Can apparently transient life events trigger long-term lower urinary tract symptoms?

INTRODUCTION

One-time life events such as neurological injury can result in lifelong lower urinary tract symptoms (LUTS). However, it is unclear whether an apparently transient life event can also trigger long-term LUTS. This review examines the possibility of an association and hypothesizes the pathogenesis.

METHODS

A pubmed search was conducted using the MeSH words "life change events," "child abuse," or "stress disorders, Posttraumatic", and LUTS. Additional manuscripts were identified by a hand and citation search.

RESULTS

Long-term LUTS was noted following temporally remote childhood sexual abuse, adverse childhood experiences, and stressful experiences in adults. There was evidence for an association of childhood sexual abuse and adverse childhood events with both storage as well as voiding LUTS. There was limited evidence that the number of adverse childhood events might increase the risk and severity of LUTS. There was evidence of an association between post-traumatic stress disorder in adults and LUTS. The finding of mental health disorders in such patients could explain some but not all of the observed association suggesting that other factors might also be important.

CONCLUSIONS

There is an association noted between apparently transient lifetime events and the subsequent reporting of LUTS. The timing of these adverse experiences might be important in determining the propensity for clinical manifestation. There is a need to explore this association, establish causality, and determine the underlying etiopathogenesis.

The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder

PURPOSE

The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process that will maximize symptom control and quality of life, while minimizing adverse events and burden of disease.

METHODS

An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements.

RESULTS

This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including non-invasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB.

CONCLUSION

Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

Percutaneous tibial nerve stimulation for the overactive bladder: A single-arm trial

AIMS

We hypothesise that PTNS is a safe and effective treatment for OAB. Overactive bladder (OAB) is estimated to affect 11.8% of women worldwide, causing diminished quality of life. Lifestyle modifications, muscarinic receptor antagonist and beta-adrenoreceptor agonist remain the mainstay of treatment but are limited by their efficacy and adverse effects. Access to third-line therapies of intravesical botulinum toxin type A or sacral neuromodulation is limited by their invasive nature. Percutaneous tibial nerve stimulation (PTNS) has emerged as a non-invasive treatment option for OAB.

METHODS

This study was a single-arm trial of women requesting third-line treatment for OAB. The primary treatment outcome was patient-reported visual analogue score (VAS) improvement of at least 50%. Secondary outcome measures were Urinary Distress Inventory Short Form (UDI-6) score and two-day bladder diary. Patients also provided feedback on adverse effects encountered.

RESULTS

In the 84 women recruited, initial treatment protocol showed a success rate of 77.2% among those who completed treatment based on VAS, with a statistically significant improvement in mean UDI-6 score of 20.13 (P < 0.01, standard deviation: 12.52). Continued success following tapering protocol of 60.8% and a mean maintenance protocol of 14.2 months was achieved. No adverse effects were reported.

CONCLUSION

The results from this study are in concordance with previously published literature on the effectiveness and safety of PTNS as a treatment modality for OAB. Further randomised controlled trials to evaluate the optimal treatment protocol are warranted to establish a standardised regime.

Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital

Objective

To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications.

Methods

A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022.

Results

Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I.

Conclusion

SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study

OBJECTIVES

Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose.

METHODS

Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0.

RESULTS

A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05).

CONCLUSIONS

There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

TikTok and YouTube Videos on Overactive Bladder Exhibit Poor Quality and Diversity

INTRODUCTION

We sought to assess the quality, understandability, actionability, and diversity of speakers in videos on TikTok and YouTube regarding overactive bladder.

METHODS

Using Application Program Interface, the top 500 TikTok and 120 YouTube videos on overactive bladder were retrieved. Videos unrelated to overactive bladder, those not in English, longer than 10 minutes, or lacking both text and audio were excluded. Surgical technique videos for providers were also excluded. Videos were scored by trained raters using 2 validated instruments: PEMAT (Agency for Healthcare Research and Quality's Patient Education Materials Assessment Tool) for actionability and understandability, and the DISCERN instrument for quality of consumer health information. We also examined for evidence of misinformation and commercial bias.

RESULTS

One hundred thirty-six TikTok videos and 75 YouTube videos met inclusion criteria. Eighty-eight percent of TikTok videos had poor PEMAT actionability scores (a score below 75%), as compared to 60% of YouTube videos. Both YouTube and TikTok videos scored low on PEMAT understandability. Ninety-eight percent of TikTok videos and 65% of YouTube videos were poor quality (DISCERN score <3). YouTube videos had higher actionability and quality than TikTok videos (P < .001) but did not differ on understandability (P = .769). Twenty-three percent of TikTok and 11% of YouTube videos had high misinformation (score >3). Commercial bias was present in 10% of TikTok and 19% of YouTube videos.

