The OAB Treatment Landscape and How to Choose a Treatment

Overactive bladder (OAB) is one of the most prevalent and clinically impactful conditions encountered in urologic practice. Steven Bernstein, MD, a urologist with more than 3 decades of experience whose practice for the past 17 years has focused exclusively on female voiding dysfunction, sees approximately 500 new bladder patients annually, a substantial proportion of whom present with OAB. He emphasizes that in its most severe forms, OAB can remove patients from normal daily activities and that effective, sustainable long-term management is both a clinical imperative and an attainable goal.

The treatment algorithm for OAB in Bernstein's practice begins with comprehensive behavioral modification, including attention to fluid intake, caffeine consumption, and optimization of underlying medical comorbidities such as poorly controlled diabetes or fluid overload from heart failure. When pharmacotherapy is warranted, anticholinergics are typically the preferred first agent in drug-naive patients, with beta-3 agonists often limited by payer restrictions. Patients who have not achieved adequate symptom control after behavioral and pharmacologic interventions are candidates for third-line therapy, at which point neuromodulation and procedural options enter the discussion.

Among available third-line options—sacral neuromodulation, percutaneous tibial nerve stimulation, and onabotulinumtoxinA ([onabotA, Botox)—Bernstein describes a stepwise clinical evolution in his practice. He found tibial nerve stimulation to be insufficiently efficacious and sacral neuromodulation, although highly effective, to carry a high patient burden in terms of surgical procedures, device management, and potential complications. After FDA approval approximately 13 years ago, onabotA proved to be comparably effective with a more favorable procedural profile, and Bernstein's subsequent work has centered on further reducing the procedural burden while maintaining efficacy—with the goal of improving patient experience and long-term persistence on therapy.