Overactive bladder (OAB) is pervasive among older adults, with over 30% of adults ≥ 65 years negatively affected by this syndrome (1). OAB often leads to social isolation, mental health disorders, and other medical comorbidities, resulting in most seeking treatment (2, 3). Minimally invasive OAB therapy [i.e., posterior tibial nerve stimulation (PTNS), intradetrusor botulinum toxin injections (BTX), and sacral neuromodulation (SNM)] are commonly used in older adults, particularly if pharmacotherapy fails or is avoided due to concerns of unwanted side effects. Unfortunately, minimally invasive OAB therapy is often chosen based on an unstandardized approach and therefore many older adults may end up changing therapies due to lack of efficacy, unwanted adverse events, or inconvenience. The objective of this study was to describe patterns in changing minimally invasive OAB therapy among older adults. Given the lack of a standard approach to selecting initial therapy, it was hypothesized that changing minimally invasive OAB therapy would be common among older adults.

This retrospective cohort study included 100% of fee-for-service Medicare beneficiaries who underwent minimally invasive OAB therapy 2015-2020. Eligible beneficiaries were identified using appropriate diagnosis and procedural codes. Beneficiaries with neurogenic bladder diagnoses were excluded. The primary outcome was changing minimally invasive OAB therapy, defined as having >1 type of minimally invasive therapy within 2 years of the index treatment. A Sankey diagram was created to visualize the flow and sequence of treatments. Multivariable modified Poisson regression was performed to identify factors associated with changing minimally invasive OAB therapy.

Among the 111,939 beneficiaries who underwent minimally invasive OAB therapy during the study period, 18,444 (16.5%) changed therapy within 2 years. Nearly half of those who changed therapies were ages 66-74 years (49.2%) and the vast majority were female (79.9%). Among beneficiaries who changed minimally invasive OAB therapy, those undergoing PTNS had the highest rate of change (44.8%), followed by BTX (31.7%) and then SNM (23.5%). As shown in the Sankey diagram (Figure), the most common change was from PTNS to BTX (29.1%), followed by BTX to SNM (20.9%) and SNM to BTX (20.0%). Factors associated with increased likelihood of changing therapy were: PTNS as initial therapy [aRR 1.43, 95% CI 1.38-1.48 versus (vs) SNM], female sex (aRR 1.12, 95% CI 1.09-1.16), and higher frailty index (mild to severe frailty aRR 1.08, 95% CI 1.03-1.14 vs not frail). Older age (≥85 years aRR 0.60, 95% CI 0.57-0.63 vs 65-74 years) and non-white race (aRR 0.79, 95% CI 0.75-0.84) were associated with lower likelihood of changing therapy.

In this national cohort of Medicare beneficiaries who underwent minimally invasive OAB therapy, approximately one out of six beneficiaries changed therapy within 2 years. Changing therapy was most common among those receiving PTNS, with nearly half of PTNS recipients changing to BTX or SNM within 2 years. Among those who changed therapy, BTX was the most common treatment that beneficiaries switched to. Surprisingly, older age was associated with lower likelihood of changing therapy, yet pre-frailty and frailty increased the likelihood of changing therapy.

In this national cohort of Medicare beneficiaries, 16.5% changed minimally invasive OAB therapy within 2 years of initiating minimally invasive therapy. More work is needed in older adults with OAB to improve selection of initial OAB therapy to achieve more efficient symptom resolution.

Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20(6):327-336. doi:10.1007/s00345-002-0301-4
Zhang Y, Wu X, Liu G, Feng X, Jiang H, Zhang X. Association between overactive bladder and depression in American adults: A cross-sectional study from NHANES 2005–2018. Journal of Affective Disorders. 2024;356:545-553. doi:10.1016/j.jad.2024.04.030
Jensen S, Walker D, Elsouda D, et al. An observational, patient-reported outcome study of sleep quality and depression among individuals with overactive bladder syndrome. Neurourology and Urodynamics. 2024;43(2):437-448. doi:10.1002/nau.25348