The long-term natural history of overactive bladder symptoms due to idiopathic detrusor overactivity in women

Barriers and facilitators to overactive bladder therapy adherence

AIMS

To provide an overview of the barriers and facilitators to overactive bladder (OAB) therapy initiation and adherence.

METHODS

A PubMed and Embase literature search was conducted to identify barriers to OAB therapy adherence.

RESULTS

OAB therapy adherence is associated with improvements in urinary symptoms, and quality of life with reductions in annual costs for OAB-related expenditures. However, adherence rates to behavioral therapies are as low as 32% at 1 year, only 15%-40% of treated patients remain on oral medications at 1 year due to several factors (e.g., inadequate efficacy, tolerability, and cost), and 5%-10% of OAB patients progress to advanced therapies. While some common barriers to therapy adherence are often fixed (e.g., costs, lack of efficacy, time, side effects, treatment fatigue), many are modifiable (e.g., lack of knowledge, poor relationships, negative experiences, poor communication with providers). Patient-centered care may help address some modifiable barriers. Emerging data demonstrate that patient-centered care in the form of treatment navigators improves OAB therapy adherence and progression to advanced therapies in the appropriate patient.

CONCLUSIONS

There are numerous modifiable barriers to OAB therapy adherence. A patient-centered lens is needed to elicit patient goals, establish realistic treatment expectations, and tailor therapy to improve therapy adherence, optimize outcomes, and reduce healthcare expenditures. Further research is needed to develop and study low-cost, scalable solutions.

Urinary cytokines in women with refractory detrusor overactivity: A longitudinal study of rotating antibiotic versus placebo treatment

Over 50% of women with detrusor overactivity (DO), who do not respond to therapy have been shown to have bacteriuria, which may stimulate the release of inflammatory cytokines than can enhance nerve signalling, leading to symptoms of urgency. This study made use of a consecutive series of urine samples collected from women with refractory DO, who participated in a clinical trial of rotating antibiotic therapy. The aim was to determine the effect of bacteriuria and antibiotic treatment on the levels of urinary cytokines, and to correlate the cytokine concentration with patient outcome measures relating to urgency or urge incontinence. The urinary cytokines chosen were IL-1α, IL-1 receptor antagonist, IL-4, IL-6, IL-8, IL-10, CXCL10 (IP-10), MCP-1 and TNF-α. The presence of bacteriuria stimulated a significant increase in the concentrations of IL-1α (P 0.0216), IL-1 receptor antagonist (P 0.0264), IL-6 (P 0.0003), IL-8 (P 0.0043) and CXCL-10 (P 0.009). Antibiotic treatment significantly attenuated the release of IL-1α (P 0.005), IL-6 (P 0.0027), IL-8 (P 0.0001), IL-10 (P 0.049), and CXCL-10 (P 0.042), i.e. the response to the presence of bacteria was less in the antibiotic treated patients. Across the 26 weeks of the trial, antibiotic treatment reduced the concentration of five of the nine cytokines measured (IL-1α, IL-6, IL-8, IL-10 and CXCL-10); this did not reach significance at every time point. In antibiotic treated patients, the urinary concentration of CXCL-10 correlated positively with four of the six measures of urgency. This study has shown that cytokines associated with activation of the innate immune system (e.g. cytokines chemotactic for or activators of macrophages and neutrophils) are reduced by antibiotic therapy in women with refractory DO. Antibiotic therapy is also associated with symptom improvement in these women, therefore the inflammatory response may have a role in the aetiology of refractory DO.

Do the definitions of the underactive bladder and detrusor underactivity help in managing patients: International Consultation on Incontinence Research Society (ICI-RS) Think Tank 2017?

AIMS

The Think Tank aimed to discuss the pitfalls and advantages of current definitions in terms of research and management of underactive bladder (UAB). UAB broadly defines a symptom complex of bladder emptying problems and does not indicate a specific pathology. Detrusor underactivity (DU) is a urodynamic diagnosis from pressure-flow studies. The correlation of UAB with DU remains to be precisely determined.

METHODS

The presentations and subsequent discussion, leading to research recommendations during the Think Tank of the International Consultation on Incontinence Research Society in Bristol, 2017, are summarized.

RESULTS

To develop more specific individualized management strategies, the Think Tank panel proposed (i) that, since defining a single type of index patient to represent all UAB will not fulfill all clinical research needs, several index patients should be defined by phenotyping of patients with UAB, including, children, young men and women, elderly male and female patients with co-existing DU and detrusor overactivity, and neurological patients with UAB; (ii) prospective longitudinal studies to assess the natural history of UAB, in the different target populations, based on different UAB phenotypes, should be initiated; (iii) DU should be precisely defined by urodynamic parameters; and (iv) work to develop validated specific questionnaires combined with non-invasive tests for screening, diagnosis and follow up, needs to be continued.

CONCLUSIONS

The precise relationship of UAB to DU remains to be defined. Phenotyping patients with UAB/DU, performing prospective trials of natural history, and developing symptom questionnaires and diagnostic investigations will improve our ability to identify and treat UAB/DU.

