Comparative Effectiveness of Anticholinergic Therapy for Overactive Bladder in Women: A Systematic Review and Meta-analysis

Safety and Efficacy of Trospium Chloride and Solifenacin in Stroke-Induced Neurogenic Lower Urinary Tract Dysfunction: A Randomized Controlled Trial

BACKGROUND

Neurogenic dysfunction of the lower urinary tract is one of the challenging diseases with high burdens in urology. Our study aims to evaluate the efficacy of a 4-week treatment with Solifenacin and Trospium chloride and assess their safety and impact on quality of life.

METHODS

Following the selection of 206 stroke patients from two centers who met specific eligibility criteria, including a clinical diagnosis of stroke, normal cognitive function, and the presence of lower urinary tract symptoms (LUTS), participants were randomly assigned to receive oral Solifenacin, Trospium chloride, or a placebo. Under the supervision of the Ethics Committee, the baseline characteristics, compliance with medication, and outcomes were monitored, gathered, and analyzed.

RESULTS

The majority of participants were male, with a mean age of 67.3, and most had ischemic stroke. The groups had no significant difference in urinary symptoms after stroke. All of the symptoms in the study groups, according to the NBSS questionnaire, were decreased following treatment compared to the baseline (p < 0.05). After treatment, ICIQ-OAB, and ICIQ-LUTS-QOL total scores and bothersome scores decreased significantly compared to baseline (p < 0.001). When compared to the placebo, both Trospium chloride and Solifenacin alleviated symptoms according to the NBSS questionnaire and ICIQ-LUTS-QOL, total ICIQ-OAB, and the total score of ICIQ-OAB-Bothersome. However, the total LUTS-QOL-Bothersome score did not change in the active treatment groups compared to the placebo. While comparing the two drugs, these values were similar except for the total score of LUTS-QOL-Bothersome, ICIQ-OAB, and ICIQ-OAB-Bothersome in favor of the Solifenacin group. Moreover, Solifenacin had fewer side effects compared to Trospium chloride or placebo.

CONCLUSION

The study analyzed 206 stroke patients in two international centers and found both drug arms effective in treating overactive bladder. However, inconsistencies were found in efficacy and safety, necessitating further studies with larger populations.

TRIAL REGISTRATION

This triple-blind, multicenter, randomized controlled trial was done on 206 stroke patients after getting Ethical Committee approval and registering the project on IRCT (IRCT20160606028304N2).

Methodologies Used in Studies of Self-Management Interventions for Urinary Incontinence in Adult Women: An Integrative Review

BACKGROUND

Urinary incontinence (UI) affects approximately 60% of women in the United States and negatively impacts self-esteem, sexual function, participation in social activities, and quality of life (QOL). Self-management interventions show promise for improving UI symptoms and QOL. Previous reviews of UI self-management studies have focused on outcomes for older women. However, the literature lacks a synthesis of methodologies of these studies.

PURPOSE

The purpose of this integrative review was to synthesize and evaluate methodologies used in studies of self-management interventions for UI in adult women.

METHODS

Using an integrative review approach, a search of PubMed, CINAHL, and Embase was conducted yielding 1404 results, 23 of which met inclusion criteria. Data abstracted from each article included author(s), year of publication, study design and purpose, sample, country and setting, measures of UI symptoms, and intervention description.

RESULTS

Findings showed methodological differences, particularly in design, assessment of UI subtypes, measures of UI symptoms, and intervention components. Multicomponent self-management interventions were used in 18 studies and 1 component used in 5 studies. Education, pelvic floor muscle exercises, and bladder training were the intervention components most frequently used, either alone or in combination; however, intervention components were not consistently aligned with the UI subtypes. Analysis of ethical matters revealed areas for improvement, specifically in reporting privacy and confidentiality and in methods to obtain informed consent.

CONCLUSIONS

Results highlight opportunities to improve the rigor of methodologies used in studies of self-management interventions for UI in adult women.

Patient and Clinician Challenges with Anticholinergic Step Therapy in the Treatment of Overactive Bladder: A Narrative Review

Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β3-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β3-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.

Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006.

OBJECTIVES

To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.

Weak association between arterial hypertension and overactive bladder baseline symptoms and treatment responses

While animal studies have suggested an association between the presence of hypertension and the presence and/or severity of overactive bladder syndrome (OAB) symptoms, little clinical data is available. We have conducted a pre-specified secondary analysis of a non-interventional study involving 4450 OAB patients being treated with solifenacin to explore the existence of an association between OAB and hypertension using three parallel and overlapping definitions of hypertension to enhance robustness of analysis. Regardless of definition, patients with hypertension were older and had greater OAB symptom severity in univariate analyses. In multiple regression models including age as explanatory covariate, most relationships held up but effect sizes of concomitant hypertension on OAB severity were small (odds ratios <1.35 in all cases) and were deemed to be unlikely of clinical relevance. % Changes in symptom severity were somewhat smaller in univariate analysis, but effect sizes were small. We conclude that OAB and arterial hypertension are associated but effect sizes are too small to justify adaptation of clinical practice for OAB patients with concomitant hypertension.

National Trends in Third-Line Treatment for Overactive Bladder Among Commercially Insured Women, 2010-2019

OBJECTIVE

To investigate whether the 2010 introduction of percutaneous tibial nerve stimulation and the 2013 introduction of intradetrusor onabotulinumtoxinA were associated with an increase in overall utilization of third-line treatments.

METHODS

Using medical claims data from IBM Marketscan database 2010-2019, diagnosis codes were used to identify adult women with overactive bladder. Procedure codes were used to identify third-line treatments. The annual proportion of patients receiving third-line treatments was calculated, as well as the proportion of each treatment received. These were modeled as a function of treatment year using linear regression; a regression coefficient significantly different from 0 was considered evidence of a significant change in utilization over time.

