Is there a link between overactive bladder and the metabolic syndrome in women? A systematic review of observational studies

Increased prevalence of metabolic syndrome in female patients with overactive bladder: A population-based study

OBJECTIVES

To assess the association between overactive bladder syndrome (OAB) and the metabolic syndrome (MetS).

PATIENTS AND METHODS

A population-based study was conducted to compare OAB patients with age-, sex- and ethnicity-matched control subjects regarding the prevalence of the parameters of the MetS, with respect to obesity, hyperlipidemia, hypertension and diabetes mellitus. The characteristics of the OAB population were assessed. Adjusted odds ratios (OR) were calculated by logistic regression.

RESULTS

110 024 OAB patients and 220 455 controls. were identified. OAB was associated with a higher prevalence of MetS (35.4% vs. 27.5%, p < 0.001). The fully adjusted OR for MetS in patients with OAB compared to controls was 1.44; 95% confidence interval (CI) 1.42-1.46; p < 0.001. Among metabolic parameters, obesity was found to be the strongest factor associated with OAB (OR 1.55, 95% CI 1.53-1.58, p < 0.001), and higher high-density lipoprotein cholesterole levels (>50) had a protective effect on the risk of OAB (OR 0.75, 95% CI 0.73-0.76, p < 0.001).

CONCLUSIONS

Data from this cohort suggest that OAB is positively associated with MetS. Clinicians approaching patients with OAB should be aware of this association. A multimodal treatment focusing on the MetS may be considered in these patients.

Diabetes mellitus, systemic inflammation and overactive bladder

Background

Increasing evidence emphasizes the potential relationship between diabetes and OAB (overactive bladder). However, large population epidemiology is still lacking.

Methods

This cross-sectional study included six cycle NHANES surveys, with a total of 23863 participants. Logistic regression models were constructed to analyze the association between diabetes mellitus, diabetes-related markers, and inflammatory biomarkers with OAB. Restricted cubic splines were used to analyze the non-linear associations. Mediating analysis was performed to test the effect of inflammatory biomarkers on the relationship between diabetes-related markers and OAB. Finally, machine learning models were applied to predict the relative importance and construct the best-fit model.

Results

Diabetes mellitus participants' OAB prevalence increased by 77% compared with non-diabetes. As the quartiles of diabetes-related markers increased, the odds of OAB monotonically increased in three models (all p for trend < 0.001). Glycohemoglobin exhibited a linear association with OAB (p for nonlinearity > 0.05). White blood cells significantly mediated the associations between diabetes-related markers (glycohemoglobin, fasting glucose, and insulin) with OAB, and the proportions were 7.23%, 8.08%, and 17.74%, respectively (all p < 0.0001). Neutrophils partly mediated the correlation between (glycohemoglobin, fasting glucose, and insulin) and OAB at 6.58%, 9.64%, and 17.93%, respectively (all p < 0.0001). Machine learning of the XGBoost model constructs the best fit model, and XGBoost predicts glycohemoglobin is the most important indicator on OAB.

Conclusion

Our research revealed diabetes mellitus and diabetes-related markers were remarkably associated with OAB, and systemic inflammation was an important mediator of this association.

Methylglyoxal and Advanced Glycation End Products (AGEs): Targets for the Prevention and Treatment of Diabetes-Associated Bladder Dysfunction?

Methylglyoxal (MGO) is a highly reactive α-dicarbonyl compound formed endogenously from 3-carbon glycolytic intermediates. Methylglyoxal accumulated in plasma and urine of hyperglycemic and diabetic individuals acts as a potent peptide glycation molecule, giving rise to advanced glycation end products (AGEs) like arginine-derived hydroimidazolone (MG-H1) and carboxyethyl-lysine (CEL). Methylglyoxal-derived AGEs exert their effects mostly via activation of RAGE, a cell surface receptor that initiates multiple intracellular signaling pathways, favoring a pro-oxidant environment through NADPH oxidase activation and generation of high levels of reactive oxygen species (ROS). Diabetic bladder dysfunction is a bothersome urological complication in patients with poorly controlled diabetes mellitus and may comprise overactive bladder, urge incontinence, poor emptying, dribbling, incomplete emptying of the bladder, and urinary retention. Preclinical models of type 1 and type 2 diabetes have further confirmed the relationship between diabetes and voiding dysfunction. Interestingly, healthy mice supplemented with MGO for prolonged periods exhibit in vivo and in vitro bladder dysfunction, which is accompanied by increased AGE formation and RAGE expression, as well as by ROS overproduction in bladder tissues. Drugs reported to scavenge MGO and to inactivate AGEs like metformin, polyphenols, and alagebrium (ALT-711) have shown favorable outcomes on bladder dysfunction in diabetic obese leptin-deficient and MGO-exposed mice. Therefore, MGO, AGEs, and RAGE levels may be critically involved in the pathogenesis of bladder dysfunction in diabetic individuals. However, there are no clinical trials designed to test drugs that selectively inhibit the MGO-AGEs-RAGE signaling, aiming to reduce the manifestations of diabetes-associated bladder dysfunction. This review summarizes the current literature on the role of MGO-AGEs-RAGE-ROS axis in diabetes-associated bladder dysfunction. Drugs that directly inactivate MGO and ameliorate bladder dysfunction are also reviewed here.

Prevalence of overactive bladder among overweight and obese women: A prospective cross-sectional cohort study

OBJECTIVE

To evaluate the effect of body mass index (BMI) on the prevalence of overactive bladder syndrome (OAB), severity of symptoms, and quality of life in affected patients.

METHODS

We conducted a prospective cross-sectional study of 1351 consecutive patients who were recruited between June 2021 and May 2022. Patients were divided according to BMI (normal: <25.0, overweight: 25-29.9, obese: ≥30) and menopausal status. The latter were divided according to the presence or absence of urinary incontinence in the normal, wet-OAB and dry-OAB groups. A validated questionnaire, the International Consultation on Incontinence Questionnaire in Overactive Bladder (ICIQ-OAB), in the English and Arabic languages was used.

RESULTS

A total of 1351 patients were included. For women who were overweight, there was a greater prevalence of dry-OAB (p = 0.02), However, the prevalence of both dry and wet-OAB were higher in obese women (p < 0.00001). Compared to women with a normal BMI, women who were overweight or obese had a greater likelihood of developing abnormal daytime urine frequency and nocturia, with p values ≤ 0.01. The ORs of overweight and obese women were 3.1 and 5.3, respectively, for experiencing wet OAB in comparison to women with a normal BMI. Additionally, the odds of developing severe OAB in overweight and obese women were 5.8 and 18.6, respectively, which negatively affects their quality of life (QoL).

CONCLUSION

The risk of developing OAB symptomatology is significantly greater in overweight and obese patients. As BMI increases, the symptomatology, perceived discomfort and QoL of patients with OAB worsen.

Association between Sitting Time and Urinary Incontinence in the US population: Data from the National Health and Nutrition Examination Survey (NHANES) 2007 to 2018

Background

Urinary incontinence (UI) is a common health problem that affects the quality of life and health of millions of people in the United States (US). We aimed to investigate the association between sitting time and UI symptoms in the US population.

Methods

A cross-sectional survey of participants aged 20 and above from the National Health and Nutrition Examination Survey 2007-2018 was performed. A self-report questionnaire that reported complete data on UI, sitting time and covariates was included. Weighted multivariable logistic and regression models were used to assess the association between sitting time and UI symptoms.

Results

A total of 22,916 participants were enrolled. Prolonged sitting time was associated with urgency UI (UUI, odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.1 to 1.3, p = 0.001). Compared with patients with sitting a time shorter than 7 hours (h), moderate recreational activity modified the association between sitting time and mixed UI in males in the fully adjusted model (OR = 2.5, 95% CI = 1.4 to 4.5, p = 0.002). A sitting time over 7 h was related to mixed UI (MUI, OR = 1.6, 95% CI = 1.1 to 2.2, p = 0.01) in males, and stress UI (SUI, OR = 0.9, 95% CI = 0.8 to 0.98, p = 0.03) in females. However, no significant difference was found among the UI, SUI, and MUI groups in fully adjusted model.

Conclusions

A prolonged sitting time (≥7 h) was associated with UUI symptoms in all populations, SUI symptoms in females and MUI symptoms in males compared with sitting time lower than 7 h. Compared with those sit shorter than 7 h, moderate recreational activity may be a modifier between prolonged sitting and MUI symptoms in male participants, which warrants further studies for confirmation.

