Defining overactive bladder: Epidemiology and burden of disease

Associations between overactive bladder and sleep patterns: a cross-sectional study based on 2007-2014 NHANES

OBJECTIVES

To determine whether relationship exists between overactive bladder (OAB) and sleep patterns through the cross-sectional study.

PATIENTS AND METHODS

Patients from the National Health and Nutrition Examination Survey (NHANES) 2007-2014 were included in this study. Data were extracted through questionnaires, including demographics, dietary and health-related behaviors, body measurements and disease information. Three sleep factors were included to aggregate overall sleep scores, ranging from 0 to 3. A sleep score of 0 to 1, 2 or 3 was expressed as a bad, intermediate or healthy sleep pattern, respectively. The Overactive Bladder Symptom Score (OABSS) scale was applied to quantify the severity of OAB for each participant. Weighted logistic regression models were used to investigate the associations between sleep and OAB.

RESULTS

A total of 16,978 participants were enrolled in this study. The relationship between OAB and sleep patterns was statistically significant. After fully adjusting for confounding factors, the OAB risk of patients with intermediate and poor sleep patterns obviously increased by 26% and 38%, respectively, and mild (OR = 1.21, 95% CI [1.03,1.42]), moderate (OR = 1.45, 95% CI [1.27,1.66]) and severe (OR = 1.57, 95% CI [1.18,2.09]) OAB were significantly associated with sleep pattern grouping. The prevalence of OAB is significantly higher in patients with bad sleep patterns, and vice versa.

CONCLUSION

This study indicated that there is a positive relationship between OAB and worse sleep-related issues.

Animal models of interstitial cystitis/bladder pain syndrome

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a chronic disorder characterized by pelvic and/or bladder pain, along with lower urinary tract symptoms that have a significant impact on an individual's quality of life. The diverse range of symptoms and underlying causes in IC/BPS patients pose a significant challenge for effective disease management and the development of new and effective treatments. To facilitate the development of innovative therapies for IC/BPS, numerous preclinical animal models have been developed, each focusing on distinct pathophysiological components such as localized urothelial permeability or inflammation, psychological stress, autoimmunity, and central sensitization. However, since the precise etiopathophysiology of IC/BPS remains undefined, these animal models have primarily aimed to replicate the key clinical symptoms of bladder hypersensitivity and pain to enhance the translatability of potential therapeutics. Several animal models have now been characterized to mimic the major symptoms of IC/BPS, and significant progress has been made in refining these models to induce chronic symptomatology that more closely resembles the IC/BPS phenotype. Nevertheless, it's important to note that no single model can fully replicate all aspects of the human disease. When selecting an appropriate model for preclinical therapeutic evaluation, consideration must be given to the specific pathology believed to underlie the development of IC/BPS symptoms in a particular patient group, as well as the type and severity of the model, its duration, and the proposed intervention's mechanism of action. Therefore, it is likely that different models will continue to be necessary for preclinical drug development, depending on the unique etiology of IC/BPS being investigated.

What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence Under the Auspices of the European Association of Urology, Female Non-neurogenic Lower Urinary Tract Symptoms Guidelines Panel

CONTEXT

Overactive bladder syndrome (OAB) is highly prevalent among women and has a negative impact on their quality of life. The current available treatments for OAB symptoms include conservative, pharmacological, or surgical modalities.

OBJECTIVE

To provide an updated contemporary evidence document regarding OAB treatment options and determine the short-term effectiveness, safety, and potential harms of the available treatment modalities for women with OAB syndrome.

EVIDENCE ACQUISITION

The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched for all relevant publications up to May 2022. The risk of bias assessment followed the recommended tool in the Cochrane Handbook for Systematic Reviews of Interventions, and quality of evidence was assessed using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A meta-analysis was performed where appropriate.

EVIDENCE SYNTHESIS

Antimuscarinics and beta-3 agonists were significantly more effective than placebo across most outcomes, with beta-3 agonists being more effective at reducing nocturia episodes and antimuscarinics causing significantly higher adverse events. Onabotulinumtoxin-A (Onabot-A) was more effective than placebo across most outcomes, but with significantly higher rates of acute urinary retention/clean intermittent self-catheterisation (six to eight times) and urinary tract infections (UTIs; two to three times). Onabot-A was also significantly better than antimuscarinics in the cure of urgency urinary incontinence (UUI) but not in the reduction of mean UUI episodes. Success rates of sacral nerve stimulation (SNS) were significantly higher than those of antimuscarinics (61% vs 42%, p = 0.02), with similar rates of adverse events. SNS and Onabot-A were not significantly different in efficacy outcomes. Satisfaction rates were higher with Onabot-A, but with a higher rate of recurrent UTIs (24% vs 10%). SNS was associated with 9% removal rate and 3% revision rate.

CONCLUSIONS

Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include Onabot-A bladder injections or SNS. The choice of therapies should be guided by individual patient factors.

PATIENT SUMMARY

Overactive bladder is a manageable condition. All patients should be informed and advised on conservative treatment measures in the first instance. The first-line treatment options for its management include antimuscarinics or beta-3 agonists medication, and posterior tibial nerve stimulation procedures. The second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation procedure. The therapy should be chosen based on individual patient factors.

Treatment outcome of women with urodynamic mixed urinary incontinence: an observational study

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is a common yet understudied condition. It remains a therapeutic challenge, with the presence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). There is limited information on the optimal management for women with urodynamic MUI (urodynamic stress incontinence and detrusor overactivity). We assessed the treatment outcome of pelvic floor muscle training (PFMT), medical treatment and surgery for women who were diagnosed with urodynamic MUI.

METHODS

A prospective observational study was carried out on women with urodynamic MUI from 2010 to 2018. All women underwent clinical assessment and standardised urodynamic evaluation. All women received PFMT from a specialised continence advisor as initial management. Antimuscarinics and/or continence surgery were considered according to the woman's response and symptoms after PFMT. Subjective outcome after each treatment modality was analysed.

RESULTS

A total of 198 women were included for analysis. All women received PFMT, 104 (52.5%) showing improvement in urinary incontinence. Eighty-seven (43.9%) women were offered antimuscarinics, of whom 58 (29.3%) showed subjective improvement in both SUI and UUI, and 10 (5%) reported a reduction in UUI but persistent SUI. A total of 55 (27.7%) women received surgical treatment, with 20 receiving continence procedures. Sixteen out of twenty (80%) of them reported improvement in both SUI and UUI. None reported worsening of urgency or UUI. Overall, across all treatment modalities, 73.8% of women showed improvement in both SUI and UUI.

CONCLUSION

Future analyses can help to inform which patients will have a higher success rate after each treatment modality and help focus treatment effort on those with a high risk of persistent symptoms. This will provide relevant data in counselling women, giving reasonable expectations and directing the management of women with urodynamic MUI.

Determining patient preferences in the treatment of medication-refractory overactive bladder

INTRODUCTION

Overactive bladder (OAB) is often suboptimally addressed by behavioral or pharmacological treatments. Less than 15% of patients choose to pursue advanced OAB therapy (sacral nerve stimulation [SNS], percutaneous tibial nerve stimulation [PTNS], and bladder onabotulinum toxin type-A [BTX-A]). We seek to better understand which factors are most important to patients when choosing a third-line therapy.

METHODS/MATERIALS

We developed a conjoint analysis survey that included five attributes of the third-line options for OAB (SNS, PTNS, and BTX-A). We administered the survey to new patients with urinary incontinence at two institutions. A hierarchical Bayes random effects regression analysis was used to determine the relative importance of the attributes. A choice simulator was used to model which third-line treatment options patients preferred. We followed patients to see if they pursued their predicted treatment.

RESULTS

A total of 108 patients completed the study of whom 89% were women. There was representation from all age groups. The most important attributes of decision-making were the frequency of future procedures, the risk of catheterization, and the need for a device. On market simulation, SNS was the preferred treatment option (47%), followed by PTNS (29%) and BTX-A (14%). Only 10% of patients did not find any treatment option acceptable.

CONCLUSIONS

Frequent follow-up, risk of catheterization, and the need for a device were the most important attributes when making a decision on third-line OAB therapy. On market simulation, SNS is the preferred treatment for all age groups though the ultimate choice in third-line therapy may be affected by external factors.

