Best Treatments for Overactive Bladder

Best Treatments for Overactive Bladder

Nondrug strategies such as Kegel exercises and bladder training can work as well as medication without the risk of side effects

Last updated: August 2016

At-A-Glance

If you’re one of the millions of men and women who suffer from overactive bladder symptoms—the sudden need to urinate, incontinence, making frequent trips to the bathroom—don’t be reeled in by recent TV ads that make it seem like drugs are the only solution. The truth is that the drugs are only moderately effective and can trigger side effects so bothersome, such as dry mouth and constipation, that many people quit taking them. Instead, most people can get the relief they need with lifestyle changes, such as cutting back on liquids and caffeine, doing Kegel exercises, and bladder training. Studies have found that behavioral treatments and lifestyle adjustments, when practiced diligently, can help relieve symptoms and can be as effective as medication.

That’s why our medical advisers and major medical organizations, such as the American College of Physicians and the American Urological Association (AUA), recommend that you try the nondrug strategies before considering medication.

If following nondrug strategies for several weeks doesn’t provide enough relief, it may be time to try adding a medication. If that's the case, you may want to continue the lifestyle changes and behavioral treatments because the two together may be helpful.

For this report, we evaluated the following medications: darifenacin (Enablex); fesoterodine (Toviaz); mirabegron (Myrbetriq); oxybutynin (available as a pill [Ditropan XL and generic], a skin patch [Oxytrol], and a topical gel [Gelnique]); solifenacin (Vesicare); tolterodine (Detrol and generic, Detrol LA and generic); and trospium (generic only).

Our analysis found that none of those drugs are clearly more effective than the others. But they differ in cost and the side effects they cause. Most cause constipation, drowsiness, dry mouth, blurry vision, and dizziness. Myrbetriq works by a different mechanism than the other drugs, so it doesn’t cause those side effects, but it can raise blood pressure and increase the risk of urinary tract infections and colds.

Considering the limited effectiveness of overactive bladder medications, and the risk and likelihood of experiencing side effects, we have not chosen a drug as a Consumer Reports Best Buy Drug.


However, if after trying lifestyle changes, you and your doctor conclude that a drug is worth trying, you could consider generic extended-release oxybutynin.


This medicine costs about twice as much as generic short-acting oxybutynin if you are paying out of pocket, but it offers the convenience of once-a-day dosing and research suggests it has a lower risk of side effects than short-acting oxybutynin and some other drugs, including short-acting tolterodine.


Some people tolerate the side effects of generic short-acting oxybutynin tablets well. So if your insurance does not cover medications, you might consider trying that first as it is significantly less expensive.


Background

The hallmark symptom of overactive bladder is a sudden need to urinate. But people with the condition can also leak urine (incontinence) or experience the need to go to the bathroom many times each day—more than eight times—or twice or more while sleeping each night.

The cause of overactive bladder isn’t fully understood. In some people, the bladder muscles contract at the wrong time, making it feel like you urgently need to go to the bathroom, or trigger urine leakage. Drugs used to treat the condition relax the bladder muscles, which can increase the storage size of the bladder and reduce the urge to urinate.

The symptoms of overactive bladder are very common. Between 11 and 16 million women in the U.S. experience overactive bladder, according to the federal Agency for Healthcare Research and Quality. Some estimates indicate that an equal number of men also experience overactive bladder, although these symptoms can sometimes be caused by prostate problems.

The condition can develop in men or women of any age, but is more likely to occur in older adults. It’s important to note that overactive bladder symptoms are not always that troublesome or permanent and may go away. Studies show that it resolves after a year in for about 35 percent of women who develop it. But for the majority of women, the condition persists for years.

Recognize the Symptoms of Overactive Bladder


■ Urinating eight or more times per day


■ Waking up more than twice a night to go to the bathroom


■ An overwhelming and sudden need to urinate, even if you’ve recently gone to the bathroom


■ Leaking urine before you’re able to make it to a bathroom. (About half of the people with overactive bladder have urge-related leakage.)


Could Your Overactive Bladder Be Something Else?

Urgency, incontinence, and urinary frequency can all be caused by having urinary tract infections (UTI), kidney stones, prostate infection or enlargement, or could be from medicine you take to treat other conditions, such as high blood pressure. The first question your doctor might ask if you’re having urinary problems is what medicines you’re taking. If they don’t ask, be sure to bring it up.

