The responsiveness of the OAB-q among OAB patient subgroups

Clinical tools for evaluating the severity of overactive bladder: A systematic review of psychometric properties

OBJECTIVES

To systematically evaluate the evidence describing the psychometric properties of clinical measures for assessing overactive bladder symptoms (urinary urgency with or without urge urinary incontinence, urinary frequency and nocturia). To evaluate the quality of this evidence-base using the COnsensus-based Standards for selecting health status Measurement INstruments (COSMIN) checklist and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tools.

DATA SOURCES

Five electronic databases (CINAHL, EMBASE, MEDLINE, Scopus and Web of Science) were searched from dataset inception to August 2023.

REVIEW METHODS

Study screening, data extraction and quality appraisal were performed by two independent authors. Inclusion criteria were studies testing one or more psychometric properties of clinical tools for the assessment of overactive bladder symptoms among adults aged 18 years and older for both sexes. The methodological quality and quality of the evidence were evaluated using the COSMIN checklist and GRADE tools, respectively.

RESULTS

The search identified 40 studies totalling 10,634 participants evaluating the psychometric properties of 15 clinical tools. The COSMIN methodological quality was rated good for most measures, and the GRADE quality of evidence ranged from low (13%) to high (33%). The Overactive Bladder Symptom Score, Overactive Bladder Questionnaire and Neurogenic Bladder Symptom Score were of good methodological and high-GRADE evidence qualities.

CONCLUSION

Overactive Bladder Symptom Score, the Overactive Bladder Questionnaire and the Neurogenic Bladder Symptoms Score are promising psychometrically sound measures. The Overactive Bladder Symptom Score has been applied to the most culturally diverse populations supported by studies of good methodological and high-GRADE evidence quality.

Lax Uterosacral Ligament and Urge Urinary Incontinence: MRI Findings in Symptomatic Patients Versus Healthy Volunteers

INTRODUCTION AND HYPOTHESIS

The objective was to explore the association between urge urinary incontinence (UUI) and lax uterosacral ligaments (USL) using MRI.

METHODS

Sixty-seven female participants were recruited prospectively: 41 continent volunteers (control group) and 26 patients with UUI. Static proton density- and T2-weighted turbo spin echo sequences of MR images were used. A radiologist employed a standardized grid system to record structural observations of the USLs on sequentially numbered axial MR images and then applied a four-point grading scale to assess ligament visibility. MR images were interpreted by a radiologist and a urologist, and then validated by an expert radiologist.

RESULTS

The comparison between the mean length of uterosacral ligaments in the control and UUI groups was highly statistically significant (p < 0.001). The mean length of the right USL was 38 ± 11 mm, and the left USL was 35 ± 12 mm in the UUI group. In the control group, the mean length of the USL was 22 ± 9 mm on the right side and 18 ± 9 mm on the left side, along their craniocaudal extent. The highest inter-observer agreement was on the level of origin and insertion (image numbers), whereas the lowest agreement was on the anatomical site of origin and insertion of the USL in both the control and UUI groups.

CONCLUSIONS

The average length of USLs in patients with UUI is significantly longer than that in healthy continent women, indicating laxity. Our findings support the relationship between the laxity of the USL and UUI symptoms and have therapeutic implications.

Measures of quality of life of people with neurogenic overactive bladder: A systematic review of psychometric properties

OBJECTIVE

To identify psychometrically robust quality-of-life (QOL) outcome measures for evaluating QOL among people with neurogenic overactive bladder (OAB).

STUDY DESIGN

Electronic databases (CINAHL, EMBASE, MEDLINE, Scopus and Web of Science) were searched from inception to January 2023. Two independent reviewers participated in study screening, data extraction and quality appraisal. Studies were included if they validated at least one psychometric property of a QOL outcome measure among adults (age ≥ 18 years) with neurogenic OAB. The COnsensus-based Standards for selecting health status Measurement INstruments (COSMIN) checklist and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool were used to evaluate the methodological quality and quality of evidence, respectively, for each included study.

