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Idiopathic overactive bladder with urgency urinary incontinence — MSRA MCQ

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HardUrologyIdiopathic overactive bladder with urgency urinary incontinenceMSRA

A 78-year-old woman has urgency urinary incontinence, with 3 urgency-related leakage episodes daily and 11 daytime voids on a 3-day bladder diary. She has completed 8 weeks of bladder training and reduced caffeine intake without satisfactory benefit. Urine dipstick is negative for blood, nitrites and leucocytes; pelvic examination shows no prolapse or pelvic mass; and post-void residual volume is 35 mL. She has no stress incontinence, voiding difficulty or neurological symptoms. Solifenacin previously reduced her urgency but caused severe constipation and acute confusion, so it was stopped. She has stage 4 chronic kidney disease (eGFR 24 mL/min/1.73 m², stable) and treated hypertension. Her blood pressure remains 182/112 mmHg on repeated measurement today; she has no headache, chest pain, breathlessness, focal neurological symptoms or visual disturbance. A separate plan is made to assess and intensify her antihypertensive treatment. What is the most appropriate pharmacological treatment for her overactive bladder symptoms?

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Correct answer: C — Start vibegron 75 mg once daily

This woman has idiopathic overactive bladder: her diary confirms urgency-related leakage and frequency, urine testing is negative, there is no prolapse or neurological cause, and the low residual volume argues against clinically important impaired emptying. Conservative treatment has been inadequate. Antimuscarinics are not suitable because solifenacin caused clinically significant constipation and acute confusion. NICE recommends vibegron as an option for adults when antimuscarinics are unsuitable, ineffective or not tolerated. Vibegron 75 mg is therefore appropriate. Its SmPC states that no dose adjustment is needed for severe renal impairment provided GFR is above 15 mL/min and dialysis is not required; her eGFR is 24 mL/min/1.73 m². The low residual volume and absence of obstructive symptoms make the retention precaution less limiting, although she should be advised to report voiding difficulty. Mirabegron is contraindicated because her blood pressure meets the SmPC definition of severe uncontrolled hypertension (systolic at least 180 mmHg and/or diastolic at least 110 mmHg). Restarting solifenacin or using oxybutynin re-exposes her to an antimuscarinic burden after significant cognitive and gastrointestinal adverse effects. Desmopressin is directed at troublesome nocturia, which is not her predominant problem, and requires particular caution in older people with hypertension.

Reference: NICE TA999: Vibegron for treating symptoms of overactive bladder syndrome (04 September 2024) — https://www.nice.org.uk/guidance/ta999/chapter/1-Recommendations Obgemsa 75 mg film-coated tablets Summary of Product Characteristics (Revised 06 March 2025) — https://www.medicines.org.uk/emc/product/15962/smpc Obgemsa 75 mg film-coated tablets Summary of Product Characteristics (Revised 06 March 2025) — https://www.medicines.org.uk/emc/product/15962/smpc