Concomitant overactive bladder treatment and adherence to pelvic floor physical therapy

Objectives: Pelvic floor physical therapy (PFPT) and medications are used as first and second line therapies in the treatment of overactive bladder (OAB). The objective of this study is to assess whether adherence to PFPT improves with concomitant initiation of medications for the treatment of OAB.

Methods: This is a retrospective cohort study of women with OAB and PFPT referral. Women with concomitant OAB medication prescription (PT+Med) were compared to those without OAB medication prescription (PT). The primary objective was to assess PFPT adherence defined as ≥50% attendance of the recommended number of PFPT visits. Women age ≥18 years old with a PFPT referral from an urogynecology provider for OAB or associated diagnoses between 1/1/2017 and 6/1/2020 were included. Patients with prior PFPT, concomitant pelvic pain diagnosis, predominant stress urinary incontinence or prior OAB third line therapy were excluded. Standard tests of comparison were used with multivariable logistic regression used to control for confounders.

Results: A total of 114 women were included with 62 in PT alone group and 52 in PT+Med group. Median age was 66 years and women in PT group had a higher BMI (PT 27.0 kg/m², PT+Med 30.0 kg/m², =0.003) and less vaginal estrogen use (PT 53%, PT+Med 77%, p=0.01). Menopausal status, smoking status and comorbidity index were similar between groups. Symptom bother measured by Urogenital Distress Inventory (UDI) was higher in the PT+Med group (PT 33, PT+Med 40, p=0.03). Women in the PT alone group completed more PT sessions (PT 3, PT+Med 0, p=0.01) and were more likely to be adherent to ≥50% recommended PFPT visits (PT 60%, PT+Med 14%, p=0.02).The PT+Med group was more likely to progress to third line therapy (PT 0%, PT+Med 10%, p=0.02). On multivariable logistic regression model, PFPT adherence remained significantly lower for PT+med group when controlling for BMI, estrogen use, diabetes, third line therapy, and UDI score (aOR 0.24, 95% CI 0.07-0.09, p=0.03). Vaginal estrogen use (aOR 2.97, 95%CI 1.02-8.68, p=0.05) and BMI (aOR 1.09, 95%CI 1.01-1.18, p=0.04) also were significant.

Conclusions: The addition of OAB medication prescription at the time of PFPT referral for women with OAB decreased adherence rates to PFPT. Patients treated with PFPT and concomitant medication were also more likely to attend no PT sessions and progress onto third line therapy. This may be due to women with more bothersome symptoms moving through the treatment algorithm faster or because the medications work before the patient can see PFPT and therefore never initiate formal PFPT. More research is needed to understand patient preferences regarding OAB treatment choice and timing of medication initiation.