A Primer for the Primary Care Physician: Management of Overactive Bladder Syndrome

Overactive bladder syndrome affects millions of women in the U.S. and is defined by urinary urgency, urinary frequency, and small volume voids, with or without nocturia and incontinence. Overactive bladder is a diagnosis of exclusion, and several therapies exist for the management of this condition. This article outlines a systematic approach that the primary care physician can take when treating a patient with overactive bladder.

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study

Objective

To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence.

Design

Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources.

Methods

Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken.

Results

Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties.

Conclusions

Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

Urodynamic findings in patients with Creutzfeldt-Jakob disease: a case report

AIM OF STUDY

Urinary dysfunction in Creutzfeldt-Jakob disease (CJD) patients is attributed to functional incontinence, since they often have immobility and loss of motivation. In contrast, previously no urodynamic findings are available in CJD patients.

CASE REPORT

We had 2 CJD patients who had urinary frequency and urinary retention. We performed urodynamics with the spouse's informed consent in order to explore the mechanism of urinary dysfunction in those cases. Case 1 had typical acute cognitive deterioration with incontinence and urinary retention, while case 2 had subacute cognitive deterioration (that started after admission) and nocturia. The urodynamic findings were diverse. One feature was detrusor overactivity during bladder filling in case 1. Another feature of urodynamic finding includes neurogenic change of sphincter EMG in case 1 and decreased bladder sensation in case 2.

CONCLUSION

Urodynamics in our two CJD patients revealed detrusor overactivity and neurogenic sphincter electromyogram, presumably reflecting pathological lesions in the prefrontal cortex/basal ganglia as well as the sacral spinal cord in CJD.

Long-term follow-up of intravesical botulinum toxin-A injections in women with idiopathic overactive bladder symptoms

INTRODUCTION

Intravesical botulinum toxin (BoNT-A) is a safe and effective treatment for overactive bladder syndrome. There are many reports on the clinical experience with BoNT-A, especially in patients with neurogenic detrusor overactivity. The US Food and Drug Administration has recently approved its use for idiopathic overactive bladder (iOAB). Various studies have reported positive results for iOAB in the short-term. Yet little is known about the results after repeated BoNT-A injections. In this study, we evaluated the long-term results of botulinum toxin (BoNT-A) in women with iOAB.

METHODS

Patients treated with BoNT-A from 2004 until 2009 were evaluated in a non-academic teaching hospital (Zuyderland MC, Heerlen, the Netherlands). All female patients with a follow-up of >5 years with idiopathic bladder dysfunction were included. All patients received 200 U of onabotulinum toxin-A in 20 intradetrusor injections. In some patients, we applied a dose adjustment for repeated injections. Patients were instructed how to use clean intermittent self-catheterization (CISC) before the treatment. We advised patients to commence CISC if post-void residual exceeded 150 ml.

RESULTS

A total of 128 women were included. All patients had at least 5-year follow-up after their first injection. The mean follow-up was 97 (60-125) months. The mean age was 67 (46-88) years. Of all patients, 30 % were still on BoNT-A treatment at the last follow-up visit. Of the 70 % that discontinued treatment, 27 % had insufficient effect and 43 % had tolerability issues. Most patients discontinued treatment after the first (79 %) and second (19 %) injections. Only 2 % of patients discontinued treatment after more than two injections during follow-up.

CONCLUSION

Intravesical BoNT-A is an effective treatment for women with idiopathic OAB. However, in time, almost two-thirds of patients in our study discontinued therapy. Most patients discontinue treatment after one or two injections and mainly due to tolerability issues.

[Validation of urgency scale to detect and assess urgency in patients with overactive bladder]

INTRODUCTION

Urinary urgency is a hallmark symptom of overactive bladder (OAB). Several scales have been used to measure urgency. Taking into account the exceptional importance of these scales, it is important to determine their reliability, which depends directly on the accuracy of the wording and clarity to patients.

AIM

To determine reliability of Russian-language translation of the Patient Perception of Intensity of Urgency Scale (PPIUS) in identifying and assessing urgency in patients with OAB.

MATERIALS AND METHODS

The study included 50 patients (46 women and 4 men) aged 19 to 70 years (mean age 56.5 years). At the time of entering the study, all patients had symptoms of OAB and received anticholinergic therapy for at least 3 months with any drug approved for the use in Russia. PPIUS scale validation was performed by assessing reliability, absence of "habituation" effect of and indicators of convergent, divergent, and content validity.

RESULTS

The Russian version of voiding diary with PPIUS scale was found to have good psychometric properties and besides the content validity also had significant signs of convergent and divergent validity.

CONCLUSION

The Russian-language versions of urgency scales PPIUS and TUFS can be considered validated for using in clinical practice and in clinical and non-interventional studies in patients with OAB in Russia.

Systemic Nonurological Symptoms in Patients with Overactive Bladder

PURPOSE

We compare the systemic (nonurological) symptoms between patients with overactive bladder and subjects without overactive bladder. We also compare the urinary symptoms, quality of life and psychosocial measures between the 2 subgroups of patients with overactive bladder with a high vs low systemic symptom burden.

MATERIALS AND METHODS

Patients diagnosed with overactive bladder (51) and age matched individuals without overactive bladder (30) were administered the polysymptomatic, polysyndromic questionnaire to assess the numbers and distribution of systemic symptoms across multiple organ systems. Validated instruments were administered to evaluate urinary symptoms (ICIQ-UI, ICIQ-OAB, OAB-q, USS), quality of life (UDI-6, IIQ-7, OAB-q) and psychosocial difficulties (depression, anxiety, stress, sexual trauma, sleep, fatigue). Patients with overactive bladder were divided into 2 subgroups (with and without widespread systemic symptoms) and their responses were compared.

RESULTS

Patients with overactive bladder reported significantly more systemic (nonurological) symptoms compared to controls (mean ± SD 17.5 ± 12.3 vs 6.4 ± 7.9 symptoms, p <0.001). Differences were observed across multiple organ systems (neurologic, cardiopulmonary, gastrointestinal, sexual, musculoskeletal and gynecologic, p <0.05). About a third of patients with overactive bladder (31.4%) reported widespread systemic symptoms across multiple organ systems (mean 32.0 symptoms). The presence of widespread systemic symptoms among patients with overactive bladder was correlated with worse incontinence/overactive bladder symptoms (ICIQ-UI, OAB-q), poorer quality of life (UDI-6, IIQ-7, OAB-q) and more psychosocial difficulties (depression, anxiety, fatigue and higher stress, p <0.05).

CONCLUSIONS

The increased presence of nonurological symptoms in overactive bladder suggests an underlying systemic etiology and pathogenetic mechanisms that may contribute to overactive bladder. This study highlights the importance of understanding systemic factors in urological conditions otherwise thought to be organ specific.

Comprehensive Health-Related Quality of Life is Influenced by Nocturia and Sleep Disturbance: Investigation Based on the SF-8

We investigated the influence of nocturia and sleep disturbance on health-related quality of life(HRQOL) using the Medical Outcomes Study 8-item Short Form Health Survey (SF-8) in patients with nocturia. We also assessed the effect of therapeutic intervention by means of an anticholinergic agent on the results of the SF-8. One hundred and eighty-four patients who voided at least once per night were surveyed using the SF-8, Overactive Bladder Symptom Score (OABSS), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS). These parameters were also evaluated before and after 12 weeks of imidafenacin treatment in 51 patients with OAB accompanied by nocturia. The SF-8 physical component summary score (PCS) showed a significant decrease as nighttime voiding frequency increased. The mental health component summary score was 47.1 and 47.6 (which were lower than the standard value of 50) in the group with a nighttime frequency of once and ≥3/night, respectively. The SF-8 PCS and 6 subscales were negatively associated with nighttime voiding frequency, while the PSQI global score was positively associated with it. Imidafenacin significantly improved the OABSS, PSQI, and ESS, as well as the SF-8 score. This is the first study using the SF-8 to show that nocturia and sleep disturbance have a major influence on comprehensive HRQOL and that the SF-8 can be used to monitor HRQOL in OAB patients receiving treatment for nocturia.

Is pretreatment cystometry important in predicting response to mirabegron in women with overactive bladder symptoms?

