Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response

Detrusor Overactivity May Be a Prognostic Factor for Better Response to Combination Therapy Over Monotherapy in Male Patients With Benign Prostatic Enlargement and Storage Lower Urinary Tract Symptoms

Purpose

Several trials have shown that in men with overactive bladder (OAB) and benign prostate enlargement (BPE), the combination of an α-blocker with an anticholinergic is superior to α-blocker monotherapy. The purpose of this study is to explore whether urodynamic detrusor overactivity (DO) affects clinical outcomes in men with BPE and OAB.

Methods

This is a post hoc analysis of a prospective, randomized trial, designed to evaluate the changes of morphometric parameters of the prostate following monotherapy or combination therapy in men with BPE-OAB. The initial study recruited men aged ≥50 years, with BPE and predominantly storage lower urinary tract symptoms (LUTS). Patients were randomized to receive tamsulosin monotherapy or a combination of tamsulosin and solifenacin for 26 weeks. All participants completed a 3-day bladder diary and the International Prostate Symptom Score (IPSS), and then underwent pressure-flow and ultrasonographic studies. Data were stratified and analysed based on the urodynamic observation of DO at baseline (DO vs. non-DO). The primary endpoint was the mean change in urgency episodes from baseline. Secondary outcomes were the changes in nocturia, total IPSS, and urodynamic parameters.

Results

Sixty-nine men were initially randomized, but only 60 men were included in this analysis. Urgency episodes significantly improved in men with DO who received combination therapy compared to the DO monotherapy subgroup (P=0.04) or to the non-DO combination treatment subgroup (P=0.038). Nocturia also improved in the DO combination treatment subgroup as compared to the non-DO combination subgroup (P=0.037). The 24-hour frequency and total IPSS significantly improved from baseline without significant differences among the subgroups.

Conclusions

The present study suggests that baseline DO could be a prognostic factor for a better response to combination therapy over monotherapy in men with BPE and storage LUTS.

Impact of urodynamic evaluation on the treatment of women with idiopathic overactive bladder: a systematic review

INTRODUCTION

Overactive bladder (OAB) is a common clinical condition affecting women. The impact of urodynamics (UDS) on the management of idiopathic OAB in women is highly debated. This systematic review analyzes the impact of UDS on the choice and on the outcomes of treatment of female idiopathic OAB.

EVIDENCE ACQUISITION

A systematic literature search in the PubMed/Medline, Web of Science, Scopus and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement to identify clinical trials, randomized controlled trials, meta-analyses, and guidelines on female OAB and UDS published from 2000. A total of 1554 records were initially identified and 12 articles were included in the final qualitative synthesis.

EVIDENCE SYNTHESIS

UDS represents the main tool to diagnose detrusor overactivity (DO) in OAB female patients which is considered one of the major OAB underlying pathophysiology factor. UDS can underline the presence of voiding dysfunction that could be considered as another underlying cause of uncomplicated female OAB. On the basis of this urodynamic findings, we can better define different aspects of OAB syndrome leading to a more tailored and proper treatment.

CONCLUSIONS

UDS can have a useful role in the diagnosis of idiopathic OAB in women given the possibility to gain a precise diagnosis and, therefore, a tailored treatment based on the underlying cause. The integration of clinics with UDS and all the other diagnostic available tools is desirable.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 2 - Male and neurogical population

Recent studies in literature, have raised some doubts on the routine use of urodynamic testing. Many physicians and articles recommend a selective use of this tool, considering carefully risks and benefits. These recommendations are intended to guide clinicians in the right selection of the male and neurological patients to submit to a urodynamic evaluation. This is the second part of a previous article regarding the urodynamic recommendations in the female population. We reviewed the literature, regarding the use of UDS in male and neurological population with lower urinary tract symptoms (LUTS). Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and urogynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in male and neurological population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with LUTS, and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

A Preliminary Study on the Impact of Detrusor Overactivity on the Efficacy of Selective Bladder Denervation for the Treatment of Female Refractory Overactive Bladder

OBJECTIVE

To determine whether the presence of detrusor overactivity (DO) is associated with the 12-week and 12-month clinical outcomes of selective bladder denervation (SBD) in women with refractory overactive bladder (OAB).

METHODS

Prospective single institutional study of refractory OAB females who underwent a urodynamic study and were categorized according to DO status (DO- vs DO+) prior to receiving SBD.