RESULTS

We identified 3,067,515 unique individuals with a diagnosis of overactive bladder, including 14,652 who initiated third-line treatments. The annual percentage of women with overactive bladder who initiated third-line treatment was 0.18% and did not change significantly over 10 years (P = .82). However, the proportion receiving sacral neuromodulation decreased significantly (P <.001), with a compensatory increase in intradetrusor onabotulinumtoxinA. Within 6 years of its introduction, onabotulinumtoxinA accounted for almost half of third-line treatments initiated.

CONCLUSION

Overall, third-line therapies for non-neurogenic overactive bladder are utilized infrequently among privately insured women. Over the past decade, the introduction of new treatment options has led to a shift in the type of treatment initiated, rather than to an increase in the overall utilization of third-line therapies.

Nanotechnology as a tool to advance research and treatment of non-oncologic urogenital diseases

Nanotechnology represents an expanding area of research and innovation in almost every field of science, including Medicine, where nanomaterial-based products have been developed for diagnostic and therapeutic applications. Because of their small, nanoscale size, these materials exhibit unique physical and chemical properties that differ from those of each component when considered in bulk. In Nanomedicine, there is an increasing interest in harnessing these unique properties to engineer nanocarriers for the delivery of therapeutic agents. Nano-based drug delivery platforms have many advantages over conventional drug administration routes as this technology allows for local and transdermal applications of therapeutics that can bypass the first-pass metabolism, improves drug efficacy through encapsulation of hydrophobic drugs, and allows for a sustained and controlled release of encapsulated agents. In Urology, nano-based drug delivery platforms have been extensively investigated and implemented for cancer treatment. However, there is also great potential for use of nanotechnology to treat non-oncologic urogenital diseases. We provide an update on research that is paving the way for clinical translation of nanotechnology in the areas of erectile dysfunction (ED), overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and catheter-associated urinary tract infections (CAUTIs). Overall, preclinical and clinical studies have proven the utility of nanomaterials both as vehicles for transdermal and intravesical delivery of therapeutic agents and for urinary catheter formulation with antimicrobial agents to treat non-oncologic urogenital diseases. Although clinical translation will be dependent on overcoming regulatory challenges, it is inevitable before there is universal adoption of this technology to treat non-oncologic urogenital diseases.

What Are Realistic Expectations to Become Free of Overactive Bladder Symptoms? Experience from Non-interventional Studies with Propiverine

INTRODUCTION

Unmet expectations are a major cause of perceived treatment failure and discontinuation of treatment. To enable evidence-based counselling of patients on realistic expectations, we determined the chance of patients with overactive bladder becoming free of a given symptom upon treatment with a muscarinic antagonist in a non-interventional setting.

METHODS

Two non-interventional studies included 1335 and 745 patients, respectively, who received 30 or 45 mg q.d. propiverine ER for 12 weeks. They were monitored for becoming free of urgency, urinary incontinence, frequency, or nocturia. Analyses were also performed in subgroups defined by basal symptom severity, age, and gender. Categorical data are shown as a percentage of the respective population. Continuous data are expressed as means or as median depending on whether the variability was considered to exhibit a normal distribution.

RESULTS

The probability of becoming symptom-free was largest for incontinence and frequency (about 50%), but lesser for urgency (about 20%) and nocturia (about 10%). Greater basal severity of a symptom reduced the chance to become free of that symptom upon treatment, but the chance to become free of incontinence and frequency was still considerable. Age and gender had only minor if any effects on the chance of becoming symptom-free. These findings are in line with those of a limited number of randomized controlled trials.

CONCLUSION

These data provide an evidence base for the counselling of patients with overactive bladder on realistic expectations of treatment outcomes. We propose that realistic expectations can lead to greater long-term adherence.

Evaluation and Treatment of Urinary Incontinence in Women

This review focuses on the diagnosis, evaluation, and treatment of urinary incontinence (UI). UI is a common diagnosis that is encountered among women in their lifetime. Stress, urge (overactive bladder), and overflow are the most commonly encountered types of incontinence, but anatomic and neurologic causes are important to rule out. There are many treatment options available for the management of UI, and most patients will benefit from conservative strategies including weight loss, timed voiding, fluid intake reduction, pelvic floor strengthening exercises, and medications. For those who do not achieve adequate improvement with conservative measures, surgical intervention can provide good symptom relief.

Axonics® system for treatment of overactive bladder syndrome and urinary urgency incontinence

Introduction: Overactive bladder and urge urinary incontinence affect millions of women and men and results in billions of dollars in health-care expenses. First- and second-line therapy includes behavioral modifications and/or pharmacotherapies however, many patients' symptoms remain or progress on these treatments. There has been concern regarding the detrimental side effects of the most widely prescribed medications for these bladder symptom management.Areas covered: As a result, there has been increased interest in continuous sacral neuromodulation, an FDA approved therapy for refractory urinary urgency and urge urinary incontinence. In this article, we specifically review current research on the efficacy and patient/provider satisfaction and safety profile of the Axonics® System. In addition, we address the current state of sacral neuromodulation and potential future direction and applicability.Expert opinion: The Axonics® system is a safe effective device for the treatment of overactive bladder and urinary urge incontinence. Additionally, it affords patient's the convenience of a rechargeable, compact, MRI safe system. It should be noted that the rechargeable system, while allowing for approximately 15 years of battery and lead life, may have its challenges in terms of charge burden. Furthermore, this system is easily adapted for experienced implanters of sacral neuromodulating devices.

