Botulinum toxin A for refractory OAB and idiopathic urinary retention: Can phenotyping improve outcome for patients: ICI-RS 2019?

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.

Phenotypes of BPS/IC

Purpose of Review

The aim of this review is to summarise the latest research related to different phenotypes of BPS/IC, addressing the evidence for current well-defined phenotypes as well as identifying novel potential phenotypes and highlighting areas for future study.

Recent Findings

Two distinct phenotypes of BPS/IC are well-recognised: Hunner’s lesion disease and non-Hunner’s lesion BPS/IC. Recent studies have shown these phenotypes exhibit distinct clinical, pathological and cystoscopic features, and targeted treatment to Hunner’s lesions can prove effective. Recent studies have also identified new potential phenotypes based on biochemical, molecular and histological markers, pathophysiological mechanisms of disease, clinical features, cystoscopic findings, radiological features and urodynamic factors. This evidence has improved our understanding of the underlying mechanism of disease and may enable more personalised and targeted therapy in the future.

Summary

Novel phenotypes of BPS/IC relate to the presence of certain biomarkers, alterations in the urinary microbiome, the characteristics of pain and presence of co-existing somatic and psychosocial conditions, altered patterns of brain white matter changes and urodynamic features. Further study is required to evaluate whether these potential phenotypes are clinically useful based on their ability to guide treatment selection and predict outcome from therapy, and therefore optimise therapeutic outcomes.