Overactive Bladder Syndrome: Evaluation and Management

Post-stroke urinary incontinence is associated with behavior control deficits and overactive bladder

BACKGROUND

Although urinary incontinence in stroke survivors can substantially impact the patient's quality of life, the underlying neuropsychological mechanisms and its neural basis have not been adequately investigated. Therefore, we investigated this topic via neuropsychological assessment and neuroimaging in a cross-sectional study.

METHODS

We recruited 71 individuals with cerebrovascular disease. The relationship between urinary incontinence and neuropsychological indices was investigated using simple linear regression analysis or Mann-Whitney U test, along with other explanatory variables, e.g., severity of overactive bladder. Variables with a p-value of <0.1 in the simple regression analysis were entered in the final multiple linear regression model to control for potential confounding factors. To carry out an in-depth examination of the neuroanatomical substrate for urinary incontinence, voxel-based lesion-behavior mapping was performed using MRIcron software.

RESULTS

Behavioral control deficits and severity of overactive bladder were closely related to severity of urinary incontinence. The voxel-based lesion-behavior mapping suggests a potential role for ventromedial prefrontal cortex lesioning in the severity of urinary incontinence, although this association is not statistically significant.

CONCLUSIONS

Post-stroke urinary incontinence is closely related to two factors: neurogenic overactive bladder, a physiological disinhibition of micturition reflex, and cognitive dysfunction, characterized by behavior control deficits.

Can we increase the value of data from bladder diaries? International Consultation on Incontinence-Research Society 2023

BACKGROUND

Bladder diaries represent a fundamental component in the assessment of patients presenting with lower urinary tract symptoms. Nevertheless, their importance often remains underappreciated and undervalued within clinical practice. This paper aims to conduct a comprehensive review of the existing literature concerning the utility of bladder diaries, underscore the criticality of their precision, elucidate the factors contributing to noncompliance with bladder diary completion, and investigate potential strategies for enhancing patient compliance.

MATERIALS AND METHODS

A review of the English-language scientific literature available in the domains of Medline, Embase, Emcare, Midirs, and Cinahl was conducted. This was supplemented by discussion at the International Consultation on Incontinence Research Society Proposal session to define knowledge and identify gaps in knowledge surrounding the utility of bladder diaries. The existing evidence and outcome of the relevant discussion held in the meeting are presented.

RESULTS

Bladder diaries (BD) serve to characterize the nature and severity of storage lower urinary tract symptoms (LUTS) and provide an objective record of an individual's urination patterns. They aid in the refinement and customization of treatment strategies based on the clinical responses documented in the diary, optimizing treatment outcomes. Notably, both BD and urodynamic studies (UDS) play complementary yet distinct roles in LUTS evaluation. BD offers a more comprehensive and accessible approach to assessing specific storage LUTS, particularly due to their affordability and widespread availability, especially in resource-limited settings. Nevertheless, the absence of a standardized BD format across global healthcare systems presents a significant challenge. Despite being recognized as reliable, noninvasive, validated, and cost-effective tools for evaluating patients with LUTS, the implementation and completion of BD have proven to be complex. The introduction of automated bladder diaries heralds an era of precise, real-time data collection, potentially enhancing the patient-clinician relationship. Completion of bladder diaries depends on an array of individual, social, and healthcare-specific factors. Compliance with bladder diary completion could be enhanced with clear instructions, patient education, regular follow-ups and positive re-enforcement. This study has identified four critical areas for future research: Addressing healthcare disparities between affluent and developing nations, enhancing the current functionality and effectiveness of bladder diaries, exploring the feasibility of incorporating bladder diaries into the treatment and education process and improving the quality and functionality of existing bladder diaries.

CONCLUSION

Bladder diaries play a pivotal role in the evaluation and management of patients with LUTS, providing a holistic perspective. When their complete potential is harnessed, they have the capacity to revolutionize the paradigm of LUTS management, ushering in a patient-centered era of care.

Tolterodine Tartrate Loaded Cationic Elastic Liposomes for Transdermal Delivery: In Vitro, Ex Vivo, and In Vivo Evaluations

OBJECTIVE

Tolterodine tartrate (TOTA) is a first-line therapy to treat overactive urinary bladder (OAB). Oral delivery causes high hepatic clearance, xerostomia, headache, constipation, and blurred vision. We addressed Hansen solubility parameter (HSP) and Design Expert oriented optimized cationic elastic liposomes for transdermal application.

METHODS

The experimental solubility was conducted in HSPiP predicted excipients to tailor formulations using surfactants, stearylamine, ethanol, and phosphatidylcholine (PC). These were evaluated for formulation characteristics. The optimized OTEL1 and OTEL1-G (gel) were compared against the drug solution (DS) and liposomes. In vitro and ex vivo studies were accomplished to investigate the insights into the mechanistic understanding of TOTA release and permeation ability. Finally, confocal laser scanning microscopy (CLSM) supported ex vivo results.

RESULTS

HSP values of TOTA were closely related to tween-80, stearylamine, and human's skin. The size (153 nm), %EE (87.6%), and PDI (0.25) values of OTEL1 were in good agreement to the predicted values (161 nm, 80.4%, and 0.31) with high desirability (0.963). Spherical and smooth OTEL1 (including OTEL1-G and liposomes) vesicles followed non-Fickian drug release as compared to DS (Fickian) as evidence with n > 0.5 (Korsmeyer and Peppas coefficient). OTEL1 (containing lipid and surfactant as 90 mg and 13.8 mg, respectively) exhibited 2.6 and 1.8-folds higher permeation flux than DS and liposomes, respectively. Biocompatible cationic OTEL1 was safe and non-hemolytic.

CONCLUSIONS

OTEL1 was promised as a lead vesicular approach and an alternative to conventional oral therapy to treat OAB in children and advanced age patients.

Sacral Magnetic Neuromodulation with Intermittent Theta Burst Waveform Enhances Overactive Bladder: In Vivo Study

BACKGROUND

The current treatment options for overactive bladder (OAB) continue to pose challenges for refractory cases and may involve invasive procedures. To assess the potential benefit of non-invasive repetitive peripheral magnetic stimulation (rPMS) on sacral roots using intermittent theta burst stimulation (iTBS) as treatment option for OAB. The study involved a total of 33 rats, which were divided into three different experimental phases.

MATERIALS AND METHODS

To induce bladder overactivity rats were pretreated with a continuous transvesical infusion of 0.5% acetic acid (AA). During bladder infusion, the intravesical pressure was recorded using cystometrography (CMG) to investigate the effects of AA pretreatment and the therapeutic intervention of acute sacral rPMS using iTBS.

RESULTS

Pre-application of rPMS with iTBS at a 100% intensity significantly extended the mean first voiding time (Tv) in normal healthy rats to 132%. Acute rPMS iTBS at a 100% intensity resulted in a significant increase of the inter-contraction interval (ICI) to 121%. An AA model was established with continuous saline infusion after 0.5% AA treatment and resulted in significant reductions of Tv to 42% and ICI to 56% of the corresponding control values. Subsequently, rPMS iTBS at a 100% intensity on the sacral nerve effectively inhibited AA-induced bladder overactivity and significantly increased the ICI to 167%∼222%. No significant changes in maximum bladder pressure (Pmax) were found.

CONCLUSIONS

Sacral nerve rPMS with iTBS demonstrated the ability to suppress AA-induced bladder overactivity. This promising modality could be developed as an alternative approach to enhance bladder continence in OAB syndrome patients.

Update on Overactive Bladder Therapeutic Options

BACKGROUND

Millions of Americans are burdened by overactive bladder (OAB) syndrome and the psychogenic and economic hardships that accompany it. Several theories attempt to explain OAB as a neurogenic dysfunction, myogenic dysfunction, urothelial dysfunction, or decreased expression of a channel protein secondary to bladder outlet obstruction. Given that the etiology of OAB is a working theory, the management of OAB is also an evolving subject matter in medicine. There are uncertainties surrounding the pathophysiology of OAB, the strength of a clinical diagnosis, and accurate reporting because of the disease's stigma and decreased use of health care.

DATA SOURCES

This is a narrative review that used PubMed, Google Scholar, Medline, and ScienceDirect to review literature on current and future OAB therapies.

RESULTS

Currently, first-line treatment for OAB is behavioral therapy that uses lifestyle modifications, bladder-control techniques, and psychotherapy. Second-line therapy includes antimuscarinic agents or beta 3 adrenergic agonists, and studies have shown that combination therapy with antimuscarinics and beta 3 adrenergic agonists provides even greater efficacy than monotherapy. Third-line therapies discussed include onabotulinumtoxinA, posterior tibial nerve stimulation, and sacral neuromodulation. OnabotulinumtoxinA has been FDA-approved as a nonpharmaceutical treatment option for refractory OAB with minimal side effects restricted to the urinary tract. Posterior tibial nerve modulation and sacral neuromodulation are successful in treating refractory OAB, but the costs and complication rates make them high-risk procedures. Therefore, surgical intervention should be a last resort. Estrogen therapy is effective in alleviating urinary incontinence in postmenopausal women, consistent with the association between estrogen deficiency and genitourinary syndrome. Potassium channel activators, voltage-gated calcium channel blockers, and phosphodiesterase inhibitors look to be promising options for the future of OAB management. As new therapies are developed, individuals with OAB can better personalize their treatment to maximize their quality of life and cost-effective care.