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate for any association between pretreatment cystometry results and outcome of treatment with mirabegron in women with overactive bladder (OAB) symptoms.

METHODS

This was a prospective observational study of women with OAB symptoms that proved refractory to conservative management. All women underwent filling and voiding subtraction cystometry prior to further treatment. Women were treated with mirabegron 50 mg once daily, and outcomes were evaluated after 6 weeks' treatment. The primary outcome measure was change in symptoms as indicated by response to the Patient Global Impression of Improvement (PGI-I) scale. The presence of detrusor overactivity (DO), the highest detrusor pressure recorded during the filling phase, the presence of urodynamic stress incontinence (USI), cystometric capacity, voided volume, maximum flow rate and detrusor pressure at maximum flow were all compared between responders and nonresponders.

RESULTS

The study population consisted of 169 women; response rate to mirabegron was 69.8 %. There was no association between the presence of DO or maximum detrusor pressure during filling and USI, cystometric capacity, maximum flow rate and detrusor pressure at maximum flow and treatment response. In a subgroup with OAB symptoms refractory to previous treatment with antimuscarinics, there was an association between the presence of DO and a positive treatment response (p = 0.02).

CONCLUSIONS

Overall, there is no association between urodynamic findings and response to treatment with mirabegron. This may reflect the fact that mirabegron's mode of action mechanisms are not measurable using cystometry. In women with refractory symptoms, however, the presence of DO is associated with a positive response to treatment.

Gender differences in overactive bladder

Overactive bladder (OAB) is a common condition in both women and men. Although prevalence's are similar in both genders, sex specific differences do exist in relation to individual OAB symptoms as well as degree of bother and quality of life. The added effect of prostatic enlargement in men leads to slightly different evaluation and treatment regimens in both genders. This review will examine the gender differences in OAB related to epidemiology, OAB evaluation, investigation and treatment. This information will assist the primary care physician in assessing and initiating treatment in patients with OAB. It will further the understanding of the spectrum of treatments available for OAB and assist in determining the appropriateness and timing of referral of such patients to a urologist.

Potential benefits of diagnosis and treatment on health outcomes among elderly people with symptoms of overactive bladder

OBJECTIVES

This study examined potential benefits of diagnosing and treating elderly adults with overactive bladder (OAB) symptoms.

METHODS

Data were analysed from the OAB Re-Contact Study (N = 2750), a cross-sectional, self-reported Internet survey. Elderly respondents (65+ years old) with OAB were identified according to current medication use to control OAB symptoms or by scores > 14 (men) or > 16 (women) on the OAB Awareness Tool. Treated were those currently using prescription medication and never treated were those who never used prescription medication for OAB. Outcome measures included health-related quality of life, activity impairment, OAB-related severity and symptoms, and healthcare resource use (e.g. hospitalisations). Generalised linear models predicted health outcomes as a function of diagnosis or treatment, adjusting for covariates.

RESULTS

Diagnosed vs. not diagnosed elderly respondents had higher mental component summary (MCS) scores and SF-6D health utilities, and less activity impairment. Treated vs. never treated elderly respondents had higher MCS and SF-6D health utilities, less activity impairment, fewer OAB symptoms, lower OAB Awareness Tool scores, and lower odds of having bladder problems or incontinence. There were no significant differences in healthcare resource use. Further analysis by age group (middle-aged vs. elderly respondents) revealed significantly greater diagnosis- and treatment-related benefits on MCS (2.93 and 4.49 points more, respectively) and activity impairment (1.24 and 1.37 times as much, respectively) among elderly respondents.

CONCLUSIONS

Diagnosis and treatment were each associated with a lower health burden for elderly adults with OAB symptoms. These findings highlighted the importance of diagnosis and treatment in alleviating OAB symptoms and their impact on health outcomes.

Reliability of Thai-Version Overactive Bladder Symptom Scores (OABSS) Questionnaire and the Correlations of OABSS with Voiding Diary, International Prostate Symptom Score (IPSS), and Patient Perception of Bladder Condition (PPBC) Questionnaires

BACKGROUND

Overactive bladder (OAB) is defined by subjective symptoms such as urgency, frequency, and urge incontinence, rather than objective measures. Using questionnaires like OABSS can help in diagnosis and evaluation of patients'symptoms for further assessment.

OBJECTIVE

To evaluate test-retest reliability of OABSS in 2-week interval and to evaluate the correlation of OABSS with voiding diary, IPSS, and PPBC.

MATERIAL AND METHOD

Between August 2009 and January 2011, 56 Thai women aged more than 18 years, attending urogynecology clinic at King Chulalongkorn Memorial Hospital were recruited in the study. They were diagnosed as having the overactive bladder with these criteria, symptoms of urinary frequency, urgency with or without urge incontinence, for more than three months, and at least one episode of urgency with or without incontinence in last three days. After giving the written informed consents, the patients were instructed to complete the voiding diary before starting the study and at the second visit (two weeks apart). The Thai version of self-answered questionnaires (OABSS, IPSS, and PBC) were also given at 0- and 2-week visit. The questionnaires were translated by one linguist from the Language Institute, Chulalongkorn University, Thailand, and translated back by another linguist to English. The content and language validity were checked by one urogynecologist at our department. The study was conducted after the protocol was approval by the Institutional Review Board (IRB).

RESULTS

The test-retest reliabilities (intraclass correlation) of the OABSS, PPBC, and IPSS total score were 0.88, 0.44, and 0.85. The overall Cronbach's alpha of OABSS was 0.31 and 0.41 at 0- and 2-week respectively.

CONCLUSION

Thai version of OABSS was reliable, valid, and related to the abnormal voiding symptoms. Further use of Thai version OABSS questionnaire was advocated for both clinical study and clinical practice in Thai women with OAB.

Continuous urethral pressure measurements; measurement techniques; pressure variations; clinical interpretations; and clinical relevance. A Systematic Literature Analysis

AIMS

The clinical relevance of urethral pressure variations (UPV) in the pathophysiology of over active bladder syndrome (OAB) has remained controversial to date. Some studies report an association with OAB and/or detrusor over activity (DO). Recently the International Consultation on Incontinence-Research Society recommended new clinical research to be performed on this subject. We provide a systematic review of the literature to specify this recommendation.

METHODS

Literature search was performed in PubMed, Embase, Web of Science, Cochrane, Central, Cinahl, Academic Science Premier, Science Direct, and Wiley Online using a sensitive search string combination. All authors independently reviewed and scored full text papers and consensus about methodological quality was obtained according to Oxford Level of Evidence (LoE).

RESULTS

Four hundred eighty seven abstracts were screened, 25 papers met all predefined inclusion selection criteria. Incidence figures of UPV varied between 2% and 95%. Studies are of poor methodological quality with Oxford LoE scores of 3B and 4. Measurement methods and techniques show a large variety. The above mentioned association of DO/OAB with UPV is however frequently reported.

CONCLUSION

There exists a phenomenon of UPV, apart from DO, which may be a separate entity within OAB syndrome. Large variation in measurement techniques and patient populations hinders fundamental research as well as clinical progress. Clinical relevance of UPV and consequences for treatment therefore are yet to be established. Future prospective research with well-defined patient population and standardised urodynamic measurement techniques is needed. Results of standardized and objective evaluations should be compared to clinical signs and symptoms by validated questionnaires. Neurourol. Urodynam. 36:51-56, 2017. © 2015 Wiley Periodicals, Inc.

Association between Menopausal Symptoms and Overactive Bladder: A Cross-Sectional Questionnaire Survey in China

Purpose

The association between menopause and overactive bladder is controversial. The purpose of this study was to determine the association between menopausal symptoms and overactive bladder, and identify the risk factors for overactive bladder.

Methods

A cross-sectional study was performed. The study included 403 women aged 36–76 years who visited the menopause clinic at Peking University First Hospital between September 2012 and December 2013. The overactive bladder symptom score and modified Kupperman index questionnaires were used. Differences were assessed using descriptive statistics to determine any association between the overactive bladder symptom score and modified Kupperman index score, and to evaluate the risk factors for overactive bladder.