CONCLUSIONS

Actionability, understandability, and quality for overactive bladder-related content is poor on YouTube and TikTok. With increasing access to social media, it is important that health care providers and organizations invest resources in patient education on health literacy.

Intraoperative Predictors of Sacral Neuromodulation Implantation and Treatment Response: Results From the ROSETTA Trial

PURPOSE

We determined the utility of intraoperative data in predicting sacral neuromodulation outcomes in urgency urinary incontinence.

MATERIALS AND METHODS

Intraoperative details of sacral neuromodulation stage 1 were recorded during the prospective, randomized, multicenter ROSETTA trial, including responsive electrodes, amplitudes, and response strengths (motor and sensory Likert scales). Stage 2 implant was performed for stage 1 success on 3-day diary with 24-month follow-up. An intraoperative amplitude response score for each electrode was calculated ranging from 0 (no response) to 99.5 (maximum response, 0.5 V). Predictors for stage 1 success and improvement at 24 months were identified by stepwise logistic regression confirmed with least absolute shrinkage and selection operator and stepwise linear regression.

RESULTS

Intraoperative data from 161 women showed 139 (86%) had stage 1 success, which was not associated with number of electrodes generating an intraoperative motor and/or sensory response, average amplitude at responsive electrodes, or minimum amplitude-producing responses. However, relative to other electrodes, a best amplitude response score for bellows at electrode 3 was associated with stage 1 failure, a lower reduction in daily urgency urinary incontinence episodes during stage 1, and most strongly predicted stage 1 outcome in logistic modeling. At 24 months, those who had electrode 3 intraoperative sensory response had lower mean reduction in daily urgency urinary incontinence episodes than those who had no response.

CONCLUSIONS

Specific parameters routinely assessed intraoperatively during stage 1 sacral neuromodulation for urgency urinary incontinence show limited utility in predicting both acute and long-term outcomes. However, lead position as it relates to the trajectory of the sacral nerve root appears to be important.

Urodynamics Are Essential to Predict the Risk for Upper Urinary Tract Damage after Acute Spinal Cord Injury

We used clinical parameters to develop a prediction model for the occurrence of urodynamic risk factors for upper urinary tract (UUT) damage during the first year after acute spinal cord injury (SCI). A total of 97 patients underwent urodynamic investigation at 1, 3, 6, and 12 months after acute SCI, within the framework of a population-based longitudinal study at a single university SCI center. Candidate predictors included demographic characteristics and neurological and functional statuses 1 month after SCI. Outcomes included urodynamic risk factors for UUT damage: detrusor overactivity combined with detrusor sphincter dyssynergia, maximum storage detrusor pressure (pDetmax) ≥ 40 cmH₂O, bladder compliance < 20 mL/cmH₂O, and vesicoureteral reflux. Multivariable logistic regression was used for the prediction model development and internal validation, using the area under the receiver operating curve (aROC) to assess model discrimination. Two models showed fair discrimination for pDetmax ≥ 40 cmH₂O: (i) upper extremity motor score and sex, aROC 0.79 (95% CI: 0.69-0.89), C-statistic 0.78 (95% CI: 0.69-0.87), and (ii) neurological level, American Spinal Injury Association Impairment Scale grade, and sex, aROC 0.78 (95% CI: 0.68-0.89), C-statistic 0.76 (95% CI: 0.68-0.85). We identified two models that provided fair predictive values for urodynamic risk factors of UUT damage during the first year after SCI. Pending external validation, these models may be useful for clinical trial planning, although less so for individual-level patient management. Therefore, urodynamics remains essential for reliably identifying patients at risk of UUT damage.

Neutralizing Antibody Formation with OnabotulinumtoxinA (BOTOX®) Treatment from Global Registration Studies across Multiple Indications: A Meta-Analysis

Though the formation of neutralizing antibodies (NAbs) during treatment with botulinum neurotoxin is rare, their presence may nonetheless affect the biological activity of botulinum toxin and negatively impact clinical response. The goal of this updated meta-analysis was to evaluate and characterize the rate of NAb formation using an expanded dataset composed of 33 prospective placebo-controlled and open-label clinical trials with nearly 30,000 longitudinal subject records prior to and following onabotulinumtoxinA treatment in 10 therapeutic and aesthetic indications. Total onabotulinumtoxinA doses per treatment ranged from 10 U to 600 U administered in ≤15 treatment cycles. The NAb formation at baseline and post-treatment was tested and examined for impact on clinical safety and efficacy. Overall, 27 of the 5876 evaluable subjects (0.5%) developed NAbs after onabotulinumtoxinA treatment. At study exit, 16 of the 5876 subjects (0.3%) remained NAb positive. Due to the low incidence of NAb formation, no clear relationship was discernable between positive NAb results and gender, indication, dose level, dosing interval, treatment cycles, or the site of injection. Only five subjects who developed NAbs post-treatment were considered secondary nonresponders. Subjects who developed NAbs revealed no other evidence of immunological reactions or clinical disorders. This comprehensive meta-analysis confirms the low NAb formation rate following onabotulinumtoxinA treatment across multiple indications, and its limited clinical impact on treatment safety and efficacy.

