The AUA and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction’s guideline for overactive bladder was recently amended to include updates regarding patient factors and treatment selection as well as second- and fourth-line treatments. In this interview, Sandip Vasavada, MD, a member of the guideline amendment panel, discusses the rationale behind the amendment, the role of overactive bladder drugs in the treatment of nocturia, and treatment of refractory OAB. (To read the amended guideline, see bit.ly/oabguideline.) Dr. Vasavada is urologic director, the Center for Female Urology and Reconstructive Pelvic Surgery at Cleveland Clinic. Dr. Vasavada was interviewed by Urology Times Editorial Consultant Gopal H. Badlani, MD, professor of urology, Wake Forest Baptist Medical Center, Winston-Salem, NC.
What prompted the recent amendment to the OAB guideline?
Every time new data comes out, we assess the current guideline to determine whether there is anything we need to add. In this case, the guideline update was done because there was new data regarding second-line therapies, predominantly medication use. Specifically, the data indicated that the use of an anticholinergic in conjunction with a beta-3 agonist is an option for patients who perhaps didn’t get significant relief with either beta-3 agonist or anticholinergic monotherapy.
Does the guideline address the inability to prescribe beta-3 agonists initially, especially in the elderly?
It doesn’t directly address that. There is an ongoing national dialogue on the use of anticholinergics in the elderly especially that concerns its potential adverse effects on cognition. While beta-3 agonists work on a different nerve receptor, the issue of initial prescription also has to do with pharmaceutical coverage, and that is a tougher area to address.
How do you sequence treatment in a drug-naive patient who presents with symptoms of OAB?
Just like any other patient we see with OAB, we still want to go through the pathway sequentially. I think we would all agree that proceeding from least invasive to most invasive therapy is still best. We did keep a little bit of flexibility within this current guideline, but the main point is still starting with behavioral therapies and fluid management as well as pelvic floor exercises and continuing that to the second- and third-line therapies if initial therapies do not work after an acceptable period of time. That’s one of the points we’d like to emphasize.
What is the role of OAB drugs in a patient with predominantly daytime symptoms with minimal nighttime frequency?
They still have a strong role. You don’t have to have a lot of nighttime symptoms to merit the need for overactive bladder drugs, although OAB seems to have a day and night tendency for many. Regardless, some patients seem to have predominantly daytime symptoms. Again, we’d want to determine whether there’s a behavioral factor or something else going on during the day that is creating their overactive bladder. Is there a transient cause or another factor that’s perhaps creating the disparity between day and night? We can target our interventions at some of the behavioral factors in addition to using medications. We wanted to also emphasize this in the guideline.
Do drugs help patients with predominantly sensation-driven frequency?
I think the data would suggest there are some slight improvements, but not as much as we like to believe. The sensory symptoms are oftentimes quite challenging; you’re looking at different scales. Most data is on urge incontinence and frequency as harder endpoints. Still, the hallmark of OAB is urgency, pathologic urgency specifically, and it is still probably best assessed using a variety of validated instruments.