Phosphodiesterase 5 inhibitors for the treatment of erectile dysfunction: a trade-off network meta-analysis

CONTEXT

Erectile dysfunction (ED) is a major health care problem worldwide and phosphodiesterase 5 inhibitors (PDE5Is) are the pharmacological treatment of choice. However, the optimal PDE5I for ED treatment is not known.

OBJECTIVE

To investigate trade-offs between efficacy and adverse events for various PDE5Is in treating ED.

EVIDENCE ACQUISITION

A review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Medline, Scopus, reference lists of relevant articles, and systematic reviews were searched. Eligible studies were randomized controlled trials comparing at least one PDE5I for treating ED with placebo or another PDE5I.

EVIDENCE SYNTHESIS

We included 82 trials (47 626 patients) for efficacy analysis and 72 trials (20 325 patients) for adverse event analysis. In the trade-off analysis of starting dosages, sildenafil 50mg had the greatest efficacy but also had the highest rate of overall adverse events. Tadalafil 10mg had intermediate efficacy but had the lowest overall rate of all adverse events. Vardenafil 10mg and avanafil 100mg had similar overall adverse events than sildenafil 50mg but a markedly lower global efficacy. Udenafil 100mg had similar global efficacy to that of tadalafil 10mg but its overall adverse event rates were higher.

CONCLUSIONS

This is the first trade-off analysis of the different PDE5Is currently available. For individuals who prioritize high efficacy, sildenafil 50mg appears to be the treatment of choice. Men wishing to optimize tolerability should take tadalafil 10mg or switch to udenafil 100mg in the case of insufficient efficacy.

PATIENT SUMMARY

For patients with erectile dysfunction who wish to prioritize high efficacy, sildenafil 50mg appears to be the treatment of choice. Men who wish to optimize tolerability should take tadalafil 10mg or switch to udenafil 100mg in the case of insufficient efficacy.

Sensory evoked potentials of the bladder and urethra in middle-aged women: the effect of age

OBJECTIVES

To investigate feasibility, reproducibility and age dependency of sensory evoked cortical potentials (SEPs) after electrical stimulation of different locations in the lower urinary tract (LUT) in a cohort of middle-aged healthy women.

SUBJECTS AND METHODS

In a group of 10 healthy middle-aged women [mean (sd) height 165 (5) cm and age 43 (6) years), electrical stimulation (0.5 and 3 Hz) was applied to the bladder dome, trigone, and proximal and distal urethra. SEPs were recorded at the Cz electrode with reference to Fz. All measurements were repeated three times with an interval of 3-5 weeks. Current perception thresholds (CPT), SEP latencies and amplitudes were analysed. Results were compared with a group of younger women published previously.

RESULTS

LUT SEPs demonstrated two positive (P1, P2) and one negative peak (N1). The mean (sd) N1 latency was 108.9 (7.8), 116.2 (10.7), 113.2 (13.4) and 131.3 (35.6) ms for the bladder dome, trigone, proximal and distal urethra, respectively. N1 latencies, except for the distal urethra, were significantly shorter than those in younger women. Taking all data, i.e. young and middle-aged women, into account, there was a significant negative correlation between the variable age and CPT/dome (r = -0.462, P = 0.04) and N1 latency/dome (r = -0.605, P = 0.005) and a significant positive correlation between the variable age and N1P2 amplitude/dome (r = 0.542, P = 0.014).

CONCLUSION

LUT SEPs can be induced in middle-aged women with reliable N1 responses. Unexpectedly, N1 responses reveal a shortening with increasing age particularly when compared with younger women. Changes in sensory afferents may be explained by age-related qualitative reorganisations within the urothelium and suburothelium potentially altering afferent nerve excitability, which may have an impact on the development of non-neurological LUT symptoms (LUTS, e.g. overactive bladder) in women.

Sono-electro-magnetic therapy for treating chronic pelvic pain syndrome in men: a randomized, placebo-controlled, double-blind trial

Objective

To assess the efficacy and safety of sono-electro-magnetic therapy compared to placebo in men with refractory CPPS.

Patients and Methods

In a randomized, placebo-controlled, double-blind single center trial, we assessed the effect of sono-electro-magnetic therapy in men with treatment refractory CPPS. Sixty male patients were randomly assigned to treatment with either sono-electro-magnetic (n = 30) or placebo therapy (n = 30) for 12 weeks. The primary outcome was a change in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) from baseline to 12 weeks.

