Efficacy and Tolerability of Tolterodine Extended Release in Male and Female Patients with Overactive Bladder

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.

OBJECTIVE

To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.

EVIDENCE ACQUISITION

A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of male LUTS.

PATIENT SUMMARY

A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006.

OBJECTIVES

To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.

European Association of Urology Guidelines on Male Urinary Incontinence

CONTEXT

Urinary incontinence (UI) is a common condition in elderly men causing a severe worsening of quality of life, and a significant cost for both patients and health systems.

OBJECTIVE

To report a practical, evidence-based, guideline on definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of UI.

EVIDENCE ACQUISITION

A comprehensive literature search, limited to studies representing high levels of evidence and published in the English language, was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a grade of recommendation were assigned.

EVIDENCE SYNTHESIS

UI can be classified into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence. A detailed description of the pathophysiology and diagnostic workup has been reported. Simple clinical interventions, behavioural and physical modifications, and pharmacological treatments comprise the initial management for all kinds of UI. Surgery for SUI includes bulking agents, male sling, and compression devices. Surgery for UUI includes bladder wall injection of botulinum toxin A, sacral nerve stimulation, and cystoplasty/urinary diversion.

CONCLUSIONS

This 2022 European Association of Urology guideline summary provides updated information on definition, pathophysiology, diagnosis, and treatment of male UI.

PATIENT SUMMARY

Male urinary incontinence comprises a broad subject area, much of which has been covered for the first time in the literature in a single manuscript. The European Association of Urology Non-neurogenic Male Lower Urinary Tract Symptoms Guideline Panel has released this new guidance, with the aim to provide updated information for urologists to be able to follow diagnostic and therapeutic indications for optimising patient care.

Nocebo Response in the Pharmacological Management of Overactive Bladder: A Systematic Review and Meta-analysis

CONTEXT

The role of a nocebo response in managing urology patients is unclear.

OBJECTIVE

To assess the nocebo response in randomized placebo-controlled overactive bladder (OAB) trials of pharmacological treatment by investigating the adverse events in the placebo arms.

EVIDENCE ACQUISITION

PubMed, Scopus, Embase, and Cochrane Central Register of Controlled Trials were searched to identify potential randomized controlled trials published from 1998 to November 2019. After evaluating the risk of bias in the selected studies, all selected full-text articles were included due to their overall acceptable quality. We extracted the event rate of the most commonly reported adverse events in the placebo arms of OAB trials, and finally, we performed a meta-analysis to calculate the cumulative rate of certain adverse events. The primary outcomes were the event rate of adverse events in the placebo arms of OAB trials of pharmacological treatment, and differences in adverse events in the placebo groups based on drug type and routes of administration.

EVIDENCE SYNTHESIS

After a systematic search and risk of bias assessment, 57 trials comprising 15 446 patients were included in this systematic review. We selected 13 commonly reported adverse events for the meta-analysis. Owing to the possible differences in study samples and design, we used a random model for the analysis. The average age of the patients was 59.5 yr and 79.8% were female. Dry mouth was the most commonly evaluated adverse event reported in 57 studies comprising 15 324 patients; the mean event rate was 4.9% (95% confidence interval [CI] 0.042-0.057, p < 0.001). Constipation was the second most commonly reported adverse event in 49 studies comprising 14 556 patients; the mean event rate of constipation was 2.6% (95% CI 0.022-0.031, p < 0.001). The event rate of headache was evaluated in 33 studies comprising 10 202 patients, with a mean event rate of 3.1% (95% CI 0.026-0.037, p < 0.001).

CONCLUSIONS

Dry mouth, constipation, headache, and nasopharyngitis were the most prevalent events in the included studies. The nocebo response plays a statistically significant role in causing and/or facilitating adverse events. Health care providers should have a better understanding of the positive and negative expectations associated with therapies to achieve the best possible outcomes for each individual patient. Finally, identification of the real effect of nocebo requires studies that also include a no-treatment arm. Research could help us better understand and potentially modify the nocebo response.