Pathophysiology of Overactive Bladder and Pharmacologic Treatments Including β3-Adrenoceptor Agonists -Basic Research Perspectives

Overactive bladder (OAB) is a symptom-based syndrome defined by urinary urgency, frequency, and nocturia with or without urge incontinence. The causative pathology is diverse; including bladder outlet obstruction (BOO), bladder ischemia, aging, metabolic syndrome, psychological stress, affective disorder, urinary microbiome, localized and systemic inflammatory responses, etc. Several hypotheses have been suggested as mechanisms of OAB generation; among them, neurogenic, myogenic, and urothelial mechanisms are well-known hypotheses. Also, a series of local signals called autonomous myogenic contraction, micromotion, or afferent noises, which can occur during bladder filling, may be induced by the leak of acetylcholine (ACh) or urothelial release of adenosine triphosphate (ATP). They can be transmitted to the central nervous system through afferent fibers to trigger coordinated urgency-related detrusor contractions. Antimuscarinics, commonly known to induce smooth muscle relaxation by competitive blockage of muscarinic receptors in the parasympathetic postganglionic nerve, have a minimal effect on detrusor contraction within therapeutic doses. In fact, they have a predominant role in preventing signals in the afferent nerve transmission process. β3-adrenergic receptor (AR) agonists inhibit afferent signals by predominant inhibition of mechanosensitive Aδ-fibers in the normal bladder. However, in pathologic conditions such as spinal cord injury, it seems to inhibit capsaicin-sensitive C-fibers. Particularly, mirabegron, a β3-agonist, prevents ACh release in the BOO-induced detrusor overactivity model by parasympathetic prejunctional mechanisms. A recent study also revealed that vibegron may have 2 mechanisms of action: inhibition of ACh from cholinergic efferent nerves in the detrusor and afferent inhibition via urothelial β3-AR.

Advances in the natural history of urinary incontinence in adult females

The aim of this review is to summarise the related characteristics of the natural history of female urinary incontinence (UI) using a narrative descriptive approach. PubMed, EMBASE and Web of Science were searched for articles published from 1 January 2010 to 1 January 2020 on the natural history of female UI, which including incidence, persistence, progression, remission, and regression of a single subtype of UI and the mutual influence of different UI subtypes. This literature review includes 15 articles published, indicates that UI is highly dynamic, with symptoms varying according to disease severity and subtype and influenced by multiple factors at different disease stages. Recent studies have increased our understanding of the natural history of UI. Future research should systematically analyse the progression of each subtype of UI and interactions between subtypes to prevent the progression of UI across females life course.

Flat Magnetic Stimulation for Urge Urinary Incontinence

Background and Objectives: Strategies for overactive bladder syndrome (OAB) management involve, among others, strengthening the bladder outlet to suppress urgency and neuromodulating the sacral roots. Magnetic stimulation (MS) is a technology that involves an extracorporeal device that is able to provide an electromagnetic field specifically designed to interact with pelvic floor neuromuscular tissue. The resulting tissue electrical activity induces contraction of the pelvic muscle and neuromodulation of the S2-S4 sacral roots. Flat Magnetic Stimulation (FMS) is a relevant advancement involving homogeneous electromagnetic fields, which are able to optimize the effect on the entire pelvic area. However, the benefits of this new technology for OAB syndrome are poorly known. Consequently, the aim of our study is to analyze the outcomes and quality of life (QoL) impact of FMS with Dr. Arnold (DEKA, Calenzano, Italy) in women suffering from OAB syndrome associated with urinary incontinence. Materials and Methods: This prospective study included patients with OAB, urge urinary incontinence, and no ongoing OAB treatments. At baseline (T0), the Incontinence Impact Questionnaire (IIQ-7), the Female Sexual Function Index (FSFI-19), and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) were collected. Patients underwent 8 FMS sessions of 25 min each in one month. At the termination of the therapy (T1), women repeated the ICIQ-UI SF, FSFI-19, and IIQ-7 tools. Moreover, the Patient Global Impression of Improvement (PGI-I) questionnaire was collected to evaluate the cure rate. Results: Our study enrolled a total of 57 consecutive patients. Most women had at least one second- or third-line treatment before FMS, while the remaining naive patients had contraindications to pharmacological treatments. No women reported adverse effects during the treatment. After the treatment, we observed a decrease in the IIQ-7 (p < 0.001) and ICIQ-UI SF scores (p < 0.001) and an improvement in sexual function (p < 0.001) evaluated with FSFI-19. According to PGI-I scores, 42 (73.7%) women referred to some kind of improvement, scoring ≤ 3 points. Specifically, 8.7% of patients considered themselves very much improved, 29.8% much improved, 35.1% minimally improved, and 26.3% found no changes. FMS was effective in treating OAB symptoms without any adverse effects. The mechanism is supposed to be related to suppressing the initiation of micturition. This makes FMS a promising device for treating naive and refractory urge urinary incontinence. Conclusions: The new FMS represents a promising non-pharmacological option for the treatment of naive and refractory OAB.

Synthesis and secretion of Nerve Growth Factor is regulated by Nitric Oxide in bladder cells in vitro under a hyperglycemic environment

Urine samples of female patients with overactive bladder (OAB) are characterized by low levels of nerve growth factor (NGF) and elevated concentrations of nitric oxide (NO) compared to healthy controls. We therefore examined how NO might regulate NGF synthesis using rat bladder smooth muscle (SMCs) and urothelial (UROs) cells in culture. In UROs, incubation in hyperglycemic conditions to mimic insulin insensitivity present in the OAB cohort increased secretion of NO and concomitantly decreased NGF, except when the NO synthase inhibitor, l-NAME (1 mM) was present. Sodium nitroprusside (SNP) (300 μM, 24 h), a NO generator, decreased NGF levels and decreased cyclic GMP (cGMP) content, a process validated by the cGMP synthase inhibitor ODQ (100 μM). Alternatively, SNP increased mRNA of both NGF and matrix metalloproteinase-9 (MMP-9). MMP-9 knockout of UROs by Crispr-Cas9 potently decreased the effect of SNP on NGF, implying a dependent role of NO on MMP-9. On the other hand, matrix metalloproteinase-7 (MMP-7) activity was increased by SNP, which taken together with increase in NGF mRNA, suggests a compensatory mechanism. In SMCs, hyperglycemic conditions had the same effect on extracellular content of NO and NGF than in UROs. SNP also decreased NGF secretion but increased cGMP content. Stable permeable analogs of cGMP 8-(4-Chlorophenylthio)-cGMP (1 mM) and N2,2'-O-Dibutyryl-cGMP (3 mM) inhibited NGF release. NGF and MMP-9 mRNA expression was unchanged by SNP. Deletion of MMP-9 in SMCs by Crispr-Cas9 did not alter the effect of SNP. Finally, SNP decreased MMP-7 activity, diminishing the conversion of proNGF to NGF. These results demonstrate that enhanced NO secretion triggered by high glucose decreases NGF secretion through pathways unique for each cell type that involve cGMP and proteases MMP-7 and MMP-9. These results might help to explain our observations from the urine from patients with OAB associated with metabolic syndrome.

Effects of Sleeve Gastrectomy on Pelvic Floor Disorders in Female Patients with Severe Obesity: a Prospective Study

INTRODUCTION

Obesity is associated with pelvic floor disorders (PFD). Sleeve gastrectomy (SG) is one of the most effective weight loss methods. Although SG has been found to improve urinary incontinence (UI) and overactive bladder (OAB), its impact on fecal incontinence (FI) remains controversial.

MATERIALS AND METHODS

This prospective, randomized study involved 60 female patients with severe obesity who were randomly assigned to two groups: the SG group and the diet group. The SG group underwent SG, while the diet group received a low-calorie, low-lipid diet for 6 months. The patients' condition was assessed before and after the study using three questionnaires: the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), the Overactive Bladder 8-Question Awareness Tool (OAB-V8), and the Wexner Score (CCIS).

RESULTS

After 6 months, the SG group had a significantly higher percentage of total weight loss (%TWL) compared to the diet group (p<0.01). Both groups showed a decrease in the ICIQ-FLUTS, OAB-V8, and CCIS scores (p<0.05). UI, OAB, and FI improved significantly in the SG group (p<0.05), but no improvement was observed in the diet group (p>0.05). The correlation between %TWL and PFD was statistically significant but weak, with the strongest correlation between %TWL and ICIQ-FLUTS score and the weakest correlation between %TWL and CCIS score (p<0.05).

CONCLUSIONS

We recommend bariatric surgery for the treatment of PFD. However, given the weak correlation between %TWL and PFD after SG, further research should explore factors other than %TWL that are effective in recovery, particularly in relation to FI.

Detrusor underactivity is associated with metabolic syndrome in aged primates

Lower urinary tract (LUT) dysfunction is prevalent in the elderly population, and clinical manifestations include urinary retention, incontinence, and recurrent urinary tract infections. Age-associated LUT dysfunction is responsible for significant morbidity, compromised quality of life, and rising healthcare costs in older adults, but its pathophysiology is not well understood. We aimed to investigate the effects of aging on LUT function by urodynamic studies and metabolic markers in non-human primates. Adult (n = 27) and aged (n = 20) female rhesus macaques were evaluated by urodynamic and metabolic studies. Cystometry showed detrusor underactivity (DU) with increased bladder capacity and compliance in aged subjects. Metabolic syndrome indicators were present in the aged subjects, including increased weight, triglycerides, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), and high sensitivity C-reactive protein (hsCRP), whereas aspartate aminotransferase (AST) was unaffected and the AST/ALT ratio reduced. Principal component analysis and paired correlations showed a strong association between DU and metabolic syndrome markers in aged primates with DU but not in aged primates without DU. The findings were unaffected by prior pregnancies, parity, and menopause. Our findings provide insights into possible mechanisms for age-associated DU and may guide new strategies to prevent and treat LUT dysfunction in older adults.