Results

The 12-week difference between sono-electro-magnetic and placebo therapy in changes of the NIH-CPSI total score was −3.1 points (95% CI −6.8 to 0.6, p = 0.11). In secondary comparisons of NIH-CPSI sub-scores, we found differences between groups most pronounced for the quality-of-life sub-score (difference at 12 weeks −1.6, 95% CI −2.8 to −0.4, p = 0.015). In stratified analyses, the benefit of sono-electro-magnetic therapy appeared more pronounced among patients who had a symptom duration of 12 months or less (difference in NIH-CPSI total score −8.3, 95% CI −14.5 to 2.6) than in patients with a longer symptom duration (−0.8, 95% CI −4.6 to 3.1; p for interaction = 0.023).

Conclusions

Sono-electro-magnetic therapy did not result in a significant improvement of symptoms in the overall cohort of treatment refractory CPPS patients compared to placebo treatment. Subgroup analysis indicates, however, that patients with a symptom-duration of 12 months or less may benefit from sono-electro-magnetic therapy, warranting larger randomized controlled trials in this subpopulation.

Trial Registration

ClinicalTrials.gov NCT00688506

Prostatic artery embolization versus conventional TUR-P in the treatment of benign prostatic hyperplasia: protocol for a prospective randomized non-inferiority trial

BACKGROUND

Benign prostatic hyperplasia (BPH) is a prevalent entity in elderly men and transurethral resection of the prostate (TURP) still represents the gold standard of surgical treatment despite its considerable perioperative morbidity. Recently, prostatic artery embolization (PAE) was described as a novel effective and less invasive treatment alternative. Despite promising first results, PAE still has to be considered experimental due to a lack of good quality studies. Prospective randomized controlled trials comparing PAE with TUR-P are highly warranted.

METHODS/DESIGN

This is a single-centre, prospective, randomized, non-inferiority trial comparing treatment effects and adverse events of PAE and TURP in a tertiary referral centre. One hundred patients who are electable for both treatment options are randomized to either PAE or TURP. Changes of the International Prostate Symptom Score (IPSS) after 3 months are defined as primary endpoint. Changes in bladder diaries, laboratory analyses, urodynamic investigations and standardised questionnaires are assessed as secondary outcome measures. In addition contrast-enhanced magnetic resonance imaging of the pelvis before and after the interventions will provide crucial information regarding morphological changes and vascularisation of the prostate. Adverse events will be assessed on every follow-up visit in both treatment arms according to the National Cancer Institute Common Terminology Criteria for Adverse events and the Clavien classification.

DISCUSSION

The aim of this study is to assess whether PAE represents a valid treatment alternative to TURP in patients suffering from BPH in terms of efficacy and safety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02054013.

Protocol for a prospective magnetic resonance imaging study on supraspinal lower urinary tract control in healthy subjects and spinal cord injury patients undergoing intradetrusor onabotulinumtoxinA injections for treating neurogenic detrusor overactivity

BACKGROUND

The control of the lower urinary tract is a complex, multilevel process involving both the peripheral and central nervous system. Due to lesions of the neuraxis, most spinal cord injury patients suffer from neurogenic lower urinary tract dysfunction, which may jeopardise upper urinary tract function and has a negative impact on health-related quality of life. However, the alterations to the nervous system following spinal cord injury causing neurogenic lower urinary tract dysfunction and potential effects of treatments such as intradetrusor onabotulinumtoxinA injections on lower urinary tract control are poorly understood.

METHODS/DESIGN

This is a prospective structural and functional magnetic resonance imaging study investigating the supraspinal lower urinary tract control in healthy subjects and spinal cord injury patients undergoing intradetrusor onabotulinumtoxinA injections for treating neurogenic detrusor overactivity.Neuroimaging data will include structural magnetic resonance imaging (T1-weighted imaging and diffusion tensor imaging) as well as functional, i.e. blood oxygen level-dependent sensitive magnetic resonance imaging using a 3 T magnetic resonance scanner. The functional magnetic resonance imaging will be performed simultaneously to three different bladder stimulation paradigms using an automated magnetic resonance compatible and synchronised pump system.All subjects will undergo two consecutive and identical magnetic resonance imaging measurements. Healthy subjects will not undergo any intervention between measurements but spinal cord injury patients will receive intradetrusor onabotulinumtoxinA injections for treating neurogenic detrusor overactivity.Parameters of the clinical assessment including bladder diary, urinalysis, medical history, neuro-urological examination, urodynamic investigation as well as standardised questionnaires regarding lower urinary tract function and quality of life will serve as co-variates in the magnetic resonance imaging analysis.

