Behavioral Compared With Drug Therapy for Overactive Bladder Symptoms in Parkinson Disease

Importance: Overactive bladder (OAB) symptoms in Parkinson disease (PD) are burdensome, and the adverse effects of drug treatment can worsen PD-associated morbidity. Drug adverse effects are avoided with pelvic floor muscle exercise-based behavioral therapy. Objective: To assess the noninferiority of behavioral compared with solifenacin drug therapy for OAB symptoms in persons with PD. Design, Setting, and Participants: This 12-week randomized noninferiority trial of behavioral therapy compared with solifenacin was conducted between 2018 and 2023 within 4 US Veterans Affairs health care systems. Eligible participants were diagnosed with PD by a movement disorder neurologist and had an International Consultation on Incontinence Questionnaire OAB module (ICIQ-OAB) symptom score of 7 or higher (range, 0-16; higher score indicates worse symptoms) and Montreal Cognitive Assessment (MOCA) score of 18 or higher (range, 0-30). Participants were randomized 1:1 after stratification by sex, recruitment site, OAB severity, and PD motor symptom severity. Analyses were conducted from October 2023 to April 2024. Interventions: Behavioral therapy was implemented by a nurse practitioner and included pelvic floor muscle training and urge suppression strategies. Solifenacin therapy started at 5 mg daily, with titration to 10 mg daily if needed. Main Outcome and Measures: The primary outcome was the 12-week ICIQ-OAB score across groups within a 15% noninferiority margin. Adverse events were assessed every 2 weeks for 8 weeks and again at 12 weeks. Results: A total of 77 persons with PD (65 [84%] male; mean [SD] age, 71.3 [8.9] years; mean [SD] years with PD, 6.6 [5.8]) were randomized to behavioral (n = 36) or drug therapy (n = 41). Seventy-three participants completed the study (4 dropped out in drug group). Baseline characteristics were balanced across groups, including MOCA score (mean [SD], drug, 23.9 [3.1]; behavioral, 24.8 [3.3]) and ICIQ-OAB score (mean [SD], drug, 9.1 [1.7]; behavioral, 8.5 [1.4]). At 12 weeks postrandomization, ICIQ-OAB scores across groups indicated clinically significant improvement and were within the a priori noninferiority margin of 15% (mean [SD] score, drug, 5.8 [2.4]; behavioral, 5.5 [2.0]; P = .02). Dry mouth and falls were reported more frequently in the drug compared with the behavioral group. Conclusions and Relevance: Results of this randomized noninferiority trial suggest that behavioral therapy is noninferior to drug therapy in improving OAB symptoms in PD. These findings may inform clinical guidelines for urinary symptoms in PD to consider behavioral therapy as an initial treatment option. Trial Registration: ClinicalTrials.gov Identifier: NCT03149809.