Pharmacologic Treatment of Male Stress Urinary Incontinence: Systematic Review of the Literature and Levels of Evidence

[Künstliche Harnsphincter zur Behandlung von Stress-Harninkontinenz - eine oft nicht ausgelastete Behandlungsoption in Deutschland]

ABSTRAKT

Harninkontinenz ist in Deutschland weit verbreitet und betrifft Millionen von Frauen und Männern. Vor allem Männer, die postoperativ dauerhaft inkontinent sind, werden hierzulande trotz der ausreichenden Verfügbarkeit chirurgischer Optionen unterbehandelt. Der künstliche Schließmuskel wird seit Jahrzehnten erfolgreich zur Behandlung angeborener und erworbener Stress-Harninkontinenz bei Männern und Frauen sowie neurogener Harninkontinenz eingesetzt und wird in Form neuer Modelle weiterentwickelt. Aufgrund der guten Ergebnisse, Es gilt jetzt als Standardtherapie für Männer mit anhaltender, mittelschwerer bis schwerer Harninkontinenz. Die operationstechnische Technik ist anspruchsvoll, kann aber erlernt werden. Die meisten Komplikationen können in erfahrenen Händen deutlich reduziert werden. Patientenzufriedenheit mit künstlichen Harnsphinctern (AUS) ist hoch und korreliert mit der Kontinenzrate und nicht mit der relativ hohen Revisionsrate, weshalb diese Behandlungsoption in Deutschland zunehmend mehr Patienten mit mittelschwerer bis schwerer Harninkontinenz angeboten werden sollte. Urologen in der allgemeinen Praxis spielen in diesem Zusammenhang eine zentrale Rolle.

Therapeutic potential of muscle growth promoters in a stress urinary incontinence model

Weakness of urinary sphincter and pelvic floor muscles can cause insufficient urethral closure and lead to stress urinary incontinence. Bimagrumab is a novel myostatin inhibitor that blocks activin type II receptors, inducing skeletal muscle hypertrophy and attenuating muscle weakness. β₂-Adrenergic agonists, such as 5-hydroxybenzothiazolone derivative (5-HOB) and clenbuterol, can enhance muscle growth. We hypothesized that promoting muscle growth would increase leak point pressure (LPP) by facilitating muscle recovery in a dual-injury (DI) stress urinary incontinence model. Rats underwent pudendal nerve crush (PNC) followed by vaginal distension (VD). One week after injury, each rat began subcutaneous (0.3 mL/rat) treatment daily in a blinded fashion with either bimagrumab (DI + Bim), clenbuterol (DI + Clen), 5-HOB (DI + 5-HOB), or PBS (DI + PBS). Sham-injured rats underwent sham PNC + VD and received PBS (sham + PBS). After 2 wk of treatment, rats were anesthetized for LPP and external urethral sphincter electromyography recordings. Hindlimb skeletal muscles and pelvic floor muscles were dissected and stained. At the end of 2 wk of treatment, all three treatment groups had a significant increase in body weight and individual muscle weight compared with both sham-treated and sham-injured rats. LPP in DI + Bim rats was significantly higher than LPP of DI + PBS and DI + Clen rats. There were more consistent urethral striated muscle fibers, elastin fibers in the urethra, and pelvic muscle recovery in DI + Bim rats compared with DI + PBS rats. In conclusion, bimagrumab was the most effective for increasing urethral pressure and continence by promoting injured external urethral sphincter and pelvic floor muscle recovery.

Use of Duloxetine for Postprostatectomy Stress Urinary Incontinence: A Systematic Review

CONTEXT

The recommended treatment of postprostatectomy stress urinary incontinence (PPSUI) after failure of pelvic floor muscle training is primarily surgical intervention with a male sling or artificial urinary sphincter. The use of pharmacological therapy in this setting is unlicensed and controversial.

OBJECTIVE

To systematically review the available evidence regarding the efficacy and safety of duloxetine for the treatment of stress urinary incontinence following prostate surgery (radical or endoscopic).

EVIDENCE ACQUISITION

The EMBASE, MEDLINE/PubMed, and Cochrane Central Register of Controlled Trials were searched from inception up until April 17, 2020. All studies evaluating the role of duloxetine in men with PPSUI were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed data extraction. The quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE); Cochrane; and Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I) tools.