Results

A total of 304 women were finally enrolled. The prevalence of overactive bladder was 9.43%, and the modified Kupperman index score; number of sexual problems; and frequency of urinary tract infections, vertigo, melancholia, and mood swings were significantly higher in patients with overactive bladder than in the patients without overactive bladder (p < 0.05). Menopausal symptoms (modified Kupperman index score ≥ 15) (odds ratio: 1.049, 95% confidence interval: 1.006–1.095, p = 0.025) and a low frequency of sexual intercourse in the last 6 months (odds ratio: 2.580, 95% confidence interval: 1.228–5.422, p = 0.012) were identified as independent risk factors for overactive bladder. The frequency of sexual intercourse was found to decrease with an increase in the severity of overactive bladder (p = 0.004, linear-by-linear association = 0.001).

Conclusion

Menopausal symptoms may be closely associated with overactive bladder, and sexual activity may be associated with the severity of overactive bladder. Moreover, sexual problems, urinary tract infections, vertigo, melancholia, and mood swings may be associated with overactive bladder.

Validation of the lower urinary tract symptom score

INTRODUCTION

To develop and validate a lower urinary tract symptom score (LUTSS) as a measure of lower urinary tract symptom (LUTS) severity and a treatment outcome tool in adults.

MATERIALS AND METHODS

An expert panel was convened to develop the LUTSS questionnaire. Content validity was achieved by obtaining subject and expert feedback from two prospective drafts. Subjects were divided into three groups: normal, LUTS and overactive bladder (OAB). Questionnaire was administered on two separate occasions within 1-2 weeks. Test-retest reliability, internal consistency, discriminant validity, criterion validity and responsiveness to change were also assessed.

RESULTS

The questionnaire contains 14 questions with answers scored on a 5-point Likert scale (0-4). It includes 9 storage, 4 voiding and 1 bother question. One hundred ninety-one patients completed it; 80 males and 111 females, mean age 65 years (range 22-91). Seventy-two had OAB, 91 LUTS without OAB and 28 were normal. Test-retest intraclass correlation was 0.96 and Cronbach's-□ was 0.77, indicating strong test-retest reliability and internal consistency, respectively. ANOVA and post-hoc bootstrap-generated adjustments showed significant differences between the three groups (p < 0.001), demonstrating discriminant validity. Responsiveness to change was exhibited by the significant decrease between preop and postop scores and a concurrent patient global impression of improvement (PGI-I) score indicative of symptomatic improvement.

CONCLUSION

The 14-question LUTSS is a validated questionnaire that assesses a full range of LUTS in men and women. The ordinal nature of the data with its highly specific description of symptoms makes it ideally suited as a nuanced and comprehensive symptom score and patient reported outcome (PRO) tool.

[DIAGNOSIS AND TREATMENT OF OVERACTIVE BLADDER SYNDROME IN PELVIC INJURIES]

Case records of 1994 patients with injuries of the pelvic ring were analyzed. The article presents the results of examination and treatment of patients with urinary tract dysfunction. A frequent complications of pelvic fractures include overactive bladder syndrome (OAB) (18.9%). Many factors play a role in the development of this syndrome, in particular damage to the pelvic diaphragm and the development of pelvic hematoma. OAB is more common in unstable pelvic fractures (24.8%). Surgical stabilization of the pelvic ring injuries and the use of M-cholinoblockers and a1-blockers lead to a reduction of OAB.

Cost-Effectiveness of Mirabegron Compared with Antimuscarinic Agents for the Treatment of Adults with Overactive Bladder in the United Kingdom

BACKGROUND

Mirabegron, a first-in-class selective oral β3-adrenoceptor agonist, has similar efficacy to most antimuscarinic agents and a lower incidence of dry mouth in patients with overactive bladder (OAB).

OBJECTIVES

To evaluate the cost-effectiveness of mirabegron 50 mg compared with oral antimuscarinic agents in adults with OAB from a UK National Health Service perspective.

METHODS

A Markov model including health states for symptom severity, treatment status, and adverse events was developed. Cycle length was 1 month, and the time horizon was 5 years. Antimuscarinic comparators were tolterodine extended release, solifenacin, fesoterodine, oxybutynin extended release and immediate release (IR), darifenacin, and trospium chloride modified release. Transition probabilities for symptom severity levels and adverse events were estimated from a mirabegron trial and a mixed treatment comparison. Estimates for other inputs were obtained from published literature or expert opinion. Quality-adjusted life-years (QALYs) and total health care costs, including costs of drug acquisition, physician visits, incontinence pad use, and botox injections, were modeled. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Base-case incremental cost-effectiveness ratios ranged from £367 (vs. solifenacin 10 mg) to £15,593 (vs. oxybutynin IR 10 mg) per QALY gained. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of £20,000/QALY gained, the probability of mirabegron 50 mg being cost-effective ranged from 70.2% versus oxybutynin IR 10 mg to 97.8% versus darifenacin 15 mg. A limitation of our analysis is the uncertainty due to the lack of direct comparisons of mirabegron with other agents; a mixed treatment comparison using rigorous methodology provided the data for the analysis, but the studies involved showed heterogeneity.

CONCLUSIONS

Mirabegron 50 mg appears to be cost-effective compared with standard oral antimuscarinic agents for the treatment of adults with OAB from a UK National Health Service perspective.

Beta-3 adrenergic receptors could be significant factors for overactive bladder-related symptoms

The treatment failure often happens in overactive bladder (OAB) partly owing to its unknown pathogenesis. The purpose of this study is to find significant receptors or biological markers for OAB-related symptoms for establishment of potential order-made therapeutic strategies. The overactive bladder symptom scores (OABSS) and international prostate symptom scores (IPSS)/quality of life (QOL) were questioned in all the 18 patients with OAB diagnosis. Their bladder mucosal tissues were taken from the random biopsy of bladder cancer suspected patients without any finding such as inflammation or carcinoma in situ. They were investigated quantitatively by immunohistochemical (IHC) stainings for inflammatory or immune-system (Interleukin (IL)-6 and cyclooxygenase-2 (Cox-2)), Caspase-3 apoptosis markers, angiogenesis (CD-31), epithelial-mesenchymal transition (E-cadherin) and muscarinic receptor (Muscarine-2 (M)-2), adrenergic receptors (ARs) (alpha 1-d (α1-d) and beta-3 (β-3)). The statistical correlation between the expressions of these 5 markers and 3 receptors and these symptom scores were examined under the comparison between OAB patients and control patients who had urgency score with less than 2 in OABSS. The OABSS and IPSS/QOL was 7.39 ± 2.69 and 21.2 ± 6.59/4.33 ± 1.33, respectively but those of control patients were 2.00 ± 1.41 and 10.1 ± 9.52/2.14 ± 1.46, respectively (P<0.05). Regarding the correlation of those markers' expressions and symptom scores, in OAB patients, OABSS total significantly correlated with β-3 AR expressions (P=0.0457). IPSS post-voiding significantly correlated with β-3 AR expressions (P=0.0308) but no significant relationship in control patients (P>0.05). In conclusion, this study demonstrated that β-3 AR in our tested 8 markers or receptors was correlated strongly with OAB-related symptoms. These data may help elucidate the pathophysiology of OAB and offer possible strategy for its order-made therapies.

[Persistence in the treatment of overactive bladder (OAB) with Mirabegron in a multicentre clinical study]

OBJECTIVE

The objective of this monitoring was to evaluate persistence in the treatment of patients with overactive bladder syndrome (OAB) using mirabegron.

DESIGN

Prospective clinical study.

SETTING

10 gynecological and urological departments in CZE.

MATERIALS AND METHODS

This is an analysis of a prospective, multicenter monitoring which started in May 2014 and will continue for 1 year. This monitoring included patients 18 years old who have had symptoms of OAB for minimum 3 months. The patient check-up was performed 6 months (±2 weeks) after the first visit. The dosage of mirabegron was 50 mg per day. For the evaluation the treatment efficacy we employed the TS-VAS and PPBC. During the check-up it was ascertained how many patients discontinued the treatment with mirabegron, and reasons for this interruption were established. The statistics were calculated using the software SPSS 20.0.