Exploring lifelong overactive bladder: Transitions, evidence, and clinical implications; A modified Delphi process

INTRODUCTION

Overactive bladder (OAB) is a prevalent urological condition characterized by urinary urgency, with or without urgency urinary incontinence, accompanied by increased daytime frequency and nocturia. However, the current definition of OAB lacks a specified time frame, hindering our understanding of the temporal aspects and transitions that occur within the OAB spectrum.

METHODS

A modified Delphi study was conducted in three rounds, involving a panel of international experts in functional urology, urogynaecology, geriatrics, transitional medicine, and pediatric urology. The study took place between February 2023 and June 2023 and employed two sequential rounds of online surveys, followed by a final hybrid group discussion session in June 2023.

RESULTS

The Delphi process resulted in a consensus definition of lifelong OAB as a persistent and continuous condition that may manifest differently from birth and evolve over time, with varying levels of clinical perception. The course of its progression is influenced by transition periods and modifying factors, mainly anatomical, hormonal, and psychosocial/stressors. Three main transition periods were identified: achievement of daytime continence, adulthood to elderly, and transition to frail elderly. The panel also considered the therapeutic and diagnostic implications of lifelong OAB, as well as future research prospects in terms of importance and feasibility.

CONCLUSIONS

Future longitudinal research is needed to develop this concept and further identify transitions and temporal dynamics.

Antibiotics for UTI Prevention After Intradetrusor OnabotulinumtoxinA Injections

IMPORTANCE

Urinary tract infections (UTIs) occur in 8.6% to 48.1% of patients after intradetrusor onabotulinumtoxinA injections.

OBJECTIVE

The objective of this study was to evaluate both choice and duration of antibiotic prophylaxis on the incidence of UTI within 30 days after in-office onabotulinumtoxinA injections.

STUDY DESIGN

We included a single-site, retrospective cohort of 305 patients with overactive bladder or bladder pain syndrome receiving postprocedure prophylactic antibiotics for in-office, 100-unit intradetrusor onabotulinumtoxinA injections from 2019 to 2023. Categories of antibiotic prophylaxis compared included (1) nitrofurantoin 100 mg twice daily for 3 days, (2) nitrofurantoin 100 mg twice daily for 5 days, (3) trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily for 3 days, and (4) "other regimens." Primary outcome was incidence of UTI within 30 days. Variables were compared via χ2 test. Crude/adjusted odds were estimated using binary logistic regression.

RESULTS

Incidence of UTI was 10.4% for 3-day nitrofurantoin, 20.5% for 5-day nitrofurantoin, 7.4% for 3-day trimethoprim-sulfamethoxazole, and 25.7% among "other regimens" (P = 0.023). Differences among primary regimens were substantial but not statistically significant: 3-day trimethoprim-sulfamethoxazole had 31% lower odds of UTI versus 3-day nitrofurantoin (odds ratio [OR], 0.689; P = 0.518). Compared with 3-day nitrofurantoin regimen, the 5-day nitrofurantoin regimen had twice the odds of UTI (OR, 2.22; P = 0.088). Those receiving "other regimens" had nearly 3 times the odds of UTI (OR, 2.98; P = 0.018). Results were similar adjusting for age and race. Overall urinary retention rate was 1.97%.

CONCLUSIONS

Prophylactic antibiotic choice and duration of treatment potentially affect UTI incidence after in-office, intradetrusor onabotulinumtoxinA injections. Nitrofurantoin and trimethoprim-sulfamethoxazole for 3 days have the lowest UTI incidence.

Evaluation of Food Effect on the Pharmacokinetics of Velufenacin, a New Muscarinic Receptor Antagonist, in Healthy Subjects

Velufenacin (DA-8010) is a new muscarinic receptor antagonist under development for the treatment of overactive bladder. This study aimed to evaluate the effect of food on the pharmacokinetics (PK) and safety of velufenacin in healthy subjects. A randomized, open-label, single-dose, 4-sequence, 4-treatment, 4-period crossover study was conducted. Subjects received a single oral dose of velufenacin 2.5 or 5 mg in a fasted or fed (high-fat meal) state in each period with a 7-day washout. PK parameters including maximum plasma concentration (Cmax ) and area under the concentration-time curve from time 0 to the last measurable point were compared between the fed and fasted states. Twenty-seven subjects completed the study. The mean area under the concentration-time curve from time 0 to the last measurable point of the velufenacin 2.5 and 5 mg doses under the fed condition showed a 1.5- and 1.3-fold increase, respectively, compared to the fasted condition. The corresponding values for Cmax were a 2.3- and 2.0-fold increase, respectively. The time to reach Cmax was comparable regardless of the dose or food intake, showing median values of 4.5-5.0 hours. These results suggest a modest increase of velufenacin absorption by food intake. Velufenacin was generally safe and well tolerated at the 2.5 and 5 mg doses regardless of food.

The impact of diabetes on overactive bladder presentations and associations with health-seeking behavior in China, South Korea, and Taiwan: Results from a cross-sectional, population-based study

BACKGROUND

This study aimed to explore the impact of diabetes on overactive bladder (OAB) presentations and related predictors of healthcare-seeking behavior among adults aged ≥ 40 years in China, Taiwan, and South Korea.

METHODS

An internet-based survey was conducted to assess the prevalence of diabetes, OAB presentations, and self-perceived urinary symptoms by a multi-national sample of 8284 individuals who completed the survey between June 2, 2015 and July 31, 2015. Independent associations with health-seeking behavior for urinary symptoms were estimated with odds ratio (OR) with 95% confidence interval (95% CI) using multivariate logistic regression.

RESULTS

Diabetes was reported in 13.6% of participants and OAB was 20.8%. Diabetic participants were older than non-diabetic participants in both sexes. Participants with diabetes reported a higher rate of OAB (43.1%) and increased bothersome symptoms associated with OAB than those without diabetes. Participants with diabetes (OR, 3.07 [2.39-3.96]], urgent incontinence (OR, 2.38 [1.86-3.03]), frequency (OR, 1.86 [1.45-2.38]), and nocturia (OR, 1.14 [1.05-1.24]) were associated with healthcare-seeking behavior.

CONCLUSION

The proportion of diabetic participants with OAB was 2.5-fold higher than those without diabetes. Diabetes, urinary frequency, nocturia, and urgent incontinence are predictors of medical treatment-seeking behavior, but the key symptom of OAB-urgency is not a predictor of treatment-seeking behavior. It is important for clinicians to recognize the interplay between diabetes and OAB and to early identify various bothersome urinary symptoms for better health outcomes in daily practice.

Systematic review and meta-analysis of urinary incontinence prevalence and population estimates

INTRODUCTION

Incontinence impacts the quality-of-life of people suffering from the disease. However, there is limited information on the prevalence of incontinence due to the stigma, lack of awareness, and underdiagnosis.

OBJECTIVE

This study aims to conduct a systematic review and meta-analysis of overactive bladder (OAB) and nonobstructive urinary retention (NOUR).

METHODS

The authors conducted a systematic review following the PRISMA guidelines using Embase, MEDLINE, and PubMed databases to identify the relevant publications in the English language. Two reviewers independently assessed the articles and extracted the data. Review papers were assessed for content and references. A meta-analysis of proportions was conducted using the RStudio software. To address the age heterogeneity, a subanalysis was conducted. Pooled data were overlayed on the Canadian population and a sample of 10 populous countries to estimate the number of people suffering from incontinence.

RESULTS

Twenty-eight and eight articles were selected for OAB and NOUR, respectively. The pooled prevalence of OAB in men and women was 12% (95% CI: 9%-16%) and 15% (95% CI: 12%-18%), respectively. The estimated prevalence of NOUR was 15.6%-26.1% of men over 60 and 9.3%-20% of women over 60. The subanalysis pooled prevalence of OAB in men and women was 11% (95% CI: 8%-15%) and 12% (95% CI: 9%-16%), respectively. We estimated that 1.4-2.5 million women and 1.3-2.2 million men suffer from OAB in Canada.

CONCLUSION

Urinary incontinence is an under-reported and underdiagnosed prevalent condition that requires appropriate treatment to improve a patient's quality-of-life.

Prevalence of overactive bladder in Chinese women: A systematic review and meta-analysis

BACKGROUND

Overactive bladder (OAB) is a significant public health issue that adversely affects the quality of life of patients and imposes a significant socioeconomic burden, with varying prevalence rates across study populations in Chinese women. A systematic review and meta-analysis were conducted to estimate the prevalence of OAB in Chinese women.