RESULTS

Database searches identified 47 studies that tested the psychometric properties of 15 QOL measures in a total of 19,994 participants with stroke, spinal cord injury, Parkinson's disease or multiple sclerosis. The Incontinence Quality of Life Questionnaire (I-QOL), King's Health Questionnaire, Overactive Bladder Questionnaire and Qualiveen were the best validated measures, with strong reliability, validity and responsiveness. I-QOL was the most robust, cross-culturally administered and psychometrically strong measure. The COSMIN checklist indicated sufficient methodological quality for 70% of measures, and the modified GRADE tool indicated quality of evidence ranging from moderate (67%) to high (33%).

CONCLUSIONS

This review identified the I-QOL as a culturally diverse measure with robust reliability, validity and responsiveness for assessing QOL among people with neurogenic OAB. These findings are supported by studies with good methodological quality (COSMIN) and high-quality evidence (GRADE).

A systematic review of English language patient-reported outcome measures for use in urogynaecology and female pelvic medicine

INTRODUCTION

Patient-reported outcome measures (PROMs) are widely used in clinical practice and research in urogynaecology. There is no consensus on which PROMs should be used. No unifying document identifies all available PROMs and compares the psychometric properties of these.

METHODS

Systematic review of the literature following PRISMA guidelines. Studies where women had been administered an English-language PROM which assessed pelvic-floor symptomatology and psychometric properties had been reported were included.

RESULTS

85 PROMs assessing pelvic-floor symptoms in a urogynaecology population were identified. 43 PROMs assessed lower urinary tract symptoms in 95 studies, four PROMS assessed vaginal symptoms in seven studies, 20 PROMs assessed bowel symptoms in 27 studies and three PROMs assessed sexual symptoms in seven studies. 15 PROMs assessed two or more of these symptom areas in 60 studies. PROMs with the with the best available psychometric evidence within these five areas were (urinary symptoms) the Incontinence Quality-of-Life questionnaire (I-QOL aka ICIQ-UIqol) and International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), (bowel symptoms) the Accidental Bowel Leakage Evaluation (ABLE) questionnaire and the International Consultation on Incontinence Bowel questionnaire (ICIQ-B), (vaginal symptoms) the Pelvic Organ Prolapse Symptom Score (POPSS), (sexual symptoms) the Pelvic organ prolapse- urinary Incontinence Sexual function Questionnaire- IUGA revised (PISQ-IR) and (comprehensive PROMs) the Australian Pelvic Floor Questionnaire and the Electronic Personal Assessment Questionnaire-Pelvic-Floor (ePAQ-PF).

CONCLUSIONS

Multiple PROMs with robust psychometric properties are available. Some widely used PROMs have weak evidence. Formal recommendations on which English-language PROMs to use within clinical practice and research in urogynaecology are required.

Evaluation and treatment of urinary incontinence in the aging male

Risk of urinary incontinence (UI) increases with age and can have detrimental effects on patients and caregivers. UI should not be considered a normal part of aging and warrants a comprehensive evaluation. Treatment of UI in the aging male requires special consideration, particularly when it comes to comorbid conditions and potential side effects of intervention. The aim of this review is to discuss the evaluation of, risk factors for, and management of UI in the aging male.

Cost-Effectiveness of Sacral Neuromodulation versus OnabotulinumtoxinA for Refractory Urgency Urinary Incontinence: Results of the ROSETTA Randomized Trial

PURPOSE

Sacral neuromodulation and intradetrusor onabotulinumtoxinA injection are therapies for refractory urgency urinary incontinence. Sacral neuromodulation involves surgical implantation of a device that can last 4 to 6 years while onabotulinumtoxinA therapy involves serial office injections. We assessed the cost-effectiveness of 2-stage implantation sacral neuromodulation vs 200 units onabotulinumtoxinA for the treatment of urgency urinary incontinence.

