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Koudonas A, Anastasiadis A, Tsiakaras S, Langas G, Savvides E, Mykoniatis I, Memmos D, Baniotis P, Vakalopoulos I, de la Rosette J, Dimitriadis G. Overview of current pharmacotherapeutic options in benign prostatic hyperplasia. Expert Opin Pharmacother 2023; 24:1609-1622. [PMID: 37448198 DOI: 10.1080/14656566.2023.2237406] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Benign prostatic hyperplasia (BPH) represents the histological entity of prostate cell proliferation, which inflicts a gradually increasing obstruction of the bladder outlet and is accompanied by a progressing manifestation of lower urinary tract symptoms (LUTS). BPH management algorithm includes conservative measures, pharmaceutical agents, and surgical procedures. AREAS COVERED A comprehensive literature review was performed using PubMed, Scopus, and Google Scholar databases to identify publications written in English, analyzing BPH pharmaceutical treatment. The search was conducted from January 2000 to January 2023. Six main drug classes can be administered, either as monotherapy or in combination. Furthermore, the authors provide current direction of research on future medications, which focuses on a more etiological interference to the BPH pathophysiological mechanism. EXPERT OPINION The available medications represent an effective first-line step of BPH/LUTS therapy. Currently, the administration of BPH medications is tailored to patient/disease characteristics and entails long-time adherence to therapy. The emergence of new surgical modalities, which combine significantly lower morbidity compared to standard procedures and more durable effects than the available medications, seems to challenge the current treatment algorithm. More direct comparisons and the increasing experience with these surgical modalities will delineate the switch points between various therapy levels along the BPH management sequence.
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Affiliation(s)
- Antonios Koudonas
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Anastasios Anastasiadis
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Stavros Tsiakaras
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Georgios Langas
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | | | - Ioannis Mykoniatis
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Dimitrios Memmos
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Panagiotis Baniotis
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Ioannis Vakalopoulos
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
| | - Jean de la Rosette
- Department of Urology, Istanbul Medipol Mega University Hospital, Istanbul, Turkey
| | - Georgios Dimitriadis
- 1st Department of Urology, Aristotle University of Thessaloniki, School of Medicine, "G.Gennimatas" General Hospital, Thessaloniki, Greece
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Gravas S, Gacci M, Gratzke C, Herrmann TRW, Karavitakis M, Kyriazis I, Malde S, Mamoulakis C, Rieken M, Sakalis VI, Schouten N, Speakman MJ, Tikkinen KAO, Cornu JN. Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms. Eur Urol 2023; 84:207-222. [PMID: 37202311 DOI: 10.1016/j.eururo.2023.04.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/06/2023] [Indexed: 05/20/2023]
Abstract
CONTEXT Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology. OBJECTIVE To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS. EVIDENCE ACQUISITION A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations. EVIDENCE SYNTHESIS The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities. CONCLUSIONS The guidelines provide an evidence-based approach for the management of male LUTS. PATIENT SUMMARY A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.
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Affiliation(s)
- Stavros Gravas
- Department of Urology, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Mauro Gacci
- Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Christian Gratzke
- Department of Urology, University Hospital Freiburg, Freiburg, Germany
| | | | - Markos Karavitakis
- Department of Urology, University General Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Iason Kyriazis
- Department of Urology, General University Hospital of Patras, Patras, Greece
| | - Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | | | - Vasileios I Sakalis
- Department of Urology, Hippokrateion General Hospital, Thessaloniki, Greece.
