A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment

The Urobiome and Its Role in Overactive Bladder

Urine is no longer considered to be sterile. After the existence of the microbiome was revealed through metagenomic analysis using next-generation sequencing, the relationship between characteristics of the microbiome and diseases have been studied and published in various journals. A microbiome exists in the urinary tract and is associated with urinary tract infection, malignancy of the genitourinary tract, and lower urinary tract symptoms. Based on the urine sampling method, sampling site, culture method, and sex, the characteristics of the microbiome vary. Most of the Lactobacillus species are identified mainly in women, and various other species are identified in men. These microorganisms can cause or prevent various diseases. Variations in the microbiome are seen in those with and without disease, and an asymptomatic status does not indicate the absence of microbes. This microbiome has been implicated in a variety of lower urinary tract symptoms and diseases, in particular, overactive bladder. The microbiome differs between patients with urgency and urge urinary incontinence and healthy individuals. There are many aspects of the microbiome yet to be studied in relation to other lower urinary tract symptoms.

Drugs Currently Undergoing Preclinical or Clinical Trials for the Treatment of Overactive Bladder: A Review

Background

Overactive bladder (OAB) is a common clinical condition for which current drug treatment comprises drugs blocking the cholinergic nerve supply, or augmenting the adrenergic nerve supply, to the detrusor muscle of the urinary bladder. Current treatments have drawbacks, including lack of efficacy and the development of adverse effects in some patients. Hence, new and better drugs for treating OAB will be clinically useful.

Objective

This review is meant to provide information on drugs currently undergoing preclinical or clinical trials for the treatment of OAB published in journal articles or elsewhere.

Methods

The cited articles were retrieved from PubMed and Google Scholar from January 1, 1990, to December 31, 2021. The search terms used were contraction or contractility, detrusor, inhibition, isolated or in vitro, in vivo, overactive bladder, and relaxant effect or relaxation.

Results

There are 4 classes of new drugs under various stages of development for the treatment of OAB. These are drugs acting on the autonomic nerve supply to the detrusor muscle of the urinary bladder that include the anticholinergics tarafenacin and afacifenacin and the β₃ adrenoceptor agonists solabegron and ritobegron; drugs acting on ion channels in the detrusor muscle (eg, potassium channel openers and calcium channel blockers), drugs acting on cellular enzymes like phosphodiesterase-5 inhibitors and Rho kinase inhibitors, and drugs acting on miscellaneous targets (eg, pregabalin and trimetazidine).

Conclusions

Drugs currently used to treat OAB target only the cholinergic and adrenergic cellular signalling pathways. There are many other drugs under trial targeting other cellular pathways that may be useful for treating OAB. Their approval for clinical use might improve the treatment of patients with OAB. (Curr Ther Res Clin Exp. 2022; 83:XXX–XXX)

Delivering patient-centered care through shared decision making in overactive bladder

INTRODUCTION

Men and women living with overactive bladder (OAB) face many treatment decisions as they progress through the treatment pathway. Decisions to pursue specific therapies are highly preference sensitive and ideal for shared decision making (SDM). The aim of this narrative review is to provide urologists with a practical summary of methods to elicit preferences and facilitate SDM to promote patient-centered care for OAB.

METHODS

We explore OAB as a preference sensitive condition through a review of treatment outcomes and present available data on prediction tools, patient preferences, and decision aids. We propose a paradigm for applying Everyday SDM to OAB care.

RESULTS

Clinical outcome data points to equipoise (balanced outcomes) between options for first-, second-, and third-line OAB therapies, making OAB preference sensitive and appropriate for SDM. Methods to personalize care through individualized outcome prediction calculators and tools to elicit patient preferences are emerging. While patient information about OAB is readily available, we identified few OAB decision aids that facilitate patient preference elicitation and SDM.

CONCLUSIONS

OAB is a preference sensitive condition, where treatment is largely based on the patient's preferences and values. SDM is an ideal approach to supporting patients through these treatment decisions. We propose the application of Everyday SDM, a personalized, clinically efficient methodology as a method to support patient-centered OAB care.

Emerging molecular mechanisms and genetic targets for developing novel therapeutic strategies for treating bladder diseases

Bladder diseases affect millions of patients worldwide and compromise their quality of life with a substantial economic impact. The not fully understood aetiologies of bladder diseases limit the current diagnosis and therapeutic options to primarily symptomatic treatment. In addition, bladder targeted drug delivery is challenging due to its unique anatomical features and its natural physiological function of urine storage and frequent voiding. Therefore, current treatment options often fail to provide a highly effective, precisely targeted and long-lasting treatment. With the growing maturity of gene therapy, comprehensive studies are needed to provide a better understanding of the molecular mechanisms underpinning bladder diseases and help to identify novel gene therapeutic targets and biomarkers for treating bladder diseases. In this review, molecular mechanisms involved in pathology of bladder cancer, interstitial cystitis and overactive bladder syndrome are reviewed, with focus on establishing potential novel treatment options. Proposed novel therapies, including gene therapy combined with nanotechnology, localised drug delivery by nanoparticles, and probiotics, are discussed in regard to their safety profiles, efficacy, treatment lenght, precise targeting, and in comparison to conventional treatment methods.

The gut, vaginal, and urine microbiome in overactive bladder: a systematic review

INTRODUCTION AND HYPOTHESIS

The objective was to systemically review the current literature on the association of gut, vaginal, and urinary dysbiosis in female patients with overactive bladder (OAB).

METHODS

We performed a comprehensive literature search following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) protocols for systematic reviews. In the EMBASE, CINAHL, and Medline databases, a search was conducted using key words such as "microbiome," "microbiota," "microflora," "overactive bladder," "urge," "gut," "vaginal." Articles were screened using the online tool www.covidence.org . Two independent reviewers screened studies at each stage and resolved conflicts together. We excluded papers that discussed pediatric patients and animal studies. In total, 13 articles met this criterion, which included 6 abstracts.

RESULTS

After identifying 817 unique references, 13 articles met the criteria for data extraction. Articles were published from 2017 to 2021. No study reported the same microbiota abundance, even in healthy individuals. Overall, there was a loss of bacterial diversity in OAB patients compared with controls. Additionally, the bacterial composition of the controls and OAB patients was not significantly different, especially if the urine was collected midstream. Overall, the composition of the microbiome is dependent on the specimen collection methodology, and the metagenomic sequencing technique utilized. OAB urine microbiome is more predisposed to alteration from the gut or vaginal influences than in controls.

CONCLUSIONS

Current evidence suggested a potential relationship among gut, vaginal, and urinary microbiome in OAB patients, but there are very limited studies.

What is the real burden of the overactive bladder? Results from a national prevalence study

OBJECTIVE

To describe the prevalence of overactive bladder determining patient-reported outcome measures (PROMS) and potential risk factors.

METHODS

A cross-sectional population-based study to estimate lower urinary tract symptoms (LUTS) prevalence in the Colombian population was performed (COBaLT study). Overactive bladder (OAB) was assessed using 2002 International Continence Society definitions and the Report on the Terminology for Female Pelvic Floor Dysfunction. PROMS were included to evaluate participant's perceptions of health-related quality of life (QoL). Spanish validated questionnaires were used, including the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) and Patient Perception of Bladder Condition (PPBC) scale.