A teaching tool about the fickle p value and other statistical principles based on real-life data

A poor understanding of statistical analysis has been proposed as a key reason for lack of replicability of many studies in experimental biomedicine. While several authors have demonstrated the fickleness of calculated p values based on simulations, we have experienced that such simulations are difficult to understand for many biomedical scientists and often do not lead to a sound understanding of the role of variability between random samples in statistical analysis. Therefore, we as trainees and trainers in a course of statistics for biomedical scientists have used real data from a large published study to develop a tool that allows scientists to directly experience the fickleness of p values. A tool based on a commonly used software package was developed that allows using random samples from real data. The tool is described and together with the underlying database is made available. The tool has been tested successfully in multiple other groups of biomedical scientists. It can also let trainees experience the impact of randomness, sample sizes and choice of specific statistical test on measured p values. We propose that live exercises based on real data will be more impactful in the training of biomedical scientists on statistical concepts.

Diagnosis and management of overactive bladder: A review

AIM

Overactive bladder (OAB) is a common and troublesome condition that can significantly impair quality of life. This review aims to educate providers of obstetrics and gynecology services about available therapies for OAB and what to expect following treatment.

METHODS

Here, we review published data from studies that have evaluated available treatments for OAB. Relevant articles published over the past 2 decades, including large multicenter trials, were identified through a literature search using PubMed.gov, and the references in those articles were also manually searched to find additional articles. Treatment guidelines and product labels were also reviewed.

RESULTS

Behavioral therapy is recommended as a first choice for OAB management; pharmacologic treatment (anticholinergics, β₃ -adrenoceptor agonists) as second-line treatment; and onabotulinumtoxinA, peripheral tibial nerve stimulation, and sacral nerve stimulation as third-line therapy for patients refractory or intolerant to first- and second-line treatments. A stepwise approach to treatment through first-, second-, and third-line therapies is recommended, recognizing this may not be appropriate for all patients.

CONCLUSIONS

To optimize symptom control and set realistic expectations, patients should be carefully monitored and counseled appropriately on available treatment options.

Factors Associated with Decisions for Initial Dosing, Up-Titration of Propiverine and Treatment Outcomes in Overactive Bladder Syndrome Patients in a Non-Interventional Setting

Two doses of propiverine ER (30 and 45 mg/d) are available for the treatment of overactive bladder (OAB) syndrome. We have explored factors associated with the initial dosing choice (allocation bias), the decision to adapt dosing (escalation bias) and how dosing relative to other factors affects treatment outcomes. Data from two non-interventional studies of 1335 and 745 OAB patients, respectively, receiving treatment with propiverine, were analyzed post-hoc. Multivariate analysis was applied to identify factors associated with dosing decisions and treatment outcomes. Several parameters were associated with dose choice, escalation to higher dose or treatment outcomes, but only few exhibited a consistent association across both studies. These were younger age for initial dose choice and basal number of urgency and change in incontinence episodes for up-titration. Treatment outcome (difference between values at 12 weeks vs. baseline) for each OAB system was strongly driven by the respective baseline value, whereas no other parameter exhibited a consistent association. Patients starting on the 30 mg dose and escalating to 45 mg after 4 weeks had outcomes comparable with those staying on a starting dose of 30 or 45 mg. We conclude that dose escalation after 4 weeks brings OAB patients with an initially limited improvement to a level seen in initially good responders. Analysis of underlying factors yielded surprisingly little consistent insight.

Diagnosis and Management of Postpartum Pelvic Floor Disorders

Pelvic floor disorders are common in the postpartum period. These disorders can significantly affect one's quality of life during a period that is already filled with emotional and physiologic change. This review focuses on the presentation, diagnosis, and treatment of the 3 major pelvic floor disorders in postpartum women, namely, urinary incontinence, fecal incontinence, and pelvic organ prolapse.

Is the addition of vaginal electrical stimulation to transcutaneous tibial nerve electrical stimulation more effective for overactive bladder treatment? A randomized controlled trial

INTRODUCTION AND OBJECTIVES

Overactive bladder (OAB) is a prevalent disorder that increases with age and impairs patients' quality of life. Guidelines recommend behavior modifications as the first-line treatment; however, physiotherapy has also been used with success, safety, and low cost. Transcutaneous tibial nerve electrical stimulation (TTNS) and vaginal electrical stimulation (VS) are being used in clinical physiotherapy practice. This study aimed to verify whether the addition of VS to TTNS is more beneficial than TTNS alone for women with OAB.

PATIENTS AND METHODS

In all, 106 women aged >18 years diagnosed with OAB or mixed urinary incontinence with prevalent OAB symptoms were randomly divided into 2 groups: Group 1: TTNS (n = 52); Group 2: TTNS + VS (n = 54). The 3 day voiding diary, pelvic floor muscle strength (Ortiz Scale), King's Health Questionnaire, and Overactive Bladder Questionnaire were assessed before and after treatment. Urinary frequency was considered the primary outcome, and a reduction of ≥ 3 micturitions/day was considered clinically relevant. Mixed linear models were used to compare the 2groups.

RESULTS

Initially, the groups were similar in age, body mass index, number of pregnancies, time of OAB onset, and prevalence of OAB symptoms. After treatment, a reduction in urinary frequency of 1.5 micturitions was observed in Group 2, which was not clinically relevant despite being statistically significant.

CONCLUSIONS

The addition of VS to TTNS for the treatment of OAB was not more effective than TTNS as a single therapy.

Bladder bacterial diversity differs in continent and incontinent women: a cross-sectional study

BACKGROUND

Since the discovery of the bladder microbiome (urobiome), interest has grown in learning whether urobiome characteristics have a role in clinical phenotyping and provide opportunities for novel therapeutic approaches for women with common forms of urinary incontinence.

OBJECTIVE

This study aimed to test the hypothesis that the bladder urobiome differs among women in the control cohort and women affected by urinary incontinence by assessing associations between urinary incontinence status and the cultured urobiome.

