Minimally invasive therapies (intravesical onabotulinumtoxinA injection, sacral neuromodulation, and percutaneous tibial nerve stimulation) are attractive treatment options for the management of idiopathic overactive bladder in older adults. These therapies offer a low-risk safety profile that avoids the systemic side effects of OAB pharmacotherapy that are often worse in older adults. While the treatments are overall well-tolerated, each therapy differs by degree of invasiveness, time commitment, and associated risks. Given recent changes to the AUA Guidelines recommend consideration of minimally invasive therapies before a trial of medications, understanding how these therapies are utilized among older adults, especially in comparison to one another, is important for guiding treatment selection. Given the role of comparative outcomes in counseling about these treatment options and unique considerations in older adults. The aim of this study was to compare outcomes for continuation of minimally invasive therapy, as a proxy for treatment success, for overactive bladder (OAB) in older adults over 2 years.

This is a retrospective cohort study of a 100% sample of fee-for-service Medicare beneficiaries undergoing minimally invasive therapy for idiopathic OAB from 2015-2020. Therapies were identified by Current Procedural Terminology codes and included intravesical onabotulinumtoxinA injections (BTX-A), sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS). The primary outcome was the continuation of therapy, defined as 1. BTX-A: at least one repeat injection within 2 years; 2. SNM: progression to implantable tibial nerve stimulator placement within 90 days and without explant at 2 years; 3. PTNS: completion of induction therapy (11 treatments in 15 weeks) followed by at least 9 maintenance treatments within 2 years, based on prior research. Propensity score weighting (including age, race, sex, frailty, comorbidity, Area Deprivation Index, and procedure year) and weighted modified Poisson regression were used to compare outcomes between treatment groups.

A total of 111,494 Medicare beneficiaries initiated minimally invasive OAB therapy during the study period, and 34.5% (n=38,502) demonstrated continuation of therapy over 2 years. Rates of therapy continuation were as follows: BTX (58%), SNM (36.3%), PTNS (9.9%). On weighted regression analyses, beneficiaries undergoing BTX were 5.9-times more likely to continue treatment compared to PTNS (95% CI 5.71-6.10) and 1.63-times more likely to continue treatment compared to SNM (95% CI 1.60-1.65). Beneficiaries undergoing SNM were 3.63-times more likely to continue treatment compared to PTNS (95% CI 3.57-3.68).

In this national cohort of Medicare beneficiaries with idiopathic OAB who completed an index minimally invasive OAB therapy, a minority of older adults continue minimally invasive OAB therapy after initiating treatment. Of the minimally invasive therapies, BTX-A was found to be the most effective and continued therapy, and PTNS was the least. In developing therapy-specific definitions of continuation based on administrative claims to standardize outcome assessment, this study represents the first step toward assessing the relative effectiveness of minimally invasive therapies among older adults with OAB in a real-world setting.

Among the minimally invasive OAB therapies, older adults with idiopathic OAB are more likely to continue BTX-A and least likely to continue PTNS over 2 years of follow up. However, rates for continuation of any type of minimally invasive OAB therapy are low overall. This information may be helpful to clinicians to consider when counseling their patients on treatment options for of minimally invasive OAB therapies. Further research is needed to determine reasons for discontinuation of lack of continuation of minimally invasive OAB therapy, specifically in older adults.

Continence 19S (2026) 102653
DOI: 10.1016/j.cont.2026.102653