MATERIALS AND METHODS

Prospective economic evaluation was performed concurrent with the ROSETTA (Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment) randomized trial of 386 women with 6 or more urgency urinary incontinence episodes on a 3-day diary. Analysis is from the health care system perspective with primary within-trial analysis for 2 years and secondary 5-year decision analysis. Costs are in 2018 U.S. dollars. Effectiveness was measured in quality adjusted life-years (QALYs) and reductions in urgency urinary incontinence episodes per day. We generated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves.

RESULTS

Two-year costs were higher for sacral neuromodulation than for onabotulinumtoxinA ($35,680 [95% CI 33,920-37,440] vs $7,460 [95% CI 5,780-9,150], p <0.01), persisting through 5 years ($36,550 [95% CI 34,787-38,309] vs $12,020 [95% CI 10,330-13,700], p <0.01). At 2 years there were no differences in mean reduction in urgency urinary incontinence episodes per day (-3.00 [95% CI -3.38 - -2.62] vs -3.12 [95% CI -3.48 - -2.76], p=0.66) or QALYs (1.39 [95% CI 1.34-1.44] vs 1.41 [95% CI 1.36-1.45], p=0.60). The probability that sacral neuromodulation is cost-effective relative to onabotulinumtoxinA is less than 0.025 for all willingness to pay values below $580,000 per QALY at 2 years and $204,000 per QALY at 5 years.

CONCLUSIONS

Although both treatments were effective, the high cost of sacral neuromodulation is not good value for treating urgency urinary incontinence compared to 200 units onabotulinumtoxinA.

Mirabegron improves quality-of-life, treatment satisfaction, and persistence in patients with overactive bladder: a multi-center, non-interventional, real-world, 12-month study

OBJECTIVE

Observational studies can provide evidence about patient outcomes in routine clinical practice. This prospective, non-interventional study (BELIEVE) is the largest real-world European study to date to assess quality-of-life, treatment satisfaction, resource utilization, and persistence in patients with overactive bladder (OAB) who were prescribed mirabegron as part of routine clinical practice.

METHODS

The primary objective was to evaluate change from baseline in quality-of-life based on overactive bladder questionnaire (OAB-q) sub-scales. Secondary objectives included evaluation of treatment persistence, patient satisfaction, healthcare resource utilization and adverse events (AEs). Follow-up was for 12 months with visit windows at 2-4 and 10-12 months. Median change from baseline in total OAB-q and its sub-scales (Health-related quality-of-life [HRQoL] and symptom bother scale) were assessed.

RESULTS

Overall, 862 patients were enrolled from eight European countries. In the Full Analysis Set (FAS), 73.7% were female, mean age was 61.2 years; 47.7% ≥65 years. At baseline, 41.3% had switched from other OAB treatments, 42.2% were treatment naïve, 10.1% were lapsed, and 6.4% were on combination treatment. Symptom bother and HRQoL total scores improved from baseline to 2-4 and 10-12 months. There was a notable improvement in dry rate, increasing from 34.9% at baseline to 43.7% at 10-12 months in the FAS, and a reduction in pad use. Persistence was high, with 53.8% of FAS patients remaining on mirabegron at 10-12 months. Overall, no unexpected safety issues were observed and AEs were consistent with the known safety profile of mirabegron.

CONCLUSION

Patients receiving mirabegron in a real-world setting reported meaningful improvements in QoL and health status, with a persistence rate of 53.8% at 12 months for the FAS. No unexpected safety issues were observed, and AEs were consistent with the known safety profile of mirabegron.

Patient-reported outcomes in patients with overactive bladder treated with mirabegron and tolterodine in a prospective, double-blind, randomized, two-period crossover, multicenter study (PREFER)

Background

The PREFER study was an assessment of medication tolerability, treatment preference and symptom improvement during treatment with mirabegron (M) and tolterodine (T) extended release (ER) in patients with overactive bladder (OAB). In this analysis of PREFER, patient-reported outcomes (PROs) were assessed during treatment.

