Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

Antibiotic therapy for treating overactive bladder is not supported by clinical evidence

A number of reports have suggested that the use of prolonged antibiotic treatment could be an effective therapy for patients with overactive bladder (OAB); however, this approach is contrary to existing recommendations regarding the prolonged non-specific use of antibiotics. The existing evidence in this area seems to be circumstantial and anecdotal but, despite this limitation, the use of long-term antibiotic therapy for OAB seems to be increasing. Review and synthesis of the existing evidence for use of antibiotic therapy in patients with OAB identify few studies - just seven papers and four conference proceedings - which are heterogeneous in their design, inclusion and exclusion criteria, treatment regimen employed, approach to the use of antimuscarinic medications, follow-up protocols, and measured outcomes. Overall, the limitation of these published data, the potential adverse events associated with long-term antibiotic use, concerns about antimicrobial resistance and the wide availability of other conventional treatments mean that no compelling data support the routine use of antibiotic therapy and that antibiotic treatment of OAB is not supported by an adequate contemporary evidence base. In the absence of acute urinary tract infection, the management of the non-specific syndrome of OAB should follow existing evidence-based investigational and treatment guidelines. Contemporary therapy following attention to fluid intake relies upon anticholinergic or β3-adrenergic agonist treatment with progression to intravesical onabotulinumtoxinA therapy or neuromodulation in non-responders to oral therapy.

The Potential Role of Urinary Microbiome in Benign Prostate Hyperplasia/Lower Urinary Tract Symptoms

Historically, urine in the urinary tract was considered “sterile” based primarily on culture-dependent methods of bacterial detection. Rapidly developing sequencing methods and analytical techniques have detected bacterial deoxyribonucleic acid and live bacteria in urine, improving our ability to understand the urinary tract microbiome. Recently, many studies have revealed evidence of a microbial presence in human urine in the absence of clinical infections. In women, fascinating evidence associates urinary tract microbiota with lower urinary tract symptoms (LUTS). However, the association between urinary tract microbiota and men with LUTS, particularly those with benign prostate hyperplasia (BPH), has not been established. In addition, the identification of the proinflammatory cytokines and pathogens responsible for the clinical progression of BPH is still underway. This review article aimed to address microbiome-related evidence for BPH. Further studies are required for a comprehensive understanding of the relationship between the urogenital microbiome and BPH pathogenesis to facilitate the development of preventive and therapeutic approaches for male LUTS.

Urinary Tract Infection in Overactive Bladder: An Update on Pathophysiological Mechanisms

Overactive bladder (OAB) is a clinical syndrome defined by urinary urgency, increased daytime urinary frequency and/or nocturia, with or without urinary incontinence, that affects approximately 11% of the western population. OAB is accepted as an idiopathic disorder, and is charactersied clinically in the absence of other organic diseases, including urinary tract infection. Despite this, a growing body of research provides evidence that a significant proportion of OAB patients have active bladder infection. This review discusses the key findings of recent laboratory and clinical studies, providing insight into the relationship between urinary tract infection, bladder inflammation, and the pathophysiology of OAB. We summarise an array of clinical studies that find OAB patients are significantly more likely than control patients to have pathogenic bacteria in their urine and increased bladder inflammation. This review reveals the complex nature of OAB, and highlights key laboratory studies that have begun to unravel how urinary tract infection and bladder inflammation can induce urinary urgency and urinary frequency. The evidence presented in this review supports the concept that urinary tract infection may be an underappreciated contributor to the pathophysiology of some OAB patients.

The use of urinary biomarkers in the diagnosis of overactive bladder in female patients. A systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and other proteins are related to overactive bladder (OAB) syndrome, as their urinary concentrations are significantly different from those of the general non-OAB population. This review aims to systematically assess whether NGF, BDNF, and other urinary by-products can be used as potential biomarkers to manage women with OAB.

