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Vargas Maldonado D, Schulte PJ, Latuche LR, Vassilaki M, Petersen RC, Occhino JA, Linder BJ. Assessing the Impact of Overactive Bladder Medications on Cognition. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00223. [PMID: 38710025 DOI: 10.1097/spv.0000000000001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
IMPORTANCE Emerging literature has associated the use of anticholinergic medications to cognitive decline. OBJECTIVE The aim of this study was to evaluate the association of overactive bladder medications on cognitive function with prospective longitudinal cognitive assessments. STUDY DESIGN A population-based cohort of individuals 50 years and older who had serial validated cognitive assessment, in accordance with the Mayo Clinic Study of Aging, was evaluated from October 2004 through December 2021. Anticholinergic overactive bladder medications were grouped by traditional anticholinergic medications and central nervous system (CNS)- sparing anticholinergic medications and compared to no medication exposure. A linear mixed effects model with time-dependent exposures evaluated the association between overactive bladder anticholinergic medication exposure and subsequent trajectories of cognitive z-scores. RESULTS We included 5,872 participants with a median follow-up of 6.4 years. Four hundred forty-three were exposed to traditional anticholinergic medications, 60 to CNS-sparing medications, and 5,369 had no exposure. On multivariable analyses, exposure to any anticholinergic overactive bladder medication was significantly associated with deterioration in longitudinal cognitive scores in the language and attention assessments compared to the control cohort. Traditional anticholinergic medication exposure was associated with worse attention scores than nonexposed participants. Exposure to CNS-sparing anticholinergic medications was associated with a deterioration in the language domain compared to those unexposed. Among women, traditional anticholinergic medication exposure was associated with worse global and visuospatial scores than nonexposed participants, but this association was not identified in the CNS-sparing group. CONCLUSION Exposure to anticholinergic overactive bladder medications was associated with small but significantly worse decline in cognitive scoring in the language and attention domains when compared to nonexposed individuals.
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Welk B, Krhut J, Sýkora R. An individual participant meta-analysis of mirabegron in multiple sclerosis and spinal cord injury. Neurourol Urodyn 2024; 43:803-810. [PMID: 38477368 DOI: 10.1002/nau.25439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/03/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Our objective was to conduct an individual patient data meta-analysis (IPDMA) of the two published randomized placebo-controlled trials of mirabegron in people with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) or multiple sclerosis (MS). METHODS We identified two randomized, placebo-controlled trials. We extracted individual patient data from the trials and evaluated two primary outcomes: change in maximum cystometric capacity and change in the patient perception of bladder condition (PPBC). We also evaluated several secondary outcomes related to urodynamic function and quality of life. We conducted three exploratory analyses to test hypotheses based on our clinical experiences with mirabegron in NLUTD. Analysis of covariance with adjustment for baseline values was used for the statistical analysis. RESULTS Our IPDMA included 98 patients from the two trials. The results showed that mirabegron was associated with a significant improvement in maximum cystometric capacity (+41 mL, p = 0.04) and in the PPBC (-0.8, p < 0.01) compared to placebo. Secondary outcomes including peak neurogenic detrusor overactivity pressure (-20 cm H2O, p < 0.01), incontinence-QOL score (+12, p < 0.01), and 24 h pad weights (-79 g, p = 0.04) also improved significantly compared to placebo. Exploratory analyses found similar improvements in people with MS and SCI; some outcomes improved to a greater degree among people with incomplete SCI, or SCIs that were below T7. CONCLUSIONS Our IPDMA provides evidence supporting the use of mirabegron in patients with NLUTD due to SCI or MS. Further work evaluating differential responses in people with different SCI lesion characteristics may be warranted.
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Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Jan Krhut
- Department of Urology, University Hospital, Ostrava, Czech Republic
- Department of Surgical Studies, Ostrava University, Ostrava, Czech Republic
| | - Radek Sýkora
- Department of Urology, University Hospital, Ostrava, Czech Republic
- Department of Surgical Studies, Ostrava University, Ostrava, Czech Republic
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Dmochowski RR, Newman DK, Rovner ES, Zillioux J, Malik RD, Ackerman AL. Patient and Clinician Challenges with Anticholinergic Step Therapy in the Treatment of Overactive Bladder: A Narrative Review. Adv Ther 2023; 40:4741-4757. [PMID: 37725308 PMCID: PMC10567877 DOI: 10.1007/s12325-023-02625-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/21/2023] [Indexed: 09/21/2023]
Abstract
Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β3-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β3-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Diane K Newman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric S Rovner
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | - Jacqueline Zillioux
- Department of Urology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Rena D Malik
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A Lenore Ackerman
- Departments of Urology and Obstetrics and Gynecology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, Box 951738, Los Angeles, CA, 90095-1738, USA.
