The 2024 AUA/SUFU Guideline on the Diagnosis and treatment of Idiopathic Overactive Bladder¹ (OAB) is not an update of the previous OAB guideline,² but is a new document generated by a fresh systematic review of the contemporary evidence on the diagnosis and management of OAB in all genders. It centers on an approach that maximizes OAB symptom control and patient quality of life through shared decision-making, while minimizing adverse events and burden of disease. The most notable feature of this current guideline is that it departs from the conventional “step therapy” model,³ which once dictated a linear treatment progression through behavioral modification, pelvic floor muscle therapy, pharmacotherapy, and finally advanced interventions. Contrary to its predecessors, this narrative does not advise the sequential treatment ladder, suggesting instead an individualized selection of therapeutic options. As a result, we have eliminated the terms “first-, second-, or third-line therapy,” and prefer to classify treatments by invasiveness. However, this does not imply that one must progress through all less invasive therapies before attempting more complex strategies. The treatments are more correctly viewed as a menu of options to be decided on by the patient and clinician based on shared decision-making. Shared decision-making emphasizes tuning treatment choices to the patient’s preferences, symptom severity, and tolerance to potential side effects, rather than adhering to a rigid, stepwise protocol. This patient-centered approach is reflected in the structuring of therapeutic interventions by invasiveness (Table), rather than a hierarchical sequence, thus promoting a personalized treatment strategy and avoiding pharmacotherapy when needed or desired, recognizing the potential harm of antimuscarinic medications.

Another notable feature in this guideline is the explicit inclusion of patients with prostates, acknowledging that OAB symptoms are prevalent across this demographic. In light of this, when applicable data are available, there is a tailored analysis dedicated to the treatment of men, thereby rectifying a common misapprehension that all urinary symptoms in men are primarily attributable to prostatic concerns. This misperception has historically led to the underdiagnosis and undertreatment of OAB in such individuals. The guidelines differentiate between patients who exhibit symptoms of both benign prostatic hyperplasia (BPH) and OAB, and those who exclusively or primarily suffer from OAB, directing tailored treatment toward accurate diagnoses.

Another patient-centered aspect of this guideline is the acknowledgment that virtual care (telemedicine) is possible for the initial evaluation or follow-up of the patient with OAB. The limitations of the inability to perform a physical exam, postvoid residual urine volume, or obtain a urine specimen are discussed, with strategies provided to obtain these data points during follow-up at a local laboratory (urine sample) or imaging center (postvoid residual urine volume). Many patients are being cared for through telemedicine, improving access to care for patients in remote locations or with limited opportunity for transportation to provider’s office; the safety of this provision of care is supported by the new guideline.

A final change in the guideline includes a focus on the impact of nonurological contributing factors (eg, medical comorbidity, obesity, constipation, pelvic floor dysfunction) and guidance on those conditions whose treatment could improve the symptoms of OAB. This approach underscores the multifaceted nature of OAB management. Similarly, the guideline recognizes a spectrum of pathophysiological mechanisms potentially contributing to OAB symptoms—from neurological disturbances involving afferent and efferent pathways, detrusor overactivity, or muscle hypersensitivity, to pelvic floor dysfunction, anatomical distortions, microbial implications, and even central nervous system changes suggestive of a correlation with cognitive decline due to loss of frontal cortex inhibition. Current pharmacotherapies target muscarinic and β3 adrenergic receptors, but research indicates promising avenues with other molecular targets, such as cannabinoid and purinergic receptors, holding the promise of enhanced efficacy, optimal tolerance, and reduced financial burden for future medical treatments.⁴

The challenges in diagnosing and managing OAB are accentuated by its enigmatic pathophysiological origins and the absence of definitive diagnostic tests that reliably delineate treatment pathways. Current research endeavors focus on phenotyping OAB, predicting response to therapy, and the integration of these insights into a collaborative decision-making process with patients. Each step of this journey offers fertile ground for further research and development.

Above all, a strategy of transparent communication with patients is paramount, underlining the chronic nature of OAB and setting realistic expectations regarding symptom management. Clear discussions may help consolidate a holistic approach that is agile enough to adapt treatments over the lifetime of the patient.

In summary, the new OAB guideline features a shared decision-making process that outlines options for care that respect the patient’s lifestyle and preferences while optimizing therapeutic response through multifaceted and adaptable therapeutic interventions. This is the essence of contemporary OAB management—the harmonization of patient-centered care with evidence-based medicine to achieve the best possible outcomes for individuals grappling with the complexities of an overactive bladder.