RESULTS

A prospective monitoring was performed on 206 patients. Their mean age was 62.8 years (range 23-89); mean body mass index for the whole group of patients was 27.3. At the check-up 6 months post-initiation of treatment it emerged that 55/206 (27%) patiens had discontinued the treatment. The reasons for discontinuation of treatment were: 24/55 (43%) insufficient treatment efficacy, 29/55 (53%) other reasons (the main reasons here were hospitalisation, surgery, gravidity) and 2/55 discontinued therapy because of side effects. The side effects were tachycardia, eye irritation, lower abdominal pain and vasculitis, and they were mild in nature. The termination of the study was 7/28 (25%) in the group of patients without previous treatment before mirabegron. Discontinuation of the treatment in the group of patients with previous anticholinergic treatment was 48/178 (27%). At the evaluation of the efficacy of the treatment during the check-up 6 months after initiation of treatment the mean TS-VAS was 77.5, a decrease of the scale of bothers evaluated by PPBC before treatment from a mean value of 3.56 to a value of 1.77.

CONCLUSIONS

Our hypothesis, that persistence in treat-ment with mirabegron would be relatively high due to reduced side effects and better cure effect, was confirmed, and this is the reason for higher rates of persistence in the treatment at 6 months check-up (73%).

Effectiveness of pelvic floor muscle training on symptoms and uroflowmetry parameters in female patients with overactive bladder

BACKGROUND/AIM

To evaluate the effects of pelvic floor muscle training (PFMT) on symptoms of overactive bladder (OAB) as well as uroflowmetry parameters and functional bladder capacity.

MATERIALS AND METHODS

Fifty-nine female patients with OAB symptoms were included. Patients were assessed by SEAPI-QMM, uroflowmetry, and abdominal ultrasound. A specially designed PFMT program using a Pilates ball was generated for patients. The training period was 1-h sessions twice a week for 6 weeks and aerobic home exercises to be performed at home 4 or 5 times every other day. Following training, subjects were reevaluated for body mass index, SEAPI questionnaire, and uroflowmetry.

RESULTS

Initial mean SEAPI score, mean maximum and average flow rates, and mean voided volume were 9.8 ± 7.2, 29.8 ± 16.4 mL/s, 16.3 ± 8.7 mL/s, and 211.6 ± 173.5 mL, respectively. After completion of the training program, SEAPI scores improved significantly to 3.4 ± 6.4 (P < 0.05). Maximum and average flow rate results did not show significant changes, whereas voided volume seemed to have improved in conjunction with patients' symptom scores (Pearson correlation coefficient: 0.86).

CONCLUSION

According to. our results, we think that proper PFMT results in increase of functional bladder capacity as well as improvement in OAB symptoms and can be recommended as first-line therapy or in conjunction with medical therapy in severe cases.

[Etiology and own experience in the primary monosymptomatic nocturnal enuresis in children]

Primary monosymptomatic nocturnal enuresis (PMNE) is the most frequent (85%) type of enuresis in children. It remains a diagnostic and therapeutic challenge to establish its etiology and implement a proper treatment.

AIM

The aim of the study was to establish the causes of PMNE in children on the basis of own investigations and assess factors having influence over PMNE etiology, which would enable the choice of effective therapy.

MATERIALS AND METHODS

The study concerned 85 children with PMNE aged from 5 to 15 years. The patients were under the care of Nephrology Outpatient Clinic at Institute of Mather and Child in years 2009-2014. The detailed medical history, physical examination as well as laboratory investigations of blood and urine, and radiological investigations of the urinary tract, were carried out. Statistical analysis was performed using R software.

RESULTS

In all patients, we have successfully detected the etiology of children of PMNE. The basic, equally frequent (62.3%), PMNE etiopathogenetic factors turned to be: too small bladder capacity resulting from the detrusor hyperactivity, and night polyuria mainly caused by vasopressin deficiency or abnormal eating and hygienic habits, occurring separately or in conjunction with each other. Too small bladder capacity occurred mainly (37.6%, group C) as the only etiological factor of PMNE, and in 24.7% (group A) in a conjunction with nocturnal polyuria due to decreased excretion of vasopressin. Night polyuria was caused by the deficiency of vasopressin in most cases (37.6%) and occurred mainly (24.7%, group D) in a conjunction with small bladder capacity, and rarely alone (12.9%, group B). In 24.7% (group A) it appeared due to eating and hygienic abnormal habits. We have proved statistically significant differences in mean voiding frequency and volume (p<0.0001) between groups A-B and C-D. Mean morning urine specific gravity (p<0.0001) also differed significantly between group C and B (p<0.0001) as well as C and D (p=0.0004).

CONCLUSIONS

PMNE in all patients was attributed to specific causes outside the circle of psychological disorders what reduced patient stigmatization. PMNE etiology is very complex and diverse. It still remains a challenge and requires and individual diagnostic and therapeutic approach. Voiding frequency above 8 daily with voiding volumes usually below 100 ml suggest etiology connected with small bladder capacity, while morning urine specific gravities below 1.021 g/ml can be connected with vasopressin deficiency or excessive fluid intake before the bedtime. The developed diagnostic approach along with borderline values are hints that can aid physicians in establishing PMNE causes.

[Therapy of overactive bladder (OAB)]

Overactive bladder (OAB) is a symptom complex which is present in approximately 17% of the European population. It is observed in the presence or absence of incontinence (wet or dry) and is associated with a high degree of psychological stress as well as high costs for the healthcare system. Myogenic, urothelial and neurogenic factors lead to frequently unknown changes of muscular, neural and connective tissue. For the definition, etiology and diagnostics of the disease the previous continuing medical education (CME) article "Diagnosis of overactive bladder (OAB)" should be consulted. In recent years some improvements have been made in OAB-related research, in terms of pathophysiological models and new pharmacological approaches with the development of new therapeutic agents. Besides classical substances, recently approved agents are increasingly being used for the therapy of OAB. Furthermore, non-pharmaceutical approaches and surgical techniques still play an important role in the therapy of OAB.

[INJECTION OF BOTULINUM TOXIN TYPE A IN THE BLADDER DETRUSOR AND SUBMUCOSA IN PATIENTS WITH OVERACTIVE BLADDER WITHOUT DETRUSOR OVERACTIVITY]

The objective of the study was to compare the efficacy and safety of injections of botulinum toxin type A in the submucosal layer of the bladder and in detrusor in patients who were refractory to anticholinergic therapy of overactive bladder without detrusor overactivity. 100 U botulinum toxin type A was diluted in 10 ml of 0.9% saline and injected with 0.5 ml (5 units) of this solution in 20 points of the bladder (the back and side walls except Letto triangle). In twenty-two patients (the first group) botulinum toxin was injected into the submucosal layer of the bladder, while in 34 patients (second group) - into the detrusor. In the first group after 1 and 3 months 3 (14%) patients and after 6 months 2 (9%) patients had positive treatment outcomes (improvement of symptoms in more than 50%). In 22 (65%) of the 34 patients of the second group positive results were observed at 1 and 3 months and in 17 (50%) - at 6 months. After 9 months, all patients had a relapse of urgent and frequent urination. Difficulties in emptying the bladder were observed in three (9%) of the second group patients who had to resort to periodic self-catheterization for 2-20 weeks. The obtained results allow us to state that the injections of 100 U of botulinum toxin type A in the submucosal layer of the bladder are ineffective in patients with overactive bladder without detrusor overactivity, whereas injections in the detrusor lead to a statistically significant improvement in symptoms of urgent and frequent urination for 6 months.

[ASSESSMENT OF EFFICIENCY OF TREATMENT OF OVERACTIVE BLADDER IN ELDERLY PATIENTS]

The effectiveness of overactive bladder treatment with M-cholinoblocker solifenacin (Vesicare) as monotherapy and in combination with α1-andrenoblocker terazosin (Setegis) or bladdrer training in elderly patients was evaluated. The results of 12 weeks treatment in all treatment modality groups were comparable. Use of solifenacin in combination with α1-andrenoblocker in comparison to solifenacin monotherapy resulted in longer symptoms remission.

