Once other medical causes of similar symptoms have been excluded, first-line OAB management comprises fluid intake advice and bladder training, supplemented by antimuscarinic drugs if necessary. Urodynamic confirmation of the diagnosis is required for OAB patients whose symptoms are refractory to first-line interventions. If patients are severely bothered by OAB despite optimization of medical treatment, they may proceed to invasive treatments, including neuromodulation, enterocystoplasty, detrusor myectomy, or urinary diversion. Our burgeoning understanding of the complex cellular, neural and integrative physiology of the bladder offers new insights into the causative mechanisms of OAB, and reasons why patients sometimes fail to respond to treatment. Study of sensory information pathways in the lower urinary tract has led to identification of the urothelium, afferent nerves and interstitial cells as key cellular elements in OAB. In-depth knowledge of the hierarchy of central nervous system control is lacking, but functional imaging is beginning to elucidate the challenges that lie ahead. New treatments under investigation include botulinum neurotoxin-A injection, oral β3-adrenergic agonists, and novel modalities for nerve stimulation. The subjective nature of urinary urgency, the lack of animal models and the multifactorial pathophysiology of OAB present significant challenges to effective clinical management.

Key Points

  • In modern usage, overactive bladder (OAB) is a clinical diagnosis based on symptoms, whereas detrusor overactivity is a urodynamic diagnosis; the terms are not interchangeable

  • Overall prevalence of OAB is approximately 12%, increasing with advancing age

  • Diagnosis is based on presence of urinary urgency; other causes of this symptom, such as urinary tract infection and pelvic malignancy, should be excluded

  • First-line treatment should be conservative (that is, fluid intake advice and bladder training); antimuscarinic drug treatment should be individually tailored according to patient response and adverse effects

  • Specialized treatment options following confirmatory urodynamic diagnosis are reconstructive surgery and modulation of either sensory or motor nerve input

  • The mechanisms that underlie OAB may operate at all levels of lower urinary tract control, affecting bladder sensation, motor activity and reflexes

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Figure 1: CNS centers involved in control of lower urinary tract function.
Figure 2: Urodynamic traces for OAB.

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Authors and Affiliations

  1. Royal Liverpool University Hospital, L3 5PS, Liverpool, UK

    Dev M. Gulur

  2. Urology Department, Bristol Urological Institute, Southmead Hospital, BS10 5NB, Bristol, UK

    Marcus J. Drake

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  1. Dev M. Gulur
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D. M. Gulur and M. J. Drake made substantial contributions to the researching and writing of this article. M. J. Drake reviewed the manuscript before submission.

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Correspondence to Marcus J. Drake.

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Competing interests

D. M. Gulur declares no competing interests. M. J. Drake declares the following competing interests: speaker engagements, research and advisory boards for Astellas and Pfizer, speaker engagements for Ferring Pharmaceuticals, research for Allergan.

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Gulur, D., Drake, M. Management of overactive bladder. Nat Rev Urol 7, 572–582 (2010). https://doi.org/10.1038/nrurol.2010.147

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