Pelvic Floor Muscle Exercises as a Treatment for Urinary Incontinence in Postmenopausal Women: A Systematic Review of Randomized Controlled Trials

Women frequently suffer from urinary incontinence due to atrophic changes in the urogenital tract. Recommended conservative treatment includes evaluation of pelvic-floor strength and the functional use of pelvic-floor-muscle (PFM) training. Following the PRISMA 2020 guidelines, a search was conducted in the electronic databases PubMed, Web of Science, and Scopus for articles with at least one group performing PFM exercises in post-menopausal women with urinary incontinence. Eight articles were included, and each study had at least one group of PFM exercise-based intervention alone or combined. The volume or duration, frequency, and number of sessions were heterogeneous. All the studies reported significant differences in favor of PFM exercise in strength, quality of life, and/or severity of urinary incontinence. PFM exercise is a highly recommended intervention to treat urinary incontinence in postmenopausal women. However, more research is needed to establish specific factors such as dose-response relationships and to standardize methods for measuring effects.

Acupuncture for treating overactive bladder in adults

BACKGROUND

Overactive bladder is a common, long-term symptom complex, which includes frequency of micturition, urgency with or without associated incontinence and nocturia. Around 11% of the population have symptoms, with this figure increasing with age. Symptoms can be linked to social anxiety and adaptive behavioural change. The cost of treating overactive bladder is considerable, with current treatments varying in effectiveness and being associated with side effects. Acupuncture has been suggested as an alternative treatment.

OBJECTIVES

To assess the effects of acupuncture for treating overactive bladder in adults, and to summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (including In-Process, Epub Ahead of Print, Daily), ClinicalTrials.gov and WHO ICTRP (searched 14 May 2022). We also searched the Allied and Complementary Medicine database (AMED) and bibliographic databases where knowledge of the Chinese language was necessary: China National Knowledge Infrastructure (CNKI); Chinese Science and Technology Periodical Database (VIP) and WANFANG (China Online Journals), as well as the reference lists of relevant articles.  SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and cross-over RCTs assessing the effects of acupuncture for treating overactive bladder in adults.

DATA COLLECTION AND ANALYSIS

Four review authors formed pairs to assess study eligibility and extract data. Both pairs used Covidence software to perform screening and data extraction. We assessed risk of bias using Cochrane's risk of bias tool and assessed heterogeneity using the Chi2 testand I2 statistic generated within the meta-analyses. We used a fixed-effect model within the meta-analyses unless there was a moderate or high level of heterogeneity, where we employed a random-effects model. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 15 studies involving 1395 participants in this review (14 RCTs and one quasi-RCT). All included studies raised some concerns regarding risk of bias. Blinding of participants to treatment group was only achieved in 20% of studies, we considered blinding of outcome assessors and allocation concealment to be low risk in only 25% of the studies, and random sequence generation to be either unclear or high risk in more than 50% of the studies. Acupuncture versus no treatment One study compared acupuncture to no treatment. The evidence is very uncertain regarding the effect of acupuncture compared to no treatment in curing or improving overactive bladder symptoms and on the number of minor adverse events (both very low-certainty evidence). The study report explicitly stated that no major adverse events occurred. The study did not report on the presence or absence of urinary urgency, episodes of urinary incontinence, daytime urinary frequency or episodes of nocturia. Acupuncture versus sham acupuncture Five studies compared acupuncture with sham acupuncture. The evidence is very uncertain about the effect of acupuncture on curing or improving overactive bladder symptoms compared to sham acupuncture (standardised mean difference (SMD) -0.36, 95% confidence interval (CI) -1.03 to 0.31; 3 studies; 151 participants; I2 = 65%; very low-certainty evidence). All five studies explicitly stated that there were no major adverse events observed during the study. Moderate-certainty evidence suggests that acupuncture probably makes no difference to the incidence of minor adverse events compared to sham acupuncture (risk ratio (RR) 1.28, 95% CI 0.30 to 5.36; 4 studies; 222 participants; I² = 0%). Only one small study reported data for the presence or absence of urgency and for episodes of nocturia. The evidence is of very low certainty for both of these outcomes and in both cases the lower confidence interval is implausible. Moderate-certainty evidence suggests there is probably little or no difference in episodes of urinary incontinence between acupuncture and sham acupuncture (mean difference (MD) 0.55, 95% CI -1.51 to 2.60; 2 studies; 121 participants; I2 = 57%). Two studies recorded data regarding daytime urinary frequency but we could not combine them in a meta-analysis due to differences in methodologies (very low-certainty evidence). Acupuncture versus medication Eleven studies compared acupuncture with medication. Low-certainty evidence suggests that acupuncture may slightly increase how many people's overactive bladder symptoms are cured or improved compared to medication (RR 1.25, 95% CI 1.10 to 1.43; 5 studies; 258 participants; I2 = 19%). Low-certainty evidence suggests that acupuncture may reduce the incidence of minor adverse events when compared to medication (RR 0.34, 95% CI 0.26 to 0.45; 8 studies; 1004 participants; I² = 51%). The evidence is uncertain regarding the effect of acupuncture on the presence or absence of urinary urgency (MD -0.40, 95% CI -0.56 to -0.24; 2 studies; 80 participants; I2 = 0%; very low-certainty evidence) and episodes of urinary incontinence (MD -0.33, 95% CI -2.75 to 2.09; 1 study; 20 participants; very low-certainty evidence) compared to medication. Low-certainty evidence suggests there may be little to no effect of acupuncture compared to medication in terms of daytime urinary frequency (MD 0.73, 95% CI -0.39 to 1.85; 4 studies; 360 participants; I2 = 28%). Acupuncture may slightly reduce the number of nocturia episodes compared to medication (MD -0.50, 95% CI -0.65 to -0.36; 2 studies; 80 participants; I2 = 0%, low-certainty evidence). There were no incidences of major adverse events in any of the included studies. However, major adverse events are rare in acupuncture trials and the numbers included in this review may be insufficient to detect these events.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect acupuncture has on cure or improvement of overactive bladder symptoms compared to no treatment. It is uncertain if there is any difference between acupuncture and sham acupuncture in cure or improvement of overactive bladder symptoms. This review provides low-certainty evidence that acupuncture may result in a slight increase in cure or improvement of overactive bladder symptoms when compared with medication and may reduce the incidence of minor adverse events. These conclusions must remain tentative until the completion of larger, higher-quality studies that use relevant, comparable outcomes. Timing and frequency of treatment, point selection, application and long-term follow-up are other areas relevant for research.

Comparison of lumbopelvic stability, low back pain and well-being of women who have overactive bladder syndrome to asymptomatic controls: cut-off points

AIMS

Overactive bladder (OAB) syndrome has been associated with core muscles weakness, which is important in aetiology of low back pain (LBP) and affects general well-being. This study aimed to compare the lumbopelvic stability, LBP and well-being of women with OAB to asymptomatic controls and to determine the cut-off points.

METHODS

Women with (OAB group, n = 36) and without OAB syndrome (control group, n = 36) were included. The lumbopelvic stability with the Sahrmann and McGill trunk muscle endurance tests, LBP intensity with the Visual Analogue Scale were assessed. As for general well-being, sleep quality with the Pittsburgh Sleep Quality Index (PSQI), fatigue severity with the Fatigue Severity Index (FSI), anxiety and depression levels with the Hospital Anxiety Depression Scale (HADS-A, HADS-D) were evaluated.

RESULTS

In the OAB group compared to the control group, the lumbopelvic stability scores were lower (p < 0.001) while LBP prevalence (p < 0.001), pain intensity (p = 0.020), and PSQI, FSI, HADS-A, and HADS-D scores (p < 0.001) were higher. The cut-off points for trunk extension, flexion, right and left lateral flexion endurance tests and Sahrmann test were ≤9.42 sec, ≤8.62 sec, ≤19.26 sec, ≤5.16 sec, and ≤2 level, respectively. The cut-off points for PSQI, FSI, HADS-D, HADS-A were >5, >5.22, >6 and >6 scores, respectively.

CONCLUSIONS

Women with OAB syndrome had lower lumbopelvic stability, higher LBP prevalence and intensity, lower sleep quality, and more fatigue, anxiety, and depression levels compared to asymptomatic women. The cut-off values were detected between the occurrence of OAB and lumbopelvic stability and general well-being parameters.