METHODS

Relevant published articles on the prevalence of OAB in Chinese women were searched through July 21, 2022, using PubMed, EMbase, The Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), WanFang Data, and VIP databases. After the independent screening of articles, data extraction, and quality assessment of included studies by two investigators, a meta-analysis was performed using Stata 16.0 software, and the prevalence was determined using a random-effects model. To identify potential sources of heterogeneity, subgroup analyses were conducted with subgroup categories including age, Body Mass Index (BMI), region, and survey year. Publication bias was assessed by visually examining the funnel plot and Egger's test.

RESULTS

Twenty studies were included in this meta-analysis. The results of the random-effects model indicated that the prevalence of OAB in Chinese women was 14% (95% Confidence Interval: 9%-18%). The prevalence increased significantly in the past decade (from 8% in pre-2006 to 18% in 2016-2021). A prevalence (18%) was observed among women aged 31-40 compared with other age groups. The BMI range of 24-27.9 (18%) was higher than the other groups. Additionally, the prevalence of this BMI range was comparatively higher in North China and Southwest China (21%) than in Central China and East China. In addition, publication bias was observed.

CONCLUSIONS

OAB incidence has increased in Chinese women over the last two decades, affecting more than 20% of women aged 31-40 years and above. With the increasing prevalence of OAB, greater emphasis has been placed on implementing preventative and control measures.

Heterogeneity of placebo effects on urinary incontinence in overactive bladder syndrome: A meta-analysis of Japanese placebo-controlled clinical trials

OBJECTIVES

The effect sizes, changes over time, and heterogeneity of placebo effects on frequency of urination for voiding disorders in Japanese clinical trials have been published. This study evaluated the characteristics of placebo effects on overall and urge incontinence in overactive bladder patients.

METHODS

A meta-analysis of Japanese placebo-controlled clinical trials was conducted to determine placebo effects on the daily frequency of overall (n = 16) and urge (n = 11) incontinence and identify factors that should be considered in clinical trials.

RESULTS

The between-study heterogeneity variance of placebo effects for overall and urge incontinence at 8 weeks was estimated as I2  = 70.3% and 64.2%, and the prediction interval for the ratio of means ranged from g = 0.31-0.91 and 0.32-0.81, respectively. Subgroup analysis using the random-effects model showed placebo effects in overall incontinence (p = 0.08) and urge incontinence (p < 0.0001). The ratio of means (95% confidence interval) of urge incontinence frequency from baseline to 4 (n = 10), 8 (n = 10), and 12 (n = 7) weeks were 0.65 (0.57, 0.74), 0.51 (0.42, 0.62), and 0.48 (0.36, 0.64), respectively, for the random-effects model. Regression analysis did not reveal any significant factors that influenced placebo effects.

CONCLUSIONS

This meta-analysis confirmed the characterization of placebo effects on overall and urge incontinence, which demonstrates heterogeneity between trials. The impact of population, follow-up period, and endpoints on placebo effects should be considered when designing clinical trials for overactive bladder syndrome.

Efficacy and safety of vaginal electrical stimulation as an alternative or adjunct treatment for overactive bladder syndrome in women: a meta-analysis of randomized controlled trials

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the efficacy and safety of vaginal electrical stimulation (VES) as an alternative or adjunct treatment for overactive bladder (OAB) syndrome in women.

METHODS

Five English-language databases and four Chinese-language databases were searched to identify relevant studies. Studies comparing VES (VES alone or VES plus other interventions) with other interventions (medicines, bladder training, or PFMT) were included. Voiding diary, quality of life (QoL), and adverse events were extracted from the included studies for comparison.

RESULTS

Seven trials with 601 patients in total were reviewed. The results showed that when compared with other interventions, VES alone significantly improved urgency episodes (p = 0.0008) and voiding frequency (p = 0.01), but did not significantly reduce nocturia (p = 0.85), urinary incontinence episodes (p = 0.90) and number of pads (p = 0.87). When VES plus other interventions was compared with other interventions, the former significantly improved voiding frequency (p < 0.00001), nocturia (p < 0.00001), and number of pads (p = 0.03), but it did not significantly reduce urinary incontinence episodes (p = 0.24). Both VES alone (p < 0.00001) and VES plus other interventions (p = 0.003) showed significant benefit on QoL.

CONCLUSIONS

This study demonstrated that VES alone decreased urgency episodes and QoL better than other therapies. Although VES alone reduced voiding frequency better and VES plus other therapies decreased nocturia, number of pads, urgency episodes, and QoL better than other therapies, the results should be interpreted with caution for clinical practice because some of the RCTs included were of low quality and because of the small number of studies included.

Inhibition of Contractility of Isolated Caprine Detrusor by the Calcium Channel Blocker Cilnidipine and Reversal by Calcium Channel Openers

Background

Cilnidipine is a fourth-generation calcium channel blocker that is clinically used to treat hypertension. It is a dihydropyridine that blocks L- and N-type calcium channels. The inhibitory effect of cilnidipine on isolated detrusor muscle contractility has not been studied. This study investigated the inhibitory effect of cilnidipine on isolated caprine (goat) detrusor muscle contractility and the reversal of the inhibition by calcium channel openers.

Methods

Fourteen caprine detrusor strips were made to contract using 80 mM potassium chloride before and after addition of three concentrations (20, 40, and 60 µM) of cilnidipine. Two reversal agents, the L-type calcium channel opener FPL64716, and the N-type calcium channel opener GV-58, were investigated for their ability to reverse the inhibitory effect of 40 µΜ cilnidipine on potassium chloride-induced detrusor contractility.

Results

Cilnidipine caused a dose-dependent and statistically significant inhibition of detrusor contractility at all concentrations of cilnidipine used (20, 40, and 60 µΜ). The inhibitory effect of 40 µM cilnidipine on detrusor contractility was significantly reversed by the addition of FPL64716 and GV-58.

Conclusions

Cilnidipine inhibits the contractility of the isolated detrusor by blocking L- and N-type calcium channels. Cilnidipine could be evaluated for treating clinical conditions requiring relaxation of the detrusor such as overactive bladder.

Formulation and evaluation of taste-masked oral disintegrating tablet containing tolterodine-loaded montmorillonite

Background and purpose

The present study aimed to obtain a taste-masked oral disintegrating tablet (ODT) containing tolterodine tartrate (TT) intercalated into montmorillonite (MMT).

Experimental approach

The TT-MMT hybrid was prepared by ion exchange reaction. The effect of the initial concentration of TT, MMT, temperature, and pH on the encapsulation efficiency (EE) % of the drug in MMT was evaluated. The selected TT-MMT hybrid was characterized by X-ray diffraction (XRD), Fourier transforms infrared (FTIR), differential scanning calorimetry (DSC), and scanning electron microscopy (SEM). Then, the optimized TT-MMT hybrid was incorporated in the ODT prepared by direct compression method and taste-masking assessment performed by a human test panel.

Findings/Results

The EE% of TT was in the range of 22.67 to 71.06% in different formulations. It was found that increases in MMT concentration significantly increased EE%. DSC and XRD studies indicated that the TT was intercalated in the MMT interlayer space in an amorphous or molecular state. In-vitro release studies at pH 6.8 showed that the amount of the drug released from the TT-MMT hybrid was negligible for the first 3 min. The post-compression of ODT also showed satisfactory results in terms of friability, hardness, disintegration time, and taste.

Conclusion and implications

MMT-ODT could be a suitable vehicle for the taste masking of TT, with the potential for use in patients with swallowing problems.

A Comparative Study of Solifenacin, Mirabegron, and Their Combination as Bladder Relaxants in the Management of Overactive Bladder

Introduction  Overactive bladder (OAB) is a medical state that presents as the urgency of urine and increased frequency of micturition and is diagnosed on the basis of the presence of these symptoms in the absence of other explainable diagnoses. The management of this condition includes conservative management, medical management/pharmacotherapy, and surgical management. The overactive bladder has been treated with smooth muscle relaxants, but there are conflicting results. Hence, this study aimed to assess the result of the two smooth muscle relaxants, mirabegron and solifenacin, and their combination to manage an overactive bladder. Methodology  A clinical trial was conducted at Swaroop Rani Nehru Hospital, Motilal Nehru Medical College, Prayagraj, India, over the period from November 2019 to December 2020. Ninety patients with OAB were divided into three groups: G1, G2, and G3. These groups were administered solifenacin, mirabegron, and a combination of mirabegron and solifenacin (S+M), respectively. Follow-ups were conducted at 2, 4, 12, and 18 weeks for evaluation. Data were entered into IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States). Appropriate statistical tests, including the chi-square and ANOVA, were employed in this study. Observation  The combination of mirabegron and solifenacin was significantly more effective in terms of response compared to solifenacin alone. There was no significant difference between solifenacin versus mirabegron, or between mirabegron (M) and the combination of mirabegron (M) and solifenacin (S). Side effects were more severe in patients taking high doses of solifenacin. Conclusion  The S + M combination has higher efficacy than solifenacin and mirabegron when given alone.