EVIDENCE SYNTHESIS

The search yielded 234 studies. After excluding duplicates, 140 titles and abstracts were screened, and eight reports (348 patients) were eligible for inclusion in the final review. Duloxetine was assessed in two scenarios: (1) early use to reduce the time to attain continence and (2) treatment of persistent PPSUI. Most men had mild-to-moderate incontinence at baseline. Overall, duloxetine resulted in a mean dry rate of 58% (25-89%), mean improvement in pad number of 61% (12-100%), and mean improvement in 1-h pad weight of 68% (53-90%) at short-term follow-up (mean 1-9 mo; low to moderate certainty of evidence). However, mean adverse event rates were relatively high, and treatment was discontinued in 38% (low certainty of evidence).

CONCLUSIONS

Duloxetine has demonstrated good short-term cure and/or improvement in treating men with persistent PPSUI, as well as in reducing the time to attain continence. However, a proportion of men discontinue treatment due to adverse events. The overall certainty evidence is moderate to low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for further randomised trials with longer follow-up, utilising consistent outcome reporting measures. Despite these limitations, the findings from this review will aid patient counselling regarding this less invasive treatment option, thereby allowing personalisation of care centred around the values and preferences of individual patients.

PATIENT SUMMARY

Duloxetine has good success rates in the short term, in terms of improving incontinence symptoms in men who have undergone prostate surgery. However, some men experience side effects bad enough to require cessation of treatment. Further studies are needed to determine whether duloxetine maintains its effectiveness in the long term.

A cocktail of growth factors released from a heparin hyaluronic-acid hydrogel promotes the myogenic potential of human urine-derived stem cells in vivo

Traditional cell therapy technology relies on the maximum expansion of primary stem cells in vitro, through multiple passages and potential differentiation protocols, in order to generate the abundance of cells needed prior to transplantation in vivo. Implantation of in vitro over-expanded and pre-differentiated cells typically results in poor cell survival and reduced regeneration capacity for tissue repair in vivo. We hypothesized that implantation of primary stem cells, after a short time culture in vitro (passage number ≤p3), in combination with controlled release of relevant growth factors would improve in vivo cell viability, engraftment and tissue regeneration. The goal of this study was to determine whether the release of myogenic growth factors from a heparin-hyaluronic acid gel (hp-HA gel) could enhance in vivo cell survival, in-growth and myogenic differentiation of human urine-derived stem cells (USC) with a corresponding enhancement in graft vascularization, innervation and regenerative properties. Human USC were obtained from healthy adult donors (n = 6), expanded and then mixed with a hp-HA gel containing sets of growth factors known to enhance myogenesis (IGF1, HGF, PDGF-BB), neurogenesis (NGF, FGF) and angiogenesis (VEGF), or a cocktail with a combination of growth factors. Primary cultured USC (p3) mixed with the hp-HA gel and the various combinations of growth factors, were subcutaneously injected into athymic mice. In vivo cell survival, engraftment and functional differentiation within the host tissue were assessed. The implanted grafts containing USC and the growth factor cocktail showed the greatest number of surviving cells as well as increased numbers of cells that expressed myogenic and endothelial cell markers as compared to other groups 4 weeks after implantation. Moreover, the graft with USC and the growth factor cocktail showed increased numbers of blood vessels and infiltrating neurons. Thus, growth factors released in a controlled manner from an hp-HA gel containing USC efficiently improved in vivo cell survival and supported vascularization and myogenic differentiation within the grafts. This study provides evidence for the use of primary USC and growth factors in a hydrogel as a novel mode of cell therapy for the promotion of myogenic differentiation for the treatment of injured muscle tissue. STATEMENT OF SIGNIFICANCE: Cell therapies are a promising treatment option for neuromuscular dysfunction disorders. However, major limitations in cell retention and engraftment after implantation remain a hindrance to the use of stem cell therapy for the treatment of muscle injuries or diseased tissues. Implanted long-term in vitro cultured cells tend to demonstrate low rates of survival and tissue engraftment, lessened paracrine effects, and poor homing and differentiation. Human USC are an easily obtainable stem cell source that possess stem cell characteristics such as a robust proliferative potential, paracrine effects on neighboring cells, and multi-potential differentiation. In this study, we demonstrated that a combination of primary human USC with a cocktail of growth factors combined in a hyaluronic gel was optimal for cell survival and engraftment, including myogenic differentiation potential of USC, angiogenesis and host nerve fiber recruitment in vivo. The present study also demonstrated that the use of primary urine derived stem cells at early passages, without in vitro pre-differentiation, implanted in a hyaluronic-heparin hydrogel containing a cocktail of growth factors, provided an alternative safe site-specific delivery method for cell therapy.

