Optimizing care for men with overactive bladder, with Keith Xavier, MD

Overactive bladder (OAB) and urge urinary incontinence (UUI) are frequently underrecognized in men despite their significant impact on quality of life, according to Keith Xavier, MD, URPS, a urologist with Urology Partners of North Texas in Arlington, Texas.

In this Q&A, Xavier discusses the importance of increasing awareness of OAB in men and shares his experience using the implantable tibial neurostimulator Altaviva in this patient population, including his approach to patient selection and where the therapy fits within the treatment algorithm. Altaviva was approved by the FDA in September 2025 for patients with UUI based on results from the TITAN 2 pivotal trial, which demonstrated the safety and efficacy of the device in this patient population.¹

Urology Times: What drew you to Altaviva as a treatment option for your male patients with urge urinary incontinence?

Xavier: A lot of men [have] overactive bladder and urge urinary incontinence, but we as urologists tend to forget about that or put it to the side. We're usually more concerned with their prostate issues, which a lot of those men have, but a lot of men end up needing treatment for their overactive bladder and urge incontinence. We've had sacral neuromodulation and Botox injections, but Altavita, an implantable tibial, is a nice alternative option for these men. It's non-surgical [and] you don't have to do any repeat procedures. A lot of men are open to that, so that's given me another tool to treat these men.

Urology Times: How has your patient selection process for Altaviva in men evolved as your experience with the device has grown?

Xavier: I've been doing Altaviva since September. Initially in both male and female patients, I was using it in patients with less severe symptoms and urge incontinence episodes. As with a lot of other procedures, as you get more comfortable with it, you expand your patient population. Now, similar to with female [patients], I do feel comfortable offering it to a wide range of men who have refractory urge incontinence and in men who have [had] their prostate treated. A lot of men don't necessarily want sacral neuromodulation because they don't want surgery or maybe they're not great surgery candidates. I also see that a lot of men do not want intravesical Botox injections, more so than in women. They don't want repeated cystoscopies. I think a lot of men are interested in choosing [Altaviva as an option].

Urology Times: How does your workup for male patients with UUI influence whether Altaviva is the right intervention vs other management approaches?

Xavier: It's important to do diagnostic testing with male patients, more so than in female patients. Men are a little bit more complicated with their prostate enlargement issues as they get older, so I do think diagnostic testing is very helpful. Urodynamics is especially helpful to distinguish if men have bladder outlet obstruction, overactive bladder, or both. Based on the predominant symptoms, do they have more flow type issues or more storage issues? Overactive bladder questionnaires can also be helpful.

A lot of times in men, treating the prostate is the first thing we'll do, whether that's with medications or with the different BPH procedures that we have available to us. But a lot of men will still have storage issues or overactive [bladder] issues. Some men may develop them more after a BPH procedure, and that's where I think [we should consider] the third-line overactive bladder treatment options. Once again, some men may not be interested in sacral neuromodulation or Botox injections. We as clinicians may even be hesitant to do [Botox], especially men who have had prostate issues; we worry about Botox leading to more retention issues. Then you have Altaviva, which is a minimally invasive, efficient, reproducible, quick procedure done with local. If you look at the TITAN 2 study, not many men were in that trial, but it was a very large trial. We know that [Altaviva is] efficacious in patients with moderate to severe urge incontinence and overactive bladder. You can [use these data] to offer it in men, and a lot of men are willing to give it a shot.

Urology Times: How has Altaviva performed in men who have already undergone a prostate surgery or radiation?

Xavier: Those are the majority of the men that I've tried Altaviva on. We see a lot of men who have had [the] outlet [issues taken care] with a BPH procedure, but a lot of those men still have bothersome storage symptoms: urge incontinence, overactive bladder, the frequency/nocturia symptoms. Those are men who are great candidates for not only third-line treatment options but implantable tibial [neuromodulation] such as Altaviva. I see a lot of men who are post-prostate cancer treatment, and a lot of those men have had a radical prostatectomy, but then have had subsequent adjuvant radiation, and a lot of those men will develop overactive bladder symptoms—urge incontinence and nocturia—and they're very unhappy. Medications can help, but sometimes meds are not the answer. That's where you could start looking at other options. Sacral neuromodulation is a reasonable option in these men, but it's nice to have implantable tibials such as Altaviva as another option. I think Botox is a little tricky and maybe not as ideal as some of the other treatment options for these men.