RESULTS

Among the 23 patients, 10 were DO- and 13 were DO+. Both groups reported improvement at 12 weeks on the 24-hour pad weight test, in urgency urinary incontinence (UUI) and urgency. At 12 months, both groups still reported improvement in urgency, but only the DO- group reported reduction on the pad weight test and only the DO+ group maintained improvement in the UUI rate. Clinical success (≥50% reduction in UUI) was achieved by all DO- and by 69% of DO+ patients at 12 weeks, and by 60% of DO- and 92% of DO+ patients at 12 months. Treatment benefit (Treatment Benefit Scale ≤2) was reported in 90% of DO- and 85% of DO+ patients at 12 weeks, and in 60% of DO- and 85% of DO+ patients at 12 months. When directly comparing both group outcomes, the only significant difference was the greater reduction of UUI in the DO- group at 12 weeks (-9.0 vs -6.5; P = .045).

CONCLUSION

Refractory OAB females appear to be effectively treated by SBD regardless of baseline DO status. DO status does not seem to be associated with the 12-week and 12-month outcomes of SBD.

The role of urodynamics in females with lower urinary tract symptoms

Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used.

Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: ‘female urology’, ‘lower urinary tract symptoms’, ‘urodynamic’, ‘incontinence’, ‘overactive bladder’, ‘bladder outlet obstruction’. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society.

Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS.

Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity.

Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence

Ambulatory urodynamic monitoring: state of the art and future directions

Urodynamic studies are a key component of the clinical evaluation of lower urinary tract dysfunction and include filling cystometry, pressure-flow studies, uroflowmetry, urethral function tests and electromyography. However, pitfalls of traditional urodynamics include physical and emotional discomfort, artificial test conditions with catheters and rapid retrograde filling of the bladder, which result in variable diagnostic accuracy. Ambulatory urodynamic monitoring (AUM) uses physiological anterograde filling and, therefore, offers a longer and more physiologically relevant evaluation. However, AUM methods rely on traditional catheters and pressure transducers and do not measure volume continuously, which is required to provide context for pressure changes. Novel telemetric AUM (TAUM) methods that use wireless, catheter-free, battery-powered devices to monitor bladder pressure and volume while patients carry out their daily activities are currently being investigated. TAUM devices under current development are innovating in the areas of remote monitoring, rechargeable energy sources, device deployment and retrieval and materials engineering to provide increased diagnostic accuracy and improved comfort for patients with incontinence or voiding dysfunction. These devices hold promise for improving the diagnosis and management of patients with lower urinary tract disorders.

The impact of urodynamics on treatment and outcomes in women with an overactive bladder: a longitudinal prospective follow-up study

INTRODUCTION AND HYPOTHESIS

The aim of this study was to establish if the management of women with overactive bladder (OAB) and patient-reported outcomes differed based on the findings of urodynamics (UDS).

METHODS

A prospective, longitudinal observational study conducted in urogynaecology clinics in 22 UK hospitals participating in the Diagnostic Accuracy of Bladder Ultrasound Study (BUS). A total of 687 women with OAB symptoms or urgency-predominant mixed urinary incontinence were recruited into a diagnostic study that used UDS as the reference standard. Detailed clinical history and International Consultation on Incontinence OAB Short Form (ICIQ-OAB sf) questionnaire responses were obtained before the UDS test was carried out. These questionnaires were subsequently collected at a mean of 7 and 20 months, along with patient global impression of improvement and details on medical and surgical treatments. The relationship between UDS diagnosis and treatment was examined using a multinomial regression model; logistic and repeated measures regressions were used to examine other outcomes.

RESULTS

We recruited 687 women and the response rate was 69% at 20 months. Treatment subsequent to UDS was highly associated with diagnosis (p < 0.0001). Women who received treatment concordant with their UDS findings were more likely to report an improvement in bladder symptoms (57% vs 45%; p = 0.02) and ICIQ-OAB sf scores (0.5 points, 95%CI: 0.1 to 0.9; p = 0.02).

CONCLUSIONS

Urodynamics influenced treatment decisions made by clinicians in determining treatment pathways in women presenting with OAB. Women treated based on UDS diagnoses appear to have greater reductions in symptoms than those who do not.

The predictive value of ePAQ in the urodynamic diagnoses-A prospective cohort study

AIMS

To assess whether the electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) had accuracy in predicting the urodynamic diagnoses of Detrusor Overactivity (DO) and/or Urodynamic Stress Incontinence (USI).

METHODS

Tertiary urogynaecology unit linked to an academic university teaching hospital. Consecutive women who presented with lower urinary tract symptoms (LUTS) and were booked to have urodynamic studies. Women completed an ePAQ-PF prior to having urodynamics (UDS) by clinicians who were blinded to the ePAQ-PF results while conducting this procedure. Receiver Operating Characteristics (ROC) curves were constructed for predictive accuracy of overactive bladder (OAB) score in DO and of stress urinary incontinence (SUI) score in USI. Prospective cohort study designed to meet the requirements of the standards for reporting of diagnostic accuracy (STARD).