Controlled release of insulin-like growth factor 1 enhances urethral sphincter function and histological structure in the treatment of female stress urinary incontinence in a rat model

OBJECTIVES

To determine the effects of controlled release of insulin-like growth factor 1 (IGF-1) from alginate-poly-L-ornithine-gelatine (A-PLO-G) microbeads on external urethral sphincter (EUS) tissue regeneration in a rat model of stress urinary incontinence (SUI), as SUI diminishes the quality of life of millions, particularly women who have delivered vaginally, which can injure the urethral sphincter. Despite several well-established treatments for SUI, growth factor therapy might provide an alternative to promote urethral sphincter repair.

MATERIALS AND METHODS

In all, 44 female Sprague-Dawley rats were randomised into four groups: vaginal distension (VD) followed by periurethral injection of IGF-1-A-PLO-G microbeads (VD + IGF-1 microbeads; 1 × 10⁴ microbeads/1 mL normal saline); VD + empty microbeads; VD + saline; or sham-VD + saline (sham).

RESULTS

Urethral function (leak-point pressure, LPP) was significantly lesser 1 week after VD + saline [mean (sem) 23.9 (1.3) cmH₂ O] or VD + empty microbeads [mean (sem) 21.7 (0.8) cmH₂ O) compared to the sham group [mean (sem) 44.4 (3.4) cmH₂ O; P < 0.05), indicating that the microbeads themselves do not create a bulking or obstructive effect in the urethra. The LPP was significantly higher 1 week after VD + IGF-1 microbeads [mean (sem) 28.4 (1.2) cmH₂ O] compared to VD + empty microbeads (P < 0.05), and was not significantly different from the LPP in sham rats, demonstrating an initiation of a reparative effect even at 1 week after VD. Histological analysis showed well-organised skeletal muscle fibres and vascular development in the EUS at 1 week after VD + IGF-1 microbeads, compared to substantial muscle fibre attenuation and disorganisation, and less vascular formation at 1 week after VD + saline or VD + empty microbeads.

CONCLUSION

Periurethral administration of IGF-1-A-PLO-G microbeads facilitates recovery from SUI by promoting skeletal myogenesis and revascularisation. This therapy is promising, but detailed and longer term studies in animal models and humans are needed.

Cell therapy for stress urinary incontinence: Present-day frontiers

Stress urinary incontinence (SUI) significantly diminishes the quality of patients' lives. Currently available surgical and nonsurgical therapies remain far from ideal. At present, advances in cellular technologies have stirred growing interest in the use of autologous cell treatments aimed to regain urinary control. The objective was to conduct a review of the literature and analyse preclinical and clinical studies dedicated to various cell therapies for SUI, assessing their effectiveness, safety, and future prospects. A systematic literature search in PubMed was conducted using the following key terms: "stem," "cell," "stress," "urinary," and "incontinence." A total of 32 preclinical studies and 15 clinical studies published between 1946 and December 2014 were included in the review. Most preclinical trials have used muscle-derived stem cells and adipose-derived stem cells. However, at present, the application of other types of cells, such as human amniotic fluid stem muscle-derived progenitor cells and bone marrow mesenchymal stromal cells, is becoming more extensive. While the evidence shows that these therapies are effective and safe, further work is required to standardize surgical techniques, as well as to identify indications for their use, doses and number of doses. Future research will have to focus on clinical applications of cell therapies; namely, it will have to determine indications for their use, doses of cells, optimal surgical techniques and methods, attractive cell sources, as well as to develop clinically relevant animal models and make inroads into understanding the mechanisms of SUI improvement by cell therapies.

Stem Cell Therapy for Male Urinary Incontinence

INTRODUCTION

Among the medical and surgical options which have been proposed in the last years for the management of male stress urinary incontinence (SUI), stem cell therapy represents a new frontier treatment. The aim of this paper is to update the current status of stem cell therapy in animal and human studies for the management of iatrogenic male SUI.

MATERIAL AND METHODS

A PubMed review of the literature on stem cell therapy for the treatment of male SUI was performed.