RESULTS

A total of 1060 individuals were assessed. The mean age of participants was 42.2 years, and most participants were Hispanic (93.15%). The overall prevalence of OAB syndrome was 31.70%, and it was more frequently reported in women than in men (39.25% vs. 24.15%). Most participants with OAB did not perceive their symptoms as bothersome. The most bothersome symptom, associated with moderate/severe impact in QoL was urinary urgency. According to the PPBC questionnaire 75.6% of the participants reported that their bladder condition does not cause any problem, while 11.% reported moderate to severe bother. The multivariable model showed high blood pressure and anxiety were associated with OAB in men. In females, depression, obstructive sleep apnea, IBS, and pelvic organ prolapse were associated with OAB syndrome.

CONCLUSIONS

Using the symptomatic definition of OAB can overestimate the real impact and burden of the condition, and treatment should be targeted to those symptomatic patients with QoL impairment as they would benefit from further management. The questionnaires seem to overestimate the condition, since we assessed it from a PROMS perspective there is not such a marked QoL impact.

Overactive bladder (OAB): a failed concept needing revision to accommodate an external anatomical control system

THESIS AND AIMS

In 45 years, the definitions and practice of the urodynamically based overactive bladder (OAB)/detrusor overactivity (DO) system have failed to adequately address pathogenesis and cure of urinary urge incontinence, frequency and nocturia.

METHODS

We analysed the OAB syndrome with reference to the Integral Theory paradigm's (ITS) binary feedback system, where OAB in the female is viewed as a prematurely activated, but otherwise normal micturition caused mainly, but not entirely, by ligament damage/laxity. The ITS Clinical Assessment Pathway which details the relationships between structural damage (prolapse), ligaments and dysfunction (symptoms) is introduced.

RESULTS

The ITS was able to "better explain" OAB pathophysiology in anatomical terms with reference to the binary model. The phasic patterns diagnostic of "detrusor overactivity" are explained as a struggle for control by the closure and micturition reflexes. The exponentially determined relationship between urethral diameter and flow explains why obstructive patterns occur, why they do not and why urine may leak with no recorded pressure. Mechanically supporting ligaments ("simulated operations") during urodynamic testing can improve low urethral pressure, negative pressure during coughing with SUI and diminish urge sensation or even DO patterns, transforming urodynamics from non-predictive test to accurate predictor of continence surgery results. High cure rates for OAB by daycare repair of damaged ligaments is a definitive test of the binary system's validity.

CONCLUSION

Conceptual progression of OAB to the Integral Theory paradigms's prematurely activated micturition validates OAB component symptoms as a syndrome, explains pathogenesis, and unlocks a new way of understanding, diagnosing, treating and researching OAB.

An indirect comparison meta-analysis of noninvasive intravesical instillation and intravesical injection of botulinum toxin-A in bladder disorders

BACKGROUND

Botulinum toxin type A (BTX-A) intravesical instillation and BTX-A intravesical injection are both effective treatments or overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), but direct comparative studies of the two treatments are lacking.

METHODS

We conducted a pairs-comparison meta-analysis and an adjusted indirect comparison meta-analysis extracting published data from randomized controlled trials in literature databases from the inception of each database to Aug. 31, 2021, evaluating efficacy and safety of BTX-A intravesical instillation and BTX-A intravesical injection. We also carried out a subgroup analysis.

RESULTS

We identified 24 trials in 21 studies were included in our study, of which 18 trials in 17 studies were BTX-A intravesical injections, 6 trials in 4 studies were BTX-A intravesical instillation. Compared with the normal saline injection, BTX-A intravesical injections for patients with OAB and IC/ BPS can obviously improve the symptoms of urinary frequency, urgency episode, UI and UUI, but BTX-A significantly increased the rate of urinary retention and urinary tract infection and increased PVR (p < 0.05). Adjusted indirect comparison meta-analysis showed that BTX-A intravesical injections was more effective than BTX-A intravesical instillation (p > 0.05). Surprisingly, BTX-A intravesical instillation had fewer side effects than BTX-A intravesical injections (p < 0.05).

CONCLUSIONS

Although BTX-A intravesical injections of OAB and IC/BPS has been significantly superior the BTX-A intravesical instillation, it has major side effects, but this needs to be confirmed by more large-scale, multicenter, direct comparison randomized controlled trials.

Patient-tailored healthcare and tibial nerve neuromodulation in the treatment of patients with overactive bladder symptoms

Purpose

The aim of this study was to demonstrate features predictive of treatment response for patient‐tailored overactive bladder (OAB) intervention with an implantable tibial neurostimulator using patient and technical prediction factors.

Materials and Methods

This study was designed as a follow‐up study based on parameter settings and patients' preferences during the pilot and extended study of the implantable tibial nerve stimulator (RENOVA™ iStim system). For this study, we compared all treatment parameters (stimulation amplitude, frequency, and pulse width) and usage data (duration of treatment) during the different follow‐up visits.

Results

We obtained usage data from a total of 32 patients who were implanted with the system between February and September 2015. Age, sex, body mass index (BMI) and previous experience with percutaneous tibial nerve stimulation (PTNS) treatment were considered as possible prediction factors for treatment success. However, only BMI was considered a statistically significant prediction factor (p = 0.042). A statistically significant increase in mean treatment level was seen in the responder group during the 3 month follow‐up visit (mean: 6.7 mA, SD 0.416) as compared with the initial system activation visit (mean: 5.8 mA, SD 0.400) (p = 0.049). No other visits demonstrated statistically significant changes in both groups (responders and nonresponders) during the defined timepoints.

Conclusion

This data underscores the need to use patient‐tailored OAB treatment. BMI was found to be a negative predictive factor for treatment success. However, it was not possible to develop a specific responder model. A model predicting response to treatment could be useful for implementing shared decision making.

Overactive Bladder Symptoms Within Nervous System: A Focus on Etiology

Overactive bladder (OAB) is a common debilitating condition characterized by urgency symptoms with detrimental effects on the quality of life and survival. The exact etiology of OAB is still enigmatic, and none of therapeutic approaches seems curative. OAB is generally regarded as a separate syndrome, whereas in clinic, OAB symptoms could be found in numerous diseases of other non-urogenital systems, particularly nervous system. The OAB symptoms in neurological diseases are often poorly recognized and inadequately treated. This review provided a comprehensive overview of recent findings related to the neurogenic OAB symptoms. Relevant neurological diseases could be mainly divided into seven kinds as follows: multiple sclerosis and related neuroinflammatory disorders, Parkinson’s diseases, multiple system atrophy, spinal cord injury, dementia, peripheral neuropathy, and others. Concurrently, we also summarized the hypothetical reasonings and available animal models to elucidate the underlying mechanism of neurogenic OAB symptoms. This review highlighted the close association between OAB symptoms and neurological diseases and expanded the current knowledge of pathophysiological basis of OAB. This may increase the awareness of urological complaints in neurological disorders and inspire robust therapies with better outcomes.