STUDY DESIGN

With institutional review board oversight, urine specimens from 309 adult women were collected through transurethral catheterization. These women were categorized into 3 cohorts (continent control, stress urinary incontinence [SUI], and urgency urinary incontinence [UUI]) based on their responses to the validated Pelvic Floor Distress Inventory (PFDI) questionnaire. Among 309 women, 150 were in the continent control cohort, 50 were in the SUI cohort, and 109 were in the UUI cohort. Symptom severity was assessed by subscale scoring with the Urinary Distress Inventory (UDI), subscale of the Pelvic Floor Distress Inventory. Microbes were assessed by expanded quantitative urine culture protocol, which detects the most common bladder microbes (bacteria and yeast). Microbes were identified to the species level by matrix-assisted laser desorption and ionization time-of-flight mass spectrometry. Alpha diversity indices were calculated for culture-positive samples and compared across the 3 cohorts. The correlations of UDI scores, alpha diversity indices, and species abundance were estimated.

RESULTS

Participants had a mean age of 53 years (range 22-90); most were whites (65%). Women with urinary incontinence were slightly older (control, 47; SUI, 54; UUI, 61). By design, UDI symptom scores differed (control, 8.43 [10.1]; SUI, 97.95 [55.36]; UUI, 93.71 [49.12]; P<.001). Among 309 participants, 216 (70%) had expanded quantitative urine culture-detected bacteria; furthermore, the urinary incontinence cohorts had a higher detection frequency than the control cohort (control, 57%; SUI, 86%; UUI, 81%; P<.001). In addition, the most frequently detected species among the cohorts were as follows: continent control, Lactobacillus iners (12.7%), Streptococcus anginosus (12.7%), L crispatus (10.7%), and L gasseri (10%); SUI, S anginosus (26%), L iners (18%), Staphylococcus epidermidis (18%), and L jensenii (16%); and UUI, S anginosus (30.3%), L gasseri (22%), Aerococcus urinae (18.3%), and Gardnerella vaginalis (17.4%). However, only Actinotignum schaalii (formerly Actinobaculum schaalii), A urinae, A sanguinicola, and Corynebacterium lipophile group were found at significantly higher mean abundances in 1 of the urinary incontinence cohorts when compared with the control cohort (Wilcoxon rank sum test; P<.02), and no individual genus differed significantly between the 2 urinary incontinence cohorts. Both urinary incontinence cohorts had increased alpha diversity similar to continent control cohort with indices of species richness, but not evenness, strongly associated with urinary incontinence.

CONCLUSION

In adult women, the composition of the culturable bladder urobiome is associated with urinary incontinence, regardless of common incontinence subtype. Detection of more unique living microbes was associated with worsening incontinence symptom severity. Culturable species richness was significantly greater in the urinary incontinence cohorts than in the continent control cohort.

Optimizing Nonsurgical Treatments of Overactive Bladder in the United States

Overactive bladder syndrome is a prevalent condition impacting quality of life, activities of daily living, work productivity, physical and psychological health, sleep, and sexuality. Published guideline recommendations and effective behavioral, pharmacologic, and neuromodulatory therapies exist; however, adherence can be poor. Clinicians have important roles educating patients, setting treatment expectations, and providing follow-up. Determining patient goals, routinely assessing and adjusting therapy, and combining treatment strategies may improve outcomes. We review the benefits and challenges of overactive bladder treatments and propose approaches to improve patient management, with the goals of initiating therapy earlier and achieving better patient satisfaction, functioning, and quality of life.

Evaluation and Treatment of Overactive Bladder in Women

Overactive bladder (OAB) is a symptom complex that includes urinary urgency, frequency, urgency incontinence, and nocturia. It is highly prevalent, affecting up to 12% of the adult population, and can significantly impact quality of life. The diagnosis of OAB is made by history, physical examination, and a urinalysis to rule out underlying infection or other concerning potential etiologies. The need for additional testing is based on the initial evaluation findings, and is recommended in cases of underlying urinary tract infection, microscopic hematuria, obstructive voiding symptoms, and symptoms refractory to previous treatments. Initial management includes behavioral modification with attention to total daily fluid intake, avoidance of bladder irritants, treatment of constipation, weight loss, timed voiding, urge-suppression techniques, and pelvic floor physical therapy. Options for oral medications include antimuscarinic agents and β adrenergic agents, and can be used following or in conjunction with behavioral treatment. For patients refractory to behavioral therapy and oral medications, consideration should be given to referral to a specialist (eg, a urologist or urogynecologist) for discussion of more advanced therapies such as sacral neuromodulation, percutaneous tibial nerve stimulation, and intradetrusor injection of onabotulinumtoxinA. These more advanced treatments have favorable efficacy compared with oral agents in randomized trials, although each has a unique risk/benefit profile and shared decision-making with the individual patient is crucial. Here, we review pertinent considerations in the clinical evaluation and management of OAB in women.

Do overactive bladder symptoms and their treatment-associated changes exhibit a normal distribution? Implications for analysis and reporting

AIMS

To explore the use of means vs medians (assuming or not the presence of normal distribution) in studies reporting overactive bladder syndrome symptoms and to test for normal distribution of basal values and treatment-associated changes thereof in two large noninterventional studies.

METHODS

Systematic review of all original studies reporting on at least one overactive bladder syndrome symptom published in four leading urology journals in 2016 to 2017. Testing of the normal distribution of urgency, incontinence, frequency, and nocturia in two large noninterventional studies (n = 1335 and 745).

