Phase IIb, multicenter, double-blind, randomized, placebo-controlled, parallel-group study to determine effects of elocalcitol in women with overactive bladder and idiopathic detrusor overactivity

Vitamin D levels and the risk of overactive bladder: a systematic review and meta-analysis

CONTEXT

Overactive bladder is treated mainly with behavioral and drug therapy, and symptoms of urinary frequency and incontinence are challenging to eliminate. There is thus a continuous unmet need for new drugs with a substitution effect mechanism.

OBJECTIVE

It not known whether vitamin D deficiency can lead to overactive bladder or urinary incontinence or whether vitamin D supplementation alleviates bladder symptoms. This comprehensive systematic review with meta-analysis was conducted to determine whether overactive bladder is associated with vitamin D deficiency.

DATA SOURCES

The PubMed and Cochrane Library databases were searched systematically up to July 3, 2022.

DATA EXTRACTION

Initially, 706 articles were identified in the literature search, of which 13 were included in the systematic review: 4 randomized controlled trials, 3 cohort studies, 3 cross-sectional studies, and 3 case-control studies.

DATA ANALYSIS

An increased risk of overactive bladder and urinary incontinence was observed with vitamin D deficiency (odds ratio [OR] = 4.46; 95%CI, 1.03-19.33; P = 0.046 and OR = 1.30; 95%CI, 1.01-1.66; P = 0.036, respectively). Vitamin D levels were relatively low in patients with overactive bladder or urinary incontinence (SMD = -0.33; 95%CI, -0.61 to -0.06, P = 0.019). On the basis of existing data, the risk of urinary incontinence was reduced by 66% after vitamin D supplementation (OR = 0.34; 95%CI, 0.18-0.66; P = 0.001). Egger test was conducted to assess publication bias, and the results were tested for robustness using a sensitivity analysis.

CONCLUSIONS

Vitamin D deficiency increases the risk of overactive bladder and urinary incontinence, and vitamin D supplementation reduces the risk of urinary incontinence. The development of new strategies to prevent or alleviate bladder symptoms is crucial. Vitamin D supplementation may be gaining recognition as an effective strategy for prevention or alleviation of bladder symptoms such as overactive bladder and incontinence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022351443.

Total and free 25-hydroxyvitamin D concentrations and risk of urinary incontinence in women participating in Nurses Health Studies I & II

BACKGROUND

Urgency urinary incontinence (UUI) occurs in >40% of older women. Our objective was to examine the relationship of total and free plasma 25-hydroxyvitamin D (25(OH)D) and UUI to evaluate vitamin D status as a novel target for prevention of UUI.

METHODS

We conducted a nested case control study using the Nurses' Health Study (NHS) and NHS II. Using stored plasma samples from 2000, we measured total 25(OH)D, free 25(OH)D, and intact parathyroid hormone (PTH) levels and examined their relationship to incident UUI from 2000 to 2013. Plasma biomarker levels were categorized as quartiles. Multivariable-adjusted odds ratios of UUI were estimated by conditional logistic regression models (with matching by age) across categories of each biomarker and covariates.

RESULTS

The analytic sample included 398 cases of incident UUI and 398 matched controls with a mean age of 50 years. We found a strong correlation of plasma levels of total 25(OH)D with free 25(OH)D (r=0.5). Plasma total 25(OH)D and free 25(OH)D concentrations were negatively correlated with PTH (r=-0.08 AND -0.09, respectively). Overall, we found no evidence that levels of total plasma 25(OH)D, free 25(OH)D, or PTH were related to incident UUI after adjustment for obesity, physical activity, cigarette smoking, menopausal status, hypertension, and type 2 diabetes.

CONCLUSIONS

Free plasma 25(OH)D by quartile, as well as total plasma 25(OH)D, was not associated with incident UUI in women. We found that plasma total and free 25(OH)D were highly correlated with each other and inversely correlated with PTH. Plasma free 25(OH)D did not provide additional predictive value in determining risk of UUI.

The effect of vitamin D on urgent urinary incontinence in postmenopausal women

INTRODUCTION AND HYPOTHESIS

Conflicting results have been reported on the effect of vitamin D supplementation on urinary incontinence (UI). Therefore, the aim of this study was to evaluate the effect of consuming vitamin D oral supplements on improving urge UI (UUI) in postmenopausal women with vitamin D deficiency.

METHODS

This randomized clinical trial was conducted in 2019-2020 in postmenopausal women with UUI or nocturia more than once at night with vitamin D levels less than 30 ng/ml. After recording the severity of UI and its impact on the patient's daily life, patients were randomly divided into two groups of 45 patients: one taking vitamin D3 (50,000 IU) tablets and one taking placebo weekly for 8 weeks.

RESULTS

There was no significant difference between the two groups in terms of the severity of UI and the frequency of nocturia before treatment. However, after treatment, in the vitamin D group, the severity of UI and the frequency of nocturia significantly reduced. Before treatment, the impact of UI on patients' daily life was reported to be high in more than 70% of patients in both groups, which was not significantly different; however, after treatment, its impact was significantly reduced in the vitamin D group.

CONCLUSIONS

The findings of the present study showed that in postmenopausal women with UUI or nocturia, weekly use of vitamin D 50,000 IU tablets for 8 weeks can reduce the severity of UI and the frequency of nocturia, and reduce their impact on disruption in daily life.

