Pharmacotherapy adherence and costs versus nonpharmacologic management in overactive bladder

OBJECTIVE

To evaluate adherence with overactive bladder (OAB) pharmacotherapy and compare costs between patients receiving pharmacotherapy versus nonpharmacologic management.

STUDY DESIGN

Retrospective cohort study using anonymous, patient-level data from administrative claims from the PharMetrics database.

METHODS

Patients 18 years of age or older who received an OAB diagnosis or OAB medication prescription from January 1, 2005, through December 31, 2006, were identified. Eligible patients had continuous health plan enrollment from 6 months before to 12 months after the index date (date of first OAB prescription or first OAB diagnosis); exclusion criteria included prior OAB therapy use. Study cohorts were stratified as OAB therapy or nonpharmacologically managed based on evidence of treatment and matched using propensity score methodology. Outcomes included adherence rates with OAB therapy (defined as proportion of days covered [PDC]) and comparative costs of OAB pharmacotherapy versus nonpharmacologic management from a healthcare payer perspective.

RESULTS

Adherence among OAB therapy patients was low, with 14% of patients achieving PDC of 80% or higher and an average PDC of 32%. Unadjusted total costs were approximately 3% higher for OAB therapy versus nonpharmacologically managed patients due to higher pharmacy costs. Conversely, outpatient service and inpatient hospitalization costs were higher for nonpharmacologically managed patients. Results did not change after adjusting for patient characteristics.

CONCLUSION

Results confirm low adherence to OAB pharmacotherapy, with few patients achieving PDC of 80% or higher. Total costs were higher among OAB therapy patients due to higher pharmacy costs, but outpatient and inpatient costs were higher among nonpharmacologically managed patients. Additional research into optimizing pharmacotherapeutic regimens may provide insight into improving treatment adherence.

[Overactive bladder syndrome. How to manage it]

Overactive bladder syndrome (OAB) is a chronic and distressing condition characterized by urinary urgency and increased frequency of micturition with or without urge incontinence. Such symptoms can exert a negative impact on many aspects of quality of life, including social function and interaction, physical activity and psychological well-being. In a survey of some 4500 people aged more than 40 years old in Japan, the prevalence of OAB was 12.4%. Even though OAB is prevalent and troublesome, many patients with OAB never seek medical help for their symptoms because of embarrassment and misconception about bladder control problems. Thus, it is important to broaden the actual knowledge about OAB among community-based people. We hope that this citizen joint symposium would help the participants to understand the useful information about OAB.

Percutaneous tibial nerve stimulation for treatment of overactive bladder and urinary retention in an elderly population

Percutaneous tibial nerve stimulation (PTNS) is a treatment option for patients who present with urinary urgency, frequency, urge incontinence, or urinary retention. When behavior modification and/or pharmacotherapy did not adequately relieve symptoms, this treatment was found to decrease incidence of overactive bladder or retention symptoms in the authors' patient population.

Management of refractory overactive bladder in adults

Urologists experience frustration in the treatment of refractory overactive bladder for a multitude of reasons. Clinical failure experienced in managing these patients can lead to long office interactions and feelings of inadequacy for both patient and provider. With newer, technically straightforward interventions, this population can be approached with confidence. Appropriately timed diagnostics are essential in identifying neoplastic, neurogenic, and infectious causes for refractory overactive bladder. When approached in an efficient, stepwise fashion, outcomes can be highly satisfactory for both the patient and the provider.

Changing treatments for overactive bladder

Overactive bladder is a common urological diagnosis which is often untreated as patients fail to seek help for this embarrassing problem. Elizabeth Waine and Mark Stott summarise the symptoms and investigations for overactive bladder and provide an overview of the treatments available.

Overactive Bladder and Continence Guidelines: implementation, inaction or frustration?

Guidelines for the management of continence and overactive bladder are generally available across Europe. For a majority of countries, these have been adopted by professional societies in either urology or gynaecology for local use. There has, however, been little monitoring of formal implementation of these guidelines and seldom any attempt to audit their operation. The state of continence care therefore remains largely unknown. This article reviews current guidelines and their status across Europe and examines what might be relevant from other disease areas to promote successful implementation.

[Trospium chloride in combined treatment of females with genital prolapse and overactive urinary bladder]

The trial of efficacy of trospium chloride (TC) in a dose of 45 mg/day in females with overactive bladder (OAB) symptoms preserved after genital prolapse (GP) surgical correction included 28 females (age 55-82, mean age 68.07 +/- 12 years). GP was corrected by means of vaginal hysterectomy and anterior colporraphy. Treatment results were assessed 3 months after surgery basing on urine diary. Overall TC efficacy reached 82%. Symptoms attenuated in patients with and without detrusor overactivity: voiding frequency reduced by 31 and 24%, imperative voidings reduced by 26 and 8%, mean urine volume rose by 28 and 19%, respectively. Side effects were mild. TC demonstrated good efficacy in OAB patients, it noticeably improved quality of life.