Prospective, Randomized, Multicenter Trial of Peroneal Electrical Transcutaneous Neuromodulation vs Solifenacin in Treatment-naïve Patients With Overactive Bladder

PURPOSE

We investigated the safety and efficacy of peroneal electrical transcutaneous neuromodulation using the URIS neuromodulation system in a home-based setting in comparison with standard treatment using solifenacin in treatment-naïve female patients with overactive bladder.

MATERIALS AND METHODS

A total of 120 patients were screened, of whom 77 were randomized in a 2:1 ratio to 12 weeks of treatment with daily peroneal electrical transcutaneous neuromodulation or solifenacin 5 mg. The primary endpoint was safety; efficacy assessments included proportion of responders, defined as subjects with ≥50% reduction in bladder diary-derived variables; Overactive Bladder-Validated 8-question Screener, and European Quality of Life-5 Dimensions questionnaire; and treatment satisfaction after 12 weeks of therapy.

RESULTS

Seventy-one out of 77 randomized patients completed the study. In the peroneal electrical transcutaneous neuromodulation group 6/51 (12%) patients reported a treatment-related adverse event vs 12/25 (48%) in the solifenacin group (P < .001). No clinically significant changes were observed in any other safety endpoint. The proportions of responders in the peroneal electrical transcutaneous neuromodulation group vs the solifenacin group were 87% vs 74% with respect to Patient Perception of Intensity of Urgency Scale grade 3 urgency episodes, 87% vs 75% with respect to grade 3+4 urgency episodes, and 90% vs 94% with respect to urgency incontinence episodes. In post hoc analyses we observed significant improvement over time in multiple efficacy variables in both treatment arms.

CONCLUSIONS

Peroneal electrical transcutaneous neuromodulation is a safe and effective method for overactive bladder treatment associated with a significantly lower incidence of treatment-related adverse events compared to solifenacin and a considerably better benefit-risk profile.

Temporal development of unfavourable urodynamic parameters during the first year after spinal cord injury

OBJECTIVES

To describe the temporal development of and risk factors for the occurrence of unfavourable urodynamic parameters during the first year after spinal cord injury (SCI).

PATIENTS AND METHODS

This population-based longitudinal study used data from 97 adult patients with a single-event traumatic or ischaemic SCI who underwent video-urodynamic investigation (UDI) at a university SCI centre. The first occurrences of unfavourable urodynamic parameters (detrusor overactivity combined with detrusor sphincter dyssynergia [DO-DSD], maximum storage detrusor pressure ≥40 cmH₂ O, bladder compliance <20 mL/cmH₂ O, vesico-ureteric reflux [VUR] and any unfavourable parameter [composite outcome]) were evaluated using time-to-event analysis.

RESULTS

The majority of the population (87/97 [90%]) had at least one unfavourable urodynamic parameter. Most unfavourable urodynamic parameters were initially identified during the 1- or 3-month UDI, including 92% of the DO-DSD (78/85), 82% of the maximum storage pressure ≥40 cmH₂ O (31/38), and 100% of the VUR (seven of seven) observations. No low bladder compliance was observed. The risk of DO-DSD was elevated in patients with thoracic SCI compared to those with lumbar SCI (adjusted hazard ratio [aHR] 2.38, 95% confidence interval [CI] 1.16-4.89). Risk of maximum storage detrusor pressure ≥40 cmH₂ O was higher in males than females (aHR 8.33, 95% CI 2.51-27.66), in patients with a cervical SCI compared to those with lumbar SCI (aHR 14.89, 95% CI 3.28-67.55), and in patients with AIS Grade B or C compared to AIS Grade D SCI (aHR 6.17, 95% CI 1.78-21.39). No risk factors were identified for the composite outcome of any unfavourable urodynamic parameter.

CONCLUSIONS

The first UDI should take place within 3 months after SCI as to facilitate early diagnosis of unfavourable urodynamic parameters and timely treatment. Neuro-urological guidelines and individualised management strategies for patients with SCI may be strengthened by considering sex and SCI characteristics in the scheduling of UDIs.