[Prediction of overactive bladder treatment outcome by using long-term urodynamics]

In Germany, overactive bladder (OAB) syndrome affects around 6.5 million people over the age of 40. The primary treatment consists of anticholinergics or beta-3-receptor agonists. After an anticholinergic treatment period of around 4 months, compliance is around 40%, which is probably due a larger proportion of nonresponders. One condition of an efficient medication treatment is the presence of detrusor overactivity (DO). However, the detection rate of DO during standard urodynamics is very low. The primary goal in the future is to target OAB treatment by detection of DO. Using the Wille Capsule (WiCa) in an in vitro model, DO could be detected over a time period of 72 h, which would ensure a higher compliance to the OAB treatment in a positive way.

[Perspective study of urodynamic factors with pre- and post-operation overactive bladder symptoms for anterior vaginal prolapse]

OBJECTIVE

To identify pre-operative demographic and urodynamic (UD) parameters related to overactive bladder (OAB) symptoms of pre-operation and persistence of after pelvic organ prolapse (POP) repair.

METHODS

From Jan 1, 2010 to Oct 31, 2012, this perspective study examined demographic and UD data of 175 patients undergoing POP surgery. Pre- and post- operative urinary distress inventory 6 (UDI- 6) scores for frequency and urge urinary incontinence (UUI) were analyzed, and correlations between scores and pre-operative UD data were also analyzed.

RESULTS

(1)Surgery resulted in a improvement of frequency (71.0% , 71/100) and UUI (69.2% , 63/91) at 12-24 months follow-up. (2)Pre-operative UD parameters: first desire of bladder <100 ml, 6.3% (11/175); detrusor overactivity, 14.9% (26/175); post-void residual ≥50 ml, 11.4% (20/175); maximal flow rate (Qmax), (16±7) ml/s. (3)Comparison of pre- operative UD datas between patients with OAB symptoms and without, with OAB symptoms group had more patients of type III stress urinary incontinence [5% (5/91) versus 0 (0/84), P = 0.022]. (4)Qmax was higher in improvement in UUI group than that in persistent UUI after POP repair [(17±7) ml/s versus (13±5) ml/s, P < 0.01].

CONCLUSIONS

POP repair significantly reduces OAB symptoms; however, there had not exact predictor for symptoms of persistent frequency, UUI after POP repair. Persistent UUI symptom may be related to Qmax of pre-operative UD.

Urodynamic characterization of lower urinary tract symptoms in women less than 40 years of age

INTRODUCTION

Lower urinary tract symptoms (LUTS) in young women is becoming a more recognized urologic issue that can arise from many causes, each with their own management strategy. The purpose of this study was to determine the rates of various etiologies for LUTS in women under 40 years of age.

MATERIALS AND METHODS

Video urodynamic studies (VUDS) were performed in 70 women age 40 years or less with LUTS for greater than 6 months between March 2005 and June 2012 at Weill Cornell Medical College. Patients with culture-proven bacterial urinary tract infections, pelvic organ prolapse greater than grade I, symptoms for less than 6 months, a history of neurologic disease, or previous urological surgery affecting voiding function, were excluded from the analysis.

RESULTS

The mean age of the patients was 31.95 ± 5.57. There were 48 patients that presented with more than one urinary symptom (68.57%). The most frequent complaints included: urinary frequency (n = 42, 34.15%), incontinence (n = 26, 21.14%), and urinary urgency (n = 22, 17.89%). The most common urodynamic abnormality was dysfunctional voiding (n = 25, 28.74%), detrusor overactivity (n = 15, 20.00%), bladder outlet obstruction (n = 8, 11.43%). There were no significant differences seen in complaints or AUA symptom and quality of life scores across diagnosis groups.

CONCLUSIONS

Persistent LUTS can present in younger women with an unclear etiology, which may be characterized using VUDS. The most common etiology found is dysfunctional voiding followed by detrusor overactivity. This study shows that the etiology can be more accurately determined using VUDs, which can assist in management.

The efficacy and tolerability of the β3-adrenoceptor agonist mirabegron for the treatment of symptoms of overactive bladder in older patients

INTRODUCTION

mirabegron is a β3-adrenoceptor agonist developed for the treatment of symptoms of overactive bladder (OAB). As the prevalence of OAB increases with age, a prospective subanalysis of individual and pooled efficacy and tolerability data from three 12-week, randomised, Phase III trials, and of tolerability data from a 1-year safety trial were conducted in order to evaluate the efficacy and tolerability of mirabegron in subgroups of patients aged ≥65 and ≥75 years.

METHODS

primary efficacy outcomes were change from baseline to final visit in the mean number of incontinence episodes/24 h and the mean number of micturitions/24 h. Tolerability was assessed by the incidence of treatment-emergent adverse events (TEAEs).

RESULTS

over 12 weeks mirabegron 25 mg and 50 mg once-daily reduced the mean numbers of incontinence episodes and micturitions/24 h from baseline to final visit in patients aged ≥65 and ≥75 years. Mirabegron was well tolerated: in both age groups, hypertension and urinary tract infection were among the most common TEAEs over 12 weeks and 1 year. The incidence of dry mouth, a typical anticholinergic TEAE, was up to sixfold higher among the older patients randomised to tolterodine than any dose of mirabegron.

CONCLUSIONS

these analyses have demonstrated the efficacy of mirabegron over 12 weeks and the tolerability of mirabegron over 12 weeks and 1 year in OAB patients aged ≥65 and ≥75 years, supporting mirabegron as a therapeutic option in older patients with OAB.

Assessment of treatment-seeking behavior and healthcare utilization in an international cohort of subjects with overactive bladder

Abstract Objective: To assess the association between incontinence severity, treatment-seeking behavior, and healthcare resource utilization (HRU) among participants with overactive bladder (OAB) in eight countries.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey of subjects ≥18 years old in Australia, Europe, and North America, who had a past OAB diagnosis and/or experienced ≥1 urinary incontinence (UI) episode in the preceding 12 months, were eligible to participate. Subjects contacted for the survey were primarily from a voluntary medication monitoring registry, MediGuard. Predominantly stress incontinence subjects were excluded. Incontinence severity was assessed by the number of UI episodes over 3 days and grouped as 0 ('dry'), 1-2, 3-4, and ≥5 UI episodes/day. Subject demographics, employment status, comorbidities, treatment-seeking behavior (past OAB diagnosis; spoken to healthcare provider [HCP]), and HRU (diagnostic tests; HCP visits in 6 months before screening) were analyzed by incontinence severity.

RESULTS

Overall, 1341 subjects with OAB (mean age 54.5 years; 70.7% female) were surveyed; 20.2%, 47.7%, 18.8%, and 13.3% of subjects reported 0, 1-2, 3-4, and ≥5 UI episodes/day, respectively. Employment status and comorbidities were significantly (p < 0.05) associated with incontinence severity. The two measures of treatment-seeking behavior were significantly (p < 0.05) associated with incontinence severity groups; the proportion of subjects with a past diagnosis of OAB were 35.8%, 44.8%, 52.4%, and 64.0% in the 0, 1-2, 3-4, and ≥5 UI episodes/day groups, respectively; and 59.0%, 63.6%, 65.9%, and 78.1% of subjects in the respective UI severity groups talked to a HCP about their OAB symptoms. Multivariate linear regression analyses showed a positive and consistent association between incontinence severity and HRU; subjects reported a mean of 2.7, 4.1, 4.4, and 7.7 diagnostic tests overall (p < 0.001), and a mean of 1.4, 2.2, 2.7, and 4.0 HCP visits in the 0, 1-2, 3-4, and ≥5 UI episodes/day groups, respectively (p < 0.001). A potential limitation of the study is the cross-sectional survey methodology which limits the ability to draw causal inferences from the results. Additionally, since this is a web-based survey it is possible respondents who have access to/are familiar with technology were more likely to be enrolled.

CONCLUSIONS

Incontinence severity was positively associated with both treatment-seeking behavior and HRU among subjects with OAB.

The overlap and distinction of self-reported symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder: a questionnaire based analysis

PURPOSE

We compared symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder based on patient self-reported symptoms on validated questionnaires.

MATERIALS AND METHODS

We prospectively recruited 26 patients diagnosed with interstitial cystitis/bladder pain syndrome, 53 diagnosed with overactive bladder and 30 healthy controls to participate in a questionnaire based study that inquired about lower urinary tract symptoms. The questionnaires used were GUPI, ICSI, ICPI, ICIQ-OAB, ICIQ-UI, IUSS, numerical rating scales of the severity of bladder pain, pressure or discomfort, and numerical rating scale of the severity of urgency and frequency symptoms.

