Effect of Pharmacotherapy for Overactive Bladder on the Incidence of and Factors Related to Urinary Tract Infection: A Systematic Review and Meta-analysis

PURPOSE

The aim of this meta-analysis was to investigate the effect of pharmacotherapy for overactive bladder on the pathogenesis of urinary tract infection.

MATERIALS AND METHODS

A comprehensive search was performed in MEDLINE and the Cochrane Library using terms for overactive bladder, antimuscarinic agents, and beta 3-adrenoceptor agonists. The primary end point was the emergence of urinary tract infection after pharmacotherapy for overactive bladder. The secondary end point was the emergence of urinary retention, dysuria, and/or increased residual urine volume after overactive bladder treatment. Meta-analyses were conducted using random-effects models.

RESULTS

A total of 35,939 patients in 33 trials (29 trials of antimuscarinic agents vs placebo, and 9 trials of beta 3-adrenoceptor agonists vs placebo) that included patients with overactive bladder were identified. At 1-3 months after treatment, the incidence of urinary tract infections was statistically significantly higher in the patients treated with antimuscarinic agents (RR: 1.23, 95% CI: 1.04, 1.45; P = .013) than in the placebo control group. The incidence of urinary tract infections was not increased in the patients treated with beta 3-adrenoceptor agonists (RR: 1.04, 95% CI: 0.76, 1.42; P = .796). Antimuscarinic agents also statistically significantly increased the risks of urinary retention, dysuria, and/or increased residual urine volume (RR: 2.88, 95% CI: 1.79, 4.63; P < .001), whereas beta 3-adrenoceptor agonists did not (RR: 1.26, 95% CI: 0.38, 4.14; P = .708).

CONCLUSIONS

This meta-analysis showed that antimuscarinic agents statistically significantly increased the incidences of urinary tract infection and lower urinary tract symptoms and dysfunction, but beta 3-adrenoceptor agonists did not. To prevent urinary tract infection emergence, beta 3-adrenoceptor agonists might be safer than antimuscarinic agents.

Associations Between Unmet Social Needs and Overactive Bladder

PURPOSE

There is growing interest in how social determinants of health may explain relationships between social conditions and health. Overactive bladder is common in the United States, posing a significant public health burden. It was the goal of the present study to assess whether overactive bladder was associated with unmet social needs in a large, cross-sectional sample of patients.

MATERIALS AND METHODS

A community-based sample of adults was recruited electronically to complete questionnaires on clinical and demographic information, urinary symptoms and unmet social needs. Multivariable logistic regression was used to assess for association between overactive bladder and multiple unmet social needs.

RESULTS

The sample of 3,617 participants had a mean±SD age of 47.9±17.3 years. The majority of participants identified as White, non-Hispanic (83.5%), and female (77.6%). A total of 1,391 patients (38.5%) were found to have overactive bladder. The presence of overactive bladder was associated with numerous unmet social needs, including housing instability, food insecurity, worry about utilities, lack of transportation, skipping medical appointments, needing legal help, stress in personal relationships, worry about toilet access and plumbing at home, and lack of social supports. On multivariable analysis adjusting for multiple covariates, all associations between overactive bladder and social needs remained significant.

CONCLUSIONS

Multiple unmet social needs were associated with overactive bladder, which may have implications for the overall management of overactive bladder patients. It is important for providers to consider these unmet social needs of patients, as highlighting and addressing these factors hopefully can help improve care of individuals with overactive bladder.

De Novo Urinary Storage Symptoms Are Common after Radical Prostatectomy: Incidence, Natural History and Predictors

PURPOSE

After radical prostatectomy (RP), clinical complaints of new onset storage symptoms may be related to anastomotic strictures or may accommodate for stress urinary incontinence; however, a subgroup of men will experience de novo storage symptoms in the absence of stricture or stress urinary incontinence. As therapies for overactive bladder have improved, we sought to assess the prevalence, natural history and risk factors of de novo storage dysfunction in continent men.