Overactive bladder

Overactive bladder (OAB) is a common condition (prevalence 14%-18% of Canadians) and has a significant negative impact on quality of life. OAB may be idiopathic or may occur with other common conditions such as bladder outlet obstruction, neurological disease, or stress incontinence. Primary care physicians may safely diagnose this condition by history and physical exam with a minimum of widely available lab tests. Management with behavioral therapies and pharmacotherapy is generally quite successful and warranted. Multiple anticholinergic medications are available and have been shown to be effective. Subtle differences in structure and mechanism of these agents may yield improved therapeutic benefit or tolerability and thus it is reasonable to try more than one drug to achieve the optimal results. For patients that fail behavioral and initial pharmacotherapy or when other complicating conditions are identified, referral to a specialist is indicated; however, the majority of patients with OAB do not require cystoscopy or urodynamics. Successful treatments for OAB do exist and it is worth screening for these disabling complaints at the primary care level.

Pediatric voiding dysfunction: a case study

A 14-year-old male was evaluated and treated for frequent urination associated with straining to void, a sensation of incomplete emptying, and nocturia. Treatment and outcomes are presented in this article.

A comparison of the efficacy of darifenacin alone vs. darifenacin plus a Behavioural Modification Programme upon the symptoms of overactive bladder

PURPOSE

This study assessed the benefit of adding behavioural modification to darifenacin treatment for overactive bladder (OAB).

MATERIALS AND METHODS

The ABLE trial was a randomised, open-label, parallel-group, multicentre study of 12 weeks of darifenacin treatment [with voluntary up-titration from 7.5 mg once daily (qd) to 15 mg qd at week 2] alone or in combination with a Behavioural Modification Programme (BMP) for men and women with dry or wet OAB. Efficacy was assessed as the change in the number (per day) of micturitions (primary variable), urge urinary incontinence (UUI) episodes, urgency episodes, pads used and nocturnal voids. Health-related quality of life (HRQoL) was also evaluated. Tolerability and safety assessments included adverse events and the number of discontinuations.

RESULTS

Of 592 patients screened, 395 were randomised, 190 to darifenacin alone and 205 to darifenacin + BMP. At baseline, the majority of subjects were dry (mean 2.8 and three UUI episodes per day in the darifenacin and darifenacin + BMP groups respectively). At study end, darifenacin alone and darifenacin + BMP both produced significant reductions from baseline in median numbers of micturitions, UUI episodes, urgency episodes and nocturnal voids (all p < 0.05), but not in the number of pads used. HRQoL also improved. There were no significant differences between treatment groups in efficacy or HRQoL variables.

CONCLUSIONS

Darifenacin treatment provides a degree of normalisation of micturition variables and improvement in HRQoL that cannot be further enhanced by behavioural therapy of the type used in this study. Whether behavioural modification would add benefit over darifenacin treatment in patients with more pronounced incontinence problems remains to be determined.

Effect of Thalamic Deep Brain Stimulation on Lower Urinary Tract Function

OBJECTIVE

The precise mechanisms underlying cerebral regulation of lower urinary tract function are still poorly understood. In patients with disabling essential tremor (ET) refractory to pharmacotherapy, thalamic deep brain stimulation (DBS) is an effective treatment for tremor control. Here, we evaluated the effect of thalamic DBS on urodynamic parameters in patients with ET.

PATIENTS AND METHODS

We investigated seven patients (two females, five males) with ET 15-85 mo after implantation of DBS leads into the ventral intermediate nucleus of the thalamus. We compared urodynamic parameters during thalamic DBS (ON state) and 30 min after turning the stimulator off (OFF state).

RESULTS

In the ON compared with the OFF state, there was a significant decrease in bladder volume at first desire to void (median, 218 ml vs. 365 ml, p=0.031), at strong desire to void (median, 305 ml vs. 435 ml, p=0.031), and at maximum cystometric capacity (median, 345 ml vs. 460 ml, p=0.016). No significant differences between the ON and OFF state were detected for changes in detrusor pressure during filling cystometry, bladder compliance, maximum detrusor pressure, detrusor pressure at maximum flow rate, maximum flow rate, voided volume, and postvoid residual.

CONCLUSIONS

Thalamic deep brain stimulation resulted in an earlier desire to void and decreased bladder capacity, suggesting a regulatory role of the thalamus in lower urinary tract function. Therefore, the thalamus may be a promising target for the development of new therapies for lower urinary tract dysfunction.

Maximal functional electrical stimulation as a single treatment: is it cost-effective?

