Overactive Bladder in Women: A Major Health Issue Still Poorly Understood and Poorly Treated

Overactive bladder affects millions of women, yet modern neuromodulation therapies remain largely inaccessible to them.Medications and Botox offer only temporary relief and often cause significant side effects or long-term complications.Sacral neuromodulation, although effective for selected patients, is rarely available to women because gynecology was historically excluded from its development.The European Neuropathy Foundation is committed to correcting this imbalance by advancing research and education in female pelvic nerve disorders.Our mission is to restore fair access to neuromodulation and promote solutions adapted to women and to gynecologic practice.Women deserve better care, and ENF is dedicated to making it happen.

Understanding Overactive Bladder (OAB): Definition, Impact, Prevalence, and Economic Burden

Overactive bladder (OAB) is a chronic condition characterized by a sudden, uncontrollable urge to urinate, often accompanied by frequency (urinating more than 8 times in 24 hours), nocturia (waking at night to urinate), and sometimes urge incontinence, the involuntary leakage of urine following the urge.Importantly, OAB is not caused by infection or other obvious pathology, it is a functional disorder, often linked to pelvic nerve dysfunction.

For many women, OAB is far more than a bladder problem. It affects daily life, sleep, sexuality, mental health, work productivity, and social interactions. Women frequently describe feeling embarrassed, anxious, or “trapped” by their bladder. Many avoid travel, physical activities, intimate relationships, or even simple outings due to fear of leakage or needing immediate access to a bathroom.

Prevalence and Incidence

OAB is extremely common, far more than most people realize. Globally, up to 17–20% of adults suffer from OAB symptoms. In women, prevalence increases with age:

• 12–15% of women in their 30s

• 20–30% after age 45

• 40% or more in women over 65

More than 60 million women in Europe and over 80 million in the United States are estimated to be affected. Incidence rises significantly after childbirth, pelvic surgery, or menopause. Despite its frequency, less than 40% of women seek medical help, often due to embarrassment or lack of awareness that effective treatments exist.

OAB is therefore not a rare disorder — it is one of the most widespread chronic conditions affecting women.

Impact on Quality of Life

The consequences of OAB extend far beyond urinary symptoms:

• Emotional effects: anxiety, depression, loss of confidence, fear of social embarrassment

• Sleep disruption: leading to fatigue, cognitive difficulty, irritability

• Sexual dysfunction: pain, avoidance of intimacy, decreased satisfaction

• Social isolation: avoidance of travel, exercise, or public spaces

• Professional limitations: reduced concentration, missed workdays, decreased productivity

• Relationship strain: embarrassment, guilt, withdrawal

Studies show that the impact of OAB on daily functioning is comparable to chronic diseases such as diabetes or rheumatoid arthritis,  yet it remains largely underestimated and undertreated.

Economic Burden and Healthcare Costs

OAB is also a major financial burden, both for patients and for healthcare systems.

Direct medical costs

• Medications (anticholinergics, beta-3 agonists):

  
  

  recurring prescriptions with high discontinuation rates (70–90% at 12 months)

• Repeated consultations and diagnostic testing

• Absorbent products and protective garments

• Botox injections every 6–12 months

• Management of side effects and complications (urinary retention, UTIs)

• Sacral neuromodulation procedures and follow-up care

• Increased hospitalizations in elderly populations due to falls from urgency/nocturia

In Europe and the U.S., direct costs exceed 5–8 billion EUR/USD annually.

Indirect costs

• Lost work productivity

• Early retirement or reduced work hours

• Travel limitations

• Need for caregiving support

• Psychological and social consequences that reduce overall life participation

When direct and indirect costs are combined, OAB is estimated to generate over 20 billion EUR/USD per year in total societal costs. For individual women, daily expenses (pads, protective underwear, medications, doctor visits) may reach 1,000–2,000 EUR per year, often paid out-of-pocket.

Why OAB Needs More Attention

Despite its prevalence, OAB is often dismissed as an unavoidable part of aging or childbirth, a misconception that leads to suffering in silence. In reality, OAB is a neurological disorder of pelvic nerve regulation, not merely a “bladder” problem. It requires modern, targeted treatments, and gynecology must play a central role in improving access to these therapies. Understanding OAB is the first step toward better care, better treatments, and restoring quality of life for millions of women.

Why neuromodulation must finally find its place in gynecology

Overactive bladder (OAB) is one of the most common and most disruptive conditions affecting women. It causes sudden and uncontrollable urges to urinate, frequent daytime and nighttime voiding, and sometimes leakage that can severely limit daily life.Beyond the physical discomfort, the emotional and social impact is profound: loss of confidence, anxiety, sleep disturbance, reduced intimacy, embarrassment, and withdrawal from normal activities.