PATIENT SUMMARY

In this meta-analysis of 57 studies comprising 15 446 patients, we reviewed the adverse events extracted from the placebo arms of randomized controlled trials studying therapies for overactive bladder. Dry mouth, constipation, headache, and urinary tract infection were the most common adverse events. Adverse events varied based on the drug type and the route of administration. Negative expectations from the therapy and giving verbal information to the patient can cause/alleviate adverse events.

Gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic drugs for overactive bladder treatment

Introduction: Overactive bladder (OAB) has a heterogeneous presentation that varies between individuals and by gender. Treatment with antimuscarinic medications is standard first line pharmacotherapy for most patients with OAB. However, gender specific differences in the pharmacokinetics and pharmacodynamics of antimuscarinic therapy are often overlooked and not discussed.Areas covered: This review will explore differences by gender between the presentation and treatment of OAB. We will discuss the differences between sexes in terms of lower urinary tract anatomy, muscarinic receptors, and hormone variation. The effect of antimuscarinics on males and females as well as adherence and persistence patterns will be reviewed in order to fully review all available literature on the gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic use in the treatment of OAB.Expert opinion: Despite extensive research into various antimuscarinic formulations and therapeutic regimens for the treatment of OAB, identification of gender specific pharmacokinetic and pharmacodynamics considerations remains scant. As our knowledge and understanding of OAB, muscarinic receptors, and antimuscarinic medications evolve, we will hopefully be better able to understand and implement gender-specific and genomic-sprecific treatment regimens and considerations for improved clinical outcomes.

Treatment of Concomitant OAB and BPH

The etiology of men's lower urinary tract storage and voiding symptoms involves a contribution from both detrusor and outlet. As such, treatment of benign prostatic enlargement (BPE) ± benign prostatic obstruction (BPO) with standard alpha-adrenergic blockade and 5-alpha reductase inhibitor therapy may leave a population of men with persistent and bothersome urinary storage symptoms. An abundance of adequately powered, randomized, placebo-controlled trials indicate that the use of antimuscarinics and beta-3 adrenergic agonists, either alone or in combination with standard BPE/BPO therapy, leads to improvement in storage symptoms. At the same time, metrics associated with urinary emptying, such as maximum flow rate, post-void residual urinary volume, and incidence of treatment-associated urinary retention, appear to be stable and not significantly impacted by the addition of antimuscarinics.

Korean clinical practice guideline for benign prostatic hyperplasia

In 2014, the Korean Urological Association organized the Benign Prostatic Hyperplasia Guideline Developing Committee composed of experts in the field of benign prostatic hyperplasia (BPH) with the participation of the Korean Academy of Family Medicine and the Korean Continence Society to develop a Korean clinical practice guideline for BPH. The purpose of this clinical practice guideline is to provide current and comprehensive recommendations for the evaluation and treatment of BPH. The committee developed the guideline mainly by adapting existing guidelines and partially by using the de novo method. A comprehensive literature review was carried out primarily from 2009 to 2013 by using medical search engines including data from Korea. Based on the published evidence, recommendations were synthesized, and the level of evidence of the recommendations was determined by using methods adapted from the 2011 Oxford Centre for Evidence-Based Medicine. Meta-analysis was done for one key question and four recommendations. A draft guideline was reviewed by expert peer reviewers and discussed at an expert consensus meeting until final agreement was achieved. This evidence-based guideline for BPH provides recommendations to primary practitioners and urologists for the diagnosis and treatment of BPH in men older than 40 years.

Update on medical therapy for male LUTS

The medical management of lower urinary tract symptoms (LUTS) is aimed at addressing voiding and storage symptoms in patients with benign prostate hyperplasia (BPH) symptoms with or without an over-active bladder (OAB). Current available options for BPH include alpha-blockers, 5-alpha reductase inhibitors and phosphodiesterase type 5 inhibitors. For OAB, options include antimuscarinics, with or without an alpha-blocker, the beta-3-adrenergic agonist mirabegron and the synthetic diuretic desmopressin. With the availability of numerous options and combinations available for the treatment of LUTS, individual patient assessment is the key to optimal symptom control and management of adverse effects.