Effects of overactive bladder syndrome on female sexual function

This study was to evaluate the impact of the symptoms of overactive bladder (OAB) syndrome on female sexual function. Seventy nine patients with OAB (OAB group) and 79 healthy women (control group) underwent physical examination at our center, and had their sexual function evaluated using the female sexual function index (FSFI). In accordance with the presence or absence of urge incontinence, the OAB group was further divided into the wet and dry groups. The sexual function was evaluated again after 3 months of pharmacotherapy. We investigate the difference of sexual function between OAB and control group. The effect of OAB severity and OAB pharmacotherapy on sexual function was also explored. There were no significant differences between OAB group and control group, including age, body mass index (BMI), education, occupation, fertility, parity, childbirth, and menopause. Compared with the control group, the OAB group had significantly lower FSFI scores. The respective mean ± standard error FSFI scores in the control group and the OAB group were 2.98 ± 1.07 and 2.27 ± 0.96 for desire, 3.48 ± 1.16 and 2.32 ± 1.44 for arousal, 4.60 ± 1.13 and 3.10 ± 1.95 for lubrication, 3.37 ± 0.87 and 2.63 ± 1.04 for orgasm, 3.58 ± 1.02 and 2.41 ± 1.35 for sexual satisfaction, 3.58 ± 1.02 and 2.41 ± 1.35 for sexual pain, and 22.24 ± 5.29 and 15.59 ± 7.47 for the total score (P < .05 for all comparisons). The scores for desire, lubrication, orgasm, sexual satisfaction, pain, and total FSFI between the OAB-dry and OAB-wet subgroup were similar while score of arousal in OAB-wet subgroup was significantly increased compared with that of OAB-dry. OABSS score was commonly used in the assessment of OAB severity. The difference of the FSFI scores among mild OAB group, moderate OAB group, and severe OAB group was statistically significant (P < .05). Female FSFI sexual function scores were significantly improved after OAB pharmacotherapy (P < .05). Women with OAB syndrome have poorer sexual function than healthy women. Patients with more serious OAB experience more disturbing sexual dysfunction. Female sexual function scores were significantly improved after OAB pharmacotherapy.

The impact of overactive bladder on health-related quality of life in Korea: based on the results of a Korean Community Health Survey

PURPOSE

This study aimed to assess the impact of overactive bladder on health-related quality of life (HRQoL) in a community-based sample of Korean population.

METHODS

The data of adults aged 19 and over that who participated in the 2012 Korean Community Health Survey were analyzed. Overactive bladder severity was classified as normal, mild, moderate, or severe using the Overactive Bladder Symptom scores, and HRQoL was evaluated using EQ-5D-3L. Relations between HRQoL and the severities and symptoms of OAB were investigated. Sampling weighted adjusted multiple regression analysis was performed to determine the effect of OAB symptom severity on HRQoL.

RESULTS

Of the 226,867 study subjects, 12,303 (5.4%) had OAB, and 552 (0.2%) had an OABSS of ≥ 12, indicating severe OAB. The problem -reporting rate significantly increased in all EQ-5D-3L dimensions as OAB severity increased. After adjusting for other variables, OAB severity had a significant effect on EQ-5D-3L index. Urge incontinence had greatest impact on quality of life.

CONCLUSIONS

As the severity of OAB increased from mild to severe, quality of life decreased significantly. OAB was found to negatively affect HRQoL.

Efficacy of Daily Intake of Dried Cranberry 500 mg in Women with Overactive Bladder: A Randomized, Double-Blind, Placebo Controlled Study

PURPOSE

We sought to determine the efficacy of dried cranberry on reducing symptoms of overactive bladder in women.

MATERIALS AND METHODS

Eligible women aged 18 or older with overactive bladder were randomized to either daily dried cranberry powder (500 mg) or placebo (500 mg) and followed for 24 weeks. Efficacy was measured by 3-day voiding diaries and Overactive Bladder Questionnaire Short Form, Patient Perception of Bladder Condition, Sexual Quality of Life-Female and Pelvic Floor Distress Inventory surveys. Statistical analyses were performed by BIOFORTIS using SAS® software version 9.4.

RESULTS

Of the 98 women who were randomized 77 completed all the visits and 60 were included in the per protocol analysis. Compared to placebo using per protocol analysis the cranberry group showed a significant reduction of daily micturitions (-1.91, 95% CI -3.74--0.88, p=0.0406), urgency episodes (-2.81, 95% CI -4.82--0.80, p=0.0069), and Patient Perception of Bladder Condition scores (-0.66, 95% CI -1.23-0.08, p=0.0258) at 24 weeks of followup. Mean volume per micturition, nocturia and the remaining survey outcomes did not differ significantly between the groups (p >0.05).

CONCLUSIONS

Daily intake of dried cranberry powder reduced daily micturition by 16.4%, urgency episodes by 57.3% and patient perception of bladder condition by 39.7%. However, an intent-to-treat analysis showed no statistically significant difference between the groups for these measurements (p >0.05). Future larger studies with longer followup periods are needed to further determine the long-term effect of cranberry on overactive bladder.

A randomized, controlled trial of transcutaneous tibial nerve stimulation to treat overactive bladder and neurogenic bladder patients

INTRODUCTION

We aimed to determine if transcutaneous tibial nerve stimulation (TTNS) is effective at treating overactive bladder (OAB) symptoms among neurogenic and non-neurogenic patients.

METHODS

We conducted a randomized, double-blind, sham-controlled study. Adult patients were recruited from one of two groups: 1) women with OAB; and 2) patients with neurogenic disease and bladder symptoms. The intervention was stimulation of the posterior tibial nerve, for 30 minutes, three times per week for 12 weeks at home using transcutaneous patch electrodes. The primary outcome was improvement of the patient perception of bladder condition (PPBC). We used ANCOVA (with adjustment for baseline values) and followed the intention-to-treat principle; we reported marginal means (MM) and a p<0.05 was considered significant.

RESULTS

We recruited 50 patients (OAB n=20, neurogenic bladder n=30); 24 were allocated to the sham group and 26 to the active TTNS group. Baseline characteristics in both groups were similar. At the end of the study, there was no significant difference in the PPBC between sham or active groups: 13% (3/24) of sham patients and 15% (4/26) of active TTNS patients were responders (p=0.77), and the MM of the end-of-study PPBC score was 3.3 (95% confidence interval [CI] 2.8-3.7) vs. 2.9 (95% CI 2.5-3.4), respectively (p=0.30). Similarly, there were no significant differences in secondary outcomes (24-hour pad weight, voiding diary parameters, or condition-specific patient-reported outcomes). The results were similar within the OAB and neurogenic bladder subgroups.

CONCLUSIONS

TTNS does not appear to be effective for treating urinary symptoms of people with OAB or neurogenic bladder dysfunction.

Medical evaluation and management of male and female voiding dysfunction: a review

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.

Factors Associated with Improvements in Patient-Reported Outcomes During Mirabegron or Antimuscarinic Treatment of Overactive Bladder Syndrome: A Registry Study (PERSPECTIVE)

Introduction

Patient-reported outcomes (PROs) provide valuable insights about the effectiveness of overactive bladder (OAB) treatments. The aim of PERSPECTIVE (a Prospective, non-intErventional Registry Study of PatiEnts initiating a Course of drug Therapy for overactIVE bladder) was to provide real-world evidence from the USA and Canada on patient-perceived effectiveness and safety of mirabegron and antimuscarinics for treating OAB symptoms.

Methods

This prospective, non-interventional registry followed adult patients with OAB who were starting treatment with mirabegron or antimuscarinics. All treatment decisions were made at the discretion of the treating healthcare provider with no mandatory visits after enrollment. The primary objective was to identify factors associated with improved treatment effectiveness from a patient perspective mainly using the OAB Questionnaire Short-Form (OAB-q SF). The form was sent to patients via email link at baseline and months 1, 3, 6, and 12. Treatment-emergent adverse event (TEAE) data were collated from investigator reports.

Results

Overall, 1514 patients were included (female 73.5%, mean age 62.2 years). Mirabegron was initiated by 613 patients and antimuscarinics by 901 patients. A PRO response rate of approximately 60% was achieved (575 patients did not complete baseline PROs). Similar improvements in OAB-q SF symptom bother score and health-related quality of life (HRQoL) total score were observed for mirabegron and antimuscarinic initiators. Covariate-adjusted models demonstrated that worse baseline PRO score, Hispanic ethnicity, being treatment naïve, and use of complementary/supportive OAB therapies at baseline were significantly associated with greater improvements in both scores. The most frequent TEAEs were gastrointestinal disorders (dry mouth, constipation, and nausea) and nervous system disorders (headache, somnolence, and dizziness).

Conclusion

There are no differences between mirabegron and antimuscarinics in terms of patient-reported OAB symptom bother and HRQoL.

Trial Registration

ClinicalTrials.gov identifier, NCT02386072.

Funding

Astellas Pharma Global Development, Inc.

Plain Language Summary

Plain language summary available for this article.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-00994-7) contains supplementary material, which is available to authorized users.