Cognitive impairment does not impact sacral neuromodulation implant rates for overactive bladder

OBJECTIVE

To evaluate the impact of cognitive impairment (CI) diagnoses on sacral neuromodulation (SNM) outcomes in older patients.

MATERIALS AND METHODS

We completed a retrospective review of all patients aged ≥55 years who underwent test-phase SNM (peripheral nerve evaluation (PNE) or stage 1) for overactive bladder (OAB) between 2014 and 2021 within a large multi-regional health system. Patient demographics, relevant comorbidities, CI diagnoses (dementia or mild CI), and SNM procedures were recorded. Logistic regression modeling was performed to evaluate the impact of CI on SNM implantation rates.

RESULTS

Five-hundred and ten patients underwent SNM test phase (161 PNE, 349 Stage 1) during the study period. The mean age was 71.0(8.5) years, and most (80.6%) were female. Overall, 52(10.1%) patients had a CI diagnosis at the time of SNM, and 30 (5.8%) were diagnosed at a median of 18.5 [9.25, 39.5] months after SNM. Patients with CI diagnoses were older, with more comorbidities, and were more likely to undergo PNE. Univariable comparison found no difference in implantation rate based on pre-SNM CI (85.4% vs. 76.9%, p = 0.16). Multivariable analysis identified PNE (OR 0.43, 95% CI 0.26-0.71), age (OR 0.96, 95%CI 0.93-0.98), and prior beta-3 agonist use (OR 0.60, 95% CI 0.37-0.99) but not CI or dementia as independent negative predictors of implantation. Implanted patients had a median follow-up of 25 [12.0, 55.0] months. Explant and revision rates did not differ according to CI.

CONCLUSION

Patients with OAB and CI diagnoses proceed to SNM implant at rates similar to patients without CI diagnoses. A diagnosis of CI should not necessarily exclude patients from SNM therapy for refractory OAB.

Intravesical Injection of Botulinum Toxin Type A in Patients with Refractory Overactive Bladder-Results between Young and Elderly Populations, and Factors Associated with Unfavorable Outcomes

Intravesical botulinum toxin type A (BoNT-A) injection has been recognized as the standard treatment for refractory overactive bladder (OAB). However, its therapeutic efficacy and safety have not been thoroughly reviewed in elderly patients. This study aims to provide treatment outcomes for patients aged ≥75 years, and to identify factors associated with unfavorable outcomes. Patients receiving intradetrusor injections of 100 U onabotulinumtoxinA for refractory OAB between 2011 and 2021 were retrospectively reviewed. Urodynamic parameters, underlying comorbidities, subjective success, and unfavorable outcomes were assessed. A total of 192 patients were included, and 65 of them were classified into the elderly group. For the elderly group, 60.0% experienced subjective dryness, and 84.6% remained subjective success at 6 months after the injections. The prevalence rates of common unfavorable outcomes, including urinary tract infections, large post-void residual urine volume, and urinary retention, were 9.2%, 27.7%, and 12.3%, respectively. Multivariate analysis revealed that female, baseline urodynamic parameters, and diabetes mellitus were associated with unfavorable outcomes in the elderly group. Intravesical BoNT-A injections provide comparable therapeutic efficacy and safety concerns in elderly patients with refractory OAB. A thorough consultation for treatment benefits and possible adverse events is mandatory before the procedure.

Phenotyping of Urinary Urgency Patients Without Urgency Incontinence, and Their Comparison to Urgency Incontinence Patients: Findings From the LURN Study

PURPOSE

We characterize patients with urinary urgency with vs without urgency urinary incontinence who presented to clinics actively seeking treatment for their symptoms.

MATERIALS AND METHODS

Participants who enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network were categorized into urinary urgency with vs without urgency urinary incontinence. Participants were followed for 1 year; their urinary symptoms, urological pain, psychosocial factors, bowel function, sleep disturbance, physical activity levels, physical function, and quality of life were compared. Mixed effects linear regression models were used to examine the relationships between urgency urinary incontinence and these factors.

RESULTS

Among 683 participants with urinary urgency at baseline, two-thirds (n=453) also had urgency urinary incontinence; one-third (n=230) had urinary urgency-only without urgency urinary incontinence. No differences were detected in urological pain between urinary urgency-only and urgency urinary incontinence. Those with urgency urinary incontinence had more severe urgency and frequency symptoms, higher depression, anxiety, perceived stress scores, more severe bowel dysfunction and sleep disturbance, lower physical activity levels, lower physical function, and worse quality of life than those with urinary urgency-only. Among those with urinary urgency-only at baseline, 40% continued to have urinary urgency-only, 15% progressed to urgency urinary incontinence, and 45% had no urgency at 12 months. Fifty-eight percent with urgency urinary incontinence at baseline continued to report urgency urinary incontinence at 12 months, while 15% improved to urinary urgency-only, and 27% had no urgency.