Methods

PREFER was a two-period, 8-week crossover, double-blind, phase IV study (NCT02138747) of treatment-naïve adults with OAB ≥3 months randomized to 1 of 4 treatment sequences (M/T; T/M; M/M; T/T), separated by a 2-week washout. Tolterodine ER was dosed at 4 mg for 8 weeks and mirabegron was dosed at 25 mg for 4 weeks then increased to 50 mg for the next 4 weeks. At each visit, PROs related to treatment satisfaction, quality of life and symptom bother were assessed using the OAB Satisfaction (OAB-S; 3 independent scales/5 single-item overall assessments), OAB-q (total health-related QoL [HRQoL] and subscales [Sleep, Social, Coping, Concern] and Symptom Bother scale) and Patient Perception of Bladder Condition (PPBC) questionnaires. Responder rates were reported for OAB-q subscales based on a minimal important difference (MID; ≥ 10-point improvement) and OAB-S Medication Tolerability score ≥ 90.

Results

In total, 358 randomized patients received ≥1 dose of double-blind study medication and completed ≥1 post-baseline value (OAB-S scale, OAB-q, PPBC): M/T (n = 154), T/M (n = 144), M/M (n = 30) or T/T (n = 30). At end of treatment (EoT), mirabegron and tolterodine ER were associated with similar mean improvements in 7 of the 8 OAB-S scores investigated, OAB-q scales and PPBC. A higher percentage of patients achieved clinically relevant improvements (MID) in OAB-q scales and OAB-S Medication Tolerability score during treatment with mirabegron than tolterodine ER.

Conclusions

On average, patients with OAB experienced improvements in treatment satisfaction, HRQoL and symptom bother that were of a similar magnitude during treatment with mirabegron or tolterodine ER. However, during mirabegron treatment, patients were more likely to achieve clinically relevant improvements in tolerability and HRQoL (as measured by the MID for the OAB-q or an OAB-S Medication Tolerability score ≥ 90) than during tolterodine ER treatment.

Trial registration

NCT02138747; registered May 13, 2014.

Cost-Effectiveness Analysis of Anticholinergics Versus Botox for Urgency Urinary Incontinence: Results From the Anticholinergic Versus Botox Comparison Randomized Trial

OBJECTIVES

This study aimed to compare the cost-effectiveness of Botox and anticholinergic (AC) medications for the management of urgency urinary incontinence (UUI).

METHODS

Cost and effectiveness data were analyzed from participants in the Anticholinergic versus Botox Comparison randomized trial of daily AC medication versus 100 U of intradetrusor Botox injection. Societal costs included the following: treatment costs, patient costs, and medical and nonmedical utilization during the 6-month trial. Quality-adjusted life-years (QALYs) were calculated based on questionnaire-derived utility measures and annualized based on data collected at baseline through 6 months. We also estimated the average direct costs for each treatment through 9 months - the duration of time when approximately half the Botox participants maintained adequate symptom control.

RESULTS

Data were analyzed on the 231 women who completed a 6-month follow-up in the Anticholinergic versus Botox Comparison trial (119 AC and 112 Botox). The mean reduction in UUI episodes per day was not significantly different per group. The cumulative mean direct costs through the first 6 months also were similar: $1339 for the AC group and $1266 for the Botox group with AC costs exceeding Botox costs after 5 months. Both groups had considerable QALY gains. Annualizing the 6-month trial results to a 12-month measure, the AC and Botox groups averaged 0.702 and 0.707 QALYs, respectively. Estimates through 9 months favored Botox, showing that AC participants incurred a higher cost per month of adequate symptoms control ($305) compared with Botox participants ($207).

CONCLUSIONS

Botox and AC medications have similar costs and effectiveness in the first 6 months of UUI treatment. If costs and outcomes are considered through 9 months, Botox may have significantly lower costs but similar UUI symptom control as AC.

Adherence to Oral Therapy for Urgency Urinary Incontinence: Results from the Anticholinergic Versus Botox Comparison (ABC) Trial

OBJECTIVES

Medication adherence with urgency urinary incontinence (UUI) treatment is challenging and the best assessment methodology is uncertain. We sought to describe adherence with anticholinergic (AC) versus placebo (P) by comparing pill counts and MEMSCAP event data and to identify factors associated with adherence.