A comparison of sacral neuromodulation vs. transvaginal electrical stimulation for the treatment of refractory overactive bladder: the impact on quality of life, body image, sexual function, and emotional well-being

Overactive bladder syndrome (OAB) is defined by the presence of urinary urgency, with or without urge incontinence, usually accompanied by an increase in urinary frequency and nocturia in the absence of urinary tract infections (UTI) or other diseases. The overall prevalence of OAB symptoms in the female population is reported to be 16.6% and increases with advancing age and menopause. The aetiology of OAB is not fully understood and is likely to affect a heterogeneous population of patients due to changes to their central and peripheral nervous systems. Although OAB is frequently associated with female sexual dysfunction (FSD), its real impact on sexual function in women has been evaluated only in a few studies. The first line of treatment for OAB includes behavioural modification and physical therapy, either as monotherapies or in combination. Many patients who have not had success in managing their symptoms with more conservative therapies may decide to resort to third-line treatments for refractory OAB. These treatments include neuromodulation therapies, particularly transvaginal electrical stimulation (TES) and sacral neuromodulation (SN). The aim of this short commentary is to provide an overview of the effectiveness of these treatments and of their impact on quality of life, body image, sexual function, and emotional well-being.

Combination Pharmacotherapy for Treatment of Overactive Bladder (OAB)

Overactive bladder syndrome (OAB) negatively affects the quality of life of patients and their interactions with society. Treatment of OAB starts with behavioral modification and then pharmacotherapy using monotherapy with either antimuscarinics or β3 agonists. The third-line more invasive approaches are the next treatment option currently recommended. Both antimuscarinic agents and β3 agonists work through a different molecular pathway. This brings up the potential of having an additive effect when using a combination treatment for patients with OAB. Currently, the potential for using combination therapy to treat OAB in patients who had no improvement with a monotherapy approach before we attempt a more invasive approach is being explored. Several studies have shown the benefits of combination therapy which will be an additional option to the tools to treat OAB.

Urodynamic and Bladder Diary Factors Predict Overactive Bladder-wet in Women: A Comparison With Overactive Bladder-dry

Purpose

To identify factors predicting the presence of overactive bladder syndrome (OAB)-wet, compared with OAB-dry.

Methods

Between September 2007 and September 2013, the medical records of 623 women with OAB who completed a 3-day bladder diary and underwent urodynamic studies in a medical center were retrospectively reviewed. OAB-wet was diagnosed in patients who complained of at least one episode of urgency incontinence in the previous month; otherwise, OAB-dry was diagnosed. Multivariable logistic regression analysis was used to predict the presence of OAB-wet.

Results

Age (odds ratio [OR], 1.05; P<0.001), maximal flow rate (Qmax) (OR,1.06; P<0.001), voided volume (OR, 0.996; P=0.001), detrusor pressure at maximal flow rate (PdetQmax) (OR, 1.02; P=0.003), urgency episodes (OR, 1.04; P<0.001) and urodynamic stress incontinence (OR,1.78; P=0.01) were independent predictors for the presence of OAB-wet vs. OAB-dry. If we use bladder contractility index as a variable for multivariable logistic regression analysis, bladder contractility index (OR, 1.012; P<0.001) become an independent predictor for OAB-wet.

Conclusions

A smaller bladder capacity and more frequent urgency episodes were predictors of OAB-wet, and the above findings indicate that OAB-wet and OAB-dry might be a continuum of OAB. Old age, high Qmax, high PdetQmax and urodynamic stress incontinence were also predictors for OAB-wet, and the above results reveal that OAB-wet and OAB-dry have partially different clinical and urodynamic features. Further studies might be performed to elucidate whether different treatment strategies between OAB-dry and OAB-wet can improve treatment efficacy.

Mirabegron: a Beta-3 agonist for overactive bladder

OBJECTIVE

To review the literature regarding the efficacy and safety of mirabegron for the treatment of overactive bladder (OAB).

DATA SOURCES

A literature search was performed using MEDLINE (PubMed) prior to December 31, 2013, using the terms "mirabegron" and "randomized-controlled trial."

STUDY SELECTION/DATA EXTRACTION

All published, double-blind, randomized-controlled trials assessing mirabegron were included. Articles were reviewed and included if mirabegron was used as monotherapy and if the primary outcome analyzed drug efficacy.

DATA SYNTHESIS

The efficacy of mirabegron for the treatment of OAB has been demonstrated in the selected five randomized, placebo-controlled trials. The majority of these trials lasted 12 weeks and compared various doses of mirabegron with placebo and/or tolterodine extended-release (ER). Primary efficacy outcomes for the trials included mean number of micturitions per 24 hours and mean number of incontinence episodes per 24 hours. Included trials showed statistically significant reductions in both efficacy outcomes for various doses of mirabegron when compared with placebo.

CONCLUSION

Based on the trials reviewed, mirabegron has been efficacious in reducing mean number of micturitions and incontinence episodes per 24 hours, as well as in improving other secondary outcomes such as OAB symptoms and quality-of-life measures. Common adverse drug events seen with mirabegron include: hypertension, nasopharyngitis, urinary tract infections, headache, constipation, upper respiratory tract infection, arthralgia, diarrhea, tachycardia, abdominal pain, and fatigue. Given the efficacy and safety data currently available, mirabegron represents a reasonable alternative to antimuscarinics for patients with OAB. Future studies are needed to determine the utility of mirabegron for OAB in a variety of demographics.

The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review

BACKGROUND

Functional bladder and bowel problems are common in children and have a serious psychological as well as physical impact. The objective of this scoping review was to synthesise evidence on the impact of such conditions both on children's quality of life (QOL) and their parents.

METHODS

The scoping review followed Arksey and O'Malley's framework. Relevant studies were identified by a comprehensive search of scientific databases. Inclusion criteria focused on children with bladder and bowel dysfunction, their QOL, and impact on parents. Studies were analysed for aims, study populations, measures, and results.

RESULTS

A total of 783 records were retrieved with 30 meeting the criteria. Most studies found that QOL was reduced in children with nocturnal enuresis, day bladder dysfunction, bowel dysfunction, and combined bladder and bowel dysfunction. Parents' QOL and social-emotional functioning were also negatively affected.

CONCLUSIONS

Functional bladder and bowel problems should be identified and treated as early as possible to minimise negative impacts on QOL of children and their carers. Future research should focus on how to best provide early and effective intervention in the most accessible manner.

Antimuscarinic use and discontinuation in an older adult population

INTRODUCTION

Although antimuscarinics are typically the first-line pharmacological treatment option for overactive bladder, patients often discontinue therapy. The aim of this research project is to identify the rate of antimuscarinic discontinuation, switching, and continuation and differences in discontinuation among different antimuscarinics.

METHODS

Using the 5% random sample of Medicare Claims Data, we identified a cohort of patients aged ≥ 66 years old who newly initiated antimuscarinics between January 1, 2007 and December 31, 2012. Treatment discontinuation was defined as no subsequent fills of the initial antimuscarinic in the days' supply plus a 30 day grace period. We ascertained percentages of patients who discontinued antimuscarinics, switched antimuscarinics, or died within 12 months of antimuscarinic initiation. Cox proportional hazards models were used to determine time to discontinuation of individual antimuscarinics relative to oxybutynin immediate-release (IR).

RESULTS

Among the 42,886 new-users of antimuscarinics, 71.8% discontinued, 10.8% switched, and 3.2% died prior to antimuscarinic discontinuation or switching while only 14.2% continually filled an antimuscarinic for one year. In the multivariable analysis, patients who were initiated on oxybutynin extended-released (ER), tolterodine, trospium, darifenacin, solifenacin, and fesoterodine were significantly less likely to be discontinued therapy compared to oxybutynin IR (p < 0.001).

CONCLUSION

After one year of antimuscarinic initiation, only 14% of older adult patients continuously utilized their initial antimuscarinic therapy suggesting a need for clinical interventions to improve continual use of antimuscarinics.

Vibegron (RVT-901/MK-4618/KRP-114V) Administered Once Daily as Monotherapy or Concomitantly with Tolterodine in Patients with an Overactive Bladder: A Multicenter, Phase IIb, Randomized, Double-blind, Controlled Trial

BACKGROUND

Antimuscarinics have shown modest efficacy with unwanted side effects in patients with overactive bladder (OAB). Efficacy of vibegron, a new β3-adrenergic receptor agonist, for OAB is unknown.

OBJECTIVE

To evaluate the efficacy of once-daily oral vibegron in OAB patients (primary), and its safety, tolerability, and efficacy when administered alone or concomitantly with tolterodine (secondary).