Other conditions can cause symptoms similar to those of overactive bladder, too—especially the need to make frequent bathroom trips. These include bladder cancer, diabetesheart disease, and neurologic disorders, such as multiple sclerosis, Parkinson’s disease, spinal cord injuries, and strokes.

Other conditions can also cause urine leakage. For example, “stress incontinence”—leaking urine when you cough, sneeze, run, jump, or even laugh—is sometimes confused with overactive bladder. It’s caused by a weakness of the muscles that help keep the bladder closed. Some people have a combination of overactive bladder and stress incontinence.

Another bladder disorder called “overflow incontinence” can have symptoms similar to overactive bladder. This condition is usually caused by an inability to empty the bladder, due to an obstruction or a problem with the muscles that contract the bladder. So much urine builds up in the bladder that it starts leaking out.

Overactive Bladder is Not Normal

Though not life-threatening, overactive bladder is inconvenient, can be embarrassing, and can reduce your quality of life. Some people with the condition find it difficult to leave the house, sit through a meeting, enjoy a dinner out, or go to a movie.

Many people hesitate to seek treatment because they are embarrassed, or because they mistakenly think their symptoms are a normal part of aging and can’t be helped. In fact, overactive bladder is not normal, and treatment can ease your symptoms and improve your quality of life.

Your doctor will start by asking about your symptoms and medical history, such as any medications you are taking and any operations or procedures you have undergone. Your doctor might ask you to fill out a “bladder diary” to keep track of how often you go to the bathroom and how often you have urine leakage. Your doctor should also give you a physical examination and check for problems with your urine or bladder.

The Bottom Line: If you have strong urinary urgency or leakage, or if you have to urinate so many times a day that it interferes with your life, see a physician to get an accurate diagnosis. You might not need a drug. Nondrug treatments can be very helpful, and are usually—and should be—recommended before drugs for most people.

Nondrug Treatments

Most people with overactive bladder can get the relief they need with lifestyle changes, such as cutting back on caffeinated beverages and drinking less fluid between dinner and bedtime, doing Kegel exercises, and bladder training. Studies have found that those nondrug strategies can help relieve symptoms and can be just as effective as medication alone by decreasing the number of trips to the bathroom and how many incontinence episodes you experience.

It’s not clear how long the benefits last, but some evidence suggests that many people are helped by bladder training and Kegel exercises for as long as 3 years, but it's difficult to know for certain because those studies have been small. But nondrug measures don’t carry the risk of side effects that medications pose.

That’s why our medical advisers and major medical organizations, such as the American College of Physicians and the American Urological Association, recommend that you try the nondrug strategies before considering medication.

By reducing the amount of liquids and certain beverages you consume, you can reduce the number of trips you need to make to the bathroom, which might also help reduce leakage episodes as well.

Kegel exercises help by strengthening the pelvic muscles that control urination. And bladder training helps improve bladder control. For example, you might establish a schedule to urinate at regular intervals or hold your urine for progressively longer periods of time. It may take several weeks before you notice a benefit; experts recommend trying bladder training for up to 6 weeks and Kegels for at least 15 weeks.

For more information on those nondrug strategies, see the National Institutes of Health website on overactive bladder.

Find out how to do Kegel exercises correctly

Drug Treatments

If bladder training, Kegel exercises, and lifestyle adjustments don’t provide enough relief, you and your doctor may consider adding a medication. The medicines we evaluated in this report are listed below.

All of these have been approved by the Food and Drug Administration to treat overactive bladder. The oldest are oxybutynin, available since 1976, and tolterodine (Detrol), first approved in 1998. Most of the medications are now available as less expensive generics.

Drugs evaluated in this analysis:

Generic Name Brand Name(s) Available as a Generic Drug?
Darifenacin tablet Enablex Yes
Fesoterodine tablet Toviaz Tentative approval

Mirabegron tablet

Myrbetriq

No

Oxybutynin tablet Ditropan XL Yes
Oxybutynin skin gel Gelnique No
Oxybutynin skin patch Oxytrol, Oxytrol for Women (OTC) No
Solifenacin tablet Vesicare Yes
Tolterodine tablet Detrol, Detrol LA Yes
Trospium tablet Generic only Yes

However, the benefits of overactive bladder medicines can often be marginal and the side effects can cause many people to stop taking them—including blurred vision, constipation, dizziness, dry mouth, and even mental confusion, especially in older people. Because of this, our medical advisers recommend that you try nondrug measures—such as bladder training, Kegel exercises, and the various lifestyle modifications mentioned earlier—before you try a medication. If they don’t work, it might be worth trying one of the drugs we discuss. The response to these drugs varies; you might tolerate it well and be able to adapt to the side effects. But you should discuss with your doctor any side effects you experience.