MATERIALS AND METHODS

We retrospectively analyzed urinary symptom questionnaires completed by patients who were continent prior to RP and did not have postoperative anastomotic strictures at our institution from 2002 to 2019. De novo storage dysfunction, assessed as new onset or worsening urgency or frequency, was assessed at 6, 12, 18 and 24 months after RP, and association between it and patient and preoperative factors was determined.

RESULTS

A total of 2,619 patients were included in the final analysis. An initial 34% of patients reported de novo storage symptoms at 6 months, which decreased to 26% at later followup. We found evidence that minimally invasive surgery and nonWhite race were associated with reporting worsening symptoms. The association between postoperative hematoma and worsening symptoms was less conclusive but was of clear clinical relevance (OR 3.15; 95% CI 1.04, 9.54; p=0.042).

CONCLUSIONS

A significant number of RP patients experience de novo storage symptoms. Patients who underwent minimally invasive surgery are at higher risk. At-risk patients should be counseled on the incidence of de novo storage symptoms and offered early treatment per overactive bladder guidelines.

The Effect of Social Determinants of Health on Overactive Bladder Symptom Severity

PURPOSE

Social determinants of health may significantly impact overall health and drive health disparities. We evaluated the association between social determinants of health and overactive bladder severity.

MATERIALS AND METHODS

We conducted a multicenter, cross-sectional study of patients presenting to outpatient female pelvic medicine and reconstructive surgery clinics at Montefiore Medical Center (Bronx, New York) and Johns Hopkins Bayview Medical Center (Baltimore, Maryland) from November 2018 to November 2019. Surveys were administered to screen for overactive bladder (Overactive Bladder-Validated 8-Question Screener) and to evaluate social determinants of health. Ordinal logistic regression models were used to examine the association between overactive bladder symptom level and social determinants of health items, while adjusting for age, race, body mass index, parity, history of pelvic surgery and clinical site.

RESULTS

A total of 256 patients with a mean±SD age of 58.6±14.2 years and body mass index of 30.4±7.5 kg/m² were recruited over a 12-month period. Our sample was 33.6% White, 32% Black and 29.3% Hispanic, with 5.1% categorized as other. A higher overactive bladder symptom level was associated with food insecurity (OR 2.51, 95% CI 1.03-6.11), financial strain (OR 1.94, 95% CI 1.06-3.53), difficulty finding or keeping employment (OR 3.14, 95% CI 1.01-9.72) and difficulty concentrating (OR 2.48, 95% CI 1.25-4.95), after adjusting for site, age, race, body mass index, parity and previous pelvic surgery.

CONCLUSIONS

In this cross-sectional study, certain social determinants of health were associated with greater overactive bladder severity. Unmet social needs may impact the success of overactive bladder treatment. Urologists should consider collaborating with social work and mental health specialists to better serve patients with overactive bladder and social determinants of health needs.

Persistence and Adherence of Anticholinergics and Beta-3 Agonist for the Treatment of Overactive Bladder: Systematic Review and Meta-Analysis, and Network Meta-Analysis

PURPOSE

We aimed to investigate the persistence and adherence rate of overactive bladder medications and factors that affect these rates.

MATERIALS AND METHODS

We conducted electronic English-language literature searches of the PubMed®, Cochrane Library, and EMBASE® databases from the earliest available date of indexing through May 21, 2019 using the Medical Subject Headings (MeSH) terms and EMBASE subject headings (Emtree). Primary measurement outcomes were overall persistence and adherence rate at 6, 12, 24, and 36 months in anticholinergics and mirabegron. Secondary outcomes were individual effect of each medication on persistence and adherence rate at 12 months, and moderating factors affecting the overall persistence and adherence rate at 12 months.