Does metabolic syndrome influence the efficacy of mirabegron treatment in female patients with overactive bladder?

INTRODUCTION AND HYPOTHESIS

We aimed to determine whether the presence of metabolic syndrome (MS) affects the efficacy of mirabegron in treatment-naïve women with overactive bladder (OAB).

METHODS

Women being treated with mirabegron 50 mg were allocated to MS and non-MS groups, and the efficacy of treatment of OAB was compared using the OAB symptom score (OABSS) and a 3-day voiding diary before and 12 weeks after starting treatment. The Wilcoxon signed-rank and Mann-Whitney U tests and multivariate logistic regression were used for statistical analyses, and a p-value < 0.05 was considered to represent statistical significance.

RESULTS

Of the 197 patients who completed the trial, 43 (23.9%) had MS. After 12 weeks of mirabegron treatment, both the MS and non-MS groups showed significant improvements in OABSS score, the number of incontinence episodes/24 h, the number of micturition episodes/24 h, and the number of episodes of urgency/24 h. The factors associated with clinically important differences in OABSS were the presence of hyperglycemia (odds ratio 2.43, 95% confidence interval [CI] 1.05-5.60) and OABSS score at baseline (odds ratio 1.23, 95% CI 1.09-1.39).

CONCLUSIONS

Mirabegron is effective in patients with and without MS, and comorbid hyperglycemia and severe OAB symptoms before treatment are predictors of the efficacy of mirabegron treatment.

Association of diabetes, hypertension, and their combination with basal symptoms and treatment responses in overactive bladder patients

Introduction: Pelvic hypoperfusion caused by atherosclerosis has been proposed as a cause of lower urinary tract dysfunction including overactive bladder syndrome (OAB). Limited data indicate that OAB patients with concomitant diabetes or hypertension, known risk factors of atherosclerosis, may exhibit greater baseline OAB symptoms and slightly smaller therapeutic responses to treatment, but the impact of a combined presence of diabetes and hypertension has not been reported. Therefore, we have explored whether the combined presence of both comorbidities is associated with greater baseline OAB symptoms than that of either comorbidity alone. Secondary questions were exploration of the impact of either comorbidity on baseline symptoms, and of the impact of either comorbidity alone and their combination on therapeutic responses.

Methods: Data from two non-interventional studies applying treatment with propiverine ER 30 or 45 mg/d for 12 weeks were analyzed.

Results: Number of urgency episodes in the combination group was greater than with each comorbidity alone. The impact of comorbidities on baseline intensity of incontinence, frequency or nocturia or Patient Perception of Bladder Condition was less consistent or absent. Either comorbidity alone was associated with a smaller % improvement of symptoms, and their combination had a greater effect than either alone. However, all attenuations associated with comorbidity were small relative to the overall improvement.

Conclusions: We conclude that comorbidities of diabetes and hypertension have detectable effects on OAB symptoms and treatment responses, but the small magnitude of these alterations does not justify changing existing paradigms for the clinical management of OAB.

Effects of ospemifene on overactive bladder in postmenopausal women with vulvovaginal atrophy

OBJECTIVE

Overactive bladder (OAB) is a complex and multifactorial syndrome associated with urinary frequency, urgency and incontinence. The menopause-associated hormonal changes play a role in the development of this condition. Vaginal estrogens are effective in improving OAB in postmenopausal women (PMW) with vulvovaginal atrophy (VVA). Ospemifene is a selective estrogen receptor modulator licensed for the treatment of VVA. This study aimed to evaluate the effects of ospemifene on OAB symptoms in PMW with VVA.

METHODS

Forty PMW suffering from OAB and VVA received oral ospemifene (60 mg/day) for 12 weeks. All patients were assessed with a urodynamic study, a 3-day bladder diary and validated questionnaires (International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form [ICIQ-UI SF] and International Consultation on Incontinence Questionnaire - Overactive Bladder [ICIQ-OAB]) at enrollment and at the end of the study.

RESULTS

Cytometric capacity, bladder compliance and verbal sensory threshold responses during bladder filling were improved after treatment. The voiding diary showed a significant reduction of daily voids, urge urinary incontinence episodes and nocturnal events. The median overall scores of the ICIQ-UI and ICIQ-OAB were also significantly improved.

CONCLUSIONS

Our study suggest that treatment with ospemifene in PMW suffering from OAB is associated with a reduction of OAB symptoms due to a decreased bladder sensitivity and with an improvement in quality of life.

Predictive factors of de novo overactive bladder in clinically localized prostate cancer patients after robot-assisted radical prostatectomy

OBJECTIVES

To assess the postoperative status of clinically localized prostate cancer patients who underwent robot-assisted radical prostatectomy (RARP) with a focus on de novo overactive bladder (OAB).

METHODS

The present study included 156 patients who did not have preoperative OAB and underwent RARP between December 2015 and April 2020 at our institution. Patients were divided into the de novo OAB group and non-OAB group based on the findings of overactive bladder symptoms score (OABSS) 6 months after RARP, and comparative assessments were performed between the two groups.

RESULTS

Six months after RARP, de novo OAB was detected in 38 (24.4%) out of 156 patients. Body mass index (BMI) and the proportion of patients with hypertension were significantly higher in the de novo OAB group than in the non-OAB group. No significant differences were observed in the other characteristics examined. Furthermore, the preoperative findings of uroflowmetry and a urodynamic study did not significantly differ between the two groups. Despite the lack of significant differences in preoperative OABSS, total international prostate symptom score, the voiding symptom score, storage symptom score, and quality of life score between the two groups, all of these findings 6 months after RARP were significantly worse in the de novo OAB group than in the non-OAB group. Among the several factors examined, only BMI was independently associated with the development of de novo OAB 6 months after RARP.

CONCLUSIONS

Patients with a high BMI may develop de novo OAB after RARP, resulting in the significant deterioration of lower urinary tract symptoms.

Metabolic Syndrome and Overactive Bladder Syndrome May Share Common Pathophysiologies

Metabolic syndrome (MetS) is defined by a group of cardiovascular risk factors, including impaired glucose tolerance, central obesity, hypertension, and dyslipidemia. Overactive bladder (OAB) syndrome consists of symptoms such as urinary urgency, frequency, and nocturia with or without urge incontinence. The high prevalences of metabolic syndrome (MetS) and overactive bladder (OAB) worldwide affect quality of life and cause profound negative impacts on the social economy. Accumulated evidence suggests that MetS might contribute to the underlying mechanisms for developing OAB, and MetS-associated OAB could be a subtype of OAB. However, how could these two syndromes interact with each other? Based on results of animal studies and observations in epidemiological studies, we summarized the common pathophysiologies existing between MetS and OAB, including autonomic and peripheral neuropathies, chronic ischemia, proinflammatory status, dysregulation of nutrient-sensing pathways (e.g., insulin resistance at the bladder mucosa and excessive succinate intake), and the probable role of dysbiosis. Since the MetS-associated OAB is a subtype of OAB with distinctive pathophysiologies, the regular and non-specific medications, such as antimuscarinics, beta-3 agonist, and botulinum toxin injection, might lead to unsatisfying results. Understanding the pathophysiologies of MetS-associated OAB might benefit future studies exploring novel biomarkers for diagnosis and therapeutic targets on both MetS and OAB.

Obesity and Voiding Parameters in a Community-Based Population of Okinawa, Japan: Kumejima Digital Health Project (KDHP)

(1) Background: Evidence has accumulated regarding the etiology of lower urinary tract symptoms associated with obesity and metabolic syndrome. Therefore, the present study aimed to identify which subjectively and objectively measured voiding parameters were associated with obesity in a community-based population. (2) Methods: Voiding parameters on a self-administered questionnaire and a digital self-health monitoring system for urine excretion (s-HMSU) were compared between participants with and without obesity, defined as a body mass index ≥ 25 kg/m2 (n = 30 and 29, respectively), from a community in Okinawa, Japan. Logistic regression analysis was employed to calculate the odds ratios of abnormalities in voiding parameters for the obese group, with the non-obese group serving as a reference. (3) Results: The obese group had odds ratios of 5.17 (95% confidence interval: 1.33−20.0) for shortened hours of undisturbed sleep (<302 min) by s-HMSU and 7.65 (1.88−31.1) for nighttime urinary frequency by a questionnaire after adjusting for age and sex. In addition, the obese group had an adjusted odds ratio of 2.27 (0.76−6.78) for decreased maximum bladder capacity (<212 mL) by s-HMSU. (4) Conclusion: the results of the present study suggest that nocturia and shortened hours of undisturbed sleep are signs of obesity.