RESULTS

390 women with a mean age of 54.2 (range 21-92) years were recruited. The majority (n = 294; 75%) were White Caucasian and had two children (n = 157; 40.3%). Of them, 67.2% (n = 262) had DO and USI was confirmed in 21.5% (n = 84). The area under the ROC curve for DO was 0.704 (95% confidence interval 0.650-0.759) and for USI it was 0.731 (95% confidence interval 0.652-0.778).

CONCLUSIONS

The OAB and SUI scores on the ePAQ-PF demonstrated that they are fair predictors in diagnosing DO and USI. As the OAB and SUI score on ePAQ-PF increased so did the likelihood of DO (up to a score of 75) and USI on UDS.

Effectiveness of BTX-A and neuromodulation in treating OAB with or without detrusor overactivity: a systematic review

INTRODUCTION AND HYPOTHESIS

Patients with refractory overactive bladder (OAB) pose a therapeutic challenge. Guidelines such as those from the National Institute for Health and Care Excellence recommend invasive treatments such as botulinum toxin-A ((BTX-A), sacral neural stimulation (SNS) etc. only if there is detrusor overactivity (DO) on urodynamics.

METHODS

Our aim was to systematically evaluate evidence based on the presence or absence of DO in relation to differences in effectiveness and complications related to invasive treatment in patients with refractory OAB. We carried out a systematic search of Cochrane, MEDLINE, Embase, CINAHL, LILACS, meta-Register of Controlled Trials (mRCT), CENTRAL, and Google Scholar databases from inception until April 2016. Abstracts presented at IUGA, ICS and EAU conferences (until April 2016) were included and journals that were hand searched.

RESULTS

We found five studies (two prospective cohort studies and subgroup analyses of two randomized controlled trials (RCTs) and one cohort study for BTX-A, one multicenter prospective cohort study for percutaneous tibial nerve stimulation (PTNS) and three (one RCT and two cohort studies) for SNS. The outcomes in patients without (n = 77) or with (n = 135) DO were similar in the context of urodynamic findings, bladder diaries, quality of life (QoL) questionnaires, etc. when treated with BTX-A [odds ratio (OR) 1.52, 95% confidence interval (CI) 0.40-5.77] or SNS (50 patients without and 81 with DO; OR1.37, CI 0.76-2.48). Outcomes for PTNS (based on a single study) seem to be better in patients without DO.

CONCLUSION

The limited evidence suggests that urodynamic diagnosis of DO does not alter patient reported outcomes for invasive treatments such as BTX-A and SNS. Noninferiority RCTs powered to evaluate the role of DO in predicting treatment response are required.

Evaluation of female overactive bladder using urodynamics: relationship with female voiding dysfunction

Purpose:

To investigate the role of urodynamic study (UDS) in female patients with overactive bladder (OAB) analyzing the relationship between OAB symptoms and female voiding dysfunction (FVD).

Materials and Methods:

We analyzed the clinical and urodynamic data of 163 women with OAB symptoms. OAB symptoms were categorized as dry and wet. FVD was described as detrusor underactivity (DUA), which was defined as a maximum flow rate (Q_max) of ≤15mL/s associated with a detrusor pressure at Q_max (PdetQ_max) of ≤20cmH₂O, along with bladder outlet obstruction (BOO), which was defined as a Q_max of ≤15mL/s with a PdetQ_max of >20cmH₂O. Clinical and urodynamic results were compared between patients with dry and wet symptoms and between those with and without FVD.

Results:

78 (47.9%) had dry, and 85 (52.1%) had wet symptoms. The entire group had a relatively low Q_max (15.1±6.6mL/s) and relatively high number of BOO (42.9%, 70/163) and DUA (8.6%, 14/163). A significantly higher number of patients with wet symptoms had detrusor overactivity compared to those with dry, as detected by the UDS (p<0.05). No significant differences were found in BOO and DUA number between dry and wet groups. Further, the international prostate symptom score did not different significantly between patients with and without FVD.

Conclusion:

A significant number of women with OAB had voiding dysfunction. However, the OAB symptoms themselves were not useful for predicting the presence of FVD. Therefore, UDS may be necessary for accurate diagnosis in women with OAB symptoms.

Is pretreatment cystometry important in predicting response to mirabegron in women with overactive bladder symptoms?

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate for any association between pretreatment cystometry results and outcome of treatment with mirabegron in women with overactive bladder (OAB) symptoms.