Intradetrusor OnabotulinumtoxinA Injections at the Time of Holmium Laser Enucleation of the Prostate for Men with Severe Storage Symptoms

Introduction: Intradetrusor onabotulinumtoxinA (OTA) injection is a well-established treatment option for refractory overactive bladder; however, its use at the time of holmium laser enucleation of the prostate (HoLEP) for men with bladder outlet obstruction (BOO) and severe storage symptoms has not been previously reported. Materials and Methods: We retrospectively identified men with BOO and severe storage symptoms who underwent treatment with 200 U of intradetrusor OTA (Botox®) at the time of HoLEP. Patients were propensity score matched to a cohort of HoLEP-only patients based on age, Michigan Incontinence Symptom Index (M-ISI) score, preoperative urinary retention, urge incontinence, and prostate size. Perioperative, postoperative, and patient-reported outcomes were examined between groups. Results: We identified 82 men who underwent HoLEP, including 41 patients in the OTA group and 41 patients in the control group. There was no difference in operative times (59 minutes OTA vs 55 minutes control, p = 0.2), rates of same-day trial of void (TOV) (92% OTA vs 94% control, p = 0.7), or rates of same-day discharge (88% OTA vs 85% control, p = 0.6) between groups. There was no difference in temporary postoperative urinary retention (7% OTA vs 2% control, p = 0.3) between groups. Patients who received OTA injections had a significant reduction in their incontinence scores at 3-month follow-up (M-ISI -8, interquartile range [IQR]: -13 to 0, p < 0.001), whereas control patients did not (M-ISI -5, IQR: -8 to -1, p = 0.2). There was no difference in rates of 90-day complications between groups (OTA 10% vs control 5%, p = 0.7). Conclusions: Intradetrusor OTA at the time of HoLEP is safe and is associated with improved urinary incontinence scores and AUA Symptom Score. Rates of same-day discharge and same-day TOV after HoLEP were not affected by OTA. These findings support the role of OTA as an adjunct to surgical intervention in men with incontinence in the presence of BOO.

A treatment prediction strategy for overactive bladder using a machine learning algorithm that utilized data from the FAITH study

AIMS

To use machine learning algorithms to develop a model to accurately predict treatment responses to mirabegron or antimuscarinic agents in patients with overactive bladder (OAB), using real-world data from the FAITH registry (NCT03572231).

METHODS

The FAITH registry data included patients who had been diagnosed with OAB symptoms for at least 3 months and were due to initiate monotherapy with mirabegron or any antimuscarinic. For the development of the machine learning model, data from patients were included if they had completed the 183-day study period, had data for all timepoints and had completed the overactive bladder symptom scores (OABSS) at baseline and end of study. The primary outcome of the study was a composite outcome combining efficacy, persistence, and safety outcomes. Treatment was deemed "more effective" if the composite outcome criteria for "successful," "no treatment change," and "safe" were met, otherwise treatment was deemed "less effective." To explore the composite algorithm, a total of 14 clinical risk factors were included in the initial data set and a 10-fold cross-validation procedure was performed. A range of machine learning models were evaluated to determine the most effective algorithm.

RESULTS

In total, data from 396 patients were included (266 [67.2%] treated with mirabegron and 130 [32.8%] treated with an antimuscarinic). Of these, 138 (34.8%) were in the "more effective" group and 258 (65.2%) were in the "less effective" group. The groups were comparable in terms of their characteristic distributions across patient age, sex, body mass index, and Charlson Comorbidity Index. Of the six models initially selected and tested, the decision tree (C5.0) model was chosen for further optimization, and the receiver operating characteristic of the final optimized model had an area under the curve result of 0.70 (95% confidence interval: 0.54-0.85) when 15 was used for the min n parameter.

CONCLUSIONS

This study successfully created a simple, rapid, and easy-to-use interface that could be further refined to produce a valuable educational or clinical decision-making aid.

Bladder Wall Structure Alterations in Patients Treated With Botulinum Toxin for Detrusor Overactivity - A Morphological Study

BACKGROUND/AIM

The overactive bladder syndrome (OAB) is a bothersome condition that affects up to 33% of the population. In up to 69% of the cases, the underlying condition is an overactive detrusor (DO). Treatment options rely on behavioral changes, medical treatment, neuromodulation, and invasive treatment, such as injecting botulinum toxin (BoNT) in the detrusor or augmentation cystoplasty. The aim of this study was to evaluate, by morphological assessment on cold-cup biopsies of the bladder, the effect of botulinum toxin injections on the bladder wall, focusing on the histological structure and signs of inflammation and fibrosis.

PATIENTS AND METHODS

We evaluated consecutive patients with DO that received BoNT intradetrusor injections. We analyzed inflammation and fibrosis in 36 patients, divided into two groups based on their history of BoNT treatment. Our patients underwent at least one round of injections and specimens were compared individually, before and after each injection.

RESULTS

A decrease in inflammation was found in 26.3% of the cases, a reactive increase in 31.5%, and no change in 42.1%. No de novo or increase in preexisting fibrosis was found. In some cases, fibrosis diminished after a second round of BoNT.

CONCLUSION

In most cases, BoNT intradetrusor injections in DO patients showed no effect on bladder wall inflammation and actually improved the inflammatory condition of the muscle in a significant number of samples.

Microbiome in urological diseases: Axis crosstalk and bladder disorders

Since the identification of the human urinary microbiome, numerous studies have characterized this microbial community and improved our knowledge of its association with urinary diseases. This association between urinary diseases and microbiota is not confined to the urinary microbiota; it is interconnected with the microbiota of other organs. The gastrointestinal, vaginal, kidney, and bladder microbiota all affect urinary diseases because they work with their respective organs to control the growth and operation of the immune, metabolic, and nervous systems through dynamic bidirectional communication along the bladder-centered axis. Therefore, disturbances in the microbial communities may result in the emergence of urinary diseases. In this review, we describe the increasing and intriguing evidence of complicated and critical relationships that may contribute to the development and progression of urinary diseases through disruption of the microbiota in various organs.

Identification, assessment and treatment of urinary incontinence and bowel control issues

Urinary incontinence and bowel control issues are prevalent within the general population and have significant adverse effects on peoples' daily lives and quality of life. This article examines the prevalence of urinary incontinence and bowel control issues and describes some of the more common types of issues. The author explains how to undertake a basic urinary and bowel continence assessment and outlines some of the treatment options, including lifestyle interventions and medicines.

Safety, tolerability, and pharmacokinetics of single and multiple ascending Oral doses of DA-8010 in healthy subjects: First-in-human phase I study

This study assessed the safety, tolerability, and pharmacokinetics of single and multiple oral doses of DA-8010, a muscarinic M₃ receptor antagonist, in healthy subjects. This was a randomized, double-blind, placebo-controlled, ascending single (Part A: 1, 2.5, 5, 20, and 40 mg QD fasted and 10 mg QD fasted and fed) and multiple doses (Part B: 5, 10, and 20 mg QD from Days 1 to 7 fasted), sequential-group study. Safety data were analyzed descriptively, time to maximum plasma concentration (t_max ) nonparametrically, and pharmacokinetic parameters using power and mixed models and ANOVA. Of 109 subjects randomized (Part A = 69 and Part B = 40; each part consisted a female group), 31 (44.9%) in Part A and 29 (72.5%) in Part B experienced treatment-emergent adverse events (TEAEs) in a dose-related manner. Common drug-related TEAEs in Part A and B were dizziness (8.7% and 15.0%), headache (5.8% and 12.5%) and blurred vision (8.7% and 20%). One male (20 mg) and one female (10 mg) from Part B discontinued the study due to a confusional state, and nausea and vomiting. Irrespective of sex, DA-8010 was steadily absorbed following single and multiple doses in the fasted state with increased systemic exposure in a dose-proportional manner with maximum plasma concentration occurring at a median t_max between 4.0 and 6.0 h. A high-fat meal increased systemic exposure. DA-8010 was safe, well tolerated, and well absorbed at lower doses and moderately tolerated at higher doses without any notable effects of food and sex.

A systematic review and in silico study of potential genetic markers implicated in cases of overactive bladder

OBJECTIVE

The contribution of genetic factors to the presence of an overactive bladder is recognized. This study aimed to (1) assemble and synthesize available data from studies assessing differential gene expression in patients with overactive bladder vs controls without overactive bladder and (2) determine possible correlations and functional pathways between genes.

DATA SOURCES

We searched PubMed, Ovid or Medline, and Wiley Cochrane Central Register of Controlled Trials databases between January 1, 2000, and December 15, 2021.

STUDY ELIGIBILITY CRITERIA

Studies were included if gene expression was detected and quantified using molecular approaches performed on human bladder tissue specimens directly and excluded if the gene expression analysis was carried out from blood and urine specimens alone.

METHODS

A systematic review was completed to identify publications that reported differently expressed gene candidates among patients with overactive bladder vs healthy individuals. Gene networking connections and pathway analysis were performed employing Metascape software, where inputs were identified from our systematic review of differentially expressed genes in overactive bladder.