OBJECTIVE

The ideal electrical parameters for maximal functional electrical stimulation (MFES) in the treatment of an overactive bladder have not yet been well established. It has been speculated that unsatisfactory results may be due to a low stimulation intensity and that the number of sessions may also be an outcome-determining factor. Herein, we present the results obtained in a group of consecutively treated patients who were given 10 sessions of MFES at the highest tolerable amplitude.

MATERIAL AND METHODS

A total of 60 patients (29 females, 31 males) with an overactive bladder were treated. All subjects underwent a urodynamic assessment and completed a 48-h micturition chart prior to treatment, immediately after the last session and 3 months after termination of treatment. The patients were thoroughly informed that the result of the treatment depended on the amplitude that they could endure; there was a gradual increase in amplitude to the maximum level that did not cause painful discomfort.

RESULTS

Immediately after termination of the stimulation, almost half of the subjects reported an improvement in their condition. However, few subjects experienced sustained symptom amelioration 3 months post-stimulation. Decreases in micturition frequency and the number of leakage episodes were noted immediately after cessation of treatment but these decreases were no longer significant 3 months post-treatment.

CONCLUSIONS

In this series, although MFES was effective in the short term, the long-term treatment outcome was unsatisfactory. A critical review suggests that outcome success is proportional to the patient's ability and willingness to accept quite a high stimulation intensity or, alternatively, follow-up home treatment. Hence, the implementation of strict primary as well as secondary selection criteria can hopefully identify patients most suitable for MFES. Another lesson to be learnt is that the identification of crucial prerequisites of successful treatment is mandatory before embarking on controlled studies.

Development and validation of the overactive bladder satisfaction (OAB-S) questionnaire

AIMS

To develop and validate a measure of patient satisfaction with treatment in overactive bladder: the Overactive Bladder Satisfaction Questionnaire (OAB-S).

METHODS

Development of the questionnaire included a comprehensive literature review, development of a conceptual model, item elicitation and cognitive debriefing interviews with US-English and US-Spanish patients, and assessment of the questionnaire's translatability in other languages. Psychometric validation of the questionnaire was run on a longitudinal, non-randomized study involving 201 OAB patients. Analyses included construct validity, concurrent validity, tests of reliability, known-group validity, and responsiveness (exploratory).

RESULTS

The OAB-S is a patient-completed questionnaire including five scales: OAB Control Expectations (ten items); Impact on Daily Living with OAB (ten items); OAB Control (ten items); OAB Medication Tolerability (six items); and Satisfaction with Control (ten items) and five single-item overall assessments of patient's fulfillment of OAB medication expectations, interruption of day-to-day life due to OAB, overall satisfaction with OAB medication; willingness to continue OAB medication and improvement in day-to-day life due to OAB medication. The hypothesized structure of the questionnaire was supported by statistical analyses. Internal consistency reliability coefficients (ranging from 0.76 to 0.94) and test-retest reliability coefficients (ranging from 0.72 to 0.87) were good for all dimensions. All dimensions except tolerability discriminated well according to self-reported OAB severity level and incontinence status.

CONCLUSION

The OAB-S is a valid, comprehensive instrument to assess satisfaction with treatment of OAB based on independent scales that have demonstrated satisfactory psychometric performance.

Successful treatment of overactive bladder in a child with myasthenia gravis

Detrusor overactivity in patients with congenital myasthenia gravis is a rare finding. Owing to the underlying disease, anticholinergic treatment is not possible. We present the case of a 6-year-old child in whom a significant improvement was achieved by means of functional electrical stimulation.

Dorsal genital nerve stimulation for the treatment of overactive bladder symptoms

AIM

To evaluate percutaneous placement of electrodes adjacent to the dorsal genital nerve (DGN) and measure the effects of electrical stimulation on symptoms of urge incontinence during 1 week of home use.

METHODS

Prospective, multicenter study. Subjects with urge incontinence underwent percutaneous placement of an electrode using local anesthetic. Test stimulation was applied to confirm electrode placement and cystometry was conducted with and without application of electrical stimulation. A 7-day testing period with the electrode connected to an external pulse generator was performed and was followed by a 3-day post-treatment test period. Bladder diaries, 24 hr pad tests, and adverse event queries were obtained.

RESULTS

Twenty-one women were enrolled with an average age of 52.7 years and average duration of incontinence of 6 years. Percutaneous electrode placement required 5-10 min and was well tolerated. There was no relationship between the acute effects of stimulation on cystometry and the results during home use. Pad weight was reduced by >or= 50% in 13 of 17 subjects (76%) (4 did not complete 24 hr pad testing) and 47% of subjects reported >or=50% reduction in incontinence episodes. Of the subjects who reported severe urgency at baseline, 81% experienced a 50% or greater improvement. Seven subjects experienced nine adverse events ranging from skin irritation to pain and bruising around the electrode exit site.