SKA-31-induced activation of small-conductance calcium-activated potassium channels decreased modulation of detrusor smooth muscle function in a rat model of obesity

Increased excitability and contractility of detrusor smooth muscle (DSM) cells are associated with overactive bladder (OAB), which is often induced by obesity. Small-conductance Ca²⁺-activated K⁺ (SK) channels regulate the excitability and contractility of DSM cells. Selective pharmacological activation of SK channels attenuates hyperpolarization and the decreased relaxation effect in DSM cells in obesity-induced OAB. However, additional data are needed to confirm the regulatory effect of SK channels on the function of DSM cells in obesity-related OAB. The tested hypothesis was that activation of SK channels decreases modulation of DSM function in a rat model of obesity-related OAB. Female Sprague Dawley rats were fed a normal diet (ND) or a high-fat diet (HFD), weighed after 12 weeks, and subjected to urodynamic study, patch-clamp electrophysiology, and isometric tension recording. The average body weight and incidence of OAB were increased in the HFD group. Patch-clamp studies revealed that pharmacological activation of SK channels with SKA-31 had attenuated hyperpolarization of DSM cells. In addition, isometric tension recordings indicated that SKA-31 decreased relaxation of spontaneous phasic contractions of DSM strips in the HFD group. Attenuated function of SK channels increased the excitability and contractility of DSM cells, which contributed to the occurrence of OAB, suggesting that SK channels are potential therapeutic targets for control of OAB.

Association between chronic conditions and urinary incontinence in females: a cross-sectional study using national survey data

BACKGROUND

Urinary incontinence affects up to half of women, yet few speak to their health care provider about or receive treatment for the condition. To aid with identifying subpopulations at risk for urinary incontinence, we examined the associations between 10 chronic health conditions and urinary incontinence among Canadian adult females.

METHODS

We conducted a cross-sectional analysis of survey data from the Canadian Community Health Survey (2013-2014) involving female respondents aged 25 years or older living in a private dwelling. Presence of chronic conditions and urinary incontinence were measured by self-report. We used logistic regression modelling with sampling weights, controlling for age, income, ethnicity, body mass index and smoking. Multiple imputation and probabilistic bias analysis were used to address missing covariate data and unmeasured confounding from parity.

RESULTS

Our analysis included 60 186 respondents representing more than 12 million Canadian females, of whom 45.8% (95% confidence interval [CI] 45.0%-46.6%) reported at least 1 chronic condition. Chronic conditions were associated with more than twice the odds of urinary incontinence (adjusted odds ratio [OR] 2.42, 95% CI 2.02-2.89). Associations were largest for bowel disorders (adjusted OR 2.92, 95% CI 2.44-3.49); modest for chronic obstructive pulmonary disease (adjusted OR 2.00, 95% CI 1.63-2.45), asthma (adjusted OR 1.82, 95% CI 1.52-2.19), arthritis (adjusted OR 1.98, 95% CI 1.74-2.24) and heart disease (adjusted OR 1.73, 95% CI 1.48-2.02); and smallest for diabetes (adjusted OR 1.20, 95% CI 1.02-1.41) and high blood pressure (adjusted OR 1.27, 95% CI 1.12-1.44). Results slightly attenuated but did not substantively change after imputation and bias analysis.

INTERPRETATION

We found that chronic conditions are associated with significantly higher odds of comorbid urinary incontinence among Canadian adult females, which is consistent with previous research. Our findings support routine inquiry regarding urinary incontinence symptoms among women accessing health care for chronic conditions.

Network-Based Differences in the Vaginal and Bladder Microbial Communities Between Women With and Without Urgency Urinary Incontinence

Background

Little is known about the relationship of proximal urogenital microbiomes in the bladder and the vagina and how this contributes to bladder health. In this study, we use a microbial ecology and network framework to understand the dynamics of interactions/co-occurrences of bacteria in the bladder and vagina in women with and without urgency urinary incontinence (UUI).

Methods

We collected vaginal swabs and catheterized urine specimens from 20 women with UUI (cases) and 30 women without UUI (controls). We sequenced the V4 region of the bacterial 16S rRNA gene and evaluated using alpha and beta diversity metrics. We used microbial network analysis to detect interactions in the microbiome and the betweenness centrality measure to identify central bacteria in the microbial network. Bacteria exhibiting maximum betweenness centrality are considered central to the microbe-wide networks and likely maintain the overall microbial network structure.

Results

There were no significant differences in the vaginal or bladder microbiomes between cases and controls using alpha and beta diversity. Silhouette metric analysis identified two distinct microbiome clusters in both the bladder and vagina. One cluster was dominated by Lactobacillus genus while the other was more diverse. Network-based analyses demonstrated that vaginal and bladder microbial networks were different between cases and controls. In the vagina, there were similar numbers of genera and subgroup clusters in each network for cases and controls. However, cases tend to have more unique bacterial co-occurrences. While Bacteroides and Lactobacillus were the central bacteria with the highest betweenness centrality in controls, Aerococcus had the highest centrality in cases and correlated with bacteria commonly associated with bacterial vaginosis. In the bladder, cases have less than half as many network clusters compared to controls. Lactobacillus was the central bacteria in both groups but associated with several known uropathogens in cases. The number of shared bacterial genera between the bladder and the vagina differed between cases and controls, with cases having larger overlap (43%) compared to controls (29%).

Conclusion

Our study shows overlaps in microbial communities of bladder and vagina, with higher overlap in cases. We also identified differences in the bacteria that are central to the overall community structure.

Patient-tailored healthcare and tibial nerve neuromodulation in the treatment of patients with overactive bladder symptoms

Purpose

The aim of this study was to demonstrate features predictive of treatment response for patient‐tailored overactive bladder (OAB) intervention with an implantable tibial neurostimulator using patient and technical prediction factors.

Materials and Methods

This study was designed as a follow‐up study based on parameter settings and patients' preferences during the pilot and extended study of the implantable tibial nerve stimulator (RENOVA™ iStim system). For this study, we compared all treatment parameters (stimulation amplitude, frequency, and pulse width) and usage data (duration of treatment) during the different follow‐up visits.

Results

We obtained usage data from a total of 32 patients who were implanted with the system between February and September 2015. Age, sex, body mass index (BMI) and previous experience with percutaneous tibial nerve stimulation (PTNS) treatment were considered as possible prediction factors for treatment success. However, only BMI was considered a statistically significant prediction factor (p = 0.042). A statistically significant increase in mean treatment level was seen in the responder group during the 3 month follow‐up visit (mean: 6.7 mA, SD 0.416) as compared with the initial system activation visit (mean: 5.8 mA, SD 0.400) (p = 0.049). No other visits demonstrated statistically significant changes in both groups (responders and nonresponders) during the defined timepoints.

Conclusion

This data underscores the need to use patient‐tailored OAB treatment. BMI was found to be a negative predictive factor for treatment success. However, it was not possible to develop a specific responder model. A model predicting response to treatment could be useful for implementing shared decision making.

Characterizing the Spectrum of Bladder Health and Lower Urinary Tract Symptoms (LUTS) Among Women: Results From the CARDIA Study

OBJECTIVES

To operationalize a new definition for bladder health, we examined the distribution of lower urinary tract symptoms (LUTS) and impact, along with associated factors, among women in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS

We performed cluster analyses using validated LUTS symptom burden and impact scales collected between 2005-2006 and 2010-2011. We performed multinomial logistic regression analyses to evaluate cardiovascular factors (metabolic syndrome, cardiovascular health behaviors, and inflammation) between clusters after adjusting for covariates (demographic, obstetric/gynecologic, co-morbidities).

RESULTS

Among CARDIA women (median age 51, range 42-59) with complete LUTS data (n = 1302), we identified and compared 4 cluster groups: women who reported no or very mild symptoms and no impact on well-being (bladder health, 44%, n = 569), versus women with LUTS and negative impact on well-being ranging from mild (31%, n = 407), moderate (20%, n = 259), to severe (5%, n = 67). With each 1-point lower BMI (kg/m2), odds of membership in mild (OR 0.97, CI 0.95-0.99), moderate (OR 0.95, CI 0.93-0.98), and severe (OR 0.90, CI 0.88-0.94) LUTS cluster groups versus the bladder health group were lower. Compared to women with metabolic syndrome, women without metabolic syndrome had lower odds of membership in mild (OR 0.67, CI 0.45-0.99), moderate (OR 0.51, CI 0.33-0.79), and severe (OR 0.48, CI 0.24-0.94) LUTS cluster groups versus the bladder health group.

CONCLUSION

Two out of 5 midlife women met our definition of bladder health. Bladder health and cardiovascular health among women may share common factors, including lower BMI and the absence of metabolic syndrome.