RESULTS

Among 48 eligible articles, 86% reported means (assuming a normal distribution), 6% medians (not making this assumption), and 8% a combination thereof. Baseline values for all four symptoms and treatment-associated alterations thereof deviated from a normal distribution (P < .0001 in all cases). Means overestimated basal value and absolute changes thereof as compared with medians, for example, basal number of incontinence episodes in study 1 5.1 vs 4. Differences between means and medians for percentage changes of symptoms were small and did not consistently favor means over medians.

CONCLUSIONS

Dominant reporting of means implies the assumption of a normal distribution of overactive bladder syndrome symptoms but our data from two noninterventional studies do not support this assumption. We recommend that basal values and absolute symptom changes should be reported as medians and subjected to nonparametric analysis; means may be appropriate for the reporting of percentage changes of symptoms.

Cerebral White Matter Disease and Response to Anti-Cholinergic Medication for Overactive Bladder in an Age-Matched Cohort

OBJECTIVE

To determine if the presence of cerebral white matter disease (WMD) affects the response to anti-cholinergic medications.

MATERIALS AND METHODS

This was a retrospective cohort of age-matched patients treated for OAB with anti-cholinergic medications between January 2010 and December 2017. Inclusion criteria were a chief complaint of OAB, never evaluated by a urogynecologist for OAB, treated with a maximum dose for a minimum of 4 weeks, and underwent head computed tomography (CT) within 12 months of starting therapy. Patients with WMD were matched 1:1 by age and number of prior failed antimuscarinics to controls with normal head CTs. Exclusion criteria included incomplete documentation of therapeutic response, non-WMD CT abnormalities, and non-idiopathic OAB. The primary outcome was anti-cholinergic treatment failure. Pairwise analysis between groups was performed using Wilcoxon rank-sum and Fisher's exact test where appropriate. Univariate logistic regression was performed, and any variable that was associated with treatment failure and a p value ≤ 0.2 was included in the multivariable regression analysis.

RESULTS

Sixty-eight cases were matched with 68 controls. Patients with WMD were more likely to have undergone hysterectomy (57.4% vs. 41.2%, p = 0.04) and to use diuretics (31.1% vs. 19.1%, p = 0.04). Patients with WMD were more likely to fail treatment compared with controls (60.7% vs. 29.4%, p = 0.004). After adjusting for confounders, WMD was strongly associated with an increased probability of failure (aOR = 7.31, 95% CI: 1.49-12.20). Additional significant risk factors for treatment failure were the previous number of failed medications (aOR = 3.65 per medication, 95% CI: 1.48-9.01) and a rising HbA1c (aOR: 1.39 per 1.0% increase, 95% CI: 1.0-1.91).

CONCLUSION

WMD is independently associated with anti-muscarinic treatment failure in women with overactive bladder symptoms.

Anticholinergic Drugs for Overactive Bladder in Frail Older Patients: The Case Against

Urinary incontinence (UI) is a common and disabling problem among older people. Anticholinergic drugs (ADs) are a pharmacological option recommended for overactive bladder or mixed UI when non-pharmacological approaches have failed. However, UI is a more prevalent and complex condition in frail older people and to simply assume that AD actions are the same across all age groups would be wrong. This article reviews evidence for the efficacy and safety of these drugs, especially when prescribed for frail older people. Although ADs have a small but statistically significant benefit for UI in non-frail people, the vast majority choose to discontinue treatment because they feel that the beneficial effects do not outweigh the burden of taking the medication. Not only are the most frail older people more likely to experience adverse effects but there is also no evidence that these drugs are effective for UI. In addition, there is a mounting body of evidence that they impair cognitive function. The continued use of ADs in frail older people simply does not hold water.

Comparison of Oral Sodium Bicarbonate and Solifenacin Treatment in Female Overactive Bladder Patients With Acidic Urine pH

OBJECTIVE

In this study, we planned to compare the effects of oral sodium bicarbonate (NaHCO3) and anticholinergic (solifenacin) treatments in women with overactive bladder (OAB) and acidic urine pH values (<6).

METHODS

According to the referral order of OAB patients, 8 g/d oral NaHCO3 (group 1) or 5 mg/d solifenacin succinate (group 2) was given to the patients. Both treatment regimens were applied one at a time for 12 weeks in total. Laboratory values, bladder diary, Patient Perception of Bladder Condition score, Patient Perception of Intensity of Urgency Scale, Overactive Bladder-Validated 8-Question Awareness Tool, and the King's Health Questionnaire (KHQ) scores before and after treatment were compared.

RESULTS

A total of 59 patients were evaluated. Thirty-one patients were included in group 1, and 28 patients were included in group 2. No difference was detected in pretreatment and posttreatment laboratory values other than urine pH values in both groups. Whereas there was no difference in pretreatment urine pH values among the 2 groups, posttreatment urine pH values were significantly higher in group 1 compared with group 2 (P = 0.08, P < 0.001, respectively). There was a significant amelioration in the bladder diary parameters, symptom scores, and KHQ values measured after treatment in both groups. However, degree of amelioration in posttreatment outcomes was similar among the groups.

CONCLUSIONS

It was demonstrated that urinary alkalization made with oral NaHCO3 in female OAB patients with acidic urine pH had a significantly positive effect on symptoms and symptom scores, and these results are similar to the results of solifenacin treatment.

Evaluation of Urine Choline Levels in Women With and Without Overactive Bladder Syndrome

OBJECTIVE

The objective of this study was to determine whether levels of choline (Ch) differ in women with and without overactive bladder (OAB) symptoms.

METHODS

New patients were evaluated using the overactive bladder symptom score; Medical, Epidemiologic, and Social Aspects of Aging (MESA) urgency incontinence questionnaire; and Impact Questionnaire 7 and provided a urine sample. Patients were stratified into asymptomatic controls, scoring 0 on overactive bladder symptom score and the MESA questionnaire, and patients with OAB and urgency incontinence (OAB-wet). Patients with conditions predisposing to OAB or had a history of OAB treatment were excluded. Choline detection was accomplished using a commercially available kit. Wilcoxon rank sum test and Fisher exact test were used to express differences between groups. Spearman ρ correlation was used to determine the relationship between Ch and questionnaire scores. Logistic regression was used to identify significant variables associated with OAB.

