While you wait...
While you wait...
The Truth About Overactive Bladder Medications: Benefits, Risks, and Alternatives
If you've ever been prescribed medication for overactive bladder, you might wonder what it's actually doing and what the risks are. In this episode, I break down the two main types of medications used to treat OAB: anticholinergics and beta-3 agonists. We'll talk about how they work, the side effects (including memory concerns), and how to weigh the benefits and risks. I also explore alternative options like Botox and nerve stimulation, and why shared decision-making with your provider matters more than ever. If bladder urgency or leaking has been part of your life, this episode will help you make informed, confident choices about your treatment path.
For more information on this topic:
https://pubmed.ncbi.nlm.nih.gov/34213600/
Timeline
00:30 Introduction to Overactive Bladder
00:48 Behavioral Treatments for Overactive Bladder
00:57 Medications for Overactive Bladder
01:18 Anticholinergic Medications and Memory Concerns
01:37 Types of Medications for Overactive Bladder
03:55 Studies on Anticholinergics and Cognitive Impairment
03:23 Clinical Guidelines and Recommendations
04:26 Prevalence and Types of Overactive Bladder
05:00 Side Effects and Risk Factors
05:38 Research Findings on Anticholinergics
08:32 Considerations for Prescribing Medications
10:38 Alternative Treatments and Final Thoughts
Hi there. Today I wanted to talk to you a little bit about medications that we use to treat overactive bladder or urgency urinary incontinence. So when we have patients that come in with these symptoms, we do a history, we do a physical, sometimes we do a little bit of testing. The first line of treatment is always behavioral.
Looking at what you're drinking, teaching you to do urge suppression, teaching you about your muscles, strengthening those muscles. Then if that treatment is inadequate, the next line of treatment is frequently prescribing a medication. Patients have lots of questions about medications. Most medications have side effects.
Very few medications just do exactly what we want them to do. Sometimes they do a little bit more. Sometimes those things are good. Sometimes they're not so good. And one of the concerns about the medications that we use for overactive bladder is some of them have been associated with some memory loss.
And so these are questions that I get asked all the time, and I just wanted to spend a little bit of time and talk about them. So for overactive bladder, there are two families of medications, and the first family is the anticholinergic family. This group of medications blocks acetylcholine, which is a neurotransmitter that controls the parasympathetic system.
So it works in the how you pee mechanism. Then there is another family of medications that impact the beta three adrenergic receptor, and this also impacts the urination mechanism. Both of these medications help you to hold urine. They decrease frequency, they decrease urgency. They should decrease the associated leakage.
So in this anticholinergic family, there are six medications and these medications have been around since 1975, so they've been around for the longest. The beta three adrenergic receptor modulators have been around since 2012, so they're a much newer category of medication and there are only two medications in this family.
So there are eight medications that we have that we use to treat overactive bladder. So one of the big concerns about the anticholinergic medications is memory loss. And you know, this really isn't a side effect that is reasonable for anyone. Um, and this is something that really worries people. I, I think as we get older, everyone worries about losing their memory, having some word finding difficulties.
And so this is just a concern for so many people and nobody wants to do anything that that might make memory worse. There have been several studies that have linked all Cholinergics, so there are lots of other medications in the Anticholinergic family. They aren't just bladder medications. There are also antidepressants, antihistamines, or lots of other medications and types of medications that fall into this anticholinergic family.
They're used to treat a, a wide variety of conditions, but there have been studies that have linked all anticholinergics to cognitive impairment, to Alzheimer's and to dementia in general. So I am going to discuss the AOGs. So that is the American Urogynecologic Society Clinical Consensus Statement about anticholinergic use and cognition in women with overactive bladder.
So again, this is a guideline statement, just talking about what patients need to know and what clinicians need to know about this association. So again, overactive bladder urgency plus minus leaking an increase in daytime frequency going to the bathroom all the time, and it can also include an increase in nighttime frequency as well.
Some patients have OAB wet, and that means that they're actually leaking. Other patients have OAB dry, which means they don't leak. This condition happens to about 12 to 17% of the general population. And it is definitely more common in women in these two families of medication. So the anticholinergics and then the beta three adrenergic, the beta three adrenergic have less side effects.
