Presenting w/ OAB s/sx (urgency, frequency, nocturia, +/- urge-incontinence) Assess w/ H&P (including assessment of bladder sx), UA to exclude microhematuria and infection. [CP] Urgency—a sudden, compelling desire to pass urine that is difficult to defer—is the hallmark sx of OAB. Hx: fluid intake, voids per day/night, diuretic/other med use, degree of bother, comorbid conditions, etc. PSA (in appropriate pt population) If dx unclear or more info needed: UCx, PVR, sx questionnaire and/or voiding diary. [CP]   ◦ PVR: measure w/ U/S bladder scanner immediately post void; if U/S scanner not available, use urethral cath. Not recommended for initial w/u unless diagnostic uncertainty: urodynamics, cystoscopy, urinary tract imaging. [CP] Assess for comorbid conditions that may contribute to urinary frequency, urgency, or UUI and educate pts on how managing them can affect bladder sx. [EO]   ◦ Comorbid conditions include obesity, constipation, pelvic organ prolapse, genitourinary syndrome of menopause, glucosuria, obstructive sleep apnea, anxiety/depression, and tobacco cessation. Telemedicine may be offered for initial eval, w/ the understanding that a physical exam won’t be performed and to obtain UA at a lab (or review recent lab results). [EO] Engage w/ pts in shared decision-making, accounting for their values, preferences, and tx goals to help them make an informed decision on different tx modalities or to explore the option of no tx. [CP] OAB is preference centered; no specific tx has clear superiority. May use monotherapy or combo of therapies. May combine or change therapies if the pt:   ◦ Is unwilling or unable to undergo certain therapies   ◦ Has intolerable side effects   ◦ Doesn’t have adequate sx improvement Noninvasive therapies Discuss incontinence mgmt strategies—e.g., pads, diapering, barrier creams—w/ all pts w/ UUI. [EO] Offer bladder training to all pts w/ OAB. [SR/A] Offer behavioral therapies to all pts w/ OAB: [CP]   ◦ Bladder training/timed voiding   ◦ Fluid mgmt (e.g., fluid restriction at night, avoiding polydipsia)   ◦ Caffeine reduction   ◦ Physical activity/exercise   ◦ Dietary modification (e.g., low fat, high fruit/vegetable, whole grain)   ◦ Mindfulness May offer select noninvasive therapies to all pts w/ OAB: [CP]   ◦ PFMT (e.g., urge suppression, muscle strengthening)   ◦ Magnetic stimulation   ◦ Transcutaneous electrical stimulation   ◦ TTNS   ◦ Transvaginal electrical stimulation   ◦ Yoga   ◦ Hypnosis Insufficient evidence: nutraceuticals, vitamins, supplements, herbal remedies. [EO] Pharmacotherapy Offer oral antimuscarinics (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium) or β3-adrenoceptor agonists (mirabegron, vibegron). [SR/A] Transdermal oxybutynin patch (Oxytrol (males only; Rx) and Oxytrol for Women (OTC)) may be offered. [R/C] Choose tx based on side-effect profile, in the context of shared decision-making. [CP]   ◦ Antimuscarinics: common: dry mouth, constipation, voiding dysfunction/incomplete emptying, retention, blurred vision; rare: palpitations, tachycardia, and QT prolongation, which can lead to torsades de pointes. ER superior to IR formulations for ↓ side effects.   ◦ β3 agonists: may have fewer side effects than antimuscarinics, esp. dry mouth and constipation, and less effect on PVR, resulting in ↓rates of voiding dysfunction, but may affect CV function; mirabegron not recommended if severe, uncontrolled HTN (SBP ≥180 mmHg or DBP ≥110 mmHg). Discuss potential risk for dementia and cognitive impairment w/ pts taking or prescribed antimuscarinics. [CP] Don’t use antimuscarinics if narrow-angle glaucoma (unless approved by pt’s ophthalmologist); use w/ extreme caution if impaired gastric emptying or urinary retention hx [CP]; if PVR >250-300 mL, use w/ caution. If obstructive voiding sx appear, monitor PVR. Assess tx for efficacy and onset of side effects w/in 4-8wk of tx initiation. [EO]   ◦ If intolerable side effects or inadequate improvement: May offer a different medication in the same class or a medication from a different class. [CP] For pts on antimuscarinics, switching to a β3 agonist may be more tolerable, due to apparently lower rates of common side effects, while maintaining efficacy.   ◦ If inadequate improvement w/ a single medication: May offer combo tx w/ a medication from a different class—e.g., antimuscarinic + β3 agonist. [CR/B] Minimally invasive therapies May offer to pts unable/unwilling to undergo behavioral, noninvasive, or pharmacological therapies [CP]   ◦ If inadequate response to behavioral tx or medication mgmt: PTNS, implantable tibial nerve stimulation, BTX, and SNM assoc w/ high success rates, durable efficacy, excellent pt satisfaction.   ◦ Acupuncture: similar improvements to pharmacotherapy in tx-naïve pts (low-certainty evidence).   ◦ Laser and radiofrequency: not recommended (poor-quality evidence). Offer in the context of shared decision-making; trials of behavioral, noninvasive, or pharmacological mgmt not required. [EO] Discontinue oral meds if appropriate response to minimally invasive procedure, but restart if efficacy not maintained. [EO]   ◦ If good tx response: There’s likely no added benefit to continuing OAB meds; are assoc w/ polypharmacy, added cost, and potential side effects. Comorbid benign prostatic hyperplasia In the context of shared decision-making, clinicians may offer noninvasive therapies, pharmacotherapy, or minimally invasive therapies. [EO]   ◦ If OAB-predominant LUTS: bladder outlet reduction surgeries—e.g., transurethral resection, HoLEP, or photovaporization of the prostate; robotic waterjet tx; temporary implantable nitinol baskets; drug-coated balloon; water vapor thermal tx; prostatic artery embolization.   ◦ For procedural interventions, discuss possibility of de novo or worsening OAB sx and other adverse events—e.g., transient urge incontinence after HoLEP, worse OAB sx after photoselective vaporization of the prostate. Address persistent/de novo bothersome OAB sx after surgical tx. If pt chooses pharmacotherapy, offer monotherapy w/ antimuscarinic or β3 agonist, or combo tx w/ an α-blocker + an antimuscarinic or β3 agonist. [CR/B]   ◦ If OAB-predominant LUTS: Assess relative contribution of BOO secondary to BPH. Evaluate presence and severity of urinary sx w/ AUA’s Mgmt of LUTS Sx Attributed to BPH guideline.   ◦ While antimuscarinics may slightly ↑ PVR volumes, they don’t seem to be assoc w/ significantly ↑risk of urinary retention in pts w/ coexisting BOO. Discuss retention risk w/ pts w/ ↑PVR values. Antimuscarinics’ effects on pts w/ residual volumes >200 mL aren’t well studied.   ◦ No strong evidence or agreed-upon order in which to initiate monotherapy or combo tx for OAB-predominant LUTS w/ BPH   ◦ RCTs of individual antimuscarinics (e.g., fesoterodine, tolterodine ER) and β3 agonists (e.g., mirabegron) show efficacy for each in pts w/ predominant OAB sx.   ◦ Combo tx w/ an α-blocker (e.g., tamsulosin) + an antimuscarinic or β3 agonist (e.g., mirabegron) improves OAB sx to a significantly greater extent than does an α-blocker alone in pts w/ OAB-predominant LUTS. Telemedicine may be used for f/u visits. [EO] Inadequate response to (or not a candidate for) behavioral and drug tx Assess pharmacotherapy for efficacy and onset of side effects w/in 4-8wk of tx initiation. [EO] If intolerable side effects or inadequate improvement: May offer a different medication in the same class or a medication from a different class. [CP] For pts on antimuscarinics, switching to a β3 agonist may be more tolerable, due to apparently lower rates of common side effects, while maintaining efficacy. If inadequate improvement w/ a single medication: May offer combo tx w/ a medication from a different class—e.g., antimuscarinic + β3 agonist. [CR/B] If inadequate response to noninvasive monotherapy, may combine it w/ ≥1 of the following: behavioral tx, noninvasive tx, pharmacotherapy, minimally invasive therapies. [EO] Combo tx options include:   ◦ TTNS + Kegel exercises + bladder training: significant improvement in women.   ◦ Adding tolterodine ER to combo of PFMT + behavioral changes: overall but nonsignificant improvement in males.   ◦ TTNS + vaginal stimulation + topical estrogen   ◦ Antimuscarinics + PTNS If no improvement: Discontinue 1 or both therapies; pursue other treatments. If incremental but unsatisfactory improvement: May initiate additional therapies. When combining >2 therapies, proceed in stepwise fashion, w/o adding multiple treatments simultaneously. If inadequate response to, or intolerable side effects from, pharmacotherapy or behavioral tx, offer ≥1 of the following: [MR/A] Sacral neuromodulation (SNM)   ◦ Adverse events: surgical revision for pain or infection, device discomfort, lead migration.   ◦ Assoc w/ high immediate and long-term success rates (>50% improvement) in both BTX-naïve pts and in those w/ an inadequate response to or who can’t tolerate BTX Percutaneous tibial nerve stimulation (PTNS)   ◦ ↓ of ~2 voids/day, 1-2 nocturia episodes, and 1-2 urinary incontinence episodes/day vs. baseline Intradetrusor botulinum toxin (BTX) injection   ◦ 100U intradetrusor BTX injection improves OAB sx in male and female pts w/ inadequate response to, or who’ve experienced intolerable side effects from, antimuscarinics and/or β3 agonists.   ◦ Low side-effect profile   ◦ If pt doesn’t experience sx relief w/ β3 agonist, may bypass antimuscarinics and move directly to BTX.   ◦ May offer to pts who’ve declined oral pharmacotherapy   ◦ Offer w/ caution if primarily nocturnal sx. Significant ↓ in nocturia vs. placebo has marginal clinical significance.   ◦ Most-common adverse effects: UTI; incomplete bladder emptying requiring CIC; gross hematuria.   ◦ To r/o UTI, perform sx assessment and UA +/- cx before procedure; active UTI is a contraindication until treated.   ◦ Measure PVR before procedure. Perform BTX injection w/ caution if PVR ≥100-200 mL; account for voided volumes and voiding sx. [CP]   ◦ Long-term need for repeat injections (typically q3-12mo)   ◦ Pts w/ inadequate response to BTX 100U and minimal side effects may be offered BTX 200U, but monitor for adverse effects.   ◦ Techniques that either spare or include the trigone are effective.   ◦ Pts w/ adequate sx relief w/ no UTI or incomplete bladder emptying after BTX injection may opt for telemedicine in the f/u visit, although PVR and UA can’t be easily obtained. If sx have worsened or not adequately improved after intradetrusor BTX injection, obtain PVR. [CP] Evaluate pt ~2wk after initial BTX injection. Chance of UTI is highest 2wk post procedure. Obtain PVR and UA +/- cx. UTI or incomplete emptying may be the reason for lack of sx improvement. If PVR ↑ w/ respect to voided volume (i.e., PVR 100-300 mL), may start CIC, based on voiding/emptying sx or UTI presence. If acute UTI, treat based on AUA/CUA/SUFU Recurrent Uncomplicated UTIs in Women guideline. If pt empties well after 1st BTX injection, may check PVR post procedure for subsequent injections; retention after hx of good emptying is rare. If inadequate response to pharmacotherapy or minimally invasive therapies, may perform urodynamics (UDS) to further evaluate bladder function and exclude other disorders. [CP] May be esp. helpful if suspicious of other diagnoses, e.g., BOO, SUI, acontractile or underactive detrusor that presents w/ OAB sx. If mixed urinary incontinence or unaware incontinence, UDS + voiding diary may give clues on bladder sensation, DO presence and characteristics, volume at which incontinence occurs, and stress leak point pressure. Consider if suspicion of poor bladder compliance. Pts may not respond as well to medical or interventional OAB tx and need surgical procedures (e.g., bladder augmentation) to achieve sx resolution. DO may represent a different OAB phenotype; correlates w/ worse sx and greater QOL impairment. In severely affected pts who haven’t responded to other tx options, may offer bladder augmentation cystoplasty or urinary diversion. [EO] Weigh risks of short- and long-term surgical morbidity, need for CIC (for continent diversions or bladder augmentation), and absence of data on QOL outcomes. Chronic indwelling cath (urethral, suprapubic) recommended only when OAB therapies are contraindicated, ineffective, or no longer desired, and always in the context of shared decision-making. [EO] Urethral cath   ◦ Risks: urethral trauma, including erosion and, in severe cases, urethral loss; significant urinary incontinence; need for reconstructive surgery.   ◦ Regular f/u needed to detect potential signs of urethral trauma   ◦ Increasing the cath size or balloon volume not recommended for incontinence related to cath bypassing or leakage; may exacerbate damage to urethra and sphincters. Optimal mgmt involves comprehensive eval to identify underlying cause. Suprapubic tube (SPT)   ◦ Preferred option, due to ↓likelihood of urethral damage   ◦ Risks: bowel perforation and vascular injury, which can be mitigated w/ routine use of U/S-guided SPT placement; development of granulation tissue; bleeding; cath site erosion; loss of access during cath changes. Complications of both urethral cath and SPT   ◦ Common: cath-assoc UTI; bladder calculi; cath obstruction; bladder spasms; pain; ↓bladder capacity; urine leakage.   ◦ Long-term use assoc w/ ↑hazard ratio for bladder cancer (4.8) vs. matched controls. Bladder cancer–specific death, though rare (0.3% over a median of ~9y), is 8.7-fold higher vs. controls.   ◦ Long-term use assoc w/ small but ↑risk of squamous cell bladder carcinoma that may be secondary to chronic inflammation.