Personal goals and expectations of OAB patients in the UK

INTRODUCTION

In clinical practice and in research patient-centred outcomes are often utilised to help improve communication between patients and clinicians and to help manage expectations from treatment. However, many of these goals are generic and do not adequately capture the details of day to day life that bother patients the most and that they hope will improve with therapy. This study aimed to understand what are the goals of patients with overactive bladder symptoms in the UK who were taking part in a clinical trial and to assess goal achievement.

METHODS

This was a qualitative analysis of the patients goals recorded using the Self-Assessment Goal Achievement (SAGA) Questionnaire during the UK study assessing flexible dose fesoterodine in adults (SAFINA) trial. Free text patient goals were completed at baseline and an assessment of achievement was performed at the end of treatment. Grounded theory was used to develop themes and sub themes.

RESULTS

Three hundred and thirty-one patients completed the trial and 1137 open ended goals were set. Six themes emerged from the data including, OAB, other LUTS and finishing the task in hand with multiple subthemes noted.

CONCLUSIONS

By assessing and understanding what is important to the patient, it may help to tailor patient care and treatment and improve patient satisfaction.

Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

INTRODUCTION AND HYPOTHESIS

Overactive bladder (OAB) has a multifactorial aetiology, and for some women symptoms may be associated with chronic urothelial inflammation secondary to bacterial colonisation. One marker of such inflammation may be urinary nerve growth factor (NGF). We hypothesised that for women with OAB and urothelial inflammation, urinary NGF would be reduced following antibiotic therapy.

METHODS

Women with overactive bladder and urodynamic diagnosis of detrusor overactivity who were refractory to anticholinergics, and had histological evidence of urothelial inflammation were treated with a 6-week course of rotating antibiotics. Urinary NGF was measured by ELISA before and after treatment. Three-day bladder diaries, the Patients' Perception of Intensity of Urgency Scale, the King's Health Questionnaire and the Patients' Perception of Bladder Condition questionnaire were used to assess subjective and objective outcomes of therapy.

RESULTS

Thirty-nine women with refractory DO were recruited. The NGF levels decreased significantly after antibiotic therapy (Wilcoxon signed rank test; p = 0.015). There were significant improvements in daytime frequency, nocturia and urgency (p < 0.05), and 74 % of women reported improvement in perception of their bladder condition.

CONCLUSIONS

Urinary NGF is responsive to antibiotic therapy. Women with refractory overactive bladder and elevated NGF may benefit from antibiotic treatment.

Clinical and urodynamic differences among women with overactive bladder according to the presence of detrusor overactivity

INTRODUCTION AND HYPOTHESIS

We tried to determine whether clinical and urodynamic differences exist between women with and without detrusor overactivity (DO) using a large database of overactive bladder (OAB) patients.

METHODS

We reviewed the medical records of 513 women who underwent urodynamic studies for OAB symptoms without neurogenic or anatomical conditions that affect micturition function. Clinical symptoms were evaluated using a 3-day frequency-volume chart (FVC) including the Urinary Sensation Scale and American Urological Association Symptom Index (AUA-SI). All clinical and urodynamic findings were compared between women with and without DO.

RESULTS

The patients' mean age was 58.9 years. DO was identified urodynamically in 167 (32.6 %) women. Those with DO were older (62.9 vs 57.0 years, p < 0.001); however, no differences in AUA-SI, episodes of daytime voiding, and episodes of nocturia were observed between the groups. Functional bladder capacity was smaller in women with DO; however, this difference did not reach statistical significance. Women with DO had significantly more urgency incontinence symptoms than those without DO (55.1 vs 29.5 %, p < 0.001). In urodynamic parameters, the volumes at first desire to void and strong desire to void and maximum cystometric capacity were significantly smaller, and detrusor pressure at the opening was significantly higher in women with DO compared to subjects without DO (26.2 vs 21.2 cmH(2)O, p = 0.004).

CONCLUSIONS

Our findings suggest a more severe disturbance of bladder function when DO exists, although no differences were observed in symptom scores and 3-day FVC parameters among women with OAB symptoms according to the presence of DO.

Overactive bladder: the importance of tailoring treatment to the individual patient

INTRODUCTION

Overactive bladder (OAB) is a prevalent and persistent condition that is often under-diagnosed and under-treated, and which frequently requires tailored treatment for successful management.

METHODS

This consensus opinion-based review summarizes the discussions of a group of experts in the field of OAB that were assembled to evaluate the importance of correct diagnosis and appropriate pharmacotherapy in patients with OAB.

RESULTS

A thorough diagnostic process is crucial for allowing exclusion of underlying medical issues and differentiation from genitourinary conditions other than OAB. In addition, selecting the most appropriate pharmacotherapy needs to be carefully considered in the context of each patient with OAB. In general, patients with OAB tend to be older with various comorbidities and often receiving multiple concomitant medications. Treatment decisions should take into consideration the differing potential for antimuscarinic medications to alter cognitive and cardiovascular functions, both of which may be compromised in this patient population.