RESULTS

A total of 9 studies were included in the final analysis and 11 genes were identified as being up-regulated (purinergic receptor P2X 2 [P2RX2], smoothelin [SMTN], growth-associated protein 43 [GAP43], transient receptor potential cation channel subfamily M member 8 [TRPM8], cadherin 11 [CDH1], gap junction protein gamma 1 [GJC1], cholinergic receptor muscarinic 2 [CHRM2], cholinergic receptor muscarinic 3 [CHRM3], and transient receptor potential cation channel subfamily V member 4 [TRPV4]) or down-regulated (purinergic receptor P2X 2 [P2RX3] and purinergic receptor P2X 5 [P2RX5]) in patients with overactive bladder. Gene network analysis showed that genes are involved in chemical synaptic transmission, smooth muscle contraction, blood circulation, and response to temperature stimulus. Network analysis demonstrated a significant genetic interaction between TRPV4, TRPM8, P2RX3, and PR2X2 genes.

CONCLUSION

Outcomes of this systematic review highlighted potential biomarkers for treatment efficacy and have laid the groundwork for developing future gene therapies for overactive bladder in clinical settings.

Microhematuria in Women Presenting for Overactive Bladder

PURPOSE OF REVIEW

Microscopic hematuria and overactive bladder are two common urologic conditions. The objective of this review is to provide an overview of current literature as well as highlight important guidelines that will aid physicians in the diagnostic workup of microscopic hematuria in patients experiencing symptoms of overactive bladder.

RECENT FINDINGS

Updated microscopic hematuria guidelines provide a structured and appropriate workup for women based on risk factors, which stratifies patients to prevent unnecessary procedures and imaging. Women presenting with microscopic hematuria in the setting of overactive bladder should undergo microscopic hematuria workup according to their risk stratification while receiving appropriate treatment for their overactive bladder. The physician should consider the presence of irritative voiding symptoms during the investigation and management of microscopic hematuria in patients with overactive bladder and should not delay overactive bladder treatment due to the presence of microscopic hematuria.

Chronic kidney disease, preoperative use of antispasmodics and lower resected prostate volume ratios are risk factors for postoperative use of adrenergic Alpha-blockers and antispasmodics

OBJECTIVES

Transurethral resection of prostate (TURP) and laser prostate surgery are common surgeries for benign prostate hyperplasia (BPH). We conducted an investigation using hospital database to evaluate the clinical factors associated with post-operative usage of alpha-blockers and antispasmodics.

METHODS

This study was conducted using retrospective clinical data from the hospital database, which contained newly diagnosed BPH patients between January 2007 and December 2012 who subsequently received prostate surgery. The study end-point was the use of alpha-blockers or antispasmodics for at least 3 months duration after 1 month of surgery. The exclusion criteria was prostate cancer diagnosed before or after the surgery, recent transurethral surgeries, history of open prostatectomy, and history of spinal cord injury. Clinical parameters, including age, body mass index, preoperative prostate specific antigen value, comorbidities, preoperative usage of alpha-blockers, anstispasmodics and 5-alpha reductase inhibitors, surgical methods, resected prostate volume ratios, and preoperative urine flow test results, were evaluated.

RESULTS

A total of 250 patients receiving prostate surgery in the database and confirmed pathologically benign were included. There was significant association between chronic kidney disease (CKD) and the usage of alpha-blockers after prostate surgery (OR = 1.93, 95% CI 1.04-3.56, p = 0.036). Postoperative antispasmodics usage was significantly associated with preoperative usage of antispasmodics (OR = 2.33, 95% CI 1.02-5.36, p = 0.046) and resected prostate volume ratio (OR = 0.12, 95% CI 0.02-0.63, p = 0.013).

CONCLUSIONS

BPH patients with underlying CKD were more likely to require alpha-blockers after surgery. In the meantime, BPH patients who required antispasmodics before surgery and who received lower prostate volume resection ratio were more liable to antispasmodics after prostate surgery.

Mirabegron and antimuscarinic use in frail overactive bladder patients in the United States Medicare population

INTRODUCTION

Overactive bladder (OAB) and frailty are independently associated with patient burden. However, economic burden and treatment-taking behavior have not been well characterized among frail patients with OAB, which, given the varying safety and tolerability profiles of available treatments, is crucial.

OBJECTIVES

To assess costs, health care resource utilization, treatment-taking behavior (persistence and adherence) to OAB medication in older, frail OAB patients.

METHODS

This was a retrospective cohort study using international business machines MarketScan Medicare Supplemental claims data. Eligible frail patients (per Claims-based Frailty Index score) initiating mirabegron were 1:2 propensity score matched (based on age, sex, and other characteristics) with those initiating antimuscarinics and were followed up to 1 year. All-cause, per-person, per-month costs, health care encounters, persistence (median days to discontinuation assessed using Kaplan-Meier methods) and adherence (≥80% of proportion of days covered at Day 365) were compared.

RESULTS

From 2527 patients with incident mirabegron (21%) or antimuscarinic (79%) dispensations, 516 incident mirabegron users (median age: 82 years, 64% female) were matched to 1032 incident antimuscarinic users (median age: 81 years, 62% female). Median cost was higher in mirabegron group ($1581 vs. $1197 per month); this was primarily driven by medication cost. There was no difference in medical encounters. Adherence (39.1% vs. 33.8%) and persistence (103 vs. 90 days) were higher in mirabegron users.

CONCLUSIONS

Among frail older adults with OAB, mirabegron use was associated with higher costs and potential improvements in treatment-taking behaviors, particularly with respect to treatment adherence, versus those initiating antimuscarinics.

Physical Agent-Based Treatments for Overactive Bladder: A Review

Almost one-fifth of the people in the world experience a decrease in quality of life due to overactive bladder (OAB) syndrome. The main bothersome symptoms are urgency accompanied by urinary frequency and nocturia. This chronic, disabling condition is first managed by reducing fluid intake and pelvic floor muscle training, supplemented with antimuscarinic drugs, if necessary. However, refractory cases often still occur. In more severe cases, invasive surgical interventions can be considered; yet, the success rate is still inconsistent, and there is a high complication rate. This condition is frustrating for patients and challenging for the medical staff involved. Although its pathophysiology has not been fully elucidated, peripheral autonomic somatic and sensory afferent receptors are considered to be involved in this condition. Hence, currently, physical agent-based treatments such as neuromodulation have taken a significant place in the third-line therapy of OAB. The efficacy and safety profiles of electrical and magnetic stimulation continue to evolve. Physical-based agents provide an appealing option owing to their effectiveness and minimal side effects. In addition, more physical therapies using light and shock energy are currently being investigated. Thus, a comprehensive understanding of these modalities is an extremely important aspect to provide the most suitable modalities for patients.

Ocular adverse effects of bladder medication: a systematic review

BACKGROUND

With the ageing population, lower urinary tract symptoms are becoming more prevalent with an estimate that by 2025, 52 million adults in the USA will be affected. After lifestyle modifications fail to resolve symptoms, second-line therapy with medications is often recommended by both the European Association of Urology and the American Urological Association. Considering the vulnerability of older patients to co-morbidities, physicians must be more aware of adverse side effects. This study aims to identify a linkage between common overactive bladder and interstitial cystitis medication and adverse ocular symptoms.

METHODS

A comprehensive literature search was conducted in MEDLINE, EMBASE, CINAHL, PsycInfo, and HealthSTAR alongside a grey literature search in clinicaltrials.gov to include all articles relating to bladder medication and vision-threatening loss. Covidence review software was utilised to conduct the systematic review.

RESULTS

In total, 222 articles were screened, and 23 articles met the inclusion criteria. Comprehensive coverage of 10 available medications was analysed. All medications reported adverse vision effects stratified over 15 categories. The most common adverse effect was reported to be blurred vision (n = 12 studies). Mirabegron had the most number of adverse types of ocular symptoms that covered 6 categories. Cizolirthine Citrate and Elocatitol had the least amount of ocular side effects reported. From the total of 8459 patients that were treated for either overactive bladder syndrome or interstitial cystitis with oral medications, 422 reported adverse vision effects.

CONCLUSIONS

This review suggests that ocular safety should be assessed in patients requiring systematic drug therapy in order to guide future research, focussing on long-term tolerability.

Drugs Currently Undergoing Preclinical or Clinical Trials for the Treatment of Overactive Bladder: A Review

Background

Overactive bladder (OAB) is a common clinical condition for which current drug treatment comprises drugs blocking the cholinergic nerve supply, or augmenting the adrenergic nerve supply, to the detrusor muscle of the urinary bladder. Current treatments have drawbacks, including lack of efficacy and the development of adverse effects in some patients. Hence, new and better drugs for treating OAB will be clinically useful.

Objective

This review is meant to provide information on drugs currently undergoing preclinical or clinical trials for the treatment of OAB published in journal articles or elsewhere.

Methods

The cited articles were retrieved from PubMed and Google Scholar from January 1, 1990, to December 31, 2021. The search terms used were contraction or contractility, detrusor, inhibition, isolated or in vitro, in vivo, overactive bladder, and relaxant effect or relaxation.

