Overactive bladder: Alternative treatment options examined

This study evaluated recent evidence on different treatment options available for overactive bladder symptoms.

Authors concluded that a number of alternative treatments are as effective as the current standard-of-care anti-muscarinic drugs.

Bladder muscle over-activity is a common cause of urinary urgency and incontinence. Drug therapy with anti-muscarinic drugs, such as tolterodine (Detrol), are often prescribed as first-line treatment. However, evidence regarding the effectiveness of anti-muscarinic drugs is mixed, and treatment is often associated with bothersome side-effects.

The aim of this study was to review recent evidence on alternatives to anti-muscarinic treatment for the management of overactive bladder symptoms.

This review included 99 separate randomized trials, involving a combined total of 27,890 patients with overactive bladders. Outcomes of different types of treatments were either compared to a placebo (a substance with no active effect, used as a control) or to another active treatment.

Physical therapy was consistently noted to be effective at reducing urinary incontinence, when compared to placebo or to no treatment. Pelvic-floor exercises coupled with a Heat and Steam Sheet (a heat-generating sheet applied to the lower abdomen and back), or with other abdominal exercises, were noted to improve urinary symptoms after 3 months of treatment. One study reported lasting improvements (maintained for at least 2 years) in urinary symptoms following pelvic-floor muscle training combined with biofeedback (a training technique used to improve control of certain bodily processes that normally happen involuntarily, such as muscle tension). Pelvic-floor muscle training assisted by biofeedback was found to be superior to pelvic-floor exercises alone, electrical stimulation, and self-help books in reducing urinary incontinence. Evidence regarding the use of vaginal cones in combination with physical therapy was inconclusive. Overall, the benefits of physical therapy were comparable to that of anti-muscarinic drugs, however, without any of the commonly associated side-effects of anti-muscarinic drugs (like dry mouth, blurry vision, constipation, and confusion).

Several studies have suggested that different types of behavioral therapy can improve urinary symptoms and quality of life. Studies have shown that bladder training significantly reduced daily urgency episodes in patients with overactive bladders. For increased effectivity, bladder training can be combined with pelvic-floor muscle training, physiotherapy, and nerve stimulation. When compared to no treatment, education of caffeine reduction was associated with improvement in urinary symptoms. Severity and frequency of incontinence episodes were also reduced following weight loss with diet and exercise. One recent study observed improved urinary urgency during both daytime and nighttime in patients that reduced their daily fluid intake by 25 to 50%.

According to 29 separate randomized trials, an injection of OnabotA (onabotulinumtoxinA, botulinum toxin A, or Botox) directly into the bladder muscle significantly reduced overactive bladder symptoms, when compared to placebo. Several studies also suggested that OnabotA is more effective at higher doses, while accounting for potential side-effects. OnabotA was similar in effect to anti-muscarinic drugs when examined over a 6-months period, with a similar rate of side-effects.

Three separate studies suggested magnetic stimulation to be a safe and effective treatment option in improving overactive bladder symptoms, when compared to placebo treatment (sham stimulation). The effects of magnetic stimulation, however, were not compared to those of other active treatments.

Electrical nerve stimulation was also examined in various studies. Sacral neuromodulation (a type of nerve stimulation treatment) was associated with high success rates for treating persistent urge urinary incontinence, when compared to placebo or to anti-muscarinic drugs. Posterior tibial nerve stimulation (another type of nerve stimulation treatment) was shown to be associated with a reduction of more than 50% in episodes of urge incontinence after 4 weeks of treatment. However, considerable side-effects such as localized discomfort, tingling, skin irritation and change in bowel habits, were commonly noted with nerve stimulation treatments. Evidence is mixed regarding additional types of nerve stimulation, such as transvaginal electrical stimulation.

Additional treatment options for overactive bladder symptoms include acupuncture and drug therapy with mirabegron (Myrbetriq). High-quality studies are currently lacking with regards to the effectiveness of acupuncture in improving overactive bladder symptoms. Three recent trials found mirabegron to significantly improve incontinence episodes compared to placebo. However, the rate of side-effects was high with mirabegron treatment, and included dizziness, high blood pressure, headaches, dry mouth, and chest pain.

The authors concluded that physical therapies, behavioral therapies, Botox injections, as well as some forms of magnetic or electrical stimulation, are all safe and effective alternative treatment options for overactive bladders.