title: Refractory overactive bladder: Beyond oral anticholinergic therapy.
abstract: OBJECTIVE
  In this review, we discuss the treatment of refractory overactive bladder (OAB) that has not adequately responded to medication therapy and we propose an appropriate care pathway to the treatment of OAB. We also attempt to address the cost of OAB treatments.
  
  
  METHODS
  A selective expert review of the current literature on the subject of refractory OAB using MEDLINE was performed and the data is summarized. We also review our experience in treating refractory OAB. The role and outcomes of various treatment options for refractory OAB are discussed and combined therapy with oral anticholinergics is explored. Emerging remedies including intravesical botulinum toxin injection and pudendal neuromodulation are also reviewed, along with conventional surgical options.
  
  
  RESULTS
  In general behavioral therapy, pelvic floor electrical stimulation, magnetic therapy and posterior tibial nerve stimulation (PTNS), have shown symptom decreases in 50-80% of patients with OAB. Depending on the study, combination therapy with oral anticholinergics seems to improve efficacy of behavioral therapy and PTNS in approximately 10-30%. In multicenter, long-term randomized controlled trials, sacral neuromodulation has been shown to improve symptoms of OAB and OAB incontinence in up to 80% of the patients treated. Studies involving emerging therapies such as pudendal serve stimulation suggest that there may be a 15-20% increase in efficacy over sacral neuromodulation, but long-term studies are not yet available. Another emerging therapy, botulinum toxin, is also showing similar success in reducing OAB symptoms in 80-90% of patients. Surgical approaches, such as bladder augmentation, are a last resort in the treatment of OAB and are rarely used at this point unless upper tract damage is a concern and all other treatment options have been exhausted.
  