Should You Try Botox injections?


Although clinical trials showed that Botox injections improved overactive bladder symptoms, our medical experts urge caution: the possible side effects can include painful urination, incomplete emptying of the bladder (which could require the insertion of a catheter), and urinary tract infections. The FDA says you should take an antibiotic along with the shot to reduce the risk of developing a UTI.


Moreover, Botox is only approved for use in people who can’t take or haven’t gotten relief from other overactive bladder medications, and it can be expensive. A single treatment can cost more than $800 without insurance and might need to be repeated every 3 to 8 months.


Comparing Drug Safety and Effectiveness

The overactive bladder drugs are only moderately effective. Studies have found that just a small proportion of people get complete relief from symptoms while taking the medications, particularly over longer periods of time. But most people can expect some relief—a decrease in the number of times a day they feel a strong urge to urinate, and a decline in the number of leakage episodes.

On average, people with overactive bladder urinate 12 times a day. Medication can reduce the number of daily bathroom trips by two to three for most people. If you have incontinence, you can expect the number of episodes to decline by one to two per day.

Of course, people respond differently to the overactive bladder drugs, so there can be variation in the reduction of urges, urinary frequency, and leakage. Some people will notice a substantial decrease in symptoms while others will barely get any relief. The only way to know how you will respond is to try one of the medicines. Also keep in mind that you might have to take the medicine for up to four weeks to see the maximum level of symptom relief.

Each of the seven drugs has strengths and weaknesses. With a few exceptions, studies that have compared the drugs with each other have found little difference among them in terms of effectiveness. That includes studies that compared the immediate-release (or short-acting) forms of these drugs to the long-acting, or extended-release forms. However, the long-acting formulations tend to have fewer side effects such as dry mouth when compared to the short-acting forms, but just as many people stop taking the long-acting forms.

Few studies have evaluated how the drugs affect the highly subjective symptom of urgency. As you might imagine, that’s more difficult to measure than the number of times you urinate. Here, too, the studies point to a modest success for the overactive bladder drugs, with a wide range of individual responses. So, depending on your own body chemistry and response, you might notice a meaningful decrease in urgency or very little change.

Overall, more than half of the patients taking an overactive bladder drug stop within six months. Some studies have found that only 10 to 20 percent of people are still taking an overactive bladder medicine after six to 12 months.

That is a very high level of treatment dropout. Some of it is for a good reason: lifestyle changes and nondrug measures have been successful at reducing their symptoms, so the drug is no longer needed. Some dropout may be due to cost, especially for people taking the newer, more expensive drugs. But about a third to one-half of the dropout is due to side effects. Patients simply can’t tolerate the drug or decide it’s not worth the minimal benefit they get.

Choosing the right overactive bladder drug for you will depend on your medical history, the severity of your condition, convenience factors (such as taking one pill a day vs. two or three times a day), a drug’s side effects, your insurance coverage, and your out-of-pocket costs. It will also depend on the other prescription and nonprescription drugs you are taking.

Additional Precautions

Since older people are more likely to have overactive bladder, doctors are especially alert to any mental confusion they might experience. If you (or someone you care for) has Alzheimer’s disease or another form of dementia (for example, dementia that develops after a stroke), your doctor might be reluctant to prescribe a drug for overactive bladder. We’d go a step further and suggest that you not take one unless your doctor feels strongly about prescribing it.

Your doctor will want to know if you have “narrow angle” glaucoma, an eye condition. The overactive bladder medicines are not recommended for people with this type of glaucoma because they can harm their vision—this does not apply to mirabegron (Myrbetriq). But most people with glaucoma have what is called “open angle” glaucoma and can safely take overactive bladder drugs.

Table 1. Overactive Bladder Drugs - Strengths and Weaknesses

 

Generic name Brand Name Strengths Weaknesses
Darifenacin Enablex
  • Taken once a day
  • Lower rate of overall side effects, dry mouth, and severe dry mouth than oxybutynin
  • Less research on effectiveness and safety than with oxybutynin and tolterodine
Fesoterodine Toviaz
  • Improves some symptoms better than Detrol LA
  • Fesoterodine 8 mg more likely to cause dry mouth than Detrol LA
  • With fesoterodine 8 mg, more people withdrew from studies due to side effects than Detrol LA
  • Some research suggests that more people may stop taking fesoterodine due to side effects than with solifenacin