RESULTS

Sixty-three women were included in the final analysis. Patients with OAB-wet were older (P = 0.001), more likely to be obese (P = 0.04), had greater apical descent (P = 0.02), were more likely to be postmenopausal (P = 0.01), and were more likely to have stress incontinence (P = 0.005). Choline was 34.8% lower in OAB compared with the controls (P = 0.014). Lower Ch levels were associated with higher MESA (Spearman ρ = -0.311, P = 0.03). After logistic regression, lower Ch (adjusted odds ratio [aOR], 0.97; 95% confidence interval [CI], 0.96-0.98), age (aOR, 1.12; 95% CI, 1.08-1.18), and body mass index (aOR, 1.09; 95% CI, 1.01-1.18) were significantly associated with OAB-wet.

CONCLUSIONS

Choline levels are significantly decreased in women complaining of OAB with urgency incontinence, and lower levels are associated with higher MESA scores.

Current Therapeutic Strategies in Clinical Urology

The field of urology encompasses all benign and malignant disorders of the urinary tract and the male genital tract. Urological disorders convey a huge economic and patient quality-of-life burden. Hospital acquired urinary tract infections, in particular, are under scrutiny as a measure of hospital quality. Given the prevalence of these pathologies, there is much progress still to be made in available therapeutic options in order to minimize side effects and provide effective care. Current drug delivery mechanisms in urological malignancy and the benign urological conditions of overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and urinary tract infection (UTI) will be reviewed herein. Both systemic and local therapies will be discussed including sustained release formulations, nanocarriers, hydrogels and other reservoir systems, as well as gene and immunotherapy. The primary focus of this review is on agents which have passed the preclinical stages of development.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

CONTEXT

The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016.

OBJECTIVE

We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination.

EVIDENCE ACQUISITION

Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria.

EVIDENCE SYNTHESIS

The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/.

CONCLUSIONS

These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances.

PATIENT SUMMARY

Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

Pharmacotherapy in overactive bladder

Overactive bladder syndrome (OAB) has a high prevalence within the population and has a negative effect on quality of life. Although the precise pathophysiology has yet to be fully elucidated, pharmacotherapeutic agents have been developed targeting two main pathways, antimuscarinic drugs and β3-adrenoreceptor agonists. Conservative management strategies, for example, bladder training, should be used as first-line treatment, with pharmacotherapy used as an adjunct if this is insufficiently effective. Antimuscarinics have a moderate effect on treating the symptoms of OAB, are associated with side effects, particularly dry mouth, and have low adherence rates in the long term. No single agent has consistently shown superiority over another. Antimuscarinics can affect cognition and may contribute to the anticholinergic burden in elderly patients. Mirabegron, a β3-agonist, appears to be as effective as antimuscarinics in improving symptoms of OAB with fewer side effects and improved adherence, and is currently recommended if treatment with antimuscarinics has failed. A combination of an antimuscarinic and β3-agonist may be worth considering if symptoms remain refractory or to reduce the side-effect profile associated with higher doses of antimuscarinics.

Level of evidence: Not applicable.

Recent advances in pharmacological management of urinary incontinence

Lower urinary tract symptoms-in particular, storage disorders (for example, urinary incontinence) as well as bladder underactivity-are major health-related problems that increase with age. Yet lower urinary tract symptoms remain under-diagnosed and poorly managed, and incontinence has been cited as the major reason for institutionalization in elderly populations and is one of the most common conditions in primary care practice. Although lifestyle and behavior therapy has been used as a useful treatment regimen for urge incontinence, medications (often used as adjunct) can provide additional benefit. This review will include current therapies used for treatment of urinary incontinence.

High Frequency Stimulation of the Pelvic Nerve Inhibits Urinary Voiding in Anesthetized Rats

Urge Urinary Incontinence: “a sudden and uncontrollable desire to void which is impossible to defer” is extremely common and considered the most bothersome of lower urinary tract conditions. Current treatments rely on pharmacological, neuromodulatory, and neurotoxicological approaches to manage the disorder, by reducing the excitability of the bladder muscle. However, some patients remain refractory to treatment. An alternative approach would be to temporarily suppress activity of the micturition control circuitry at the time of need i.e., urgency. In this study we investigated, in a rat model, the utility of high frequency pelvic nerve stimulation to produce a rapid onset, reversible suppression of voiding. In urethane-anesthetized rats periodic voiding was induced by continuous infusion of saline into the bladder whilst recording bladder pressure and electrical activity from the external urethral sphincter (EUS). High frequency (1–3 kHz), sinusoidal pelvic nerve stimulation initiated at the onset of the sharp rise in bladder pressure signaling an imminent void aborted the detrusor contraction. Urine output was suppressed and tone in the EUS increased. Stimulating the right or left nerve was equally effective. The effect was rapid in onset, reversible, and reproducible and evoked only minimal “off target” side effects on blood pressure, heart rate, respiration, uterine pressure, or rectal pressure. Transient contraction of abdominal wall was observed in some animals. Stimulation applied during the filling phase evoked a small, transient rise in bladder pressure and increased tonic activity in the EUS, but no urine output. Suppression of micturition persisted after section of the contralateral pelvic nerve or after ligation of the nerve distal to the electrode cuff on the ipsilateral side. We conclude that high frequency pelvic nerve stimulation initiated at the onset of an imminent void provides a potential means to control urinary continence.