Emerging drugs for the treatment of bladder storage dysfunction

INTRODUCTION

Current drug treatment of lower urinary tract disorders, for example, overactive bladder syndrome and lower urinary tract symptoms associated with benign prostatic hyperplasia, is moderately effective, has a low treatment persistence and some short- and long-term adverse events. Even if combination therapy with approved drugs may offer advantages in some patients, there is still a need for new agents.

AREAS COVERED

New b₃-adrenoceptor agonists, antimuscarinics, the naked Maxi-K channel gene, a novel 5HT/NA reuptake inhibitor and soluble guanylate cyclase activators are discussed. Focus is given to P2X3 receptor antagonists, small molecule blockers of TRP channels, the roles of cannabis on incontinence in patients with multiple sclerosis, and of drugs acting directly on CB1 and CB2 receptor or indirectly via endocannabinoids by inhibition of fatty acid aminohydrolase.

EXPERT OPINION

New potential alternatives to currently used drugs/drug principles are emerging, but further clinical testing is required before they can be evaluated as therapeutic alternatives. It seems that for the near future individualized treatment with approved drugs and their combinations will be the prevailing therapeutic approach.

Ocular adverse effects of bladder medication: a systematic review

BACKGROUND

With the ageing population, lower urinary tract symptoms are becoming more prevalent with an estimate that by 2025, 52 million adults in the USA will be affected. After lifestyle modifications fail to resolve symptoms, second-line therapy with medications is often recommended by both the European Association of Urology and the American Urological Association. Considering the vulnerability of older patients to co-morbidities, physicians must be more aware of adverse side effects. This study aims to identify a linkage between common overactive bladder and interstitial cystitis medication and adverse ocular symptoms.

METHODS

A comprehensive literature search was conducted in MEDLINE, EMBASE, CINAHL, PsycInfo, and HealthSTAR alongside a grey literature search in clinicaltrials.gov to include all articles relating to bladder medication and vision-threatening loss. Covidence review software was utilised to conduct the systematic review.

RESULTS

In total, 222 articles were screened, and 23 articles met the inclusion criteria. Comprehensive coverage of 10 available medications was analysed. All medications reported adverse vision effects stratified over 15 categories. The most common adverse effect was reported to be blurred vision (n = 12 studies). Mirabegron had the most number of adverse types of ocular symptoms that covered 6 categories. Cizolirthine Citrate and Elocatitol had the least amount of ocular side effects reported. From the total of 8459 patients that were treated for either overactive bladder syndrome or interstitial cystitis with oral medications, 422 reported adverse vision effects.

CONCLUSIONS

This review suggests that ocular safety should be assessed in patients requiring systematic drug therapy in order to guide future research, focussing on long-term tolerability.

The effect of vitamin D deficiency in children with overactive bladder related urinary incontinence

Purpose:

Overactive bladder (OAB) is a common syndrome associated with lower urinary tract symptoms (LUTS), especially urinary incontinence in children, which may affect the patient's quality of life (QoL). Vitamin D deficiency has been shown to be associated with OAB syndrome. This study evaluated the relationship between vitamin D status and OAB-related symptoms and QoL in children.

Materials and Methods:

The study included 52 pediatric patients with OAB-related urinary incontinence and 41 healthy children. LUTS were assessed using the Dysfunctional Voiding and Incontinence Symptoms Score (DVISS) questionnaire, and QoL was assessed using the Pediatric Incontinence Questionnaire (PINQ). Oral vitamin D supplementation was given to patients with OAB with vitamin D deficiency. Urinary symptoms and QoL were evaluated before and after vitamin D supplementation.

Results:

Vitamin D deficiency was more common in the OAB group (75%) than in the control group (36.6%). Logistic regression analysis revealed that vitamin D status (<20ng/mL) was a significant predictor of OAB. Both pre-treatment and post-treatment DVISS and PINQ scores showed a positive correlation. After vitamin D supplementation, 8 (23.5%) patients had a complete response and 19 (55.9%) patients had a partial response. Significant improvement in QoL was also achieved.

Conclusions:

Vitamin D deficiency is more common in children with urinary incontinence and OAB than in healthy children. Although vitamin D deficiency is not routinely evaluated for every patient, it should be evaluated in treatment-resistant OAB cases. Vitamin D supplementation may improve urinary symptoms and QoL in patients with OAB.

The effect of vitamin D deficiency and supplementation on urinary incontinence: scoping review

INTRODUCTION AND HYPOTHESIS

Vitamin D receptors are found in skeletal and smooth muscle cells throughout the body, specifically in the bladder detrusor muscle. We reviewed the current literature on the association between vitamin D deficiency and urinary incontinence (UI), and whether vitamin D supplementation plays a role in the treatment of UI symptoms.

METHODS

We performed a scoping review of all available studies. PubMed, Google Scholar, and PEDro databases were searched from inception until August 2020 with the keywords "urinary incontinence," "pelvic floor disorders," "lower urinary tract symptoms," "overactive bladder," and various terms for vitamin D. No language restrictions were imposed. The reference lists of all retrieved articles were also searched.

RESULTS

The search revealed 12 studies of different research methodologies after elimination. In 6 out of the 7 cross-sectional studies reviewed, a significant association between vitamin D deficiency or insufficiency and the onset and severity of UI was found. In 2 out of the 3 prospective studies included, no association between vitamin D intake and UI was found; however, both randomized controlled trials that were reviewed found that vitamin D supplementation is effective for the treatment of UI.

