The Use of Scopolamine in the Treatment of Detrusor Instability

Urinary incontinence: pharmacotherapy options

The impact of incontinence is felt by millions of people worldwide, with tremendous decrement in quality of life and enormous cost reaching billions of dollars. Urinary incontinence is defined as 'involuntary leakage of urine' and is categorized into two main types: urgency urinary incontinence (UUI) and stress urinary incontinence (SUI). Behavioral modifications and pharmacologic therapies, primarily antimuscarinic agents, are the mainstay of treatment for UUI. These drugs are moderately efficacious but have troublesome side-effects, the combination resulting in poor compliance and persistence with therapy. There are several agents on the market today, each with some variation in pharmacologic properties. Whether these translate into meaningful differences in clinical efficacy and tolerability remains a matter of debate. Treatment of SUI has seen little success with pharmacologic therapy. In Europe, duloxetine is approved for treatment of SUI with marginal success rates; this drug, although available in the United States for treatment of depression, is not approved for SUI. The search for newer and better pharmacologic options and novel therapies is on-going, fueled primarily by the high prevalence of bothersome incontinence and the tremendous number of health care dollars spent on current therapy. This review addresses pharmacologic options for treatment of urinary incontinence.

Periprostatic nerve blockage reduces postoperative analgesic consumption and pain scores of patients undergoing transurethral prostate resection

INTRODUCTION

To evaluate the effects of periprostatic bupivacaine administration on pain control and analgesic consumption after transurethral prostate resection (TURP).

MATERIALS AND METHODS

The study included 40 male patients with benign prostatic hyperplasia who underwent TURP, and they were divided randomly into two groups. All patients were operated under general anesthesia. The study group patients (n = 20) received periprostatic bupivacaine (0.5% 20 ml) injection (group I), and the control patients (n = 20) received only saline (NaCl 0.9% 20 ml) injection (group II). All injections were performed bilaterally into the periprostatic areas immediately after the TURP procedure via the transperineal route. In the postoperative period, all patients (groups I and II) received tramadol using a patient-controlled analgesia device. Postoperative pain was assessed and recorded using the visual analog scale (VAS) at postoperative hours 1, 2, 3, 4, 5, 6, 7, 8, 12, 16, 20, 24, and 48. Total tramadol consumptions and additional analgesic requirements were also recorded and compared between groups.

RESULTS

There was no difference in demographic data between the two groups (p > 0.05). VAS scores of the patients at hours 1, 3, 4, 5, 7, 8, and 12 were found to be significantly lower in group I than in group II (p < 0.05). Total tramadol consumption and patient-controlled analgesia demands of groups I and II were 153.5 +/- 52.4 vs. 465.0 +/- 55.1 mg and 17.1 +/- 7.7 vs. 77.8 +/- 7.5 mg, respectively (p < 0.001). No side effect was observed regarding bupivacaine injections.

CONCLUSIONS

Periprostatic bupivacaine administration was a useful and safe method for postoperative pain control and reduced analgesic consumption in patients undergoing TURP.