METHODS

This was a systematic review and metanalysis that was conducted according to PRISMA guidelines. Studies were identified by electronic search of Medline, Scopus, ScienceDirect, Embase, and Cochrane Register until October 2020. The included studies investigated the correlation of OAB with NGF, BDNF, and other potential biomarkers in symptomatic women and their controls.

RESULTS

Twelve studies (581 female OAB patients and 394 female controls) were included. Urinary NGF, NGF/Cr, BDNF/Cr, ATP/Cr, and PGE2/Cr ratios were identified as potential biomarkers in female OAB patients. Results of the meta-analysis indicated that uNGF [standard mean difference (SMD) 1.45, 95% CI 0.53-2.36], NGF/Cr ratio (SMD 1.23, 95% CI 0.67-1.78), BDNF/Cr ratio (SMD 0.78, 95% CI 0.006-1.50), and BDNF/Cr ratio (RR 0.78, 95% CI 0.006-1.50) were increased in female OAB patients compared to healthy controls, whereas no difference was found for the PGE2/Cr and ATP/Cr ratios. Current data are inadequate to assess any other potential biomarkers, such as urinary MDA, ATP, and cytokines, in the management of OAB in female patients.

CONCLUSIONS

uNGF, NGF/Cr, and BDNF/Cr ratio could be used in the assessment of female OAB patients. Further studies are needed to specify OAB urinary titer levels in OAB subgroups and healthy women and their potential as diagnostic and management tools in OAB women.

Urinary cytokines in women with refractory detrusor overactivity: A longitudinal study of rotating antibiotic versus placebo treatment

Over 50% of women with detrusor overactivity (DO), who do not respond to therapy have been shown to have bacteriuria, which may stimulate the release of inflammatory cytokines than can enhance nerve signalling, leading to symptoms of urgency. This study made use of a consecutive series of urine samples collected from women with refractory DO, who participated in a clinical trial of rotating antibiotic therapy. The aim was to determine the effect of bacteriuria and antibiotic treatment on the levels of urinary cytokines, and to correlate the cytokine concentration with patient outcome measures relating to urgency or urge incontinence. The urinary cytokines chosen were IL-1α, IL-1 receptor antagonist, IL-4, IL-6, IL-8, IL-10, CXCL10 (IP-10), MCP-1 and TNF-α. The presence of bacteriuria stimulated a significant increase in the concentrations of IL-1α (P 0.0216), IL-1 receptor antagonist (P 0.0264), IL-6 (P 0.0003), IL-8 (P 0.0043) and CXCL-10 (P 0.009). Antibiotic treatment significantly attenuated the release of IL-1α (P 0.005), IL-6 (P 0.0027), IL-8 (P 0.0001), IL-10 (P 0.049), and CXCL-10 (P 0.042), i.e. the response to the presence of bacteria was less in the antibiotic treated patients. Across the 26 weeks of the trial, antibiotic treatment reduced the concentration of five of the nine cytokines measured (IL-1α, IL-6, IL-8, IL-10 and CXCL-10); this did not reach significance at every time point. In antibiotic treated patients, the urinary concentration of CXCL-10 correlated positively with four of the six measures of urgency. This study has shown that cytokines associated with activation of the innate immune system (e.g. cytokines chemotactic for or activators of macrophages and neutrophils) are reduced by antibiotic therapy in women with refractory DO. Antibiotic therapy is also associated with symptom improvement in these women, therefore the inflammatory response may have a role in the aetiology of refractory DO.

Effect of antibiotics on urine leakage in women with refractory detrusor overactivity: A phase IIb randomized trial

AIM

Because bacterial cystitis is common in women with refractory detrusor overactivity, the aim was to compare the efficacy of 6 weeks of rotating antibiotics versus placebo, in conjunction with an anticholinergic, in controlling the symptoms of urge incontinence.

METHODS

In a multicenter phase IIb double-blinded randomized placebo-controlled trial, women with urodynamically proven refractory detrusor overactivity were randomized in a 2:1 ratio of antibiotics versus placebo for 6 weeks, in addition to darifenacin for 6 months. Any woman with disabling cystitis symptoms was given appropriate antibiotics ("clinical override"). The primary outcome was the degree of urge incontinence change at 6 weeks and 6 months on 24-h pad test. Secondary outcomes were changes in leaks and voids per day measured on 3-day bladder diary and quality of life measures. Microbiological data were collected at all visits.