Autonomic nervous control of the urinary bladder

The autonomic nervous system plays an important role in the regulation of the urinary bladder function. Under physiological circumstances, noradrenaline, acting mainly on β(3) -adrenoceptors in the detrusor and on α(1) (A) -adrenoceptors in the bladder outflow tract, promotes urine storage, whereas neuronally released acetylcholine acting mainly on M(3) receptors promotes bladder emptying. Under pathophysiological conditions, however, this system may change in several ways. Firstly, there may be plasticity at the levels of innervation and receptor expression and function. Secondly, non-neuronal acetylcholine synthesis and release from the urothelium may occur during the storage phase, leading to a concomitant exposure of detrusor smooth muscle, urothelium and afferent nerves to acetylcholine and noradrenaline. This can cause interactions between the adrenergic and cholinergic system, which have been studied mostly at the post-junctional smooth muscle level until now. The implications of such plasticity are being discussed.

Pharmacokinetics and toxicity of antimuscarinic drugs for overactive bladder treatment in females

INTRODUCTION

Antimuscarinics (AMs) are the mainstay of pharmacological treatment of overactive bladder (OAB), a symptom complex defined by the presence of urinary urgency, usually associated with frequency and nocturia, with or without urgency urinary incontinence. The AMs used to treat OAB differ in their pharmacological profiles, which may affect their potential for causing adverse effects (AEs).

AREAS COVERED

The present article aims to review the literature about pharmacokinetics (PK) of the different AMs used in the treatment of OAB. Furthermore, the AEs related to the use of these drugs and their incidence are presented. This systematic review is based on material searched and obtained via Medline, Pubmed and EMBASE up to March 2012 using the search terms "adverse events, pharmacokinetics, tolerability" in combination with "darifenacin, fesoterodine, imidafenacin, oxybutynin, propiverine, solifenacin, tolterodine, and trospium."

EXPERT OPINION

Antimuscarinics are the first-line pharmacological treatment for OAB. Despite the development of new molecules that improve their efficacy/safety profile, there are some drugs that are pharmacokinetically more appropriate to be prescribed in specific populations such as patients with neurological disease or the elderly. Moreover, research should be encouraged in evaluating antimuscarinics in conjunction with other drugs such as estrogens or beta-agonists. The identification of prognostic criteria for pharmacological therapy would be helpful.

Efficacy of propiverine ER with or without α-blockers related to maximum urinary flow rate in adult men with OAB: results of a 12-week, multicenter, non-interventional study

Purpose

Comparison of efficacy of propiverine extended release (ER) 30 mg o.d. in the treatment of male OAB administered as monotherapy (MT) or add-on to α-blockers (combination treatment, CT) in relation to maximum urinary flow (Q_max) in a non-interventional study.

Methods

Men ≥40 years with OAB symptoms, Q_max ≥10 ml/s, prostate volume <40 ml, post-void residuals (PVR) <100 ml, and IPSS <20 were included. OAB symptoms, IPSS, and PVR were recorded before and after 12 weeks of treatment. Participants were stratified by Q_max (group A ≥15 ml/s, group B <15 ml/s) and CT vs. MT. Safety parameters were monitored.

Results

A total of 2,219 men participated and were involved in safety analysis; 1,849 men (mean age 66 years) fulfilled the inclusion criteria and were involved in efficacy analysis. In group A, 291 men received MT and 479 CT; in group B, 184 men received MT and 895 CT. OAB symptoms improved significantly in all groups throughout the study without differences between MT and CT. IPSS improvement in group B was less with MT than with CT (−3.9 vs. −5.2; P < 0.001), whereas IPSS improvement was similar in group A (−4.6 vs. −5.1). Mean PVR change was not clinically relevant, but two men (0.1%) experienced urinary retention.

Conclusions

Under real-life conditions, treatment of OAB symptoms with propiverine ER is equally effective in men with MT or CT regardless of baseline Q_max. In men with reduced Q_max, IPSS improvement is significantly smaller with MT. The incidence of urinary retention during propiverine ER treatment is low.