Drug delivery across the skin

Since the introduction of the first through the skin (TTS) therapeutic in 1980, a total of 34 TTS products have been marketed and numerous drugs have been tested by more than 50 commercial organisations for their suitability for TTS delivery. Most of the agents which have been tested have had low molecular weights, due to the impermeability of the skin barrier. This barrier resides in the outermost skin layer, the stratum corneum. It is mechanical, anatomical, as well as chemical in nature; laterally overlapping cell multi-layers are sealed by tightly packed, intercellular, lipid multi-lamellae. Chemical skin permeation enhancers increase the transport across the barrier by partly solubilising or extracting the skin lipids and by creating hydrophobic pores. This is often irritating and not always well-tolerated. The TTS approach allows drugs (< 400 kDa in size) to permeate through the resulting pores in the skin, with a short lag-time and subsequent steady-state period. Drug bioavailability for TTS delivery is typically below 50%, avoiding the first pass effect. Wider, hydrophilic channels can be generated by skin poration, with the aid of a small electrical current (> 0.4 mA/cm2) across the skin (iontophoresis) or therapeutic ultrasound (few W/cm2; sonoporation). High-voltage (> 150 V, electroporation) widens the pores even more and often irreversibly. These standard poration methods require experience and equipment and are therefore, not practical; at best, charged/small molecules (< or = 4000 kDa in size) can be delivered efficiently across the skin. In spite of the potential harm of gadget-driven skin poration, this method is used to deliver molecules which conventional TTS patches are unable to deliver, especially polypeptides. Lipid-based drug carriers (liposomes, niosomes, nanoparticle microemulsions, etc.) were proposed as alternative, low-risk delivery vehicles. Such suspensions provide an improved drug reservoir on the skin, but the aggregates remain confined to the surface. Conventional carrier suspensions increase skin hydration and/or behave as skin permeation enhancers. The recently developed carriers; Transferomes, comprise pharmaceutically-acceptable, established compounds and are thought to penetrate the skin barrier along the naturally occurring transcutaneous moisture gradient. Transfersomes are believed to penetrate the hydrophilic (virtual) channels in the skin and widen the former after non-occlusive administration. Both small and large hydrophobic and hydrophilic molecules are deliverable across the stratum after conjugation with Transfersomes. Drug distribution after transdermal delivery probably proceeds via the lymph. This results in quasi-zero order kinetics with significant systemic drug levels reached after a lag-time of up to a few hours. The relative efficiency of TTS drug delivery with Transfersomes is typically above 50 %; with the added possibility of regional drug targeting.

Melatonin Pharmacotherapy for Nocturia in Men With Benign Prostatic Enlargement

PURPOSE

Nocturia is a common condition often attributed in aging men to benign prostatic enlargement. Older adults are prone to nocturnal sleep disturbance, of which disturbed circadian rhythm may be a component since it improves with nighttime administration of melatonin. This study was designed to investigate melatonin as a potential treatment for nocturia associated with bladder outflow obstruction in older men.

MATERIALS AND METHODS

A total of 20 men with urodynamically confirmed bladder outflow obstruction and nocturia were entered into a randomized, double blind, placebo controlled crossover study assessing the effect of 2 mg controlled release melatonin at night on nocturia. Symptoms were assessed at baseline and after each 4-week treatment period using a frequency volume chart, the International Prostate Symptom Score and symptom problem index. Maximum urinary flow rate and post-void residual urine volume were also assessed.

RESULTS

Baseline frequency of nocturia was 3.1 episodes per night. There were 7 men (35%) with detrusor overactivity and 10 (50%) had nocturnal polyuria. Melatonin and placebo caused a decrease in nocturia of 0.32 and 0.05 episodes per night (p = 0.07) and a decrease in the nocturia bother score of 0.51 and 0.05, respectively (p = 0.008). Nocturia responder rates (a reduction from baseline of at least -0.5 episodes per night) differed between the active medication and placebo groups (p = 0.04). Daytime urinary frequency, International Prostate Symptom Score, relative nocturnal urine volume, maximum urinary flow rate and post-void residual were unaffected by melatonin treatment.

CONCLUSIONS

Melatonin treatment is associated with a significant nocturia response rate, improvement in nocturia related bother and a good adverse effect profile. However, it is uncertain whether the observed changes in this study are clinically significant.

Drug therapy for urinary incontinence

Drugs used for treatment of urinary incontinence may act on the central nervous system (CNS) or peripherally. Few drugs with a defined CNS site of action are available for treatment of urine storage disorders; most of those currently used have a peripheral site of action. To treat bladder overactivity associated with urgency and urge incontinence, antimuscarinic drugs, alpha-adrenoceptor antagonists, beta-adrenoceptor agonists, prostaglandin synthesis inhibitors, and several other agents most often developed for non-urological indications, are employed. Current treatment is based on the use of antimuscarinic drugs, and oxybutynin is, despite a high incidence of side-effects, the gold standard. Pharmacological treatment of stress incontinence has had limited success, and only alpha-adrenoceptor agonists, with and without combination with oestrogens have had a documented effect. New drugs, specifically directed at treatment of urine storage disorders, are desirable.

Pharmacologic management of pelvic floor dysfunction

Pharmacologic therapy is an important part of the treatment armamentarium for urogynecologic disorders. Current and future research will determine the utility of such therapy as medications with fewer side effects and more targeted efficacy are developed.