The effect of amino acids on the bladder cycle: a concise review

The human bladder maintains a cycle of filling, storing, and micturating throughout an individual's lifespan. The cycle relies on the ability of the bladder to expand without increasing the intravesical pressure, which is only possible with the controlled relaxation of well-complaint muscles and the congruously organized construction of the bladder wall. A competent bladder outlet, which functions in a synchronous fashion with the bladder, is also necessary for this cycle to be completed successfully without deterioration. In this paper, we aimed to review the contemporary physiological findings on bladder physiology and examine the effects of amino acids on clinical conditions affecting the bladder, with special emphasis on the available therapeutic evidence and possible future roles of the amino acids in the treatment of the bladder-related disorders.

Activation of GPR18 by Resolvin D2 Relieves Pain and Improves Bladder Function in Cyclophosphamide-Induced Cystitis Through Inhibiting TRPV1

Purpose

Hyperalgesia and bladder overactivity are two main symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS). Cannabinoid receptors participate in the modulation of pain and bladder function. GPR18, a member of the cannabinoid receptor family, also participates in the regulation of pain and bladder function, but its underlying mechanisms are unknown. In this work, we sought to study the role of GPR18 in IC/BPS.

Methods

A rat model of IC/BPS was established with cyclophosphamide (CYP). Paw withdrawal threshold (PWT) measurement and cystometry were used to evaluate pain and bladder function, respectively. RT-PCR, Western blotting and immunofluorescence were used to assess the expression and distribution of GPR18. The role of GPR18 in pain and bladder function was studied by intrathecal injection of resolvin D2 (RvD2, a GPR18 agonist) and O-1918 (a GPR18 antagonist). Calcium imaging was used to study the relationship between GPR18 and TRPV1.

Results

A rat model of IC/BPS, which exhibited a decreased PWT and micturition interval, was successfully established with CYP. The mRNA and protein expression of GPR18 was reduced in the bladder and dorsal root ganglia (DRG) in rats with CYP-induced cystitis. Intrathecal injection of RvD2 increased the PWT and micturition interval. However, O-1918 blocked the therapeutic effect of RvD2. GPR18 was present in bladder afferent nerves and colocalized with TRPV1 in DRG, and RvD2 decreased capsaicin-induced calcium influx in DRG.

Conclusion

Activation of GPR18 by RvD2 alleviated hyperalgesia and improved bladder function, possibly by inhibiting TRPV1 in rats with CYP-induced cystitis.

Pharmacological Management of Urinary Incontinence: Current and Emerging Treatment

Pharmacological management of urinary incontinence (UI) is currently based on antimuscarinic and beta-3-agonist drugs. Botulinum toxin A detrusor injections represent an effective but more invasive alternative. This review covers the latest developments of the currently available drugs and the emerging compounds for the treatment of UI. Evidence shows that new antimuscarinics and beta-3-agonists with improved safety profiles may offer unique options to patients intolerant to currently available drugs. Combination therapy proved to be a non-invasive alternative for patients refractory to first-line monotherapy. Exciting advances are ongoing in the research to improve the efficacy/tolerability profile of botulinum toxin, through innovative routes of administration. Several new agents emerged from preclinical studies, some of which have now entered the clinical phase of development and could represent, in the coming years, a new way for the treatment of UI. Recent evidence on the existence of different overactive bladder phenotypes could be the key to tailored treatment. Rather than discovering new molecules, reaching the ability to identify the right drug for the right patient could be the real gamechanger of the future.

Non-invasive measurement of the internal pressure of a pressurized biological compartment using Lamb waves

In this study, we propose a mechanical analysis for estimating the internal pressure of a finitely deformed spherical compartment from Lamb wave measurements. The proposed analysis produces a dispersion relation associating Lamb wave speed with pressure using limited material parameters (only a strain stiffening term). The analysis was validated on ultrasound bladder vibrometry (UBV) experiments collected from 9 ex vivo porcine bladders before and after formalin cross-linking. Estimated pressures were compared with pressures measured directly by a pressure transducer. The proposed analysis proved broadly effective at estimating pressure from UBV based Lamb wave without calibration as demonstrated by the observed concordance between estimated and measured pressures (Lins CCC = 0.82 (0.66-0.91). Theoretical limitations and potential refinements to improve the accuracy and generality of the approach are discussed.

Urobiome: An outlook on the metagenome of urological diseases

The urinary tract likely plays a role in the development of various urinary diseases due to the recently recognized notion that urine is not sterile. In this mini review, we summarize the current literature regarding the urinary microbiome and mycobiome and its relationship to various urinary diseases. It has been recently discovered that the healthy urinary tract contains a host of microorganisms, creating a urinary microbiome. The relative abundance and type of bacteria varies, but generally, deviations in the standard microbiome are observed in individuals with urologic diseases, such as bladder cancer, benign prostatic hyperplasia, urgency urinary incontinence, overactive bladder syndrome, interstitial cystitis, bladder pain syndrome, and urinary tract infections. However, whether this change is causative, or correlative has yet to be determined. In summary, the urinary tract hosts a complex microbiome. Changes in this microbiome may be indicative of urologic diseases and can be tracked to predict, prevent, and treat them in individuals. However, current analytical and sampling collection methods may present limitations to the development in the understanding of the urinary microbiome and its relationship with various urinary diseases. Further research on the differences between healthy and diseased microbiomes, the long-term effects of antibiotic treatments on the urobiome, and the effect of the urinary mycobiome on general health will be important in developing a comprehensive understanding of the urinary microbiome and its relationship to the human body.

Overactive bladder: A review and update

Overactive bladder syndrome is a chronic, disabling condition with physical, psychological and social consequences that significantly affects the quality of life of millions of patients worldwide. The economic impact of this disorder is crucial. Overactive bladder syndrome is a little-known condition, with different manifestations from patient to patient, which causes a great deal of frustration to the medical staff involved. The patient requires a clear explanation and the full support of the attending physician. It is extremely important to establish a correct diagnosis and an effective individualized treatment. The collaboration and understanding of these patients are extremely important aspects. Improving the quality of life in these patients is the main purpose in managing this condition. There are several treatment modalities that may be used progressively, with favorable albeit inconsistent results. This condition remains extremely challenging for specialists and, unfortunately, always one of maximum interest.

The cognitive effect of anticholinergics for patients with overactive bladder

Overactive bladder (OAB) is often treated with medications that block the cholinergic receptors in the bladder (known as anticholinergics). The effect of this medication class on cognition and risk of dementia has been increasingly studied over the past 40 years after initial studies suggested that the anticholinergic medication class could affect memory. Short-term randomized clinical trials demonstrated that the administration of the anticholinergic oxybutynin leads to impaired memory and attention, and large, population-based studies showed associations between several different anticholinergic medications and dementia. However, trials involving anticholinergics other than oxybutynin have not shown such substantial effects on short-term cognitive function. This discordance in results between short-term cognitive safety of OAB anticholinergics and the long-term increased dementia risk could be explained by the high proportion of patients using oxybutynin in the OAB subgroups of the dementia studies, or a study duration that was too short in the prospective clinical trials on cognition with other OAB anticholinergics. Notably, all studies must be interpreted in the context of potential confounding factors, such as when prodromal urinary symptoms associated with the early stages of dementia lead to an increase in OAB medication use, rather than the use of OAB medication causing dementia. In patients with potential risk factors for cognitive impairment, the cautious use of selected OAB anticholinergic agents with favourable physicochemical and pharmacokinetic properties and clinical trial evidence of cognitive safety might be appropriate.