| | - Natasha Schouten
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Mark J Speakman
- Department of Urology, Taunton & Somerset Hospital, Taunton, UK
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland
| | - Jean-Nicolas Cornu
- Department of Urology, CHU Hôpitaux de Rouen - Hôpital Charles Nicolle, Rouen, France
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Muacevic A, Adler JR, Beyatlı M, Bedir S, Özgök Y. The Efficiency and Safety of Mirabegron Monotherapy for the Treatment of Urge Incontinence in Women Aged >80 Years. Cureus 2023; 15:e33685. [PMID: 36793804 PMCID: PMC9924700 DOI: 10.7759/cureus.33685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Objective We aimed to evaluate the efficacy and safety of mirabegron monotherapy in very older (>80 years) women with overactive bladder (OAB) who were discontinued anticholinergic drugs by the other departments. Material and methods The present retrospective study evaluated very older (>80 years) women with OAB who were discontinued anticholinergic drugs by the other departments between May 2018 and January 2021. Efficacy assessments were performed using Overactive Bladder-Validated Eight-Question (OAB-V8) scores before and after mirabegron monotherapy (12 weeks). Safety was evaluated based on adverse events (hypertension, nasopharyngitis, and urinary tract infection), electrocardiography, hypertension measure, uroflowmetry (UFM), and post-voiding. Patient data including demographic characteristics, diagnoses, values before and after mirabegron monotherapy, and adverse events were evaluated. Results A total of 42 very older (>80 years) women with OAB who used mirabegron monotherapy (50 mg per day) were included in this study. Frequency, nocturia, urgency, and total OAB-V8 scores were significantly lower after mirabegron monotherapy than before mirabegron monotherapy (p < 0.05, p < 0.05, p < 0.05, and p < 0.05, respectively). There was no significant difference between systolic-diastolic blood pressure and heart rate before and after mirabegron monotherapy treatment. Conclusion Mirabegron monotherapy is an effective and safe therapy in very older (>80 years) women with OAB.
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Kuo HC. How to choose appropriate medication for overactive bladder: Findings from the largest integrated clinical trial database analysis of mirabegron studies. Tzu Chi Med J 2022; 34:23-28. [PMID: 35233352 PMCID: PMC8830553 DOI: 10.4103/tcmj.tcmj_167_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 11/04/2022] Open
Abstract
Medical treatment of overactive bladder (OAB) includes antimuscarinic agents, beta-3 adrenoceptor agonist (mirabegron), or combination with both drugs. Recently, a meta-analysis reported the integrated clinical trial data from 10 phase 2–4, double-blind, 12-week mirabegron monotherapy studies. The results confirmed that mirabegron is as effective as the previously used antimuscarinic agent to treat OAB. The treatment-emergent adverse events were similar across subgroups. This article comments on this largest integrated clinical trial data analysis, and reviews the recently published literature and tries to reveal how to choose the appropriate medication for OAB. For OAB patients, starting from antimuscarinic agent is feasible. However, if the patients have risk of cognitive dysfunction, a history of constipation, dry mouth, and urinary retention, starting with mirabegron 50 mg might be more safe and appropriate. In the elderly patients with low detrusor contractility, with central nervous system lesion, and men with benign prostatic hyperplasia, starting from 25 mg mirabegron is recommended. If the treatment result is not satisfactory to the 25 mg mirabegron, increase dose to 50 mg mirabegron is appropriate. In patients who have failed from the first OAB medication either with antimuscarinics or mirabegron 50 mg, the exchange of the OAB medication to each other should be tried first. If the treatment result is still not satisfactory, a combination of antimuscarinics and mirabegron is recommended.