METHODS

This was a prospective observational study of women with OAB symptoms that proved refractory to conservative management. All women underwent filling and voiding subtraction cystometry prior to further treatment. Women were treated with mirabegron 50 mg once daily, and outcomes were evaluated after 6 weeks' treatment. The primary outcome measure was change in symptoms as indicated by response to the Patient Global Impression of Improvement (PGI-I) scale. The presence of detrusor overactivity (DO), the highest detrusor pressure recorded during the filling phase, the presence of urodynamic stress incontinence (USI), cystometric capacity, voided volume, maximum flow rate and detrusor pressure at maximum flow were all compared between responders and nonresponders.

RESULTS

The study population consisted of 169 women; response rate to mirabegron was 69.8 %. There was no association between the presence of DO or maximum detrusor pressure during filling and USI, cystometric capacity, maximum flow rate and detrusor pressure at maximum flow and treatment response. In a subgroup with OAB symptoms refractory to previous treatment with antimuscarinics, there was an association between the presence of DO and a positive treatment response (p = 0.02).

CONCLUSIONS

Overall, there is no association between urodynamic findings and response to treatment with mirabegron. This may reflect the fact that mirabegron's mode of action mechanisms are not measurable using cystometry. In women with refractory symptoms, however, the presence of DO is associated with a positive response to treatment.

Potential Biomarkers Utilized to Define and Manage Overactive Bladder Syndrome

Clinical diagnosis of overactive bladder (OAB) syndrome has great variation and usually can only be based on subjective symptoms. Measurement of urgency severity score in adjunct with voiding diary may reflect the occurrence of OAB and incontinence severity in daily life. Urodynamic study can detect detrusor overactivity (DO), but not in all OAB patients. A more objective way and less invasive tool to diagnose and assess therapeutic outcome in OAB patients is needed. Recent investigations of the potential biomarkers for OAB include urinary and serum biomarkers and bladder wall thickness. Evidence has also shown that urinary proteins, such as nerve growth factor (NGF) and prostaglandin E2 (PGE2 ) levels increase in patients with OAB, bladder outlet obstruction (BOO) and DO. Patients with OAB have significantly higher urinary NGFlevels and urinary NGF levels decrease after antimuscarinic therapy and further decrease after detrusor botulinum toxin injections. However, the sensitivity of single urinary protein in the diagnosis of OAB is not high and several lower urinary tract diseases may also have elevated urinary NGF levels. Searching for a group of inflammatory biomarkers by microsphere-based array in urine might be a better method in differential diagnosis of OAB from interstitial cystitis, urinary tract infection (UTI) or urolithiasis. Bladder wall thickness has been widely investigated in the diagnosis of BOO and pediatric voiding dysfunction.The role of bladder wall thickness in the diagnosis of OAB, however, has not reach a consistent conclusion. We hereby review the latest medical advances in this field.

Urodynamic findings in women with refractory overactive bladder symptoms

OBJECTIVES

To assess: (i) the correlation between overactive bladder symptoms and urodynamic findings in female patients; and (ii) the association of urinary symptoms with the presence of detrusor overactivity and/or bladder outlet obstruction.

METHODS

The present retrospective study included female patients with overactive bladder symptoms who underwent urodynamic evaluation by a single physician. Patients with previous anti-incontinence surgery or neurogenic bladder were excluded. Spearman's correlation coefficients were calculated to correlate overactive bladder symptoms with the urodynamic findings. Univariate and multivariate logistic regression analyses were used to determine the independent factors for detrusor overactivity and bladder outlet obstruction.

RESULTS

Overall, 1737 reports were analyzed. All patients had urgency with or without urgency urinary incontinence. Urgency, urgency urinary incontinence and nocturia correlated with detrusor overactivity. The severity of frequency, nocturia and slow stream correlated with bladder outlet obstruction. In contrast, stress urinary incontinence showed an inverse, but weak, correlation with bladder outlet obstruction. Stress urinary incontinence correlated moderately with urine leak. Storage symptoms showed an inverse, but weak, correlation with maximum cystometric capacity. Multivariate analysis data showed that age, urgency, urgency urinary incontinence and nocturia were independent predictors of detrusor overactivity, whereas the severity of frequency was a predictor of bladder outlet obstruction.

CONCLUSION

As overactive bladder symptoms increase in severity, female patients tend to have a smaller bladder capacity and a higher incidence of detrusor overactivity. A significant number of these patients have bladder outlet obstruction.

Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence?

Overactive bladder and urgency incontinence are common and distressing conditions in older people, for which the first-line pharmacological treatment is a bladder antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first-line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first-line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in particular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people.