CONCLUSIONS

The existing literature supports an association between low levels of serum vitamin D and UI. Initial evidence regarding the effect of vitamin D supplementation on UI is accumulating, yet additional, comprehensive research is warranted to establish these findings.

Serum vitamin D levels in females with urinary incontinence: a meta-analysis of observational trials

INTRODUCTION AND HYPOTHESIS

The association of vitamin D deficiency with female urinary incontinence is unclear.

METHODS

A systematic review of English and non-English articles was conducted. All observational studies in databases including PubMed, EMBASE, the Cochrane Library Trials Register, and Google Scholar were searched until 5 October 2020. Additional studies were identified by contacting clinical experts and searching the bibliographies and abstracts of the compiled articles. Search terms included urinary incontinence and vitamin D. Article data, including study quality indicators, were independently extracted by two authors using predefined data fields.

RESULTS

Two cohort studies, four case-control studies and five cross-sectional studies were included in the qualitative synthesis. Two cohort studies and one cross-sectional study, with a total of 2501 females, were included in the meta-analysis. Heterogeneity among the three studies was not observed (I2 = 0.0%, P = 0.69). All pooled analyses were based on fixed-effects models. No difference in vitamin D level was observed between the urinary incontinence group and the control group (mean difference 0.07 ng/ml; 95% confidence interval [CI] -0.57-0.72, P = 0.81, I2 = 0%).

CONCLUSIONS

Our meta-analysis revealed that adult females with urinary incontinence did not have lower serum vitamin D levels than control females.

Comparing Vitamin D Supplementation Versus Placebo for Urgency Urinary Incontinence: A Pilot Study

OBJECTIVES

To estimate the efficacy of vitamin D supplementation to reduce urgency urinary incontinence (UUI) episodes.

DESIGN

Pilot, two-arm, randomized trial conducted from 2013 to 2017. Interventions were 12 weeks of weekly oral 50,000 IU vitamin D3 or placebo.

SETTING

Academic, university-based outpatient clinic.

PARTICIPANTS

Community-dwelling postmenopausal women, 50 years or older, with at least three UUI episodes on 7-day bladder diary and serum vitamin 25-hydroxyvitamin D (25[OH]D) of 30 ng/mL or less.

MEASUREMENTS

The primary efficacy estimate was the percentage change in UUI episodes. Secondary estimates included changes in other lower urinary tract symptoms, along with exploratory subgroup analysis by race/ethnicity and obesity.

RESULTS

We randomized 56 women (aged 50-84 years; mean = 60.5 ± 8.2 years), 28 to vitamin D and 28 to placebo; 51 completed treatments. Mean serum 25(OH)D at baseline (21.2 ± 5.2 and 18.2 ± 5.6, P = .30) improved to 57.9 ± 16.3 ng/mL with vitamin D3 and 21.9 ± 8.2 ng/mL with placebo (P < .001). UUI episodes per 24-hour day decreased by 43.0% with vitamin D3 compared to 27.6% with placebo (P = .22). Among black women (n = 33), UUI episodes decreased by 63.2% with vitamin D3 compared to 22.9% with placebo (P = .03). Among obese women, UUI episodes decreased by 54.1% with vitamin D compared to 32.7% with placebo (P = .29). For all women, changes in voiding frequency (P = .40), nocturia (P = .40), urgency (P = .90), incontinence severity (P = .81), and overactive bladder symptom severity (P = .47) were not different between arms.

CONCLUSIONS

Postmenopausal women with UUI and vitamin D insufficiency demonstrated a greater than 40% decrease in UUI episodes, which did not reach statistical significance compared to placebo, except in the subset of black women. The results of this pilot study support further investigation of vitamin D3 alone or in combination with other treatments for UUI, particularly for women in higher-risk subgroups. J Am Geriatr Soc 67:570-575, 2019.

Comparison of Serum Vitamin D Levels in Relation to Bowel and Bladder Symptoms in Women with Vulvar Diseases

Objectives: We sought to investigate associations between vitamin D levels and bowel and bladder disorders in women with vulvar diseases. Methods: This is a planned sub-analysis of a cross-sectional study comparing the prevalence of bowel and bladder symptoms in women with biopsy-proven vulvar lichen sclerosus (LS) to a control group of women with non-lichenoid vulvar diseases. All subjects were recruited from a tertiary referral vulvar care clinic in a university-based practice. Serum vitamin D levels were measured and subjects self-completed questionnaires during study recruitment. Pelvic floor disorders were determined from the following questionnaires: Rome III Functional Bowel Disorders Questionnaire, the Bristol stool scale, the Medical, Social and Epidemiologic Aspects of Aging Questionnaire, and the Overactive Bladder-8 Question Version. Results: 181 women with vulvar diseases were included: 88 with LS and 93 with non-LS vulvar diseases. The mean age was 52.5 ± 15.3 years, and 94.5% were Caucasian. Vitamin D levels (26.8 ± 13.1 vs 29.5 ± 19.0 ng/mL), prevalence of low vitamin D levels (51.1% vs 45.2%), and vitamin D supplementation (42.0% vs 47.8%) were similar in women with and without LS (p ≥ 0.27). These factors did not differ between women with and without overactive bladder (OAB) (vitamin D levels 30.1 ± 17.8 vs 26.3 ± 14.8 ng/mL), urinary incontinence (27.9 ± 15.2 vs 26.4 ± 11.0 ng/mL), constipation (26.7 ± 14.8 vs 28.5 ± 16.8 ng/mL), or irritable bowel syndrome (IBS) (30.8 ± 22.1 vs 27.6 ± 13.4 ng/mL). Conclusions: In this cohort of women with vulvar diseases, vitamin D levels and supplementation were not significantly different amongst women with vulvar lichen sclerosus or other non-lichenoid vulvar diseases. Furthermore, vitamin D levels are not serum biomarkers for OAB, urinary incontinence, constipation, or IBS.