RESULTS

On univariate analysis patients with interstitial cystitis/bladder pain syndrome reported significantly more severe pain symptoms than those with overactive bladder. Patients with overactive bladder reported significantly more severe urinary incontinence symptoms than those with interstitial cystitis/bladder pain syndrome. There was no difference in frequency and urgency severity between the groups. Surprisingly, 33% of patients with overactive bladder reported pain or discomfort when the bladder filled and 46% with interstitial cystitis/bladder pain syndrome reported urgency incontinence. On multivariate analysis ICIQ-UI total scores (p = 0.01) and bladder pain severity on the numerical rating scale (p <0.01) distinguished the 2 conditions with 90.6% sensitivity and 96.1% specificity. Overactive bladder had higher ICIQ-UI and lower numerical rating scale pain scores.

CONCLUSIONS

There is considerable overlap of self-reported symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder. This overlap raises the possibility that the 2 conditions represent a continuum of a bladder hypersensitivity syndrome.

A practical primary care approach to overactive bladder

The evaluation and treatment of overactive bladder (OAB) starts in the primary care office and can be accomplished efficiently, effectively and, most importantly, safely. With appropriate knowledge of the disease and an understanding of what to look for the primary care physician (PCP) can readily make the empiric diagnosis and initiate treatment. The key for the PCP is to be able to distinguish the uncomplicated patient from the complicated one and know when to refer, if necessary. It is also essential to be able to able to identify confounding conditions that could either be the cause of the symptoms or, in fact, make them worse. The algorithm presented in this paper describes a simplified, yet complete, approach to the patient presenting with lower urinary tract symptoms (LUTS) consistent with OAB. In the paper, we explain the disease itself, its prevalence and impact, the evaluation as well as the different treatment modalities that are available for the patient. Appropriate follow up, therapy adherence techniques and referral recommendations are also discussed.

[Is the validated ICIQ-SF suitable for evaluation of OAB patients? A data analysis of intravesicular botulinum toxin therapy]

BACKGROUND

The following data analysis studied the aspects of patient satisfaction following onabotulinum toxin A (BTX-A) treatment including modification of certain parameters, such as frequency of micturition and the use of pads and in particular, the applicability of the international consultation on incontinence questionnaire short form (ICIQ-SF) and the urgency perception scale (UPS) in patients with an overactive bladder (OAB).

PATIENTS AND METHOD

In this study 40 female patients were questioned in the form of validated questionnaires (extended ICIQ-SF and UPS) before and after being injected with 300 IU of BTX-A in each detrusor muscle. The average age of the patients was 66 years. All patients experienced anticholinergic refractory, non-neurogenic OAB.

RESULTS

The recommendation rate and related patient satisfaction was 82.5 %. A significant decrease in the frequency of micturition by 50.9 % (p < 0.01) was reported as well as a significant reduction in the use of pads by 66.7 % (p < 0.01). The average number of ICIQ-SF points could be significantly (p < 0.01) reduced via BTX-A from 15.9 to 7.3. Moreover, BTX-A demonstrated a significant improvement in the urgency to urinate, which was illustrated through the UPS.

CONCLUSION

Treatment with BTX-A achieves significant improvements in female patients with anticholinergic refractory OAB with regard to the individual symptoms of OAB (e.g. pollakisuria, nocturia, undesired urination and urgency). The use of the ICIQ-SF as the only questionnaire in OAB diagnostics proved to be unsuitable as it does not include female patients with dry OAB to an adequate degree. A combination of various validated questionnaires, such as ICIQ-SF and UPS, proved to be useful.

New horizons: urinary incontinence in older people

Urinary incontinence is a common complaint in older people, and is associated with significant impact on the individual, their carers and the wider healthcare system. As the numbers of frail elderly people increase, so will the burden of incontinence. This review examines recent developments in research into the aetiology, physiology, pathology and treatment of urinary incontinence and lower urinary tract symptoms in older people, and explores potential future developments which might reduce or ameliorate both urinary incontinence and its effects on frail older people. These include increasing understanding of the importance of central control of continence, the role of the urothelium as a sensory organ, novel targets for pharmacological treatments and surgical and invasive interventions.

[Treatment of overactive bladder in older women increased doses of antimuscarinic drugs safe and effective alternative to existing methods]

The study included 95 female patients of 65 to 74 years (average age 67,1 years), who previously (more than 6 months before this study) took a course of monotherapy with hydrochloride trospium in higher dosages with unstable or weak effect. In this study, all patients were divided into three groups and were treated with two antimuscarinic drugs. The majority of older women suffering from OAB and treatment-resistant taking one antimuscarinic drug in high doses showed a significant positive progress in a state by adding a second antimuscarinic agent. The received side effects do not exceed thereof in comparison with treatment with a single drug.

[Peculiarities of clinical course, diagnostics and treatment of overactive bladder in men older than 60 years]

The article presents the issues of the characteristics of the course, diagnostics and treatment of hyperactive urinary bubble in older men. Conservative treatment of urinary incontinence includes changes in lifestyle, behavioural and medical therapy with m-anticholinergic drugs. The combination solifenacini in a dose of 5 mg/day and α1-adrenoceptor blocking agent terasolini in a dose of 2 mg/day significantly improves the results of treatment and well tolerated.

Decrease of risk of developing symptoms of OAB in elderly men and women treated with loop diuretic for hypertensive disease using solifenacin

MATERIALS AND METHODS

Randomized double blind longitudinal study was performed from December 1, 2012 to June 15, 2013 in urological ward of gerontological hospital (Vladivostok city, Russian Federation). 378 men and women over 65 (average age: 69.8 (7.2)), who suffered from stage 1 (initial) hypertension, had participated in this study. During the treatment all patients, except for those who were assigned to the control group, received Loop Diuretic Furosemide dosed at 20-30 mg per day and Solifenacin dosed at 5 mg per day (First comparison group) and 10 mg per day (Second comparison group). Functional performance of lower urinary tract (LUT) at enrollment and at the end of the treatment was evaluated using ICIQ-SF questionnaires. During the whole period of treatment patients were keeping bladder diaries where records on frequency and volume of daily urinations, episodes of urgency (EU), episodes of incontinence (EI) and other symptoms were kept.

RESULT

Comparison of data obtained from control group (7.2%), group of the patients treated with Furosemide and standard- dosed (11.1%) and low-dosed (16.2%) Solifenacin allows to draw conclusion on the absence of significant differences in number of patients with symptoms of OAB between these groups (p ≥ 0.05). At the same time percentage of patients with symptoms of OAB in the group treated only with Furosemide was significantly different from three other groups (p ≤ 0.05) and reached 46.1%.

CONCLUSION

Risk of developing symptoms of OAB in elderly patients, whose hypertensive disease has been treated with loop diuretic for a long period of time, decreases significantly, provided antimuscarinic drug Solifencin is administered at the same time. Administration of low dosed Solifenacin is sufficient for significant decrease in risk of developing symptoms of overactive bladder.

Does the onset or bother of mixed urinary incontinence symptoms help in the urodynamic diagnosis?

OBJECTIVE

To determine whether evaluation of the first occurring symptom and bother of mixed urinary incontinence (MUI) might help in the clinical assessment of incontinent women.

STUDY DESIGN

Prospective observational study carried out in a tertiary referral urogynaecology unit in London. Women who underwent urodynamic investigations for MUI were asked whether stress or urgency incontinence was the first occurring symptom and which was the most bothersome one. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the first occurring symptom and most bothersome component of their mixed urinary incontinence symptoms in relation to the urodynamic diagnosis were calculated.

RESULTS

One hundred and eighty women with MUI were studied. Initial or most bothersome urgency urinary incontinence (UUI) had a good specificity and PPV for diagnosing detrusor overactivity (DO). When UUI was the initial and most bothersome symptom the specificity and NPV increased up to 93% and 73%. Stress urinary incontinence (SUI) as first occurring or most bothersome had a moderate specificity, PPV and NPV for diagnosing urodynamic stress incontinence (USI). When SUI was the initial and most bothersome symptom the specificity, PPV and NPV increased up to 91%, 70% and 78%. Initial or most bothersome UUI with antecedent or most bothersome SUI had a high specificity and good NPV for a mixed urodynamic diagnosis of DO and USI.