Overactive bladder: A review and update

Overactive bladder syndrome is a chronic, disabling condition with physical, psychological and social consequences that significantly affects the quality of life of millions of patients worldwide. The economic impact of this disorder is crucial. Overactive bladder syndrome is a little-known condition, with different manifestations from patient to patient, which causes a great deal of frustration to the medical staff involved. The patient requires a clear explanation and the full support of the attending physician. It is extremely important to establish a correct diagnosis and an effective individualized treatment. The collaboration and understanding of these patients are extremely important aspects. Improving the quality of life in these patients is the main purpose in managing this condition. There are several treatment modalities that may be used progressively, with favorable albeit inconsistent results. This condition remains extremely challenging for specialists and, unfortunately, always one of maximum interest.

Sarcopenia and Visceral Obesity are Significantly Related to Severe Storage Symptoms in Geriatric Female Patients

Purpose

This study aimed to elucidate the relationship of psoas muscle atrophy and visceral obesity with lower urinary tract symptoms in geriatric female patients.

Patients and Methods

We retrospectively reviewed the medical records of female patients aged ≥65 years. The psoas muscle index was defined, using computed tomography, as the cross-sectional area of the psoas muscle at the third lumbar vertebral level divided by the body surface area. We also measured visceral fat area at the umbilical level using computed tomography. We used logistic regression analysis to examine the relationships between the International Prostate Symptom Score (total score, voiding subscore, and storage subscore) and variables, such as age, body mass index, psoas muscle index, and visceral fat area. The International Prostate Symptom Score was categorized as mild, moderate, or severe.

Results

One hundred thirty-nine patients were included in our study. In the logistic regression analysis, we found statistically significant relationships between severe (versus mild-to-moderate) International Prostate Symptom Score storage subscore and variables, including low and high levels of psoas muscle index and visceral fat area, respectively. We could not find any significant relationships between the International Prostate Symptom Score total score and voiding subscore and the variables.

Conclusion

Psoas muscle atrophy and visceral fat accumulation are potential risk factors for severe storage symptoms in female patients aged ≥65 years.

Effect of systemic atherosclerosis on overactive bladder symptoms in men with benign prostatic hyperplasia

OBJECTIVE

Symptoms of male overactive bladder (OAB) may be caused by several systemic pathophysiological factors rather than a single-source etiology. We investigated the clinical factors associated with the severity of OAB symptoms in treatment-naïve men with coexisting benign prostatic hyperplasia.

METHODS

We obtained records from a health promotion center database of male patients who visited between March 2019 and February 2020. Men without a history of treatment for lower urinary tract symptoms were evaluated using the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score, transrectal ultrasonography, medical history, and carotid duplex ultrasound for the evaluation of atherosclerosis. Benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS) was defined as an IPSS of eight points or higher. Patients with comorbidities that may affect their voiding function were excluded.

RESULTS

A total of 764 patients were divided into two groups based on their diagnosis: an OAB group and a non-OAB group. The non-OAB group consisted of 627 patients (82.1%) and the OAB group consisted of 137 patients (17.9%). Using multivariable analysis BPH/LUTS was identified as an independent risk factor for OAB. In the OAB group without BPH/LUTS, carotid atherosclerosis was significantly associated with the severity of OAB symptoms. A history of diabetes mellitus was the only variable that was associated with the severity of urinary urgency. Systolic blood pressure was associated with severity of urinary urgency in the OAB group with BPH/LUTS.

CONCLUSIONS

Factors associated with male OAB exhibit different pathophysiology in the severity of symptoms depending on the presence of BPH/LUTS. Treatment for atherosclerosis and associated systemic pathophysiological factors could lower OAB symptom severity in male patients without BPH/LUTS.

Bladder Hyperactivity Induced by Oxidative Stress and Bladder Ischemia: A Review of Treatment Strategies with Antioxidants

Overactive bladder (OAB) syndrome, including frequency, urgency, nocturia and urgency incontinence, has a significantly negative impact on the quality-of-life scale (QoL) and can cause sufferer withdrawal from social activities. The occurrence of OAB can result from an imbalance between the production of pro-oxidants, such as free radicals and reactive species, and their elimination through protective mechanisms of antioxidant-induced oxidative stress. Several animal models, such as bladder ischemia/reperfusion (I/R), partial bladder outlet obstruction (PBOO) and ovarian hormone deficiency (OHD), have suggested that cyclic I/R during the micturition cycle induces oxidative stress, leading to bladder denervation, bladder afferent pathway sensitization and overexpression of bladder-damaging molecules, and finally resulting in bladder hyperactivity. Based on the results of previous animal experiments, the present review specifically focuses on four issues: (1) oxidative stress and antioxidant defense system; (2) oxidative stress in OAB and biomarkers of OAB; (3) OAB animal model; (4) potential nature/plant antioxidant treatment strategies for urinary dysfunction with OAB. Moreover, we organized the relationships between urinary dysfunction and oxidative stress biomarkers in urine, blood and bladder tissue. Reviewed information also revealed the summary of research findings for the effects of various antioxidants for treatment strategies for OAB.

Is coronavirus disease 2019 associated with indicators of long-term bladder dysfunction?

Objective

Early reports have suggested that coronavirus disease 2019 (COVID‐19) can present with significant urinary frequency and nocturia, and that these symptoms correlate with markers of inflammation in the urine. We evaluated surrogate markers of chronic urinary symptoms to determine if they were more frequent after COVID‐19 infection.

Methods

Routinely collected data from the province of Ontario was used to conduct a matched, retrospective cohort study. We identified patients 66 years of age or older who had a positive COVID‐19 test between February and May 2020 and survived at least 2 months after their diagnosis. We matched them to two similar patients who did not have a positive COVID‐19 test during the same time period. We measured the frequency of urology consultation, cystoscopy, and new prescriptions for overactive bladder medications during a subsequent 3‐month period. Proportional hazard models were adjusted for any baseline differences between the groups.

Results

We matched 5617 patients with COVID‐19 to 11,225 people who did not have COVID‐19. The groups were similar, aside from a higher proportion of patients having hypertension and diabetes in the CoVID‐19 cohort. There was no significantly increased hazard of new receipt of overactive bladder medication (hazards ratio [HR]: 1.04, p = 0.88), urology consultation (HR: 1.40, p = 0.10), or cystoscopy (HR: 1.14, p = 0.50) among patients who had COVID‐19, compared to the matched cohort.

Conclusion

Surrogate markers of potential bladder dysfunction were not significantly increased in the 2–5 months after COVID‐19 infection.

Obesity, metabolic health, and urological disorders in adults: a nationwide population-based study

We evaluate the risks of various urological disorders that require treatments according to obesity and metabolic health status using a nationwide dataset of the Korean population. 3,969,788 patients who had undergone health examinations were enrolled. Participants were classified as “obese” (O) or “non-obese” (NO) using a BMI cut-off of 25 kg/m2. People who developed ≥ 1 metabolic disease component in the index year were considered “metabolically unhealthy” (MU), while those with none were considered “metabolically healthy” (MH). There were classified into the MHNO, MUNO, MHO, and MUO group. In BPH, chronic renal disease, neurogenic bladder, any medication related to voiding dysfunction, alpha-blocker, and antidiuretics, age and gender-adjusted hazard ratio (HR) was highest in MUO, but higher in MUNO than in MHO. In stress incontinence, prostate surgery, and 5alpha-reductase, HR increased in the order of MUNO, MHO, and MUO. In prostatitis, anti-incontinence surgery, and cystocele repair, HR was higher in MHO than MUNO and MUO. In cystitis, cystostomy, and anticholinergics, HR was higher in MUNO and MUO than MHO. In conclusion, obesity and metabolic health were individually or collaboratively involved in urological disorders related to voiding dysfunction. Metabolic healthy obesity needs to be distinguished in the diagnosis and treatment of urological disorders.

Shifting the treatment paradigm in idiopathic overactive bladder

PURPOSE

Overactive Bladder (OAB) is a common condition that is known to have a significant impact on Health Related Quality of Life (HRQoL). Whilst all patients will initially benefit from lifestyle modifications and behavioural therapy in the first instance drug therapy remains integral in management pathways. The purpose of this review paper is to reappraise the evidence based approach to the management of OAB in addition to exploring a new treatment algorithm for the escalation of treatment in those patients with refractory symptoms.

DESIGN

Literature Review RESULTS: Antimuscarinic drugs are currently the most commonly used medication although the introduction of mirabegron, a β3 agonist, has provided an alternative and also allowed combination therapy in those patients who have failed to improve on primary therapy or who have troublesome side effects. For those patients with symptoms of refractory OAB more invasive therapies including OnabotulinumtoxinA, sacral neuromodulation and Percutaneous Tibial Nerve Stimulation (PTNS) may be indicated.

CONCLUSION

We propose a new, evidence based, treatment algorithm for the management of OAB in patients who remain refractory to first line therapy.