Vitamin D and thiol-disulfide homeostasis levels in postmenopausal women with overactive bladder syndrome

Background

This study aimed to find a relationship between vitamin D concentration and thiol-disulfide homeostasis in the pathophysiology of overactive bladder (OAB) syndrome in postmenopausal women.

Methods

A total of 76 postmenopausal women, referred for routine controls, were recruited between January and March 2018 to participate in this study. Participants with an overactive bladder questionnaire (OAB-q) score of >11 (n = 34) were included in the OAB syndrome group, while those with a score of <5 (n = 42) were included in the control group. Serum total antioxidant capacity, ischemia-modified albumin, C-reactive protein, 25-hydroxy vitamin D levels, and thiol-disulfide homeostasis were measured.

Results

Patients with OAB syndrome had waist circumferences of 106 ± 11 cm, and their body mass indexes (BMIs) were 30.8 ± 4.8 kg/m2. The control groups' waist circumferences were 102 ± 11 cm and their BMIs were 28.9 ± 4.3 kg/m2 (p = 0.069 and p = 0.098, respectively). The level of vitamin D in the control group was 33.7 (IQR: 30.7) nmol/L and 27.0 (IQR: 27.5) nmol/L (p = 0.081) in the OAB syndrome group.

Conclusions

We were not able to demonstrate with certainty any significant relationships between serum 25-hydroxy vitamin D levels and thiol-disulfide homeostasis parameters and OAB syndrome.

Factors influencing efficacy endpoints in clinical trials for new oral medicinal treatments for overactive bladder: a systematic literature review and meta-analysis

PURPOSE

Overactive bladder (OAB) is a symptom-based disease; therefore, clinical trials to evaluate treatments for OAB employ a range of efficacy endpoints. Since factors that influence efficacy endpoints can affect trial outcomes, their identification could aid in the design of future OAB clinical trials. We investigated factors influencing different efficacy endpoints used in clinical trials with OAB patients and examined their characteristics to determine future clinical trial strategies for new medicinal treatments for OAB.

METHODS

Data from placebo-controlled double-blind trials in patients with OAB were extracted via a systematic literature review. The integrated differences for efficacy endpoints were calculated. Heterogeneity was assessed using the Q statistic and I² statistic. Factors influencing efficacy endpoints were identified through univariate and multivariate meta-regression analyses.

RESULTS

Forty-one controlled trials were analyzed. Substantial heterogeneity between studies was observed for each efficacy endpoint (P > 0.001, I² > 70%). We found with multivariate meta-regression analysis that period of recording in a bladder diary and year of publication were significantly likely to influence the change from baseline in the mean number of urgency episodes in 24 h, year of publication and gender were significantly likely to influence the change from baseline in the mean number of micturitions in 24 h, and gender was significantly likely to influence the change from baseline in the mean volume voided per micturition. In contrast, there were no factors significantly associated with change from baseline in the mean number of incontinence episodes in 24 h.

CONCLUSIONS

We identified that change from baseline in the mean number of incontinence episodes in 24 h should serve as a relatively stable endpoint. In contrast, we identified factors influencing other endpoints, and the identified factors should be taken into account when planning and conducting future clinical trials.

High dose vitamin D may improve lower urinary tract symptoms in postmenopausal women

Lower urinary tract symptoms (LUTS) are common in postmenopausal women, and have been reported inversely associated with vitamin D intake and serum 25-hydroxyvitamin D (25(OH)D) levels. The aim of this study was to investigate if high dose vitamin D supplementation would affect LUTS in comparison to standard dose. In a randomized controlled study including 297 postmenopausal women with low bone mineral density, the participants were allocated to receive capsules of 20 000IU of vitamin D₃ twice a week (high dose group) or similar looking placebo (standard dose group). In addition, all the participants received 1g of calcium and 800IU of vitamin D daily. A validated questionnaire regarding LUTS was filled in at baseline and after 12 months. At baseline, 76 women in the high dose group and 82 in the standard dose group reported any LUTS. Levels of serum 25(OH)D increased significantly more in the high dose group (from 64.7 to 164.1nmol/l compared to from 64.1 to 81.8nmol/l, p<0.01). No differences between the groups were seen regarding change in LUTS except for a statistically significant reduction in the reported severity of urine incontinence in the high dose group as compared to the standard dose group after one year (p<0.05). The results need confirmation in a study specifically designed for this purpose.

Expected Next-Generation Drugs Under Development in Relation to Voiding Symptoms

New drug development is a high-risk venture, but if successful, will bring great revenues to those willing to accept the risk. In the field of urology, in particular for lower urinary tract symptoms (LUTS), the recent successful landing of drugs (e.g., mirabegron, botulinum toxin A, and tadalafil) has resulted in increased interest in new drug development. Benign prostatic hyperplasia and overactive bladder syndrome, representative LUTS diseases, are attractive targets because of their prevalence and market size in the field of urology. Additionally, the awareness about new stream of research is very important not only because of the market size and economic factors, but also because to keep steady attention to these research for the researcher’s. We have reviewed a selection of new drugs currently under development for the treatment of the two aforementioned diseases and hope to offer urologists an overview of the current situation and future directions in the field of urology.