Results

There are 4 classes of new drugs under various stages of development for the treatment of OAB. These are drugs acting on the autonomic nerve supply to the detrusor muscle of the urinary bladder that include the anticholinergics tarafenacin and afacifenacin and the β₃ adrenoceptor agonists solabegron and ritobegron; drugs acting on ion channels in the detrusor muscle (eg, potassium channel openers and calcium channel blockers), drugs acting on cellular enzymes like phosphodiesterase-5 inhibitors and Rho kinase inhibitors, and drugs acting on miscellaneous targets (eg, pregabalin and trimetazidine).

Conclusions

Drugs currently used to treat OAB target only the cholinergic and adrenergic cellular signalling pathways. There are many other drugs under trial targeting other cellular pathways that may be useful for treating OAB. Their approval for clinical use might improve the treatment of patients with OAB. (Curr Ther Res Clin Exp. 2022; 83:XXX–XXX)

Advances in Assistive Electronic Device Solutions for Urology

Recent technology advances have led urology to become one of the leading specialities to utilise novel electronic systems to manage urological ailments. Contemporary bladder management strategies such as urinary catheters can provide a solution but leave the user mentally and physically debilitated. The unique properties of modern electronic devices, i.e., flexibility, stretchability, and biocompatibility, have allowed a plethora of new technologies to emerge. Many novel electronic device solutions in urology have been developed for treating impaired bladder disorders. These disorders include overactive bladder (OAB), underactive bladder (UAB) and other-urinary-affecting disorders (OUAD). This paper reviews common causes and conservative treatment strategies for OAB, UAB and OUAD, discussing the challenges and drawbacks of such treatments. Subsequently, this paper gives insight into clinically approved and research-based electronic advances in urology. Advances in this area cover bladder-stimulation and -monitoring devices, robot-assistive surgery, and bladder and sphincter prosthesis. This study aims to introduce the latest advances in electronic solutions for urology, comparing their advantages and disadvantages, and concluding with open problems for future urological device solutions.

Surgical Complications in the Management of Benign Prostatic Hyperplasia Treatment

PURPOSE OF REVIEW

There are a variety of treatment options for men with symptomatic benign prostatic hyperplasia (BPH); transurethral resection of the prostate (TURP) remains the gold standard surgical treatment. The field continues to evolve with the introduction of new energy and laser technologies, increasing adoption of enucleation techniques, in addition to the advent of minimally invasive surgical technologies (MIST) that enable office-based treatments. The choice in surgical management has become very nuanced depending on a variety of patient and anatomic factors. There continues to be high success rates for surgical treatment of BPH; however, the risk profiles vary across the various surgical treatments. We sought to evaluate contemporary series and summarize the experience of complications associated with BPH treatment and management of these complications.

RECENT FINDINGS

A comprehensive literature review was performed, and identified 79 manuscripts, published between 2005 and 2021 characterizing the diagnosis and management of complications following BPH surgery. Commonly cited issues included bleeding, ureteral orifice injury, bladder neck injury, rectal injury, TURP syndrome, bladder neck contractures, urethral stricture disease, refractory OAB symptoms, and complications unique to new modalities of treatment. The practicing urologist has multiple surgical options to choose from in treating patients with symptomatic BPH. The surgical management of BPH is generally well tolerated with high objective success rates that allow for significant improvement in urinary quality of life. It is critical to understand the potential complications associated with these various treatment options, which will enable trainees and practicing urologists to better counsel patients and manage these potential complications.

An Evaluation of the Efficacy and Safety of Vibegron in the Treatment of Overactive Bladder

Pharmacologic treatment for overactive bladder (OAB), which is characterized by bothersome symptoms such as urgency and urge urinary incontinence (UUI), includes anticholinergics and β₃-adrenergic receptor agonists. Anticholinergics are associated with adverse effects including dry mouth, constipation, cognitive impairment, and increased risk of dementia. Therefore, the drug class of β₃-adrenergic receptor agonists may represent an effective, safe treatment option. Vibegron, a β₃-adrenergic receptor agonist, was approved for use in Japan (2018) and the United States (2020). Over the past 3 years, 2 phase 3 trials (EMPOWUR, EMPOWUR extension) have been conducted with once-daily vibegron 75 mg for the treatment of OAB, and additional secondary and subgroup analyses have detailed the efficacy and safety of vibegron. In the international phase 3 EMPOWUR trial, treatment with vibegron was associated with significant improvements compared with placebo in efficacy outcomes of micturition frequency, UUI episodes, urgency episodes, and volume voided as early as week 2 that were sustained throughout the 12-week trial. The 40-week EMPOWUR extension study, following the 12-week treatment period, demonstrated sustained efficacy in patients receiving vibegron for 52 weeks. Treatment with vibegron was also associated with improvements in patient-reported measures of quality of life. Across studies, vibegron was generally safe and well tolerated. A separate, dedicated ambulatory blood pressure monitoring study showed that treatment with vibegron was not associated with clinically meaningful effects on blood pressure or heart rate. Across all studies, vibegron was efficacious, safe, and well tolerated and thus represents a valuable treatment option for patients with OAB. Here, nearly 1 year after US approval, we review the published data on efficacy and safety of vibegron 75 mg for the treatment of OAB.

Overactive Bladder during Pregnancy: A Prospective Longitudinal Study

Background and Objectives: Overactive bladder (OAB) is a serious urination-related symptom of unknown pathogenesis that affects one’s everyday activities. The objective of this study was to examine how OAB prevalence, symptom severity, and degree of distress caused by OAB symptoms evolved throughout the course of pregnancy. Materials and Methods: A total of 659 pregnant women were recruited from 2015 to 2020, and were evaluated through the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB) on OAB symptoms, administered in the early, middle, and late stages of pregnancy. Results: Generalized estimating equation analysis revealed that the odds of OAB occurring in the middle and late stages of pregnancy were 1.90 and 2.33 times higher, respectively, than in early pregnancy. The corresponding odds for OAB-wet were 1.63 and 2.07 higher, respectively, and the odds of OAB-dry occurring during late pregnancy were 0.80 higher than during early pregnancy. Symptoms were more severe by 0.07 and 0.21 points (on a 4-point scale) in the middle and late stages of pregnancy, respectively, than in early pregnancy; distress was greater by 0.13 and 0.27 points (on a 10-point scale) in the middle and late stages of pregnancy, respectively, than in early pregnancy. The prevalence of OAB, OAB-dry, and OAB-wet was significantly higher in early pregnancy than pre-pregnancy. Conclusions: The prevalence of OAB and OAB-wet increased over the course of pregnancy, but the prevalence of OAB-dry decreased. Furthermore, symptom severity and degree of distress increased over time.

Identification of the NADPH Oxidase (Nox) Subtype and the Source of Superoxide Production in the Micturition Centre

Oxidative inflammatory damage to specialised brain centres may lead to dysfunction of their associated peripheral organs, such as the bladder. However, the source of reactive oxygen species (ROS) in specific brain regions that regulate bladder function is poorly understood. Of all ROS-generating enzymes, the NADPH oxidase (Nox) family produces ROS as its sole function and offers an advantage over other enzymes as a drug-targetable molecule to selectively control excessive ROS. We investigated whether the Nox 2 subtype is expressed in the micturition regulatory periaqueductal gray (PAG) and Barrington's nucleus (pontine micturition centre, PMC) and examined Nox-derived ROS production in these structures. C57BL/6J mice were used; PAG, PMC, cardiac tissue, and aorta were isolated. Western blot determined Nox 2 expression. Lucigenin-enhanced chemiluminescence quantified real-time superoxide production. Western blot experiments demonstrated the presence of Nox 2 in PAG and PMC. There was significant NADPH-dependent superoxide production in both brain tissues, higher than that in cardiac tissue. Superoxide generation in these brain tissues was significantly suppressed by the Nox inhibitor diphenyleneiodonium (DPI) and also reduced by the Nox-2 specific inhibitor GSK2795039, comparable to aorta. These data provide the first evidence for the presence of Nox 2 and Nox-derived ROS production in micturition centres.

Costoefectividad del régimen combinado de mirabegron/solifenacina en el tratamiento del síndrome de vejiga hiperactiva en Colombia

Objetivo Evaluar la costoefectividad incremental del régimen combinado de mirabegron/solifenacina en comparación con el uso temprano de toxina botulínica, desde la perspectiva del sistema de salud colombiano, para el tratamiento de adultos con vejiga hiperactiva.

Métodos Se empleó un modelo de Markov en que se comparan dos secuencias de tratamiento, una con y otra sin mirabegron/solifenacina, para evaluar la costoefectividad en un horizonte temporal de cinco años. Debido a la perspectiva de análisis, sólo se tuvieron en cuenta los costos médicos directos. La eficacia del tratamiento evaluado y su comparador fue medida en términos de la reducción de episodios diarios de incontinencia y de la frecuencia de micciones. Los costos fueron expresados en pesos colombianos de 2019, y se aplicó una tasa de descuento de 5% tanto para desenlaces como para costos.