DISCUSSION

This study will identify structural and functional alterations in supraspinal networks of lower urinary tract control in spinal cord injury patients with neurogenic detrusor overactivity compared to healthy controls. Post-treatment magnetic resonance imaging measurements in spinal cord injury patients will provide further insights into the mechanism of action of treatments such as intradetrusor onabotulinumtoxinA injections and the effect on supraspinal lower urinary tract control.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01768910.

Protocol for a randomized, placebo-controlled, double-blind clinical trial investigating sacral neuromodulation for neurogenic lower urinary tract dysfunction

BACKGROUND

Sacral neuromodulation has become a well-established and widely accepted treatment for refractory non-neurogenic lower urinary tract dysfunction, but its value in patients with a neurological cause is unclear. Although there is evidence indicating that sacral neuromodulation may be effective and safe for treating neurogenic lower urinary tract dysfunction, the number of investigated patients is low and there is a lack of randomized controlled trials.

METHODS AND DESIGN

This study is a prospective, randomized, placebo-controlled, double-blind multicenter trial including 4 sacral neuromodulation referral centers in Switzerland. Patients with refractory neurogenic lower urinary tract dysfunction are enrolled. After minimally invasive bilateral tined lead placement into the sacral foramina S3 and/or S4, patients undergo prolonged sacral neuromodulation testing for 3-6 weeks. In case of successful (defined as improvement of at least 50% in key bladder diary variables (i.e. number of voids and/or number of leakages, post void residual) compared to baseline values) prolonged sacral neuromodulation testing, the neuromodulator is implanted in the upper buttock. After a 2 months post-implantation phase when the neuromodulator is turned ON to optimize the effectiveness of neuromodulation using sub-sensory threshold stimulation, the patients are randomized in a 1:1 allocation in sacral neuromodulation ON or OFF. At the end of the 2 months double-blind sacral neuromodulation phase, the patients have a neuro-urological re-evaluation, unblinding takes place, and the neuromodulator is turned ON in all patients. The primary outcome measure is success of sacral neuromodulation, secondary outcome measures are adverse events, urodynamic parameters, questionnaires, and costs of sacral neuromodulation.

DISCUSSION

It is of utmost importance to know whether the minimally invasive and completely reversible sacral neuromodulation would be a valuable treatment option for patients with refractory neurogenic lower urinary tract dysfunction. If this type of treatment is effective in the neurological population, it would revolutionize the management of neurogenic lower urinary tract dysfunction.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov; Identifier: NCT02165774.

Supraspinal Control of Urine Storage and Micturition in Men--An fMRI Study

Despite the crucial role of the brain in the control of the human lower urinary tract, little is known about the supraspinal mechanisms regulating micturition. To investigate the central regulatory mechanisms activated during micturition initiation and actual micturition, we used an alternating sequence of micturition imitation/imagination, micturition initiation, and actual micturition in 22 healthy males undergoing functional magnetic resonance imaging. Subjects able to micturate (voiders) showed the most prominent supraspinal activity during the final phase of micturition initiation whereas actual micturition was associated with significantly less such activity. Initiation of micturition in voiders induced significant activity in the brainstem (periaqueductal gray, pons), insula, thalamus, prefrontal cortex, parietal operculum and cingulate cortex with significant functional connectivity between the forebrain and parietal operculum. Subjects unable to micturate (nonvoiders) showed less robust activation during initiation of micturition, with activity in the forebrain and brainstem particularly lacking. Our findings suggest that micturition is controlled by a specific supraspinal network which is essential for the voluntary initiation of micturition. Once this network triggers the bulbospinal micturition reflex via brainstem centers, micturition continues automatically without further supraspinal input. Unsuccessful micturition is characterized by a failure to activate the periaqueductal gray and pons during initiation.

Protocol for a prospective neuroimaging study investigating the supraspinal control of lower urinary tract function in healthy controls and patients with non-neurogenic lower urinary tract symptoms

INTRODUCTION

Lower urinary tract symptoms (LUTS) are highly prevalent, cause an enormous economic burden on healthcare systems and significantly impair the quality of life (QoL) of affected patients. The dependence of the LUT on complex central neuronal circuits makes it unique in comparison to other visceral functions, such as the gastrointestinal tract, but also more vulnerable to neurological diseases.

