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Dr. Smith and Dr. Cameron discuss the new OAB guideline

Commentary
Video

“Along those lines, we've taken away the traditional step therapy that has dictated overactive bladder care for quite some time,” says Ariana L. Smith, MD, FPMRS.

In this video, Ariana L. Smith, MD, FPMRS, and Anne P. Cameron, MD, FRCSC, FPMRS, discuss the recently released clinical practice guideline on the diagnosis and treatment of patients with idiopathic non-neurogenic overactive bladder (OAB).1 Smith is the director of pelvic medicine and reconstructive surgery and the chief of the section of urology at the University of Pennsylvania in Philadelphia, and Cameron is the vice chair in the department of urology and a professor of urology at the University of Michigan in Ann Arbor.

Video Transcript:

Smith: One of the big changes in the guideline is an emphasis on shared decision-making. With shared decision-making, we educate our patients, we listen to their values and preferences, and we allow, together, them to weigh their options and make a good decision for themselves. Along those lines, we've taken away the traditional step therapy that has dictated overactive bladder care for quite some time. Now, patients are able to get away from that first-, second-, and third-line therapy approach and consider all the options available to them. With this, they can think about what is important to them and what their preference is for therapy.

Cameron: Why we did this is because there is no evidence that treatments are superior if someone has cycled through all these therapies. There's no evidence behind step therapy. So, why do we do this when we do know that shared decision-making actually results in better treatment outcomes?

Smith: Another thing that's new with the guideline is the guideline is applicable to all genders. We now have a section of the guideline that allows us to treat patients who have both BPH and overactive bladder symptoms. We can do that through guideline-based care now. That gives us the opportunity to address the urgency and frequency in a person who has a prostate who traditionally may have only been offered medications like alpha blockers to improve their voiding or something to shrink their prostate. We now can give them the whole menu of options for overactive bladder.

Cameron: Another part of the new guideline that I'm really happy with is addressing comorbid conditions. I think that has been previously ignored. Constipation affects overactive bladder, GSM affects overactive bladder, diuretic use, tobacco abuse. If you treat these conditions, then people's overactive bladder symptoms get better, and they're actually getting the benefit of having the other condition treated.

Smith: Along those same lines, we have a lot of patients who come in with overactive bladder who have comorbidity and are on multiple other medications. Another important part of our guideline is to ensure that patients are being counseled on the risks of anti-muscarinic medications, specifically cognitive dysfunction that can occur on those medications, issues with memory. That's a really important addition to the guideline.

Cameron: Other new parts of the guideline that weren't included would be the new technologies involving electrical stimulation. There's now implantable tibial nerve stimulation that is FDA approved, and there was evidence included for these in the guideline. I think that technology is going to continue to evolve. There's lots of other neurostimulation technology on the way that we can look forward to in the future.

Smith: Speaking of technology, the guideline also includes safe and effective use of telemedicine to provide initial evaluation of patients who have overactive bladder symptoms. So, we may have to defer part of our initial evaluation. We'll have to defer the physical exam and find another way to get a urinalysis, maybe sending the patient to a lab or reviewing some prior lab data, but it really opens up the opportunity to treat more patients, providing more access to care through telemedicine.

Cameron: This is really pragmatic. I mean, this is how people are practicing overactive bladder care right now. What we hope is that people are able to use this with guideline-based care that probably most of us are already doing with our patients and providing better care. Now, what is lacking is our insurance providers haven't caught up yet since the guideline was published last week. So, we hope that insurers will consider this new guideline and this new evidence in being able to cover these necessary treatments for our patients. Because really, the best treatment is the treatment that the patient and the provider come up with for the patient. Again, going through step therapy and trying lower-level therapies to get ultimately what's going to work for the patient is not serving the patient. That takes a long time. So, we really encourage people to use this guideline and we hope insurance will follow suit.

Smith: I think we'll be sending them a lot of copies of the new guidelines.

This transcription has been edited for clarity.

References

1. Cameron AP, Chung DE, Dielubanza EJ, et al. The AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder. J Urol. Published online April 23, 2024. doi:10.1097/JU.0000000000003985

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