DESIGN, SETTING, AND PARTICIPANTS

International, phase IIb, randomized, double-blind, placebo- and active comparator-controlled, two-part superiority trial (2011-2013) in OAB-wet or OAB-dry patients aged 18-75 yr (NCT01314872).

INTERVENTIONS

Part 1: once-daily oral vibegron monotherapy (3 [V3], 15 [V15], 50 [V50], or 100 [V100] mg), tolterodine extended release 4mg (TER4), or placebo for 8 wk, or combination V50/TER4 for 4 wk and then V50 for 4 wk; part 2: V100/TER4, V100, TER4, or placebo for 4 wk.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Average daily micturitions at week 8 of part 1 (primary); urge incontinence episodes, total incontinence episodes, and urgency episodes (secondary).

RESULTS AND LIMITATIONS

Overall, 1395 patients were randomized. From baseline to week 8, V50 and V100 significantly decreased average daily micturitions (least square mean difference [95% confidence interval], -0.64 [-1.11, -0.18]; p=0.007 and -0.91 [-1.37, -0.44]; p<0.001, respectively) and the number of urge incontinence episodes (-0.72 [-1.11, -0.33] and -0.71 [-1.10, -0.32], respectively; both p<0.001) versus placebo. All vibegron doses were well tolerated. The incidence of dry mouth was higher with TER4 than with vibegron monotherapy. Results are limited by the relatively short treatment duration.

CONCLUSIONS

Once-daily V50 and V100 improved OAB symptoms; vibegron was well tolerated as monotherapy and concomitantly with tolterodine. Further development is warranted.

PATIENT SUMMARY

Antimuscarinics, commonly used to treat overactive bladder, produce modest efficacy and unwanted side effects. In this study, a different type of drug (vibegron) was efficacious and safe, alone or with an antimuscarinic (tolterodine).

Risk of psychiatric disorders in overactive bladder syndrome: a nationwide cohort study in Taiwan

Population-based cohort study investigating the risk of depression and other psychiatric disorders for patients with overactive bladder (OAB) syndrome is unavailable. This study investigated the subsequent risk of psychiatric disorders among patients with OAB in an Asian population. Using data from the National Health Insurance Research Database of Taiwan, we established a cohort with 811 patients in an exposed group with OAB between January 1, 2000 and December 31, 2000, and a non-exposed group, without OAB, of 2433 patients without OAB matched by age and year of diagnosis. The occurrence of psychiatric disorders and Cox regression model measured adjusted HRs (aHR) were monitored until the end of 2013. The overall incidence of psychiatric disorders was 41.7% higher in the exposed group with OAB than in the non-exposed group without OAB (14.2% vs 10.1%, p<0.001), with an aHR of 1.34 (95% CI 1.12 to 1.80, p<0.001) for the OAB cohort. OAB was associated with the increased risk of dementia, anxiety, depressive, sleep, and psychotic disorders, with aHRs as 1.53 (p=0.040), 1.61 (p<0.001), 2.10 (p<0.001), 1.43 (p<0.001), and 2.49 (p=0.002), respectively. The risk of psychiatric disorders, including depression and anxiety, is significantly higher in patients with OAB than in those without OAB. Evaluation of psychiatric status in patients with OAB is strongly recommended.

Anticholinergic burden and comorbidities in patients attending treatment with trospium chloride for overactive bladder in a real-life setting: results of a prospective non-interventional study

BACKGROUND

Elderly people are representative for the patients most likely to be treated with anticholinergics for overactive bladder (OAB). They often receive further drugs with anticholinergic properties for concomitant conditions. This increases the risk for side effects, including central nervous system disorders. Data on comorbidities and baseline anticholinergic burden of OAB patients seen in urological practice is scarce. Therefore, we included an epidemiological survey on these issues in our study which assessed the effectiveness and tolerability of trospium chloride (TC) in established dosages under routine conditions.

METHODS

Outpatients (≥ 65 years of age), for whom treatment with TC was indicated, were eligible to participate in this non-interventional, prospective study performed in 162 urological practices in Germany. Epidemiological questions were evaluated by the Anticholinergic Burden (ACB) scale and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) at baseline. Efficacy was assessed by changes in symptom-related variables of OAB after treatment. Dosage regimen, duration of treatment, adverse events, withdrawals, and ease of subdivision of the prescribed SNAP-TAB tablet were documented. Patients and physicians rated efficacy and tolerability of treatment. Statistics were descriptive.

RESULTS

Four hundred fourty-five out of 986 (47.54%) patients in the epidemiological population had a baseline ACB scale score > 0, 100 (24.72%) of whom a score ≥ 3. The median CIRS-G comorbidity index score for all patients was 5. 78.55% (608/774) of patients in the efficacy population received a daily dose of 45 mg TC. 60.03% (365/608) of them took this dose by dividing the SNAP-TAB tablet in three equal parts. Before-after-comparisons of the core symptoms of OAB showed clear improvements. An influence of the dosage scheme (1 × 45 mg TC/d vs 3 × 15 mg TC/d) on clinical outcome could not be observed. Most urologists and patients rated TC treatment as effective and well tolerated. 44 (4.37%) out of 1007 patients in the safety collective ended their treatment prematurely, while 75 patients (7.45%) experienced adverse events.

CONCLUSIONS

Anticholinergic burden and comorbidities in elderly OAB patients are frequent. The acceptance of the SNAP-TAB tablet, which facilitates flexible dosing with TC, was high, which is supportive in ensuring adherence in therapy.

TRIAL REGISTRATION

This non-interventional study was registered on October 29, 2014 with the number DRKS00007109 at the German Register of Clinical Studies (DRKS).

Differential Prescribing of Antimuscarinic Agents in Older Adults with Cognitive Impairment

BACKGROUND

Oral oxybutynin has been associated with the development of cognitive impairment.

OBJECTIVE

The objective of this study was to describe the use of oral oxybutynin versus other antimuscarinics (e.g., tolterodine, darifenacin, solifenacin, trospium, fesoterodine, transdermal oxybutynin) in older adults with documented cognitive impairment.

METHODS

This is a population-based retrospective analysis of antimuscarinic new users aged ≥ 66 years from January 2008 to December 2011 (n = 42,886) using a 5% random sample of Medicare claims linked with Part D data. Cognitive impairment was defined as a diagnosis of mild cognitive impairment, dementia, use of antidementia medication, and memory loss/drug-induced cognitive conditions in the year prior to the initial antimuscarinic claim. We used multivariable generalized linear models to assess indicators of cognitive impairment associated with initiation of oral oxybutynin versus other antimuscarinics after adjusting for comorbid conditions.

RESULTS

In total, 33% received oral oxybutynin as initial therapy. Cognitive impairment was documented in 10,259 (23.9%) patients prior to antimuscarinic therapy. Patients with cognitive impairment were 5% more likely to initiate another antimuscarinic versus oral oxybutynin (relative risk [RR] 1.05; 95% confidence interval [CI] 1.03-1.06). The proportion of patients with cognitive impairment initiated on oral oxybutynin increased from 24.1% in 2008 to 41.1% in 2011. The total cost of oral oxybutynin, in $US, year 2011 values, decreased by 10.5%, whereas the total cost of other antimuscarinics increased by 50.3% from 2008 to 2011.

CONCLUSION

Our findings suggest opportunities for quality improvement of antimuscarinic prescribing in older adults, but this may be hampered by cost and formulary restrictions.

Development of a core set of outcome measures for OAB treatment

INTRODUCTION AND HYPOTHESIS

Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).

METHODS

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.

RESULTS

The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.

CONCLUSIONS

The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

New Devices and Technologies for the Management of Overactive Bladder

PURPOSE OF REVIEW

Overactive bladder (OAB) affects millions of people in the USA and has a significant impact on their quality of life. Despite having a number of safe and effective ways of managing refractory OAB patients, there are many promising new technologies actively being studied and developed for the treatment of this population. This review examines current new devices and technologies under study for the treatment of OAB.

RECENT FINDINGS

Modifications to already established therapies such as sacral nerve stimulation (SNS) or tibial nerve stimulation (TNS) are currently being studied for refractory OAB. On the SNS front, a newly rechargeable, smaller neurostimulator has been developed and has shown promising results for the treatment of refractory OAB. There are two newly implantable TNS devices actively being studied for the treatment of refractory OAB. These implanted TNS systems will allow the patient to receive treatment from the comfort of their home without the need for frequent office visits. Most recently, radiofrequency ablation intravesical therapy has been proposed as a newer technology with the potential to reduce OAB symptoms. There are many new technologies actively being studied and developed for the management of refractory OAB patients. If shown to be safe and efficacious, these therapies may one day alter our current management of patients with OAB.

