Management of refractory overactive bladder

Key content Overactive bladder does not respond to first-line treatment in over 50% of cases. There is no agreed definition of what constitutes refractory overactive bladder. Botulinum toxin injection is effective, with a long duration of action but appreciable rates of urinary retention and infection (around 10% and 20%, respectively). There remain some questions about the preferred dose and the schedule of repeat dosing. There are few data on cost-effectiveness of botulinum toxin. Sacral nerve stimulation is an invasive, complex and expensive procedure. Sacral nerve stimulation is effective, but reoperation rates and complications are common. Percutaneous tibial nerve stimulation is a less invasive, cheaper alternative to sacral nerve stimulation but long-term efficacy is yet to be confirmed. Learning objectives To understand the available data on the efficacy and safety of botulinum toxin use. To be aware of the need for thorough assessment of patients, and the importance of multidisciplinary team review and appropriate detailed counselling. To understand the available data on the efficacy and safety of the alternative methods of neuromodulation. Ethical issues The long-term benefits and risks of these treatments are not fully defined. Is it ethical to commence potentially lifelong treatment without robust, high-quality data confirming safety?