Resultados Para el caso base, el costo del tratamiento en la secuencia que incluye mirabegron/solifenacina fue mayor, pero generó un mayor número de años de vida ajustados por calidad, y así e obtuvo una razón de costoefectividad incremental de $13.637,184 si se considera el desenlace de reducción de episodios diarios de incontinencia de 50%, y de $29.313,848 si se considera el del 100%.

Conclusiones De acuerdo con los resultados de esta evaluación, para un horizonte de análisis de cinco años, la secuencia de tratamiento con mirabegron/solifenacina es una alternativa costoefectiva, si se considera un umbral de disposición a pagar de tres veces el producto interno bruto (PIB) per cápita.

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.

Factorial design-assisted spectroscopic determination of oxybutynin hydrochloride

In this study, we have developed two facile spectroscopic methods for quantifying oxybutynin (OBT) hydrochloride in its pure form and tablets using design of experiments (DOEs). The spectroscopic methods depended on the ion-pair complex formation between the tertiary amino group in the drug and eosin in 0.2 M acetate buffer of pH 4. Method I involves spectrophotometric measurement of the absorbance of the developed complex at 550 nm and showed linearity through 1.0-10.0 µg ml-1. Method II involves spectrofluorometric measurement of the quenching influence of OBT on the native fluorescence of eosin (λ excitation/λ emission of 304/548 nm) and showed linearity through 1.0-6.0 µg ml-1. Critical parameters were identified through preliminary trials and optimized using the DOE. Additionally, the quenching mechanism was investigated and the pathway of the reaction was postulated. The fluorescence quenching constant and thermodynamic parameters were explored using the Stern-Volmer plot and Van't Hoff graph, respectively. Assessments conducted via analytical ecoscale revealed the 'excellent-greenness' of the methodology. The two methods have the potentials of being green and fast compared with other reported methods.

The influence of gut microbiome on progression of overactive bladder symptoms: a community-based 3-year longitudinal study in Aomori, Japan

PURPOSE

To assess the influence of gut microbiome on overactive bladder (OAB) symptoms progression.

METHODS

This was a 3-year longitudinal study, Hirosaki in Japan. We assessed OAB symptoms and reviewed the medication records of each subject in 2016. We extracted 16S rRNA genes from fecal samples and analyzed gut microbiomes via next-generation sequencing. We evaluated the changes in urinary urgency (UU) and/or urgent urinary incontinence (UUI) from 2016 to 2019. We defined UU/UUI-progression as exacerbation of UU and/or UUI. We compared the clinical backgrounds and microbiota structure between UU/UUI-progression subjects and non-progression (controls). We assessed the impact of gut microbiome on the UU/UUI-progression via multivariate logistic regression analyses.

RESULTS

Of 669 subjects, 126 were UU/UUI-progression subjects. These subjects had a higher age and prevalence of proton pump inhibitor (PPI) use (14% vs. 5.4%, P = 0.003), irritable bowel syndrome, sleep disturbance, and metabolic syndrome than those without. We found the different microbiota structures between subjects with UU/UUI-progression and those without. A higher relative abundance of genus Streptococcus (harmful bacterial genus for human health) appeared in UU/UUI-progression subjects (3.8% vs. 2.3%, P < 0.001). Multivariate analysis revealed that age ≥ 65 years, current smoking, sleep disturbance, metabolic syndrome, and genus Streptococcus (Odds ratio: 1.05, P = 0.029) were independent risk factors for UU/UUI-progression. PPI use turned to be a significant risk factor on a multivariate analysis without including genus Streptococcus.

CONCLUSIONS

Gut microbiome might be associated with a risk for OAB symptoms progression. PPI use might cause gut dysbiosis and increase this risk.

Correlation between neutrophil to lymphocyte ratio and overactive bladder in South Korean women: a community-based, cross-sectional study

OBJECTIVE

Many women with overactive bladder (OAB) do not seek medical care despite urinary symptoms. As the diagnosis and treatment of OAB are often late, there is a need to identify undiagnosed OAB patients and start effective treatment. Furthermore, an objective and appropriate screening biomarker for OAB is needed. This study aimed to investigate the relationship between serum neutrophil-to-lymphocyte ratio (NLR) and OAB in South Korean women.

DESIGN

Cross-sectional, retrospective study.

SETTING

Jeju National University Hospital.

PARTICIPANTS

This study included a total of 4394 women (mean age=48.6 years) who underwent self-referred health screenings.

INTERVENTIONS

Blood tests were conducted and the NLR was calculated by dividing the number of neutrophils by the number of lymphocytes.

OUTCOME MEASURES

The severity of OAB was evaluated using the OAB Symptom Score (OABSS).

RESULTS

Approximately 9.8% of participants (n=432) were diagnosed with OAB. The association pattern between the NLR and urinary tract symptoms was variable; however, NLR was associated with OAB, by the OABSS and OAB severity (p<0.001). The NLR had a significant relationship with OAB after age, body mass index, homoeostatic model assessment for insulin resistance, 25-hydroxyvitamin D, stress status, and medication for hypertension (OR 1.19, 95% CI 1.06 to 1.32) were adjusted.

CONCLUSIONS

Elevated NLR is associated with OAB; hence, NLR may be a cost-effective and readily available biomarker of OAB in women.

The Microbiome’s Function in Disorders of the Urinary Bladder

The introduction of next generation sequencing techniques has enabled the characterization of the urinary tract microbiome, which resulted in the rejection of the long-held notion of urinary bladder sterility. Since the discovery and confirmation of the human bladder microbiome, an increasing number of studies have defined this microbial community and understand better its relationship to urinary pathologies. The composition of microbial communities in the urinary tract is linked to a variety of urinary diseases. The purpose of this review is to provide an overview of current information about the urinary microbiome and diseases as well as the development of novel treatment methods.

Efficacy of non-pharmacological interventions in patients with overactive bladder: A protocol for systematic review and network meta-analysis

Background

Some meta‐analyses have proved the superiority of non‐pharmacological interventions in overactive bladder (OAB), but the best choice is still controversial.

Aim

To assess the most effective interventions in female with OAB.

Methods

Studies for relevant randomized controlled trials which compare different kinds of non‐pharmacological interventions in females with OAB will be retrieved from 8 databases including PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Database, VIP Database and China Biology Medicine disc, from inception to 1 January 2021. After screening titles and abstracts, detailed data including participates, interventions and outcomes will be extracted according to the eligible criteria. Then, Cochrane risk‐of‐bias tool will be used to assess the quality of the literature. The pairwise meta‐analysis will be conducted by STATA. Network meta‐analysis will be performed to compare and rank the effects of different non‐pharmacological interventions, in terms of alleviation of symptoms, by OpenBUGS, R and STATA.

Results

This network meta‐analysis will present the best available evidence about non‐pharmacological interventions for OAB to both relieve symptoms and improve life quality.

The effect of treatment of obstructive sleep apnea syndrome on overactive bladder symptoms

OBJECTIVE

To evaluate the effect of the treatment of obstructive sleep apnea syndrome on overactive bladder symptoms.

METHODS

All patients who applied to the outpatient clinic with complaints of snoring and apnea were evaluated by polysomnography between years 2017 and 2019. obstructive sleep apnea syndrome severity was evaluated according to the apnea-hypopnea-index. All patients were filled with questionnaire form as overactive bladder symptoms score, international quality of life, international consultation on incontinence questionnaire short-form, and 3-day bladder diary before polysomnography and three months after continuous positive airway pressure therapy and surgical treatment.

RESULTS

A total of 125 patients, 34 (27.2%) patients with mild obstructive sleep apnea syndrome, 27 (21.6%) patients with moderate obstructive sleep apnea syndrome, and 64 (51.2) patients with severe obstructive sleep apnea syndrome were included in the study. The prevalence of overactive bladder symptoms in three obstructive sleep apnea syndrome groups were 67.6, 53.8, and 48.4%, respectively, and there was no statistical difference between the groups (p=0.190). obstructive sleep apnea syndrome treatment such as surgical treatment or continuous positive airway pressure therapy was applied to 45.5% (31 patients) patients with obstructive sleep apnea syndrome and overactive bladder. Three months after treatment, the overactive bladder symptoms score significantly decreased from 16.1±7.9-12.80±9.82, international quality of life was significantly increased from 105.0±23.2-110.4±22.2, and incontinence questionnaire short-form decreased from 11.9±4.0-10.4±5.6 (p=0.009, p=0.023, and p=0.248, respectively). There was a significant decrease between before and after treatment in terms of mean day-time frequency and mean urgency episodes of patients (p=0.007, p=0.002).

CONCLUSIONS

Both surgery and continuous positive airway pressure treatment of obstructive sleep apnea syndrome improved overactive bladder symptoms, overactive bladder symptoms score, international quality of life, day-time frequency, and urgency episodes.

Antimuscarinic use among older adults with dementia and overactive bladder: a Medicare beneficiaries study

OBJECTIVES

This study examined the incidence and predictors of antimuscarinic medication use including non-selective antimuscarinics among older adults with dementia and overactive bladder (OAB).