METHODS

The randomized controlled AC versus Botox Comparison trial of women with moderate to severe idiopathic UUI included 126 participants initiating AC plus P bladder injection and 121 receiving P pills plus Botox injection. Adherence data on 243 participants (124 AC and 119 P) were calculated by pill count and MEMSCAP data for each 2-month interval during the 6-month study that allowed for dose escalation/drug change. Overall composite adherence estimates were calculated using the average of both methods and weighted by the duration of each 2-month interval.

RESULTS

Treatment groups had no significant differences in dosing duration (P = 0.76) or mean adherence (AC, 83.3% [16.8] vs. P, 84.8% [13.8]). Only 53% of women met the dichotomous outcome of more than 80% adherence during all intervals. Correlation between adherence by pill counts versus MEMSCAP decreased over time with pill counts demonstrating higher adherence than MEMSCAP (r = 0.53, 0.50, and 0.36 for each 2-month interval). Lower adherence was associated with higher baseline incontinence severity and better UUI quality of life for the AC group and with current smoking status in both groups.

CONCLUSIONS

Adherence using pill counts and MEMSCAP was reasonably correlated and similar in both the AC and P groups. In the AC group, higher baseline incontinence severity and better UUI Quality of Life were associated with decreased adherence. Smokers were less adherent.

The effect of mirabegron on patient-related outcomes in patients with overactive bladder: the results of post hoc correlation and responder analyses using pooled data from three randomized Phase III trials

PURPOSE

To understand how improvements in the symptoms of overactive bladder (OAB) seen with the β3-adrenoceptor agonist mirabegron 50 mg, correlate with patient experience as measured by validated and standard patient-reported outcomes (PROs), and to identify whether there is overall directional consistency in the responsiveness of PROs to treatment effect.

METHODS

In a post hoc analysis of pooled data from three randomized, double-blind, placebo-controlled, 12-week Phase III trials of mirabegron 50 mg once daily, responder rates for incontinence frequency (≥50 % reduction in incontinence episodes/24 h from baseline to final visit), micturition frequency (≤8 micturitions/24 h at final visit), and PROs [minimally important differences in patient perception of bladder condition (PPBC) and subsets of the overactive bladder questionnaire (OAB-q) measuring total health-related quality of life (HRQoL), and symptom bother] were evaluated individually and in combination.

RESULTS

Mirabegron 50 mg demonstrated greater improvement from baseline to final visit than placebo for each of the responder analyses, whether for individual objective and subjective outcomes or combinations thereof. These improvements versus placebo were statistically significant for all double and triple responder analyses and for all single responder analyses except PPBC. PRO measurements showed directional consistency and significant correlations, and there were also significant correlations between objective and subjective measures of efficacy.

CONCLUSIONS

The improvements in objective measures seen with mirabegron 50 mg translate into a meaningful clinical benefit as evident by the directional consistency seen in HRQoL measures of benefit.

Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence

BACKGROUND

Anticholinergic medications and onabotulinumtoxinA are used to treat urgency urinary incontinence, but data directly comparing the two types of therapy are needed.

METHODS

We performed a double-blind, double-placebo-controlled, randomized trial involving women with idiopathic urgency urinary incontinence who had five or more episodes of urgency urinary incontinence per 3-day period, as recorded in a diary. For a 6-month period, participants were randomly assigned to daily oral anticholinergic medication (solifenacin, 5 mg initially, with possible escalation to 10 mg and, if necessary, subsequent switch to trospium XR, 60 mg) plus one intradetrusor injection of saline or one intradetrusor injection of 100 U of onabotulinumtoxinA plus daily oral placebo. The primary outcome was the reduction from baseline in mean episodes of urgency urinary incontinence per day over the 6-month period, as recorded in 3-day diaries submitted monthly. Secondary outcomes included complete resolution of urgency urinary incontinence, quality of life, use of catheters, and adverse events.

