Current treatment guidelines for overactive bladder (OAB) advocate a linear patient pathway based on treatment invasiveness,1 recommending less invasive treatments before more invasive ones. In daily practice, effectiveness and side-effect tolerance may differ among patients, making outcomes difficult to predict, and this situation is compounded by the fact that it can take weeks to months for the effects of treatment to be evaluated adequately. Together, these features mean that the current treatment algorithm may not lead to a quick reduction in symptom severity for many patients, leading to impaired quality of life and additional costs.2 We aimed to explore the pathways followed by patients with overactive bladder (OAB) from diagnosis to final treatment.

This was a single-center, retrospective cohort study of female patients diagnosed with OAB in a large Dutch non-academic teaching hospital. We enrolled patients referred to the outpatient urology clinic between January 1st, 2014, and September 30th, 2016. Electronic medical records (EMRs) were further checked for exclusion criteria, including age <18 years and other pathology that could explain the OAB symptoms (e.g., urinary tract infection, bladder tumor, bladder stones or anatomic abnormalities, and neurogenic OAB). Follow-up ended when a patient experienced satisfactory response and did not require further treatment, or on January 1st, 2020. The choice of treatment was made by the patient and the urologist from among PFMT, antimuscarinics, mirabegron, PTNS, BoNT-A, and since 2017, SNM. We defined successful treatment as the satisfactory reduction of symptoms with no need for further treatment, as evaluated in an outpatient visit or phone call by the treating urologist. Treatment combinations offered more than ten times are reported separately, but those offered less often are reported as “other combined therapy.”
The number, sequence, and duration of offered treatment steps were analyzed, and the effectiveness, reasons for discontinuation, and possible case-mix variables influencing OAB treatment were studied. We used Display R (www.displayr.com) to create This was created using data for all participants, including those with no follow-up data. Treatment duration was assessed using only patients with at least one follow-up contact recorded in the EMR after starting treatment. Statistical analysis was done with IBM SPSS version 24 (IBM Corp., Armonk, NY, USA). a Sankey’s plot to visualize the sequence of OAB treatments.

In total, 120 patients were enrolled and underwent a median of 2 steps (range, 1–6) over a median total treatment duration of 28 weeks (range, 5–256). Treatment typically started with drug therapy, including antimuscarinics (38%; 95%CI, 30%–47%), antimuscarinics plus pelvic floor muscle therapy (21%; 95%CI, 15%–29%), or mirabegron (11%; 95%CI, 6%–18%). However, 52% of patients required further treatment, with Botulinum toxin A injections being most effective (67%; 95%CI, 42%–85%), followed by antimuscarinics plus percutaneous tibial nerve stimulation (50%; 95%CI, 25%–75%), and antimuscarinics plus pelvic floor muscle therapy (36%; 95%CI, 21%–54%). Other therapies showed lower effectiveness. Common reasons for discontinuation were insufficient response and side-effects. Overall, 22 patients were lost to follow up.

We detailed the OAB patient pathway from diagnosis to a satisfactory final treatment outcome in a large cohort of women over a 6-year follow up period. The findings indicated that most patients received at least two treatments before achieving a satisfactory result and that this took a median duration of 28 weeks. Insufficient response most often followed PFMT, mirabegron, and PTNS, while discontinuation due to side-effects was most often associated with antimuscarinics plus PFMT, antimuscarinic monotherapy, or mirabegron. To the best of our knowledge, no previous study of the OAB patient pathway has analyzed both the number and sequence of treatments.

Most patients try at least two treatments before they experience satisfactory symptom relief. Treatment evaluations require time because therapeutic onsets differ by patient and treatment. Our data can help to manage expectations among urologists and patients when seeking treatment for OAB.

Peyronnet B, Mironska E, Chapple C, Cardozo L, Oelke M, Dmochowski R, et al. A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment. Eur Urol. 2019;75(6):988–1000.
Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Corey R, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20(6):327–36.