METHODS AND ANALYSIS

This is a prospective neuroimaging study investigating the supraspinal control of LUT function in healthy controls and in patients with non-neurogenic LUTS. The clinical assessment will include medical history, neuro-urological examination, bladder diary, urine analysis, urodynamic investigations, as well as standardised questionnaires regarding LUTS and QoL. The acquisition of neuroimaging data will include structural assessments (T1-weighted imaging and diffusion tensor imaging) as well as functional investigations using blood-oxygen-level dependent sensitive functional MRI (fMRI) in a 3 T MR scanner. The fMRI will be performed during four different bladder tasks using an automated MR-compatible and MR-synchronised pump system. The first three task-related fMRIs will consist of automated, repetitive filling of 100 mL warm (37°C) saline starting with (1) an empty bladder, (2) a low prefilled bladder volume (100 mL) and (3) a high prefilled bladder volume (persistent desire to void). The fourth task-related fMRI will comprise of automated, repetitive filling of 100 mL cold (4-8°C) saline starting with an empty bladder.

ETHICS AND DISSEMINATION

The local ethics committee approved this study (KEK-ZH-Nr. 2011-0346). The findings of the study will be published in peer-reviewed journals and presented at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

This study has been registered at clinicaltrials.gov (http://www.clinicaltrials.gov/ct2/show/NCT01768910).

Efficacy and adverse events of antimuscarinics for treating overactive bladder: network meta-analyses

CONTEXT

Millions of people worldwide experience overactive bladder (OAB), and antimuscarinics are the pharmacologic treatment of choice. Several conventional meta-analyses have been published, but they fail to quantify efficacy and adverse events across drugs, dosages, formulations, and pharmaceutical forms.

OBJECTIVE

To perform two network meta-analyses summarizing the efficacy and adverse events of antimuscarinics in the treatment of OAB.

EVIDENCE ACQUISITION

Medline and Scopus searches, previous systematic reviews, conference abstracts, book chapters, and the reference lists of relevant articles were searched. Trialists were contacted. Eligible studies were randomized trials that compared at least one antimuscarinic for treating OAB with placebo or with another antimuscarinic, and that reported efficacy and/or adverse event outcomes. Efficacy was assessed for six outcomes (perception of cure or improvement, urgency episodes per 24h, leakage episodes per 24h, urgency incontinence episodes per 24h, micturitions per 24h, and nocturia episodes per 24h). Adverse events were assessed in seven categories according to the Common Terminology Criteria for Adverse Events. Across all outcomes, a summary efficacy and an adverse event score were computed. Two authors independently extracted data.

EVIDENCE SYNTHESIS

For the comparison of the efficacy, 76 trials enrolling 38 662 patients were included; for adverse events, 90 trials enrolling 39 919 patients were included. In the subset of studies reporting on treatments and dosages as used in clinical practice, 40 mg/d trospium chloride, 100mg/g per day oxybutynin topical gel, and 4 mg/d fesoterodine had the best efficacy, while higher dosages of orally administered oxybutynin and propiverine had the least favorable relationship of efficacy and adverse events.

CONCLUSIONS

This is the first study allowing trade-offs between efficacy and adverse events of various drugs and dosages in the treatment of patients with OAB. Differences among the various antimuscarinics call for careful, patient-centered management in which regimen changes should be considered.

Is there a direct antimicrobial effect of botulinum neurotoxin type A?

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Several studies describe a reduction of symptomatic urinary tract infections in patients with neurogenic detrusor overactivity after intradetrusor injections of botulinum neurotoxin A (BoNT/A). It was, however, unclear if a direct antibacterial effect of BoNT/A plays a role in this clinical observation. This is the first study to investigate a potential antibacterial effect of two frequently used BoNT/A formulations (i.e. Botox® and Dysport®), providing evidence that BoNT/A does not exert an antibacterial effect on lower urinary tract pathogens.

OBJECTIVE

• To determine a potential direct antimicrobial effect of botulinum neurotoxin type A (BoNT/A).