[EVALUATING THE RELATIONSHIP BETWEEN LOWER URINARY TRACT SYMPTOMS AND ENDOTHELIAL FUNCTION USING FLOW-MEDIATED DILATION, AND THE EFFECTS OF TADALAFIL]

(Objective) Recently, lower urinary tract symptoms (LUTS) were reported to be associated with endothelial dysfunction. Endothelial function is non-invasively measured by flow-mediated dilation (FMD). As tadalafil has the potential to improve atherosclerosis, we evaluated the relationship between LUTS and endothelial function using FMD, and the effects of tadalafil. (Patients and methods) We conducted FMD examinations for a total of 122 males, and analyzed its association with IPSS, OABSS, and cardiovascular risks. Furthermore, 21 BPH patients received 5 mg of tadalafil per day for one year. We defined the Low FMD group as FMD < 3.9% and the Control group as other values, and compared the effects of tadalafil between groups. (Results) In the 122 male patients, FMD was negatively correlated with nocturia and OABSS. Patients with hypertension or coronary artery disease had a lower FMD than those without.In the tadalafil administration study, the Low FMD group achieved greater improvement of IPSS, OABSS and FMD than the Control group. (Conclusion) FMD examination revealed that endothelial dysfunction is closely associated with LUTS in males, and that tadalafil is effective for patients with endothelial dysfunction.

The Effect of Cardiovascular Morbidity on Clinical Responsiveness to Anticholinergics in Postmenopausal Women With Urge Urinary Incontinence

OBJECTIVE

To evaluate whether there is an association between severity of cardiovascular morbidity and urge urinary incontinence (UUI), and to assess the clinical responses of postmenopausal female patients in different cardiovascular risk groups to anticholinergics.

METHODS

A total of 220 postmenopausal female patients aged 43-70 years old with overactive bladder with UUI between December 2019 and July 2020 were included. They were divided into 3 groups according to the Framingham risk score that calculates the 10-year risk of cardiovascular disease development: low-risk (n: 90, 40.9%), intermediate-risk (n: 47, 21.3%), and high-risk (n: 83, 37.8%).Their demographic and clinical data were recorded. The intensity of UUI and its effect on quality of life (QoL) were evaluated at admission, 8th week and 16th week of anticholinergic therapy.

RESULTS

At admission attendance, BMI, smoking rate, presence of hypertension and diabetes mellitus, total cholesterol level and severity of UUI were higher in the high-risk group, whereas HDL level was lower and the effect of UUI on QoL was worse (P< .001). At the 16-week follow-up the improvement of UUI severity and QoL was significantly more pronounced in the low-risk and intermediate-risk groups (P< .001).The highest daily-dryness rates were observed in the low-risk group (65.6%), while the highest rates for refractory overactive bladder (OAB) were seen in the high-risk group (19.3%).

CONCLUSION

Our findings show that more severe UUI and more impaired QoL is observed in high-risk patients for cardiovascular morbidity. Individualized treatment may be important in the high-risk group since they may benefit less from anticholinergics and refractory OAB can be more common.

Attenuated regulatory function of the small-conductance Ca2+-activated K+ channel in detrusor smooth muscle cells excitability in an obese rat model

PURPOSE

Overactive bladder (OAB) is related to detrusor overactivity (DO), which is caused by the increased detrusor smooth muscle (DSM) cells excitability. Small-conductance Ca²⁺-activated K⁺ (SK) channels is a fundamental regulator of excitability and contractility in DSM cells. Obesity-related OAB is associated with the decreased expression and regulatory function of SK channels in DSM layer. However, the regulation role of SK channels in obesity-related OAB DSM cell excitability is still unknown. Here, we tested the hypothesis that obesity-related OAB is associated with reduced expression and activity of SK channels in DSM cells.

METHODS

Female Sprague-Dawley rats were fed a normal diet (ND) or a high-fat diet (HFD) and weighed after 12 weeks. We performed urodynamic study, single-cell quantitative reverse transcription-polymerase chain reaction (qRT-PCR), and patch-clamp electrophysiology.

RESULTS

Increased average body weights and urodynamically demonstrated OAB were observed in HFD rats. Single-cell qRT-PCR experiments discovered the decreased mRNA expression level of SK channel in DSM cell from HFD rats. Patch-clamp studies revealed that NS309, a SK channel activator, had an attenuated effect on membrane potential hyperpolarization in HFD DSM cells. In addition, the reduced whole cell SK channel currents were recorded in HFD DSM cells.

CONCLUSIONS

Attenuated SK channels expression and function, which results in the increased DSM cells excitability and contributes to DO, is discovered in obesity-related OAB DSM cells, suggesting that SK channels might be potential therapeutic targets to control OAB.

New participant stratification and combination of urinary biomarkers and confounders could improve diagnostic accuracy for overactive bladder

Overactive bladder (OAB) is a highly prevalent symptom complex characterised by symptoms of urinary urgency, increased frequency, nocturia, with or without urge incontinence; in the absence of proven infection or other obvious pathology. The underlying pathophysiology of idiopathic OAB is not clearly known and the existence of several phenotypes has been proposed. Current diagnostic approaches are based on discordant measures, suffer from subjectivity and are incapable of detecting the proposed OAB phenotypes. In this study, cluster analysis was used as an objective approach for phenotyping participants based on their OAB characteristic symptoms and led to the identification of a low OAB symptomatic score group (cluster 1) and a high OAB symptomatic score group (cluster 2). Furthermore, the ability of several potential OAB urinary biomarkers including ATP, ACh, nitrite, MCP-1 and IL-5 and participants’ confounders, age and gender, in predicting the identified high OAB symptomatic score group was assessed. A combination of urinary ATP and IL-5 plus age and gender was shown to have clinically acceptable and improved diagnostic accuracy compared to urodynamically-observed detrusor overactivity. Therefore, this study provides the foundation for the development of novel non-invasive diagnostic tools for OAB phenotypes that may lead to personalised treatment.

Is urinary incontinence associated with sedentary behaviour in older women? Analysis of data from the National Health and Nutrition Examination Survey

BACKGROUND

Urinary incontinence (UI) is a common geriatric syndrome associated with physical and cognitive impairments. The association between type of UI and sedentary behaviour (SB) has not been explored.

AIM

To determine association between moderate-severe UI, or any stress UI (SUI) or any urgency UI (UUI) and SB in community-dwelling older women.

METHODS

Women aged 60 and over from the 2005-2006 cycle of the National Health and Nutrition Examination Survey (NHANES) with objectively measured (accelerometer) and self-reported SB and UI data were selected. Multivariate models exploring association between moderate-severe UI and SB, or SUI and SB, or UUI and SB were analysed using logistic regression adjusted for factors associated with UI.

RESULTS

In the overall sample of 459 older women, 23.5% reported moderate-severe UI, 50.5% reported any SUI and 41.4% reported any UUI. In bivariate analysis objectively measured proportion of time in SB was associated with moderate-severe UI and UUI (p = 0.014 and p = 0.047) but not SUI. Average duration of SB bouts in those with moderate-severe UI or any SUI was no longer than older women reporting no continence issues, but it was significantly (19%) longer in older women with any UUI (mean difference 3.2 minutes; p = 0.001). Self-reported SB variables were not associated with any type of UI. Multivariate analysis showed an association between UUI and a longer average duration of SB bouts (OR = 1.05, 95% CI = 1.01-1.09, p = 0.006) but no association with moderate-severe UI or SUI.

CONCLUSION

UUI was significantly associated with increased average duration of SB bouts in community-dwelling older women. The importance of objective measurement of SB is highlighted and suggests that decreasing time in prolonged sitting may be a target intervention to reduce UUI. Future studies are required to further explore the association between SB and incontinence.

Botulinum toxin A for refractory OAB and idiopathic urinary retention: Can phenotyping improve outcome for patients: ICI-RS 2019?

AIMS

Botulinum toxin A (BTX-A) is a well-established treatment for refractory idiopathic overactive bladder (OAB). It has also been used with short-term success in treating idiopathic urinary retention. However, efficacy and complication rates are variable and predicting those likely to benefit most from treatment would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society (ICI-RS) meeting in 2019 a Think Tank addressed the question of how we can improve the way we phenotype patients undergoing BTX-A treatment.

METHODS

The Think Tank conducted a literature review and expert consensus meeting focussing on how advances in basic science research of the mechanism of action of BTX-A, as well as assessment of psychological comorbidity, can be translated into clinical practice to improve patient selection for therapy.

RESULTS

Idiopathic OAB and idiopathic urinary retention are heterogenous conditions encompassing several phenotypes with multiple potential pathophysiological mechanisms. Animal models have demonstrated a central nervous system mechanism of action of intravesically injected BTX-A and this has been confirmed in human functional MRI studies, but whether this tool can be used to predict outcome from treatment remains to be determined. Phenotyping based on psychological comorbidity using validated screening tools should be studied as a way to potentially optimize patient selection for therapy.

CONCLUSIONS

Advances in basic science research into the mechanism of action of BTX-A have improved our understanding of the pathophysiology of OAB and may lead to novel ways to phenotype patients. Psychological assessment is another way in which phenotyping may be improved. Areas for further research are proposed.