CONCLUSIONS

Patients with urgency urinary incontinence have severe storage symptoms, more psychosocial symptoms, poorer physical functioning, and worse quality of life. Our data suggested urgency urinary incontinence may be a more severe manifestation of urinary urgency, rather than urinary urgency and urgency urinary incontinence being distinct entities.

Dementia Associated with Anticholinergic Drugs Used for Overactive Bladder: A Nested Case-Control Study Using the French National Medical-Administrative Database

PURPOSE

We analyzed the relationship between use of anticholinergic drugs to treat overactive bladder (OAB) and risk of incident dementia in older patients, overall and for each drug separately.

MATERIALS AND METHODS

We conducted a nested case-control study using the French National Medical-Administrative Database. We identified incident dementia cases and controls from January 1, 2013 to December 31, 2018 in individuals aged ≥60 years. Controls were matched 5:1 to cases by date of case diagnosis (index date), age, sex, and income. We set a 5-year exposure period ending 2 years before the index date (lag-time period to avoid protopathic bias). We quantified cumulative exposure to flavoxate, oxybutynin, solifenacin, trospium, and fesoterodine using defined daily doses (DDDs). We performed conditional logistic regression analyses adjusted for factors known to be associated with OAB and/or dementia including obesity, diabetes, stroke, coronary heart disease, and psychotic disorders.

RESULTS

We analyzed 4,810 cases and 24,050 matched controls with a median age of 82 years. OAB anticholinergic use was associated with an increased risk of dementia (adjusted OR [aOR]=1.23, 95% CI 1.10-1.37) with a cumulative dose-response: aOR=1.07 (95% CI 0.91-1.25) for 1-90 DDDs, aOR=1.29 (1.05-1.58) for 91-365 DDDs and aOR=1.48 (1.22-1.80) for >365 DDDs. Considering each OAB anticholinergic separately showed a particularly marked increased risk of dementia for oxybutynin and solifenacin, but no increased risk for trospium.

CONCLUSIONS

When treating OAB in older patients, OAB anticholinergics should be used with caution, taking into account the patient's cognitive status, the anticholinergic load, and the different therapeutic options.

Why Patients Fall Through the Cracks: Assessment of Patients' Overactive Bladder Treatment

Objective: Despite an established treatment algorithm for overactive bladder (OAB), it is unclear how many patients proceed through each step. Our objective was to evaluate the percentage of patients receiving each step of care and identify reasons why patients did not receive certain treatments. Methods: This was a retrospective cohort study with cross-sectional survey of new OAB patients. The medical record was queried for relevant patient characteristics and documentation of conservative, medical, and third-line therapies. In the survey, patients were asked about current bladder symptoms and reasons why they did not use certain treatments. Descriptive statistics were used for analysis. Results: One hundred eleven patients met the inclusion criteria; the most common diagnosis was mixed incontinence (40%, n = 45). The median number of visits for OAB was 2 (range 1-8). On retrospective analysis, 64% (71) of patients had documented attempts at conservative therapy. Seventy-six percent (84) of patients attempted medical therapy, and only 11% (12) progressed to any third-line therapy. Fifty-nine percent (64) of eligible patients responded to the survey. Fifty-three percent (34) of respondents reported persistent moderate to very severe bother due to bladder symptoms. Thirty percent to fifty percent of patients who did not attempt one or more of the three levels of OAB therapy reported that they were never offered that treatment option. Conclusions: Many patients do not progress to the next steps in OAB therapy despite failure of more conservative treatments. Barriers to care included limited follow-up and education about other therapy options. A formalized institutional care pathway may lead to improved OAB treatment.

Associations among Physician-Patient Communication, Patient Satisfaction, and Clinical Effectiveness of Overactive Bladder Medication: A Survey of Patients with Overactive Bladder

This cross-sectional survey study evaluated associations between physician−patient communication and patient satisfaction with overactive bladder (OAB) medical care or clinical effectiveness. Japanese patients aged ≥50 years with OAB who had taken OAB medication within 2 years received a web-based survey regarding OAB medical care, physician−patient communication on OAB symptoms and treatment, and OAB symptom score (OABSS) change with treatment. Associations between physician−patient communication and patient satisfaction or OAB medication effectiveness (≥3-point improvement in OABSS) were investigated by multivariate analysis with confounding factors. Stratified analyses were performed based on medication continuation or discontinuation (for reasons except symptom improvement). Of the 1004 respondents included in the analyses, 58.0% continued treatment, and 23.7% discontinued for reasons except symptom improvement. Satisfaction with OAB care was associated with reported effectiveness, medication side effects, physician−patient communication, and whether medication was switched. Medication effectiveness was associated with patient−physician communication, female sex, and not switching medication. Significantly more patients in the continuation group were satisfied and had improvement of ≥3 points in OABSS (p < 0.001 for both). The findings suggest that, in Japan, adequate physician−patient communication contributes significantly to improving clinical effectiveness and satisfaction with medical care in OAB patients as well as treatment continuation.