MATERIALS AND METHODS

• A prospective study was carried out using onabotulinumtoxin A (Botox®) and abobotulinumtoxin A (Dypsort®) in agar diffusion and broth microdilution assays with various clinical urinary tract isolates (Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Pseudomonas aeruginosa, Acinetobacter baumannii, Citrobacter freundii, Klebsiella oxytoca and Bacillus subtilis). • Inhibition zones (mm) of bacteria around a disc containing 20 µL saline with 4 IU of Botox® were measured in the agar diffusion assay. • Minimal inhibitory concentrations (MICs, IU/mL) of both toxins for all bacteria were determined in the broth microdilution assay after overnight incubation at 35 °C.

RESULTS

• There was no inhibition zone in the agar diffusion assays with any bacterial strain. • The microdilution test using Botox® and Dysport® showed bacterial growth in all dilutions, i.e. MICs > 20 and >100 IU/mL for Botox® and Dysport®, respectively.

CONCLUSIONS

• BoNT/A has no direct antimicrobial effect. • The reduced frequency of symptomatic urinary tract infections (sUTIs) in patients with neurogenic detrusor overactivity (NDO) after BoNT/A intradetrusor injections seems to be caused by different indirect mechanisms, which are still not completely understood.

[Sacral neuromodulation for neurogenic bladder dysfunction]

Sacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patient's activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.

External urethral sphincter pressure measurement: an accurate method for the diagnosis of detrusor external sphincter dyssynergia?

Background

Combined pelvic floor electromyography (EMG) and videocystourethrography (VCUG) during urodynamic investigation are the most acceptable and widely agreed methods for diagnosing detrusor external sphincter dyssynergia (DESD). Theoretically, external urethral sphincter pressure (EUSP) measurement would provide enough information for the diagnosis of DESD and could simplify the urodynamic investigation replacing combined pelvic floor EMG and VCUG. Thus, we evaluated the diagnostic accuracy of EUSP measurement for DESD.

Patients & Methods

A consecutive series of 72 patients (36 women, 36 men) with neurogenic lower urinary tract dysfunction able to void spontaneously was prospectively evaluated at a single university spinal cord injury center. Diagnosis of DESD using EUSP measurement (index test) versus combined pelvic floor EMG and VCUG (reference standard) was assessed according to the recommendations of the Standards for Reporting of Diagnostic Accuracy Initiative.

Results

Using EUSP measurement (index test) and combined pelvic floor EMG and VCUR (reference standard), DESD was diagnosed in 10 (14%) and in 41 (57%) patients, respectively. More than half of the patients presented discordant diagnosis between the index test and the reference standard. Among 41 patients with DESD diagnosed by combined pelvic floor EMG and VCUR, EUSP measurement identified only 6 patients. EUSP measurement had a sensitivity of 15% (95% CI 5%–25%), specificity of 87% (95% CI 76%–98%), positive predictive value of 60% (95% CI 30%–90%), and negative predictive value of 56% (95% CI 44%–68%) for the diagnosis of DESD.

Conclusions

For diagnosis of DESD, EUSP measurement is inaccurate and cannot replace combined pelvic floor EMG and VCUR.

Transcutaneous electrical nerve stimulation: an effective treatment for refractory non-neurogenic overactive bladder syndrome?

PURPOSE

To assess the effect of transcutaneous electrical nerve stimulation (TENS) for treating refractory overactive bladder syndrome (OAB).

PATIENTS AND METHODS

A consecutive series of 42 patients treated with TENS for refractory OAB was prospectively investigated at an academic tertiary referral centre. Effects were evaluated using bladder diary for at least 48 h and satisfaction assessment at baseline, after 12 weeks of TENS treatment, and at the last known follow-up. Adverse events related to TENS were also assessed.

RESULTS

Mean age of the 42 patients (25 women, 17 men) was 48 years (range, 18-76). TENS was successful following 12 weeks of treatment in 21 (50 %) patients, and the positive effect was sustained during a mean follow-up of 21 months (range, 6-83 months) in 18 patients. Following 12 weeks of TENS treatment, mean number of voids per 24 h decreased significantly from 15 to 11 (p < 0.001) and mean voided volume increased significantly from 160 to 230 mL (p < 0.001). In addition, TENS completely restored continence in 7 (39 %) of the 18 incontinent patients. Before TENS, all 42 patients were dissatisfied or very dissatisfied; following 12 weeks of TENS treatment, 21 (50 %) patients felt satisfied or very satisfied (p < 0.001). No adverse events related to TENS were noted.

CONCLUSIONS

TENS seems to be an effective and safe treatment for refractory OAB warranting randomized, placebo-controlled trials.