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Drugs to treat overactive bladder

Comparing effectiveness, safety, and price

Last updated: November 2013

At-a-glance

Drugs used to treat overactive bladder are only modestly effective. And, the side effects can be so bothersome that you stop taking them. If you suffer from mild symptoms, first consider trying other things besides drugs. For example, cut back on caffeinated beverages, and for several weeks try Kegel exercises to strengthen your pelvic muscles, which help control urination, and see if those provide enough relief. People with more severe symptoms can also benefit from those steps, but might experience added relief from also taking medication.

For this report, we evaluated the medications: darifenacin (Enablex); fesoterodine (Toviaz); mirabegron (Myrbetriq); oxybutynin (Ditropan XL, a skin patch called Oxytrol, a topical gel called Gelnique, and generic); solifenacin (Vesicare); tolterodine (Detrol and generic, Detrol LA); and trospium (Sanctura, Sanctura XR and generic).

Our analysis found that none of those drugs are clearly more effective than the others. But they do differ in cost and the side effects they cause, which include: constipation, drowsiness, dry mouth, blurry vision, and dizziness. Studies have found that Ditropan XL, Detrol LA, Oxytrol, Sanctura, Vesicare, and Enablex may cause fewer side effects.

Taking effectiveness, side effects, and cost into account, we have chosen the following as a Consumer Reports Best Buy Drug if you and your doctor conclude that a drug is worth trying.


                 ■ Generic tolterodine


This medicine costs quite a bit more than generic oxybutynin if you are paying out of pocket. We chose it as a Best Buy because it has a lower risk of side effects. But some people tolerate the side effects of generic oxybutynin tablets well. So if your insurance does not cover medications, you might consider trying oxybutynin first as it is significantly less expensive.


Another option is tolterodine extended-release (Detrol LA). But since this medication is not available as a generic, it may cost more depending on your insurance coverage. But it offers the convenience of one-a-day dosing and a lower risk of side effects than oxybutynin.


Background

Overactive bladder is a condition characterized by the sudden need to urinate. You may also have leaking urine (incontinence) or experience the need to go to the bathroom many times each day—more than eight times—or two times or more each night.

The symptoms of overactive bladder and related incontinence are very common. Between 11 and 16 million women in the U.S. experience overactive bladder and incontinence, according to the Agency for Healthcare Research and Quality. Some estimates indicate that an equal number of men also experience overactive bladder, although these symptoms can  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 permanent and may go away. Studies show that the condition resolves after a year in up to 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?

 

If you believe you may have an overactive bladder, it’s important to see your doctor to get an accurate diagnosis, because a host of other conditions can cause symptoms—especially frequent bathroom trips—similar to those associated with overactive bladder. These include diabetes, heart disease, and a variety of neurologic disorders, such as multiple sclerosis, Parkinson’s disease, spinal cord injuries, and strokes.

Other conditions that 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 obstruction that does not allow all the urine to be expelled.

Urgency, incontinence, and urinary frequency can also be caused by urinary tract infections (UTI), kidney stones, prostate infection or enlargement, or 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.

 

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.

If you don’t respond to behavioral therapies or medication, or you have other complications, then you might need to see a urologist, urogynecologist, or other specialist.

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.

Other treatments besides drugs

The most important nondrug treatments are often called “bladder training.” For example, you might be taught how to time urination at regular intervals and hold your urine for progressively longer periods of time.

You’ll also likely learn how to do Kegel exercises to strengthen the pelvic muscles that control urination. Once you learn how to do them, they can be worked into your daily routine. For example, you could do a set of Kegels in your car while stopped at a red light. Lifestyle changes can also help. These include cutting back on certain drinks and foods, including caffeinated and alcoholic beverages, and drinking less fluid between dinner and bedtime.

Studies have found that behavioral treatments and lifestyle adjustments, when practiced diligently, can help relieve symptoms. They decrease the number of trips to the bathroom and incontinence episodes.

See the National Institutes of Health website on overactive bladder for more information about Kegel exercises, bladder training, and lifestyle changes.

 

Drug treatments for overactive bladder

 

Those changes don’t provide enough relief, you and your doctor may consider adding a medication. The medicines we evaluate in this report are listed below.

All these have been approved by the Food and Drug Administration to treat overactive bladder. The oldest is oxybutynin, available since 1976, and tolterodine (Detrol), first approved in 1998. The short-acting forms of oxybutynin and tolterodine are now available as less expensive generic drugs.

Drugs evaluated in this analysis:

Generic Name Brand Name(s) Available as a Generic Drug?
Darifenacin tablet Enablex No
Fesoterodine tablet Toviaz No

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 No
Tolterodine tablet Detrol Yes
Tolterodine extended-release capsule Detrol LA No
Trospium tablet Sanctura Yes
Trospium extended-release capsule Sanctura XR No

Oxytrol for Women patch and Botox injections


Our medical advisers recommend caution before using either the Oxytrol for Women patch or Botox injections for an overactive bladder.


The symptoms of overactive bladder can be caused by other conditions, such as bladder infections and bladder cancer, so it’s important to see a doctor to get an accurate diagnosis before trying the patch on your own. In addition, the patch can cause skin reactions at the site of application in about a quarter of patients—in 11 percent of people the reactions are so severe, they stop using the patch.


Botox has downsides, too. While clinical trials showed that Botox injections improved overactive bladder symptoms, the possible side effects 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 and might need to be repeated every 3-8 months.


Who needs medication?

In people with overactive bladder, it is thought that bladder muscles contract at the wrong time, making it feel like you urgently need to go to the bathroom. It can also lead to 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.

