UC Irvine
UC Irvine Previously Published Works
Title
Clinical Pathways of Third-Line Treatment of Overactive Bladder in the Elderly
Permalink
https://escholarship.org/uc/item/9v36194j
Journal
Current Bladder Dysfunction Reports, 10(4)
ISSN
1931-7212
Authors
Farhan, B
Ghoniem, G
Publication Date
2015-12-01
DOI
10.1007/s11884-015-0341-4
Peer reviewed
eScholarship.org Powered by the California Digital Library
University of California
1 23
Current Bladder Dysfunction Reports
ISSN 1931-7212
Curr Bladder Dysfunct Rep
DOI 10.1007/s11884-015-0341-4
Clinical Pathways of Third-Line Treatment
of Overactive Bladder in the Elderly
Bilal Farhan & Gamal Ghoniem
1 23
Your article is protected by copyright and all
rights are held exclusively by Springer Science
+Business Media New York. This e-offprint is
for personal use only and shall not be self-
archived in electronic repositories. If you wish
to self-archive your article, please use the
accepted manuscript version for posting on
your own website. You may further deposit
the accepted manuscript version in any
repository, provided it is only made publicly
available 12 months after official publication
or later and provided acknowledgement is
given to the original source of publication
and a link is inserted to the published article
on Springer's website. The link must be
accompanied by the following text: "The final
publication is available at link.springer.com”.
GERIATRIC BLADDER DYSFUNCTION (GM GHONIEM, SECTION EDITOR)
Clinical Pathways of Third-Line Treatment of Overactive
Bladder in the Elderly
Bilal Farhan
1
& Gamal Ghoniem
1
#
Springer Science+Business Media New York 2015
Abstract Overactive bladder (OAB) is a syndrome of urinary
urgency, usually accompanied by frequency, nocturia, and
sometimes urinary urgency incontinence . There are many
guidelines for the OAB treatment which are constructed on a
stepwise fashion starting from the least invasive to the more
invasive therapy. The emergence of third-line therapy (AUA/
SUFU guidelines) has resulted in significant decrease of more
invasive surgery and improved patients’ quality of life. The
aim of a clinical pathway is to improve the quality of care,
reduce risks, increase patient satisfaction, and increase the
efficiency in the use of resources. The available options for
the third-line OAB treatments include intravesical injection of
botulinum toxin A, percutaneous tibial nerve stimulation
(PTNS), and sacral nerve stimulation (SNS). The available
evidence confirms that all three treatment approaches are well
tolerated and effective, although only botulinum toxin type A
(BoNTA) and SNS can achieve nearly a cure of urgency urinary
incontinence (UUI). The choice among the different third-line
treatment depends on patient preference, availability, and local
expertise. The application of these pathways can improve in-
continence care by letting physicians adequately communicate
with patients and select individualized therapy at an early stage
especially for elderly patients.
Keywords Overactivebladder
.
Clinicalpathways
.
Third line
treatment
.
Onabotulinum toxin A
.
Sacral neuromodulation
.
Percutaneous tibial nerve stimulation
Introduction
Idiopathic overactive bladder (I-OAB) is defined by the Inter-
national Continence Society (ICS) as symptom complex of
Burinary urgency that is frequently accompanied by urinary
frequency (voiding eight or more times in a 24-hour period)
and nocturia (awakening two or more times at night to void),
with or without urgency urinary incontinence (UUI), in the
absence of a urinary tract infection or other obvious
pathology^ [1]. Symptoms may or may not be associated with
detrusor overactivity (DO) [2–4]. Patients with neurologic
disorders often experience voiding dysfunction. When this
voiding dysfunction is consistent with OAB, it is termed neu-
rogenic overactive bladder (N-OAB) [5]. OAB is a common
chronic condition with its prevalence increases with age in
both women and men, and it should not be considered as part
of normal aging process [6–8].
OAB has a significant burden for patients and healthcare
providers such as negative impact on the social, physical,
psychological, financial, and sexual aspects of quality of life
but generally do not affect survival [9].
In general, a clinical pathway is a structured method for the
patient-care management of a well-defined group of patients
during a well-defined period of time. A clinical pathway clear-
ly states the goals and key elements of care based on evidence-
based medicine (EBM) guidelines, best practice, and patient
expectations. The aim of a clinical pathway is to improve the
quality of care, reduce risks, increase patient satisfaction, and
increase the efficiency in the use of resources. This includes
facilitating the communication and coordinating roles an d
This article is part of the Topical Collection on Geriatric Bladder
Dysfunction
* Gamal Ghoniem
gghoniem@uci.edu
Bilal Farhan
farhanb@uci.edu
1
Department of Urology, University of California, Irvine, 333 City
Blvd. W est, Ste 2100, Orange, CA 92868, USA
Curr Bladder Dysfunct Rep
DOI 10.1007/s11884-015-0341-4
Author's personal copy
sequencing the activities of the multidisciplinary care team,
patie nts, and their relat ives. It also requires documenting,
monitoring, and evaluating variances and providing the nec-
essary resources and outcomes.