CONCLUSION

Tailoring treatment to individual patients by comprehensive patient assessment may lead to more effective management of patients with OAB, especially those receiving polypharmacy for comorbidities.

Antimuscarinics for the treatment of overactive bladder: understanding the role of muscarinic subtype selectivity

INTRODUCTION AND HYPOTHESIS

Antimuscarinic agents appear to exert their therapeutic activity in overactive bladder (OAB) via blockade of the M(3) muscarinic receptor subtype. Antimuscarinics are broadly similar in efficacy, but their safety and tolerability profiles vary, which may reflect differences in muscarinic receptor selectivity profiles.

METHODS

This review of available literature aims to determine whether antimuscarinic agents with greater M(3) selectivity have clinical advantages over less selective drugs.

RESULTS

Antimuscarinic agents differ widely in their propensity to cause cognitive and cardiovascular (CV) effects, which appear mainly to be related to differences in their relative selectivity for binding to non-M(3) receptors, including M(1) receptors in the brain and cardiac M(2) receptors.

CONCLUSIONS

Cognitive and CV effects are especially pertinent for the OAB patient who tends to be older with various comorbidities and is often taking multiple medications. Hence, it is important to consider the risk/benefit balance of antimuscarinic agents when selecting OAB treatment.

Patient experience with darifenacin - results of a short-term community-based survey in managing overactive bladder

OBJECTIVE

This community-based program evaluated patients' experiences with darifenacin over 3 weeks' treatment in a predominantly primary care clinical practice setting.

METHODS

Physicians (n = 2117, 50% primary care physicians, 35% urologists, 10% obstetrician/gynecologist, 5% other) were asked to introduce the program to patients with overactive bladder (OAB). Patients received an enrollment kit including a 30-day darifenacin voucher, activated if patients registered for the program via telephone or online. Patients (≥ 18 years of age) completed a brief automated survey to evaluate frequency of urge urinary incontinence episodes (UUIEs), micturitions/24 hours, urge severity/24 hours (10 point scale: 0 = not at all severe; 10 = very severe), and treatment tolerability (10 point scale: 0 = very poorly tolerated; 10 = very well tolerated). Patients also completed a second survey 3 weeks after starting darifenacin. Statistical analyses were not prospectively planned or performed.

RESULTS

A total of 2165 patients completed both surveys. At baseline, mean age of completers was 66 years, 76% were female, and 47% reported prior use of OAB medications. After 3 weeks' treatment, patients experienced reductions in UUIEs and micturitions. Urge severity was reduced by >30% after 3 weeks (mean scores: 6.7 at baseline vs. 4.6 after 3 weeks' treatment) and treatment was well tolerated (mean score: 7.7). Overall, 85% of patients who participated in the program did so due to physician influences.

CONCLUSIONS

The results of this 3-week, self-reported community-based survey indicate that patients were generally satisfied with darifenacin treatment and experienced a reduction in OAB symptoms. Darifenacin was generally well tolerated.

Urinary incontinence, overactive bladder, and other lower urinary tract symptoms: a longitudinal population-based survey in men aged 45-103 years

BACKGROUND

Lower urinary tract symptoms (LUTS) such as urinary incontinence (UI) and overactive bladder (OAB) are highly prevalent conditions, but there are few studies describing progression and remission of LUTS in men, especially over the long term.

OBJECTIVE

To describe the prevalence of UI, OAB, and LUTS using current International Continence Society definitions in the same men studied longitudinally over time.

DESIGN

Prospective, population-based, longitudinal study.

SETTING AND PARTICIPANTS

In 1992, 10 458 men aged 45-99 yr, resident in the city of Gothenburg, were selected at random from the Population Register.

MEASUREMENTS

The men received a postal questionnaire about the presence of LUTS, as well as questions on social, medical, health-related quality of life (HRQoL), and demographic data. Responders in 1992 were reassessed 11 yr later in 2003 using a similar questionnaire.

RESULTS AND LIMITATIONS

In 2003, 4072 of the 7763 men who responded in 1992 were still available in the Population Register and 3257 men (80%) aged 56-103 yr, responded. Prevalence of UI and OAB had increased (p<0.01) in the same men assessed in 1992 (4.5% and 15.6%, respectively) and 2003 (10.5% and 44.4%, respectively). The prevalence of nocturia, urgency, slow stream, hesitancy, incomplete emptying, postmicturition dribble, and the number of daytime micturitions had also increased (p<0.01). Only a minority reported regression of symptoms. Men with UI or OAB reported a poorer (p<0.001) HRQoL compared with men without UI or OAB.

CONCLUSIONS

There was a marked increase in the prevalence of UI, OAB, and other LUTS in the same men assessed longitudinally over this 11-yr period. UI and OAB had a negative influence on HRQoL, and men who developed UI or OAB had a greater deterioration in HRQoL than men who had no change in their UI/OAB status over time.