Identifying Patient-Centered Research Priorities in Overactive Bladder by Crowdsourcing and Targeted Recruitment

INTRODUCTION

Patient perspectives in quality-of-life improvement are critical to measuring treatment outcomes. We aimed to identify patient priorities for overactive bladder (OAB) research.

METHODS

Participants were recruited utilizing the Amazon Mechanical Turk database, an online marketplace where individuals receive payment for completing tasks. Those who scored 4 or higher on the OAB-V3, a simple 3-question screening survey, were requested to complete an "OAB-q and Prioritization Survey," which identified preferences for future OAB research priorities, demographic and clinical data, and symptom severity via the OAB-q. Participants must have correctly answered an attention-confirming question to have their responses included in the final analysis.

RESULTS

Of 555 responders, 352 screened positive on the OAB-V3 and 232 completed the followup survey and met study criteria. The top 3 research preferences were: discovering the etiology of OAB (31%); individualized treatment based on age, race, gender and comorbidities (19%); and identifying the fastest OAB treatments (15%). Participants who selected etiology of OAB in the top 3 research priorities (56%) were older (38.7±2.1 vs 33.9±1.5 years, p=0.05) and had significantly lower mean health-related quality of life scores than those who did not (25.1±2.5 vs 35.5±3.9, p=0.02).

CONCLUSIONS

Using Amazon Mechanical Turk, we present the first report of OAB research priorities identified by patients experiencing OAB symptoms. Crowdsourcing offers a timely and cost-effective manner to learn directly from people with OAB symptoms. Few participants sought treatment for OAB despite having bothersome symptoms.

Development and validation of prediction model for incident overactive bladder: The Nagahama study

Objectives

We aimed to develop models to predict new‐onset overactive bladder in 5 years using a large prospective cohort of the general population.

Methods

This is a secondary analysis of a longitudinal cohort study in Japan. The baseline characteristics were measured between 2008 and 2010, with follow‐ups every 5 years. We included subjects without overactive bladder at baseline and with follow‐up data 5 years later. Overactive bladder was assessed using the overactive bladder symptom score. Baseline characteristics (demographics, health behaviors, comorbidities, and overactive bladder symptom scores) and blood test data were included as predictors. We developed two competing prediction models for each sex based on logistic regression with penalized likelihood (LASSO). We chose the best model separately for men and women after evaluating models' performance in terms of discrimination and calibration using an internal validation via 200 bootstrap resamples and a temporal validation.

Results

We analyzed 7218 participants (male: 2238, female: 4980). The median age was 60 and 55 years, and the number of new‐onset overactive bladder was 223 (10.0%) and 288 (5.8%) per 5 years in males and females, respectively. The in‐sample estimates for C‐statistic, calibration intercept, and slope for the best performing models were 0.77 (95% confidence interval 0.74–0.80), 0.28 and 1.15 for males, and 0.77 (95% confidence interval 0.74–0.80), 0.20 and 1.08 for females. Internal and temporal validation gave broadly similar estimates of performance, indicating low optimism.

Conclusion

We developed risk prediction models for new‐onset overactive bladder among men and women with good predictive ability.

Exploratory evaluation of baseline cognition as a predictor of perceived benefit in a study of behavioral therapy for urinary incontinence in Parkinson disease

AIMS

While behavior-based pelvic floor muscle exercise therapy is an effective treatment for overactive bladder in Parkinson's disease (PD) patients, cognitive function may be a predictor of rehabilitation outcomes.

METHODS

In a planned exploratory analysis, participants who had a Montreal Cognitive Assessment (MoCA) with a score ≥18 who were randomized in a clinical trial to behavioral treatment were classified by perceived improvement (Benefit vs. No Benefit) as reported on a validated Satisfaction and Benefit Questionnaire. General cognition (MoCA), motor procedural learning (Serial reaction time task), verbal memory (Buschke delayed recall), spatial memory (Nonverbal/Spatial selective reminding test), and working memory (Wisconsin card sorting task) were compared between the two groups using Wilcoxon rank-sum test.