Differences in efficacy and safety of pharmaceutical treatments between men and women: an umbrella review

Being male or female is an important determinant of risks for certain diseases, patterns of illness and life expectancy. Although differences in risks for and prognoses of several diseases have been well documented, sex-based differences in responses to pharmaceutical treatments and accompanying risks of adverse events are less clear. The objective of this umbrella review was to determine whether clinically relevant differences in efficacy and safety of commonly prescribed medications exist between men and women. We retrieved all available systematic reviews of the Oregon Drug Effectiveness Review Project published before January 2010. Two persons independently reviewed each report to identify relevant studies. We dually abstracted data from the original publications into standardized forms. We synthesized the available evidence for each drug class and rated its quality applying the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Findings, based on 59 studies and data of more than 250,000 patients suggested that for the majority of drugs no substantial differences in efficacy and safety exist between men and women. Some clinically important exceptions, however, were apparent: women experienced substantially lower response rates with newer antiemetics than men (45% vs. 58%; relative risk 1.49, 95% confidence interval 1.35–1.64); men had higher rates of sexual dysfunction than women while on paroxetine for major depressive disorder; women discontinued lovastatin more frequently than men because of adverse events. Overall, for the majority of drugs sex does not appear to be a factor that has to be taken into consideration when choosing a drug treatment. The available body of evidence, however, was limited in quality and quantity, confining the range and certainty of our conclusions.

Solifenacin treatment in men with overactive bladder: effects on symptoms and patient-reported outcomes

OBJECTIVE

In the few studies to evaluate antimuscarinics for overactive bladder (OAB) in men, safety has been the primary focus. In OAB efficacy trials, subject populations have been predominantly female and patient-reported outcomes (PROs) have been assessed only recently. We present a post hoc analysis of PRO-based findings from the subset of men (without presumed bladder outlet obstruction [BOO]) from two large, independent, open-label trials of solifenacin.

METHODS

Subjects with OAB for > or =3 months received flexibly dosed solifenacin for 12 weeks. At baseline and 4-week intervals, subjects completed the Patient Perception of Bladder Condition (PPBC) and Overactive Bladder Questionnaire (OAB-q). In one study, subjects also completed 3-day bladder diaries. At baseline, mean PPBC scores were similar in both studies and indicative of moderate-to-severe problems.

RESULTS

After 12 weeks of solifenacin, mean PPBC scores improved significantly (p < 0.0001); values were suggestive of minor-to-moderate problems. Mean scores on the OAB-q were also significantly improved after solifenacin (p values < or =0.001). In men without presumed BOO, solifenacin significantly improved PRO measures of symptom bother, health-related quality of life, and overall perception of bladder problems.

CONCLUSION

Results from these two studies support the use of solifenacin as a well-tolerated and efficacious treatment option for providing symptom relief in men with OAB without BOO.

Role of fesoterodine in the treatment of overactive bladder

Muscarinic receptors have long been the target receptors for treatment of patients with overactive bladder (OAB). These patients experience symptoms of urgency, urinary frequency and nocturia, with or without urge incontinence (the involuntary leakage of urine associated with urge). Fesoterodine, a pro-drug, structurally and functionally related to tolterodine, is the newest agent developed for the treatment of OAB. Fesoterodine is broken down to the active metabolite, 5-hydroxy-methyl-tolterodine (5-HMT) by non-specific esterases. This metabolism results in the complete breakdown of the parent compound and is responsible for dose related improvements in clinical efficacy and health related quality of life. Like other antimuscarinic agents including tolterodine, fesoterodine is associated with improvements in clinical variables related both to bladder filling (decreasing micturition frequency and increasing mean voided volume) and urgency (urgency and urge incontinence episodes). Improvements in health related quality of life following treatment with fesoterodine is indicated by improvements in 7 of the 9 variables measured by the King’s Health Questionnaire. Also like other antimuscarinic agents, fesoterodine use is associated with adverse events including dry mouth. However the incidence of dry mouth is reduced with fesoterodine, compared to oxybutynin, due to the improved bladder selectivity of 5-HMT.

