Use of Third Line Therapy for Overactive Bladder in a Practice with Multiple Subspecialty Providers: Beyond the Abstract

In a climate of rising healthcare costs and a growing aging population, the treatment of overactive bladder (OAB) will become increasingly important.  Treatment should focus on maximizing quality of life for patients in the most cost-effective way possible.  In this study we demonstrate that while only 20% of patients will find satisfactory improvement of their OAB symptoms using medications, only a fraction of the remaining 80%  will receive treatment with third line therapy, even in a subspecialty tertiary referral center.  Third line therapies which include onabotulinumtoxinA injections in the bladder and neuromodulation are advocated in the AUA/SUFU OAB guidelines as the next line of therapy when pharmacotherapy fails.1  All of these options have proven effectiveness, and sacral neuromodulation (SNM) in particular has shown to decrease expenditures on anticholinergic medications.2  In addition, while the upfront costs of third line therapies such as SNM may be high, the long term benefit in quality adjusted life years favors these treatments.3  

In addition, anticholinergic medications are associated with a risk of cognitive decline with long-term use, and this relationship has been shown to be dose-dependent.4  Although causality has not been established, there is a plausible mechanism for this association with dementia which can further worsen overall health and well-being.  It is important to counsel patients that if they are not getting satisfactory relief of OAB symptoms on medications, they should seek alternative treatment.  

Overall, third line therapy should be used in a larger proportion of patients with refractory OAB.  At this time we believe that the primary barrier to progression to third line therapy is lack of knowledge about these treatments amongst both physicians and patients.  By promoting awareness and knowledge about third line therapy we can improve the quality and efficiency of care for OAB patients.

Written by: Dena Moskowitz and Kathleen C Kobashi

Read the Abstract


1 Gormley, E.A., D.J. Lightner, K.L. Burgio, et al., Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol, 2012. 188(6 Suppl): p. 2455-63.

2 Anger, J.T., A.P. Cameron, R. Madison, et al., The effect of sacral neuromodulation on anticholinergic use and expenditures in a privately insured population. Neuromodulation, 2014. 17(1): p. 72-4; discussion 74.

3 Autiero, S.W., N. Hallas, C.D. Betts, et al., The cost-effectiveness of sacral nerve stimulation (SNS) for the treatment of idiopathic medically refractory overactive bladder (wet) in the UK. BJU Int, 2015. 116(6): p. 945-54.

4 Gray, S.L., M.L. Anderson, S. Dublin, et al., Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med, 2015. 175(3): p. 401-7.

SUFU MyBladder app