Otilonium bromide (OB) is a drug with spasmolytic activity belonging to quaternary ammonium derivatives and extensively used to treat patients affected by the Irritable Bowel Syndrome (IBS). Thanks to its peculiar pharmacokinetic, OB concentrates in the large bowel wall and acts locally. From the pharmacodynamics point of view, OB is able to inhibit i) the main patterns of human colonic motility in vitro; ii) the contractility caused by excitatory motor neurons stimulation (pre-synaptic action) and iii) the contractility caused by the direct action of excitatory neurotransmitters (post-synaptic action). Interestingly, these effects derive from a complex interaction between the drug and several cellular targets. The main action consists in the blockade of Ca2+ entry through L-type Ca2+ channels and interference with intracytoplasmatic Ca2+ mobilization necessary for SMC contraction, thus preventing excessive bowel contractions and abdominal cramps. Further, OB blocks the T-type Ca2+ channels and interferes with the muscarinic responses; it interacts, directly or indirectly, with the tachykinin receptors on SMC and on primary afferent neurons whose combined effects may result in the reduction of motility and abdominal pain. In summary, a revision of this complex picture of OB activity could help to better address its therapeutic use.