Basic mechanisms of urgency: roles and benefits of pharmacotherapy

INTRODUCTION

Since urgency is key to the overactive bladder syndrome, we have reviewed the mechanisms underlying how bladder filling and urgency are sensed, what causes urgency and how this relates to medical therapy.

MATERIALS AND METHODS

Review of published literature.

RESULTS

As urgency can only be assessed in cognitively intact humans, mechanistic studies of urgency often rely on proxy or surrogate parameters, such as detrusor overactivity, but these may not necessarily be reliable. There is an increasing evidence base to suggest that the sensation of ‘urgency’ differs from the normal physiological urge to void upon bladder filling. While the relative roles of alterations in afferent processes, central nervous processing, efferent mechanisms and in intrinsic bladder smooth muscle function remain unclear, and not necessarily mutually exclusive, several lines of evidence support an important role for the latter.

CONCLUSIONS

A better understanding of urgency and its causes may help to develop more effective treatments for voiding dysfunction.

Efficacy and tolerability of fesoterodine in men with overactive bladder: a pooled analysis of 2 phase III studies

OBJECTIVES

To assess the efficacy, safety, and tolerability of fesoterodine 4 and 8 mg in men with overactive bladder.

METHODS

This was a subanalysis of pooled data from 358 men enrolled in 2 double-blind, placebo-controlled phase III trials. Subjects with frequency and urgency or urgency urinary incontinence (UUI) were randomized to fesoterodine 4 mg, fesoterodine 8 mg, or placebo for 12 weeks. Efficacy endpoints included bladder diary variables and subject-reported treatment response.

RESULTS

By week 12, men treated with fesoterodine 4 or 8 mg had significantly greater median percentage improvements in micturition frequency, urgency episodes, and UUI episodes versus placebo and significantly greater percentages reported a treatment response versus placebo. Significant increases in mean voided volume (MVV) per micturition versus placebo occurred with fesoterodine 8 mg only. At week 12, fesoterodine 8 mg was significantly more efficacious than fesoterodine 4 mg in improving UUI episodes and MVV per micturition. The most commonly reported adverse events with fesoterodine 4 and 8 mg were dry mouth (12.5% and 37.7% vs 5.6% with placebo) and constipation (2.5% and 8.8% vs 0.8% with placebo). Symptoms suggestive of urinary retention were reported in 0.8%, 0.8%, and 5.3% of men in the placebo, fesoterodine 4 mg, and fesoterodine 8 mg groups, respectively; only 1 subject, in the fesoterodine 8 mg group, was catheterized.

CONCLUSIONS

Fesoterodine 4 and 8 mg are generally safe, efficacious, and well tolerated for the treatment of overactive bladder symptoms in men. The 8 mg dose provides additional benefit and allows for treatment individualization.

Tolterodine extended-release for overactive bladder

Overactive bladder (OAB) is a common problem. Affected individuals suffer decreased quality of life and productivity. The mainstay of pharmacological treatment of OAB is antimuscarinic agents. Tolterodine was the first antimuscarinic drug designed specifically for treating OAB. Compared with the immediate-release (IR) drug, once-daily tolterodine extended-release (ER) releases the drug in a steady but constant manner lowering peak and trough drug levels. This translates to more constant serum concentrations and theoretically better patient tolerability. The dry mouth rate for the ER formulation has been reported to be lower than for the IR formulation. Recent literature strongly supports the efficacy and safety of tolterodine ER in carefully selected older men with OAB symptoms. Tolterodine ER is well tolerated and withdrawal rates are similar to those in placebo. Fesoterodine is a new antimuscarinic that shares the same active metabolite as tolterodine and may provide less pharmacokinetic variability. We support tolterodine ER for treating for OAB. It has proven efficacy and tolerability.

Effects of tolterodine ER on patient-reported outcomes in sexually active women with overactive bladder and urgency urinary incontinence

OBJECTIVE

To assess the effects of tolterodine extended release (ER) on patient-reported outcomes (PROs) in sexually active women with overactive bladder (OAB) and urgency urinary incontinence (UUI).