RESULTS

Of 249 women who underwent randomization, 247 were treated, and 241 had data available for the primary outcome analyses. The mean reduction in episodes of urgency urinary incontinence per day over the course of 6 months, from a baseline average of 5.0 per day, was 3.4 in the anticholinergic group and 3.3 in the onabotulinumtoxinA group (P=0.81). Complete resolution of urgency urinary incontinence was reported by 13% and 27% of the women, respectively (P=0.003). Quality of life improved in both groups, without significant between-group differences. The anticholinergic group had a higher rate of dry mouth (46% vs. 31%, P=0.02) but lower rates of catheter use at 2 months (0% vs. 5%, P=0.01) and urinary tract infections (13% vs. 33%, P<0.001).

CONCLUSIONS

Oral anticholinergic therapy and onabotulinumtoxinA by injection were associated with similar reductions in the frequency of daily episodes of urgency urinary incontinence. The group receiving onabotulinumtoxinA was less likely to have dry mouth and more likely to have complete resolution of urgency urinary incontinence but had higher rates of transient urinary retention and urinary tract infections. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health; ClinicalTrials.gov number, NCT01166438.).

Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline

PURPOSE

The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of non-neurogenic overactive bladder (OAB).

MATERIALS AND METHODS

The primary source of evidence for this guideline is the systematic review and data extraction conducted as part of the Agency for Healthcare Research and Quality (AHRQ) Evidence Report/Technology Assessment Number 187 titled Treatment of Overactive Bladder in Women (2009). That report searched PubMed, MEDLINE®, EMBASE and CINAHL for English-language studies published from January 1966 to October 2008. The AUA conducted additional literature searches to capture treatments not covered in detail by the AHRQ report and relevant articles published between October 2008 and December 2011. The review yielded an evidence base of 151 treatment articles after application of inclusion/exclusion criteria. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed.

RESULTS

The evidence-based guideline statements are provided for diagnosis and overall management of the adult with OAB symptoms as well as for various treatments. The panel identified first through third line treatments as well as non-FDA approved, rarely applicable and treatments that should not be offered.

CONCLUSIONS

The evidence-based statements are provided for diagnosis and overall management of OAB, as well as for the various treatments. Diagnosis and treatment methodologies can be expected to change as the evidence base grows and as new treatment strategies become obtainable.

Quality of life in patients with overactive bladder: validation and psychometric properties of the Spanish Overactive Bladder Questionnaire-short Form

BACKGROUND

Overactive bladder (OAB) is characterized by the symptoms of urinary urgency or urge incontinence, which appear without a local pathological or metabolic explanation. OAB is defined by symptoms and the evaluation of treatment effectiveness should be based upon patient perceptions. The Overactive Bladder Questionnaire-Short Form (OAB-q SF) is a brief, self-administered patient-reported outcomes tool with two scales assessing symptom bother and health-related quality of life (HR-QOL) in patients with OAB.

OBJECTIVE

This study aimed to adapt the OAB-q SF into Spanish and to estimate its psychometric properties in patients with symptomatic overactive bladder.

METHODS

The Spanish version of the OAB-q SF was administered on two occasions, 3 months apart, to a set of patients of both sexes, over 18 years of age, diagnosed with OAB, scoring ≥8 on the OAB-V8 scale (a self-reported 8-item OAB screening and awareness tool), and able to understand patient-reported-outcome instruments written in Spanish. Patients were recruited consecutively at urology clinics. Feasibility, internal consistency (Cronbach's alpha), test-retest reliability, structure of instrument, criteria and construct validity and responsiveness were examined using classic test theory statistics.

RESULTS

Data from 246 OAB patients (mean age 57.7 years, 76% women, 99% Caucasian, 37% workers and 36% with a primary education) were evaluated. Floor and ceiling effects ranged between 0.8% and 33%, and missing items were below 2%. Cronbach's alphas attained 0.811 and 0.922 for symptom-bother and HR-QOL domains, respectively. These two subscales matched the original structure and explained variances above 50%, which correlated moderately with EQ-5D (EuroQol) [r = -0.28 and r = +0.31, respectively (p < 0.001 in both cases)]. A significant change in OAB-q SF mean domain scores (-23.8; 95% CI -26.3, -21.3; and +17.7; 95% CI 15.4, 20.6; p < 0.001 in both cases; [effect sizes: 1.32 and 0.98]) was observed after 3 months of medical treatment.