Vitamin D deficiency and lower urinary tract symptoms in males above 50 years of age

Context:

Lower urinary tract symptoms (LUTSs) in elderly males are usually related to benign prostatic hyperplasia (BPH) in the majority of cases. It is estimated that BPH affects half of men above the age of 50 years. Recently, a relationship between Vitamin D deficiency and LUTS in elderly males has been reported.

Aims:

The aim of this study was to analyze Vitamin D levels in males aged above 50 years presenting with LUTS.

Settings and Design:

This is a prospective case–control study.

Patients and Methods:

This was a case–control study in which males above 50 years of age who presented with LUTS (Group A) were compared with a control group (Group B) without LUTS. Both groups were investigated regarding Vitamin D level, prostate-specific antigen (PSA), International Prostatic Symptoms Score (IPSS), prostate size, flow rate, serum calcium levels, and abdominal ultrasonography.

Statistical Analysis Used:

Statistical software package (SPSS Inc., Chicago, IL, USA) was used for the statistical analyses, performing t-test for quantitative data to compare between the two groups. Pearson's correlation coefficient “r” test was calculated between two quantitative, continuous variables in Group A. P <0.05 was considered statistically significant.

Results:

A total of 150 patients were studied. There were 70 and 80 patients in Groups A and B, respectively. The mean age of Group A patients was 60.32 ± 11.93 years versus 58.12 ± 10.55 years for Group B patients (P > 0.05). The mean value of Vitamin D level was 40.82 ± 29.46 nmol/L in Group A and 70.25 ± 22.42 nmol/L in Group B (P < 0.001). The mean value of prostate size was 50.12 ± 23.24 g in Group A and 30.68 ± 4.90 g in Group B (P < 0.001). The mean serum calcium level was 2.4 ± 0.14 mmol/L and 2.50 ± 0.15 mmol/L in Groups A and B, respectively (P < 0.001). The mean value of PSA in Group A was 2.24 ± 1.95 ng/ml versus 2.11 ± 0.45 ng/ml in Group B (P < 0.001). The mean value of IPSS in Group A was 13.38 ± 5.32 ml/s versus 3.41 ± 2.42 ml/s in Group B. The mean value of Q max in uroflowmetry in Group A was 11.5 ± 2 ml/s versus 15.4 ± 1 ml/s in Group B.

Conclusions:

Men older than 50 years of age with LUTS have lower levels of Vitamin D compared to men without LUTS.

Potential Primary Endpoint for Exploratory Clinical Trial in Patients with Overactive Bladder: A Systematic Literature Review

OBJECTIVES

To identify a potential primary endpoint in an early-phase exploratory trial among key overactive bladder (OAB) symptoms.

METHODS

Placebo-controlled double-blinding trials in patients with OAB were extracted for systematic literature review. The correlation between key OAB symptoms recorded in bladder diaries and coefficient of variation (CV) in each study were assessed.

RESULTS

Forty-one controlled trials were extracted for the present review. Mean number of urgency episodes in 24 h was substantially associated with mean number of urgency incontinence episodes in 24 h, mean volume voided per micturition, and mean number of micturitions in 24 h (Spearman's r = 0.725, -0.661, and 0.657, respectively). Mean number of micturitions in 24 h was also substantially associated with mean volume voided per micturition (Spearman's r = -0.674). Mean number of incontinence episodes in 24 h was substantially associated with mean number of urgency incontinence episodes in 24 h and mean volume voided per micturition (Spearman's r = 0.840 and -0.628, respectively). The median CV of mean volume voided per micturition in each trial was the smallest among all endpoints.

CONCLUSIONS

Our findings suggest that volume voided per micturition is a useful symptom for evaluating OAB candidate compounds in a small sample size and represents an effective primary endpoint, especially in exploratory clinical trials.

New therapeutic strategies for the treatment of male lower urinary tract symptoms

Male lower urinary tract symptoms (LUTS) are prevalent in the general population, especially in those of advanced age, and are characterized by notable diversity in etiology and presentation, and have been proven to cause various degrees of impairment on quality of life. The prostate has traditionally been regarded as the core cause of male LUTS. As a result, medical treatment aims to provide symptomatic relief and effective management of progression of male LUTS due to benign prostatic enlargement. In this context, α₁-blockers, phosphodiesterase-5 inhibitors, and 5α-reductase inhibitors have long been used as monotherapies or in combination treatment to control voiding LUTS. There is accumulating evidence, however, that highlights the role of the bladder in the pathogenesis of male LUTS. Current research interests have shifted to bladder disorders, and medical management is aimed at the bladder. Muscarinic receptor antagonists and the newly approved β₃-adrenergic agonist mirabegron aim to alleviate the most bothersome storage LUTS and thus improve quality of life. As voiding and storage LUTS frequently coexist, combination therapeutic strategies with α₁-blockers and antimuscarinics or β₃-agonists have been introduced to manage symptoms effectively. Anti-inflammatory agents, vitamin D₃-receptor analogs, and cannabinoids represent treatment modalities currently under investigation for use in LUTS patients. Furthermore, luteinizing hormone-releasing hormone antagonists, transient receptor-potential channel blockers, purinergic neurotransmission antagonists, Rho-kinase inhibitors, and inhibitors of endothelin-converting enzymes could have therapeutic potential in LUTS management, but still remain in the experimental setting. This article reviews new strategies for the medical treatment of male LUTS, which are dictated by the potential role of the bladder and the risk of benign prostatic hyperplasia progression. Moreover, combination treatments and therapies currently under investigation are also presented.

