Minimally invasive therapies for overactive bladder are underutilized across the United States

An analysis presented at the 2025 Annual Meeting of the American Urological Association in Las Vegas, Nevada showed that the use of minimally invasive therapies for overactive bladder (OAB) remains low across the United States, with neuromodulation registering a steady decline over the past decade.

First-line therapies for OAB include behavioral changes and pharmacotherapy. When patients with OAB do not achieve significant symptom relief, they can turn to a myriad of minimally invasive therapies (MITs), including bladder botox (BB), tibial nerve stimulation (TNS), and sacral neuromodulation (SNM). While neuromodulation has emerged as a promising treatment option for OAB, with a favorable safety profile, uptake has remained relatively low compared to other treatments.

Researchers in the department of urology at the University of California San Francisco Medical Center used data from The American Urological Association Quality (AQUA) Registry to evaluate treatment trends over time, particularly focusing on the utilization of SNM. The AQUA Registry is a national Qualified Clinical Data Registry designed for the measurement and reporting of patient outcomes. Real-world data included in the registry are collected directly from electronic health records across various geographic regions and practice settings in the United States and are used to help urologists improve diagnosis and treatment outcomes.

The study group searched the database for patients aged at least 18 years who were newly diagnosed with nonneurogenic OAB from 2014 to 2023. The annual utilization of therapies per patient was examined across all study years. Only 2.9% of more than 2 million adults with a diagnosis of nonneurogenic OAB received MITs during the study period: 28,463 (1.4%) underwent BB, 19,582 (.98%) underwent SNM, and 17,045 (.85%) underwent percutaneous tibial nerve stimulation (PTNS). An overwhelming majority (97.2%) of individuals with OAB were seen in a practice where at least one MIT was offered, and three-quarters of participants were patients of practices where all MITs were available.

The researchers detected a steady increase in the proportion of patients undergoing BB from 2014 to 2023. However, the proportion of patients undergoing SNM and PTNS continued to decline over the same period. A multivariable analysis showed that individuals who underwent SNM were more likely to be men younger than 51 years, live in a rural area, and be seen or treated in a high-volume medical practice compared with those who used other minimally invasive therapies. Patient demographics, including AQUA geographic region, appeared to influence choice of SNM therapy over other MITs. Patients in the southeastern section had the highest odds of receiving SNM, followed by those in the south-central region, while patients in New England had the lowest odds of using SNM. 
“Overall utilization of minimally invasive therapies [for OAB] is low, with less than 3% of diagnosed patients receiving MITs over a 9-year period,” the authors concluded. “While bladder botox has seen a steady uptick in utilization, SNM and PTNS have declined, with the PTNS decline appearing to coincide with the COVID-19 pandemic. These findings highlight an opportunity to better understand patient and provider preferences and limitations when selecting minimally invasive therapies.”

Multiple factors may play a role in the underutilization of minimally invasive treatments for OAB, including patient preference, hesitancy, lack of awareness and communication with providers, and resource limitations. While a future analysis conducted in the post-COVID-19 era may reveal a shift in trends, patient and provider education and shared decision-making could address some of the barriers to the implementation of MITs in clinical practice