The concept of peripheral modulation of bladder sensation

It is recognized that, as the bladder fills, there is a corresponding increase in sensation. This awareness of the volume in the bladder is then used in a complex decision making process to determine if there is a need to void. It is also part of everyday experience that, when the bladder is full and sensations strong, these sensations can be suppressed and the desire to void postponed. The obvious explanation for such altered perceptions is that they occur centrally. However, this may not be the only mechanism. There are data to suggest that descending neural influences and local factors might regulate the sensitivity of the systems within the bladder wall generating afferent activity. Specifically, evidence is accumulating to suggest that the motor-sensory system within the bladder wall is influenced in this way. The motor-sensory system, first described over 100 years ago, appears to be a key component in the afferent outflow, the afferent "noise," generated within the bladder wall. However, the presence and possible importance of this complex system in the generation of bladder sensation has been overlooked in recent years. As the bladder fills the motor activity increases, driven by cholinergic inputs and modulated, possibly, by sympathetic inputs. In this way information on bladder volume can be transmitted to the CNS. It can be argued that the ability to alter the sensitivity of the mechanisms generating the motor component of this motor-sensory system represents a possible indirect way to influence afferent activity and so the perception of bladder volume centrally. Furthermore, it is emerging that the apparent modulation of sensation by drugs to alleviate the symptoms of overactive bladder (OAB), the anti-cholinergics and the new generation of drugs the β 3 sympathomimetics, may be the result of their ability to modulate the motor component of the motor sensory system. The possibility of controlling sensation, physiologically and pharmacologically, by influencing afferent firing at its point of origin is a "new" concept in bladder physiology. It is one that deserves careful consideration as it might have wider implications for our understanding of bladder pathology and in the development of new therapeutic drugs. In this overview, evidence for the concept peripheral modulation of bladder afferent outflow is explored.

The evidence for urodynamic investigation of patients with symptoms of urinary incontinence

Urodynamic studies are the gold standard to objectively diagnose dysfunction of the lower urinary tract. The widely available evidence for the clinical relevance is, however, fragmented. This article summarizes the published knowledge supporting the use of urodynamic studies in urinary incontinence in female, male and frail patients, as well as patients with relevant neurological disease. Five technological innovations are discussed briefly. Standard urodynamic cystometry can, on the basis of a solid body of evidence, objectively unveil the entire function of the lower urinary tract in all patients with urinary incontinence, regardless of the patients' perception of (ab-)normality of signs and or symptoms.

Urgency severity scale could predict urodynamic detrusor overactivity in patients with overactive bladder syndrome

AIMS

To evaluate the correlation between an urgency severity scale (USS) based on a voiding diary with detrusor overactivity (DO) in a videourodynamic study in patients with an overactive bladder (OAB).

METHODS

We prospectively enrolled 190 consecutive patients with OAB. All patients were assessed using a USS and completed a 3-day voiding diary that recorded urgency and urgency urinary incontinence (UUI) episodes and the degree of urgency severity. The highest recorded USS score in the voiding diary was considered as the USS score. A videourodynamic study was performed, and the presence of increased bladder sensation (IBS) or DO was recorded. These clinical findings and videourodynamic data were analyzed.

RESULTS

This study enrolled 65 men and 125 women. The mean patient age was 66.4 years (21-88). Among them, 82.6% had urodynamic DO, 7.9% had IBS, and 9.5% had normal urodynamic findings. The prevalence of DO was 50%, 76%, and 94% in patients with a USS = 2, 3, and 4, respectively. Multivariate analysis indicated that OAB wet, high USS and UUI were significantly associated with the presence of DO. Urodynamic DO was present in most patients with OAB wet (94.1%) or USS = 4 (95.5%); however, only 63.9% of OAB dry patients had DO. In the OAB dry patients, 11/25 (44%) with USS = 2, 30/42 (71%) with USS = 3, and 5/5 (100%) with USS = 4 had DO.

CONCLUSIONS

A high USS recorded in conjunction with a voiding diary and OAB wet were strongly associated with urodynamic DO.

Novel biomarkers for overactive bladder

Biomarkers constitute any objectively measurable indicator of a biological process. The classic biomarker used in the diagnosis of overactive bladder (OAB) has been detrusor overactivity, which is assessed urodynamically. In the search for a reliable, noninvasive alternative to urodynamics, interest has focused on genetic, imaging, and urinary factors. Along with other cytokines detectable in urine, prostaglandin E2 and nerve growth factor are indicators of low-grade inflammation. Although they correlate with OAB symptom severity, they have not been shown to have independent prognostic benefit. Imaging biomarkers have been investigated since the earliest days of video urodynamics. Despite extensive research on the ultrasonographic estimation of bladder wall thickness, further standardization of the technique is required before conclusions can be reached regarding diagnostic accuracy. Genetic factors contribute approximately half of the total risk for urgency incontinence. Functional polymorphisms of the cytochrome P450 IID6 gene significantly alter the metabolism of some commonly used anticholinergic drugs, but no genetic loci that influence risk of OAB have been definitively identified. The first genome-wide association studies for OAB are in progress, and should identify new susceptibility genes. Although current putative biomarkers correlate with OAB severity, much future work is required to assess their prognostic value, and establish their role in clinical practice.