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Yamamoto S, Kusabuka H, Matsuzawa A, Maruyama I, Yamazaki T. Vibegron shows high selectivity and potent agonist activity for β3-adrenoceptors, irrespective of receptor density. PLoS One 2023; 18:e0290685. [PMID: 37656760 PMCID: PMC10473532 DOI: 10.1371/journal.pone.0290685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
β3-Adrenoceptor (AR) agonists are used to treat patients with an overactive bladder (OAB). Clinical proof-of-concept data have been obtained for the β3-AR agonists vibegron, mirabegron, solabegron, and ritobegron; however, the selectivities of these agents have not been compared directly under the same experimental conditions. Moreover, the bladders of some patients express lower β3-AR densities than those of healthy individuals, and the β3-AR density might be expected to affect agonist activity. This study assessed the β3-AR selectivities of four β3-AR agonists and examined the effects of β-AR density on their pharmacological profiles. Functional cellular assays were performed using Chinese hamster ovary-K1 cells expressing three human β-AR subtypes transfected with different amounts of plasmid DNA (0.1, 0.05, 0.025 μg/well). The half-maximal effective concentration values, intrinsic activities (IAs), and β3-AR selectivities of vibegron, mirabegron, solabegron, and ritobegron were calculated to assess their pharmacological profiles. The β3-AR selectivities of vibegron, mirabegron, solabegron, and ritobegron were >7937-, 517-, 21.3-, and >124-fold higher than for β1-ARs, and >7937-, 496-, >362- and 28.1-fold higher than for β2-ARs, respectively, under the same experimental conditions. The IAs of mirabegron, solabegron, and ritobegron decreased in line with decreasing receptor density, while the IA of vibegron was maintained at the same level as that of the full agonist isoproterenol at various β3-AR densities. Vibegron has high β3-AR selectivity and exhibits full agonist activity, regardless of the β3-AR density. These results suggest that vibegron is a highly effective and safe drug for treating OAB.
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Affiliation(s)
- Shota Yamamoto
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., Azumino, Nagano, Japan
| | - Hotaka Kusabuka
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., Azumino, Nagano, Japan
| | - Akane Matsuzawa
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., Azumino, Nagano, Japan
| | - Itaru Maruyama
- Central Research Laboratories, Kissei Pharmaceutical Co., Ltd., Azumino, Nagano, Japan
| | - Takanobu Yamazaki
- Watarase Research Center, Kyorin Pharmaceutical Co., Ltd., Nogi-machi, Tochigi, Japan
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Glazyrine V, Au D, Starkey J, Thompson J, Parker W. Evaluating Financial Toxicity in Urologic Practice. Urology 2023; 179:16-22. [PMID: 37353088 DOI: 10.1016/j.urology.2023.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/27/2023] [Accepted: 04/05/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To evaluate financial toxicity in Urologic surgery using the Comprehensive Score for financial Toxicity (COST) as well as validate a single item measure of toxicity. METHODS A cross-sectional study of 182 patients undergoing oncologic and benign urologic procedures at a single academic medical center. Oncologic procedures included robotic assisted laparoscopic prostatectomy, transurethral resection of bladder tumor, and radical cystectomy. Benign procedures included holmium laser enucleation of the prostate, intravesical chemodenervation, ureteroscopy laser lithotripsy, and ureteral stent exchange. Retrospective review, patient interviews, and the previously validated COST survey, as well as a novel single item measure of toxicity were used pre and post-op. Descriptive statistics and logistic regression models compared COST scores by type of urologic procedure. RESULTS Eighty (44%) patients underwent oncologic procedures and 102 (56%) benign procedures. Benign patients were most likely to have lower income and be younger than oncologic patients, with a median age of 56.7 vs 64.9. One in 4 patients undergoing urologic procedures experienced moderate to severe financial toxicity, without a statistically significant difference between the benign and the oncology groups pre- or post-operatively. Single item measure strongly correlated with COST (r = -0.80) pre- and post-operative. CONCLUSION The COST survey and a single-item financial toxicity measure are both valid tools that can be used to measure financial toxicity in urology. Further research is needed to elicit the exact cause of financial toxicity in the heterogenous urologic patient population.
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Affiliation(s)
| | - Daniel Au
- The University of Kansas, Department of Urology, Kansas City, KS
| | - Jared Starkey
- The University of Kansas, Department of Urology, Kansas City, KS
| | - Jeffrey Thompson
- The University of Kansas, Department of Urology, Kansas City, KS
| | - William Parker
- The University of Kansas, Department of Urology, Kansas City, KS.
