Third‐line therapy for overactive bladder in the elderly: Nuances and considerations

Abstract

Introduction: Overactive bladder (OAB) disproportionally affects older adults in both incidence and severity. OAB pharmacotherapy is often problematic in the elderly due to polypharmacy, adverse side effect profiles and contraindications in the setting of multiple comorbidities, and concerns regarding the risk of incident dementia with anticholinergic use. The burden of OAB in older patients coupled with concerns surrounding pharmacotherapy options should motivate optimization of nonpharmacologic therapies in this population. At the same time, several aspects of aging may impact treatment efficacy and decision-making. This narrative review critically summarizes current evidence regarding third-line OAB therapy use in the elderly and discusses nuances and treatment considerations specific to the population. Methods: We performed an extensive, nonsystematic evidence assessment of available literature via PubMed on onabotulinumtoxinA (BTX-A), sacral neuromodulation, and percutaneous tibial nerve stimulation (PTNS) for OAB, with a focus on study in elderly and frail populations.Results: While limited, available studies show all three third-line therapies are efficacious in older populations and there is no data to support one option over another. BTX-A likely has a higher risk of urinary tract infection and retention in older compared to younger populations, especially in the frail elderly. PTNS incurs the lowest risk, although adherence is poor, largely due to logistical burdens. Conclusion:Advanced age and frailty should not preclude third-line therapy for refractory OAB, as available data support their efficacy and safety in these populations. Ultimately, treatment choices should be individualized and involve shared decision-making.

Role of Urological Botulinum Toxin-A Injection for Overactive Bladder and Voiding Dysfunction in Patients with Parkinson’s Disease or Post-Stroke

“…Usually, intradetrusor injection of BoNT-A for OAB is classified as the third-line option among all OAB therapies [ 6 ]. Meanwhile, first-line management includes behavior therapies and lifestyle modifications followed by pharmacotherapy as second-line therapy [ 7 ].…”

“…Meanwhile, first-line management includes behavior therapies and lifestyle modifications followed by pharmacotherapy as second-line therapy [ 7 ]. Nevertheless, mainstream pharmacotherapy of OAB, which includes antimuscarinics and β3 agonists, is often problematic in older adults [ 6 ]. Constipation, dry mouth, blurred vision, and cognitive impairment are common adverse effects of antimuscarinics.…”

“…Constipation, dry mouth, blurred vision, and cognitive impairment are common adverse effects of antimuscarinics. Furthermore, researchers have reported a strong association between the use of antimuscarinics and risk of incident dementia [ 6 ]. Hence, of particular concern in elderly PD or post-stroke patients, procedural interventions (i.e., third-line therapies) must be optimized in older patients with motor symptoms, such as using BoNT-A injection, sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS).…”

Management of complex OAB patients: A call to action

“…In this Special Issue, we present a collection of review articles that thoughtfully span the most complex issues faced by both patient and practitioner as it relates to diagnosis, shared decision making, therapy, and longterm management with proposed solutions by experts in the field for some of the most challenging OAB populations. 8 We provide a pragmatic approach to shared decision making and the tools to accomplish this in the review by Paudel and Lane. 9 The most clinically complex patients are those with overlapping lower urinary tract conditions, hence these are discussed thoroughly in Shapiro et al, 10 where the intersection of OAB and prostatic enlargement are explored.…”

“…In this Special Issue, we present a collection of review articles that thoughtfully span the most complex issues faced by both patient and practitioner as it relates to diagnosis, shared decision making, therapy, and long‐term management with proposed solutions by experts in the field for some of the most challenging OAB populations 8 . We provide a pragmatic approach to shared decision making and the tools to accomplish this in the review by Paudel and Lane 9 .…”