  
  CONCLUSIONS
  The vast majority of OAB patients can be managed successfully by behavioral options with or without anticholinergic medications. When those fail, neuromodulation or intravesical botulinum toxin therapies are successful alternatives for most of the remaining group. We encourage practitioners responsible for the care of OAB patients to gain experience with these options. More research is needed to assess the cost-effectiveness of various OAB treatments.
authors.affiliation: Center for Continence Care and Female Urology, Metro Urology Specialists, 2550 University Avenue West, Suite 240N, St. Paul, MN 55114.
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Glinski
authors.forename: Steven
authors.initials: S
authors.lastname: Siegel
references.citation: Urologe A. 2003 Jun;42(6):819-22
references.pmid: 12851774
references.citation: BJU Int. 2003 Jan;91(1):54-60
references.pmid: 12614251
references.citation: J Urol. 2001 Apr;165(4):1193-8
references.pmid: 11257669
references.citation: Am J Obstet Gynecol. 1948 Aug;56(2):238-48
references.pmid: 18877152
references.citation: Eur Urol. 2006 Mar;49(3):519-27
references.pmid: 16413656
references.citation: Br J Urol. 1987 Jun;59(6):526-8
references.pmid: 3690182
references.citation: J Urol. 2000 Jun;163(6):1849-54
references.pmid: 10799197
references.citation: Urol Clin North Am. 2005 Feb;32(1):109-12
references.pmid: 15698883
references.citation: J Am Med Assoc. 1951 Jul 7;146(10):915-7
references.pmid: 14841055
references.citation: Neurourol Urodyn. 1995;14(1):11-23
references.pmid: 7742844
references.citation: Urology. 2004 Mar;63(3):461-5
references.pmid: 15028438
references.citation: Neurourol Urodyn. 2005;24(4):305-9
references.pmid: 15977260
references.citation: Urology. 1997 Dec;50(6):934-40
references.pmid: 9426726
references.citation: Neurourol Urodyn. 2007;26(1):19-28; discussion 36
references.pmid: 17078071
references.citation: J Urol. 1990 Apr;143(4):671-8
references.pmid: 2179579
references.citation: Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005429
references.pmid: 16034974
references.citation: JAMA. 2002 Nov 13;288(18):2293-9
references.pmid: 12425706
references.citation: Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005654
references.pmid: 16437536
references.citation: BJU Int. 2006 Mar;97(3):547-50
references.pmid: 16469023
references.citation: J Urol. 2006 Mar;175(3 Pt 1):835-41
references.pmid: 16469561
references.citation: J Urol. 1996 Jan;155(1):127-30
references.pmid: 7490809
references.citation: Acta Obstet Gynecol Scand. 1959;38:487-502
references.pmid: 13852819
references.citation: Tech Urol. 2001 Jun;7(2):126-32
references.pmid: 11383990
references.citation: JAMA. 1998 Dec 16;280(23):1995-2000
references.pmid: 9863850
references.citation: Br J Nurs. 2002 Apr 25-May 8;11(8):560-5
references.pmid: 11979209
references.citation: J Urol. 2001 Jan;165(1):15-9
references.pmid: 11125353
references.citation: BJU Int. 2006 May;97(5):1035-8
references.pmid: 16643487
references.citation: Eur Urol. 2001 Jan;39(1):101-6
references.pmid: 11173947
references.citation: Scand J Urol Nephrol. 2005;39(3):230-3
references.pmid: 16118096
references.citation: J Urol. 2002 Sep;168(3):1044-7
references.pmid: 12187219
references.citation: J Urol. 2006 Jul;176(1):177-85
references.pmid: 16753396
references.citation: Acta Obstet Gynecol Scand Suppl. 1998;168:22-4
references.pmid: 9744785
references.citation: Eur J Obstet Gynecol Reprod Biol. 1995 Nov;63(1):27-30
references.pmid: 8674561
references.citation: J Am Geriatr Soc. 1991 Aug;39(8):785-91
references.pmid: 2071809
references.citation: Urol Clin North Am. 2005 Feb;32(1):89-99
references.pmid: 15698881
references.citation: Mol Med Today. 1996 Oct;2(10):418-24
references.pmid: 8897436
references.citation: J Urol. 2005 May;173(5):1644-6
references.pmid: 15821527
references.citation: J Am Geriatr Soc. 2000 Apr;48(4):370-4
references.pmid: 10798461
references.citation: Br J Urol. 1967 Feb;39(1):3-12
references.pmid: 5336762
references.citation: Microbiol Immunol. 1995;39(3):161-8
references.pmid: 7603360
references.citation: J Urol. 2005 Nov;174(5):1873-7; discussion 1877
references.pmid: 16217327
references.citation: J Urol. 1999 Aug;162(2):352-7
references.pmid: 10411037
references.citation: Neurourol Urodyn. 2005;24(7):643-7
references.pmid: 16178000
references.citation: Urology. 2004 Jun;63(6):1071-5
references.pmid: 15183952
references.citation: J Urol. 1996 Nov;156(5):1744-7
references.pmid: 8863585
references.citation: Neurourol Urodyn. 2003;22(3):227-32
references.pmid: 12707873
references.citation: Tech Urol. 1995 Winter;1(4):181-7
references.pmid: 9118389
references.citation: J Urol. 1989 Aug;142(2 Pt 2):505-8; discussion 520-1
references.pmid: 2746767
references.citation: Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(1):40-3
references.pmid: 11999205
references.citation: Mayo Clin Proc. 2003 Jun;78(6):687-95
references.pmid: 12934777
references.citation: Urol Clin North Am. 2005 Feb;32(1):71-8, vii
references.pmid: 15698879
references.citation: Urology. 2000 Dec 4;56(6 Suppl 1):87-91
references.pmid: 11114569
references.citation: JAMA. 1991 Feb 6;265(5):609-13
references.pmid: 1987410
references.citation: Neurourol Urodyn. 2005;24(3):226-30
references.pmid: 15825153
references.citation: Am J Manag Care. 2005 Jul;11(4 Suppl):S121-9
references.pmid: 16161385
references.citation: Urol Clin North Am. 2005 Feb;32(1):11-8
references.pmid: 15698871