RESEARCH DESIGN AND METHODS

This multicenter, double-blind, placebo controlled trial included 411 women aged > or =18 years reporting OAB symptoms for > or =3 months; > or =8 micturitions per 24 hours (including > or =0.6 UUI episodes and > or =3 OAB micturitions) in 5-day bladder diaries at baseline, and being in a sexually active relationship for > or =6 months. Subjects randomized to placebo or tolterodine ER completed validated OAB- or incontinence-specific questionnaires, including the Patient Perception of Bladder Condition (PPBC), Overactive Bladder Questionnaire (OAB-q), Urgency Perception Scale (UPS), and the Incontinence Impact Questionnaire (IIQ) at baseline and week 12, as well as the Perception of Treatment Benefit and Treatment Satisfaction questions at week 12. This study is registered with ClinicalTrials.Gov (identifier: NCT00143481).

RESULTS

The mean age of enrolled women was approximately 48 years. Compared with placebo, the tolterodine ER group reported significant baseline to week 12 improvements in PPBC responses (p = 0.0048); OAB-q Symptom Bother, total Health-Related Quality of Life (HRQL), and HRQL domain scores (all p < 0.05); IIQ Emotional Health domain scores (p < 0.05); proportions of subjects reporting treatment benefit (79 vs. 54%; p < 0.0001) and satisfaction (78 vs. 59%; p < 0.0001). Improvements on the UPS were not significantly different.

CONCLUSIONS

Tolterodine ER treatment was associated with improvements in multiple OAB- and incontinence-specific PROs in a sexually active, relatively young, and racially diverse population of women. The findings provide clinicians with new insights into the impact of OAB and its treatment on HRQL in this population, which has been underrepresented in previous OAB studies. Study limitations include a potential underestimation of the impact of OAB symptoms resulting from the exclusion of women who may not be sexually active because of their urinary symptoms.

Cizolirtine citrate is safe and effective for treating urinary incontinence secondary to overactive bladder: a phase 2 proof-of-concept study

BACKGROUND

Antimuscarinic agents currently dominate medical treatment for urinary incontinence secondary to overactive bladder (OAB). Alternatives to improve their risk-benefit ratio are welcomed.

OBJECTIVE

To demonstrate the efficacy and safety of oral cizolirtine citrate in this indication.

DESIGN, SETTING, AND PARTICIPANTS

A randomised, double-blind, placebo- and active-controlled, phase 2 multicentre clinical trial performed by urologists or gynaecologists at referral centres. A sample was composed of 135 outpatients with signs of lower urinary tract dysfunction and urodynamically documented detrusor overactivity; 20 patients left the study prematurely, chiefly (n=10) because of adverse events.

INTERVENTION

Allocation to treatments was asymmetrical (2:2:1) to cizolirtine citrate 800 mg/d, placebo, or oxybutynin 15 mg/d. Treatments were given for 12 wk.

MEASUREMENTS

Efficacy measures included a bladder diary, filling- and voiding-phase urodynamic evaluations, and measure of quality of life (QoL). Adverse events were systematically recorded. Statistical procedures included analysis of covariance, chi(2) tests, and calculation of 95% confidence intervals.

RESULTS AND LIMITATIONS

Most patients (92.6%) were female, and their mean age was 51.8 yr. Bladder diary variables improved significantly with active drug over placebo: The average number of voidings per 24 h was reduced by 33.4%, 17.0%, and 34.3% (p=0.001) in the cizolirtine citrate, placebo, and oxybutynin groups, respectively. The mean estimated voided volume per voluntary micturition increased by 17.8%, 0%, and 14.5% (p=0.002) in the cizolirtine citrate, placebo, and oxybutynin groups, respectively. The proportions of patients achieving fewer than eight voidings per 24 h, complete dryness, or both were also superior with active drugs over placebo. Only cizolirtine showed significant superiority over placebo to improve urodynamic parameters, although the asymmetrical allocation played against oxybutynin in the inferences. Cizolirtine citrate caused fewer antimuscarinic but more gastrointestinal (nausea) and neurologic (headache and vertigo) adverse events than oxybutynin.

CONCLUSIONS

Cizolirtine citrate is a promising agent in the treatment of OAB with urinary incontinence.