The effects of drug and behavior therapy on urgency and voiding frequency

INTRODUCTION AND HYPOTHESIS

The objective of this study was to examine the effects of drug therapy alone and combined with behavioral therapy on urgency and 24-voiding frequency in women with urge-predominant incontinence and to identify predictors of change.

METHODS

A planned analysis of data from a multi-site, randomized, controlled trial (N = 307). Bladder diaries were used to document voids, incontinence, and urgency severity.

RESULTS

Urgency scores decreased significantly within both treatment groups, but changes did not differ between groups (p = 0.30). Improvement in urgency was associated with greater baseline urgency (p < 0.0001) and black ethnicity (p = 0.03). Voiding frequency increased with drug alone and decreased slightly with combined therapy (p = 0.009), and improvement was associated with combined treatment (p < 0.0001), higher baseline frequency (p < 0.0001), and lower baseline incontinence episode frequency (p = 0.001).

CONCLUSIONS

Although combined drug and behavioral therapy does not appear to improve urgency more than drug alone, it resulted in better outcomes on voiding frequency.

Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary incontinence and for fecal incontinence. Part 1: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients

AIMS

The members of The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing' provide an executive summary of the chapter 'Dynamic Testing' that discusses (urodynamic) testing methods for patients with signs and or symptoms of urinary incontinence. Testing of patients with signs and or symptoms of faecal incontinence is also discussed.

METHODS

Evidence based and consensus committee report.

RESULTS

The chapter 'Dynamic Testing' is a continuation of previous Consultation-reports added with a new systematic literature search and expert discussion. Conclusions, based on the published evidence and recommendations, based on the integration of evidence with expert experience and discussion are provided separately, for transparency.

CONCLUSION

This first part of a series of three articles summarizes the committees recommendations about the innovations in urodynamic study techniques 'in general', about the test characteristics and normal values of urodynamic studies as well as the assessment of female with signs and or symptoms of incontinence and includes only the most recent and relevant literature references.

Extended-release trospium chloride improves quality of life in overactive bladder

OBJECTIVES

Overactive bladder syndrome (OAB) is a urinary condition that often exerts detrimental effects on an individual's quality of life (QoL). A once-daily, extended-release (ER) formulation of the quaternary amine trospium chloride has recently been developed for the treatment of OAB. The pooled health-related QoL (HRQoL) data from two multicenter, parallel-group, double-blind Phase III studies with trospium chloride ER 60 mg were analyzed.

METHODS

Subjects aged>or=18 years with urinary urgency, frequency, and an average of >or=1 urge urinary incontinence episode per day on a 3-day bladder diary were randomized (1:1) to receive once-daily trospium 60 mg ER or placebo for 12 weeks. HRQoL was assessed at baseline and at Week 12 using the King's Health Questionnaire (KHQ) and the OAB questionnaire (OAB-q).

RESULTS

Overall, 1165 subjects were randomized (trospium ER, n=578; placebo, n=587). Trospium ER produced significantly greater improvements from baseline than placebo in seven of the nine KHQ domains. At Week 12, the improvement in mean OAB-q HRQoL total score (from approximately 52 at baseline) was significantly greater with trospium ER than with placebo (+25.8 vs. +20.7; P=0.0003). Improvements from baseline were seen with trospium ER on all eight of the OAB-q symptom bother scales.

CONCLUSIONS

Once-daily trospium 60 mg ER improved the QoL of subjects with OAB, as assessed using the KHQ and the OAB-q, in two large Phase III clinical trials.

Basic mechanisms of urgency: roles and benefits of pharmacotherapy

INTRODUCTION

Since urgency is key to the overactive bladder syndrome, we have reviewed the mechanisms underlying how bladder filling and urgency are sensed, what causes urgency and how this relates to medical therapy.

MATERIALS AND METHODS

Review of published literature.

RESULTS

As urgency can only be assessed in cognitively intact humans, mechanistic studies of urgency often rely on proxy or surrogate parameters, such as detrusor overactivity, but these may not necessarily be reliable. There is an increasing evidence base to suggest that the sensation of ‘urgency’ differs from the normal physiological urge to void upon bladder filling. While the relative roles of alterations in afferent processes, central nervous processing, efferent mechanisms and in intrinsic bladder smooth muscle function remain unclear, and not necessarily mutually exclusive, several lines of evidence support an important role for the latter.

