Overactive bladder
Symptom complex of urgency, often with frequency and/or urge incontinence, in the absence of urinary tract infection and other obvious causes. EAU 2024 foundation therapy is behavioral (bladder training, caffeine reduction, pelvic floor exercises). When this is insufficient, antimuscarinics (solifenacin, tolterodine) or β3-agonists (mirabegron) are added. In refractory symptoms, intravesical botulinum toxin and neuromodulation are options.
ICD-10 N32.88 drugs
Also known as: OAB, Urge urinary incontinence, Urinary urgency
Drugs used for this condition
- AMirabegronSecond line · Selective β3-adrenoceptor agonist for overactive bladderSecond-line for overactive bladder alongside antimuscarinics per EAU 2024 and AUA 2019. Dose 50 mg once daily; start at 25 mg in older adults or with moderate renal/hepatic impairment. Efficacy is comparable to solifenacin and tolterodine (SCORPIO trial), without anticholinergic side effects – preferred in older patients and those intolerant of dry mouth. Combination mirabegron + solifenacin (combined formulation Vesomni) can be used when monotherapy is insufficient.
- ASolifenacinSecond line · Antimuscarinic for overactive bladderSecond-line for overactive bladder after behavioral therapy failure (bladder training, caffeine reduction, pelvic floor exercises) per EAU 2024 and AUA 2019. Dose 5 mg once daily; up-titrate to 10 mg if needed. Effect develops over 4 weeks, with assessment at 12 weeks. In the STAR head-to-head trial (Chapple 2005), solifenacin outperformed tolterodine on urgency episodes.
- BFesoterodineSecond line · Muscarinic receptor antagonist for overactive bladderFesoterodine is a second-line muscarinic blocker for overactive bladder. NICE NG123 (2024) and AEU 2023 place behavioural therapy first: bladder training, caffeine and fluid control, pelvic floor exercises for at least 8–12 weeks. Add fesoterodine if symptoms persist after behavioural therapy. AEMPS approves 4–8 mg once daily; start at 4 mg, titrate upward after 4 weeks if response is inadequate. Reduction in urgency episodes vs placebo: 1–2 per day (Cochrane 2012).
- BPropiverineSecond line · Muscarinic blocker with additional calcium channel blockadePropiverine is a second-line muscarinic blocker for overactive bladder. AEMPS approves it in adults and children over 5 years. NICE NG123 (2024) and EAU 2024 place behavioural therapy first; propiverine is added if symptoms persist. Starting dose 15 mg twice daily (or 30 mg SR once daily), up to 45 mg/day if needed. The Madersbacher meta-analysis (2014) showed propiverine has efficacy comparable to oxybutynin with less dry mouth.
- BTolterodineSecond line · Muscarinic receptor antagonist for overactive bladderTolterodine is a second-line muscarinic blocker for overactive bladder. NICE NG123 (2024) and EAU 2024 recommend behavioural therapy first: bladder training, caffeine restriction, a 3-day voiding diary. If symptoms persist, AEMPS approves tolterodine 2 mg twice daily (or 4 mg once daily SR). The STAR trial (Chapple 2007, Eur Urol) showed solifenacin 5–10 mg achieves better urgency control than tolterodine 4 mg SR.
- BTrospiumSecond line · Quaternary ammonium muscarinic blocker for overactive bladderTrospium is a second-line muscarinic blocker for overactive bladder and a preferred choice in older patients. NICE NG123 (2024) explicitly notes: the quaternary amine does not cross the blood-brain barrier and is less likely to cause confusion, memory impairment and somnolence than tertiary antimuscarinics (solifenacin, tolterodine, oxybutynin). AEMPS approves 20 mg twice daily on an empty stomach (or 60 mg SR once daily). With renal impairment (CrCl <30 mL/min) the dose is halved.
- CPumpkin seed extractAdd-on therapy · Botanical supplement, pumpkin seed extract (Cucurbita pepo); EMA HMPC traditional-use herbal medicinal product for BPH symptoms and overactive bladder; sold on iHerb and Amazon for «prostate health» and women's «urinary comfort»Pumpkin seed extract is one of the few herbal remedies with an EMA-recognised indication in overactive bladder (OAB) in adults, and in women this matters because OAB is 1.5–2 times more common in women than in men. The Nishimura open-label study (J Tradit Complement Med 2014) in 39 adults with OAB used Cucurbita maxima pumpkin seed oil 10 g/day for 12 weeks: daytime voids dropped 21%, nighttime voids 36% and OAB-q balance improved. The sample is small and there is no placebo control. EMA HMPC 2012 recognises pumpkin seed as a traditional-use medicinal product for OAB symptoms based on 30 years of use, not RCTs. ICS/ICI 2023 and AUA recommend behavioural therapy as first line for OAB (fluid management, Kegel pelvic-floor exercises, timed voiding) and antimuscarinics (solifenacin, tolterodine, fesoterodine) or mirabegron as second line. Herbal products are mentioned as an option for mild symptoms. If pumpkin seed is being added to standard therapy, discuss with a urogynaecologist or urologist and rule out urinary tract infection and interstitial cystitis.
- CPumpkin seed oil (Cucurbita pepo, Cucurbita maxima)Add-on therapy · Plant product, supplement. In EU – traditional herbal medicinal product per EMA HMPC monograph; AEMPS does not register as monomedicineNishimura 2014 RCT (n=39, Japan) showed moderate reductions in urgency incontinence episodes and urinary frequency with pumpkin seed oil from Cucurbita maxima 10 g/day × 12 weeks in overactive bladder patients. EMA HMPC 2012 recognises «traditional use for overactive bladder symptoms» for Cucurbita pepo. AUA/SUFU 2024 for overactive bladder list behavioural therapy (bladder training, pelvic floor exercises) first-line, antimuscarinics (solifenacin, tolterodine, mirabegron) second-line, and botulinum toxin and neuromodulation third-line. Pumpkin seed oil is not in guidelines as standalone therapy. If pumpkin seed oil was recommended for severe urgency incontinence or nocturnal polyuria without workup (urodynamics, voiding diary), consider seeking a second opinion from a urologist.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit