Use of additional therapies after minimally invasive therapies among women with overactive bladder

Objective

To evaluate the rate, timing, and predictors of additional therapy among women with idiopathic overactive bladder (OAB) following initial minimally invasive treatments (MIT).

Study Design

Retrospective single center cohort study of women with idiopathic OAB treated between 2012 and 2021. Using ICD and procedural codes, we identified women who underwent posterior tibial nerve stimulation (PTNS), sacral neuromodulation (SNM), or intradetrusor onabotulinumtoxinA (BTX). The primary outcome was receipt of additional OAB treatments,OAB medication initiation or a different MIT. Kaplan-Meier analysis estimated time to additional therapies; Cox proportional hazards and random survival forest models identified predictors.

Results

1,007 women were included (PTNS: 459; SNM: 192; BTX: 356). At three years, 75% of PTNS patients, 58% of BTX patients, and 40% of SNM women required additional therapies with most patients choosing additional pharmacotherapy rather than crossover to a different MIT. Median time to additional treatments was 10 months (PTNS), 19 months (BTX), and 53 months (SNM). Higher BMI was associated with increased risk of further treatment after SNM (HR 2.1, 95% CI: 1.1-4.2), while recurrent urinary tract infections were associated with needing additional therapies in the BTX cohort (HR 1.8, 95% CI: 1.1-3.2). Random survival forest models resulted in poor model performance.

Conclusions

Following initial MIT for idiopathic OAB, many women required additional treatment within three years, many choosing pharmacotherapy rather than transition to another MIT.

Why This Matters

Overactive bladder (OAB) affects over 20% of women in the United States, and current AUA/SUFU guidelines have shifted from traditional stepwise therapy toward shared decision-making and multimodal treatment. While minimally invasive therapies (MIT) are effective options for OAB, real-world data on patient trajectories after MIT initiation, including rates of treatment augmentation, crossover, or return to pharmacotherapy, remain limited.

This retrospective cohort of 1,007 women with idiopathic OAB provides novel data on post-MIT care-seeking, with 40–75% of patients requiring additional therapy within three years. SNM demonstrated the longest interval before additional therapy and the lowest rate of subsequent care-seeking. Notably, most women who required additional treatment chose pharmacotherapy rather than crossing over to a different MIT. Modifiable risk factors associated with additional care-seeking included higher BMI after SNM and recurrent urinary tract infections after BTX, though whether addressing these factors would reduce the need for additional therapy remains unclear.

These findings reinforce that OAB management is a dynamic, ongoing process rather than a one-time intervention, and that multimodal therapy is often necessary for optimal improvement. Clinicians can use these data to set realistic expectations during counseling, framing additional therapy as a common and anticipated part of the treatment trajectory rather than a treatment failure.