And this is definitely that we, something that we see clinically. In the six anticholinergics, there are three that cross the blood-brain barrier and three that don't. And so we think the side effects with the ones that don't clo cross the blood-brain barrier are different. There have been different studies that have looked at anticholinergics and the risk of dementia.
There was a population-based prospective cohort of about 3,500 people. That looked at this association. 10.5% of the anticholinergics used in this study were used for bladder indications, and what they found in this study was that patients that had been using five milligrams of oxybutynin for more than three years had a significant increase of dementia compared to patients that were not using it.
There was also a significant increase in Alzheimer's. So, and that risk increased by about 50%. So this is an association, these two things kind of go together, but it doesn't show causality. It doesn't mean that the medication causes the memory loss. We, we can't quite say that yet, but this association is very concerning.
There's also been, um, studies that have shown significant changes in memory plus executive functioning in patients that are using anticholinergics versus patients that are not using anticholinergics. So the risk of progression to mild dementia, the highest risk of this, so developing mild dementia is associated with high anticholinergic activity.
There was also a retrospective study of just under 50,000 patients. So this included both men and women. And in this study they looked at the risk of memory loss with anticholinergics compared to the um, P to three agonists. And what they found is that there was an increase in the risk of memory loss in patients that were taking anticholinergics in the whole population.
When they looked just at women, there was not a statistically associated correlation. These studies are all limited. There are lots of people that are on more than one anticholinergic, right? So you might be taking an antihistamine, you might be taking an antidepressant, you might be taking a bladder medication.
You might be taking any combination of these medications. There's no standardized way to calculate the burden of all of these medications. Right? So how they combine together to impact your system. So it, it can be really hard to compare. 'cause there are a lot of different variables here. I. There are multiple risk scales that are used in the studies.
Some studies will use data from pharmacies, and so that means that they are looking at prescriptions that you picked up, but they don't necessarily know if you took that prescription or not. And so that can definitely skew the data and create some bias. There is an association between these anticholinergics and the recommendations at this point in time are that when behavioral therapies fail and you're considering giving a medication, clinicians need to talk to their patients, and patients need to know that there is a risk of memory loss, there's a risk of dementia, there's a risk of Alzheimer's, and they need to discuss potential benefits rate related to quality of life.
So for some patients the benefits may outweigh the risk for other patients, that it may be the total opposite, where the risks are just too high, or they may choose to use that medication in an intermittent fashion. So, so those are things that need to be discussed. When you are giving these medications, the lowest dose should be prescribed.
So some of these studies have looked at the dose and the higher the dose of the anticholinergic, or the more frequently you take it, that increases the risk. So you wanna be on the lowest risk. You should consider the beta three agonist. So for some patients, these medications might be safer. That risk of memory loss has not been associated with them, or at least not yet if someone is on other forms of anticholinergics.
Right? So antihistamines, antidepressants, you can consider changing those medications or changing those doses, and that is something that I would do with their primary care doctor, right? Would not do that in isolation. Everybody needs to be involved with that decision. So there's also a recommendation that it is best to avoid anticholinergics for overactive bladder in women who are older than 70.
So the risk increases as you age, right? And that only makes sense, and that if you are going to use an anticholinergic, you really wanna consider one of the ones that doesn't cross the blood brain barrier. For some patients, this may be a reason to move on to third line treatment, which includes Botox and nerve stimulation.
There are different reasons that you would do this. There are different risk factors, different benefits with these treatments, but these treatments do not have any risk of changes in cognition. There was a systematic review that came out looking at this topic, right, so overactive bladder medication. The risk of changes in cognition.
This came out in the International Urogynecology Journal in 2021 and they found the same correlation. Their recommendation was that you should be very careful prescribing these medications in women who are older than 65. A UA and Sufu also agree that there needs to be a lot of shared decision making here, and there needs to be a big conversation with patients discussing this.
Again, at this point, this relationship is an association. It's not thought to be causal or we can't say that it is causal yet, but the correlation is strong enough. That it does make me hesitate to prescribe this medication. In older women, and even in younger women. It is important to discuss this and to consider other forms of treatment for overactive bladder, especially if somebody feels like that risk outweighs the benefit.
It's important that you know what your medications are and how they can impact your system, and how different medications work together.
