Extracorporeal Magnetic Stimulation is of Limited Clinical Benefit to Women with Idiopathic Detrusor Overactivity: A Randomized Sham Controlled Trial

The Impact of Extracorporeal Magnetic Stimulation as Addition to Mirabegron in Overactive Bladder Treatment in Women: A Single-Centre Randomized Sham-Controlled Study

(1) Background: The purpose of our prospective, single-blinded, randomized, sham-controlled study was to investigate the effect of the additional extracorporeal magnetic stimulation (ExMI) to pharmacological treatment in overactive bladder syndrome (OAB) in women. (2) Methods: We recruited 56 women with OAB, who were allocated into two study groups: the active group received mirabegron 50 mg daily and a total of 16 sessions of ExMI in 8 weeks, whereas the sham group received mirabegron 50 mg daily and sham stimulation following the same treatment protocol. Treatment success was evaluated after 4 and 8 weeks. (3) Results: Both groups experienced significant reduction in daytime urinary frequency, nocturia, and number of weekly incontinence episodes after 8 weeks. There were no statistically significant differences in end-point daytime urinary frequency and nocturia between groups. However, the overall average reduction rate in weekly number of incontinence episodes was 43.7% in treatment group and 24.2% in the control group. The number of urinary incontinence episodes in the treatment and control group was reduced for 3.8 ± 11.8 vs. 2.5 ± 4.3 episodes at week 4 and additional 3.3 ± 6 vs. 0.4 ± 3.2 episodes at week 8, respectively (p = 0.013). Moreover, IIQ-7 score showed a significantly greater score reduction and patients' evaluated improvement of symptoms was higher in the active group. (4) Conclusions: The addition of ExMI to mirabegron in OAB treatment further improves the weekly incontinence episode reduction rate and also leads to grater improvement in symptoms.

Physical Agent-Based Treatments for Overactive Bladder: A Review

Almost one-fifth of the people in the world experience a decrease in quality of life due to overactive bladder (OAB) syndrome. The main bothersome symptoms are urgency accompanied by urinary frequency and nocturia. This chronic, disabling condition is first managed by reducing fluid intake and pelvic floor muscle training, supplemented with antimuscarinic drugs, if necessary. However, refractory cases often still occur. In more severe cases, invasive surgical interventions can be considered; yet, the success rate is still inconsistent, and there is a high complication rate. This condition is frustrating for patients and challenging for the medical staff involved. Although its pathophysiology has not been fully elucidated, peripheral autonomic somatic and sensory afferent receptors are considered to be involved in this condition. Hence, currently, physical agent-based treatments such as neuromodulation have taken a significant place in the third-line therapy of OAB. The efficacy and safety profiles of electrical and magnetic stimulation continue to evolve. Physical-based agents provide an appealing option owing to their effectiveness and minimal side effects. In addition, more physical therapies using light and shock energy are currently being investigated. Thus, a comprehensive understanding of these modalities is an extremely important aspect to provide the most suitable modalities for patients.

Short-term effect of magnetic stimulation added to bladder training in women with idiopathic overactive bladder: A prospective randomized controlled trial

OBJECTIVE

To evaluate the efficacy of magnetic stimulation (MStim) added to bladder training (BT) on incontinence-related quality of life (QoL) and clinical parameters in women with idiopathic overactive bladder (OAB).

MATERIAL AND METHODS

Seventy-six women with idiopathic OAB were randomized into two groups using the random numbers generator as follows: Group 1 received BT alone (n: 38), and Group 2 received BT + MStim (n: 38). MStim was performed with MStim therapy armchair (Novamag NT60), 2 days a week, 20 min a day, a total of 12 sessions for 6 weeks. Women were evaluated in terms of incontinence severity (24-h pad test), 3-day voiding diary (frequency of voiding, incontinence episodes, nocturia, and number of pads), symptom severity (OAB-V8), QoL (IIQ-7), positive response and cure-improvement rates, and treatment satisfaction (Likert scale) at the baseline and the end of treatment (sixth week).

RESULTS

A statistically significant improvement was found in incontinence severity, frequency of voiding, incontinence episodes, nocturia, number of pads, symptom severity, and QoL parameters for two groups at the end of the treatment compared to the baseline values (p < 0.05). At the end of treatment; incontinence severity, incontinence episodes, nocturia, number of pads, symptom severity, and QoL were significantly improved in Group 2 compared to Group 1 (p < 0.05). No difference was found between the two groups in terms of frequency of voiding (p > 0.05). The positive response and cure-improvement rates, and treatment satisfaction were significantly higher in Group 2 than in Group 1 (p < 0.05).