If your overactive bladder symptoms are mild to moderate, and you only have rare or occasional “accidents,” your doctor will probably recommend that you try nondrug measures before you try a medication. If they don’t work, he or she might suggest that you also try one of the drugs we discuss.

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. He or she 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. The doctor might also give you a physical examination and check for problems with your urine or bladder.

Here are a few simple criteria to help you determine whether you have mild overactive bladder.

 

■ Your urges to urinate are tolerable

■ You need to hurry to the bathroom

■ You have little or no leakage

■ You urinate nine to 12 times a day. (Normal urination is four to eight times a day, though this can vary by person, change from day to day and depend on your fluid intake.)

 

If your symptoms are more severe—for example, if you need to go to the bathroom 15 times a day or more and/or you have several leakage episodes a day—it’s more likely that your doctor will prescribe medicine and recommend nondrug therapies, such as lifestyle changes and Kegel exercises.

Many doctors are hesitant to prescribe drugs for overactive bladder because of the risk of side effects. Dry mouth and constipation are common, which can be very annoying, and for some people, can be quite severe. Blurred vision and dizziness can also occur. Mental confusion is a possibility with many of the drugs, especially in older people.

Since older people are more likely to have overactive bladder, doctors are especially alert to any mental confusion they might experience. If you (or a loved one) 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 mirebegron (Myrbetriq). But most people with glaucoma have what is called “open angle” glaucoma and can safely take overactive bladder drugs.

Because the benefits of overactive bladder medicines can often be marginal, many doctors and experts think they’re not worth continuing if people experience bad side effects. That said, if your doctor thinks your condition is severe enough to warrant one of these medicines, it might be worth trying. 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.

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.

To sum up, we recommend that people with mild overactive bladder and infrequent incontinence try lifestyle changes first. If they don’t work, talk with your doctor about taking one of the overactive bladder drugs. If you have more severe symptoms, you might need to supplement nondrug measures with medication.


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. But overall, 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.

Even fewer 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.

Generally, choosing the best overactive bladder drug 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.

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
  • Improved some symptoms better than Detrol LA
  • More likely to cause dry mouth
  • More people withdrew from studies due to side effects than Detrol LA

Mirabegron

Myrbetriq

  • Taken once a day
  • Doesn’t cause mental confusion
  • Poses less risk of blurred vision and dry mouth
  • Newest drug; less research on effectiveness and safety than other drugs
  • No evidence directly comparing it to other drugs
  • May cause high blood pressure
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
  • Needs to be taken just once a day
  • Lower rate of side effects than short-acting oxybutynin
  • 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
  • Lower rate of dry mouth compared with oxybutynin 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
  • Lower rate of dry mouth than Detrol
  • Higher rates of dry mouth and constipation than Detrol LA
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-acting tolterodine or oxybutynin

Trospium  

(Short-acting)

Sanctura
  • Lower rate of severe dry mouth than oxybutynin
  • Less research on effectiveness and safety than with oxybutynin and tolterodine
Trospium (Extended-release) Sanctura XR
  • Taken once a day
  • Very limited research to date

Our 'Best Buy' pick

Taking effectiveness, side effects, safety, dosing convenience, and cost, if paying out-of-pocket, into account, we have chosen the following as a Consumer Reports Best Buy Drug:

■ Generic tolterodine

The short-acting form of tolterodine costs more than generic oxybutynin, but we chose it as a Best Buy because it offers the advantages of fewer side effects and a lower rate of people who stop using it due to adverse events. Tolterodine might be more convenient, too, because it is rarely prescribed for use more than twice a day, whereas some people might need to take oxybutynin three times per day. That could be a convenience advantage for some people, such as seniors, who take multiple medicines per day.

The long-acting form of tolterodine (Detrol LA) might also be a good option because it has a low risk of side effects and offers once-a-day convenience. But we did not choose it as a Best Buy because it is not available as a generic, so it is significantly more expensive than generic tolterodine.

If you have health insurance or Medicare drug coverage (Part D or a Medicare Advantage plan), check to see if your plan covers our Best Buy selection. But be aware that you may be charged a higher copayment than for generic oxybutynin. On the other hand, some insurance plans have a preferred medication for which they will charge you the lowest co-pay, so you should check with your plan for the specific details about drug coverage.

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, at $24 to $36 for a month’s supply. 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.

The monthly cost of the overactive bladder medications ranges from $24 to more than $300. Certain generic medications might cost as little as $4 for a month’s supply through generic drug programs run by major chain stores, such as Kroger, Sam’s Club, Target, and Walmart. For an even better bargain, you can obtain a three-month supply for $10 through these programs. We note in the price chart which generic overactive bladder medications are available through these programs. 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.

Table 2. Costs of Overactive Bladder Drugs

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 reports conducted by the Agency for Healthcare Research and Quality and the Cochrane Collaboration.


The drug costs we cite were obtained from a healthcare information company that tracks the sales of prescription drugs in the U.S. Prices for a drug can vary quite widely, even within a single city or town. All the prices in this report are national averages based on sales of prescription drugs in retail outlets. They reflect the cash price paid for a month’s supply of each drug in August 2013.


We selected the Best Buy Drug using the following criteria. The drug had to:


■ Be approved by the FDA for treating overactive bladder


■ Be as effective as other overactive bladder medicines


■ Have a safety record equal to or better than other overactive bladder medicines


The Consumer Reports Best Buy Drugs methodology is described in more detail in the Methods section at www.CRBestBuyDrugs.org.


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50. Zinner, N., J. Tuttle, and L. Marks. Efficacy and tolerability of darifenacin, a muscarinic M3 selective receptor antagonist (M3 SRA), compared with oxybutynin in the treatment of patients with overactive bladder. World Journal of Urology, 2005. 23(4): p. 248-52.

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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