RESULTS

Pooled overall persistence rate at 12 months of overactive bladder medications of anticholinergics and mirabegron was 0.218 (95% CI: 0.197-0.240). The pooled overall persistence rate at 12 months was 0.402 (95% CI: 0.277-0.528) in mirabegron, 0.249 (95% CI: 0.182-0.316) in solifenacin, and 0.220 (95% CI: 0.078-0.361) in fesoterodine. Overall adherence rate of overactive bladder medications of anticholinergics and mirabegron was 0.589 (95% CI: 0.507-0.670). The pooled overall adherence rate at 12 months was 0.654 (95% CI: 0.528-0.781) in mirabegron, 0.784 (95% CI: 0.588-0.980) in solifenacin, 0.782 (95% CI: 0.652-0.911) in fesoterodine, and 0.679 (95% CI: 0.651-0.707) in imidafenacin. Persistence and adherence rates were associated with age, gender, anticholinergic exposure history, type of medication, study type, and study year.

CONCLUSIONS

Persistence and adherence rates were lower than previously reported and were associated with certain clinical and demographic factors.

Alkalinized lidocaine solution as a first-line local anesthesia protocol for intradetrusor injection of onabotulinum toxin A: Results from a double-blinded randomized controlled trial

AIMS

Local anesthesia protocols for intradetrusor onabotulinum toxin A (BoNTA) injection lack standardization. We aimed to determine if an alkalinized lidocaine solution is more effective than lidocaine only.

METHODS

Patients of both genders aged 18 or above enlisted for intradetrusor BoNTA injection (idiopathic, neurogenic, and bladder pain syndrome) were included in a double-blinded randomized controlled trial after obtaining their informed consent. All participants filled a bladder diary and a urine culture was performed. Subjects were randomized 1:1 to Protocol A (20 ml 2% lidocaine + 10 ml 8.4% sodium bicarbonate) or Protocol B (20 ml 2% lidocaine + 10 ml 0.9% saline solution). A Numeric Rating Scale (0-10) was used to assess the level of pain immediately after the procedure (primary endpoint). Secondary endpoints included pain after 1 h, urinary tract infection, acute urinary retention, and hematuria related to the procedure.

RESULTS

A total of 116 patients were randomized. Baseline characteristics (age, sex, indication, and bladder diary parameters) of patients in Group A and B were similar. Pain scores at the end of the procedure were significantly lower with the alkalinized solution (Protocol A and B, respectively, 2.37 ± 0.31 vs. 4.44 ± 0.36, p < .01). No differences were observed 1 h after treatment (Protocol A and B, respectively, 0.54 ± 0.17 vs. 0.69 ± 0.19, p = .487). The only adverse event reported was mild-to-moderate self-limited hematuria in 15.4% of patients.

CONCLUSIONS

The use of an alkalinized lidocaine solution has proven to be significantly superior to lidocaine only as local anesthesia before intradetrusor BoNTA injection, suggesting that this may be considered a first-line option.

Efficacy of Daily Intake of Dried Cranberry 500 mg in Women with Overactive Bladder: A Randomized, Double-Blind, Placebo Controlled Study

PURPOSE

We sought to determine the efficacy of dried cranberry on reducing symptoms of overactive bladder in women.

MATERIALS AND METHODS

Eligible women aged 18 or older with overactive bladder were randomized to either daily dried cranberry powder (500 mg) or placebo (500 mg) and followed for 24 weeks. Efficacy was measured by 3-day voiding diaries and Overactive Bladder Questionnaire Short Form, Patient Perception of Bladder Condition, Sexual Quality of Life-Female and Pelvic Floor Distress Inventory surveys. Statistical analyses were performed by BIOFORTIS using SAS® software version 9.4.

RESULTS

Of the 98 women who were randomized 77 completed all the visits and 60 were included in the per protocol analysis. Compared to placebo using per protocol analysis the cranberry group showed a significant reduction of daily micturitions (-1.91, 95% CI -3.74--0.88, p=0.0406), urgency episodes (-2.81, 95% CI -4.82--0.80, p=0.0069), and Patient Perception of Bladder Condition scores (-0.66, 95% CI -1.23-0.08, p=0.0258) at 24 weeks of followup. Mean volume per micturition, nocturia and the remaining survey outcomes did not differ significantly between the groups (p >0.05).

