Overactive Bladder – clinical guidance

V2.1 Last reviewed: Jan 2023 Review date: Jan 2026

Overactive Bladder Clinical Guideline

Overactive Bladder (OAB) is urgency with or without urge incontinence, usually with frequency and nocturia.
Urge Urinary Incontinence is involuntary leakage of urine associated with urgency.
Mixed Urinary Incontinence is involuntary leakage of urine associated with urgency and also exertion, sneezing
or coughing.

Initial assessment: Refer to Urology / Urogynaecology if:

• Full history. • Visible haematuria.
• Frequency/Volume Chart (bladder diary). • Recurrent or persisting UTI associated with
• Urinalysis. haematuria in patients aged 40 years and older.
• Measurement of post-void residue. • Microscopic haematuria in patients aged >50
years.
Men • Suspected urinary tract malignancy or raised
• May include PR examination, PSA test, flow- PSA.
rate measurement. • Persisting bladder or urethral pain.
• Consider referral to Prostate Assessment Clinic. • Suspected neurological disease.
• Significant voiding difficulty.
Women • Suspected urogenital fistulae.
• Assessment of pelvic floor. • Previous continence/pelvic cancer surgery.
• Examine for vaginal atrophy and prolapse. • Previous pelvic radiation or chemotherapy

Conservative management
• All patients should have conservative treatment prior to commencement of medical therapy or referral to secondary care.
• Patients can be referred to the District Nurse Continence Clinic or the Continence Advisory Service for assessment and
conservative treatment.
• Should include patient education, lifestyle advice, bladder training and pelvic floor exercises.
• Manage patient’s environment (e.g., commode in place).
• Review medications (e.g., diuretics, anti-hypertensives, anti-depressants, antimuscarinics etc).
Post-menopausal
Post-menopausal womenwomen - Intravaginal oestrogens are recommended for women with vaginal atrophy and OAB
Intravaginal
symptoms (NICE 2006). are recommended for women with vaginal atrophy and OAB symptoms (NICE 2006).
oestrogens
E.g.,
E.g., estriol
estriol 0.1%
0.1% cream (Ovestin)(£4.45/15g)
cream (Ovestin) (£4.45/15g)or
orVagirux
Vagirux vaginal
vaginaltabs
tabs(£11.34/24).
(£11.34/24). Use
Usedaily
dailyfor
for22weeks,
weeks,then
thentwice
twice
weekly for 3 months.
weekly for 3 months.

Lifestyle
Lifestyleadvice
advice Bladder
Bladder Retraining
Retraining -- Minimum
Minimum of
of 6
6 weeks
weeks (NICE
(NICE 2006).
2006).
Modify
Modify highor
high orlow
lowfluid
fluidintake.
intake.
Healthy
Healthy eating, avoidcaffeine,
eating, avoid caffeine,reduce
reducealcohol
alcoholintake.
intake. Pelvicfloor
Pelvic floorexercises
exercises
Smoking cessation.
Smoking cessation.
Weight Trial for at least 33months
Trial for at least monthssupervised
supervisedpelvic
pelvicfloor
floormuscle
muscle
Weightloss
lossand
andexercise,
exercise,healthy
healthyeating.
eating. training by continence advisor or physiotherapist.
Constipation advice. training by continence advisor or physiotherapist.
Constipation advice.

Improved
Review at 3 months Continue

Ongoing problems

Medication therapy (See flowchart below)

Page 1 Author: R Parkinson. Ratified by Nottinghamshire APC Jan 2023

Overactive Bladder – clinical guidance
V2.1 Last reviewed: Jan 2023 Review date: Jan 2026

Overactive Bladder Clinical Guideline – Medication Therapy

Conservative management (as above)

All patients should have conservative treatment prior to commencement of medical therapy or referral to secondary care.
Post-menopausal women - Intravaginal oestrogens are recommended for women with vaginal atrophy and OAB symptoms.
E.g., estriol 0.1% cream (Ovestin) or Vagirux vaginal tablets. Use daily for 2 weeks, then twice weekly for 3 months.

YES Are anticholinergics contraindicated?

(e.g., myasthenia gravis, narrow angle glaucoma, Sjögren-syndrome, cognitive impairment).

No
First Line: Generic anticholinergics
NICE NG123: when offering antimuscarinics “take account of other existing medication affecting total anticholinergic load”.
Consider calculating the anticholinergic burden score using the ACB calculator.
These medicines can potentially cause an increase in falls risk. See Medicines and Falls Chart
Anticholinergic medications have similar efficacy and side-effect profiles, therefore select one with the lowest acquisition cost.
If the initial choice is not effective, or has troublesome side effects, consider lowering dose/strength, or a trial of an
alternative medicine from the first line options.
Medicine Strength Dose Cost/28days (Dec 22)
Oxybutynin IR* 2.5mg Twice a day £1.52
Oxybutynin IR* 5mg Twice a day (titrate to three times a day as tolerated) £1.41 - £2.12
Tolterodine* 2mg Twice a day £3.06
Solifenacin 5-10mg Once a day £3.04 - £3.56
Trospium 20mg Twice a day £4.93
*Do not offer oxybutynin or tolterodine to frail, elderly patients.
If swallowing difficulties or unable to tolerate solid formulations
1st: Oxybutynin patches 36mg (3.9mg/24hrs) Apply twice weekly £27.20
2nd: Solifenacin liquid 5-10mg Once a day £27.62 - £55.24

Improved
Review at 4-8 weeks Continue
Troublesome side effects/lack of efficacy

Second line medication β-3 agonist (non-anticholinergic):

Mirabegron 50mg MR tablet once a day (£27.07).
(contra-indicated in severe uncontrolled hypertension systolic ≥ 180 or diastolic ≥110mmHg)
Reduce to 25mg once a day if moderate hepatic impairment or eGFR <30ml/min.
Blood pressure should be taken before starting treatment and monitored regularly during treatment.

Troublesome side effects Improved

Review at 4-8 weeks Continue

Lack of efficacy

Third line medication combination:

Mirabegron MR tablet once a day + solifenacin once a day
(Unless troublesome side effects on either monotherapy)

Improved
Review at 4-8 weeks Continue
Troublesome side effects/lack of efficacy

Consider referral to Urology/Urogynaecology

Page 2 Author: R Parkinson. Ratified by Nottinghamshire APC Jan 2023