CONCLUSIONS

A better understanding of urgency and its causes may help to develop more effective treatments for voiding dysfunction.

Ultrasonographic bladder measurements can replace urodynamic study for the diagnosis of non-monosymptomatic nocturnal enuresis

OBJECTIVE

To compare urodynamic (UD) and ultrasonography (US)-based measurements for the diagnosis and follow-up of patients with non-monosymptomatic primary nocturnal enuresis (NMPNE).

PATIENTS AND METHODS

The study included 455 enuretic children (282 boys and 173 girls, mean age 9.58 years) with daytime voiding symptoms and with more than one void per night. In healthy children the upper limits for US-measured bladder wall thickness are 3 and 5 mm for a full or empty bladder, respectively. In 419 children the results showed urodynamic signs of an overactive bladder (OAB) and the US-measured bladder wall was thickened. After 6 months of antimuscarinic treatment, we re-assessed the children with US and UD; the relation between UD and US measurements was confirmed. After analysing these data, we considered the use of a new diagnostic assessment for patients with NMPNE. In children with a significant US measurement, i.e. a bladder wall with a thickness of >3 mm (full bladder) and >5 mm (empty bladder), the diagnostic assessment was concluded and therapy was started. We restricted the UD examination exclusively to those patients who either had severe intractable symptoms or did not respond to treatment. This new management was applied to 453 patients with NMPNE. After the first 6 months of therapy all the patients were assessed with a new US study.

RESULTS

In all, 343 patients (75.7%) were full-responders, with a normal bladder wall thickness; 82 (18.1%) were partial responders but with no normalization of bladder wall thickness; only 28 (6.2%) were classified as nonresponders with a persistent thickened bladder wall.

CONCLUSIONS

We favour a more conservative management: the UD study should be limited to the very few patients who either have severe intractable symptoms or do not respond to treatment. In our experience, the US study, which is not invasive, is useful for the diagnosis and follow-up of NMPNE and it is preferable to the UD study, which is invasive and often traumatic for children.

Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?

OBJECTIVE

We sought to determine if there are differences in clinical and urodynamic parameters between women with urge predominant and those with stress predominant mixed urinary incontinence (MUI).

METHODS

Charts of 99 female patients with complaints of MUI were reviewed. Patients were divided into two groups based on the subjective predominance of either stress incontinence (MSUI) or urge incontinence (MUUI). All patients completed a subjective evaluation including an AUA Symptom Index, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Objective non-invasive measures included physical exam, 48-hr voiding diary, and a 24-hr pad test. Videourodynamics studies (VUDS), performed in all patients, were reviewed and the presence and characteristics of detrusor overactivity (DO) and stress incontinence were noted.

RESULTS

There were no significant differences between groups with respect to symptom scores. MUUI patients had significantly higher pad usage, and lower maximum and average voided volumes than MSUI patients. They were also more likely to have lower urodynamic bladder capacities and demonstrable DO (70% vs. 26%) on VUDS with contractions occurring at lower bladder volumes and with higher amplitude. MSUI patients were more likely to have demonstrable SUI on physical examination (63% vs. 16%) and on VUDS (100% vs. 61%).

CONCLUSIONS

There do appear to be differences in clinical and urodynamic parameters between patients with stress predominant and urge predominant MUI. These may help to determine which component of the mixed incontinence is more problematic.

Duloxetine compared with placebo for treating women with symptoms of overactive bladder

OBJECTIVE

To evaluate duloxetine (a serotonin-noradrenaline reuptake inhibitor) in women with symptoms of overactive bladder (OAB), as it has been shown to increase the bladder capacity in an animal model.

PATIENTS AND METHODS

In all, 306 women (aged 21-84 years) were recruited and randomly assigned to placebo (153) or duloxetine (80-mg/day for 4 weeks increased to 120-mg/day for 8 weeks; 153). Symptoms of OAB were defined as bothersome urinary urgency and/or urge urinary incontinence (UI) for > or =3 months. Participants were also required to have a mean daytime voiding interval (VI) of < or=2 h and urodynamic observations of either detrusor overactivity (DOA) or urgency which limited bladder capacity to <400 mL, both with no stress UI (SUI). The primary efficacy analysis compared the treatment effects on mean change from baseline to endpoint in the mean number of voiding episodes (VE)/24 h. The secondary efficacy analyses compared the treatment effects on the number of UI episodes (IE)/24 h, in the Incontinence Quality of Life questionnaire (I-QOL) score, and on the mean daytime VI. Safety was assessed with vital signs, adverse event reporting, routine laboratory testing, electrocardiogram, and the measurement of postvoid residual urine volumes (PVR).