Hypovitaminosis D is an independent associated factor of overactive bladder in older adults

AIM OF THE STUDY

Urinary incontinence and vitamin D deficiency are common problems encountered in geriatric population. We aimed to investigate if there is a relationship between these conditions.

SUBJECTS AND METHOD

Among 2281 patients who were admitted to our geriatric medicine outpatient clinic spanning the last three years, 705 patients with known vitamin D status, urinary incontinence and subtype, and calcium plus vitamin D therapy data were included in statistical analysis. Patients who are using calcium plus vitamin D therapy were excluded. SPSS (Statistical Package for Social Sciences) version 15.0 for Windows was used for statistical analysis and p<0.05 was considered as statistically significant.

RESULTS

Mean age of the study population was 72.3±6.4years and 62.8% were female. Plasma vitamin D level (OR: 0.968, 95%CI: 0.943-0.993, p=0.013), MMSE (Mini Mental State Examination) score (OR: 0.944, 95%CI: 0.902-0.989, p=0.014), and serum ALP (Alkaline Phosphatase) level (OR: 0.995, 95%CI: 0.992-0.998, p=0.001) were found to be inversely correlated factors, and serum calcium level (OR: 1.772, 95%CI: 1.008-2.888, p=0.022) was found to be a positively correlated factor of overactive bladder. Considering the different clinical subtypes of urinary incontinence, only urgency incontinence was associated with lower plasma vitamin D level (p=0.013).

CONCLUSIONS

Vitamin D deficiency and insufficiency are independent associated factors for overactive bladder in older adults. This is explicable by effects of vitamin D on muscle growth and function.

The Influence of Maxacalcitol, Vitamin D3 Analog, on Detrusor Overactivity in Conscious Rats

OBJECTIVES

To test the hypothesis that maxacalcitol, vitamin D3 analog, would ameliorate detrusor overactivity (DO) induced by retinyl acetate instillation; to test the outcome of the combined administration of maxacalcitol and the rho kinase inhibitor - GSK 269962, amlodipine besylate, or oxybutynin chloride in this model.

METHODS

The rats were treated with maxacalcitol for 14 days. Then, cystometric studies were performed during which the animals were administered test compounds.

RESULTS

Maxacalcitol in a dose of 30 but not 15 µg/kg/day induced reduction in DO index, non-voiding contractions frequency (FNVC), and amplitude (ANVC), while increasing volume threshold to elicit non-voiding contractions (VTNVC). The 14-day-long administration of maxacalcitol at a dose of 15 µg/kg/day to animals, followed by GSK 269962 at a single dose of 10 mg/kg, led to a statistically significant reduction of intercontraction interval and bladder compliance, and an increase in DO index, without any effect on ANVC, FNVC, and VTNVC. The assessment of the combined effect of maxacalcitol (15 µg/kg/day) and amlodipine besylate (0.25 mg/kg) demonstrated an increase in intercontraction interval, bladder compliance and VTNVC, with a decrease in FNVC. No statistically significant changes were found in DO index and ANVC. The combined outcome of administering maxacalcitol (15 µg/kg/day) and oxybutynin chloride (0.25 mg/kg) did not show any statistically significant value of the measured cystometric parameters.

CONCLUSION

The outcomes of maxacalcitol administration can be the result of 3 mechanisms, that is, the upregulation of L-type Ca(2+) channels, the inhibition of the rho kinase pathway, and a so far unknown central mechanism.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.

RESULTS

This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.

CONCLUSIONS

Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

Drug therapy of overactive bladder--what is coming next?

After the approval and introduction of mirabegron, tadalafil, and botulinum toxin A for treatment of lower urinary tract symptoms/overactive bladder, focus of interest has been on their place in therapy versus the previous gold standard, antimuscarinics. However, since these agents also have limitations there has been increasing interest in what is coming next - what is in the pipeline? Despite progress in our knowledge of different factors involved in both peripheral and central modulation of lower urinary tract dysfunction, there are few innovations in the pipe-line. Most developments concern modifications of existing principles (antimuscarinics, β₃-receptor agonists, botulinum toxin A). However, there are several new and old targets/drugs of potential interest for further development, such as the purinergic and cannabinoid systems and the different members of the transient receptor potential channel family. However, even if there seems to be good rationale for further development of these principles, further exploration of their involvement in lower urinary tract function/dysfunction is necessary.

Emerging drugs for overactive bladder

INTRODUCTION

Overactive bladder (OAB) is a common problem which can have disastrous effects on the quality of life of the sufferer. There are established treatments for the problem but they have significant adverse effects. Better drugs and new treatment modalities are necessary to deal with OAB.

AREA COVERED

Antimuscarinics, mirabegron and intravesical injection of botulinum toxin A are established treatments for OAB. Sacral neuromodulation is more invasive but has been successful in treating OAB. Phase II and III trials are in progress for newer β3-agonists and various combinations of antimuscarinics, β3-agonists and antidiuretics. Targeted secretion inhibitors (TSI) can increase efficacy and reduce adverse effects. Liposome integrated botulinum toxin A has an advantage of effective administration by intravesical instillation. Both medicines are in Phase II trials. Many other drugs which have promising results are discussed.

EXPERT OPINION

Newer antimuscarinics have better tolerability. Long-term data for mirabegron has shown that it is more effective in severe OAB. Combination drugs may prove to be more effective with less adverse effects. Emerging treatments with TSI, lipotoxin and gene therapy appear promising.