RESULTS

Of the 26 participants randomized to behavioral treatment (70% male, mean age 71 ± 6.1 years), 22 participants (85%) reported Benefit and four reported No Benefit. General cognition, motor procedural learning, verbal memory, spatial memory, and working memory did not differ between these groups. While the difference between the time to complete the final practiced series and the random series of the Serial Reaction Time Task (SRTT) was statistically similar between the groups, the Benefit group performed the random sequence more quickly (567.0 ± 136.5 ms) compared to the No Benefit group (959.4 ± 443.0 ms; p = 0.03) and trended toward faster performance in the final practiced series.

CONCLUSIONS

Perceived benefit from behavioral treatment for overactive bladder was not associated with measures of baseline cognition other than faster completion of the SRTT. This is noteworthy because many behavior-based therapy studies exclude participants with mild cognitive impairment. Additional studies may evaluate if domain-specific cognitive function, particularly the assessment of implicit memory, could lead to individualized behavioral therapy recommendations.

The use of onabotulinumtoxinA to treat idiopathic overactive bladder in elderly patients is in need of study

BACKGROUND

Injecting onabotulinumtoxinA (BoTN-A) into the bladder has been established as an effective treatment of overactive bladder (OAB) and well-tolerated by patients. However, there evidence suggests the efficacy and safety of this treatment may decrease with age due to increased comorbidities and frailty. This study's objective was to establish empirical evidence regarding age-related differences in outcomes related to BoTN-A for the treatment of idiopathic OAB.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Registry for Controlled Trials were systematically searched. Results were restricted to randomized control trials of BoTN-A bladder injections for the treatment of idiopathic OAB. The resulting articles' abstracts were screened independently by two reviewers. Those passing the screen were reviewed in full. Articles were excluded if participants were <18 years old, diagnosed with neurogenic overactivity, or treated with both oral medications and BoTN-A; if the frequency and severity of OAB symptoms were not specified; or, if symptoms were not stratified by age.

RESULTS

The initial search resulted in 1572 articles; 166 were reviewed in full. None met all inclusion/exclusion criteria. However, 21 studies met all criteria except age stratification. Authors were contacted to obtain raw data to perform an independent age-based analysis, but sufficient data was not received.

CONCLUSION

While the initial systematic review did not generate the expected results, it did reveal that age-related outcomes of BoTN-A for the treatment of OAB are significantly under-studied. Given that the prevalence of OAB increases with age, this is an important knowledge gap. Our article explains the rationale for further study in this area.

Transcutaneous electrical nerve stimulation as add-on therapy in children receiving anticholinergics and/or mirabegron for refractory daytime urinary incontinence: A retrospective cohort study

AIMS

To investigate if children with daytime urinary incontinence (DUI) and overactive bladder (OAB) refractory to standard urotherapy and medicinal treatment, would experience improvement in symptoms after add-on treatment with transcutaneous electrical nerve stimulation (TENS).

METHODS

Children were retrospectively enrolled from tertiary referral centers at Aarhus and Aalborg University Hospitals. All data were retrieved from the patients' journals. All children were prescribed TENS as an add-on treatment to the highest-tolerable dose of medicinal treatment in a standardized regime of 2 h a day for around 3 months. Primary endpoints were the number of wet days per week (WDPW) and incontinence episodes per day. Effect of treatment was defined as greater or equal to 50% reduction in the frequency of DUI episodes. Secondary endpoints were to establish predictive factors for the effect of treatment using logistic regression.

RESULTS

Seventy-six children diagnosed with DUI and OAB refractory to treatment with standard urotherapy and pharmacological treatment, at the age of 5-16 years were included from February 2017 to February 2020. A reduction in WDPW (from 6.31 [5.86-6.61] to 4.27 [3.45-4.90], p < 0.05) and incontinence episodes per day (from 2.45 [1.98-2.91] to 1.43 [1.07-1.80], p < 0.05) was observed. Twelve patients became completely dry. At 6 months follow-up, seven of the 12 complete responders had relapsed while five remained dry. A history of constipation before TENS was a predictor of poor treatment response (p = 0.016).

CONCLUSIONS

TENS as add-on to anticholinergic treatment seems effective in a number of children with treatment-refractory DUI.

Artifacts and abnormal findings may limit the use of asymptomatic volunteers as controls for studies of multichannel urodynamics

BACKGROUND

Multichannel urodynamics is the gold standard for the evaluation of lower urinary tract symptoms (LUTS). When performing studies to validate new adjuncts to urodynamic testing with control patients undergoing urodynamic investigation, there is difficulty in the interpretation of urodynamic results in the asymptomatic patient due to artifacts and the invasive nature of the procedure. The purpose of this investigation was to examine urodynamics in asymptomatic volunteers in order to better understand the role of control participants in urodynamic research studies.