CONCLUSION

The Spanish version of the OAB-q SF demonstrated sufficiently strong psychometric properties of reliability, validity and responsiveness to be used in the measurement of OAB symptom severity and HR-QOL.

Anticholinergic versus botulinum toxin A comparison trial for the treatment of bothersome urge urinary incontinence: ABC trial

This trial compares the change in urgency urinary incontinence episodes over 6 months, tolerability and cost effectiveness between women receiving daily anticholinergic therapy plus a single intra-detrusor injection of saline versus a single intra-detrusor injection of 100 U of botulinum toxin A plus daily oral placebo tablets. We present the rationale and design of a randomized-controlled trial, Anticholinergic versus Botulinum Toxin, Comparison Trial for the Treatment of Bothersome Urge Urinary Incontinence: ABC trial, conducted by the NICHD-funded Pelvic Floor Disorders Network. We discuss the innovative nature of this trial and the challenges related to choice of patient population, maintaining masking, cost effectiveness, ethical considerations, measuring adherence, and placebo development and testing. Enrollment began in April, 2010. 242 participants will be randomized and primary outcome data analysis is anticipated to begin in mid 2012. Several challenges in the trial design are discussed. Randomization to placebo intra-detrusor injections may limit recruitment, potentially impacting generalizability. Other challenges included the heavy marketing of drugs for overactive bladder which could impact recruitment of drug-naïve women. In addition, anticholinergic medications often cause dry mouth, making masking difficult. Finally, adverse reporting of transient urinary retention is challenging as there is no standardized definition; yet this is the most common adverse event following intra-detrusor botulinum toxin injection. The ABC trial will help women with urgency urinary incontinence balance efficacy, side effects and cost of anticholinergic medication versus botulinum toxin intra-detrusor injection. The results have the potential to fundamentally change the therapeutic approach to this condition.

Correlates and predictors of patient satisfaction with drug therapy and combined drug therapy and behavioral training for urgency urinary incontinence in women

INTRODUCTION AND HYPOTHESIS

The goal was to identify correlates of patient satisfaction with drug and behavioral treatments for urge-predominant incontinence, which may help tailor treatments to improve satisfaction.

METHODS

Planned secondary analysis of a multi-center, clinical trial randomizing 307 women to 10 weeks of tolterodine alone or combined with behavioral training. Satisfaction was measured using the Patient Satisfaction Question (PSQ). Potential correlates included baseline demographics, incontinence characteristics and prior treatments, history and physical parameters, expectations of treatment success, and outcome variables including the Global Perception of Improvement (GPI) and Urogenital Distress Inventory (UDI).

RESULTS

After multivariable analysis, every 10-point increase in UDI change score increased odds of satisfaction by 11% (OR 1.11; 1.04-1.19). Odds of satisfaction increased among women reporting "much better" on the GPI (OR 13.8; 4.94-38.60).

CONCLUSIONS

Treatment satisfaction for women with urge-predominant incontinence was associated with patient-related outcomes reflecting impression of improvement and bother from incontinence-related symptoms.

The effects of drug and behavior therapy on urgency and voiding frequency

INTRODUCTION AND HYPOTHESIS

The objective of this study was to examine the effects of drug therapy alone and combined with behavioral therapy on urgency and 24-voiding frequency in women with urge-predominant incontinence and to identify predictors of change.

METHODS

A planned analysis of data from a multi-site, randomized, controlled trial (N = 307). Bladder diaries were used to document voids, incontinence, and urgency severity.

RESULTS

Urgency scores decreased significantly within both treatment groups, but changes did not differ between groups (p = 0.30). Improvement in urgency was associated with greater baseline urgency (p < 0.0001) and black ethnicity (p = 0.03). Voiding frequency increased with drug alone and decreased slightly with combined therapy (p = 0.009), and improvement was associated with combined treatment (p < 0.0001), higher baseline frequency (p < 0.0001), and lower baseline incontinence episode frequency (p = 0.001).