Despite its prevalence, affecting up to one in five women over the age of 40, OAB remains inadequately treated. And paradoxically, gynecology, the specialty that follows women throughout their entire lives, has been largely excluded from modern neuromodulation therapies.

Medications: limited benefit, significant side effects, high discontinuation

For decades, anticholinergic drugs have been the standard first-line treatment for OAB. While they can reduce bladder contractions, their side effects are often difficult to tolerate: dry mouth, constipation, blurred vision, drowsiness, and,especially in older women, memory problems or even an increased risk of cognitive decline. Because of this, 70–90% of women stop taking these medications within the first year, either because the symptoms do not improve or because the side effects are unacceptable.The financial burden on healthcare systems is substantial: long-term prescriptions with limited benefit, repeated consultations, and persistent loss of quality of life.

Botox injections: temporary relief, recurring risks, and ongoing cost

Second-line treatment often involves intravesical Botox injections, which can calm an overactive bladder for several months. But this approach is far from ideal. The effect is temporary, requiring repeated injections every 6–12 months, and up to 40% of patients may develop urinary retention, forcing them to perform self-catheterization - an uncomfortable, sometimes painful, often distressing practice that increases the risk of urinary tract infections.

Each injection cycle is costly, often more than 2,000 CHF, and must be repeated indefinitely. Thus, Botox provides relief, but not a durable solution.

Sacral neuromodulation: a promising technology that never reached women

Since the 1990s, sacral neuromodulation (SNM) has been considered a major innovation. By stimulating the sacral nerves, it can restore bladder control in selected patients. However, in practice, fewer than 1% of eligible women ever receive this therapy.

The reasons are structural, not medical. In many countries, as in Switzerland, SNM is supervised and performed exclusively by neuro-urologists and gastroenterologists. These professional societies define the standards, training, and access to the procedure. Gynecologists, although responsible for the majority of pelvic health issues in women, were never included. This exclusion was never based on evidence or on anatomical logic; it was simply the historical path of how the technology was introduced.Yet its consequences for women have been profound:

Gynecologists, who treat childbirth injuries, pelvic surgery sequelae, endometriosis, menopausal changes, prolapse, and pelvic nerve disorders every day, have had no access to sacral neuromodulation, and therefore neither have their patients.

Moreover, the SNM technique itself is poorly aligned with gynecologic practice. The procedure requires a two-stage surgery through the sacral foramina, a posterior and anatomically complex region near the spine that lies outside the surgical field of gynecology.It requires hospital admission, expensive equipment, implant testing, and specialized training that gynecologists are not routinely offered.

As a result, SNM remains out of reach for most women, not because they are poor candidates, but because their medical specialty was never given the tools or the opportunity.

Why neuromodulation must re-enter gynecology

The goal is not to criticize urology or SNM. The goal is to acknowledge a reality: women have been structurally excluded from direct access to neuromodulation, simply because their specialty was not involved in its development.

Yet OAB in women is rarely an isolated urological issue. It is deeply connected to neuropelveology:

• childbirth-related nerve injury,

• pelvic surgery,

• endometriosis,

• pelvic ligament laxity,

• hormonal changes,

• and pelvic neuropathies.

Neuropelveologists are the specialists who understand these conditions, who know the pelvic nerves and organs as a functional unit, and who care for women holistically across their lifespan.Gynecologists are trained in laparoscopy, abdominal surgery, and vaginal surgery, which are precisely the anatomical corridors where pelvic nerves and pelvic organs interact. It is therefore medically and ethically logical that neuromodulation - a therapy targeting pelvic nerve dysfunction - must have a place in gynecology.

But for this to happen safely and effectively, neuromodulation must be adapted to:

• the anatomical fields gynecologists already master,

• the surgical techniques they use daily,

• and the specific needs of female patients.

A technique that falls between specialties, without ownership, inevitably leads to fragmentation, poor training, and inconsistent outcomes.Women deserve better, and gynecologists must be empowered to provide it.

A priority of the European Neuropathy Foundation

The European Neuropathy Foundation (ENF) is committed to correcting this inequality. One of its core missions is to improve the care of women with overactive bladder and pelvic neuropathic disorders by promoting:

• dedicated research on female pelvic nerve health,

• clinical education for gynecologists,

• access to modern neuromodulation strategies designed for women,

• and a renewed medical focus on the real causes of pelvic dysfunction.

The ENF advocates for a future in which neuromodulation is no longer restricted to a single specialty, but becomes a natural and integral part of gynecology, where it logically belongs for millions of women worldwide.

Women deserve access to the full spectrum of modern medicine.Gynecologists deserve the tools to treat the conditions they see every day.And pelvic neuromodulation deserves to evolve into a genuinely female-centered therapy.