METHODS

The study used a new-user cohort design involving older adults (≥65 years) with dementia and OAB based on 2013-2015 Medicare data. Antimuscarinics included non-selective (oxybutynin, tolterodine, trospium, fesoterodine) and selective (solifenacin, darifenacin) medications. Descriptive statistics and multivariable logistic regression models were used to determine the incidence and predictors of new antimuscarinic use including non-selective antimuscarinics, respectively.

RESULTS

Of the 3.38 million Medicare beneficiaries with dementia, over one million (1.05) had OAB (31.03%). Of those, 287,612 (27.39%) were reported as prevalent antimuscarinics users. After applying continuous eligibility criteria, 21,848 (10.34%) incident antimuscarinic users were identified (77.6% non-selective; 22.4% selective). Most frequently reported antimuscarinics were oxybutynin (56.3%) and solifenacin (21.4%). Multivariable analysis revealed that patients ≥75 years, of black race, and those with schizophrenia, epilepsy, delirium, and Elixhauser's score were less likely to initiate antimuscarinics. Women, those with abnormal involuntary movements, bipolar disorder, gastroesophageal reflux disease, insomnia, irritable bowel syndrome, muscle spasm/low back pain, neuropathic pain, benign prostatic hyperplasia, falls/fractures, myasthenia gravis, narrow-angle glaucoma, Parkinson's disease, syncope, urinary tract infection and vulvovaginitis were more likely to initiate antimuscarinics. Further, patients with muscle spasms/low back pain, benign prostatic hyperplasia and those taking higher level anticholinergics had lower odds of receiving non-selective antimuscarinics, whereas white patients, black patients and those with schizophrenia and delirium were more likely to receive them.

CONCLUSIONS

Nearly one-third of dementia patients had OAB and over one-fourth of them used antimuscarinics. Majority of the incident users were prescribed non-selective antimuscarinics with several demographic and clinical factors contributing to their use. Given the high prevalence of OAB among dementia patients, there is a need to optimize their antimuscarinic use, considering their vulnerability for anticholinergic adverse effects.

Association between female urinary urgency and aponeurotic ptosis: Results from a community-based cross-sectional study in Japan

AIMS

To investigate the relationship between urinary urgency (UU) and aponeurotic ptosis (AP) in a health promotion project.

METHODS

This cross-sectional study analyzed 658 women in Aomori, Japan. The presence of UU was evaluated using the Overactive Bladder Symptom Score. The distance from the light reflex on the cornea to the upper eyelid (margin reflex distance-1 [MRD-1]) was measured. AP was defined as MRD-1 of less than 2.0 mm. The daily salt intake amount was estimated using the dietary questionnaire. Daily salt intake was defined as excessive if it was 10 g/day or higher. Independent factors of UU and AP were analyzed via multivariable logistic regression model.

RESULTS

The number of women with UU and AP was 193 and 65, respectively. Similar background differences were observed in age, cardiovascular disease history, renal function, hypertension, diabetes mellitus, dyslipidemia, and daily salt intake between participants with UU and those with AP. Participants with UU had a higher prevalence of AP (19% vs. 6.2%) than those without. Moreover, more than 50% of the women with AP experienced UU. Multivariable logistic analysis on UU showed that age (≥65 years), diabetes mellitus, daily salt intake (≥10 g/day), and AP (odds ratio, 2.07, p = .014) were independent factors. Multivariable analysis on AP revealed that age (≥65 years), hypertension, daily salt intake (≥10 g/day), and UU were independent factors.

CONCLUSIONS

AP was an independent indicator of UU, in addition to excessive daily salt intake. Women with AP may tend to intake excessive salt and experience UU.

How I Handle Retreatment of LUTS Following a Failed MIST

PURPOSE OF REVIEW

The goal of this paper is to review retreatment management after failed minimally invasive treatment (MIST) of various technologies.

RECENT FINDINGS

A failed MIST can be defined by the return, persistence, or worsening of LUTS, as documented by symptom scores. Persistence, development, or recurrence of comorbidities such as recurrent urinary tract infection (UTI), retention, stones, hematuria, and incontinence can also signal a failed MIST. The common etiology for MIST failure is the preoperative consequence of long-term bladder outlet obstruction (BOO) on the bladder function. Close monitoring of therapies with antimuscarinics or beta-agonists can be empirically utilized if post-void bladder residual (PVR) is low. If there is a high PVR, urodynamic studies and cystoscopy can be used to determine overactive bladder (OAB), BOO, or necrosis. Depending on the timing of the observed BOO/OAB, subsequent retreatments involving transurethral debridement, medical and behavioral therapies, or repeat surgical debulking can be employed.

The inhibitory effect of trimetazidine on detrusor contractility - a potential repositioning of trimetazidine for the treatment of overactive bladder

OBJECTIVES

This study aimed to identify the effect of trimetazidine (TMZ), an antianginal drug, on detrusor smooth muscle (DSM) contractility and its possible mechanisms of action.

METHODS

We performed in-vitro contractility studies on isolated mouse DSM strips and investigated the effect of TMZ on Ca2+ levels in fura-2-loaded A7r5 cells.

KEY FINDINGS

TMZ (300 or 1000 µM) inhibited carbachol (CCh)- and KCl-induced contractions and produced a concentration-dependent (10-1000 µM) relaxation in KCl-precontracted DSM strips. TMZ-induced relaxation was markedly decreased by BaCl2, an inward-rectifying K+ channel blocker, but was not altered by preincubation with tetraethylammonium, glibenclamide, 4-aminopyridine, propranolol, L-NAME or methylene blue. TMZ (300 or 1000 µM) reduced both the CaCl2-induced contraction of depolarized DSM strips under Ca2+-free conditions and the CCh-induced contraction of DSM strips preincubated with nifedipine in Ca2+-containing Krebs solution. Furthermore, TMZ (1000 µM) significantly decreased the Ca2+ levels in fura-2-loaded A7r5 cells.

CONCLUSIONS

TMZ decreased DSM contractility and caused a concentration-dependent relaxation of the tissue possibly through its actions on Ca2+ transients and K+ channels. Our results provide preclinical evidence that TMZ would be a potential candidate to treat disorders related to the overactivity of the bladder.

Persistence with mirabegron or antimuscarinic treatment for overactive bladder syndrome: Findings from the PERSPECTIVE registry study

Objectives

This analysis from the PERSPECTIVE (a Prospective, Non‐interventional Registry Study of Patients Initiating a Course of Drug Therapy for Overactive Bladder) study evaluated treatment persistence with mirabegron or antimuscarinics over a 12‐month period.

Methods

Participants were adults diagnosed with overactive bladder (OAB) by their health care provider (HCP), who were initiating mirabegron or antimuscarinic treatment. The HCP made all treatment decisions, and patients were followed for 12 months with no mandatory scheduled visits. Information requests were sent to patients at baseline and months 1, 3, 6, and 12. Patients were nonpersistent if they switched, discontinued, or added OAB medications/therapies to their initial treatment. Reasons for discontinuation and switching patterns were investigated.

Results

Overall, 1514 patients were included (613 mirabegron and 901 antimuscarinic initiators). Persistence rates decreased steadily over time in both groups. A low proportion of patients added or switched medication at each time point. Unadjusted Kaplan‐Meier analysis showed similar persistence rates for both groups. When the data were adjusted for patient characteristics (age, sex, and OAB treatment status), mirabegron initiators had higher persistence rates. No significant differences were noted in unadjusted median time to end of persistence. However, end of treatment persistence by any cause was longer with mirabegron (median: 9.5 vs 6.7 months for antimuscarinics). HCPs stated that the most common reasons for nonpersistence were no symptomatic improvement and side effect aversion.

Conclusions

Treatment persistence was longer for mirabegron compared with antimuscarinic initiators after controlling for patient characteristics. End of treatment persistence by any cause was also longer with mirabegron.

Prevalence and associated risk factors among patients with overactive bladder syndrome in Pakistan

Objectives:

To determine the Prevalence and associated risk factors among patients with overactive bladder syndrome in Pakistan.

Methods:

This was a community-based, face to face, cross sectional survey to calculate the prevalence and its associated risk factors. A sample of 1058 patients, women and men aged between 35 to 60 years having symptoms of overactive bladder was selected through convenience sampling from different cities of Pakistan during September to December 2020. Data was collected by using an Overactive Bladder Scoring System (OABSS) tool for prevalence and a developed questionnaire to rule out the risk factors.

Results:

The prevalence was 27.4% (n=289) and it increased with age. The average ages for women and men were 44.60±7.88 and 46.14±7.69 years respectively. The OAB prevalence was the lowest among the participants aged 35-43 years 15.2% (n=55) while it was highest among those who were aged 53-60 years 49.6%, (n=127). The age, body mass index, diabetes mellitus, income, family history, parity and urinary tract infection were found to be significant associated risk factors for overactive bladder with p value <0.05.

Conclusion:

The overall prevalence of overactive bladder was 27.4% and it does not differ by gender, hypertension, pelvic surgery, smoking, constipation and sleep while it has significant association with age, body mass index, diabetes mellitus, income, parity and urinary tract infections.