This article may help to provide a practical clinical pathway
regarding the third-line treatment for the elderly population
who suffer from refractory lower urinary tract symptoms.
The application of these pathways can improve incontinence
care by letting physicians to adequately communicate with
patients and select individualized therapy at early stage espe-
cially for elderly patients. This is a patient-centeric approach
that improves efficacy of treatment and quality of life and
safety. Keeping patients informed of the plan of care and on
schedule improves their compliance and potentially eliminates
unnecessary testing and achieves cost savings. Also, by hav-
ing a clear pathway communicated to the patient can gain
early acceptance of third-line therapies and avoid the high
drop-out noticed with medical therapy.
The treatment of OAB as recommended by the Internation-
al Consultation on Incontinence (ICI) and AUA/SUFU [10••,
11] are as follows:
First-line therapy: First-line treatments include conserva-
tive measures such as adjustment of fluid habits, review
of drug treatment, timed voiding, bladder retraining, and
pelvic floor muscle therapy. Behavioral therapies and ed-
ucation should be offered first; starting antimuscarinic
therapies at the same time as beha vior therapies may
prove clinically beneficial. This line should be offered
to all patients.
Second-line therapy: Pharmacotherapy for minimum
3 months with either antimuscarinics (extended-release
preparations should be used i nstead of immediate-
release preparations w hen possible) or oral beta-3
adrenoceptor agonist (mirabegron) should be offered
too. Despite the proven efficacy of phar mac othe rapy
treatment, it is difficult to predict the response in the in-
dividual patient, the adverse effects, and lack to adher-
ence for long period, especially for elderly Bfrail^ patients
[12, 13], who should be use with caution as they have a
lower therapeutic index and higher adverse effects (AE)
such as dizziness, dry mouth, blurred vision, and consti-
pation and the effects of multiple medications should be
considered [10••]; the elder Bfrail^ canbedefineasBelder
person who have combining impaired physical activity,
balance, muscle strength, cognition, and nutrition.^
Third-line therapy: Intradetrusor botulinum toxin type A
(BoNTA) and neuromodulation therapies such as sacral
neuromodulation (SNM) o r percutaneous tibial nerve
stimulation (PTNS) for carefully selected patients with
severe refractory OAB symptoms or those who are not
respond to or don not tolerate the second-line therapy and
are willing to undergo a surgical procedure [10••].
The AUA/SUFU guidelines state that after attempting to
treat OAB for 4 to 8 weeks with medications, taking the step
towards third-line therapy is worthwhile and justified.
Third-Line OAB Treatment
General Principle
The importance of understanding patient expectations,
goals, and satisfaction is increasingly recognized as an
important element in the decision to treat OAB. For
either I-OAB or neurogenic detrusor overactivity (N-
OAB), eliciting patient p erceptions and sharing the best
available evidence with relevant options are important in
achieving patient satisfaction [14•, 15]. Typically, when
the patient goals are defined, outcomes should be cor-
related with relief of symptom(s), patient satisfaction,
and goal achievement expectations as a result of
treatment.
We believe that the approach treatment to the patient with
OAB in the standard step-wise algorithm pathway is reason-
able (Fig. 1), but in some occasions may subject patients to
unnecessary cost and delay in treatment. The general principle
for pharmacotherapy of the elderly patient is to start with a low
dose and increase it slowly, depending on the agent’spharma-
cokinetics and pharmacodynamics and adverse effects.
Treatments of OAB at early stage may help to improve
patient care and minimize overall use of healthcare re-
sources. There is considerable evidence of delay in diag-
nosis, which may be related to embarrassment, belief that
certain bladder symptoms as normal aging process, and
assumption that will get little benefits with the treatment.
In addition, failure to adhere to medical therapy due to
lack of res ponse or adverse effects of pharmacotherapy
usually leads to frustration and abandoning of medica-
tions. The inadequate follow-up after treatment with poor
communication between patients and physician has been
identified as important factor to non-adherence [16]. It has
been shown that 10 % of patients with OAB do not start
the medication 12 months after prescription [17]. Motiva-
tion of the patient with regular follow-up visits to monitor
treatment effects and adherence may be useful [18].
Patient satisfaction with treatment is directly related
to improvement of symptoms and expectations, which
need adequate follow-up a fter initial treatment (good
motivati on) . Discussion of the pati e nt ’s goals and expec-
tation before starting treatment should be realistic and
agreed upon by the patient and physician. Patients
should be aware that OAB especially when severe is a
chronic complex condition that can be improved, but is
unlikelytobecured[19].
Curr Bladder Dysfunct Rep
Author's personal copy
