Minimally invasive therapies for older patients with urgency urinary incontinence: Current evidence and recommendations

Overactive bladder (OAB) and urgency urinary incontinence (UUI) disproportionately affect older patients and overlap with multiple geriatric syndromes including frailty and cognitive impairment. Given concerns regarding polypharmacy and anticholinergic risks in older patients, there has recently been a push from multiple societies to eliminate the concept of “step therapy” and offer patients more individualized treatment options. This may involve offering minimally invasive therapies, traditionally referred to as “third line therapies”, without requiring trials of non-invasive or pharmacologic management. This narrative review considers current evidence and recommendations for minimally invasive therapies (onabotulinumtoxin A (BTX), sacral neuromodulation (SNM), percutaneous tibial nerve stimulation (PTNS), and implantable tibial nerve stimulation (ITNS)) in older and frail patients. There are no data to support one minimally invasive therapy over another. BTX and SNM may have slightly lower efficacy compared to younger patients, but the clinical relevance of this difference is unclear. BTX may have a higher risk of UTI and retention in older frail patients. While cognitive impairment alone should not preclude SNM, it is important to consider if planning for SNM. PTNS is the lowest risk option but carries a significant logistical burden that may reduce adherence. ITNS may mitigate this logistical burden; however, there are minimal data specific to this group and older frail patients may not be appropriate candidates. Ultimately, older patients with or without frailty should be considered candidates for minimally invasive therapies for OAB/UUI as available data support their safety and efficacy in these populations. However, there may be unique considerations for this group and treatment decisions should be individualized and based on shared decision making. • Advanced age should not preclude patients from minimally invasive therapies for overactive bladder. • Intradetrusor BTX may confer higher risk of UTI and retention in older and frail patients. • Intradetrusor BTX and SNM may have slightly lower efficacy in older vs younger patients. • PTNS is the least invasive minimally invasive therapy option but adherence is limited by logistical burdens. • ITNS may bypass these burdens, but many older frail patients may not be good candidates for implant.