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Take an individualised approach when treating frail, elderly patients with nocturia. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-021-00850-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Wang HJ, Kuo HC. Effects of different urodynamic characteristics on therapeutic outcomes of overactive bladder medication in a real-life clinical practice. Tzu Chi Med J 2021; 34:441-447. [PMID: 36578645 PMCID: PMC9791855 DOI: 10.4103/tcmj.tcmj_264_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/14/2020] [Accepted: 12/01/2020] [Indexed: 12/31/2022] Open
Abstract
Objective This study retrospectively investigated the influence of urodynamic parameters and patient characteristics on success rates among patients with overactive bladder (OAB) and urodynamic detrusor overactivity (DO). Materials and Methods Consecutive patients with OAB and urodynamic DO initially received solifenacin, mirabegron, or combination of both for 1-3 months. If failed, patients were switched to another OAB medication subtype or provided additional OAB medication for a total of 6 months. A successful treatment was defined as an improvement in urgency severity and a global response assessment of ≥1. Success rates after initial or modulated OAB medication were analyzed based on patient and urodynamic characteristics. Results A total of 453 patients were enrolled, among whom 144, 255, and 54 received solifenacin, mirabegron, and combined medications, respectively. Among the patients, 259 (57.2%) had OAB dry and 194 (42.8%) had OAB wet. Patients receiving mirabegron alone had a significantly higher initial medication success rate compared to that of others. Patients with a phasic DO (50.7%), bladder outlet obstruction (BOO, 52.5%), and no central nervous system (CNS) lesions (47.5%) exhibited higher success rates than those with a terminal DO (42.0%), no BOO (42.7%), and CNS lesions (31.6%), respectively. After switching or modulating the initial OAB medication following treatment failure, 115 (62.2%) of 185 patients still showed improvement in OAB symptoms, with an overall success rate of 70.2% after 6 months of treatment. Conclusion Initial solifenacin or mirabegron treatment had a success rate of around 50%. In general, patients with a phasic DO, urodynamic BOO, and no CNS lesions have higher success rates than those with a terminal DO, no BOO, and CNS lesions, respectively. Success rates can further be improved by switching or modulating OAB medication.
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Affiliation(s)
- Hsiu-Jen Wang
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,Division of Urology, Department of Surgery, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan,Address for correspondence: Dr. Hann-Chorng Kuo, Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien, Taiwan. E-mail:
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Wolff DT, Adler KA, Weinstein CS, Weiss JP. Managing Nocturia in Frail Older Adults. Drugs Aging 2020; 38:95-109. [PMID: 33230803 DOI: 10.1007/s40266-020-00815-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2020] [Indexed: 12/17/2022]
Abstract
This review discusses the available evidence in the current evaluation and treatment of nocturia in frail older adults. No evidence specifically evaluates the use of behavioral interventions in the treatment of the frail older adult with nocturia, but their use is supported in other cohorts. Behavioral modifications and optimal management of comorbidities remain the first-line treatment for all age groups and should be emphasized in the frail due to their favorable safety profile. No studies specific to the frail older adult support the use of pharmacotherapy. Some evidence exists for the efficacy of several agents in the older adult; however, this is difficult to extrapolate to the frail, and safety concerns abound. Desmopressin may be effective in the older adult, but a high risk of hyponatremia raises concerns for its safety, and therefore it is not recommended in the frail. α-Antagonists may have limited efficacy in men with known benign prostatic hyperplasia (BPH); they are relatively well tolerated, although the risk of orthostatic hypotension in the frail should be considered. β3-agonist trials suggest limited clinical utility. Antimuscarinics are not found to be useful in this cohort and are contraindicated in the frail older adult given the ability of antimuscarinics to cause cognitive impairment, delirium, and falls. No data examine the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the frail older adult. Additionally, the American Geriatrics Society Beers Criteria recommends against the use of muscarinics in those over the age of 75 years and therefore their use is not supported.
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Affiliation(s)
- Dylan T Wolff
- Department of Urology, SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, 11203, USA.
