overactive bladder ( oab ) , defined as increased frequency and urgency with or without urge incontinence , is a very common condition , especially in middle - aged women , with a reported incidence of approximately 17% of the general female population ( 1 , 2 ) . since many women may consider oab as a natural aging phenomenon and thus do not seek treatment , its actual prevalence may be even higher . despite its common occurrence , however , our understanding ( 3 - 5 ) of the pathophysiology underlying the development of oab has remained elementary . it is managed most commonly by drug therapy , followed by various behavioral interventions and , less frequently , by surgical methods . classically , urge incontinence has been considered most important , being the key index in treatment outcome assessments . however , since the new consensus by the international continence society on the diagnosis of oab ( 6 ) , the presence or absence of actual urine leakage was regarded as less important . with the adaptation of this new definition , the number of patients newly diagnosed with oab is expected to increase , emphasizing the need to develop first - line interventions for their symptoms . the three most commonly employed methods for treating newly - diagnosed oab are bladder training , anticholinergic therapy and a combination of the two . here we report a controlled , randomized study comparing the clinical efficacy of these three methods , for the purpose of determining the most appropriate first - line therapeutic modality . between may 2001 and april 2002 , 139 women presenting with symptoms of urgency and frequency , with or without urge incontinence , were prospectively enrolled in this study . inclusion criteria included being 18 yr of age or older , having a urination frequency of 8 or more times per day , the presence of urge symptoms that may or may not accompany incontinence , symptom duration of 3 months or longer and no prior history of treatment for oab . we excluded patients with active urinary tract infection , clinically significant stress urinary incontinence , bladder outlet obstruction , interstitial cystitis , glaucoma or megacolon . also excluded were patients with a maximal urine flow rate of less than 10 ml / sec or a postvoid residual urine amount that was more than 30% of the total amount voided on uroflowmetry . upon enrollment , patients were randomly assigned to bladder training ( bt , n=46 ) , tolterodine treatment ( to , 2 mg twice daily , n=47 ) or a combination of the two ( co , n=46 ) . each patient received a physical examination and uroflowmetry with postvoid residual urine scan . in addition , each patient kept a record of urgency scores , with 0 indicating no symptoms , 1 rarely , 2 occasionally , 3 often , and 4 all the time , and a frequency - volume chart . at 12 weeks , satisfaction score was assessed , with 0 representing fully satisfied , 1 much improved , 2 slightly improved , 3 no improvement , and 4 worsened ; a change of 2 points or more was considered symptom improvement . the frequency - volume chart and a survey of adverse effects of medication were repeated every 4 weeks . patients in the bt and co groups were educated of the bladder drills by a nurse specialist . gross and functional anatomy of the lower urinary tract and pelvis were demonstrated , with instructions on how bladder drills can increase functional bladder capacity and actual voiding habits . each patient was instructed to examine her frequency - volume chart to determine the longest interval she could initially hold urination and sustain urge symptoms . each patient was then taught to increase this interval by 15-min increments , with the aim of achieving a 3 to 4 hr interval and a voided volume of 300 to 400 ml . in addition , whenever urgency occurred , patients were educated to perform kegel exercises for symptom alleviation . all bladder drill education was performed by one nurse specialist , who telephoned each patient every 2 weeks to make sure she was following the exact drill taught . in the co group , of the 139 patients , 89 ( 64.0% ) completed the 12 week treatment regimen and were subjects of outcome analyses . voiding frequency , nocturia , urgency score before and after the treatment , satisfaction score at 12 weeks and adverse events were measured in the three groups . student 's t - test was used for statistical analysis , and p<0.05 was defined as statistically significant . patient characteristics , including age , weight , symptom severity and duration , parity , pretreatment uroflowmetry profile , presence and degree of urge or stress incontinence , and urgency score , were similar among the three treatment groups ( table 1 ) . at 12 weeks , 26 patients ( 56.5% ) in the bt group , 32 ( 68.1 % ) in the to group , and 31 ( 67.4% ) in the co group had completed the protocol . mean frequency in the three groups decreased significantly , from 10.9 to 8.1 ( 25.9% ) in the bt group , from 11.6 to 8.1 ( 30.2% ) in the to group , and from 11.9 to 7.9 ( 33.5% ) in the co group ( p<0.05 each ) ( fig . nocturia also decreased significantly in the three groups , from 1.5 to 0.6 per night ( 56.1% ) in the bt group , from 1.7 to 0.6 ( 65.4% ) in the to group , and from 2.0 to 0.6 ( 66.3% ) in the co group ( p<0.05 each ) ( fig . 2 ) , as did urgency scores , from 2.6 to 1.4 ( 44.8% ) in the bt group , from 2.8 to 1.1 ( 62.2% ) in the to group , and from 3.0 to 1.2 ( 60.2% ) in the co group ( p<0.05 each ) ( fig . when we compared these changes among the three groups , we found that patients in the co group showed greater improvements in frequency and urgency scores than did patients in the bt group ( p<0.05 each ) , and that urgency scores in the to and co groups showed significantly greater improvement than in the bt group ( p=0.017 and p=0.021 , respectively ) . satisfaction scores at 12 weeks did not differ among the three groups , being 1.5 in the bt group , with improvement in 53.9% ; 1.4 in the to group , with improvement in 63.0% ; and 1.3 in the co group , with improvement in 71.0% . no adverse events were reported from the bt group , whereas 13 patients ( 40.6% ) in the to group and 12 ( 38.7% ) in the co group reported one or more adverse events ( table 2 ) . most of the events were mild and well - tolerated , except that severe dry mouth occurred in 2 patients from each group , which led them to discontinue medication ( withdrawal rates , 6.3% and 6.5% , respectively ) . despite extensive research on the complicated interactions involving the neural network of the cerebrum , sacral cord and the detrusor , little is known regarding the pathologic process that occurs during the development of oab ( 4 , 5 , 7 ) . accordingly , therapeutic approaches for oab have been diverse , consisting largely of medical therapy , but also including behavioral interventions such as bladder training , pelvic floor muscle exercises with or without