[Treatment of LUTS in BPS. When and when not to administer pills?]

Benign prostatic syndrome (BPS) is considered a diagnosis of exclusion and needs a thorough work-up. One of the pitfalls for a tailored medical treatment scheme is the objective evaluation of benign prostatic obstruction. Characteristics of the various medical therapy options and the multifactorial origin of LUTS in BPH patients imply an individualized approach. LUTS involving mostly urine storage disorders and a small prostate are suitably managed with alpha(1)-receptor antagonists, which may be combined with antimuscarinics if OAB symptoms predominate. Long-term treatment addressing clinical progression may favor combination therapy of alpha(1)-receptor antagonists with 5alpha-reductase inhibitors if prostate size is sufficient. Age, symptom severity at baseline, a large prostate volume, or a high PSA value are indicative of progression. However, combination therapy aggravates side effects, and thus a risk-benefit analysis is essential. The potential of any medication for BPS to treat obstruction is rather low. If deobstruction is the main aim of therapy, medical treatment is not suitable.

Efficacy of tolterodine on overactive bladder symptoms and sexual and emotional quality of life in sexually active women

We evaluated overactive bladder (OAB) symptoms and sexual and emotional health in sexually active women with OAB/urgency urinary incontinence (UUI) treated with tolterodine extended release (ER). Sexually active women with OAB symptoms were randomized to placebo or tolterodine ER. Five-day bladder diaries, Sexual Quality of Life Questionnaire-Female (SQOL-F), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ), and Hospital Anxiety and Depression Scale (HAD) were completed at baseline and week 12. Tolterodine ER (n = 201; mean +/- SD age, 49 +/- 12 years) reduced UUI episodes (P = 0.0029), total (P = 0.0006) and OAB (P < 0.0001) micturitions, and pad use per 24 h (P = 0.0024), and was associated with improvements in SQOL-F (P = 0.004), PISQ total (P = 0.009), and HAD Anxiety (P = 0.03) scores versus placebo (n = 210; mean +/- SD age, 47 +/- 12 years). OAB symptoms improved with tolterodine ER as did the scores of sexual health and anxiety measures in sexually active women with OAB.

Extended-release tolterodine with or without tamsulosin in men with lower urinary tract symptoms and overactive bladder: effects on urinary symptoms assessed by the International Prostate Symptom Score

OBJECTIVE

To evaluate the efficacy of tolterodine extended-release (ER) plus tamsulosin on lower urinary tract symptoms (LUTS) as assessed by changes in the International Prostate Symptom Score (IPSS) in men who met symptom entry criteria for both overactive bladder (OAB) and benign prostatic hyperplasia (BPH) trials.

PATIENTS AND METHODS

Men aged > or =40 years with an IPSS of > or =12 and diary-documented OAB symptoms (> or =8 voids/24 h and > or =3 urgency episodes/24 h, with or without urgency urinary incontinence) who reported at least moderate problems related to their bladder condition were randomized to receive placebo, tolterodine ER (4 mg), tamsulosin (0.4 mg), or tolterodine ER (4 mg) + tamsulosin (0.4 mg) once daily for 12 weeks. Patients completed the IPSS at baseline and at 1, 6 and 12 weeks.

RESULTS

Patients receiving tolterodine ER + tamsulosin had significantly greater improvements than those taking placebo on IPSS storage subscale scores and scores for all three individual storage items included on the IPSS (urinary frequency, urgency, and nocturnal micturitions) by 12 weeks. Storage subscale and urgency scores were significantly improved vs placebo at 1 and 6 weeks, whereas frequency scores were significantly improved at 6 weeks. Changes in IPSS storage subscale and individual storage item scores in the tolterodine ER and tamsulosin monotherapy groups were not significantly different from placebo at most time points. IPSS voiding subscale scores and scores for three of four individual voiding items (sensation of incomplete emptying, intermittency, and weak stream) were significantly improved by 12 weeks for patients receiving tamsulosin monotherapy vs placebo. Voiding subscale and intermittency scores were significantly improved vs placebo at 1 week; weak stream scores were significantly improved at 1 and 6 weeks. The IPSS voiding subscale and individual voiding item scores in the tolterodine ER + tamsulosin and tolterodine ER groups were not significantly different from placebo at most time points.