| | - Kerry A Adler
- Department of Urology, SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Corey S Weinstein
- Department of Urology, SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
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Mancini V, Tarcan T, Serati M, Wyndaele M, Carrieri G, Abrams P. Is coexistent overactive-underactive bladder (with or without detrusor overactivity and underactivity) a real clinical syndrome? ICI-RS 2019. Neurourol Urodyn 2020; 39 Suppl 3:S50-S59. [PMID: 32032454 DOI: 10.1002/nau.24311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
AIMS Lower urinary tract symptoms (LUTS) can be classified into symptom syndromes based on which symptoms are predominant. Overactive bladder (OAB) syndrome, a storage dysfunction, and underactive bladder (UAB) syndrome, a voiding dysfunction, are common syndromes, which urodynamic tests may show to be caused by detrusor overactivity (DO) and detrusor underactivity (DU), but can also be associated with other urethro-vesical dysfunctions. Sometimes OAB and UAB can coexist in the same patient and, if so, need a specific approach beyond treatment of the single and apparently opposing syndromes. METHODS During its 2019 meeting in Bristol, the International Consultation on Incontinence Research Society held a literature review and expert consensus discussion focused on the emerging awareness of the coexisting overactive-underactive bladder (COUB). RESULTS The consensus considered whether COUB is the combination of OAB and UAB syndromes, or a real unique clinical syndrome in the same patient, possibly with a common etiology. Definitions, pathophysiology, diagnosis, and treatment were discussed, and high-priority research questions were identified. CONCLUSIONS COUB (with or without urodynamic evidence of DO and DU) may be considered a real clinical syndrome, because it differs from single OAB and UAB, and may not be the combination of both syndromes. Urodynamic tests may be necessary in unclear cases or in cases not responding to initial treatment of the most troublesome symptoms. It is pivotal to define the evolution of the syndrome and the characteristic population, and to recognize predictive or phenotyping factors to develop a specific approach and adequate outcome measures.
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Affiliation(s)
- Vito Mancini
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Tufan Tarcan
- Department of Urology, School of Medicine, Marmara University, Istanbul, Turkey.,Department of Urology, Koç University School of Medicine, Istanbul, Turkey
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Michel Wyndaele
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Giuseppe Carrieri
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Paul Abrams
- Bristol Urological Institute, University of Bristol, Bristol, United Kingdom
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Chen JL, Jiang YH, Lee CL, Kuo HC. Precision medicine in the diagnosis and treatment of male lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Tzu Chi Med J 2019; 32:5-13. [PMID: 32110513 PMCID: PMC7015008 DOI: 10.4103/tcmj.tcmj_107_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/11/2019] [Accepted: 06/26/2019] [Indexed: 01/25/2023] Open
Abstract
Male lower urinary tract symptoms (LUTSs) are highly prevalent in men and the incidence increases with aging. The pathophysiology of male LUTSs might be bladder outlet dysfunctions such as bladder neck (BN) dysfunction, benign prostatic obstruction, and poor relaxation of external sphincter and bladder dysfunctions such as detrusor overactivity (DO), detrusor underactivity, DO, and inadequate contractility. Male LUTSs include voiding and storage symptoms, and precision diagnosis should not be done based on the symptoms alone. Videourodynamic study provides a thorough look at the bladder and bladder outlet and can clearly demonstrate the underlying pathophysiology when the initial medication fails to relieve LUTS. Medical treatment should be given based on the underlying pathophysiology of LUTS, and surgical intervention to remove prostate should only be performed when a definite bladder outlet obstruction due to prostatic obstruction has been confirmed by invasive urodynamic study.
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Affiliation(s)
- Jing-Liang Chen
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Yuan-Hong Jiang
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Cheng-Ling Lee
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Kuo HC. Individualizing medical treatment of overactive bladder. Tzu Chi Med J 2018; 30:195-199. [PMID: 30305780 PMCID: PMC6172903 DOI: 10.4103/tcmj.tcmj_83_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 04/30/2018] [Accepted: 05/13/2018] [Indexed: 12/27/2022] Open
Abstract
Overactive bladder (OAB) syndrome is highly prevalent in both men and women and might have negative impact on quality of life. Clinical trials of OAB usually highly select participants that may not reflect the real-world practice of OAB patients. The spectrum of OAB includes patients with idiopathic, neuropathic, with bladder outlet obstruction, and patients in elderly and medical comorbidities. Patients might have poor response to OAB medication or have adverse events after treatment. Therefore, treatment of OAB should be individualized to obtain therapeutic efficacy and avoid unacceptable adverse events. This article reviews the recently published literature and provides a guide for physicians to choose the appropriate treatment for different OAB patients.
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Affiliation(s)
- Hann-Chorng Kuo
- Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
- Department of Urology, School of Medicine, Tzu Chi University, Hualien, Taiwan
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