CONCLUSIONS

Daily intake of dried cranberry powder reduced daily micturition by 16.4%, urgency episodes by 57.3% and patient perception of bladder condition by 39.7%. However, an intent-to-treat analysis showed no statistically significant difference between the groups for these measurements (p >0.05). Future larger studies with longer followup periods are needed to further determine the long-term effect of cranberry on overactive bladder.

The Overactive Bladder and the AUA Guidelines: A Proposed Clinical Pathway for Evaluation and Effective Management in a Contemporary Urology Practice

INTRODUCTION

The 2014 American Urological Association Overactive Bladder Guidelines provide for the evaluation and effective treatment of patients with overactive bladder by all providers. Once the evaluation rules out other causes of these symptoms, the primary treatment of overactive bladder is behavioral. Changing bladder behavior is associated with a high degree of symptom improvement and is successful in most whereas cure remains elusive. Patient treatment outcomes will likely be inadequate if the patient remains uninformed about achievable bladder behavior, if shared and realistic goals of treatment are not established, and if the patient does not actively participate in modifying his/her bladder behavior.

METHODS

The senior authors of the AUA Overactive Bladder Guidelines from 2 major medical centers, specializing in lower urinary tract symptoms, present a unified clinical strategy for the busy outpatient clinic. A single visit rapidly evaluates and stratifies the management options for those with overactive bladder, establishing realistic treatment goals.

RESULTS

Patient evaluation, management and outcomes are remarkably similar between 2 independently developed practices, both centered on achieving patient education and clinical efficiency.

CONCLUSIONS

An algorithmic approach to the evaluation and management of overactive bladder based on the AUA guidelines emphasizes education, the setting of realistic and shared goals for management, and enhancing self-care. Evaluation and behavioral management can be efficiently started within a single visit, reducing pressure on the urologist to provide ultimately unhelpful or even harmful therapies.

Inhibition and Excitation of Bladder Function by Tibial Nerve Stimulation Using a Wirelessly Powered Implant: An Acute Study in Anesthetized Cats

PURPOSE

Tibial nerve stimulation is a minimally invasive neuromodulation treatment of overactive bladder. However, in addition to our limited understanding of the underlying mechanisms, there are also questions regarding the long-term delivery of tibial nerve stimulation therapy in patients. We aimed to characterize the effects of stimulation frequency using a wirelessly powered implantable stimulation device.

METHODS AND MATERIALS

Six α-chloralose anesthetized adult male cats were used in this study. A multicontact lead was surgically implanted subcutaneously in the hind limb and used to stimulate the tibial nerve. Using an isovolumetric bladder a short duration of electrical pulses was applied at amplitudes 3 times the motor threshold and at frequencies from 2 to 20 Hz.

RESULTS

Implant driven stimulation of the tibial nerve resulted in frequency dependent activation of bladder reflexes. Low frequency tibial nerve stimulation (2 Hz) consistently evoked excitatory responses (mean ± SE 32.9% ± 3.8%). In contrast, higher frequency tibial nerve stimulation (6 to 20 Hz) inhibited bladder function (overall mean 14.9% ± 2.4%). Although low foot motor thresholds were achieved at initial implantation (mean 0.83 ± 0.05 mA), a notable elevation in threshold amplitude was observed 5 hours after implantation.

CONCLUSIONS

To our knowledge this study provides the first evidence of frequency dependent modulation of bladder function in anesthetized cats. The inhibitory influence of tibial nerve stimulation at frequencies above 6 Hz transitioned to an excitatory effect at 2 Hz. Taken together these preclinical data support the feasibility of using a wirelessly powered implantable device to potentially modulate bladder function in patients.