Mirabegron

Myrbetriq

  • Taken once a day
  • Poses less risk of dry mouth, constipation, and dizziness
  • May cause high blood pressure
  • Increased risk of urinary tract infections and common cold
Oxybutynin tablet (Short-acting) Generic only
  • On the market longest, well-known by doctors
  • Many studies confirm its effectiveness

 

  • Highest rate of side effects, including dry mouth and constipation
  • More people report severe dry mouth compared with other drugs
  • Need to take 2 to 3 pills a day
Oxybutynin tablet (Extended-release) Ditropan XL
  • Taken once a day
  • Lower rate of side effects than short-acting oxybutynin
  • One study found lower rate of side effects than short-acting tolterodine
  • More expensive than the short-acting form
Oxybutynin transdermal patch Oxytrol
  • Available over the counter
  • No need to take a pill
  • Patch is changed every three to four days
  • Some research suggests a lower rate of dry mouth, constipation, and drowsiness than oxybutynin short-acting pill
  • Irritation at site of patch is common; can be severe
Oxybutynin topical gel Gelnique
  • No need to take a pill
  • Gel is applied to abdomen, arm, or thigh daily
  • Very limited research to date
Solifenacin Vesicare
  • Taken once a day
  • Improves some symptoms better than Detrol or Detrol LA
  • Suggestion of greater improvement in some symptoms with solifenacin 10 mg than mirabegron 50 mg
  • Lower rate of dry mouth than Detrol and oxybutynin
  • Higher rates of dry mouth than Detrol LA and mirabegron
  • Higher rates of  constipation than Detrol or Detrol LA and a suggestion of a higher rates of constipation than oxybutynin and mirabegron
Tolterodine (Short-acting) Detrol
  • Fewer patients report dry mouth or constipation than oxybutynin short-acting
  • Taken twice a day (may be an advantage over oxybutynin tablets, but a disadvantage compared with daily Detrol LA)
Tolterodine (Extended-release) Detrol LA
  • Taken once a day
  • Fewer side effects compared with oxybutynin and short-acting Detrol
  • More expensive than short- or long-acting oxybutynin

Trospium  

(Short-acting)

Generic only
  • Lower rate of severe dry mouth than oxybutynin
  • Less research on effectiveness and safety than with oxybutynin and tolterodine
Trospium (Extended-release) Generic only
  • Taken once a day
  • Little available research comparing it to other drugs

Using Medication

If diligently following nondrug strategies for several weeks doesn’t provide enough relief, it may be time to try adding a medication. But if you do decide to try a medication, continue the lifestyle changes and behavioral treatments because studies suggest the combination of a drug and nondrug strategies is more effective than either alone.

If you and your doctor conclude that a medication is worth trying you could consider generic extended-release oxybutynin.

This medicine costs about twice as much as generic short-acting oxybutynin if you are paying out of pocket. But it offers the convenience of once-a-day dosing—that could be a significant advantage for some people, such as seniors, who take multiple medicines per day—and research suggests it has a lower risk of side effects than short-acting oxybutynin and some other drugs, including short-acting tolterodine.

The short- and long-acting forms of generic tolterodine might also be good options because they have a low risk of side effects, and the long-acting form offers once-a-day convenience.

If cost is a major issue for you—for example, if you are without health insurance—we suggest that you talk with your doctor about trying low-cost generic oxybutynin first. Although it has a high rate of adverse effects, some people tolerate it well and it is the least expensive overactive bladder medication, you can find it for as little as $4 for a month’s supply at several major retailers like Kroger, Sam’s Club, or Walmart. Some stores, such as CVS and Walgreens, require a membership fee to participate and might charge higher prices. There might be other restrictions too, so check the details carefully to make sure your drug and dose are covered.

But if it does not provide you with enough symptom relief or the side effects are bothersome, you might have to try one of the other medicines.

How We Made Our Recommendation

Our evaluation is primarily based on an independent scientific review of the evidence on the effectiveness, safety, and side effects of overactive bladder medications. A team of physicians and researchers at the Pacific Northwest Evidence-Based Practice Center (EPC) conducted the analysis.


A synopsis of that forms the basis for this report. A consultant to Consumer Reports Best Buy Drugs is also a member of the Pacific Northwest EPC research team, which has no financial interest in any pharmaceutical company or product. The full Pacific Northwest EPC review of overactive bladder drugs is available here. (This is a long and technical document written for physicians). We also relied on research conducted by the Agency for Healthcare Research and Quality and the Cochrane Collaboration.


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Editor's Note:

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).



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