RESULTS

Regarding animal studies, bone marrow-, muscle- and adipose-derived stem cells have been widely studied, showing regeneration of the urethral sphincter and recovery of the damaged pelvic nerves. With regard to human studies, only four papers are available in the literature using muscle- and adipose-derived stem cells which reported a significant improvement in sphincteric function and incontinence with no severe side effects.

CONCLUSIONS

In spite of these promising results, further studies are needed with longer follow-ups and larger numbers of patients in order to clarify the potential role of stem cell therapy for the treatment of male SUI.

[Urinary incontinence in men]

Stress urinary incontinence in men is predominantly iatrogenic whereby radical prostatectomy is the most common cause with persistent stress urinary incontinence rates varying between 10 % and 25 %. The first line therapy for postoperative male stress urinary incontinence is physiotherapy, especially pelvic floor muscle rehabilitation. If conservative treatment fails to show sufficient improvement, surgical therapy is recommended. Several treatment options are currently available for the surgical treatment of male stress urinary incontinence including artificial sphincters, adjustable and functional sling systems, bulking agents and implantable balloon systems.

[Conservative treatment in male urinary incontinence]

Prevalence, pathophysiology, diagnostic and therapeutic approaches of urinary incontinence are well studied in women; however, studies on male urinary incontinence focus on incontinence following surgery of the bladder or prostate, predominantly incontinence after radical prostatectomy. Aging men suffer from incontinence, most frequently urge incontinence (overactive bladder, OAB), nearly as often as women do.The domain of conservative therapy of urinary stress incontinence in men is pelvic floor training. It remains unclear whether biofeedback procedures, electrostimulation therapy, or magnetic stimulation therapy can enhance pelvic floor training. There are data suggesting that an off-label therapy with Duloxetin®, a selective serotonin-noradrenaline reuptake inhibitor (SSNRI), improves urinary incontinence following radical prostatectomy. Antimuscarinic agents in combination with bladder training have been proven as safe and effective treatment in men with OAB. Data, however, suggest that men with OAB are far less frequently treated than women.

Inhibiting neuropeptide Y Y1 receptor modulates melanocortin receptor- and NF-κB-mediated feeding behavior in phenylpropanolamine-treated rats

Neuropeptide Y (NPY) and nuclear factor-kappa B (NF-κB) are involved in regulating anorexia elicited by phenylpropanolamine (PPA), a sympathomimetic drug. This study explored whether NPY Y1 receptor (Y1R) is involved in this process, and a potential role for the proopiomelanocortin system was identified. Rats were given PPA once a day for 4days. Changes in the hypothalamic expression of the NPY, Y1R, NF-κB, and melanocortin receptor 4 (MC4R) levels were assessed and compared. The results indicated that food intake and NPY expression decreased, with the largest reductions observed on Day 2 (approximately 50% and 45%, respectively), whereas NF-κB, MC4R, and Y1R increased, achieving maximums on Day 2 (160%, 200%, and 280%, respectively). To determine the role of Y1R, rats were pretreated with Y1R antisense or a Y1R antagonist via intracerebroventricular injection 1h before the daily PPA dose. Y1R knockdown and inhibition reduced PPA anorexia and partially restored the normal expression of NPY, MC4R, and NF-κB. The data suggest that hypothalamic Y1R participates in the appetite-suppression from PPA by regulating MC4R and NF-κB. The results of this study increase our understanding of the molecular mechanisms in PPA-induced anorexia.

[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.

Bioactivity-integrated ultra-performance liquid chromatography/quadrupole time-of-flight mass spectrometry for the identification of nuclear factor-κB inhibitors and β2 adrenergic receptor agonists in Chinese medicinal preparation Chuanbeipipa dropping pills