Systemic Nonurological Symptoms in Patients with Overactive Bladder

PURPOSE

We compare the systemic (nonurological) symptoms between patients with overactive bladder and subjects without overactive bladder. We also compare the urinary symptoms, quality of life and psychosocial measures between the 2 subgroups of patients with overactive bladder with a high vs low systemic symptom burden.

MATERIALS AND METHODS

Patients diagnosed with overactive bladder (51) and age matched individuals without overactive bladder (30) were administered the polysymptomatic, polysyndromic questionnaire to assess the numbers and distribution of systemic symptoms across multiple organ systems. Validated instruments were administered to evaluate urinary symptoms (ICIQ-UI, ICIQ-OAB, OAB-q, USS), quality of life (UDI-6, IIQ-7, OAB-q) and psychosocial difficulties (depression, anxiety, stress, sexual trauma, sleep, fatigue). Patients with overactive bladder were divided into 2 subgroups (with and without widespread systemic symptoms) and their responses were compared.

RESULTS

Patients with overactive bladder reported significantly more systemic (nonurological) symptoms compared to controls (mean ± SD 17.5 ± 12.3 vs 6.4 ± 7.9 symptoms, p <0.001). Differences were observed across multiple organ systems (neurologic, cardiopulmonary, gastrointestinal, sexual, musculoskeletal and gynecologic, p <0.05). About a third of patients with overactive bladder (31.4%) reported widespread systemic symptoms across multiple organ systems (mean 32.0 symptoms). The presence of widespread systemic symptoms among patients with overactive bladder was correlated with worse incontinence/overactive bladder symptoms (ICIQ-UI, OAB-q), poorer quality of life (UDI-6, IIQ-7, OAB-q) and more psychosocial difficulties (depression, anxiety, fatigue and higher stress, p <0.05).

CONCLUSIONS

The increased presence of nonurological symptoms in overactive bladder suggests an underlying systemic etiology and pathogenetic mechanisms that may contribute to overactive bladder. This study highlights the importance of understanding systemic factors in urological conditions otherwise thought to be organ specific.

Somatic Comorbidity in Women with Overactive Bladder Syndrome

PURPOSE

We explore the influence of co-occurring somatic illnesses on prevalent overactive bladder in women of premenopausal age.

MATERIALS AND METHODS

Data for the present study were derived from a nationwide survey on complex diseases among all twins in the Swedish Twin Registry born 1959 to 1985. The present study was limited to female twins participating in the survey (12,850). Generalized estimating equations were used to estimate odds ratios with 95% CIs. Environmental and genetic influences were assessed in co-twin control analysis.

RESULTS

Generalized estimating equations analysis showed a significant association between overactive bladder and migraine (OR 1.34, 95% CI 1.15-1.57), fibromyalgia (1.83, 1.54-2.18), chronic fatigue (1.81, 1.49-2.19) and eating disorders (1.56, 1.24-1.96). There was also a significant association with allergic disorders including asthma (1.24, 1.01-1.52) and eczema (1.22, 1.04-1.43). Among reproductive disorders, urinary tract infections (1.60, 1.40-1.84), dysmenorrhea (1.53, 1.33-1.76) and pelvic pain (1.60, 1.31-1.94) showed the strongest association with overactive bladder. Results from co-twin control analysis indicated that the significant associations observed in generalized estimating equations analysis were influenced by environmental and genetic factors without a common pathway model.

CONCLUSIONS

Our results suggest a multifactorial and complex pathogenesis of overactive bladder in which associations between various somatic illnesses and overactive bladder may be affected by environmental and genetic factors.

Impact of Dry Mouth on Fluid Intake and Overactive Bladder Symptoms in Women taking Fesoterodine

PURPOSE

We investigated the long-term relationships between dry mouth, fluid intake and overactive bladder symptoms in women undergoing treatment with fesoterodine. We hypothesized that women who experienced dry mouth would increase their fluid intake and worsen their urinary symptoms.