Additional low-dose antimuscarinics can improve overactive bladder symptoms in patients with suboptimal response to beta 3 agonist monotherapy

Purpose

We aimed to assess the patient-reported outcome (PRO) and efficacy of add-on low-dose antimuscarinic therapy in over-active bladder (OAB) patients with suboptimal response to 4-week treatment with beta 3 agonist monotherapy (mirabegron, 50 mg).

Materials and Methods

We enrolled OAB patients with 4-week mirabegron (50 mg) treatment if the patients' symptoms improved, but not to a satisfactory extent (patient perception of bladder condition [PPBC] ≥4). Enrolled patients had 8-week low-dose antimuscarinics add-on therapy (propiverine HCl, 10 mg). Patients recorded 3-day voiding diary at screening, enrollment (after 4 weeks of mirabegron monotherapy) and after 8 weeks of add-on therapy. We assessed the change of PRO (PPBC) as a primary end point and the efficacy of add-on therapy (change of frequency, urgency, urinary urgency incontinence [UUI] based on voiding diary) as a secondary end point.

Results

Thirty patients (mean age, 62.3±12.8 years; mean symptom duration, 16.0±12.3 months) were finally enrolled in the study. The mean PPBC value was 4.3±0.4 after mirabegron monotherapy, and decreased to 3.2±1.0 after 8-week add-on therapy. The mean urinary frequency decreased from 10.1±3.1 to 8.8±3, the mean number of urgency episodes decreased from 3.6±1.6 to 1.8±1.2 and the number of urgency incontinence episodes decreased from 0.7±1.0 to 0.2±0.5 after add-on therapy. No patients had event of acute urinary retention and three patients complained of mild dry mouth after add-on therapy.

Conclusions

Add-on therapy of low-dose antimuscarinics exhibits good efficacy and safety in patients with suboptimal response after 4-week of mirabegron (50 mg) monotherapy.

Assessing Preference-Based Outcome Measures for Overactive Bladder: An Evaluation of Patient-Reported Outcome Data from the BESIDE Clinical Trial

OBJECTIVES

The aim of this study was to compare outcomes using two preference-based measures of health status (EQ-5D-5L and OAB-5D) in patients with overactive bladder (OAB) treated with solifenacin plus mirabegron or solifenacin monotherapy in the BESIDE trial.

METHODS

Patients with OAB who remained incontinent after 4 weeks' treatment with solifenacin 5 mg were randomized 1:1:1 to combination treatment (solifenacin 5 mg plus mirabegron [25 mg for the first 4 weeks/50 mg for the last 8 weeks]), solifenacin 5 mg, or solifenacin 10 mg. EQ-5D-5L and OAB-q were administered at baseline, weeks 4, 8, 12, and end of treatment (EoT). OAB-5D scores were derived from OAB-q results. Responder analysis was carried out using several definitions of minimally important difference.

RESULTS

A total of 2054 patients received one or more doses of study treatment (combination, n = 694; solifenacin 5 mg, n = 684; solifenacin 10 mg, n = 676). EQ-5D-5L Index mean score changes (from baseline to EoT) were greater with combination (0.059) than with solifenacin 5 mg (0.040) and 10 mg (0.044) monotherapy, but the differences were not statistically significant. A significantly greater improvement was observed for combination on OAB-5D (0.107 vs 0.085 for 5 mg, and 0.087 for 10 mg; p ≤ 0.01). The dimensions most improved overall were anxiety/depression, pain/discomfort, and usual activities on EQ-5D-5L, and urge, urine loss, and coping on OAB-5D. The proportion of responders was significantly greater with combination compared with monotherapy using OAB-5D only.

CONCLUSIONS

Improvements were observed in all study arms on both the EQ-5D-5L and OAB-5D, although only the OAB-5D showed a statistically significant benefit for combination versus solifenacin monotherapy. Combining generic and condition-specific preference-based health status measures allowed for assessment of dimensions that were particularly relevant to this patient population, while permitting comparison with outcomes from other studies, treatments, and populations via EQ-5D.

Stimulation of the pelvic nerve increases bladder capacity in the prostaglandin E2 rat model of overactive bladder

Overactive bladder (OAB) syndrome is a highly prevalent condition that may lead to medical complications and decreased quality of life. Emerging therapies focusing on selective electrical stimulation of peripheral nerves associated with lower urinary tract function may provide improved efficacy and reduced side effects compared with sacral neuromodulation for the treatment of OAB symptoms. Prior studies investigating the effects of pelvic nerve (PelN) stimulation on lower urinary tract function were focused on promoting bladder contractions, and it is unclear whether selective stimulation of the PelN would be beneficial for the treatment of OAB. Therefore our motivation was to test the hypothesis that PelN stimulation would increase bladder capacity in the prostaglandin E₂ (PGE₂) rat model of OAB. Cystometry experiments were conducted in 17 urethane-anesthetized female Sprague-Dawley rats. The effects of intravesical PGE₂ vs. vehicle and PelN stimulation after intravesical PGE₂ on cystometric parameters were quantified. Intravesical infusion of PGE₂ resulted in decreased bladder capacity and increased voiding efficiency without a change in bladder contraction area under the curve, maximum contraction pressure, or contraction duration. Bladder capacity was also significantly decreased compared with vehicle (1% ethanol in saline) confirming that the change in bladder capacity was mediated by PGE₂ PelN stimulation reversed the PGE₂-induced change in bladder capacity and increased the external urethral sphincter electromyogram activity at a specific stimulation condition (amplitude of 1.0 times threshold at 10 Hz). These results confirm that the urodynamic changes reported in conscious rats are also observed under urethane anesthesia and that PelN stimulation is a novel and promising approach for the treatment of the symptoms of OAB.

Overactive Bladder Is Strongly Associated With Frailty in Older Individuals

OBJECTIVE

To understand the relationship between age, frailty, and overactive bladder (OAB).

MATERIALS AND METHODS

This is a prospective study of individuals age ≥65 years presenting to an academic urology practice between December 2015 and July 2016. All patients had a Timed Up and Go Test (TUGT), a parsimonious measure of frailty, on intake, and were thereby categorized as fast (≤10 seconds), intermediate (11-14 seconds), and slow (≥15 seconds). The TUGT and other clinical data were abstracted from the electronic medical record using direct queries. Logistic regression was used to examine the relationship between frailty and the diagnosis of OAB, adjusting for age, gender, and race.

RESULTS

Our cohort included 201 individuals with and 1162 individuals without OAB. Individuals with OAB had slower TUGTs (13.7 ± 7.9 seconds) than their non-OAB counterparts (10.9 ± 5.2 seconds), P <.0001, with 32.3% and 11.0% of OAB and non-OAB individuals being categorized as slow, or frail. In multivariable analysis, slower TUGT was a significant predictor of OAB (adjusted odds ratio: 3.0; 95% confidence interval: 2.0-4.8). Age was not independently associated with this diagnosis (P values >.05 for each age group).

CONCLUSION

Patients with OAB are statistically significantly frailer than individuals seeking care for other non-oncologic urologic diagnoses. Frailty, when adjusted for age, race, and gender, is a statistically significant predictor of OAB. Furthermore, frailty should be considered when caring for older patients with OAB, and OAB should be assessed when caring for frail older patients.

Primary Nonadherence to Overactive Bladder Medications in an Integrated Managed Care Health Care System

BACKGROUND

Treatment for overactive bladder (OAB) remains suboptimal, in part because of patient nonadherence to medications. Primary nonadherence is when patients fail to pick up their initial prescriptions.

OBJECTIVE

To measure primary nonadherence to OAB medications within 30 days of a first OAB prescription order using electronic medical records from a U.S. managed care health care system METHODS: A retrospective cohort study was conducted using electronic medical records from the Kaiser Permanente Southern California (KPSC) database to identify patients with new OAB prescriptions between January 1, 2007, and December 31, 2013. The index date was defined as the first order of an OAB prescription. Patients had to be aged ≥ 18 years on the index date and were required to have 12 months of continuous membership with drug benefit eligibility before, during, and after the index date. Patients were defined as primary nonadherent if they did not pick up their new OAB prescriptions within 30 days of the order date. Descriptive statistics and a multivariable logistic regression analysis with backward selection were conducted to identify factors associated with patients who were primary nonadherent versus adherent.