biofeedback , and electrical stimulation . other therapeutic approaches have included neuromodulation of the sacral nerves , intravesical instillations of antimuscarinics and bladder overdistention , with augmentation cystoplasty remaining as the last resort . naturally , non - invasive methods , including medical therapy and behavioral intervention , have been the initial treatments of choice for oab symptoms . although it is not known how bladder drills control and sustain oab symptoms , it is believed that ill - trained voiding habits leading to decreased bladder compliance by frequent voiding are corrected by progressively increasing the voiding interval , thus increasing the voided volume and the functional bladder capacity . retraining these patients to void at normal intervals would restore compliance when capacity increases and may contribute to symptom improvement ( 8 - 11 ) . observations on the electrical stimulation of the pelvic floor muscles ( 12 ) have shown that , during electrical stimulation , hyperactivity of the bladder was either diminished or completely abolished . clinically , bladder training has been shown to be effective in the management of urgency and urge incontinence ( 8 , 13 - 15 ) . when bladder training was compared with medical therapy ( 200 mg flavoxate hydrochloride plus 25 mg imipramine three times daily for 4 weeks ) , urge incontinence was completely controlled in 84% of patients in the bt group , with symptom relief in 76% , compared with 56% and 48% , respectively , in the medication group ( 16 ) . a larger study ( 17 ) , however , found that addition of behavioral interventions did not seem to offer any additional benefit to medical therapy ( tolterodine ) after 6 months . urgency episodes and daytime frequency decreased 83% and 27.3% , respectively , in the tolterodine group , compared with 78.7% and 23% , respectively , in the combination group . improvements in patients ' perception of urinary symptoms were reported by 85.9% of the tolterodine group and 81.7% of the combination group . we found that all patients , a homogeneous group of female patients , regardless of treatment methodology , reported significant improvements in all voiding parameters examined , but that the addition of medication to bt resulted in additional improvements in urgency and frequency . our finding of better outcomes in the co than in the to group may be due to the bladder training program and design used here , which was a short - term intensive course of bladder drills . as many authors have emphasized , patients ' understanding and compliance are the key factors in bladder training . accordingly , the exercise program that we used did not simply require patients to contract and relax their pelvic floor muscles for certain periods of time . instead , patients were given specific goals of 15 min each in sustaining contractions and were instructed how to increase these intervals . having such a specific aim of what to accomplish with each exercise must have been enforcing and rewarding as well . in addition , repeated instructions , confirmation and reassurance were essential and constantly encouraged patients to stay on the right track for 12 weeks . similar results have been reported ( 18 ) , in which patients were provided with written information sheets describing the aims and endpoints of therapy as well as specific instructions on bladder drills . although there were no formal bladder training sessions or additional follow - up for those in the bladder training - only group , the self - explanatory information sheets the patients kept would have reinforced and encouraged patients while on bladder drills . thus , patients on medication plus bladder training reported significantly better results after therapy than did patients on medication alone . in the previous study , in which the drills were simplified , it may have facilitated patient adherence to treatment , but without any further reinforcements , the therapeutic benefits of bt may have been compromised ( 17 ) . in this study , we found that patient adherence to treatment was lowest and discontinuation rate highest in the bt group , although the treatment efficacy results were similar at the end of 12 weeks . this may be attributed to the longer duration of patient maneuvering required before experiencing significant improvement in this bt - only group . thus , despite many efforts by the physician to make patients stay on the correct treatment regimen , it was evidently easier for patients to take medication twice a day than to repeat exercises many times a day for months . we noted no adverse effects in the bt group , whereas , in the other 2 groups , the most common adverse effect was dry mouth . we found that 6.3% of patients in the bt group and 6.5% in the co group had to discontinue medication due to severe dry mouth , percentages lower than those previously reported ( 19 , 20 ) . these results indicate that 4 mg / day tolterodine is safe and does not require dose adjustment . from these results , we conclude that bladder training , tolterodine and the combination of the two are all effective in controlling oab symptoms , with comparable patient satisfaction . since a short - term intensive course of bladder drill is as effective as medical or combined therapy in all voiding symptoms , but does not have any adverse effects , bladder training can be safely and effectively employed as first line treatment for oab . in patients who have predominantly symptoms of frequency or urgency , tolterodine may be more effective , especially when combined with bladder training .
we compared the effects of bladder training and/or tolterodine as first line treatment in female patients with overactive bladder ( oab ) . 
 one hundred and thirty - nine female patients with oab were randomized to treatment with bladder training ( bt ) , tolterodine ( to , 2 mg twice daily ) or both ( co ) for 12 weeks . 
 treatment efficacy was measured by micturition diary , urgency scores and patients ' subjective assessment of their bladder condition . 
 mean frequency and nocturia significantly decreased in all treatment groups , declining 25.9% and 56.1% , respectively , in the bt group ; 30.2% and 65.4% , respectively , in the to group ; and 33.5% and 66.3% , respectively in the co group ( p<0.05 for each ) . 
 the decrease in frequency was significantly greater in the co group than in the bt group ( p<0.05 ) . mean urgency score decreased by 44.8% , 62.2% and 60.2% in the bt , to , and co groups , respectively , and the improvement was significantly greater in the to and co groups than in the bt group ( p<0.05 for each ) . 
 although bt , to and their combination were all effective in controlling oab symptoms , combination therapy was more effective than either method alone . 
 tolterodine alone may be instituted as a first - line therapy , but may be more effective when combined with bladder training .