Cognitive-behavioral therapy and urge urinary incontinence in women. A systematic review

INTRODUCTION AND HYPOTHESIS

UUI co-exists with numerous health conditions, having a substantial negative impact on health-related quality of life and mental health. Cognitive-behavioral therapy (CBT) could help patients manage these problems by changing the way they think and behave.

METHODS

We carried out a systematic review of the literature assessing the modalities and effects of CBT as a stand-alone strategy, without adding PFMT, on symptoms and clinical signs, in women with UUI. Our secondary objective was to report modalities and effects of CBT on health-related quality of life, psychological symptoms and patient-reported satisfaction. The PRISMA methodology was used to carry out this systematic review. A literature search was conducted in PubMed, PEDro, Web of Science and Cochrane Library databases from inception to December 2020. The PICO approach was used to determine the eligibility criteria.

RESULTS

Twelve papers were included in the present review which showed beneficial effects on both symptom severity (p < 0.05) and more subjective areas such as quality of life, psychological symptoms or patient satisfaction level (p < 0.05), respectively). However, results on the effectiveness of CBT on clinical signs remains conflicting.

CONCLUSION

Based on the available literature, this review suggested a high level of evidence for the effectiveness of CBT on symptom severity and a moderate level of evidence for the effectiveness of CBT on quality of life, psychological symptoms and patient satisfaction. However, we highlighted no evidence for the effects of CBT on clinical signs.

Detrusor overactivity assessment using ultrasound bladder vibrometry

Objective. Detrusor overactivity (DO) is a urodynamic observation characterized by fluctuations in detrusor pressure (Pdet) of the bladder. Although detecting DO is important for the management of bladder symptoms, the invasive nature of urodynamic studies (UDS) makes it a source of discomfort and morbidity for patients. Ultrasound bladder vibrometry (UBV) could provide a direct and noninvasive means of detecting DO, due to its sensitivity to changes in elasticity and load in the bladder wall. In this study, we investigated the feasibility and applying UBV toward detecting DO.Approach. UBV and urodynamic study (UDS) measurements were collected in 76 neurogenic bladder patients (23 with DO). Timestamped group velocity squared (cg2) data series were collected from UBV measurements. ConcurrentPdetdata series were identically analyzed for comparison and validation. A processing approach is developed to separate transient fluctuations in the data series from the larger trend of the data and a DO index is proposed for characterizing the transient peaks observed in the data.Main Results.Applying the DO index as a classifier for DO produced sensitivities and specificities of 0.70 and 0.75 forcg2data series and 0.70 and 0.83 forPdetdata series respectively.Significance. It was found that DO can be feasibly detected from data series of timestamped UBV measurements. Collectively, these initial results are promising, and further refinement to the UBV measurement process is likely to improve and clarify its capabilities for noninvasive detection of DO.

The patient pathway for overactive bladder management: A quantitative analysis

PURPOSE

We aimed to explore the pathways followed by patients with overactive bladder (OAB) from referral to the urologist to final treatment.

METHODS

This was a single-center, retrospective cohort study of female patients diagnosed with OAB in a large Dutch nonacademic teaching hospital. The number, sequence, and duration of treatment steps offered were analyzed, and the effectiveness, reasons for discontinuation, and possible case-mix variables influencing OAB treatment were studied.

RESULTS

In total, 120 patients were enrolled and required a median of 2 steps (range, 1-6) of treatment over a median total duration of 28 weeks (range, 5-256). Treatment typically started with drug therapy, including antimuscarinics (38%; 95% CI, 30%-47%), antimuscarinics plus pelvic floor muscle therapy (21%; 95% CI, 15%-29%), or mirabegron (11%; 95% CI, 6%-18%). However, 52% of patients required further treatment, with botulinum toxin A (BoNT-A) injections being most effective (67%; 95% CI, 42%-85%), followed by antimuscarinics plus percutaneous tibial nerve stimulation (50%; 95% CI, 25%-75%), and antimuscarinics plus pelvic floor muscle therapy (36%; 95% CI, 21%-54%). Other therapies showed lower effectiveness. Common reasons for discontinuation were insufficient response and side effects. Overall, 22 patients were lost to follow-up.

CONCLUSION

Most patients try at least two treatments before they experience satisfactory symptom relief, with treatment evaluations requiring time because therapeutic onsets differ by patient and treatment. Our data can help to manage expectations among urologists and patients when seeking treatment for OAB.

Efficacy of non-pharmacological interventions in patients with overactive bladder: A protocol for systematic review and network meta-analysis

Background

Some meta‐analyses have proved the superiority of non‐pharmacological interventions in overactive bladder (OAB), but the best choice is still controversial.

Aim

To assess the most effective interventions in female with OAB.

Methods

Studies for relevant randomized controlled trials which compare different kinds of non‐pharmacological interventions in females with OAB will be retrieved from 8 databases including PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Database, VIP Database and China Biology Medicine disc, from inception to 1 January 2021. After screening titles and abstracts, detailed data including participates, interventions and outcomes will be extracted according to the eligible criteria. Then, Cochrane risk‐of‐bias tool will be used to assess the quality of the literature. The pairwise meta‐analysis will be conducted by STATA. Network meta‐analysis will be performed to compare and rank the effects of different non‐pharmacological interventions, in terms of alleviation of symptoms, by OpenBUGS, R and STATA.

Results

This network meta‐analysis will present the best available evidence about non‐pharmacological interventions for OAB to both relieve symptoms and improve life quality.

Relationships between overactive bladder and cerebral white matter hyperintensity in outpatients at a memory clinic

AIM

Cerebral small vessel disease and lower urinary tract symptoms are common in older people. However, the association between white matter hyperintensity (WMH) and overactive bladder (OAB) is not fully understood. We aimed to identify the relationship between WMH and OAB.

METHODS

We carried out neuropsychological testing and head magnetic resonance imaging (T2-weighted and fluid-attenuated inversion recovery) of 72 outpatients at a memory clinic and evaluated their Overactive Bladder Symptom Score. WMH was assessed using the Fazekas scale, and WMH volumes were determined using Software for Neuro-Image Processing in Experimental Research. OAB was diagnosed based on a urinary urgency score (the third question of the Overactive Bladder Symptom Score) of two or higher and a total Overactive Bladder Symptom Score of three or higher. Multivariate logistic analysis was carried out, with the presence/absence of overactive bladder as the outcome variable, and age, sex, body mass index and diabetes mellitus as covariates.