RESULTS

There were 9,050 patients with a new OAB prescription order; 1,662 (18%) of these were primary nonadherent. Patients with primary nonadherence were younger in age (56.9 [SD ± 16.0] years vs. 63.9 [SD ± 14.8] years; P < 0.001) and more likely to have commercial insurance (65.9% vs. 46.2%; P < 0.001). They also had lower mean Charlson Comorbidity Index (CCI) scores (1.99 vs. 2.70; P < 0.001), fewer OAB-related comorbidities, fewer concomitant medications (P < 0.005), and fewer overall prescriptions dispensed in the previous 12 months (P < 0.001) compared with adherent patients. Significant factors such as commercial insurance (P = 0.013), race other than white (P = 0.020), CCI = 0 versus CCI ≥ 2 (P = 0.001), urinary tract infections (P < 0.001), and falls (P = 0.047) were associated with a higher likelihood of primary nonadherence versus adherence.

CONCLUSIONS

Nearly 1 in 5 patients did not pick up their new OAB medications within 30 days of the order date. Knowledge of factors associated with primary nonadherence may inform strategies for improving management of OAB.

DISCLOSURES

This study was supported by a research grant provided by Astellas Pharma Global Development. Rashid and Lin do not have any financial interests or potential conflict of interest with regard to the work. Vassilakis, Kristy, and Ng were employees of Astellas Pharma Global Development when this study was conducted. Study concept and design were contributed by Rashid and Ng, along with the other authors. Rashid and Lin collected the data, and data interpretation was performed by Rashid, Ng, and Lin, along with Vassilakis and Kristy. The manuscript was written by Rashid and Ng, along with Vassilakis and Lin, and revised by Rashid, Ng, and Lin.

Solifenacin for Overactive Bladder with Incontinence: Symptom Bother and Health-Related Quality of Life Outcomes

Background:

Approximately one-third of patients with overactive bladder (OAB) experience incontinence, a bothersome symptom with a clear negative effect on quality of life.

Objective:

To assess OAB patients' perceptions of improvements in symptom bother and quality of life after taking solifenacin under conditions reflecting day-today practice.

Methods:

VOLT (the VESIcare Open-Label Trial) was a prospective, open-label study in patients with OAB (defined as urgency, urge urinary incontinence, daytime frequency, or nocturia for ≥3 mo) who were treated with flexibly dosed, once-daily solifenacin for 12 weeks. This study included subjects enrolled in VOLT who, at baseline, had urge incontinence and reported incontinence as their most bothersome symptom. All patients were started on solifenacin 5 mg/day; at week 4, the dosage could be increased to 10 mg/day and at week 8 could be maintained or decreased back to 5 mg/day. Efficacy was assessed by 3 independent patient-reported outcomes: the Patient Perception of Bladder Condition (PPBC) scale, a visual analog scale (VAS) for assessing individual symptoms, and the Overactive Bladder Questionnaire (OAB-q).

Results:

Of the 2205 patients in the VOLT full analysis set, 1586 (71.9%) had urge incontinence at baseline, of which 582 (36.7%) reported incontinence as their most bothersome symptom. In this cohort, mean PPBC score at baseline was 4.6 (indicating moderate-to-severe problems) and at endpoint had decreased significantly to 2.9 (very minor to some minor problems; p < 0.001). At endpoint, 80.4% of patients achieved improvement in their PPBC score. These patients reported significant improvements from baseline in urinary urgency, urge incontinence, frequency, and nocturia on the VAS (p < 0.001) and all OAB-q domains (symptom severity, coping, concern, sleep, social, health-related quality of life) at endpoint (p < 0.001).

Conclusions:

Patients reporting urge incontinence as their most bothersome OAB symptom can be expected to demonstrate significant improvements in multiple patient-related outcomes following treatment with flexibly dosed solifenacin.

Adverse events and treatment discontinuations of antimuscarinics for the treatment of overactive bladder in older adults: A systematic review and meta-analysis

INTRODUCTION

Antimuscarinics should be used with caution in older adults with overactive bladder (OAB) due to anticholinergic adverse events (AEs). Systematic reviews and meta-analyses (SRMAs) have analyzed safety-related outcomes but have not specified risk in the elderly, the population at highest risk for AEs. The aim of this review is to explore and evaluate AEs and treatment discontinuations in adults 65 or older taking antimuscarinics for OAB.

METHODS

Keywords were searched in MEDLINE, EMBASE, SCOPUS, and Cochrane Central Register for Controlled Trials. Randomized controlled trials (RCTs) along with sub-analyses and pooled analyses that compared antimuscarinics to placebo or another antimuscarinic were performed in February 2015. Studies assessing AEs or treatment discontinuations in a population of adults 65 or older were included. The Jadad Criteria and McHarm Tool were used to assess the quality of the trials.

RESULTS

A total of 16 studies met the inclusion criteria. Eighty AEs and 27 reasons for treatment discontinuation were described in the included studies and further explored. Anticholinergic AEs were more common in antimuscarinics compared to placebo. Incidence of dizziness, dyspepsia, and urinary retention with fesoterodine, headache with darifenacin, and urinary tract infections with solifenacin were significantly higher compared to placebo. Treatment discontinuation due to AEs and dry mouth were higher in the antimuscarinics when compared to placebo in older adults.

CONCLUSIONS

Treatment for overactive bladder using antimuscarinics in adults aged 65 or older resulted in significant increases in risk for several AEs compared to placebo including anticholinergic and non-anticholinergic AEs.

Social, Economic, and Medical Factors Associated With Solifenacin Therapy Compliance Among Workers Who Suffer From Lower Urinary Tract Symptoms

Purpose

The prevalence of hyperactive-type lower urinary tract symptoms is 45.2%, with shares of overactive bladder (OAB) and urge incontinence (UI) symptoms of 10.7% and 8.2%, respectively. We investigated the possible impact of a wide range of social, economic, and medical factors on compliance with solifenacin treatment in the working population.

Methods

Social, economic, and medical factors as well as the Overactive Bladder questionnaire – the OAB-q Short Form (OAB-q SF), bladder diaries, and uroflowmetry of 1,038 people who were administered solifenacin for a year were gathered from employer documentation.

Results

Among the subjects, 32% maintained their compliance with solifenacin treatment throughout the year. Only 65% of the patients had compliance exceeding 80%, and 17% of patients had compliance of ≥50%, yet less than 80% were still taking solifenacin 12 months after the beginning of this experiment. Working people whose compliance level was, at least, 80% had reliably higher (P≤0.01) average age, annual salary, and treatment efficacy, and a greater treatment satisfaction level, as well as a lack of satisfaction with other antimuscarinic treatments and higher rate of urge UI diagnosis. The same cohort also featured a lower level (P≤0.01) of caffeine abuse and lower share of salary spent purchasing solifenacin.

Conclusions

This study has shown that compliance with solifenacin treatment is associated with a number of significant medical, social, and economic factors. The medical factors included the type of urination disorder, severity of incontinence symptoms, presence of side effects, treatment efficacy and patients’ satisfaction with it, and experience using other antimuscarinic treatments. Among the social and economic factors, those with the strongest correlation to compliance were patient age, employment in medicine and education, annual income level, percentage of solifenacin purchase expenditures, and caffeine abuse. Factors with a weaker, but still significant, association were gender, employment in the transportation industry, and monthly income level.

Personal goals and expectations of OAB patients in the UK

INTRODUCTION

In clinical practice and in research patient-centred outcomes are often utilised to help improve communication between patients and clinicians and to help manage expectations from treatment. However, many of these goals are generic and do not adequately capture the details of day to day life that bother patients the most and that they hope will improve with therapy. This study aimed to understand what are the goals of patients with overactive bladder symptoms in the UK who were taking part in a clinical trial and to assess goal achievement.

METHODS

This was a qualitative analysis of the patients goals recorded using the Self-Assessment Goal Achievement (SAGA) Questionnaire during the UK study assessing flexible dose fesoterodine in adults (SAFINA) trial. Free text patient goals were completed at baseline and an assessment of achievement was performed at the end of treatment. Grounded theory was used to develop themes and sub themes.

RESULTS

Three hundred and thirty-one patients completed the trial and 1137 open ended goals were set. Six themes emerged from the data including, OAB, other LUTS and finishing the task in hand with multiple subthemes noted.

CONCLUSIONS

By assessing and understanding what is important to the patient, it may help to tailor patient care and treatment and improve patient satisfaction.

Multicenter Analysis of Urinary Urgency and Urge Incontinence in Patients with Anterior Urethral Stricture Disease before and after Urethroplasty

PURPOSE

Little published data exist on the impact of urethral stricture surgery on urinary urgency. We evaluated urinary urgency and urge incontinence before and after anterior urethroplasty.