Urology Times: What has the implantation experience looked like in male patients specifically, and how does it differ from the female procedure?

Xavier: The implant experience is very similar in men and women. It's a procedure that you could do in an [ambulatory surgical center] or in an outpatient hospital setting with local anesthesia. The procedure is fairly efficient and reproducible. In my experience, men and women feel the local for a little bit, and after that, they don't feel a lot, especially if you've if you've numbed them up well. It's also nice to be able to start the therapy right after the procedure. You want to make sure men are an appropriate candidate—examining their foot/ankle area, making sure they don't have too much edema, venous stasis ulcers, or any prior hardware in the foot and ankle area. That's going to be the same with men and women.

Urology Times: What has surprised you most about outcomes and quality of life responses in your male patients receiving Altaviva?

Xavier: Altaviva is FDA approved for urge-related incontinence. A lot of men who have urge incontinence also have bothersome urinary frequency, especially nocturia. What I've been surprised [by] in my experience is a lot of these men will come in and tell me, "I'm not waking up nearly as much at night," or "I'm only waking up once or less at night." A lot of these men are happy in terms of the frequency/nocturia aspect of things, and not just the incontinence aspect.

Urology Times: How do you identify and engage men who are living with UUI but have not yet sought care?

Xavier: That always has been and is still a challenge in getting those men to come in and be evaluated. It’s a challenge to get the word out to men that there are treatment options. Only about a quarter of men and women with urge incontinence and overactive bladder seek health care or even mention it to their doctor. A lot of times this is the primary care doctors. Educating the primary care doctors is something that's helpful, but it is hard to do. They're treating heart disease, diabetes, [and] all these life-threatening conditions, but I do think we [should] get the word out to the primary care physicians to ask some of the quality-of-life questions, such as "Are you happy with your urination?”

When we as urologists see men for different reasons, [we should be] asking these questions as well. Using that opportunity to make sure you're being thorough and addressing their needs can help get men the treatment that they need for this condition. As men get older, they're getting [UUI] just like women do. Maybe it's a little bit later in life, but a lot of men, in addition to BPH, will develop OAB.

Urology Times: Where does Altaviva fit within your treatment algorithm for male patients, and are there any patients where you're moving it earlier than traditional stepwise management would suggest?

Xavier: Offering it earlier in the algorithm is reasonable. This is something I am trying to do more of as I see more female and male patients. As I mentioned before, it's a minimally invasive procedure that is done with local that's very efficient with not many [adverse] effects.

If you look at the TITAN 2 trials, it is a safe and efficacious procedure, so I do think moving it earlier on in the algorithm in men is reasonable. Roughly 30% of the patients in the TITAN 2 trial had tried previous third-line overactive bladder treatment. I would characterize them as a moderate to severe population overall—a relatively overactive bladder/wet population. Those patients did well with the implant, so I think you could consider Altaviva as an option in these patients.

Urology Times: Is there anything else that you wanted to add?

Xavier: We need to think more about overactive bladder in men. It is not just an issue in women. That's going to be the majority of the patients with overactive bladder, but we can't forget about men. If these men have outlet issues, BPH issues, prostate obstruction issues, it's very reasonable to address that first, and a lot of men will do well and be happy. But up to 30% to 50% of those men will still have the storage/OAB/urge incontinence issues. Urologists are fairly aggressive in treating BPH issues because we have so many different tools. I do think we have that with overactive bladder now with sacral neuromodulation, Botox, and implantable tibial stimulation such as Altaviva.

Any men we see with urinary voiding symptoms, we have to keep OAB in the back of our mind. If you can offer those patients diagnostic testing, such as urodynamics, I do think that can help delineate OAB vs BPH. A lot of those men will have both, but I think knowing that and being able to counsel men on that is important. That's something we're seeing more of, and we [need to] keep an open mind for men with OAB.

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