Discouraged Patients, Frustrated Clinician!

I want to share with you the story of my approach to two of my patients being seen for overactive bladder symptoms of urgency and frequency during the day and night. I thought you might be interested in their stories as what I found to be successful treatments were not an approach often recommended. Their symptoms had defied most treatments.

The first patient was James, a 74-year-old man who was referred for Percutaneous tibial nerve stimulation (PTNS) treatments, having failed 2 injections of Botox and multiple overactive bladder (OAB) medications. He had refused an Interstim implant. James was tolerating his daytime symptoms but at night, he was voiding 8-9 times. He had been treated for sleep apnea with a CPAP device and no other causes for the nocturia had been found.  

The other patient Louise is a 61-year-old female, who was in good health with a 5-8 years history of OAB symptoms. She found the symptom of daytime frequency of every 2 hours to be causing issues at work, primarily an inability to keep up with tasks.  

Both patients received a 6-month behavioral treatment program and the Louise had been treated for vaginal atrophy. Despite throwing all standard OAB treatments at each patient, symptoms did not significantly improve and/or remained bothersome. Both patients had become more or less resigned to their symptoms. I thought that Louise appeared depressed at the failure of any solution. I had heard a presentation on combination drug therapy at an American Urological Association meeting so I decided to combine two OAB drugs; mirabegron 50 mg with Vesicare 5 mg. I list some of the research on combination drugs for OAB at the end of this blog, so you can read the efficacy of this approach.  

After about 3-4 weeks, James reported significant improvement as daytime symptoms had resolved and nocturia had decreased to 3 to 4 times most nights. For him, the combination of these two drugs was a “game changer.” Louise returned reporting that all symptoms had resolved. The change in her attitude was nice to see. Not all of my colleagues agree with this approach and I admit to some initial reservations. But I am more inclined to follow this treatment pathway before considering third line OAB treatment. Now that we have an approved drug for nocturia, combination drug therapy for OAB symptoms that include nighttime frequency may be the way to go.

Written by: Diane Newman, DNP, CRNP, FAAN, BCB-PMD, Nurse Practitioner (NP), Co-Director, Penn Center for Continence and Pelvic Health Director, Clinical Trials, Division of Urology, Adjunct Professor of Urology in Surgery, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Published Date: April 20th, 2018


1. Drake MJ, Chapple C, Esen AA, Athanasiou S, Cambronero J, Mitcheson D, Herschorn S, Saleem T, Huang M, Siddiqui E, Stölzel M, Herholdt C, MacDiarmid S; BESIDE study investigators. Efficacy and Safety of Mirabegron Add-on Therapy to Solifenacin in Incontinent Overactive Bladder Patients with an Inadequate Response to Initial 4-Week Solifenacin Monotherapy: A Randomised Double-blind Multicentre Phase 3B Study (BESIDE). Eur Urol. 2016 Jul;70(1):136-145

2. Herschorn S, Chapple CR, Abrams P, Arlandis S, Mitcheson D, Lee KS, Ridder A, Stoelzel M, Paireddy A, van Maanen R, Robinson D. Efficacy and safety of combinations of mirabegron and solifenacin compared with monotherapy and placebo in patients with overactive bladder (SYNERGY study). BJU Int. 2017 Oct;120(4):562-575.
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