Urinary incontinence in women

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Cancer Incidence after Initiation of Antimuscarinic Medications for Overactive Bladder in the United Kingdom: Evidence for Protopathic Bias

STUDY OBJECTIVE

To estimate the incidence of 10 common cancers among patients treated with antimuscarinic medications for overactive bladder (AMOABs).

DESIGN

Retrospective cohort study.

DATA SOURCE

United Kingdom's Clinical Practice Research Datalink.

PATIENTS

A total of 119,912 adults with no previous cancer diagnosis who were new users of AMOABs-darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium-between January 2004 and December 2012.

MEASUREMENTS AND MAIN RESULTS

Sex-specific incidence rates per 1000 person-years and 95% confidence intervals (CIs) were estimated for each study cancer (bladder, breast, colorectal, lung, melanoma, non-Hodgkin lymphoma, pancreatic, prostate, renal, and uterine cancer) overall and stratified by time since cohort entry and by cumulative AMOAB dose. Among the 119,912 patients followed for 399,365 person-years, 4117 incident study cancers occurred. The incidence rate of prostate cancer was 14.2 (95% CI 12.9-15.5) in the year after cohort entry and decreased markedly thereafter. The incidence rate of bladder cancer was also higher in the year after cohort entry than subsequently (men: 5.5, 95% CI 4.8-6.4; women: 1.2, 95% CI 1.0-1.5). The incidence rates of both prostate and bladder cancer decreased with increasing cumulative dose of AMOAB. We observed no similar relations between incidence rates of other study cancers and time since cohort entry.

CONCLUSION

High incidence rates of bladder and prostate cancer soon after AMOAB initiation and a negative correlation between incidence and cumulative AMOAB dose suggest that protopathic bias is a more likely explanation for these findings than causality. (Protopathic bias in this context means patients' urinary symptoms prompted treatment with an AMOAB, but the symptoms were actually due to a cancer that was already present, although not yet diagnosed or not yet recorded.) To avoid unnecessary delays in the diagnosis of prostate and bladder cancer, physicians should consider these diseases in patients for whom treatment with AMOABs is indicated.

Physiotherapy and behavior therapy for the treatment of overactive bladder syndrome: a prospective cohort study

PURPOSE

To determine the efficacy of physiotherapy and behavior therapy and to find specific subgroups of women with overactive bladder syndrome that might gain increased benefit from this therapy.

METHODS

Women with ≥10 micturitions per 24-h period were included. Six to nine therapy sessions were held within a 14-day interval. Efficacy end point was a reduction in micturitions and in episodes of nocturia. Secondary outcomes included ICIQ-OAB, ICIQ-OABqol and visual analog scales. Follow-up was 6 months. Levene test, Student's t test, Pearson´s and Spearman's correlations were utilized as well as the Friedman test and a multivariable-multilevel model.

RESULTS

32 women were included. Mean age was 51 ± 15.9 (years ± standard deviation, sd). Mean body mass index (BMI) was 24.4 ± 4.8 (kg/m² ± sd). There was a 22.9% reduction in the number of micturitions per 24 h (11.7 ± 1.6 vs. 9.0 ± 1.3 p < 0.001), a 21.3% reduction during the day (10.3 ± 1.4 vs. 8.1 ± 1.1 p < 0.001) and a 34.7% reduction in episodes of nocturia (1.5 ± 1.0 vs. 1.0 ± 0.8 p = 0.026). Both ICIQ-OAB (8.7 ± 2.3 vs. 5.8 ± 2.7 vs. 6.3 ± 3.3 p < 0.001) and ICIQ-OABqol (73.4 ± 25.9 vs. 47.5 ± 14.5 vs. 47.7 ± 18.6 p < 0.001) questionnaires as well as VAS (7.5 ± 1.4 vs. 4.1 ± 2.4 vs. 4.2 ± 2.7 p < 0.001) showed significant improvement persisting in the 6-month follow-up. In addition, in a multivariable model controlling for age, women who were overactive bladder syndrome therapy naïve responded significantly better than those who had already been under therapy (p < 0.001).

CONCLUSIONS

This study shows the efficacy of physiotherapy and behavior therapy in women with overactive bladder syndrome with a post-therapy effect especially for women with no prior treatment.

Is mirabegron equally as effective when used as first- or second-line therapy in women with overactive bladder?

INTRODUCTION AND HYPOTHESIS

No previous studies have investigated the efficacy of mirabegron 50 mg as the first-line therapy in OAB patients. Hence, the primary objective of this study was to evaluate the efficacy of mirabegron in treatment-naive patients in comparison with those who had discontinued antimuscarinic therapy because of insufficient efficacy.

METHODS

All consecutive women who had pure OAB symptoms (including urgency with or without urgency incontinence and frequency) for at least 3 months were considered for this study. Women were divided into two groups: women without any previous pharmacological treatment for OAB (group 1) and women with a previous history of failed antimuscarinics therapy (group 2).

RESULTS

At 3-month follow-up, the objective results on the basis of the frequency-volume chart showed a significant improvement in both groups. Furthermore, a significant reduction in the Overactive Bladder Questionnaire Short Form (OABq-SF) score and in the Indevus Urgency Severity Scale (IUSS) questionnaire were reported in both groups. However, the improvement in objective and subjective outcomes was superior in group 1 to that in group 2.

CONCLUSIONS

Mirabegron is efficacious in improving OAB symptoms in both naïve patients and those who discontinued primary antimuscarinic therapy; however, its efficacy is superior when prescribed as first-line therapy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anticholinergics for overactive bladder: Temporal trends in prescription and treatment persistence

INTRODUCTION

We sought to understand the contemporary pharmacologic management of overactive bladder (OAB) in a single-payer system. We examined temporal trends in the use of anticholinergic medications and assessed whether the likelihood of patients changing their anticholinergic therapy was predicted by their current therapy.

