#54 Overactive bladder, urge incontinence and anticholinergic drugs
CLINICAL QUESTION
In patients with overactive bladder (OAB), or urge incontinence, how well do medications work and are any of them better?
BOTTOM LINE
Both anticholinergic drugs and placebo improve overactive bladder, although medications slightly more (about ½ a trip less to the bathroom/day). The drugs oxybutynin, tolterodine, solifenacin, and darifenacin are very similar in efficacy while adverse events (dry mouth and likely constipation) vary.
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EVIDENCE
Overactive bladder (OAB) responds well to placebo1 but slightly more to anticholinergics.
- Systematic review,2 61 trials, 11,956 patients, comparing anticholinergic drugs like oxybutynin (Ditropan®) and tolterodine (Detrol®) to placebo, statistically significant difference:
- Patient reported cure or improve: 55.6% anticholinergic versus 41% placebo, Number Needed to Treat (NNT)=7.
- Anti-cholinergic reduced leaks 0.58/day better than placebo.
- Anti-cholinergic reduced micturitions 0.64/day better than placebo.
- Dry mouth was more common with anticholinergic (30.9% versus 9.8%).
- Withdrawal due to adverse events not different.
- Patient reported cure or improve: 55.6% anticholinergic versus 41% placebo, Number Needed to Treat (NNT)=7.
- Recent systematic review found similar.3
- Reviews comparing anticholinergic and other drugs:
- Comparing anticholinergics (i.e. oxybutynin versus tolterodine):4
- Oxybutynin: more dry mouth (Number Needed to Harm (NNH)=6) and withdrawal (NNH=20).
- No difference in incontinence outcome.
- Extended versus immediate release formulations offer no advantage except perhaps less dry mouth.4
- Reviews by the Canadian Expert Drug Advisory Committee found:
- Darifenacin (Enablex®): No consistent difference to oxybutynin or tolterodine.5
- Solifenacin (Vesicare®): Less dry mouth than oxybutynin and some inconsistent results compared to tolterodine, showing possible worsening constipation but small improvements in incontinence symptoms.6
- Comparing anticholinergics (i.e. oxybutynin versus tolterodine):4
- Guidelines recommend confirming if a urinary tract infection (and treating as necessary), caffeine reduction and weight reduction, supervised bladder training, and anti-cholinergic bladder medications as needed.7
- All anticholinergic treatments increase the risk of constipation:
- Comparisons are limited but tolterodine appears to have the lowest risk.8
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