CONCLUSION

MStim added to BT is more effective than BT alone in women with idiopathic OAB.

Urinary Incontinence in Women: Modern Methods of Physiotherapy as a Support for Surgical Treatment or Independent Therapy

Urinary incontinence (UI) is a common health problem affecting quality of life of nearly 420 million people, both women and men. Pelvic floor muscle (PFM) training and other physiotherapy techniques play an important role in non-surgical UI treatment, but their therapeutic effectiveness is limited to slight or moderate severity of UI. Higher UI severity requires surgical procedures with pre- and post-operative physiotherapy. Given that nearly 30%–40% of women without dysfunction and about 70% with pelvic floor dysfunction are unable to perform a correct PFM contraction, therefore, it is particularly important to implement physiotherapeutic techniques aimed at early activation of PFM. Presently, UI physiotherapy focuses primarily on PFM therapy and its proper cooperation with synergistic muscles, the respiratory diaphragm, and correction of improper everyday habits for better pelvic organ support and continence. The purpose of this work is a systematic review showing the possibilities of using physiotherapeutic techniques in the treatment of UI in women with attention to the techniques of PFM activation. Evidence of the effectiveness of well-known (e.g., PFM training, biofeedback, and electrostimulation) and less-known (e.g., magnetostimulation, vibration training) techniques will be presented here regarding the treatment of symptoms of urinary incontinence in women.

The effectiveness of magnetic stimulation for patients with pelvic floor dysfunction: A systematic review and meta-analysis

AIMS

To evaluate the value of magnetic stimulation (MS) in patients with pelvic floor dysfunction (PFD).

METHODS

The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement was followed. We searched five databases for articles published until November 2017. Included studies investigated the effects of MS on PFD. Meta-analysis of RCTs was performed using a random effects model, and narrative analysis was undertaken where meta-analysis was not possible.

RESULTS

A total of 20 studies including 1019 patients were eligible for inclusion whose level of evidence for the included studies was low. Meta-analysis of four trials comparing MS with sham intervention showed that MS was not associated with significant improvement in ICIQ-SF score (-0.52, 95%CI -1.05, 0.01; P = 0.06, I²  = 16%), QOL score (-0.27, 95%CI -0.57, 0.04; P = 0.09, I²  = 0%), number of leakages (-0.16, 95%CI -0.62, 0.29; P = 0.48, I²  = 52%), and pad test (-1.36, 95%CI -2.64, -0.08; P = 0.04, I²  = 94%). Narrative review showed that there were no convincing evidences that MS was effective for chronic pelvic floor pain, detrusor overactivity, overactive bladder, and the included RCTs had controversial results. MS may have some benefits for nocturnal enuresis and erectile dysfunction according to the trials.

CONCLUSIONS

There is no convinced evidence to support the benefits of using MS in the management of PFD. The applicability of MS in the treatment of PFD remains uncertain, so larger, well-designed trials with longer follow-up periods adopted relevant and comparable outcomes are needed to be further explored to provide a definitive conclusion.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

CONTEXT

The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016.

OBJECTIVE

We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination.

EVIDENCE ACQUISITION

Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria.

EVIDENCE SYNTHESIS

The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/.

CONCLUSIONS

These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances.

PATIENT SUMMARY

Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

Is there any Relationship Between Bladder Trabeculation and Efficacy and Safety of Intravesical Botulinum Toxin A Injection in Refractory Idiopathic Overactive Bladder Women?

Background:

Intradetrusor injection of botulinum toxin A (BTX-A) might serve as a minimally invasive substitute in patients with refractory idiopathic overactive bladder (RIOAB). The aim of this study was to evaluate the clinical outcomes related to two different doses of abo-BTX-A (AboBTX-A) in patients with RIOAB.

Materials and Methods:

This prospective clinical trial was performed on 55 women with RIOAB. After determination of trabeculation grade, 300 (no or mild) or 500 (moderate or severe) unit of AboBTX-A (Dysport) was intravesicaly injected. Before 1, 3, and 6 months after intervention, lower urinary tract symptoms during 24 h were recorded.

Results:

Of the study population, 62% had severe bladder trabeculation. The mean duration of overactive bladder (OAB) was 1.76 versus 5.85 years, for no or mild versus severe trabeculation, respectively. After injections of 300- and 500-unit dosage, there were 19% and 26% early complications such as urinary retention. There was a statistically significant difference between the two groups in OAB score after 1 month (P < 0.001) and duration of OAB symptoms, over three follow-up times (P < 0.001). The mean preinjection OAB scores between patients with and without recurrence were statistically significant (29.36 vs. 25.07; P < 0.03). Urinary tract infection as a late complication was distinguished in four patients.