METHODS

We conducted a retrospective, population-based analysis of prescription records from the PharmaNet database in BC, Canada. We identified patients treated with one or more anticholinergic prescriptions between 2001 and 2009. We characterized temporal trends in the use of anticholinergic medications. We used generalized estimating equations with a logit wing to assess the relationship between the type of anticholinergic medication and the change in prescription.

RESULTS

The 114 325 included patients filled 1 140 296 anti-cholinergic prescriptions. The number of prescriptions each year increased over the study, both in aggregate and for each individual medication. While oxybutynin was the most commonly prescribed medication (68% of all prescriptions), the proportion of newer anticholinergics (solifenacin, darifenacin, and trospium) prescribed increased over time (p<0.0001). Patients taking tolterodine (odds ratio [OR] 1.03; p=0.01) and darifenacin (OR 1.12; p=0.0006) were significantly more likely to change their prescription than those taking oxybutynin. There was no association seen for patients taking solifenacin (p=0.6) and trospium (p=0.9).

CONCLUSIONS

There are an increasing number of anticholinergic prescriptions being filled annually. Patients taking newer anticholinergics are at least as likely to change therapy as those taking oxybutynin. The reimbursement environment in BC likely affects these results. Restrictions in the available data limit assessment of other relevant predictors.

Nonantimuscarinic treatment for overactive bladder: a systematic review

The purpose of the study was to determine the efficacy and safety of nonantimuscarinic treatments for overactive bladder. Medline, Cochrane, and other databases (inception to April 2, 2014) were used. We included any study design in which there were 2 arms and an n > 100, if at least 1 of the arms was a nonantimuscarinic therapy or any comparative trial, regardless of number, if at least 2 arms were nonantimuscarinic therapies for overactive bladder. Eleven reviewers double-screened citations and extracted eligible studies for study: population, intervention, outcome, effects on outcome categories, and quality. The body of evidence for categories of interventions were summarized and assessed for strength. Ninety-nine comparative studies met inclusion criteria. Interventions effective to improve subjective overactive bladder symptoms include exercise with heat and steam generating sheets (1 study), diaphragmatic (1 study), deep abdominal (1 study), and pelvic floor muscle training exercises (2 studies). Pelvic floor exercises are more effective in subjective and objective outcomes with biofeedback or verbal feedback. Weight loss with diet and exercise, caffeine reduction, 25-50% reduction in fluid intake, and pelvic floor muscle exercises with verbal instruction and or biofeedback were all efficacious. Botulinum toxin A improves urge incontinence episodes, urgency, frequency, quality of life, nocturia, and urodynamic testing parameters. Acupuncture improves quality of life and urodynamic testing parameters. Extracorporeal magnetic stimulation improves urodynamic parameters. Mirabegron improves daily incontinence episodes, nocturia, number of daily voids, and urine volume per void, whereas solabegron improves daily incontinence episodes. Short-term posterior tibial nerve stimulation is more efficacious than pelvic floor muscle training exercises and behavioral therapy for improving: urgency, urinary incontinence episodes, daily voids, volume per void, and overall quality of life. Sacral neuromodulation is more efficacious than antimuscarinic treatment for subjective improvement of overactive bladder and quality of life. Transvaginal electrical stimulation demonstrates subjective improvement in overactive bladder symptoms and urodynamic parameters. Multiple therapies, including physical therapy, behavioral therapy, botulinum toxin A, acupuncture, magnetic stimulation, mirabegron, posterior tibial nerve stimulation, sacral neuromodulation, and transvaginal electrical stimulation, are efficacious in the treatment of overactive bladder.

An update on the use of transdermal oxybutynin in the management of overactive bladder disorder

Antimuscarinic medications are used to treat nonneurogenic overactive bladder refractory to nonpharmacologic therapy. Side effects such as dry mouth, constipation, blurred vision, dizziness, and impaired cognition limit the tolerability of therapy and are largely responsible for high discontinuation rates. Oxybutynin is a potent muscarinic receptor antagonist whose primary metabolite after first-pass hepatic metabolism is considered largely responsible for its associated anticholinergic side effects. Transdermal administration of medications bypasses hepatic processing. Specifically with oxybutynin, whose low molecular weight permits transdermal administration, bioavailability of the parent drug with oral administration is less than 10%, whereas with transdermal delivery is a minimum of 80%. The result has been an improved side effect profile in multiple clinical trials with maintained efficacy relative to placebo; however, the drug may still be discontinued by patients due to anticholinergic side effects and application site reactions. Transdermal oxybutynin is available as a patch that is changed every 3-4 days, a gel available in individual sachets, or via a metered-dose pump that is applied daily. The transdermal patch was briefly available as an over-the-counter medication for adult women, although at this time all transdermal formulations are available by prescription only.

The Burden of Overactive Bladder on US Public Health

Overactive bladder (OAB) is a highly prevalent symptom condition that affects millions of US men and women. Not only can the symptoms of OAB be very bothersome, but OAB can have significant detrimental effects on many aspects of individuals' lives, representing a particularly impactful health burden to quality of life and productivity. Estimates of the individual and societal costs for the management of OAB continue to rise, particularly as effective treatments remain elusive. As such, OAB represents a significant public health burden to the USA.

Medical management of neurogenic bladder with oral therapy

This is a review of the most current literature on medical management of the neurogenic bladder (NGB) to treat detrusor overactivity (DO), improve bladder compliance and treat urinary incontinence. The use of antimuscarinics, alpha blockers, tricyclic antidepressants, desmopressin and mirabegron will be discussed along with combination therapy to improve efficacy. These medical therapies will be the focus of this review with surgical therapy and botulinum toxin injections being the subject of other articles in this series.