CONCLUSIONS

Determination of the first occurring and most bothersome symptom in women with MUI relates closely to the urodynamic diagnosis. Therefore, our symptom-guided approach may in some cases provide useful information directing the clinician towards a more appropriate therapy when urodynamics are inconclusive or cannot be performed.

Comparison of tolterodine with standard treatment in pediatric patients with non-neurogenic dysfunctional voiding/over active bladder: a systematic review

To examine the efficacy, safety and tolerability of tolterodine in children with overactive bladder in comparison with standard treatment i.e. oxybutynin as demonstrated in randomized clinical trials and other studies. A systematic search was done to screen the studies evaluating the effect of tolterodine in children with non-neurogenic overactive bladder. Results of studies were pooled and compared. Efficacy was determined from micturition diaries and dysfunctional voiding symptoms score. Safety and tolerability were assessed from the reported treatment emergent adverse events. A total of six randomized clinical trials and 11 other studies of tolterodine in children with urinary incontinence were included in the present systematic review. The dose of tolterodine used in different settings ranged from '0.5 to 8 mg/day' instead of '0.5 to 8 mg/kg per day' and the duration of studies ranged from 2 weeks to 12 months. Both extended and immediate release preparations of tolterodine were shown to have comparable efficacy and tolterodine proved to have comparable efficacy with better tolerability than oxybutynin in these studies. It can be concluded that tolterodine is efficacious in treatment of urinary incontinence in children. Moreover, its efficacy is comparable to oxybutynin, the most commonly prescribed anticholinergic in this condition, while having better tolerability. Hence, it can be considered as first line therapy for the treatmentof urinary incontinence in children.

[Flexible approach to the appointment of solifenacin: for whom and when?]

Solifenacin at a dose of 5 mg per day has demonstrated the high efficacy in the treatment of patients with overactive bladder. However, for patients who remained dissatisfied with the outcome of treatment, the dose may be increased to 10. mg per day, which leads to the improvement of patient's condition. However, there is an opinion that treatment should be started with the use of high doses of the drug. Efficiency of solifenacin at a dose of 10 mg was accompanied by favorable safety and tolerability profile. Despite the fact that numerous studies have shown that the clinical efficacy of different anticholinergics is not very different from one another, it is known that patients may prefer some other drugs. Application of solifenacin in these patients leads to significant improvement in quality of life. Thus, flexible approach to the use of solifenacin allows to achieve the best results in the treatment of patients, including those cases where the initial treatment is not effective or is interrupted due to pronounced side effects.

Assessment and diagnosis of overactive bladder in women

Overactive bladder (OAB) is a distressing problem that affects many women in the UK. Symptoms of OAB include urinary urgency with or without urgency incontinence, usually with frequency and nocturia. This article discusses the assessment of women reporting lower urinary tract symptoms, including simple tests to be performed and specialist investigations that may be required before a diagnosis of OAB can be confirmed.

The association between the self-perception period of overactive bladder symptoms and overactive bladder symptom scores in a non-treated population and related sociodemographic and lifestyle factors

AIMS

To investigate the association between the self-perception period of OAB symptoms (SP-OAB) and the overactive bladder symptom score (OABSS), along with related sociodemographic and lifestyle factors.

METHODS

This was a cross-sectional study comprised of 192 men aged 40 years and older who participated in a prostate examination survey between February and May 2009 and proved to have OAB. Survey questionnaires included items on the OABSS and the SP-OAB assessed by the OABSS. Various sociodemographic and lifestyle factors were also included.

RESULTS

The average SP-OAB period was 24.72 ± 45.75 months and became significantly longer as the severity of OAB increased in correlation analysis (coefficient = 0.501, p < 0.001). Age, education, income, regular check-up, health maintenance and occupation were all risk factors in both OABSS and SP-OAB in univariate analysis. Body mass index (BMI), family size and SP-OAB were risk factors for OABSS in univariate analysis. Age and regular check-ups were factors in both OABSS and SP-OAB in multivariate analysis. BMI, income and SP-OAB were risk factors for OABSS.

CONCLUSION

These findings suggest that the SP-OAB is an independent risk factor for OAB progression and that various sociodemographic and lifestyle factors affect OABSS. The self-perception period should be considered in the treatment and prevention of OAB symptoms.

Urinary ATP may be a dynamic biomarker of detrusor overactivity in women with overactive bladder syndrome

BACKGROUND

Nowadays, there is a considerable bulk of evidence showing that ATP has a prominent role in the regulation of human urinary bladder function and in the pathophysiology of detrusor overactivity. ATP mediates nonadrenergic-noncholinergic detrusor contractions in overactive bladders. In vitro studies have demonstrated that uroepithelial cells and cholinergic nerves from overactive human bladder samples (OAB) release more ATP than controls. Here, we compared the urinary ATP concentration in samples collected non-invasively from OAB women with detrusor overactivity and age-matched controls.

METHODS

Patients with neurologic diseases, history of malignancy, urinary tract infections or renal impairment (creatinine clearance <70 ml/min) were excluded. All patients completed a 3-day voiding diary, a 24 h urine collection and blood sampling to evaluate creatinine clearance. Urine samples collected during voluntary voids were immediately freeze-preserved for ATP determination by the luciferin-luciferase bioluminescence assay; for comparison purposes, samples were also tested for urinary nerve growth factor (NGF) by ELISA.

RESULTS

The urinary content of ATP, but not of NGF, normalized to patients' urine creatinine levels (ATP/Cr) or urinary volume (ATP.Vol) were significantly (P<0.05) higher in OAB women with detrusor overactivity (n = 34) than in healthy controls (n = 30). Significant differences between the two groups were still observed by boosting urinary ATP/Cr content after water intake, but these were not detected for NGF/Cr. In OAB patients, urinary ATP/Cr levels correlated inversely with mean voided volumes determined in a 3-day voiding diary.

CONCLUSION

A high area under the receiver operator characteristics (ROC) curve (0.741; 95% CI 0.62-0.86; P<0.001) is consistent with urinary ATP/Cr being a highly sensitive dynamic biomarker for assessing detrusor overactivity in women with OAB syndrome.

Validation study of the Self-Assessment Goal Achievement (SAGA) questionnaire for lower urinary tract symptoms

BACKGROUND

Patients' treatment goals for overactive bladder (OAB) and other lower urinary tract symptoms (LUTS) may not be aligned with their healthcare provider's goals. Successful management of OAB symptoms is improved by individualised treatment plans with attainable treatment goals. Goal attainment setting may facilitate patient-provider interaction and the development of a personalised treatment plan based on realistic, individual goals, thereby increasing patient satisfaction and therapeutic outcomes. The purpose of this study was to validate the utility of the Self-Assessment Goal Achievement (SAGA) questionnaire for LUTS in helping patients identify and achieve realistic treatment goals.

METHODS

The 2-module SAGA questionnaire consists of nine prespecified (fixed) items and five open-ended items for goal identification and ranking (baseline module) and goal achievement rating (follow-up module). Adult patients in the United States (n = 104) seeking treatment for LUTS, including symptoms of OAB, completed the SAGA baseline module, micturition diary, other patient-reported outcome measures (PROs), and discussed their urinary goals with a clinician at baseline. The SAGA follow-up module was completed 2-4 months later. SAGA was validated based on analyses of face, concurrent, known-groups, and convergent validity and item distribution.

RESULTS

Among the nine fixed goals of SAGA, four were ranked as very important by > 50% of patients (i.e. reduce night-time frequency, daytime frequency, urine leakage, urgency). Most patients did not change the importance level of their goals after discussion with their healthcare provider. Pearson correlations between SAGA, diary variables and PRO scores were generally of low to moderate strength. The global mean (SD) follow-up SAGA T-score was 32.54 (12.54), indicating that overall goal attainment was not achieved after 3 months. The goal attainment score was significantly different between groups differing in symptom severity, health-related quality of life, bladder control and continence status.