A simple and dual-target method based on ultra-performance liquid chromatography/quadrupole time-of-flight mass spectrometry combined with dual-bioactive [nuclear factor-κB (NF-κB) and β2 -adrenergic receptor] luciferase reporter assay systems was developed to rapidly characterize the chemical structure of various bioactive compounds of TCM preparations. Chuanbeipipa dropping pills, a traditional Chinese medicine preparation used for the clinical therapy of chronic obstructive lung disease and cough caused by bronchial catarrh, was analyzed with this method. Potential anti-inflammatory and spasmolytic constituents were screened using NF-κB and β2 -adrenergic receptor activity luciferase reporter assay systems and simultaneously identified according to the time-of-flight mass spectrometry data. One β2-adrenergic receptor agonist (ephedrine) and two structural types of NF-κB inhibitors (platycosides derivatives and ursolic acid derivatives) were characterized. Platycodin D3 and E were considered new NF-κB inhibitors. Further cytokine and chemokine detection confirmed the anti-inflammatory effects of the potential NF-κB inhibitors. Compared with conventional fingerprints, activity-integrated fingerprints that contain both chemical and bioactive details offer a more comprehensive understanding of the chemical makeup of plant materials. This strategy clearly demonstrated that multiple bioactivity-integrated fingerprinting is a powerful tool for the improved screening and identification of potential multi-target lead compounds in complex herbal medicines.

Neuropeptide Y Y1 receptor knockdown can modify glutathione peroxidase and c-AMP response element-binding protein in phenylpropanolamine-treated rats

It has been reported that antioxidative enzymes, neuropeptide Y (NPY), and c-AMP response element-binding protein (CREB) are involved in regulating phenylpropanolamine (PPA)-mediated appetite suppression. Here, we investigated whether Y1 receptor (Y1R) might be involved in this regulation. Rats were daily treated with PPA for 4 days. Changes in the contents of NPY, Y1R, glutathione peroxidase (GP), and CREB were assessed and compared. Results showed that Y1R, GP, and CREB increased, with a maximal increase about 100, 200, and 150 %, respectively, on Day 2. By contrast, NPY decreased with a biggest reduction about 48 % on Day 2 and the pattern of expression during PPA treatment was opposite to those of Y1R, GP, and CREB. Central knockdown (using antisense) or inhibition (using antagonist) of Y1R expression modulated the anorectic response of PPA and the reciprocal regulation between NPY and GP (or CREB), revealing an essential role of Y1R in regulating NPY, GP, and CREB. These results suggest that Y1R participates in the reciprocal regulation of NPY, GP, and CREB in the hypothalamus during PPA treatment in conscious rats. The present results may aid the therapeutic research of PPA and related antiobesity drugs.

The identification of neuropeptide Y receptor subtype involved in phenylpropanolamine-induced increase in oxidative stress and appetite suppression

Hypothalamic neuropeptide Y (NPY) and superoxide dismutase (SOD) have been reported to participate in the regulation of appetite-suppressing effect of phenylpropanolamine (PPA), a sympathomimetic agent. This study explored whether Y1 receptor (Y1R) and/or Y5 receptor (Y5R) was involved in this regulation. Wistar rats were treated with PPA for 24 h. Changes in food intake and hypothalamic NPY, Y1R, Y5R, and SOD contents were assessed and compared. Results showed that food intake and NPY contents were decreased following PPA treatment, while Y1R and SOD contents were increased and Y5R contents remained unchanged. Moreover, although Y1R or Y5R knockdown by themselves could modify the food intake, Y1R but not Y5R knockdown could modify PPA-induced anorexia as well as NPY and SOD contents. In addition, selective inhibition of Y1R but not Y5R could modulate PPA-induced anorexia. It is suggested that Y1R but not Y5R participates in the anorectic response of PPA via the modulation of NPY and SOD. Results provide molecular mechanism of NPY-mediated PPA anorexia and may aid the understanding of the toxicology of PPA.

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.

Role of reactive oxygen species-related enzymes in neuropeptide y and proopiomelanocortin-mediated appetite control: a study using atypical protein kinase C knockdown

AIMS

Studies have reported that redox signaling in the hypothalamus participates in nutrient sensing. The current study aimed to determine if the activation of reactive oxygen species-related enzymes (ROS-RE) in the hypothalamus participates in regulating neuropeptide Y (NPY)-mediated eating. Moreover, possible roles of proopiomelanocortin (POMC) and atypical protein kinase C (aPKC) were also investigated. Rats were treated daily with phenylpropanolamine (PPA) for 4 days. Changes in the expression levels of ROS-RE, POMC, NPY, and aPKC were assessed and compared.