RESULTS

Although 278 women were screened, only 36 were randomized and 33 (91.7%) completed the trial. Leakage on 24-h pad test decreased at 6 months by 75 g in patients receiving antibiotics versus 35 g in placebo. Cure of urge incontinence occurred at 6 months in 10/21 (48%) of antibiotics versus 2/12 (17%) of placebo. Clinical override, necessitating treatment of cystitis, occurred in 41.6% of placebo versus 16.7% of the antibiotic group by 6 months.

CONCLUSION

Despite the small sample size, the study showed a significant reduction in pad leakage and leaks per day over 24 h in the active treatment group over a 6-month period. Nearly half of patients on placebo had disabling urinary tract infection symptoms that required clinical override treatment.

Comparação entre oxibutinina, eletroestimulação do nervo tibial posterior e exercícios perineais no tratamento da síndrome da bexiga hiperativa

RESUMO Objetivou-se avaliar a eficácia dos exercícios perineais, da eletroestimulação transcutânea do nervo tibial posterior (ETNTP) e da oxibutinina em mulheres com síndrome da bexiga hiperativa, que é a segunda causa mais comum de incontinência urinária, com sintomas urinários extremamente incômodos que prejudicam a qualidade de vida. Foram randomizadas 65 mulheres, das quais 57 completaram o tratamento. Formaram-se três grupos: o de exercícios perineais, ETNTP e o grupo controle, que utilizou oxibutinina. Os exercícios foram realizados em grupo, nas posições em pé, supino e sentado, duas vezes por semana, com duração de 30 minutos cada sessão, totalizando 12 sessões. Na ETNTP utilizou-se eletrodo transcutâneo posicionado em maléolo medial e outro 10cm acima, com frequência de 10Hz e largura de pulso de 200 microssegundos, por 30 minutos, duas vezes por semana, totalizando 12 sessões. Na medicação as pacientes receberam oxibutinina de 10mg/dia de liberação imediata divididos e duas doses de 5mg/dia, durante 12 semanas consecutivas. Antes e depois dos tratamentos, as pacientes passaram por uma avaliação composta pela análise do diário miccional, avaliação funcional do assoalho pélvico e aplicação de questionário de qualidade de vida OAB-V8. Houve redução da incontinência de urgência em 50%, 70,5% e 41% nos grupos de exercício, ETNTP e oxibutinina, respectivamente, com significância estatística somente da eletroestimulação. As três modalidades de tratamento foram eficazes na melhora da qualidade de vida para a terapêutica em curto prazo, estatisticamente semelhantes entre si.

Mechanisms Underlying Overactive Bladder and Interstitial Cystitis/Painful Bladder Syndrome

The bladder is innervated by extrinsic afferents that project into the dorsal horn of the spinal cord, providing sensory input to the micturition centers within the central nervous system. Under normal conditions, the continuous activation of these neurons during bladder distension goes mostly unnoticed. However, for patients with chronic urological disorders such as overactive bladder syndrome (OAB) and interstitial cystitis/painful bladder syndrome (IC/PBS), exaggerated bladder sensation and altered bladder function are common debilitating symptoms. Whilst considered to be separate pathological entities, there is now significant clinical and pre-clinical evidence that both OAB and IC/PBS are related to structural, synaptic, or intrinsic changes in the complex signaling pathways that mediate bladder sensation. This review discusses how urothelial dysfunction, bladder permeability, inflammation, and cross-organ sensitisation between visceral organs can regulate this neuroplasticity. Furthermore, we discuss how the emotional affective component of pain processing, involving dysregulation of the HPA axis and maladaptation to stress, anxiety and depression, can exacerbate aberrant bladder sensation and urological dysfunction. This review reveals the complex nature of urological disorders, highlighting numerous interconnected mechanisms in their pathogenesis. To find appropriate therapeutic treatments for these disorders, it is first essential to understand the mechanisms responsible, incorporating research from every level of the sensory pathway, from bladder to brain.