CONCLUSIONS

The results support the validity of SAGA as a measure of patients' goals and goal achievement for the treatment of LUTS, including symptoms of OAB. SAGA may improve healthcare provider-patient interactions and treatment outcomes in clinical practice.

[Correlation between age and overactive bladder symptoms in young women in Brazil]

Overactive Bladder Syndrome (OAB) is defined by the ICS (International Continence Society) as urinary urgency, with or without urgency incontinence and frequently associated with increase of frequency and nocturia.

PURPOSE

The aim of the study was to establish a correlation between OAB symptoms and Age in women aged 20-45.

MATERIALS AND METHODS

We interviewed 1050 women aged 20-45 in the area of Campinas, Brazil, to investigate the prevalence of Overactive Bladder Symptoms. In this study we used the ICIQ-OAB questionnaire (ICS standard), in its validated Portuguese version and a specific questionnaire for the demographics.

RESULTS

Overall, women aged 35-45 years showed significantly higher scores in the ICIQ-OAB questionnaire than all other groups (P<.001). Older women (35-45) presented a significantly higher score than younger women (all other groups) (P<.0001) regarding urinary frequency. Regarding frequency, there was a significant difference between the age group 35-45 (higher score) and the age groups 20-22 and 23-27 (P<.0001). Women aged 35-45 presented significantly more nocturia than women in the age groups of 28-34, 23-27 and 20-22. Women in the group of 28-34 also presented more nocturia than women aged 20-22 (P<.0001). Women aged 35-45 experienced more urgency than those in the age groups of 28-34 and 23-27 (P<.0001). Women aged 35-45 had significantly more urgency incontinence than all the other groups, and women in group of 20-22 also presented more incontinence than those aged 23-27 (P<.0001). Significant differences were also found regarding symptom bother, women in group 35-45 years old presented higher scores than the other groups regarding frequency (P<.0001), nocturia (P=.0011), urgency (P=.0015) and urgency incontinence (P<.0001).

CONCLUSIONS

In conclusion, older women present more OAB symptoms and therefore a higher score than younger women.

Detrusor overactivity in Becker muscular dystrophy

A 20-year-old man with normal motor milestones as an infant but subsequent progressive difficulty in walking in childhood, was genetically confirmed to have Becker muscular dystrophy (BMD) at age 13. He was independent in ambulation and activities of daily living. He was referred to the Department of Uro-neurology for a 5-year history of urinary urgency and incontinence. He would visit the toilet 10 times in the daytime and experience urinary urgency daily, often associated with incontinence. He did not report difficulties initiating voiding, stress incontinence, pain, or hematuria. There was no history of urinary tract infections.

[Screening test for overactive bladder in a newly developed comprehensive geriatric assessment initiative]

PURPOSE

Lower urinary tract symptoms, particularly in overactive bladder (OAB), are frequently observed among elderly patients. The impact of OAB on their quality of life is so strong that the assessment of OAB is necessary in comprehensive geriatric assessment (CGA). As CGA takes time to complete, we established a convenient instrument consisting of 2 questions on OAB and assessed its utility.

METHOD

We recruited 123 elderly patients with various diseases (mean age: 83.2 years, 63 men), in whom 2 questions on nocturia (Q1) and urinary incontinence at night (Q2) were asked. Thereafter, overactive bladder symptom scores (OABSS) were obtained to diagnose OAB based on the OAB criteria. Statistical analyses for Q1 and Q2 were performed using the OABSS criterion as a gold standard. To elucidate the clinical characteristics of the elderly patients, they were divided into 2 groups on the basis of the presence or absence of nocturia: nocturia (+) and nocturia (-) groups. The nocturia (+) group was subdivided into 2 subgroups: with or without incontinence.

RESULTS

Nocturia (Q1) was observed in 82 elderly patients and urinary incontinence (Q2) in 23, whereas OAB was diagnosed in 22. The sensitivity, specificity, and positive predictive value (PPV) of Q1 (Q1+Q2) were 100% (68.2%), 40.6% (92.1%), and 26.8% (65.2%), respectively. The nocturia (+) group patients were characterized as predominantly composed of men with cerebrovascular disease, disturbed activities of daily living, interrupted sleep, delayed wake-up time, and treatment with diuretics. Furthermore, Parkinson disease, depressive state, sedentary life style, and treatment without diuretics were frequently observed in patients in the incontinence (+) subgroup.

CONCLUSION

A low PPV with a high sensitivity of Q1 was improved by using Q1+Q2, where both Q1 and Q2 enable better assessment of OAB resulting in being a useful screening test for OAB.

Overactive bladder syndrome - management and treatment options

BACKGROUND

Overactive bladder syndrome is a symptom-based clinical diagnosis. It is characterised by urinary urgency, frequency and nocturia, with or without urge urinary incontinence. These symptoms can often be managed in the primary care setting.

OBJECTIVE

This article provides a review on overactive bladder syndrome and provides advice on management for the general practitioner.

DISCUSSION

Overactive bladder syndrome can have a significant effect on quality of life, and affects 12-17% of the population. Prevalence increases with age. The management of overactive bladder syndrome involves exclusion of underlying pathology. First line treatment includes lifestyle interventions, pelvic floor exercises, bladder training and antimuscarinic agents. Failure of conservative management necessitates urology referral. Second line therapies are more invasive, and include botulinum toxin, neuromodulation or surgical interventions such as augmentation cystoplasty or urinary diversion.

Medical management of overactive bladder

Overactive bladder (OAB) with or without urinary incontinence is a common condition in both men and women. OAB has a significant impact on quality of life for most patients. In most cases, sophisticated testing is not required for a primary care physician to diagnose OAB and start treating a patient. Management of OAB requires behavioral modification and, if necessary, pharmacotherapy may be added. If a patient does not respond to treatment initiated by a primary care physician, then he or she should be referred to a specialist in OAB to undergo further investigations and treatments.

[Overactive bladder as a mask of chronic prostatitis]

In order to investigate the frequency of symptoms of overactive bladder (OAB) in patients with chronic prostatitis and determine the effectiveness of trospium chloride in their treatment, the analysis of case histories of 154 patients referred to a urologist for the exacerbation of chronic prostatitis was performed. 27 (17.5%) patients had a diagnosis of overactive bladder; in 19 patients it was accompanied by chronic prostatitis, and in 8 patients OAB was diagnosed as separate disease. All of them have received trospium chloride 30 mg once daily for a month; patients with prostatitis simultaneously have received standard etiopathogenic therapy for this disease. A month later, a comprehensive treatment led to significant positive effect. Urinary frequency decreased by 56.1%, the functional bladder capacity increased by 82.8%, the number of urgent vesical tenesmus was reduced more than by half.

Comparison of diary-derived bladder and sleep measurements across OAB individuals, primary insomniacs, and healthy controls

INTRODUCTION AND HYPOTHESIS

Can diary-derived bladder and sleep measurements differentiate individuals with overactive bladder syndrome (OAB) from individuals with primary insomnia and healthy controls?

METHODS

Bladder- and sleep-diary data were compared in nine OAB, ten insomnia, and five control individuals. One-way analysis of variance (ANOVA) was used for normally and Kruskal-Wallis test for nonnormally distributed variables, followed, when significant effects were found, by pairwise comparisons.

RESULTS

OAB individuals woke up as frequently as insomniacs, but their awakenings were respectively shorter in duration (18.6 vs. 38.1 min.) and were predominantly initiated by nocturic events (89.2 vs. 23.9 % respectively). Regardless, their reported quality of sleep was as impaired as for the insomniacs. Furthermore, smaller mean volume voided awakenings were evident not only in those with OAB but also in insomniacs compared to controls.

CONCLUSIONS

Bladder- and sleep-diary data provide means to differentiate those with OAB from those with insomnia and healthy controls. Awakenings in OAB individuals were shorter than those with insomnia and much more likely due to the need to void. Thus, a reduction in the number of nocturic voids could be the most appropriate sleep-related outcome for nocturia therapy in individuals with OAB. In addition, limited nocturnal bladder capacity, though expected in OAB, was unexpectedly found in insomnia, possibly reflecting the role of consciousness (wakefulness at night) in modulating bladder sensation.