Moving beyond ineffective medication for OAB

Abstract

It is intriguing when reading articles extolling the virtues of anticholinergic medication in the treatment of overactive bladder (OAB) that very little time is spent exploring the issue of quality of life which, in essence, is the major complaint of this patient population.1 Unfortunately, compliance to anticholinergic medication secondary to side effects and poor patient perceived benefit in symptom reduction are extremely poor. Current data document medication adherence rates of less than 35%.2 This means two-thirds of our OAB patients are no better than when they initially saw us in consult and have had no improvement in their quality of life! The data on Botulinum toxin A (BTX A) are much more encouraging. As I reported earlier,3 a recent study by Sahai and colleagues used the Kings Health Questionnaire (KHQ) and demonstrated that the KHQ subdomains were all significantly improved in patients who received BTX A compared with placebo.4 Dmochowski has reported similar statistically significant improvements.5 It is difficult to understand the resistance to BTX A. Opponents suggest that BTX A should be second- or third-line therapy secondary to the possible risks of the procedure. The two biggest issues (distal muscle weakness and urinary retention) are definitely important possible complications. However, distal muscle weakness has never been reported post-BTX A injection for idiopathic OAB.6 This has only occurred in neurogenic OAB patients, which is an entirely different patient population. The rate of urinary retention is decreasing as we continue to modify and decrease our dose; even those unfortunate enough to go into retention still have a markedly improved quality of life.7 While many suggest that BTX A should be reserved for patients who have failed first-line therapy, I would suggest that failing anticholinergic medication is likely a foregone conclusion. Thus, it seems entirely appropriate that BTX A, with its statistically significant increased efficacy, improved patient quality of life and low side effect profile should be the first-line treatment for OAB, rather than toiling on with ineffective treatment with intolerable side effects.