MATERIALS AND METHODS

We conducted a prospective ancillary study to a 9-month open-label trial of fesoterodine for women with urgency urinary incontinence. Fluid intake was measured and compared according to reported dry mouth. Multivariable analysis was used to study the interaction between dry mouth, fluid intake and urinary symptoms.

RESULTS

During the study 407 women without dry mouth significantly reduced their fluid intake (mean decrease 172.1 ml, median 118.3 ml, p = 0.02), while 91 women with dry mouth did not (mean decrease 95.8 ml, median 118.3 ml, p = 0.54). On univariable analysis a greater proportion of women who experienced dry mouth reported improvement in their urinary symptoms compared to women without dry mouth (60.5% vs 47.2%, p = 0.03). On multivariable analysis black women were less likely to report dry mouth (OR 0.4, 95% CI 0.2-0.9, p = 0.03) and older women were less likely to report improvement in urinary symptoms (OR 0.98, 95% CI 0.96-0.99, p = 0.003). Factors not associated with improvement in urinary symptoms on multiple regression were dry mouth, baseline fluid intake volume, change in fluid intake volume and caffeine intake volume.

CONCLUSIONS

In women with overactive bladder receiving fesoterodine dry mouth may prevent restriction of fluid intake but does not diminish treatment efficacy.

Role of the Anterior Cingulate Cortex in the Control of Micturition Reflex in a Rat Model of Parkinson's Disease

PURPOSE

In the current study we examined dynamic changes in neural activity of the anterior cingulate cortex and the midbrain periaqueductal gray during the micturition reflex in a Parkinson's disease model as well as the effects of direct stimulation of the anterior cingulate cortex on the micturition reflex.

MATERIALS AND METHODS

Electrodes were inserted in the anterior cingulate cortex or the periaqueductal gray. The effects of intravenous administration of the adenosine A2A receptor antagonist ZM24138 on pelvic nerve evoked field potentials were examined. The effect of electrical stimulation of the anterior cingulate cortex was also examined.

RESULTS

Rats with Parkinson's disease showed bladder overactivity as evidenced by a significant decrease in the intercontraction interval compared with sham operated rats. Intravenous administration of ZM24138 increased the intercontraction interval in both groups with the inhibitory effects greater in rats with Parkinson's disease. It dose dependently increased the amplitude of evoked potentials in the anterior cingulate cortex of rats with Parkinson's disease but not in sham operated rats. Intravenous administration of ZM24138 decreased evoked potential amplitude in the periaqueductal gray of both groups with the inhibitory effects greater in Parkinson's disease vs sham operated rats. Electrical stimulation of the anterior cingulate cortex significantly increased the intercontraction interval.

CONCLUSIONS

These results suggest that anterior cingulate cortex neurons have an inhibitory role in bladder control. Neural activity in the anterior cingulate cortex was significantly increased along with suppression of bladder overactivity after ZM241385 administration in the Parkinson's disease model and the stimulation of the anterior cingulate cortex inhibited the micturition reflex. Understanding the roles of the anterior cingulate cortex in the modulation of micturition could provide further insights into the pathophysiology of overactive bladder.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients

AIMS

To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM).

METHODS

Patients enrolled in our longitudinal neuromodulation database were reviewed. Medical records data, and voiding diaries, Interstitial Cystitis Symptom-Problem Indices (ICSI-PI), and Overactive Bladder Questionnaires (OAB-q) at baseline and 3 months were analyzed with Pearson's χ² , Fisher's Exact test, Wilcoxon rank tests, and multivariable logistic regression.

