What is the role of OAB drugs in nocturia?
In solitary nocturia, unless there’s another cause, as often there is—fluid overload and other background factors—it can still have a role but probably less. But you have to be very careful, as anticholinergics especially can have a fair amount of side effects. We have to be considerate of that in a nocturia patient, where there may be another cause, whether it’s fluid overload, obstructive sleep apnea, edema, or any number of other causes. I would do my best to try to treat all of those attending causes before proceeding with an anticholinergic or for that matter a beta-3 agonist.
How do you define refractory overactive bladder?
I don’t believe it’s ever been formally defined, but typically a patient with refractory overactive bladder is one who’s tried and failed first- and second-line therapy and/or is intolerant to second-line therapy. Those patients then go on to the so-called third-line therapies. Again, I don’t think it’s ever been truly defined in clinical guidelines.
There are a plethora of treatments for refractory overactive bladder: percutaneous tibial nerve stimulation, sacral neuromodulation, and onabotulinum toxin. How do you sequence these treatments? Do you use an algorithm?
I don’t know if it directly falls into an algorithm because every patient has unique factors that might dictate a reason why one would be more apt to undergo one therapy over another. You have to individualize each patient scenario. Less often, determining which therapy is best for a patient would come down to a “coin flip.”
There are data suggesting that patients who fail neuromodulation then switch to Botox, and vice versa. Is that your experience?
When we ran a randomized trial, it was hard to enroll patients for whom determination of treatment came down to a coin flip. Oftentimes, there’s a specific patient factor that will guide the clinician’s choice of treatment. If a patient has bowel issues, perhaps you may lean more toward neuromodulation. For a neurogenic patient, you might tailor your recommendations toward onabotulinumtoxinA injections. If a patient doesn’t need anything more invasive therapeutically and is willing to make frequent visits, then you may consider tibial nerve stimulation.
As we learn more about OAB, it becomes apparent that particularly in the elderly, there are so many different factors to look at before you start treating the patient. What suggestions do you have for evaluating management options in this population?
I’d see if there’s anything else more easily remediable. Is there another factor? Is it stress incontinence? Is it prolapse, which often co-exists for some of these patients? Is it vaginal atrophy, which can have an effect in some patients in terms of overactive bladder symptomatology? Is it a fluid factor? If you work with your primary care colleagues to articulate what the real issue is leftover for the overactive bladder alone, you can tailor your therapy most appropriately.
Is there anything else you feel urologists should know about the updated guideline?
One of the important things we brought out with this new guideline is that one does not necessarily need to progress stepwise in order: one, two, three, four. We did codify the fourth line, which includes augmentation cystoplasty, urinary diversion, and catheter placement. The patient shouldn’t just be stopped at third-line therapy. There are, in selective situations, opportunities to deliver care with any of these slightly more invasive therapies. Perhaps someone may be cognitively at risk for using a medication, so we might consider tibial nerve stimulation earlier in the treatment pathway. Based on the guideline and expert opinion, we felt that that’s an option we wanted to leave our providers with.
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