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Carr DN, Macharia A, Hacker MR, Winkelman WD. Despite Recommendations, Anticholinergics Account for the Majority of Prescriptions to Treat Overactive Bladder in the United States. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:497-503. [PMID: 36730660 PMCID: PMC10134866 DOI: 10.1097/spv.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE There are significant associations between anticholinergic medication use and an increased risk of cognitive impairment and dementia. Many experts now advocate minimizing the use of anticholinergic medications to treat overactive bladder (OAB) in elderly women. OBJECTIVE The aim of this study was to describe temporal and geographic trends in the pharmacologic treatment of OAB for patients 65 years or older across the United States. STUDY DESIGN The U.S. Centers for Medicare & Medicaid Services publishes annual Medicare Provider Utilization and Payment Data. The data set includes the number of unique Part D beneficiaries 65 years or older with at least 1 claim for a drug and the number of 30-day fills dispensed. The database also includes the U.S. state and rural-urban commuting area designation of the prescriber. RESULTS From 2013 to 2019, Medicare Part D beneficiaries 65 years or older received 47.7 million 30-day fills for the treatment of OAB. In 2013, anticholinergics represented 98% of the total 30-day fills (5.6 million) for OAB. The use of β3 agonists was nearly 24 times greater in 2019 than in 2013. Geographic variation in prescribing practices was evident. CONCLUSIONS The number of anticholinergics dispensed for the treatment of OAB remained relatively stable, and there was a substantial increase in the use of β3 agonists. Percentages of anticholinergics dispensed varied among states. More patients are being treated for OAB; however, anticholinergics comprised the majority of prescriptions for treatment in 2019.
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Affiliation(s)
| | - Annliz Macharia
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center
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Bhide AA, Digesu GA, Swift S. Overactive bladder medication - do we need to revisit trospium chloride for our elderly patients? Int Urogynecol J 2023; 34:961-962. [PMID: 37099160 DOI: 10.1007/s00192-023-05559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 04/27/2023]
Affiliation(s)
- Alka A Bhide
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - G A Digesu
- St Mary's Hospital, Imperial College NHS Trust, London, UK.
| | - Steven Swift
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, 29425, USA
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Evidence-Informed, Interdisciplinary, Multidimensional Action Plan to Advance Overactive Bladder Research and Treatment Initiatives: Directives From State-of-the-Science Conference on Overactive Bladder and Cognitive Impairment. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:S20-S39. [PMID: 36548637 DOI: 10.1097/spv.0000000000001274] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT This article outlines an evidence-informed, interdisciplinary, multidimensional, comprehensive action plan for the American Urogynecologic Society to improve care of women with overactive bladder (OAB) while minimizing treatment-related adverse events, including cognitive impairment. It is a "call to action" to advance basic, translational, and clinical research and summarizes initiatives developed at the State-of-the-Science Conference on OAB and Cognitive Impairment to (1) develop framework for a new OAB treatment approach in women, (2) define research gaps and future research priorities, (3) champion health equity and diversity considerations in OAB treatment, (4) foster community and promote education to remove stigma surrounding OAB and urinary incontinence, and (5) elevate visibility and impact of OAB, by creating partnerships through education and engagement with health care professionals, industry, private and public payers, funding agencies, and policymakers.
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Kennelly M, Wielage R, Shortino D, Thomas E, Mudd PN. Long-term efficacy and safety of vibegron versus mirabegron and anticholinergics for overactive bladder: a systematic review and network meta-analysis. Drugs Context 2022; 11:dic-2022-4-2. [PMID: 36303599 PMCID: PMC9576010 DOI: 10.7573/dic.2022-4-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background Few randomized controlled trials evaluate the long-term efficacy and safety of pharmacotherapy for overactive bladder (OAB). This network meta- analysis compares the long-term (52-week) efficacy and safety of vibegron, mirabegron and anticholinergics for the treatment of OAB. Methods A systematic literature review and network meta-analysis were conducted following PRISMA guidelines using MEDLINE, Embase and Cochrane Central Register of Controlled Trials and terms related to OAB. Efficacy outcomes included change from baseline to week 48–52 in mean daily total urinary incontinence (UI) episodes, mean daily number of micturitions and volume voided/micturition. Efficacy outcomes were analysed using Bayesian models. Commonly reported adverse events (AEs) are described. Results Of 2098 hits retrieved, 5 publications and 1 study report describing 5 unique randomized controlled trials were included in the analyses. Mean (95% credible interval) change from baseline in total UI episodes for vibegron 75 mg (−2.2; −2.9 to −1.5) showed a significantly greater reduction than mirabegron 50 mg (−1.3; −1.9 to −0.8) and tolterodine 4 mg extended release (−1.6; −2.1 to −1.1). No significant differences were observed between vibegron and comparators for daily micturitions or volume voided/micturition. Within the manuscripts, the 4 most common AEs (range) for anticholinergics included dry mouth (5.2–90.0%), constipation (7.7–65.0%), blurred vision (3.8–35.0%) and hypertension (8.6–9.6%); the 4 most commonly reported AEs for β3-adrenergic agonists included hypertension (8.8–9.2%), urinary tract infection (5.9–6.6%), headache (5.5%) and nasopharyngitis (4.8–5.2%). Conclusion Vibegron was associated with significantly greater improvement in daily total UI episodes at 52 weeks than mirabegron and tolterodine. When reported, the most common AE for anticholinergics was dry mouth and for β3-adrenergic agonists was hypertension. Hypertension incidence was similar between drug classes.