RESULTS

Results showed that ROS-RE, POMC, and aPKC increased, with a maximal response on Day 2 (anorectic effect) and with a restoration to the normal level on Day 4 (tolerant effect). By contrast, NPY expression decreased, and the expression pattern of NPY proved opposite those of ROS-RE and POMC. Central inhibition of ROS production by ICV infusion of ROS scavenger attenuated PPA anorexia, revealing a crucial role of ROS in regulating eating. Cerebral aPKC knockdown by ICV infusion of antisense aPKC modulated the expression of ROS-RE, POMC, and NPY.

CONCLUSION

Results suggest that ROS-RE/POMC- and NPY-containing neurons function reciprocally in regulating both the anorectic and tolerant effects of PPA, while aPKC is upstream of these regulators.

INNOVATION

These results may further the understanding of ROS-RE and aPKC in the control of PPA anorexia.

Knocking down the transcript of NF-kappaB modulates the reciprocal regulation of endogenous antioxidants and feeding behavior in phenylpropanolamine-treated rats

It has been reported that oxidative stress, antioxidants, and neuropeptide Y (NPY) are involved in regulating the feeding behavior of phenylpropanolamine (PPA), a sympathomimetic drug. This study explored whether transcription factor NF-κB is involved in this effect. Rats were treated daily with PPA for 4 days. Changes in hypothalamic NF-κB, NPY, superoxide dismutase (SOD), and glutathione peroxidase (GPx) levels during PPA treatment were assessed and compared. Results showed that NF-κB, SOD, and GPx increased, with a maximal response on Day 2, while the food intake and NPY decreased with the biggest reduction on Day 2 during PPA treatment. To further determine whether NF-κB was involved, intracerebroventricular infusion of antisense oligonucleotide was performed at 1 h before daily PPA in free-moving rats. Cerebral NF-κB knockdown could modify PPA anorexia and the expressions of NPY, SOD, and GPx. It is suggested that hypothalamic NF-κB participates in the reciprocal regulation of NPY and antioxidants, which mediated the appetite-suppressing effect of PPA. Results may further the understanding of the molecular mechanisms of PPA.

[Urinary incontinence after radical prostatectomy: do older patients have an increased risk?]

The investigation was intended to research the correlation between age and urinary incontinence after radical prostatectomy (RP). We considered the effects of RP as well as bladder function impairment and urge symptomatology of the elderly. A total of 3,912 patients after RP were included subsequent to aftercare. They were divided into age groups, and data on micturition and urinary loss were documented. We found that urinary loss was proportional to age. We concluded that older patients need more intense diagnostic workup and treatment during rehabilitation with respect to urinary incontinence. Presurgical advice should consider these facts.

[Radiotherapy influence, about results of the InVance(®) male sling in men with stress urinary incontinence]

AIMS

To study impact of previous radiotherapy on urodynamic parameters, continence and complication rate, after prosthetic implantation with InVance® device.

PATIENTS AND METHODS

We included 106 patients between August 2004 and March 2009. We stratified urinary incontinence according to pads daily used, in grade I (one to two pads), II (three to four), or III (more than four or condom catheter use). We compared one group of 24 patients with previous radiotherapy (R) to 82 control patients (T) without one. Follow-up was made at three and six postoperative months and then annually. Results were classified into: no leaks, improved or failure.

RESULTS

Mean follow-up was 14.8 months (median=12.8) in group R and 12.4 months (median=8.8) in group T. At three postoperative months, continence was achieved in 62.5% patients from group R and in 77% patients in group T (P: ns). At 12 months, results on continence were respectively 52.6% in group R and 63.2% in group T (P: ns). Six patients were explanted because of an infection (5.7%), among which two in group R (8.3%) and four in group T (4.8%). Infection was significantly linked to operative time (P: 0.02).

CONCLUSION

Previous radiotherapy has no impact on urodynamic parameters and continence, on short- and mid-term analysis, after implantation of a bone-anchored suburethral sling with InVance® device, preferentially patients with mild to moderate incontinenec urinary.