Pioneering drugs for overactive bladder and detrusor overactivity: Ongoing research and future directions

The ongoing research on pioneering drug candidates for the overactive bladder (OAB) aimed to overcome the limitations of currently licensed pharmacotherapies, such as antimuscarinics, β3-adrenergic agents, and botulinum neurotoxin, has been reviewed performing a systematic literature review and web search. The review covers the exploratory agents alternative to available medications for OAB and that may ultimately prove to be therapeutically useful in the future management of OAB patients based on preclinical and early clinical data. It emerges that many alternative pharmacological strategies have been discovered or are under investigation in disease-oriented studies. Several potential therapeutics are known for years but still find obstacles to pass the clinical stages of development, while other completely novel compounds, targeting new pharmacological targets, have been recently discovered and show potential to translate into clinical therapeutic agents for idiopathic and neurogenic OAB syndrome. The global scenario of investigational drugs for OAB gives promise for the development of innovative therapeutics that may ultimately prove effective as first, combined or second-line treatments within a realistic timescale of ten years.

Innovative pharmacotherapies for women with overactive bladder: where are we now and what is in the pipeline?

INTRODUCTION AND HYPOTHESIS

The impressive prevalence of overactive bladder (OAB) and the relevant limitations of current treatments urge the need for novel therapeutic approaches.

METHODS

A systematic literature and web search was performed to identify investigational drugs that entered the early and late phases of clinical development for women with OAB symptoms.

RESULTS

Approved pharmacological therapies for OAB (antimuscarinics, beta-3 agonists, and botulinum toxin) are evolving with the development of alternative administration methods, combination strategies, and novel compounds, expected to improve effectiveness, bladder selectivity, and dose flexibility. A wealth of investigational compounds, developed with both public and companies' indoor nonclinical disease-oriented studies, entered the early and late stages of clinical development in the last decade. Most non-anticholinergic compounds in ongoing clinical trials target central and peripheral neurotransmitter receptors involved in neurological modulation of micturition, nonadrenergic-noncholinergic mechanisms, cyclic nucleotide metabolism, different subtypes of ion channels or peripheral receptors of prostaglandins, vanilloids, vitamin D3, and opioids. Fascinating advances are ongoing also in the field of genetic therapy.

CONCLUSIONS

New pharmaceutical formulations and drug combinations are expected to be available in the next decade in order to overcome the limitations of current drugs for OAB. Although proof-of-concept, patient-oriented studies yielded disappointing results for several tentative drugs, a lot of clinical research is ongoing that is expected to provide clinicians with novel therapeutic agents in the near future.

Pathophysiology of idiopathic overactive bladder and the success of treatment: a systematic review from ICI-RS 2013

AIMS

To investigate the frequency of phenotype profiling of patients with idiopathic overactive bladder (OAB) syndrome, and to determine the effectiveness of treatment among individuals with different pathophysiologic profiles.

METHODS

The electronic databases MEDLINE, EMBASE, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and CINAHL were searched from January 1, 1980 to August 12, 2013 for interventional randomized controlled treatment trials (RCTs) of idiopathic OAB. Phenotying for pathophysiologies originating in the urothelial/mucosal layer of the bladder, the detrusor muscle cell layer, and the central nervous system were sought. Articles that analyzed urgency outcomes based on pathophysiologic profiling were selected. Due to the heterogeneity of the included interventions and outcome assessment measures, meta-analysis was not appropriate and a qualitative synthesis was undertaken.

RESULTS

Of 239 original RCTs of idiopathic OAB, 48 (20%) profiled participants on underlying pathophysiology. Less than half of these (n = 20) reported treatment efficacy for urgency symptoms by pathophysiological sub-type. One examined the effect of botulinum A toxin on interstitial cell protein expression. Four compared treatment efficacy in OAB patients with and without involuntary detrusor contractions. Fifteen compared the effect of treatment on urgency reduction in patients with detrusor overactivity. There were no consistent trends in treatment efficacy according to pathophysiologic sub-type. No studies examined urothelial dysfunction or abnormal central processing of bladder afferent signaling in response to treatment.

CONCLUSIONS

In order to advance the field of idiopathic OAB, more trials are needed that profile and test urgency outcomes in participants according to suspected underlying pathophysiology. Neurourol. Urodynam. 33:611-617, 2014. © 2014 Wiley Periodicals, Inc.

Urinary Incontinence in the Young Woman: Treatment Plans and Options Available

Urinary incontinence is a common and distressing condition, which, although not life-threatening, is known to have a significant effect on quality of life. The incidence of urinary incontinence increases with age and while stress urinary incontinence is more common in younger women, symptoms suggestive of overactive bladder are more common with increasing age. All women complaining of incontinence require simple investigation, and many will benefit from conservative and medical treatments, which may be instituted in primary care. Further investigation in the secondary-care setting should be reserved for those women with refractory or unusual symptoms. The aim of this paper is to review the epidemiology and pathophysiology of common causes of urinary incontinence in younger, premenopausal women, and to review the current algorithms for investigation and management. In addition, treatment paradigms covering conservative, medical and surgical treatment for stress urinary incontinence and overactive bladder will be reviewed.

Vitamin D in endometriosis: a causative or confounding factor?

OBJECTIVE

The aim of this paper is to review the evidence from studies that evaluated the relationship between vitamin D and endometriosis.