MATERIALS AND METHODS

Male patients who underwent 1-stage anterior urethroplasty were retrospectively identified at 8 centers. Patients with preoperative and 2-month or greater postoperative subjective urinary urgency assessments were included in study. Patients who received anticholinergic medications preoperatively were excluded. Univariate and multivariate analysis was done to analyze the association of patient characteristics with preoperative and postoperative symptoms as well as improvement or worsening of symptoms after surgery.

RESULTS

Symptom and followup data on urgency and urge incontinence were available in in 439 and 305 patients, respectively. Preoperatively 58% of the men reported urgency and 31% reported urge incontinence. Postoperatively this decreased to 40% of men for urgency and 12% for urge incontinence (each p <0.01). Of the men 37% reported improvement in urgency and 74% experienced improvement in urge incontinence. Few of those without preoperative symptoms showed worse symptoms, including urgency in 9% and urge incontinence in 5%. New urgency was more likely to develop in men with a higher body mass index (OR 1.09, p = 0.02). Men with stricture recurrence were less likely to show improvement in urgency (OR 0.24, p = 0.03). Older men were more likely to have new urge incontinence (OR 1.06, p = 0.01) and less likely to notice improvement in urge symptoms (OR 0.92, p <0.01).

CONCLUSIONS

The prevalence of urgency and urge incontinence in male patients with anterior urethral stricture is high. The majority of men experience symptom stability or improvement in urinary urge symptoms following anterior urethroplasty.

Comparison of the Effects of Vaginal Royal Jelly and Vaginal Estrogen on Quality of Life, Sexual and Urinary Function in Postmenopausal Women

INTRODUCTION

Several causes can disturb the quality of life in postmenopausal women. Stress, urinary incontinence is one of the factors that can influence the quality of life of women, since they evade social activities and limit their behavior. Vulvovaginal disorders adversely impacts sexual action, psychosocial health, and partner relationships.

AIM

The aim of this study was to examine the therapeutic properties of vaginal cream of royal jelly and estrogen on quality of life, sexual and urinary problems in postmenopausal women.

MATERIALS AND METHODS

This study was a randomized controlled clinical trial that was done on 90 married postmenopausal women 50 to 65-year-old. A total of 90 women were randomly distributed to three groups and were treated with vaginal cream of royal jelly 15%, lubricant, and conjugated estrogens for three months. Before and after intervention, quality of life and vaginal cytology were evaluated. Data was analysed by SPSS 16 using ANOVA and Tukey tests.

RESULTS

The results expressed that vaginal royal jelly is considerably more effective than conjugated estrogens and lubricant in the improvement of quality of life, sexual and urinary function in postmenopausal women (p<0.05). Results of Pap smear showed that improvement of vaginal atrophy in conjugated estrogens group was better than other groups (p<0.001), and there was no significant difference between lubricant and royal jelly groups (p=0.89).

CONCLUSION

The effectiveness of vaginal royal jelly in treatment of sexual and urinary problems of postmenopausal women is related to its estrogenic properties and could be suitable in promotion of life quality in postmenopausal women.

Efficacy and Safety of Mirabegron Add-on Therapy to Solifenacin in Incontinent Overactive Bladder Patients with an Inadequate Response to Initial 4-Week Solifenacin Monotherapy: A Randomised Double-blind Multicentre Phase 3B Study (BESIDE)

BACKGROUND

Incontinence has a greater detrimental effect on quality of life than other symptoms of overactive bladder (OAB) and is often difficult to treat with antimuscarinic monotherapy.

OBJECTIVE

To evaluate the efficacy and the safety and tolerability of combination (solifenacin 5mg and mirabegron 50mg) versus solifenacin 5 or 10mg in OAB patients remaining incontinent after 4 wk of solifenacin 5mg.

DESIGN, SETTING, AND PARTICIPANTS

OAB patients remaining incontinent despite daily solifenacin 5mg during 4-wk single-blind run-in were randomised 1:1:1 to double-blind daily combination or solifenacin 5 or 10mg for 12 wk. Patients receiving the combination were initiated on mirabegron 25mg increasing to 50mg after week 4.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary end point was a change from baseline to end of treatment (EOT) in the mean number of incontinence episodes per 24h (stratified rank analysis of covariance [ANCOVA]). Key secondary end points were a change from baseline to EOT in the mean number of micturitions per 24h (ANCOVA) and number of incontinence episodes noted in a 3-d diary at EOT (mixed-effects Poisson regression). A trial (BESIDE) comparing combination treatment (solifenacin plus mirabegron) with one treatment alone (solifenacin) tested the superiority of combination versus solifenacin 5mg, noninferiority (and potential superiority) of combination versus solifenacin 10mg (key secondary end points), and the safety and tolerability of combination therapy versus solifenacin monotherapy.

RESULTS AND LIMITATIONS

A total of 2174 patients were randomised to combination (n=727), solifenacin 5mg (n=728), or solifenacin 10mg (n=719). At EOT, combination was superior to solifenacin 5mg, with significant improvements in daily incontinence (p=0.001), daily micturitions (p<0.001), and incontinence noted in a 3-d diary (p=0.014). Combination was noninferior to solifenacin 10mg for key secondary end points and superior to solifenacin 10mg for improving daily micturitions. All treatments were well tolerated.

CONCLUSIONS

Adding mirabegron 50mg to solifenacin 5mg further improved OAB symptoms versus solifenacin 5 or 10mg, and it was well tolerated in OAB patients remaining incontinent after initial solifenacin 5mg.

PATIENT SUMMARY

In this 12-wk study, overactive bladder patients who remained incontinent despite initial solifenacin 5mg treatment received additional treatment with mirabegron 50mg. Combining mirabegron 50mg with solifenacin 5mg was superior to solifenacin 5mg alone in improving symptoms of incontinence and frequent urination, and it was well tolerated.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01908829.

Real-World Patterns of Care for the Overactive Bladder Syndrome in the United States

OBJECTIVE

To examine the "real-world" overactive bladder (OAB) practice patterns using national data in the United States.

MATERIALS AND METHODS

The Humedica EHR database was queried. This database consists of de-identified patient records from a network of organizations treating approximately over 30 million patients across states in the United States. The entire study period was from July 1, 2008, to September 30, 2013. Patients with a diagnosis of OAB between July 1, 2009, and June 30, 2012 were included and followed. Patient comorbidities, demographics, diagnostic testing, and medication usage were analyzed.

RESULTS

Of 19,309,600 subjects enrolled during the study period, 46,648 adults had a diagnosis of OAB, with follow-up of at least 6 months, and met the inclusion criteria. There were 35,315 women and 11,333 men. Compared with women, men with OAB were more likely to undergo post-void residual measurement (32% vs 22%) and diagnostic cystoscopy (10% vs 7%). Women were more likely than men to undergo urodynamics (7% vs 3%). Overall, 34% of women and 19% of men diagnosed with OAB were prescribed medication.

CONCLUSION

Few patients with OAB underwent invasive diagnostic testing. Anticholinergic medication was prescribed to a minority of patients diagnosed with OAB, indicating possible underuse of a potentially effective therapy. Men were less likely than women to receive medical therapy, despite the fact that OAB is common in both sexes.

Efficacy and duration of response to botulinum neurotoxin A (onabotulinumA) as a treatment for detrusor overactivity in women

INTRODUCTION AND HYPOTHESIS

Overactive bladder syndrome with urinary incontinence has a number of treatment options. The National Institute for Health and Care Excellence (NICE) in the UK, the American Urological Association (AUA) and the European Association of Urology (EAU) recommend intradetrusor botulinum neurotoxin A (onabotulinumA) injections in women with proven detrusor overactivity (DO) in whom conservative therapies have failed to improve symptoms. However, the effects of individual onabotulinumA treatments are of short duration and patients usually require further treatments. There is little evidence to inform long-term management strategies using onabotulinumA for DO.

METHODS

A retrospective review of patients receiving intradetrusor onabotulinumA injections for DO over a 7-year period was conducted. The primary outcome measures included patient's subjective reports of symptom change following injections (efficacy) and the duration of symptomatic relief following each treatment.

RESULTS

The analysis included 136 patients. The mean time between patients receiving intradetrusor onabotulinumA and being added to the surgical waiting list for re-treatment varied between 8.5 and 10.4 months for the first five cycles of treatment with the longest time between the third and fourth cycles. This decreased to 5.5 and 5.25 (ANOVA p = 0.015) between the fifth and sixth cycles and between the sixth and seventh cycles of treatment, respectively. Only 19.9% of patients continued treatment beyond this, with four patients receiving a seventh treatment.

CONCLUSIONS

Our results suggest that in patients who respond to onabotulinumA treatment, the duration of response declines after the fifth treatment, suggesting a possible tolerance effect and a subsequent decline in efficacy.