Synopsis
Select and monitor antimuscarinic or beta-3-agonist treatment after appropriate behavioural care, using current UK doses, contraindications, interaction checks and structured review.
- Use OAB medicine after bladder training has been offered and urgency or frequency remains troublesome; confirm infection, emptying and the diagnosis before escalation.
- Explain that benefit varies, may take at least four weeks, and antimuscarinic dry mouth and constipation are common rather than evidence of an allergy.
- Review frailty, cognition, glaucoma, gastric motility, bowel obstruction, myasthenia, residual urine, renal and hepatic function, blood pressure and total anticholinergic burden.
- NICE advises the lowest-acquisition-cost suitable anticholinergic first; do not offer flavoxate, propantheline or imipramine for OAB or urinary incontinence.
- Do not offer immediate-release oxybutynin to an older woman at higher risk of sudden physical or mental deterioration.
- Mirabegron and vibegron are NICE options when antimuscarinics are unsuitable, insufficiently effective or cause unacceptable adverse effects, subject to their individual licences.
- Review four weeks after every new medicine or dose change, sooner for adverse effects; review long-term treatment annually, or every six months when older than 75.
- Stop ineffective treatment, switch within the pathway or refer after unsuccessful or intolerable medicine trials; retain bladder training and safety-netting.
Key red flags
Painful retention, rapidly rising residual, anuria or renal impairment after treatment requires urgent bladder and urological assessment.
A painful red eye, blurred vision or halos with an antimuscarinic raises concern for acute angle closure and needs emergency ophthalmic review.
Severe headache, chest pain, neurological symptoms or blood pressure at hypertensive-crisis levels while taking mirabegron requires immediate assessment.
New delirium, hallucinations, falls, severe constipation or heat intolerance may reflect clinically important anticholinergic toxicity.
Facial swelling, breathing difficulty, widespread rash or another serious hypersensitivity reaction requires emergency treatment.
Investigation priorities
Confirm the storage pattern and establish baseline frequency, urgency, leakage and nocturia.
Management branches
Bladder training has not adequately controlled bothersome urgency or frequency.
- Recheck diary, urinalysis, emptying symptoms, fluid pattern, constipation, prolapse, neurological features and the person's treatment goal.
- Review cognition, frailty, falls, glaucoma, bowel disease, myasthenia, renal and hepatic function, blood pressure, pregnancy and every interacting medicine.
- Explain likely benefit, delayed onset, adverse effects and alternatives, then select the lowest-cost suitable anticholinergic or a NICE-indicated beta-3 agonist.