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Onur R, Bayrak Ö, Coşkun B, Tahra A, Ocakoglu G, Buyuran G, Mega E, Gungor Ugurlucan F, Ozturk GB. Clinical preferences and treatment attitudes among urologists, gynecologists, and geriatricians: An independent online questionnaire survey for comparison of treatment choices in the management of overactive bladder. Neurourol Urodyn 2022; 41:1914-1923. [DOI: 10.1002/nau.25050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/30/2022] [Accepted: 09/08/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Rahmi Onur
- Department of Urology, School of Medicine Marmara University Istanbul Turkey
| | - Ömer Bayrak
- Department of Urology, School of Medicine Gaziantep University Gaziantep Turkey
| | - Burhan Coşkun
- Department of Urology, School of Medicine Uludag University Bursa Turkey
| | - Ahmet Tahra
- Department of Urology, School of Medicine Istanbul Medeniyet University Istanbul Turkey
| | - Gokhan Ocakoglu
- Department of Bioistatistic, School of Medicine Uludag University Bursa Turkey
| | - Gorkem Buyuran
- Department of Urology, School of Medicine Gaziantep University Gaziantep Turkey
| | - Ertunc Mega
- Department of Gynecology and Obstetrics Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Funda Gungor Ugurlucan
- Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Gulistan Bahat Ozturk
- Department of Geriatrics, Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
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Tracey A. Pelvic Floor Physical Therapy and Its Merit in the Treatment of Female Urogenital Pain. Curr Pain Headache Rep 2022; 26:775-782. [DOI: 10.1007/s11916-022-01076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
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Ali MU, Fong KNK, Kannan P, Bello UM, Kranz GS. Effects of nonsurgical, minimally or noninvasive therapies for urinary incontinence due to neurogenic bladder: a systematic review and meta-analysis. Ther Adv Chronic Dis 2022; 13:20406223211063059. [PMID: 35321402 PMCID: PMC8935404 DOI: 10.1177/20406223211063059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/10/2021] [Indexed: 12/18/2022] Open
Abstract
Objective: To determine the effects of nonsurgical, minimally or noninvasive therapies on urge urinary incontinence (UUI) symptoms and quality of life (QoL) in individuals with neurogenic bladder (NGB). Data Sources: Cochrane library, EMBASE, MEDLINE, PEDro, Scopus, and Web of Science databases were searched from inception to September 2021. Review Methods: Randomized controlled trials that compared therapies such as intravaginal electrical stimulation (IVES), transcutaneous electrical nerve stimulation (TENS), neuromuscular electrical stimulation (NMES), transcutaneous tibial nerve stimulation (TTNS), pelvic floor muscle training (PFMT), and behavioural therapy (BT) to control were included. Study screening, data extraction, and study quality assessments were performed by two independent authors. Results: Fourteen trials with 804 participants were included in the study after screening of 4281 potentially relevant articles. Meta-analyses revealed a significant effect of electrical stimulation on UUI due to multiple sclerosis (standardized mean difference (SMD): −0.614; 95% confidence interval (CI): −1.023, −0.206; p = 0.003) and stroke (SMD: −2.639; 95% CI: −3.804, −1.474; p = 0.000). The pooled analyses of TTNS (weighted mean difference (WMD): −12.406; 95% CI: −16.015, −8.797; p = 0.000) and BT (WMD: −9.117; 95% CI: −14.746, −3.487; p = 0.002) revealed significant effects of these interventions on QoL in people with Parkinson’s disease. However, meta-analyses revealed nonsignificant effects for PFMT (WMD: −0.751; 95% CI: −2.426, 0.924; p = 0.380) and BT (WMD: −0.597; 95% CI: −1.278, 0.083; p = 0.085) on UUI due to Parkinson’s disease. Conclusions: Our meta-analyses found electrical stimulation to be beneficial for improving the symptoms of UUI among people with multiple sclerosis and those with stroke. Our review also revealed that TTNS and BT might improve QoL for people with NGB due to Parkinson’s disease, although the effects of PFMT and BT on UUI warrant further investigation.
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Affiliation(s)
- Mohammed Usman Ali
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Nigeria
| | - Kenneth Nai-Kuen Fong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Priya Kannan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Umar Muhammad Bello
- Centre for Eye and Vision Research (CEVR) Limited, Hong Kong, China; Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong Department of Physiotherapy, Yobe State University Teaching Hospital, Damaturu, Nigeria
| | - Georg S. Kranz
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
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