Refractory Overactive Bladder

Abstract

Overactive bladder (OAB) is a prevalent health issue that affects millions of people of all ages around the world. OAB comprises a constellation of symptoms that includes urinary frequency and urgency with or without urgency incontinence and can have a tremendous impact on an individual’s quality of life. The American Urological Association OAB guidelines suggests starting with first- and second-line therapies that include conservative measures (avoidance of dietary bladder irritants and physical therapy) and pharmacotherapy (antimuscarinics or beta-3 agonists), respectively. When first- and second-line therapies are ineffective in providing relief of symptoms, one can consider more advanced therapies such as neuromodulation, onabotulinum toxin A injection of the bladder, and surgical reconstruction of the lower urinary tract. This chapter provides a case-based illustration of the approach to OAB.

Commentary by David E. Rapp, University of Virginia, Department of Urology, Charlottesville, VA, USA

Commentary

• David E. Rapp 

This chapter details the challenges that practitioners often face when treating patients with refractory overactive bladder (OAB). As this chapter highlights, this begins with defining success. Although there are numerous validated questionnaires that can be used to assess patient outcomes, there is no gold-standard questionnaire and great variation exists across providers with respect to questionnaire of choice [24]. Further, outside of patient-reported measures used to assess symptom improvement, it also commonly suggested that ultimately, it is patient satisfaction that may be most important [25].

Accordingly, Dr. Van Kerrebroeck highlights the importance that patient expectation can have on outcomes and patient satisfaction. For this reason, it is not only important to define the degree of improvement that a patient considers sufficient for satisfaction, but also the symptom of primary concern to each patient. Furthermore, it is best to do this in a formal fashion prior to surgery. For example, once defined, this shared outcome goal can be included both in the clinic note and written on educational materials given to patients so as to serve as a reference when discussing outcomes postoperatively.

Optimizing patient satisfaction is critical as we transition into the era of quality care and reimbursement models (value-based purchasing). Indeed, urinary incontinence assessment and treatment planning are both priority measures under the Merit-based Incentive Payment Program (MIPS) in the United States [26]. Further, patient satisfaction and experience surveys (e.g., HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems) are increasingly being used as a metric of care quality and to shape reimbursement. Although such surveys reflect numerous aspects of the overall patient experience, patient satisfaction with treatment outcome no doubt plays a significant role in survey score. Such initiatives highlight the previously discussed importance of defining patient expectations when treating OAB in order to help promote satisfaction.

A second important consideration in this era of health care is cost. This chapter provides a comprehensive discussion of advanced therapies for refractory OAB. Indeed, the introduction of treatments such as botulinum toxin and neuromodulation has allowed urologists to transform the lives of many patients in a minimally invasive fashion. While these advances should be celebrated, we also must learn to utilize these treatments in a cost-effective manner. However, we presently lack detailed evidence-based algorithms to help guide clinical strategy. As Dr. Van Kerrebroeck details, debate exists with respect to choice of initial advanced therapy and also approaches to use if botulinum toxin or neuromodulation fails. Importantly, we need quality studies to help guide these algorithms with focus not only on clinical success but also cost-effectiveness. Although there is emerging evidence to help promote a cost-effective approach [27], much more is needed.

Finally, it is important to stress another critical treatment for refractory OAB – conservative therapy. Certainly, conservative therapies (dietary modification, behavioral therapy, pelvic floor physical therapy) should be exhausted prior to considering advanced therapies. However, they must also serve as important adjunctive approaches to advanced therapies. Far too often, patients consider advanced therapies as rationale to reinstitute behaviors unfavorable to successful bladder management. For this reason, long-term follow-up after advanced therapies can be helpful as an opportunity to not only assess symptom control but also to provide re-education regarding conservative approaches.