Canadian Journal of Urology - Volume 23, Supplement 1

© The Canadian Journal of Urology™; 23(Supplement 1); February 2016

or fistula. Urodynamics should be undertaken before

any invasive treatments are pursued for OAB.

The main role of further investigations is to exclude

an underlying cause for the symptoms. Imaging such

as plain x-ray and urinary tract ultrasound can be used

to exclude stones and bladder lesions.

Treatment

Treatment for OAB in both genders should take

a graded approach with the most conservative

measures attempted first. Any underlying medical

conditions should be managed and optimized

especially urinary tract infections, diabetes, cardiac

disease and constipation. Lifestyle modifications and

behavioral therapies should be embarked upon by

patients early andmaintained alongside various other

treatments. Weight loss, exercise, smoking cessation

and modification of fluid and caffeine intake can be

difficult for patients to successfully implement into

their lives, but these measures should be encouraged.

Behavioral therapy aims to teach patients to learn

bladder control and improve their symptoms. Timed

voiding and bladder retraining techniques can reduce

symptoms of frequency and urgency. Pelvic floor

physiotherapy is also important, especially in women.

Apart from very mild cases, pharmacotherapy is

much more efficacious than behavioral measures in

reducing symptoms and improving quality of life. The

ideal approach is to combine pharmacotherapy with

conservativemeasures to produce an optimal outcome.

A wide range of medical treatments are available

at the urologists’ disposal. Some gender differences

are apparent in our use of medical treatments for this

condition. The broad classes of drugs used to treat

OAB include anticholinergic or antimuscarinic agents,

desmopressin, tricyclic antidepressants, beta 3 agonists

and intravesical Botox injections.

17-20

Specifically in

men, the role of alpha blockers in conjunction with

anticholinergics has been extensively studied.

21,22

Male patients may also benefit from PDE5 inhibitors

for LUTS.

In resistant cases, sacral neuromodulation

and posterior tibial nerve stimulation have been trialed

with encouraging results.

End stage cases may need

to resort to augmentation enterocystoplasty but this

has now become exceedingly rare.

Anticholinergic medications

Antimuscarinic or anticholinergic agents are usually

the first line pharmacotherapy in OAB. They work by

blocking the effects of neurotransmitter acetylcholine

by binding to nicotinic and muscarinic receptors.

More selective anticholinergics have more affinity

for M2 and M3 receptors (the predominant receptors

in the bladder) and therefore may have a better side

effect profile. Antimuscarinics work by reducing

involuntary detrusor contractions, thereby reducing

symptoms of frequency and urgency. It also improves

bladder capacity. Traditional and more selective

anticholinergics are used in both men and women

with good results.

Some unique features of some of the anticholinergics

do exist. Darifenacin (Enablex) is highly specific for

M3 receptors. Although its effectiveness is comparable

to other OAB medications, its unique feature is its

lack of effect on cognitive function.

24,25

This is an

important issue in elderly patients that commonly have

OAB. One downside of this medication is its slightly

higher incidence of constipation as compared to other

anticholinergics.

Fesoterodine (Toviaz) is extensively hydrolyzed

by serum esterases to 5-HMT, being the same active

metabolite as tolterodine (Detrol). Unlike tolterodine,

fesoterodine is not metabolized by the liver, which

results in more consistent and predictable blood

levels.

Furthermore, two well designed trials have

shown that fesoterodine is effective and well tolerated

in the elderly and even in the fragile elderly with no

significant cognitive dysfunction.

26,27

Fesoterodine is

one of only three drugs that received a Fit for theAged

(FORTA) classification B or “beneficial” rating in the

oral drug treatment of lower urinary tract symptoms

in the elderly.

One particular concern in using anticholinergic

medications in men is the potential risk of acute

urinary retention (AUR), especially in men with co-

existing OAB and bladder outlet obstruction. The

safety and efficacy of anticholinergic medications used

alone or in combination with alpha blockers in men

with OAB has been reviewed in the literature. Abrams

et al studied the safety of tolterodine for the treatment

of OAB in men with bladder outlet obstruction.

This

study demonstrated that tolterodine was safe in men

with mild to severe bladder outlet obstruction who

also had urodynamically confirmed DO. It did not

precipitate urinary retention or worsen preexisting

LUTS with the incidence of adverse events being

comparable in both treatment and placebo groups.

Anticholinergic treatments appear to be safe and

effective in men with predominant OAB symptoms.

Combination therapy (anticholinergic drug and alpha

blocker) has been found to be more effective than

monotherapy in treating men with OAB.

According

to Kaplan et al, the incidence of AUR in men receiving

anticholinergic medications was low (< 3%) with no

significant changes in maximum flow rate or PVR

Eapen AND Radomski