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Idiopathic overactive bladder with detrusor overactivity — MSRA MCQ

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HardUrologyIdiopathic overactive bladder with detrusor overactivityMSRA

A 66-year-old woman is referred for specialist management of urgency urinary incontinence. Urine culture is negative and post-void residual volume is 28 mL. She has completed supervised bladder training and has had no meaningful benefit from sequential trials of solifenacin and mirabegron. Urodynamic assessment demonstrates detrusor overactivity. She wishes to consider an invasive treatment but states that she would be unable to perform clean intermittent catheterisation because of severe hand osteoarthritis and would decline a temporary indwelling catheter if urinary retention occurred. What is the most appropriate next management step?

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Correct answer: C — Refer for local or regional MDT assessment for percutaneous sacral nerve stimulation

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · A = shown as D · C = shown as E

This woman has idiopathic overactive bladder with objectively demonstrated detrusor overactivity, negligible residual urine and failure of conservative and pharmacological treatment. Intravesical botulinum toxin type A would normally be an invasive option after MDT review, but it should be started only if the woman is willing to undertake clean intermittent catheterisation if significant voiding dysfunction develops, or accept a temporary indwelling catheter if she cannot self-catheterise. Her stated refusal of both options makes botulinum toxin inappropriate. Percutaneous sacral nerve stimulation is the appropriate next invasive option after local or regional MDT review when symptoms have not responded to conservative measures and medicines, and the woman is not prepared to accept the catheterisation risk associated with botulinum toxin. A is attractive because detrusor overactivity is confirmed and medication has failed, but the catheterisation contingency is not acceptable to her. C is less appropriate because adequate treatment trials from both antimuscarinic and beta-3 agonist classes have failed and she seeks invasive management. D is reserved for substantially later-line management when less invasive options are unsuitable or unsuccessful. E does not treat detrusor overactivity and exposes her to avoidable catheter-related morbidity; she has no retention-related indication for long-term catheterisation.

Reference: NICE: Urinary incontinence and pelvic organ prolapse in women: management (Published 2019; minor updates March 2025) — https://www.nice.org.uk/guidance/ng123/chapter/recommendations NICE: Urinary incontinence and pelvic organ prolapse in women: management (Published 2019; minor updates March 2025) — https://www.nice.org.uk/guidance/ng123/chapter/recommendations NICE: Urinary incontinence and pelvic organ prolapse in women: management (Published 2019; minor updates March 2025) — https://www.nice.org.uk/guidance/ng123/chapter/recommendations