A blinded observational cohort study of the microbiological ecology associated with pyuria and overactive bladder symptoms

INTRODUCTION AND HYPOTHESIS

This study sought to characterise the microbial ecology of the lower urinary tract in patients with symptoms of overactive bladder (OAB) using culture of the urinary urothelial cell sediment. The pathological significance of the microbiome was assessed through its relationship with known urothelial inflammatory markers and patient reported symptoms.

METHODS

Adult female patients with OAB symptoms and asymptomatic controls were assessed at 12 study visits scheduled every 4 weeks. At each visit, all participants provided a clean-catch midstream urine (MSU) that was analysed to count white and uroepithelial cells, submitted to standard culture and spun urothelial-cell-sediment culture. Symptoms were assessed using validated questionnaires.

RESULTS

This analysis shows that OAB patients differ consistently from controls, demonstrating differences in bacterial ecology (t -4.57, p 0.0001), in the microscopic pyuria count (t -6.37, p 0.0001) and presence of infected urothelial cells (t -4.21, p 0.0001). The primary outcome measure of bacterial growth [colony-forming units (CFU) ml^-1] was higher in OAB patients than in controls throughout the 12 months. Data showed a correlation between symptoms and pyuria, with notable urgency correlating with pyuria and epithelial cell shedding. The routine urine cultures (with a threshold of reporting a positive result as 10⁵ CFU/ml) were unable to distinguish OAB patients from controls. However, sediment cultures differed significantly, and there was a correlated increased immune response amongst OAB patients.

CONCLUSIONS

This study supports the need to re-examine the OAB phenotype given this association with microbial colonisation.

A case controlled study examining the bladder microbiome in women with Overactive Bladder (OAB) and healthy controls

OBJECTIVE

To characterise the microbiome in healthy women with no bladder symptoms and to compare this to the bladder microbiome in patients with overactive bladder syndrome (OAB).

STUDY DESIGN

MSU specimens from 63 women with OAB were compared to urine from 35 controls. Urine was centrifuged and the resulting sediment pellet was re-suspended in supernatant and plated under aerobic conditions for 48h and anaerobic conditions for 7days. Each morphologically distinct colony was purity plated. Bacterial colonies were lysed and polymerase chain reaction undertaken to amplify the 16s ribosomal RNA gene. This DNA was purified and sequenced allowing identification of bacterial genera.

RESULTS

The mean number of different bacterial genera was 5.0 in both controls and OAB patients (p=0.99). The uropathogenic bacteria Proteus (P=0.01) was more commonly isolated from women with OAB. The genus lactobacillus was present less commonly in urine from OAB patients when compared to urine taken from controls (p=0.02). Overall the most commonly grown bacteria were staphylococcus (grown in 59% of samples), streptococccus (51%), corynebacterium (37%) and lactobacillus (28%). A total of 95 different genera were identified from the urine samples.

CONCLUSION

The female human bladder has a diverse microbiome with stastistically significant differences between bacterial species present in OAB patients and controls.

Efficacy of Transcutaneous Electrical Nerve Stimulation in the Treatment of Overactive Bladder

INTRODUCTION

Overactive Bladder (OAB) accounts for 40-70% cases of incontinence. The etiology is unknown though detrusor instability is found in urodynamic evaluation of almost all cases. Detrusor instability or hyperreflexia can be inhibited by direct inhibition of impulses in the pre-ganglionic afferent neuron or by inhibition of bladder pre-ganglionic neurons of the efferent limb of micturition reflex. Transcutaneous Electrical Nerve Stimulation (TENS) is based on the gate control theory of abolishing the local micturition reflex arc.

AIM

To assess the effectiveness and safety of TENS in idiopathic OAB.