Biomarkers Implicated in Lower Urinary Tract Symptoms: Systematic Review and Pathway Analyses

PURPOSE

Lower urinary tract symptoms are prevalent and burdensome, yet methods to enhance diagnosis and appropriately guide therapies are lacking. We systematically reviewed the literature for human studies of biomarkers associated with lower urinary tract symptoms.

MATERIALS AND METHODS

PubMed®, EMBASE® and Web of Science® were searched from inception to February 13, 2018. Articles were included if they were in English, performed in benign urological populations without neurological disorders or interstitial cystitis/bladder pain syndrome, and assessed a biomarker's association with or ability to predict specific lower urinary tract symptoms or urological conditions. Bioinformatic pathway analyses were conducted to determine whether individual biomarkers associated with symptoms are present in unifying pathways.

RESULTS

Of 6,150 citations identified 125 met the inclusion criteria. Most studies (93.6%) assessed biomarkers at 1 time point and were cross-sectional in nature. Few studies adjusted for potentially confounding clinical variables or assessed biomarkers in an individual over time. No individual biomarkers are currently validated as diagnostic tools for lower urinary tract symptoms. Compared to controls, pathway analyses identified multiple immune response pathways that were enriched in overactive bladder syndrome and cell migration/cytoskeleton remodeling pathways that were enriched in female stress incontinence.

CONCLUSIONS

Major deficiencies in the existing biomarker literature include poor reproducibility of laboratory data, unclear classification of patients with lower urinary tract symptoms and lack of adjustment for clinical covariates. Despite these limitations we identified multiple putative pathways in which panels of biological markers need further research.

Attenuated BK channel function promotes overactive bladder in a rat model of obesity

Overactive bladder (OAB) is mostly observed in obese individuals, and is associated with enhanced excitability and contractility of the detrusor smooth muscle (DSM). Large-conductance voltage- and Ca²⁺-activated K⁺ (BK) channels reduce the excitability and contractility of the DSM. We tested whether obesity-induced OAB is associated with altered BK channel expression and activity in the DSM. Seven-week-old female Sprague-Dawley rats (N=80) were fed a normal or high-fat diet (HFD) for 12 weeks. HFD-fed rats exhibited a higher average bodyweight and urodynamically established detrusor overactivity. mRNA levels of the Kcnma1 (BKα subunit) and Kcnmb1 (BKβ1 subunit) in whole tissues and cells from the DSM were reduced in HFD-fed rats. A selective BK channel opener, NS1619, was then applied to DSM cells from the two groups of rats. Patch-clamp techniques revealed that spontaneous transient outward currents, NS1619-induced activation of spontaneous transient outward currents, and whole-cell BK currents, as well as NS1619-induced membrane hyperpolarization, were attenuated in DSM cells from HFD-fed rats. The relaxation effect of NS1619 on contractility was reduced in DSM strips from HFD-fed rats. Thus, impaired expression of Kcnma1 and Kcnmb1 in the DSM contributes to obesity-induced OAB, suggesting that BK channels could be a useful treatment targets in OAB.

Do Lifestyle Factors Affect Lower Urinary Tract Symptoms? Results from the Korean Community Health Survey

PURPOSE

To evaluate the relationships between lower urinary tract symptoms (LUTS) and lifestyle factors (physical activity, smoking, alcohol consumption, body mass index, and stress) in Korean men.

METHODS

We analyzed the survey results of South Korean men (n=64,439) who were 40 years of age or older among whom interviews were conducted using questionnaires. Trained interviewers performed face-to-face surveys using computer-assisted personal interviewing, the International Prostate Symptom Score (IPSS), and standard questions. We assessed the relationships of lifestyle factors (physical activity, cigarette smoking, alcohol intake, height, weight, and stress) with LUTS.

RESULTS

We observed higher IPSS scores in participants who engaged in no exercise (n=46,008 [71.7%], IPSS=3.19±5.36) than in those who engaged in vigorous physical activity (n=10,657 [17.6%], IPSS=2.28±4.15). Former smokers showed higher total, storage, and voiding symptom IPSS scores than current smokers and nonsmokers. Nondrinkers had higher IPSS scores than current alcohol drinkers. In multivariable logistic regression analysis, we detected no relationship between LUTS and current alcohol drinking in the moderate and severe LUTS groups, using the mild LUTS group as a reference (moderate: 0.91; 95% confidence interval [CI], 0.91-0.91; P<0.001, severe: 0.78; 95% CI, 0.78-0.78; P<0.001). Participants with moderate to severe stress showed higher total IPSS scores than those with no or mild stress (3.38±5.77 vs. 2.88±4.90), with significant relationships between stress and LUTS found in the moderate and severe LUTS groups. In logistic regression analysis, stronger relationships were found for storage and voiding symptoms in the moderate and severe stress groups compared to the mild stress group.

CONCLUSION

A history of smoking, low levels of physical activity, low body mass index, and moderate to severe stress were associated with a greater severity of LUTS. Moderate to severe stress was also related to voiding symptoms. However, there was no association between alcohol intake and LUTS severity.

The effect of body mass index on retropubic midurethral slings

BACKGROUND

Analyzing surgical databases uses "real-life" outcomes rather than highly selected cases from randomized controlled trials. Retropubic midurethral slings are a highly effective surgical treatment for stress urinary incontinence; however, if modifiable patient characteristics alter outcomes, thereby rendering treatments less effective, patients should be informed and given the opportunity to change that characteristic.

OBJECTIVE

The aim of this study was to evaluate the effect of body mass index on patient-reported outcome measures by analyzing midurethral slings from the British Society of Urogynaecology database.

MATERIALS AND METHODS

The British Society of Urogynaecology approved analysis of 11,859 anonymized midurethral slings from 2007 to 2016. The primary outcome of this retrospective cohort study was to assess how body mass index affects patient-reported outcome measures. Outcomes were assessed at 6 weeks, 3 months, 6 months, or 12 months after surgery, depending on local arrangements. Outcomes were compared by body mass index groups using χ² tests.

RESULTS

As BMI increased, Patient Global Impression of Improvement (PGI-I) scores declined. Women with a normal body mass index (18 to <25) reported feeling better in 91.6% of cases compared to lower rates in BMI groups >30 (87.7-72%) (P < .001). Patient-reported outcome measures for stress urinary incontinence inversely correlated with body mass index, with 97% of women with normal body mass index stating that they were cured/improved compared to women in higher body mass index groups (84-94%) reporting lower rates (P < .005). Patient-reported outcome measures for overactive bladder show that as body mass index increases, patients reported higher rates of worsening symptoms (P < .05). There were higher rates of perforation at the low and high extremes of body mass index.

CONCLUSION

Our results suggest increased body mass index is associated with poorer outcomes after midurethral sling surgery, and that patients should be given the opportunity to change their body mass index. These data could help to develop a model to predict personalized success and complication rates, which may improve shared decision making and give an impetus to modify characteristics to improve outcomes.

A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment

CONTEXT

Current literature suggests that several pathophysiological factors and mechanisms might be responsible for the nonspecific symptom complex of overactive bladder (OAB).

OBJECTIVE

To provide a comprehensive analysis of the potential pathophysiology underlying detrusor overactivity (DO) and OAB.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted in April 2018, to identify randomised controlled trials, prospective and retrospective series, animal model studies, and reviews.

EVIDENCE SYNTHESIS

OAB is a nonspecific storage symptom complex with poorly defined pathophysiology. OAB was historically thought to be caused by DO, which was either "myogenic" (urgency initiated from autonomous contraction of the detrusor muscle) or "neurogenic" (urgency signalled from the central nervous system, which initiates a detrusor contraction). Patients with OAB are often found to not have objective evidence of DO on urodynamic studies; therefore, alternative mechanisms for the development of OAB have been postulated. Increasing evidence on the role of urothelium/suburothelium and bladder afferent signalling arose in the early 2000s, emphasising an afferent "urotheliogenic" hypothesis, namely, that urgency is initiated from the urothelium/suburothelium. The urethra has also recently been regarded as a possible afferent origin of OAB-the "urethrogenic" hypothesis. Several other pathophysiological factors have been implicated, including metabolic syndrome, affective disorders, sex hormone deficiency, urinary microbiota, gastrointestinal functional disorders, and subclinical autonomic nervous system dysfunctions. These various possible mechanisms should be considered as contributing to diagnostic and treatment algorithms.

CONCLUSIONS

There is a temptation to label OAB as "idiopathic" without obvious causation, given the poorly understood nature of its pathophysiology. OAB should be seen as a complex, multifactorial symptom syndrome, resulting from multiple potential pathophysiological mechanisms. Identification of the underlying causes on an individual basis may lead to the definition of OAB phenotypes, paving the way for personalised medical care.

PATIENT SUMMARY

Overactive bladder (OAB) is a storage symptom syndrome with multiple possible causes. Identification of the mechanisms causing a patient to experience OAB symptoms may help tailor treatment to individual patients and improve outcomes.