RESULTS

Of the 72 participants, 17 (24%) were diagnosed with OAB. WMH assessed by the visual rating scale was not associated with OAB. However, participants with OAB showed significantly higher WMH volume than those without OAB. Regionally, participants with OAB showed high WMH volume in the frontal, occipital and parietal lobes. Multiple logistic regression analysis showed that WMH was significantly associated with OAB (OR 1.82, 95% CI 1.11-2.98), after adjustment for clinically important confounders.

CONCLUSIONS

Cerebral WMH volume is associated with OAB, independent of age, sex, body mass index and diabetes mellitus. Geriatr Gerontol Int 2021; 21: 996-1002.

Psychiatric History and Overactive Bladder Symptom Severity in Ambulatory Urogynecological Patients

Introduction and hypothesis: A link between psychiatric comorbidities and overactive bladder symptomatology has been suggested by preclinical and clinical studies. Given this, we hypothesized that a psychiatric history and current treatment with psychotropic medications could be related to the severity of overactive bladder and incontinence symptoms in patients referred to a tertiary care urogynecological center. Methods: One hundred and twenty-seven female patients diagnosed with an overactive bladder were screened for a lifetime history of psychiatric disorders and the type and number of psychotropic medications currently taken. The overall severity of overactive bladder symptoms was assessed using the Indevus Urgency Severity Scale. The severity and impact of urinary incontinence on the quality of life were quantified with the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Urinary incontinence was further quantified with the aid of the Urinary Distress Inventory-6. The patients were screened for stress urinary incontinence using the Stamey Incontinence Score. Results: A psychiatric history, as well as current use of at least two psychotropic medications, was associated with increased severity of overactive bladder symptoms. A history of depression and current treatment with any selective serotonin reuptake inhibitor was associated with increased severity of stress urinary incontinence symptoms. Current treatment with other psychotropic medications, including sedative-hypnotics and drugs with anticholinergic properties was not related to the severity of overactive bladder and incontinence symptoms.

Effect of systemic atherosclerosis on overactive bladder symptoms in men with benign prostatic hyperplasia

OBJECTIVE

Symptoms of male overactive bladder (OAB) may be caused by several systemic pathophysiological factors rather than a single-source etiology. We investigated the clinical factors associated with the severity of OAB symptoms in treatment-naïve men with coexisting benign prostatic hyperplasia.

METHODS

We obtained records from a health promotion center database of male patients who visited between March 2019 and February 2020. Men without a history of treatment for lower urinary tract symptoms were evaluated using the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score, transrectal ultrasonography, medical history, and carotid duplex ultrasound for the evaluation of atherosclerosis. Benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS) was defined as an IPSS of eight points or higher. Patients with comorbidities that may affect their voiding function were excluded.

RESULTS

A total of 764 patients were divided into two groups based on their diagnosis: an OAB group and a non-OAB group. The non-OAB group consisted of 627 patients (82.1%) and the OAB group consisted of 137 patients (17.9%). Using multivariable analysis BPH/LUTS was identified as an independent risk factor for OAB. In the OAB group without BPH/LUTS, carotid atherosclerosis was significantly associated with the severity of OAB symptoms. A history of diabetes mellitus was the only variable that was associated with the severity of urinary urgency. Systolic blood pressure was associated with severity of urinary urgency in the OAB group with BPH/LUTS.

CONCLUSIONS

Factors associated with male OAB exhibit different pathophysiology in the severity of symptoms depending on the presence of BPH/LUTS. Treatment for atherosclerosis and associated systemic pathophysiological factors could lower OAB symptom severity in male patients without BPH/LUTS.

De novo detrusor overactivity and urgency after mid-urethral slings for urodynamic stress incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to identify incidence and risk factors of de novo urgency and detrusor overactivity (DO) following mid-urethral slings (MUS) in patients with urodynamic stress incontinence (USI) without urgency.

METHODS

A total of 688 women between January 2004 and July 2017 were reviewed retrospectively. De novo urgency was established with a positive response to question 2 on the Urogenital Distress Inventory-6 questionnaire (UDI-6). Objective cure of USI is no involuntary urine leakage during filling cystometry and pad test < 2 g. Subjective cure of stress urinary incontinence (SUI) is defined as a negative response to question 3 on UDI-6. Multivariate logistic regression was used to identify risk factors for failure.

RESULTS

Forty-four out of 688 women (6.4%) developed de novo urgency, with 16 out of 688 (2.3%) demonstrating de novo DO. Subjective cure for women with de novo urgency was significantly lower at 35 out of 44 (79.5%) compared with 556 out of 644 (86.3%) in those with no urgency (p < 0.001). Objective cure for women with de novo DO was significantly lower at 8 out of 16 (50%) compared with 599 out of 672 (89.1%) in those with detrusor stability (p < 0.001). Quality of life improved for all. Age ≥ 66 (OR, 1.23; 1.07), increased bladder sensation (OR, 4.18; 3.80), lower bladder capacity (OR, 5.28; 4.97), lower maximum urethral closure pressure (OR, 2.32; 5.20), and pad test > 100 g (OR, 1.08; 1.15) were independent risk factors for de novo urgency and DO. Diabetes (OR, 1.32) was an independent predictor of de novo urgency.

CONCLUSION

Cure is significantly reduced in women who report symptoms of de novo urgency or demonstrate DO after MUS at 1 year. Independent risk factors include age ≥ 66, increased bladder sensation, lower bladder capacity, lower maximum urethral closure pressure, greater pad loss, and diabetes.

Correction of overactive bladder with botulinum toxin type A (BTX-A)

One of the most common dysfunction is overactive bladder. The clinical symptoms are associated with an involuntary contraction of the detrusor muscle of the urethra. Drugs are the basis of overactive bladder therapy. However, the duration of drug therapy is limited due to the frequent development of side effects. The study aimed to examine the efficacy of using botulinum toxin type A (BTX-A) in patients with overactive bladder. A total of 90 patients with overactive bladder (mean age 39.86 ± 3.47 years; 59 (65.6%) women and 31 (34.4%) men) divided into two groups (45 patients each) were examined: Group 1 included patients without imperative urinary incontinence, and Group 2 included patients with imperative urinary incontinence. Patients in both groups underwent intravesical injection of 200 units of botulinum toxin type A (Xeomin). The BTX- A for treating patients with overactive bladder reduces clinical symptoms, increases the functional volume of the bladder, and facilitates an improvement in the life quality of patients. The use of BTX-A in patients suffering from overactive bladder and not responding to drug therapy with m-cholinolytics is effective and safe, which allows recommending this treatment method to correct the studied bladder dysfunction in such patients.

Association between the Trp64Arg polymorphism of the ADRB3 gene and overactive bladder

BACKGROUND

The β₃ -adrenergic receptor (ADRB3) is very important in the regulation of the human detrusor muscle function. The well-known tryptophan64arginine polymorphism of the ADRB3 gene alters the response of the receptor to various stimuli, including adrenalin and noradrenalin, and may increase the susceptibility to develop overactive bladder (OAB). Therefore, this study was performed to determine whether ADRB3 Trp64Arg polymorphism is associated with the pathophysiology of OAB syndrome.