CONCLUSIONS

In this distinct clinical research population of men who met traditional symptom entry criteria for both OAB and BPH trials, tolterodine ER + tamsulosin was significantly more effective than placebo in treating storage LUTS, including OAB symptoms. Tamsulosin monotherapy produced significant improvements in voiding LUTS.

Tolterodine for the treatment of overactive bladder

BACKGROUND

The overactive bladder syndrome is a common condition affecting approximately 12% of men and women. It is extremely disturbing with a great impact on quality of life. Its treatment involves a combination of behavioural and pharmacological therapy. The latter includes antimuscarinic drugs such as tolterodine.

OBJECTIVE

To review the safety and efficacy of tolterodine in the treatment of overactive bladder in comparison with other available antimuscarinic agents.

METHODS

A Pubmed search was carried out differentiating randomised, clinical trials; longitudinal, retrospective studies; and metanalysis on the use of tolterodine for overactive bladder treatment. In the comparison with other antimuscarinic agents, only randomised, clinical trials were considered.

RESULTS/CONCLUSION

Tolterodine is available as immediate- or extended-release formulations. It has been extensively evaluated with long-term, randomised trials for safety and efficacy showing a significant improvement in overactive bladder symptoms with an excellent tolerability profile.

Effects of oxybutynin transdermal system on health-related quality of life and safety in men with overactive bladder and prostate conditions

AIMS

Overactive bladder (OAB) is common in men and may exist concomitantly with benign prostatic hyperplasia (BPH) and obstruction. We present a subanalysis of results from men with OAB in a 6-month, open-label study of treatment with the oxybutynin transdermal system (OXY-TDS). Broad entry criteria were incorporated to yield a clinically representative population.

METHODS

All participants received OXY-TDS 3.9 mg/day. Effectiveness was assessed by changes in scores on validated questionnaires, which included the single-item Patient Perception of Bladder Condition (PPBC), the King's Health Questionnaire (KHQ) and the Beck Depression Inventory-II (BDI-II).

RESULTS

The proportion of men (n=369; mean age=69.6 years) who reported that their bladder condition caused moderate, severe or many severe problems (PPBC>or=4) improved from 77.3% at baseline to 38.1-53.6% in subsequent months. Mean KHQ scores decreased significantly (p<or=0.0196) from baseline to study end in eight of 10 domains, indicating improved health-related quality of life. The proportion of men with BDI-II score>12 (associated with a diagnosis of depression) decreased from 23.9% to 17.9% (p=0.0055). Men with a history of 'prostate problems' or use of 'BPH medication' (32.2%) had KHQ domain changes that were similar (p>or=0.1016) to those of other men. Most men (76.2%) reported no treatment-related adverse events; two men (0.5%) experienced symptoms of mild urinary retention, but neither required catheterisation.

CONCLUSIONS

Oxybutynin transdermal system treatment of men with OAB was effective and well tolerated, regardless of history of prostate condition.

Overactive bladder: an update

PURPOSE OF REVIEW

Overactive bladder is an important lower urinary tract syndrome that negatively affects the quality of life of millions of people worldwide. Both sexes and all age groups may be affected; therefore many specialists, including urologists, gynaecologists, geriatricians, paediatricians, physiotherapists and continence advisors, are involved in the management of patients with overactive bladder.

RECENT FINDINGS

There is ongoing research, both basic science and clinical trials, to establish the cause of overactive bladder and to determine the best method of managing patients who suffer from this syndrome. New theories and modified definitions of overactive bladder have been proposed, structured evidence-based management guidelines have been established, more prevalence studies have been conducted and new treatment strategies have emerged.

SUMMARY

Overactive bladder is now recognized as a chronic debilitating condition that costs millions of dollars. With an ageing population these costs will increase, and it is necessary that health systems around the world recognize this. Further research into the basic science of the condition is required to identify the true cause of overactive bladder, allowing new targeted treatments to be established.