Patient utilization survey of mirabegron prescribed for overactive bladder

Purpose

Mirabegron, a β₃-adrenoreceptor agonist, is used to treat overactive bladder. The factors affecting persistence of mirabegron use or symptom improvement are not thoroughly known, but could be related to patient characteristics. Therefore, we evaluated persistence of medication use, symptom improvement, and quality of life among Finnish mirabegron users. In addition, we assessed possible predictors of change in these variables.

Materials and Methods

Participants (52 men, 118 women) with an initial mirabegron prescription were recruited nationwide from 79 pharmacies. Volunteers were interviewed at baseline and after 6 months. Subject and clinical characteristics, symptom severity, and quality of life (EQ-5D-5L) were assessed using a visual analogue scale.

Results

Of 170 participants, 144 (84.7%) were reached after 6 months. The rate of persistent mirabegron use was 50.7%. Experiencing adverse effects (29.6%) was the most common reason for discontinuation of medication. A primary health care unit as a prescription site (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.03–4.9) was associated with increased risk for discontinuation. Mirabegron relieved symptoms in 45.2% and enhanced quality of life in 41.7% of the participants. Age <64 years was associated with better probability of symptom improvement (OR, 2.7; 95% CI, 1.1–6.8), whereas none of the other parameters assessed predicted change in quality of life.

Conclusions

In this Finnish population, 50.7% of the participants continued using mirabegron after 6 months. The prescription site seemed to be important for persistent use, which may be related to patient counseling. Younger patients were more likely to benefit from treatment with mirabegron.

Association between lower urinary tract symptoms and cardiovascular risk scores in ostensibly healthy women

OBJECTIVES

To investigate the association between lower urinary tract symptoms (LUTS) and cardiovascular disease (CVD) risk in women, as severe LUTS are known to be associated with CVD risk in men but few studies have focused on this issue in women.

SUBJECTS AND METHODS

A total of 1014 ostensibly healthy women, who participated in a voluntary health check in a health promotion centre from November 2013 to October 2015, were enrolled. LUTS were assessed using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS). CVD risk scores were calculated using the Framingham risk score and the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease (ASCVD) score. Correlation, partial correlation, and multiple logistic regression analyses were conducted.

RESULTS

The mean age and body mass index (BMI) of the women were 51 years and 22.6 kg/m² , respectively. The ASCVD score showed significant positive correlations with IPSS items Question 2 (Q2), Q3, Q5, and Q7 (all P < 0.05), total IPSS (P = 0.001), IPSS storage (P = 0.006) and IPSS voiding symptoms scores (P = 0.001) based on partial correlation analysis after adjustment for BMI. For the OABSS, the ASCVD score showed significant positive correlations with OABSS items Q2, Q3, and Q4 (P < 0.001, P = 0.017, and P < 0.001, respectively) and total OABSS (P < 0.001). Multiple logistic regression analysis showed that the moderate-severe risk groups of the OABSS and IPSS were associated with the ASCVD risk score in adjusted models (P < 0.001) compared to the none-mild OABSS and mild IPSS groups. After adjustment for age and BMI, IPSS storage score was significantly related with the ASCVD risk score (B = 0.855, P = 0.016) CONCLUSIONS: LUTS, especially storage symptoms, might be risk factors for predicting future CVD risk in women. Further prospective or cohort studies are needed to validate this possibility.

Relationship Between Central Obesity, General Obesity, Overactive Bladder Syndrome and Urinary Incontinence Among Male and Female Patients Seeking Care for Their Lower Urinary Tract Symptoms

OBJECTIVES

To describe the relationship between metabolic factors and lower urinary tract symptoms, overactive bladder syndrome (OAB) and urinary incontinence (UI).

METHODS

Adult male and female patients who presented to a clinician from the symptoms of lower urinary tract dysfunction research network were recruited. Urinary symptoms (presence of OAB, any UI, stress UI (SUI), urgency UI (UUI), urgency, frequency, and nocturia) were assessed with the lower urinary tract symptoms tool. Metabolic factors assessed included central obesity (waist circumference, using the Adult Treatment Panel III, the International Diabetes Federation thresholds, and waist circumference as a continuous variable), general obesity (body mass index as dichotomous or continuous variables), diabetes mellitus, hypertension, and dyslipidemia. Multivariable logistic regression was used to test for associations.

RESULTS

920 participants were studied. In multivariable analyses, central obesity (per 10 cm larger waist) was associated with higher odds of UI in both sexes (odds ratio [OR] = 1.16, P = .008), SUI in females (OR = 1.27, P = .008), UUI in both sexes (OR = 1.24, P = .001), OAB in females (OR = 1.248, P = .003), as well as frequency and nocturia. General obesity (5-unit increase in body mass index) was associated with UI, UUI, urgency and frequency in both sexes, and with SUI and OAB in females. We did not find associations between central or general obesity and OAB in males. Dyslipidemia was associated with nocturia ≥2.

CONCLUSION

In patients, central and general obesity were key metabolic factors associated with UI in both males and females, and with OAB in females but not in males. The association between dyslipidemia and nocturia ≥2 needs further research.

Effect of high-fat diet-induced obesity on the small-conductance Ca2+-activated K+ channel function affecting the contractility of rat detrusor smooth muscle

PURPOSE

Obesity usually induces overactive bladder (OAB) associated with detrusor overactivity, which is related to increased contractility of the detrusor smooth muscle (DSM). Small-conductance Ca²⁺-activated K⁺ (SK) channels play a constitutive role in the regulation of DSM contractility. However, the role of SK channels in the DSM changes in obesity-related OAB is still unknown. Here, we tested the hypothesis that obesity-related OAB is associated with reduced expression and activity of SK channels in DSM and that SK channels activation is a potential treatment for OAB.

METHODS

Female Sprague-Dawley rats were fed a normal diet (ND) or a high-fat diet (HFD) and weighed after 12 weeks. Urodynamic studies, quantitative reverse transcription-polymerase chain reaction (qRT-PCR), and isometric tension recording were performed.

RESULTS

Increased average body weights and urodynamically demonstrated OAB were observed in HFD rats. qRT-PCR experiments revealed a decrease in the mRNA expression level of SK channel in DSM tissue of the HFD rats. Isometric tension recordings indicated an attenuated relaxation effect of NS309 on the spontaneous phasic and electrical field stimulation-induced contractions that occurred via SK channel activation in HFD DSM strips.

CONCLUSIONS

Reduced expression and activity of SK channels in the DSM contribute to obesity-related OAB, indicating that SK channels are a potential therapeutic target for OAB.

Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Urinary Incontinence in Older Adults: A Translational Research Agenda for a Complex Geriatric Syndrome

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its ninth Bedside-to-Bench research conference, entitled "Urinary Incontinence in the Older Adult: A Translational Research Agenda for a Complex Geriatric Syndrome," October 16 to 18, 2016, in Bethesda, Maryland. As part of a conference series addressing three common geriatric syndromes-delirium, sleep and circadian rhythm disturbance, and urinary incontinence-the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these conditions. The conference provided a forum for discussing current epidemiology, basic science, and clinical and translational research on urinary incontinence in older adults; for identifying gaps in knowledge; and for developing a research agenda to inform future investigative efforts. The conference also promoted networking involving emerging researchers and thought leaders in the field of incontinence, aging, and other fields of research, as well as National Institutes of Health program personnel.

Dealing with complex overactive bladder syndrome patient profiles with focus on fesoterodine: in or out of the EAU guidelines?

Overactive bladder (OAB) syndrome is a common, complex, and challenging condition. To assist the management of these patients, the European Association of Urology (EAU) updates its guidelines annually. This review reports the presentations from the symposium titled “Dealing with complex OAB patient profiles: in or out of the EAU guidelines?” held at the 32nd EAU Annual Congress in March 2017 in London. The symposium focused on three groups of OAB patients: women who may also suffer pelvic organ prolapse, stress urinary incontinence, the genitourinary syndrome of menopause (GSM); patients at risk of cognitive impairment; and elderly patients. The aim of the symposium was to determine how the 2017 EAU guidelines can best assist physicians, as well as to assess the benefits of fesoterodine in these patients. The EAU guidelines recommend antimuscarinic agents (grade A) for the medical treatment of OAB. In women, OAB is correlated with GSM, both of which are underdiagnosed and undertreated. Fesoterodine decreases OAB symptoms and the associated limitation of physical activity. A combination of fesoterodine and vaginal estrogens is appropriate for OAB associated with GSM. In patients at risk of cognitive impairment, prescribers should pay particular attention to the choice of medication. Fesoterodine is a Pgp substrate with limited ability to cross the blood–brain barrier, which may explain the lack of negative effects on the central nervous system observed in clinical trials of this agent. OAB should not be regarded as a normal consequence of aging. Fesoterodine has been extensively investigated in the elderly, and is the only anticholinergic drug licensed for OAB in this population, rated B (beneficial) according to the Fit for the Aged classification for lower-urinary-tract symptoms. The EAU guidelines are a valuable resource for physicians managing patients with OAB, and the pharmacological properties of fesoterodine offer credible clinical advantages in these three patient groups.