MATERIALS AND METHODS

It is a prospective experimental study to evaluate the effectiveness of TENS v/s placebo in reducing OAB symptoms. (n1=20, n2 =20). Ten treatment sessions (5 sessions/week) of 30 minutes, were conducted.

RESULTS

There was a significant improvement in Overactive Bladder Symptom Scores (OABSS) in TENS group and 2 patients were completely dry following TENS therapy.

CONCLUSION

In elderly women, patients with OAB where other co-medications have their own anticholinergic side effects and impairment of cognition is a concern, TENS can be a useful intervention. TENS units are safe, economical and easily commercially available.

Urinary tract infections in women with urogynaecological symptoms

PURPOSE OF REVIEW

Urinary tract infections are common in the field of urogynaecology. Women with persistent urinary symptoms seem more likely to have bacteriuria despite negative cultures. In this review, we will give an overview of the recent insights on the relationship between urinary tract infection and persistent urinary symptoms and possible new therapeutic options.

RECENT FINDINGS

Recently published articles evaluated the prevalence of low-count bacteriuria (≥10 CFU/ml) or intracellular bacterial communities in women with overactive bladder symptoms (OAB). Differences in urinary microbioma observed in women with and without OAB symptoms were evaluated. In the light of these findings, current screening strategies were discussed and alternative screening methods for bacteriuria developed.

SUMMARY

Low-count bacteriuria (≥10 CFU/ml) seems to be more prevalent in women with OAB. Also intracellular bacterial communities are more commonly detected in these women. The microbioma found in women with urinary symptoms appeared to differ from healthy controls. The current screening methods might be insufficient as they are targeted at detecting uropathogenic Escherichia coli, mostly using a detection threshold of at least 10 CFU/ml and failing to detect intracellular bacterial communities. Studies evaluating the efficacy of treating women with low-count bacteriuria are limited but promising.

Refractory overactive bladder: a common problem?

INTRODUCTION AND HYPOTHESIS

Unsatisfactory treatment outcome sometimes is described as frequently occurring in patients treated with first-line therapy for overactive bladder (OAB). The present article reviews the different circumstances which may result in failure to respond to lifestyle interventions, behavioral therapy, and/or antimuscarinic treatment.

METHODS

An extensive literature search was conducted to identify relevant articles on pathophysiological, clinical, and pharmacological aspects of refractory OAB.

RESULTS

Missing definition, unrealistic individual expectation of treatment outcomes, lack of communication between physician and patient as well as pathophysiological and pharmacological processes were identified as relevant for failure to respond to first-line OAB treatment. Increase of patient's motivation to adhere to the prescribed treatment, critical examination of the patient in regard to the initial diagnosis, and individual adjustment of antimuscarinic therapy may be appropriate tools to improve treatment outcome in OAB patients.

CONCLUSIONS

Overall, the incidence of refractory OAB seems to be overestimated. There are several approaches to improve therapy results.

Urinary nerve growth factor in patients with detrusor overactivity

Background

Detrusor overactivity (DO) is one of the most frequent bladder dysfunctions in children up to the age of 18. Nowadays, the only way to confirm DO is by urodynamic investigation, which is an invasive procedure. Among the many mediators influencing bladder function, nerve growth factor (NGF) plays an important role. The present study was designed to measure urinary NGF (uNGF) levels in patients with DO diagnosed by urodynamic study in comparison with healthy controls.

Methods

The investigation was conducted on 44 children, divided into two groups (24 patients with DO, 20 healthy children). Uroflowmetry was performed in all enrolled to the study and cystometry only to patients. uNGF levels were estimated in both studied groups.

Results

The median uNGF level in patients with DO before treatment was higher compared with healthy controls. There were no differences between uNGF levels in patients after anticholinergic treatment and the controls. We found differences in uroflowmetry parameters between the reference group and the patients. We found correlations between uroflowmetry parameters and uNGF/cr. level.

Conclusions

The uNGF level could be used for detecting DO in children and adolescents.

Measuring uNGF level is a simple, noninvasive procedure and very useful for choosing therapy in patients with DO in various clinical conditions.