METHODS

Asymptomatic volunteers with no LUTS were recruited to undergo standard urodynamic testing as a comparison group in a study evaluating novel urodynamic techniques. To be eligible, participants had to report no LUTS, score ≤1 on all symptom questions of the International Consultation on Incontinence Questionnaire Overactive Bladder Module (ICIq-OAB) survey, have no medical conditions or to undergo any medications that affect bladder function. The urodynamics was done according to ICS standards. All tracings were evaluated by an expert neuro-urologist. Data were analyzed categorically for the presence or absence of low compliance (<30 mL/cmH20), detrusor overactivity, bladder outlet obstruction (Bladder Outlet Obstruction Index [BOOI]>40), weak contractility (bladder contractility index [BCI]<100), straining to void, poorly sustained detrusor contraction, uncoordinated EMG activity, and intermittent flow.

RESULTS

A total of 24 participants completed the study including 10 men and 14 women. All participants had at least 1 urodynamic abnormality/artifact with an average of 4.43±1.28 abnormalities/participant. The most common abnormalities included uncoordinated electromyography (EMG) activity (87.50%), straining to void (79.17%), and intermittent flow (70.83%). There were no significant differences for sex, age, Body Mass Index.

CONCLUSIONS

This study demonstrated that healthy, asymptomatic volunteers have high rates of abnormal urodynamic findings, suggesting that asymptomatic participants are not the ideal controls in research studies that involve urodynamic testing.

Current advances in neuromodulation techniques in urology practices: A review of literature

Neuromodulation has become a valid therapeutic option for patients with various lower urinary tract disorders. In clinical practice, the most used and recommended neuromodulation techniques are sacral neuromodulation (SNM), pudendal neuromodulation (PN), and percutaneous tibial nerve stimulation (PTNS). There are many theories concerning the mechanism of action of neuromodulation. Although SNM, PN, and PTNS show their activities through different nerve roots, all provide central and peripheral nervous system modulations. SNM has been approved for the treatment of overactive bladder (OAB), nonobstructive urinary retention, and fecal incontinence, while PTNS has been approved for OAB treatment. However, they are also used off-label in other urinary and nonurinary pelvic floor disorders, such as neurogenic lower urinary system disorder, interstitial cystitis, chronic pelvic pain, and sexual dysfunction. Minor and nonsurgical reversible complications are usually seen after neuromodulation techniques. In addition, in the last few years, there have been various developments in neuromodulation technology. Some of the examples of these developments are rechargeable batteries with wireless charging, improvements in programing, less invasive single-stage implantation in outpatient settings, and lower-cost new devices. We performed a literature search using Medline (PubMed), Cochrane Library, EMBASE, and Google scholar databases in the English language from January 2010 to February 2021. We included reviews, meta-analyses, randomized controlled trials, and prospective and retrospective studies to evaluate the activities and reliability of SNM, PN, and PTNS and the developments in this area in the last decade based on the current literature.

Acupuncture in addition to standard conservative treatment for overactive bladder; a feasibility trial for a randomized controlled study

AIMS

This study aims to assess the feasibility of an randomized controlled trial (RCT) to test treatment efficacy of acupuncture for symptoms of overactive bladder syndrome (OAB), a common long-term condition with physical, psychological, social and sexual consequences.

METHODS

A total of 30 participants were recruited and randomized to either standard conservative management for OAB or standard conservative management plus acupuncture. Standard care consisted of individually tailored advice regarding bladder health, pelvic floor exercises and lifestyle adjustments. The intervention group received 6 sessions of acupuncture over an 8-week period. Outcomes measured included adherence to the study protocol, recruitment rate, participant attrition rate and adverse events. A 3-day bladder diary and Incontinence Questionnaire-short form questionnaire were used to assess symptoms. The ICEpop CAPability measure for Adults measure was used to assess well-being. Outcomes were collected at baseline, after 8 weeks of intervention and 6 weeks after completing intervention. An exit questionnaire captured participant experience data.

RESULTS

Comparison of the two groups at baseline did not detect statistically significant differences in demographics and symptom profile. A total of 23 participants completed all study proceedures. Recruitment was completed in 11 months, quicker than anticipated. No serious adverse events occurred; minor adverse events were recorded in 11/114 (9.6%) treatments. A total of seven participants failed to complete one or more study proceedures with an overall attrition rate of 23.3%.

CONCLUSIONS

Most participants completed all aspects of the study and found the protocol acceptable. The interventions appear safe and well tolerated. The concept of a large-scale RCT with a similar protocol was proven and appears feasible based on this pilot work.