CONCLUSIONS

Although combined drug and behavioral therapy does not appear to improve urgency more than drug alone, it resulted in better outcomes on voiding frequency.

Effects of solifenacin on overactive bladder symptoms, symptom bother and other patient-reported outcomes: results from VIBRANT - a double-blind, placebo-controlled trial

AIM

The aim of this study was to evaluate the efficacy of solifenacin on symptom bother using the Overactive Bladder Questionnaire (OAB-q).

METHODS

In VIBRANT, a double-blind, US-based trial, patients with OAB for > or = 3 months received flexibly dosed solifenacin or placebo for 12 weeks. At baseline and 4-week intervals, patients completed the OAB-q [symptom bother and health-related quality of life (HRQL) scales] and 3-day bladder diaries; other patient-reported outcome measures were also assessed at baseline and week 12. The primary efficacy end-point was the change from baseline to end of treatment (EOT) on the OAB-q Symptom Bother scale. Adverse events (AEs) were monitored.

RESULTS

At EOT, solifenacin (n = 377) vs. placebo (n = 374) significantly improved mean symptom bother (-29.9 vs. -20.4, p < 0.0001), HRQL total (25.3 vs. 16.7, p < 0.0001) and all HRQL domain scores (Ps < 0.0001). Solifenacin vs. placebo significantly improved daily episodes of urgency, incontinence and frequency but not nocturia. Significant separation from placebo was evident as early as week 4. Overall, significantly more solifenacin vs. placebo patients reported treatment benefit (84% vs. 63%), satisfaction (80% vs. 59%) and willingness to continue (79% vs. 60%; Ps< 0.0001). Treatment-related AEs in solifenacin vs. placebo patients were dry mouth (13% vs. 2%), constipation (8% vs. 2%) and dry eye (2% vs. 0.3%).

CONCLUSIONS

As early as week 4 and through EOT, flexibly dosed solifenacin significantly improved OAB symptom bother and HRQL as well as the symptoms of urgency, frequency and incontinence compared with placebo. Significantly more solifenacin patients reported treatment benefit and satisfaction at week 12 compared with placebo.

Patient-reported outcomes with botulinum neurotoxin type A

Clinical trials establishing the efficacy of botulinum neurotoxin type A historically have included as outcomes investigator assessments and general patient global assessments of treatment. However, these outcomes are of limited value in determining the specific benefits desired by patients who seek facial rejuvenation. To address this issue, several patient-reported outcomes measures have been developed and utilized in clinical trials of botulinum neurotoxin type A (specifically, the BOTOX Cosmetic brand). The outcomes include the Self-Perception of Age (SPA) measure and the Facial Line Outcomes (FLO) questionnaire. On the FLO questionnaire, patients rate the degree to which their facial lines bother them; make them look older than they would like; prevent them from having a smooth facial appearance; and make them look tired, stressed, or angry when that is not how they feel. Several clinical trials have demonstrated significant improvements in these outcomes from baseline and versus placebo for the treatment of multiple upper facial lines as well as for treating the glabella as a single region. These outcomes data help in understanding patient objectives and motivations, establishing a treatment plan, and ensuring patient satisfaction. Clinicians can use the SPA measure for all patients to help show the value of treatment.

Urgency assessment in the evaluation of overactive bladder (OAB)

Overactive bladder (OAB) is a highly prevalent urinary condition with a profound affect on quality of life. Urinary urgency is the cornerstone symptom that defines OAB and drives all subsequent OAB symptoms. The clinical assessment and measurement of urgency has been limited by its definition, limited understanding of well-defined pathophysiology, and psychometric measurement properties. This review outlines the important issues relevant to the clinical assessment and measurement scales commonly used to evaluate and measure urinary urgency. This will have important implications toward further understanding and advancing the field of overactive bladder.