RESULTS

Patients randomized to duloxetine had significant improvements over those randomized to placebo for decreases in VE and IE, for increases in the daytime VI, and for improvements in I-QOL scores at both doses of duloxetine. Urodynamic studies showed no significant increases in maximum cystometric capacity or in the volume threshold for DOA. The most common treatment-emergent adverse events with duloxetine (nausea, 31%; dry mouth, 16%; dizziness, 14%; constipation, 14%; insomnia, 13%; and fatigue, 11%) were the same as those reported by women with SUI and were significantly more common with duloxetine than placebo. Laboratory assessments, vital signs and electrocardiograms were stable relative to baseline, with no relevant differences detected between groups. There was a significant difference in the change in PVR with duloxetine (<5 mL mean increase) but no patient reported hesitancy or retention.

CONCLUSION

In this trial, duloxetine was better than placebo for treating women with 'wet' and 'dry' symptoms of OAB associated with DOA or a bladder capacity of <400 mL.

Oxybutynin in Detrusor Overactivity

Oxybutynin has been used for the management of detrusor overactivity for over 30 years and has withstood medical scrutiny and the test of time throughout the world. Although several agents in the class of bladder relaxants have only recently been studied, oxybutynin's effectiveness in reducing urinary frequency and urge urinary incontinence is unquestioned in the medical literature. Oxybutynin is extremely safe and effective in almost every population including children, the elderly, and those who have neurogenic bladder. With more preparations available and more dosing flexibility than any other anticholinergic medication on the market, oxybutynin remains the "gold standard" for first-line therapy for patients who have detrusor overactivity.

Trospium Chloride: Distinct Among Other Anticholinergic Agents Available for the Treatment of Overactive Bladder

Trospium chloride is an antimuscarinic agent indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency. It has been available in Europe for over 20 years and in the United States since May 2004. Trospium has pharmacologic properties that are distinct from other antimuscarinic agents. The safety and efficacy profiles of trospium and how its pharmacologic properties contribute to these profiles form the basis for this review. The low incidence of adverse event of central nervous system effects and the efficacy parameters of "urgency" and "onset of action" are highlighted.

Is sensory urgency part of the same spectrum of bladder dysfunction as detrusor overactivity?

It has been suggested that the urogynecological diagnosis of sensory urgency is an early form of detrusor overactivity and may be just earlier in the spectrum of disease. The former term is generally defined as increased perceived bladder sensation during filling, a low first desire to void and low bladder capacity in the absence of recorded urinary tract infection (UTI) or detrusor overactivity. The aims of this study are to determine the prevalence and associations of sensory urgency in comparison with detrusor overactivity, and whether sensory urgency is shown to be in the same spectrum of bladder dysfunction as detrusor overactivity. Five hundred and ninety-two women attending for an initial urogynecological/urodynamic assessment took part in this prospective study. In addition to a full clinical assessment, all women underwent free uroflowmetry, residual urine volume measurement (by vaginal ultrasound) and multichannel filling and voiding cystometry. Data were separated into those having (1) sensory urgency or (2) detrusor overactivity. Apart from prevalence figures, comparative associations were sought for (3) age; (4) parity; (5) presenting symptoms; (6) presence of at least one (medically) documented UTI in the previous 12 months; (7) two or more (recurrent) documented UTIs in the previous 12 months; (8) prior hysterectomy; (9) prior continence surgery; (10) menopause; (11) menopause and HRT use; (12) sign of clinical stress leakage; (13) retroverted uterus; (14) anterior vaginal wall prolapse; (15) uterine prolapse; (16) posterior vaginal wall prolapse; (17) apical vaginal prolapse; (18, 19) maximum, average urine flow rate (MUFR, AUFR) centiles, Liverpool Nomograms; (20) median residual urine volume (RUV) in milliliters; (21, 22) voiding difficulty: VD1,VD2 (MUFR, AUFR under 10th centile Liverpool Nomogram and/or RUV >30 ml); (23) diagnosis of urodynamic stress incontinence and (24) diagnosis of uterine and/or vaginal prolapse (grade >0). The prevalence of sensory urgency was 13%. The only differences in the clinical and urodynamic profiles of it and detrusor overactivity were (1) significantly increased prevalence of the symptom of urge incontinence and (2) (by definition) abnormal detrusor contractions during filling cystometry in women with detrusor overactivity. Overall, sensory urgency and detrusor overactivity appear to be part of the same spectrum of bladder dysfunction.