METHODS

The study group (n = 150) consists of 72 patients with OAB and 78 controls without OAB. Venous blood samples were taken from all participants to analyze the ADRB3 gene Trp64Arg polymorphism using polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) assay. We compared the distribution of Trp64Arg polymorphism and symptom severity in both OAB and non-OAB subjects using χ² test and Mann-Whitney's U test, respectively.

RESULTS

The frequency of the 64Arg variant (heterozygous plus homozygous) in OAB and non-OAB subjects was 15.3% and 14.1%, respectively. There was no statistically significant difference between the OAB and non-OAB groups in regard to the distribution frequency of ADRB3 Trp64Arg polymorphism. The total frequency (OAB + non-OAB, 76 women and 74 men) of the Arg64 variant allele was 5.9% and 10.8% in women and in men, respectively. Although the frequency of the Arg64 variant was nearly twofold higher in men compared to women, the difference was not statistically significant.

CONCLUSIONS

These results demonstrated that the ADRB3 Trp64Arg polymorphism is not significantly associated with OAB syndrome in a sample of Turkish OAB patients.

Pelvic organ prolapse surgery and overactive bladder symptoms-a population-based cohort (FINPOP)

Introduction and hypothesis

It is unclear how compartment of pelvic organ prolapse (POP) impacts overactive bladder (OAB) symptom severity or improvement after POP surgery. We hypothesized that anterior and apical prolapse are more strongly associated with OAB symptoms than posterior compartment prolapse.

Methods

A total of 2933 POP surgeries from a prospective population-based cohort were divided into two groups: (1) anterior and/or apical compartment surgery (± posterior repair), N = 2091; (2) posterior repair only, N = 478. Urinary frequency and urgency urinary incontinence (UUI) were evaluated using PFDI-20 (bothersome symptom: score 3–4) at baseline, 6, and 24 months. Association between degree of POP in specific compartments and symptoms at baseline was estimated with generalized linear models and between compartment of surgery and symptom improvement with generalized estimating equations.

Results

At least one bothersome symptom was reported by 40% at baseline, 14% at 6, and 19% at 24 months. At baseline, urinary frequency was associated with degree of anterior and apical and UUI with anterior compartment prolapse. Women undergoing surgery for anterior/apical compartment started with worse symptoms and experienced greater improvement than women undergoing posterior compartment surgery. Bothersome frequency resolved in 82% after anterior/apical and in 63% after posterior compartment surgery. Bothersome UUI resolved in 75% after anterior/apical and in 61% after posterior compartment surgery. After surgery, symptom severity was comparable between groups. Bothersome de novo symptoms occurred in 1–3%.

Conclusions

OAB symptoms are more strongly related to anterior and apical than to posterior compartment prolapse, but improvement is seen after surgery for any vaginal compartment.

Association between overactive bladder and pelvic organ mobility as evaluated by dynamic magnetic resonance imaging

Overactive bladder (OAB) is a prevalent condition, which negatively impacts patients’ quality of life. Pelvic organ prolapse (POP), also prevalent in women, has been recognized as an important etiology of female OAB, although the pathophysiological mechanisms remain controversial. In this study, we reviewed findings of dynamic magnetic resonance imaging (dMRI) in 118 patients with POP and investigated the association between dMRI findings, including positions and mobilities of pelvic organs as well as parameters of pelvic organ support and bladder outlet obstruction (urethral kinking), and OAB in order to elucidate the pathophysiology of OAB in patients with POP. Our results showed that compared with non-OAB patients, OAB patients had a significantly higher body mass index, more severe pelvic floor muscle impairment, and more profound supportive defects in the uterine cervix (apical compartment). On the other hand, dMRI parameters showed hardly any significant difference between patients with mild and moderate to severe OAB. These findings may imply that levator ani impairment and defective supports of the apical compartment could be associated with the presence of OAB and that the severity of OAB could be affected by factors other than those related to pelvic organ mobility and support or urethral kinking.

Hypertension, cardiovascular disease, and nocturia: a systematic review of the pathophysiological mechanisms

Nocturia significantly impairs quality of life, especially in the elderly population, and urinary retention is a main target of treatment for urologists. In addition to nocturia, cardiovascular diseases are common in the elderly population, and a systematic review showed that hypertension and heart failure are often associated with nocturia. One possible pathogenic mechanism underlying the development of hypertension is an increase in blood pressure due to excessive salt intake in people with high-salt sensitivity. From Guyton's natriuretic curve, we can infer that salt-sensitive hypertensive patients who consume too much salt do not excrete salt during the daytime and are forced to excrete salt at night, resulting in increased urine production and nocturia. In patients with heart failure, the nocturnal supine position leads to an increase in central fluid volume due to an increase in venous return from the periphery, and the secretion of natriuretic peptide is stimulated by the stretching of the atria and ventricles. Thus, natriuresis due to hypertension and hydrodiuresis due to heart failure may cause nocturia, which can effectively be treated by the administration of thiazide diuretics and loop diuretics in the morning, respectively. Because cardiovascular diseases, such as hypertension and heart failure, can cause nocturia and because the treatment methods differ depending on the cause, it is necessary to pay close attention to nocturia in the management of lifestyle-related diseases, such as cardiovascular disease.

Artificial intelligence in functional urology: how it may shape the future

PURPOSE OF REVIEW

The aim of the present manuscript is to provide an overview on the current state of artificial intelligence (AI) tools in either decision making, diagnosis, treatment options, or outcome prediction in functional urology.

RECENT FINDINGS

Several recent studies have shed light on the promising potential of AI in functional urology to investigate lower urinary tract dysfunction pathophysiology but also as a diagnostic tool by enhancing the existing evaluations such as dynamic magnetic resonance imaging or urodynamics. AI may also improve surgical education and training because of its automated performance metrics recording. By bringing prediction models, AI may also have strong therapeutic implications in the field of functional urology in the near future. AI may also be implemented in innovative devices such as e-bladder diary and electromechanical artificial urinary sphincter and could facilitate the development of remote medicine.

SUMMARY

Over the past decade, the enthusiasm for AI has been rising exponentially. Machine learning was well known, but the increasing power of processors and the amount of data available has provided the platform for deep learning tools to expand. Although the literature on the applications of AI technology in the field of functional urology is relatively sparse, its possible uses are countless especially in surgical training, imaging, urodynamics, and innovative devices.

Native tissue repair of cardinal/uterosacral ligaments cures overactive bladder and prolapse, but only in pre-menopausal women

INTRODUCTION

The aim of this article was to study the effect of native tissue cardinal/uterosacral ligament repair on overactive bladder (OAB) and pelvic organ prolapse (POP).