RESULTS

Of 407 patients, 134 (33%) had at least one reoperation over median 28.9 months follow-up (range 1.6-121.7); 78/407 (19%) were revised, and 56/407 (14%) were explanted. The most common reason for reoperation was lack of efficacy/worsening symptoms (n = 87). The reoperations group had a higher proportion of women (P = 0.049), lower mean body mass index (BMI; P = 0.010), more reprogramming events (P < 0.0001), longer median follow-up (P = 0.0008), and higher proportions with interstitial cystitis (P = 0.013), using hormone replacement therapy (P = 0.0004), and complications (P < 0.0001). Both reoperations/no reoperations groups had similar improvements in ICSI-PI (P < 0.0001 for both), OAB-q severity (P < 0.0001 for both) and quality of life (P < 0.0001 for both). On multivariate analysis, only longer follow-up (P = 0.0011; OR 1.048; CI 1.019, 1.078) and having a complication (P < 0.0001; OR 23.2; CI 11.47, 46.75) were significant predictors of reoperations. In women only, using HRT at time of implant was also predictive of reoperation (P = 0.0027; OR 3.09; CI 1.48, 6.46).

CONCLUSIONS

In this largest known series to date, one third of the patients required reoperation and the most common reason was lack of efficacy/worsening symptoms. Ongoing study is needed as the technology continues to evolve. Neurourol. Urodynam. 36:354-359, 2017. © 2015 Wiley Periodicals, Inc.

Augmentation cystoplasty: Urodynamic and metabolic outcomes at 10-year follow-up

OBJECTIVE

To review the urodynamic outcomes, renal function and metabolic complications after augmentation cystoplasty with at least 10 years of follow-up.

METHODS

Augmentation cystoplasty performed in two tertiary referral centers from 1995 to 2004 were reviewed. Ten years or more postoperative course was studied by review of the clinical notes, urodynamic reports and laboratory results.

RESULTS

A total of 40 patients were included in this study. The mean age at surgery was 43 years, and 47.5% of patients were female. Median follow up was 13 years. Bladder capacity significantly increased from 283 ± 151 to 492 ± 123 mL (P < 0.01), with a percentage change of +130%. The compliance of the bladder was increased by 87%, and detrusor overactivity decreased by 54.2%. There were no significant changes in preoperative and postoperative estimated glomerular filtration rate (68.3 mL/min vs. 76.6 mL/min, P = 0.798). Three patients (7.5%) had more than one episode of symptomatic urinary tract infection per year.

CONCLUSION

The present study confirms the effectiveness of augmentation cystoplasty in increasing bladder capacity, improving bladder compliance and reducing detrusor overactivity. The preservation of renal function and low metabolic complication rate provide solid evidence for carrying out this time-honored procedure in patients with neurogenic or non-neurogenic bladder dysfunction.

Posterior tibial nerve stimulation vs parasacral transcutaneous neuromodulation for overactive bladder in children

PURPOSE

Parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation have emerged as effective methods to treat overactive bladder in children. However, to our knowledge no study has compared the 2 methods. We evaluated the results of parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation in children with overactive bladder.

MATERIALS AND METHODS

We prospectively studied children with overactive bladder without dysfunctional voiding. Success of treatment was evaluated by visual analogue scale and dysfunctional voiding symptom score, and by level of improvement of each specific symptom. Parasacral transcutaneous electrical nerve stimulation was performed 3 times weekly and posterior tibial nerve stimulation was performed once weekly.

RESULTS

A total of 22 consecutive patients were treated with posterior tibial nerve stimulation and 37 with parasacral transcutaneous electrical nerve stimulation. There was no difference between the 2 groups regarding demographic characteristics or types of symptoms. Concerning the evaluation by visual analogue scale, complete resolution of symptoms was seen in 70% of the group undergoing parasacral transcutaneous electrical nerve stimulation and in 9% of the group undergoing posterior tibial nerve stimulation (p = 0.02). When the groups were compared, there was no statistically significant difference (p = 0.55). The frequency of persistence of urgency and diurnal urinary incontinence was nearly double in the group undergoing posterior tibial nerve stimulation. However, this difference was not statistically significant.