Conclusion:

In RIOAB, by adjusted dosage of AboBTX-A related to the grade of bladder trabeculation, in addition to maintain efficacy, consequent complications might not be affected by dosage and the drug dosage could be increased to nearly 60% with less concern associated to complication

Nonantimuscarinic treatment for overactive bladder: a systematic review

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.

Clinical Guideline for Female Lower Urinary Tract Symptoms

The "Japanese Clinical Guideline for Female Lower Urinary Tract Symptoms," published in Japan in November 2013, contains two algorithms (a primary and a specialized treatment algorithm) that are novel worldwide as they cover female lower urinary tract symptoms other than urinary incontinence. For primary treatment, necessary types of evaluation include querying the patient regarding symptoms and medical history, examining physical findings, and performing urinalysis. The types of evaluations that should be performed for select cases include evaluation with symptom/quality of life (QOL) questionnaires, urination records, residual urine measurement, urine cytology, urine culture, serum creatinine measurement, and ultrasonography. If the main symptoms are voiding/post-voiding, specialized treatment should be considered because multiple conditions may be involved. When storage difficulties are the main symptoms, the patient should be assessed using the primary algorithm. When conditions such as overactive bladder or stress incontinence are diagnosed and treatment is administered, but sufficient improvement is not achieved, the specialized algorithm should be considered. In case of specialized treatment, physiological re-evaluation, urinary tract/pelvic imaging evaluation, and urodynamic testing are conducted for conditions such as refractory overactive bladder and stress incontinence. There are two causes of voiding/post-voiding symptoms: lower urinary tract obstruction and detrusor underactivity. Lower urinary tract obstruction caused by pelvic organ prolapse may be improved by surgery.

[European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence]

CONTEXT

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

OBJECTIVE

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

EAU guidelines on surgical treatment of urinary incontinence

CONTEXT

The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology.

OBJECTIVE

We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.

Pelvic floor muscle training for urgency urinary incontinence in women: a systematic review

The objective of this study is to evaluate the effectiveness of existing physiotherapy modalities for the treatment of urge urinary incontinence (UUI). A systematic review was performed for primary studies of physiotherapy techniques for UUI published in English between 1996 and August 2010 in major electronic databases. Only randomized clinical trials that reported outcomes separately for women with UUI were included. Outcomes assessed were reduction in UUI, urinary frequency, and nocturia. Data from 13 full-text trials including the modalities of pelvic floor muscles exercises with or without biofeedback, vaginal electrical stimulation, magnetic stimulation, and vaginal cones were analyzed. The methodologic quality of these trials was fair. Significant improvement in UUI was reported for all physiotherapy techniques except vaginal cone therapy. There are insufficient data to determine if pelvic physiotherapy improves urinary frequency or nocturia. Evidence suggests that physiotherapy techniques may be beneficial for the treatment of UUI.

Comparison of different treatment protocols in the treatment of idiopathic detrusor overactivity: a randomized controlled trial

Objective: To investigate and compare the effectiveness of various treatment protocols for the treatment of women with idiopathic detrusor overactivity.

Design: Prospective, randomized controlled trial.

Setting: Departments of Physiotherapy and Rehabilitation and Obstetrics and Gynaecology, Hacettepe University.

Subjects: Forty-six subjects were randomized to three groups.

Interventions: The first group received only pharmacotherapy, the second group received only physiotherapy and in the third group pharmacotherapy was combined with physiotherapy (combined therapy group).

Main measures: All patients were evaluated at the beginning and at the end of treatment. Assessment parameters were maximum cystometric capacity, electromyographic activity of pelvic floor muscles, voiding diary parameters, the amount of urine leakage and the quality of life score.

Results: The maximum cystometric capacity and the electromyographic activity of pelvic floor muscles increased significantly and the number of voids/day and incontinence episodes/day, and the amount of urine leakage reduced significantly ( P < 0.05) in both physiotherapy and combined therapy groups while there was no significant difference in the pharmacotherapy group. After treatment, the number of voids/day increased by 0.3 ± 3.4 in the pharmacotherapy group ( P > 0.05) and decreased by 5.1 ± 5.5 and 4.7 ± 5.6 in the physiotherapy and combined therapy groups, respectively ( P < 0.05). Statistically significant improvements were observed in all groups according to the number of voids/night and the quality of life scores at the end of the treatment.

Conclusion: The physiotherapy protocol we introduced in the present study with or without anticholinergic therapy has a substantial positive impact on the treatment of female patients with idiopathic detrusor overactivity.