MATERIAL AND METHODS

Inclusion criteria included decrease of urge symptoms following insertion of a gauze tampon in the posterior fornix of vagina ('simulated operation'). Exclusion criteria included SUI, POP grades 3-4. The surgery consisted of plication of cardinal/uterosacral ligaments. Post-operative assessment was performed at3, 6, 12 and 18 months after surgery and included evaluation by stage of prolapse, Urinary Distress Inventory Short Form 6 (UDI-6), Overactive Bladder Questionnaire (OAB-q), Pelvic Floor Impact Questionnaire- Short Form 7 (PFIQ-7), and International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-SF) questionnaires and voiding diary.

RESULTS

At 3 months, cure rates for frequency, urgency, nocturia and prolapse were comparable. By the 6-month review, catastrophic failure commenced in the postmenopausal group, parallel for all pa-rameters, starkly contrasting with premenopausal group. At 18 months, % cure rates for pre-menopausal (post-menopausal in brackets) were 79.6 (15.4) for POP, 67.3 (20.5) for urgency, 87.7 (20.5) for nocturia and 59.2 (15.4) for frequency.

CONCLUSIONS

We hypothesize the stepwise parallel recurrence of POP and symptoms in the menopausal group was a consequence of collagen deficiency in the plicated ligaments. Nevertheless, plication of uterosacral-cardinal ligament complex is simple, inexpensive, effective, especially applicable pre-menopausally for POP and as an alternative treatment option in that difficult group of pre-menopausal women who have major OAB/nocturia symptoms but only minimal prolapse.

Bladder Hyperactivity Induced by Oxidative Stress and Bladder Ischemia: A Review of Treatment Strategies with Antioxidants

Overactive bladder (OAB) syndrome, including frequency, urgency, nocturia and urgency incontinence, has a significantly negative impact on the quality-of-life scale (QoL) and can cause sufferer withdrawal from social activities. The occurrence of OAB can result from an imbalance between the production of pro-oxidants, such as free radicals and reactive species, and their elimination through protective mechanisms of antioxidant-induced oxidative stress. Several animal models, such as bladder ischemia/reperfusion (I/R), partial bladder outlet obstruction (PBOO) and ovarian hormone deficiency (OHD), have suggested that cyclic I/R during the micturition cycle induces oxidative stress, leading to bladder denervation, bladder afferent pathway sensitization and overexpression of bladder-damaging molecules, and finally resulting in bladder hyperactivity. Based on the results of previous animal experiments, the present review specifically focuses on four issues: (1) oxidative stress and antioxidant defense system; (2) oxidative stress in OAB and biomarkers of OAB; (3) OAB animal model; (4) potential nature/plant antioxidant treatment strategies for urinary dysfunction with OAB. Moreover, we organized the relationships between urinary dysfunction and oxidative stress biomarkers in urine, blood and bladder tissue. Reviewed information also revealed the summary of research findings for the effects of various antioxidants for treatment strategies for OAB.

Association of Metabolic Syndrome Components and Overactive Bladder in Women

Background

To identify associations between metabolic syndrome (MS) components and overactive bladder (OAB) in women.

Methodology

The present study was conducted prospectively between February 2021 and April 2021 and included the assessment of women admitted to the cardiology outpatient clinic and their female relatives. Records were made of the demographic characteristics of patients and blood tests, including cholesterol, high-density lipoproteins (HDL), low-density lipoproteins (LDL), triglyceride, and fasting glucose levels (FG). In addition, the score on the Overactive Bladder Questionnaire-8-item (OAB-V8) form was noted. The study population was divided into two groups according to OAB-V8 score. The groups were compared in terms of participant demographic properties, OAB-V8 scores, metabolic component values, and blood test results.

Results

In total, 200 participants with a mean age of 49.8 years were enrolled in the study. Participants with OAB had significantly higher body mass index (BMI) (30.1 kg/m² versus 27.1 kg/m²; p = 0.001) and longer waist circumference (97.8 cm versus 89.0 cm; p = 0.001). Similarly, the mean FG and LDL levels were significantly higher in participants with OAB (p = 0.001 and p = 0.001). Lastly, mean OAB-V8 score was 20.2 for participants with OAB and 4.8 for participants without OAB. Multivariate regression analysis showed that higher BMI and longer waist circumference were significantly associated with OAB (1.228-fold; p = 0.001 and 1.058-fold; p = 0.001, respectively). Additionally, multivariate regression analysis found that higher LDL level and FG were predictive factors for OAB (1.115-fold; p = 0.003 and 1.229-fold; p = 0.001, respectively).

Conclusions

The present study found that higher BMI, longer waist circumference, and higher LDL and FG levels were predictive factors for OAB development in women.

Tadalafil ameliorates bladder overactivity by restoring insulin-activated detrusor relaxation via the bladder mucosal IRS/PI3K/AKT/eNOS pathway in fructose-fed rats

The pathophysiologies of metabolic syndrome (MS) and overactive bladder (OAB) might overlap. Using fructose-fed rats (FFRs) as a rodent model of MS we investigated the effects of tadalafil (a phosphodiesterase type 5 inhibitor) on the dysregulated insulin signalling in the bladder mucosa and bladder overactivity. Micturition behaviour was evaluated. Concentration-response curves on detrusor relaxation to insulin stimulation were examined. Expression and phosphorylation of proteins in the insulin signalling pathway were evaluated by Western blotting. Levels of detrusor cGMP and urinary nitrite and nitrate (NOx) were measured. We observed FFRs exhibited metabolic traits of MS, bladder overactivity, and impaired insulin-activated detrusor relaxation in organ bath study. A high-fructose diet also impeded insulin signalling, reflected by overexpression of IRS1/pIRS1^Ser307 and pIRS2^Ser731 and downregulation of PI3K/pPI3K^Tyr508, AKT/pAKT^Ser473, and eNOS/peNOS^Ser1177 in the bladder mucosa, alongside decreased urinary NOx and detrusor cGMP levels. Tadalafil treatment restored the reduced level of mucosal peNOS, urinary NOx, and detrusor cGMP, improved the insulin-activated detrusor relaxation, and ameliorated bladder overactivity in FFRs. These results suggest tadalafil may ameliorate MS-associated bladder overactivity by restoring insulin-activated detrusor relaxation via molecular mechanisms that are associated with preservation of IR/IRS/PI3K/AKT/eNOS pathway in the bladder mucosa and cGMP production in the bladder detrusor.

Sacral neuromodulation in patients with refractory overactive bladder symptoms after failed Botulinum toxin therapy: Results in a large cohort of patients

Aims

Sacral neuromodulation (SNM) and Botulinum toxin A (BoNT‐A) injections are well‐known third‐line treatment options in patients with refractory overactive bladder (OAB). Our aim is to evaluate the success rate of SNM in patients who received prior therapy with BoNT‐A injections.

Methods

All patients with OAB symptoms referred for SNM between 2006 and 2019 were included. History taking and 3‐day voiding diaries assessed the complaints and suitability for SNM. The success rate of SNM in patients who received prior BoNT‐A was compared with BoNT‐A naive patients. Success was defined as an improvement of 50% or greater in voiding diary parameters. Satisfaction was registered at their most recent visit.