CONCLUSIONS

Electrodes to stimulate the DGN can be placed percutaneously and a home testing period showed a reduction in overactive bladder symptoms with DGN stimulation.

Overactive bladder syndrome presentations at the 31st International Urogynecological Association Annual Meeting

There were 586 abstracts presented at the 31st Annual Meeting of the International Urogynecological Association in Athens, Greece, in September 2006. Many of these abstracts focused on the common condition of overactive bladder syndrome. The results of large multicenter industry-sponsored trials such as MATRIX, STAR, and SUNRISE were presented. Smaller trials of new treatments, including pudendal nerve stimulation and botulinum toxin A injection, were presented. A pair of studies addressed the importance of anatomic correction of pelvic organ prolapse in the treatment of overactive bladder syndrome. Nineteen abstracts are reviewed here.

Management of overactive bladder syndrome

Overactive bladder (OAB) syndrome is the term used to describe the symptom complex of urinary urgency with or without urge incontinence, usually with frequency and nocturia. Drug treatment continues to have an important role in the management of women with OAB. Other treatment options include conservative management with lifestyle interventions, modification of fluid intake, and physiotherapy including bladder retraining. Surgery remains the last resort in the treatment and is usually reserved for intractable detrusor overactivity, as it is associated with significant morbidity. This article reviews the management of the overactive bladder with specific focus on newer developments in the medical treatment of OAB in women.

Urologischer Erkrankungen bei Patienten mit Meningomyelozele

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

[Current condition of diagnosis and therapy of overactive urinary bladder in Czech Republic]

INTRODUCTION

The concept of overactive bladder (OAB), indicates complex symptoms of urgency, with or without urgent incontinence and it is generally accompained by urinary frequency and nocturia. Overactive urinary bladder belongs to one of the most common health problem in our population with significant impact on quality of life. The aim of this study is to assess this problem simultaneously between gynecologists and urologists in Czech Republic, by forwarding questionnaire.

MATERIAL AND METHODS

There were 290 respondants who answered this assessment. Out of this total number, 181 were gynecologists, and 109 urologists. Of this total number, 104 gynecologists (57.5%) work in out-patient clinic, 21 of them (11.6%) in hospital, and 56 (30.9%) in both this departments. 31 of urologists (28.4%) work in out-patient clinic, 15 of them (13.8%) in hospital, and 63 (57.8%) in both this departments. Inquiry and questions included in questionnaire were espescially aimed at definition, diagnosis, and therapy of OAB. Results were worked by method of descriptive statistics, used instrumental method was anonym.

RESULTS

Respondant gynecologists in the course of a week meet approx. 5.54 patients who suffering OAB, and respondant urologists meet in a week approx. 12.46 patients who suffering OAB. Correct definition of OAB mentioned only by 9 respondants (3.1%). At any rate, 57 respondants (19.6%) mentioned the basic symptoms i.e. urgency, urinary frequency, and urgent incontinence in their answer. Most common parameters employed for diagnosis of OAB including pt. history (280 respond. 965%), urine examination (255/87.5%), local urogynecological examination (247/85.2%), urodynamic investigation (183/63.1%), validated questionnaire (174/60%), voiding diary (139/47.9%), uroflowmetry (138/47.6%), and cystoscopy (134/46.2%). Most frequent therapeutic option is anticholinergic, followed by urinary bladder training, and application of local estrogen.

CONCLUSION

Common knowledge about OAB problem is still low among experts and specialists. Diagnostic and therapeutic approach of OAB is significantly different between gynecology and urology. It is somehow advisable to have many centers in where the problem of OAB can be completely engaged and solved.

Overactive bladder: treatment options in primary care medicine

Overactive bladder is a highly prevalent condition, affecting approximately 33 million adults in the United States. Despite the considerable impact this condition has on patients' quality of life, overactive bladder remains underrecognized and undertreated as a result of patient embarrassment and reluctance to seek medical help, as well as a lack of proactive questioning by physicians. The present article encourages physicians to initiate a dialogue with patients regarding urinary control and, specifically, overactive bladder. Treatment options for overactive bladder recommended in the current article include both nonpharmacologic and pharmacologic therapies. Properties of antimuscarinic agents, including three new drug therapies, are reviewed and provided for physicians to optimize therapy options, particularly among elderly patients.

[Effects of transcranial magnetotherapy on electroencephalographic parameters in females with overactive urinary bladder]

Urodynamic parameters and bioelectric brain activity were studied in 30 females aged 24-66 years with overactive bladder (OAB) before and after transcranial magnetotherapy. It was found that OAB patients have disorders of bioelectric brain activity by two types of EEG patterns (I.A. Svyatogor classification)--thalamic and stem, Patients with thalamic type EEG benefit more from magnetotherapy higher efficacy of which manifests with regress of clinical symptoms and urodynamic improvement.