DESIGN

Comprehensive review.

MATERIALS AND METHODS

Systematic literature search in Medline for relevant publications from 1946 until June 2013.

RESULTS

Endometriosis risk may be influenced by dietary vitamin D intake and plasma hydroxyvitamin D concentration. Vitamin D receptor and vitamin D metabolizing enzymes, 24-hydroxylase and 1-α hydroxylase, are found in the normal cycling endometrium and also in the eutopic and ectopic endometrium of women with endometriosis. The endometrium is a target of 1, 25 dihydroxyvitamin D actions through regulation of specific genes and via immunomodulation. The endometrium in endometriosis expresses dysregulation of some vitamin D enzymes and receptors. If vitamin D and its metabolites are implicated in endometriosis-associated infertility, it is likely through interference with HOXA10 gene expression. The Gc2 phenotype of vitamin D binding protein is prevalent in women with endometriosis and may be implicated in its pathogenesis. In a mouse model, Elocalcitol, a VDR-agonist was shown to reduce the development of endometriotic lesions and recurrence.

CONCLUSION

A biological plausibility for a role of vitamin D, as an immunomodulator and anti-inflammatory agent, in the pathogenesis and treatment of endometriosis is suggested in this article, but is difficult to illustrate due to sparse evidence from human studies limited primarily to case-control studies. A significant knowledge gap precludes the establishment of a clear cause-effect relationship. The intriguing leads presented herein need to be investigated further with placebo-controlled supplementation trials.

New developments in the medical management of overactive bladder

Overactive bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence and is usually associated with frequency and nocturia. Whilst the majority of women will benefit from initial management with conservative and behavioural intervention a significant number will require medical therapy. Antimuscarinics are currently the most widely prescribed drugs for OAB although very often persistence with medication is limited due to lack of efficacy or intolerable adverse effects. The review, whilst giving a brief overview of OAB syndrome, will focus on new developments in drug therapy for OAB. In addition to evaluating new drugs with different methods of action it will also specifically focus on alternative modalities of treatment and how they may benefit patients with this troublesome and distressing condition.

Future direction in pharmacotherapy for non-neurogenic male lower urinary tract symptoms

BACKGROUND

The pathophysiology of male lower urinary tract symptoms (LUTS) is highly complex and multifactorial. The shift in perception that LUTS are not sex or organ specific has not been followed by significant innovations regarding the available drug classes.

OBJECTIVE

To review pathophysiologic mechanisms and clinical and experimental data related to the development of new pharmacologic treatments for male LUTS.

EVIDENCE ACQUISITION

The PubMed database was used to identify articles describing experimental and clinical studies of pathophysiologic mechanisms contributing to male LUTS and, supported by them, new pharmacotherapies with clinical or experimental evidence in the field.

EVIDENCE SYNTHESIS

Several pathologic processes (eg, androgen signaling, inflammation, and metabolic factors) and targets (eg, the urothelium, prostate, interstitial cells, detrusor, neurotransmitters, neuromodulators, and receptors) have been implicated in male LUTS. Some newly introduced drugs, such as phosphodiesterase type 5 inhibitors and β3-adrenergic agonists, have just started broad use in clinical practice. Drugs with potential benefit, such as vitamin D3 receptor analogs, gonadotropin-releasing hormone antagonists, cannabinoids, and drugs injected into the prostate, have been evaluated in experimental studies and have progressed to clinical trials. However, safety and efficacy data for these drugs are still scarce. Some compounds with interesting profiles have only been tested in experimental settings (eg, transient receptor potential channel blockers, Rho-kinase inhibitors, purinergic receptor blockers, and endothelin-converting enzyme inhibitors).

CONCLUSIONS

New pathophysiologic mechanisms of male LUTS are described that lead to the continuous development of new pharmacotherapies. To date, few drugs have been added to the current armamentarium, and several are in various phases of clinical or experimental investigation.

Effects of vitamin D analog on bladder function and sensory signaling in animal models of cystitis

OBJECTIVE

To measure the effects of nonhypercalcemic vitamin D receptor agonist elocalcitol on bladder function in rats with cyclophosphamide-induced cystitis and on bladder function and sensory nerve activity in a mouse with acetic acid-evoked bladder irritation.

MATERIALS AND METHODS

Female Wistar rats and male Balb/C mice were gavaged once daily with elocalcitol diluted in miglyol 812 (treatment group) or miglyol alone (control group). On experimental day 12, polyethylene tubing was implanted into the urinary bladder in all the animals. In the mice, a bipolar electrode was positioned under a single postganglionic bladder nerve. At 48 hours after surgery, bladder function was measured in awake, freely moving rats during bladder filling with 0.9% NaCl and both bladder function and sensory nerve activity was measured in awake, restrained mice during continuous intravesical infusion of 0.9% NaCl followed by 0.25% acetic acid.

RESULTS

In rats, the treatment group showed a significant increase in bladder capacity and decrease in number of nonvoiding bladder contractions. In mice, the filling pressure during saline infusion was similar in both groups; however, during acetic acid infusion, the average filling pressure was significantly increased (47%) in the control group but not in the elocalcitol treatment group. The firing rate at filling pressure for the treatment group was 3.6-fold and 2.7-fold lower than that in the control group during the saline and acetic acid infusion, respectively.

CONCLUSION

Oral treatment with elocalcitol suppressed signs of detrusor overactivity in both animal models and exerted strong suppressive effect on urinary bladder sensory signaling during filling in mice.