Results

A total of 263 patients underwent SNM test stimulation, of which 75 (16 male/57 female) received prior BoNT‐A and 188 (46 male/142 female) were BoNT‐A naive. Success rate for SNM in BoNT‐A naive patients was 72.9% and in BoNT‐A patients 66.7% (p = 0.316). Success rate after ≤2 BoNT‐A injections was 68.5%, compared to 61.1% after ≥3 injections (p >  0.05). Success rate in patients perceiving lack of efficacy of BoNT‐A was 67.4% (p > 0.05), subjected to temporary CISC was 73.7% (p > 0.05) and with temporary effect of BoNT‐A was 50% (p > 0.05). In 86% of BoNT‐A patients the system was still activated and used to their satisfaction at their last follow‐up visit (mean FU, 40.70 months).

Conclusion

SNM in patients with refractory OAB who failed prior BoNT‐A is an excellent approach. The number of injections nor reason of BoNT‐A discontinuation have predictive value for success with SNM.

Evaluation of the relationship of cholinergic metabolites in urine and urgency urinary incontinence

Introduction and hypothesis

To investigate differences in urine cholinergic metabolites in women with urinary urgency incontinence (UUI) and responders (R) and non-responders (NR) to anti-cholinergic medications (AC).

Methods

Patients with UUI and age-matched controls were evaluated pre- and post-treatment using OABSS, UDI-6 and IIQ-7. Controls were defined as having a cumulative OABSS of zero. Patients with UUI were treated with AC and followed for 12 weeks. Responders were those with a > 50% decrease in the total OABSS score. Urine samples were collected from all participants for evaluation. Metabolite detection was accomplished using commercial assay kits. Wilcoxon-rank sum test and Fisher’s exact test were used to express differences between groups. Spearman’s rho correlation coefficient was used to determine the relationship between acetylcholine (Ach), choline (Ch), acetylcholinesterase (AchE) and questionnaire scores.

Results

We recruited 39 with UUI and 33 controls. We found concentrations of Ch [29.0 (IQR: 24.2–42.5) μmol vs. 15.2 (IQR: 7.5–24.1) μmol] and Ach [65.8 (IQR: 30.4–101.8) nmol and 33.1 (IQR: 11.9–43.8) nmol] were higher in the UUI group compared to controls (p = 0.003 and p < 0.001, respectively] and no differences in AchE concentrations. In the UUI group, 43.6% responded to AC after 12 weeks of therapy. There were no differences in Ch or AchE levels between R and NR; Ach levels were higher in the R group [82.1 nmol (IQR: 54.8–118.1) vs. 50.3 nmol (IQR: 29.9–68.2), p = 0.007]. Ch and Ach were positively associated with pre-treatment OABSS parameters.

Conclusions

Urine Ach is higher in responders to anti-cholinergic therapy, and urine cholinergic metabolites were higher in the UUI patients compared to controls.

The Postural Tachycardia Syndrome (PoTS) Bladder-Urodynamic Findings

OBJECTIVE

To evaluate the urodynamics (UDS) of patients with postural tachycardia syndrome (PoTS).

METHODS

Patients with a confirmed diagnosis of PoTS referred by the department of neuro-cardiology to the neuro-urology were identified and their UDS were retrospectively reviewed.

RESULTS

In total, 50 patients (47 = 94.0% female) with confirmed PoTS and available UDS were identified. Mean age of females and males was 32.4 and 28.2 years, P = .15. Intermittent self-catheterisation was being used by 15/47 (31.9%) females at assessment. Detrusor overactivity was observed in 6 females (12.8%) (all at end fill and associated with urgency). In total, 14 (29.8%) females had no sensation of filling. No patients had an "unsafe" bladder. In total, 15/47 (31.9%) of women were unable to void with UDS catheters. Straining was reported in 22/35 (68.8%) of females. The female bladder outflow obstruction index = P_DetQ_max - 2.2(Q_max) was over 5 in 10/28 (35.7%) and over 18 in 5 (17.9%). The bladder contractility index = P_DetQ_max + 5Q_max was under 100 in 18/28 (28.6%) women.

CONCLUSION

The UDS of patients with "PoTS bladder" often demonstrate a poorly sensate but stable and safe bladder with functional obstruction and impaired bladder contractility that may necessitate straining or intermittent self-catheterisation.

Efficacy of salt reduction for managing overactive bladder symptoms: a prospective study in patients with excessive daily salt intake

This study aimed to investigate the efficacy of salt intake restriction on overactive bladder (OAB) symptoms in patients with excessive salt intake. Patients received a brochure on nutritional guidance regarding salt intake reduction and received health education every 4 weeks for 12 weeks. Data from overactive bladder symptom score (OABSS) questionnaires and frequency volume charts (FVCs) were evaluated. The daily salt intake was estimated by determining the urinary sodium and creatinine concentrations using spot urine samples. Of the 98 patients included, 71 (72.4%) successfully restricted their daily salt intake after 12 weeks (salt restricted [R] group), while 27 (27.6%) did not (salt non-restricted [N-R] group). The scores to each OABSS question and the resulting total score improved significantly in the R group; however, the individual scores remained unchanged and the total score increased in the N-R group. The FVC data indicated improved voided volumes in the R group as compared to in the N-R group. Ultimately, 17 (23.9%) patients in the R group no longer fulfilled the OAB diagnostic criteria after salt intake reduction. Thus, salt intake reduction improved urinary symptoms in patients with OAB and may be a therapeutic option for OAB in patients with excessive daily salt intakes.

A 3-year longitudinal survey of overactive bladder in community-dwelling male residents aged 40 years and above

OBJECTIVES

To evaluate the short-term evolution and risk factors of overactive bladder (OAB) in community-dwelling male residents aged 40 years and above in central Taiwan.

METHODS

This was a 3-year longitudinal cohort study. From January 2012 to December 2012, community residents aged 40 years and above, living in central Taiwan, were invited to participate in this study. A yearly Overactive Bladder Symptom Score (OABSS) questionnaire was used to assess the prevalence, incidence, remission, persistence, and relapse of OAB for three consecutive years. OAB was defined as total OABSS ≧4 and urgency score ≧2.

RESULTS

Nine hundred forty-one male residents aged ≧40 years were recruited. The prevalence of OAB was 15%. The male residents with OAB were older, had a history of urological surgery, were unemployed, had lower educational levels, and lower yearly incomes compared with male residents without OAB. The prevalence increased with age when stratified into different age cohorts (40-49, 7%; 50-59, 12.7%; 60-69, 18.2%; ≧70, 32%; P < .001). Age ≧60 (odds ratio [OR] 2.58; 95% CI, 1.62-4.11) and history of urological surgery (OR 2.85; 95% CI, 1.29-6.30) were the major risk factors after multivariable logistic regression analysis. Eight hundred participants completed all the 3 years' questionnaires. The second- and third-year incidence rates of OAB were 10% (69/691) and 6.2% (42/674), respectively. The remission rates were 47.7% (52/109) and 46% (58/126), respectively. The two-year OAB persistence rate was 30.3% (33/109).

CONCLUSIONS

The prevalence and yearly incidence of OAB are high in community-dwelling male residents aged ≧40 years in central Taiwan. Age is an important risk factor.