The effect of protein kinase C-delta knockdown on anti-free radical enzyme and neuropeptide Y gene expression in phenylpropanolamine-treated rats

Hypothalamic neuropeptide Y (NPY) has been reported to involve in regulating behavioral response of phenylpropanolamine (PPA), a sympathomimetic agent. This study explored if protein kinase C (PKC)-delta signaling participated in this regulation. Moreover, possible roles of anti-free radical enzyme catalase (CAT) and nitrogen oxide synthase (NOS) were also examined. Rats were treated daily with PPA for 4 days. Changes in food intake and hypothalamic NPY, PKCdelta, CAT, and NOS contents were assessed and compared. Results showed that PKCdelta and CAT increased during PPA treatment, which were concomitant with decreases in NPY content and food intake, while the change of NOS was expressed differently. Moreover, PKCdelta knockdown could modify PPA anorexia as well as NPY and CAT expression, while NOS expression remained unchanged. Furthermore, pre-treatment with NOS inhibitor could modify both PPA anorexia and NPY content. It is suggested that PKCdelta participates in the anorectic response of PPA via the modulation of NPY and CAT, while NOS contribute to this modulation via a different mechanism during PPA treatment. Results provide molecular mechanism of NPY-mediated PPA anorexia and may aid the therapeutic research of PPA and other anti-obesity drugs.

[Conservative management of postoperative urinary incontinence in men]

Urinary incontinence in men most commonly occurs after radical prostatectomy. Of these patients, 3-23% remain incontinent a year after prostatectomy. Data on conservative therapy for postoperative incontinence is contradictory. Nonetheless, conservative treatment strategies must generally be attempted before any operative technique. Early pelvic floor muscle training with or without biofeedback therapy and duloxetine seem to have a positive effect on continence. Further randomised controlled studies are necessary to accurately assess other conservative therapeutic options such as extracorporeal magnetic innervation and electrical stimulation therapy.

Medical management of stress urinary incontinence: is there a future?

Stress urinary incontinence (SUI) is a common problem among women worldwide. Multiple treatment modalities exist, ranging from physiotherapy to surgery. Numerous reports demonstrate mixed results for efficacy and safety of several oral agents used to treat SUI. Although there are data suggesting reasonable efficacy for several medications, surgery still remains the mainstay of treatment for most women. This article reviews the available oral agents that have been studied and assesses the data supporting their use while highlighting the limitations of each.

Urodynamic changes and initial results of the AdVance male sling

OBJECTIVES

To present the urodynamic changes and early results associated with the AdVance male sling. The AdVance male sling is a treatment option for postprostatectomy incontinence (PPI), with the goal of eliminating urinary incontinence without affecting voiding parameters. A concern of any procedure in treating men with PPI is whether the treatment induces obstruction and causes retention.

METHODS

Data were prospectively collected from 13 patients undergoing AdVance male sling placement for PPI. Urodynamic testing was performed at baseline and repeated at 6 months postoperatively. A 24-hour pad test and the Incontinence Quality of Life questionnaire were completed preoperatively and at 3 and 6 months postoperatively.

RESULTS

The median age at the procedure was 63.3 years (range 44.7-74.7). The mean preoperative and 6-month postoperative patient-reported pad use was 4.52 and 1.04, respectively (2-tailed t test, P = .0009). The 24-hour pad test, performed preoperatively and at 6 months postoperatively, yielded a pad weight of 779.3 and 67.6 g, respectively (P = .03). The Valsalva leak point pressure improved significantly (P = .032), but the detrusor voiding pressure, postvoid residual urine volume, and maximal and average flow rates remained relatively unchanged. At 3 and 6 months postoperatively, the Incontinence Quality of Life scores had improved significantly compared with the preoperative scores (P <.01).

CONCLUSIONS

These results are encouraging, because this series has demonstrated a significant improvement in patient-reported pad use, 24-hour pad test weights, and Valsalva leak point pressure without signs of obstruction. The improvement in incontinence was accompanied without any changes in the other voiding parameters and with significant improvement in the quality-of-life measures. Ongoing studies with longer follow-up are pending to compare their results with these promising early results.

[Is medical therapy useful in the management of stress urinary incontinence?]

In Germany, only duloxetine is registered for treating stress urinary incontinence in adult women; duloxetine treatment for stress urinary incontinence in children or men is poorly investigated and still off-label. Trials in women based on the evidence level 1B and meta-analyses have demonstrated that duloxetine significantly reduced the frequency of incontinence episodes and increased incontinence-related quality of life. However, duloxetine must be used on a regular base to maintain these positive effects. Therefore, duloxetine seems to be especially indicated in women who refuse or cannot be subjected to physical or surgical treatment and are willing to accept the long-term use and possible side effects of the drug. Furthermore, duloxetine could be useful in women to support pelvic floor physiotherapy or in female patients awaiting incontinence surgery.