Name: Medication For Overactive Bladder
Creator: COB Foundation
Published: 2018-12-13T00:00:00.000Z

When lifestyle changes and bladder training aren’t providing enough relief from overactive bladder symptoms, medication becomes the next step. Most people with OAB will try at least one pharmaceutical treatment at some point, and understanding your options helps you have better conversations with your doctor about what might work for you.

I should be honest upfront: OAB medications help many people, but they’re rarely a complete solution and the side effects put some people off. The goal is usually to reduce symptoms enough to improve quality of life, not necessarily to eliminate every urgent dash to the toilet.

How OAB Medications Work

To understand OAB drugs, it helps to know what’s happening in your bladder. The detrusor muscle in the bladder wall contracts to push urine out when you void. In OAB, this muscle contracts too frequently or at inappropriate times, creating that urgent “I need to go now” feeling, even when your bladder isn’t particularly full.

Most OAB medications work by reducing these unwanted contractions, essentially calming down an overactive detrusor. There are two main drug classes that do this through different mechanisms, plus some newer options for specific situations.

Anticholinergic Medications (Antimuscarinics)

Anticholinergics have been the first-line medical treatment for OAB for decades. They block acetylcholine, a chemical messenger that triggers bladder muscle contractions 1. By blocking this signal, the bladder muscle relaxes and can hold more urine before signalling urgency.

Several anticholinergic medications are available:

Oxybutynin (brand names include Cystrin, Ditropan, Lyrinel XL) is the oldest and most widely prescribed. It works, but tends to have more side effects than newer options. Lyrinel XL is an extended-release version that causes less dry mouth because it releases the drug slowly. Kentera is a skin patch version that bypasses the liver, further reducing side effects (particularly dry mouth) because less of the drug gets converted to the metabolite that causes this problem.

Tolterodine (Detrusitol, Detrusitol XL) was developed specifically to target the bladder more selectively than oxybutynin, with the aim of causing fewer side effects. The extended-release formulation is generally better tolerated.

Solifenacin (Vesicare) is a newer anticholinergic with once-daily dosing. Studies suggest it may have a slightly better balance of effectiveness and tolerability compared to older options 2.

Fesoterodine (Toviaz) is related to tolterodine. It comes in two strengths, allowing doctors to start with a lower dose and increase if needed.

Trospium chloride (Regurin) doesn’t cross into the brain as readily as other anticholinergics because it’s a large molecule. This makes it potentially preferable for older adults concerned about cognitive effects.

Propiverine (Detrunorm) and Darifenacin (Emselex) are other options your doctor might consider depending on your individual circumstances.

Side Effects of Anticholinergics

Acetylcholine doesn’t just affect the bladder. It operates throughout the body, which is why anticholinergics cause side effects beyond the bladder:

Dry mouth is the most common complaint, affecting roughly 20-30% of people taking these medications. It ranges from mildly annoying to significant enough that people stop taking the drug. Sugar-free gum and frequent sips of water help some people; others use saliva substitutes or switch to a different medication.

Constipation occurs because the gut also relies on acetylcholine for normal movement. Staying well hydrated and eating adequate fibre helps counteract this.

Dry eyes may develop, which is particularly relevant if you wear contact lenses or already have dry eye problems.

Blurred vision can occur, especially when reading or doing close work.

Cognitive effects are a real concern, particularly for older adults. Anticholinergics can cause confusion, memory problems, and may contribute to cognitive decline with long-term use 3. NHS guidance suggests doctors should be cautious about prescribing anticholinergics to people over 65, especially those already experiencing memory problems or taking other medications with anticholinergic properties 4.

The side effect profile is why many people cycle through several different anticholinergics trying to find one that works adequately without causing intolerable problems. Extended-release formulations and transdermal patches generally cause fewer side effects than immediate-release tablets.

Beta-3 Agonists

Mirabegron (Betmiga) and the newer Vibegron work through a completely different mechanism. Instead of blocking bladder contractions, they activate beta-3 receptors in the bladder muscle, causing it to relax during filling 5. This improves the bladder’s storage capacity without the anticholinergic side effects.

For people who can’t tolerate anticholinergics, or who are worried about cognitive effects, beta-3 agonists are a genuine alternative. They don’t cause dry mouth, constipation, or the cognitive effects associated with anticholinergics.

The trade-off is a different side effect profile. The most common issues with mirabegron include:

Urinary tract infections (occurring in about 3% of users)
Tachycardia (faster heart rate, around 1-2% of users)
Hypertension (blood pressure may increase)
Atrial fibrillation is a rare but more serious concern

Because of these cardiovascular effects, beta-3 agonists aren’t suitable for everyone. People with severe uncontrolled hypertension or certain heart conditions should avoid them. Your GP will check your blood pressure before starting treatment and may monitor it periodically.

Despite these caveats, beta-3 agonists have become increasingly popular, particularly for older patients where the anticholinergic cognitive risks are most concerning.

Combination Therapy

Some people take both an anticholinergic and a beta-3 agonist together when neither alone provides sufficient relief. One trial found the combination reduced incontinence episodes by about 3 per day compared to 2 per day with solifenacin alone 6.

This isn’t first-line treatment. Most guidelines suggest trying single-drug therapy first. But it’s an option when monotherapy isn’t working well enough.

Desmopressin for Night-time Symptoms

If nocturia (waking at night to urinate) is your main problem, desmopressin may help. This synthetic hormone is a replacement for vasopressin, which normally tells your kidneys to produce less urine overnight.

Desmopressin reduces urine production for several hours after taking it, which means your bladder fills more slowly while you’re trying to sleep. It’s also used for nocturnal enuresis (bedwetting) in both children and adults.

The main risk with desmopressin is hyponatraemia (low sodium levels in the blood), which can be serious. This risk is higher in older adults and women. Doctors typically start with a low dose and check sodium levels after starting treatment. You’ll also be advised to restrict fluid intake in the evening when using this medication.

Desmopressin doesn’t address daytime OAB symptoms, so it’s often used alongside other treatments rather than as standalone therapy.

Botulinum Toxin (Botox) Injections

When tablets aren’t working, Botox offers another option. This involves injecting botulinum toxin directly into the bladder wall during a cystoscopy (a procedure where a camera is passed into the bladder). The toxin blocks nerve signals to the bladder muscle, reducing unwanted contractions.

Botox can work well for people who haven’t responded to oral medications. In clinical trials, around 60% of patients had at least a 50% reduction in incontinence episodes 7. The effects typically last 6-9 months before wearing off, at which point the injections need repeating.

The downsides? Botox doesn’t work for everyone. There’s a risk of urinary retention (difficulty emptying the bladder completely), which occurs in roughly 5-10% of patients. Because of this, you’ll need to be comfortable with the possibility of learning intermittent self-catheterisation (ISC) before having the procedure. Urinary tract infections are also more common after Botox treatment.

Botox for OAB is usually only offered through specialist clinics after other treatments have been tried.

Neuromodulation Therapies

For people who can’t tolerate medications or haven’t responded to them, there’s also electrical stimulation of the nerves that control the bladder.

Percutaneous Tibial Nerve Stimulation (PTNS)

PTNS (sometimes marketed as Urgent PC) involves inserting a small needle near the ankle and passing a mild electrical current that stimulates the tibial nerve. This nerve shares a pathway with the nerves controlling the bladder, and the stimulation appears to help regulate bladder activity.

Treatment typically involves weekly 30-minute sessions for 12 weeks, followed by maintenance sessions. It’s minimally invasive and has few side effects. Studies report that 60-80% of patients see improvement, though the effect tends to be more modest than Botox for those who respond well to either 8.

Sacral Nerve Stimulation (SNS)

Sacral neuromodulation (brand name Interstim) is a more invasive option involving a permanently implanted device similar to a pacemaker. Electrodes are placed near the sacral nerves, and the device delivers continuous low-level electrical stimulation.

Before committing to permanent implantation, patients undergo a trial period with a temporary external stimulator to see whether they respond. Those who have significant symptom improvement during the trial can then have the permanent device implanted.

SNS can be highly effective for the right patients, but it’s surgery with associated risks, and the devices occasionally need adjustment or replacement. It’s generally reserved for people who haven’t responded to other treatments.

What to Expect When Starting Medication

A few practical points about OAB medication:

Give it time. Most OAB medications take 4-8 weeks to show their full effect. Don’t give up after a few days.

Side effects may settle. Dry mouth and other side effects often improve over the first few weeks as your body adjusts.

Don’t stop suddenly. If you want to stop a medication, discuss it with your doctor first. For some drugs, gradual reduction is preferable.

Keep a bladder diary. Recording your symptoms before and during treatment helps you and your doctor assess whether the medication is actually working.

Combine with lifestyle measures. Medication shouldn’t replace the lifestyle changes and bladder training that form the foundation of OAB management. People who do both tend to do better than those who rely on pills alone.

When Medication Isn’t Working

Not everyone responds well to OAB medication, and some people can’t tolerate the side effects. If you’ve tried several options without adequate improvement, it’s worth asking your GP for a referral to a urologist or urogynecologist. Specialist assessment can confirm the diagnosis (sometimes symptoms attributed to OAB have other causes), review whether you’re on the optimal treatment, and discuss advanced options like Botox or neuromodulation.

The COB Foundation provides fact sheets on all the medications discussed here. Contact us for more information or support in managing your bladder condition.