Navigating the challenges of overactive bladder management in women

PURPOSE: Overactive bladder (OAB) is common among women, increases in prevalence with age, and exerts a considerable physical, psychological and socioeconomic burden. This narrative review discusses issues specific to the management of OAB in women. METHODS: The review is based on discussions at a symposium held at the International Urogynecological Association/European Urogynaecological Association meeting (Barcelona, Spain; June 2025) supplemented by a PubMed search of articles (published in English since 1 January 2020) describing current treatment practices, unmet clinical needs and future directions for the management of OAB in women. RESULTS: The pathophysiology of OAB in women is multifactorial, involving detrusor overactivity, urothelial and sensory dysfunction, and central nervous system dysregulation, with additional contributions from hormonal and age-related changes. Management of OAB has evolved toward an individualised, stepwise approach. Behavioural and lifestyle interventions remain first-line therapy, followed by pharmacological options, such as antimuscarinics and β3-adrenergic agonists. For refractory cases, onabotulinumtoxin A and neuromodulation are established third-line treatments. Local oestrogen therapy or prasterone may provide benefit in selected postmenopausal women, whereas radiofrequency and urethral bulking strategies remain investigational. Emerging evidence supports newer β3-agonists, such as vibegron, which may provide comparable efficacy to established β3-agonists (e.g. mirabegron) with improved cardiovascular tolerability. Treatment selection for women with OAB should consider comorbidities, drug safety, cognitive and cardiovascular risk in older patients, and challenges with adherence. CONCLUSION: Further research into underlying mechanisms, long-term outcomes and strategies to optimise treatment adherence will be essential to improve symptom control and quality of life for women living with OAB.