CONCLUSIONS

We found that parasacral transcutaneous electrical nerve stimulation is more effective in resolving overactive bladder symptoms, which matches parental perception. However, there were no statistically significant differences in the evaluation by dysfunctional voiding symptom score, or in complete resolution of urgency or diurnal incontinence.

Intake of caffeinated, carbonated, or citrus beverage types and development of lower urinary tract symptoms in men and women

Evidence to substantiate recommendations for restriction of caffeinated or acidic beverages as self-management for lower urinary tract symptoms (LUTS) is limited. We examined longitudinal and acute associations between beverage intake and LUTS in the Boston Area Community Health (BACH) cohort (n = 4,144) between 2002 and 2010. Multivariable models tested associations between baseline intakes and progression of LUTS at 5-year follow-up, between follow-up intakes and International Prostate Symptom Scores at follow-up, and between 5-year intake changes and LUTS progression. Greater coffee or total caffeine intake at baseline increased the odds of LUTS progression in men (coffee: >2 cups/day vs. none, odds ratio = 2.09, 95% confidence interval: 1.29, 3.40, P-trend = 0.01; caffeine: P-trend < 0.001), particularly storage symptoms. Women who increased coffee intake by at least 2 servings/day during follow-up (compared with categories of decreased or unchanged intakes) had 64% higher odds of progression of urgency (P = 0.003). Women with recently increased soda intake, particularly caffeinated diet soda, had higher symptom scores, urgency, and LUTS progression. Citrus juice intake was associated with 50% lower odds of LUTS progression in men (P = 0.02). Findings support recommendations to limit caffeinated beverage intake for LUTS, and in men, they suggest benefits of citrus juice consumption. Further clinical research is warranted, particularly of the precise role of sodas containing artificial sweeteners in bladder sensations and urological function.

Down-regulation of nerve growth factor expression in the bladder by antisense oligonucleotides as new treatment for overactive bladder

PURPOSE

Nerve growth factor over expression in the bladder has a role in overactive bladder symptoms via the mediation of functional changes in bladder afferent pathways. We studied whether blocking nerve growth factor over expression in bladder urothelium by a sequence specific gene silencing mechanism would suppress bladder overactivity and chemokine expression induced by acetic acid.

MATERIALS AND METHODS

Female Sprague-Dawley® rats anesthetized with isoflurane were instilled with 0.5 ml saline, scrambled or TYE™ 563 labeled antisense oligonucleotide targeting nerve growth factor (12 μM) alone or complexed with cationic liposomes for 30 minutes. The efficacy of nerve growth factor antisense treatments for acetic acid induced bladder overactivity was assessed by cystometry. Bladder nerve growth factor expression levels and cellular distribution were quantified by immunofluorescence staining and enzyme-linked immunosorbent assay. Effects on bladder chemokine expression were measured by Luminex® xMAP® analysis.

RESULTS

Liposomes were needed for bladder uptake of oligonucleotide, as seen by the absence of bright red TYE 563 fluorescence in rats instilled with oligonucleotide alone. At 24 hours after liposome-oligonucleotide treatment baseline bladder activity during saline infusion was indistinct in the sham and antisense treated groups with a mean ± SEM intercontraction interval of 348 ± 55 and 390 ± 120 seconds, respectively. Acetic acid induced bladder overactivity was shown by a decrease in the intercontraction interval to a mean of 33.2% ± 4.0% of baseline in sham treated rats. However, the reduction was blunted to a mean of 75.8% ± 3.4% of baseline in rats treated with liposomal antisense oligonucleotide (p <0.05). Acetic acid induced increased nerve growth factor in the urothelium of sham treated rats, which was decreased by antisense treatment, as shown by enzyme-linked immunosorbent assay and reduced nerve growth factor immunoreactivity in the urothelium. Increased nerve growth factor in bladder tissue was associated with sICAM-1, sE-selectin, CXCL-10 and 1, leptin, MCP-1 and vascular endothelial growth factor over expression, which was significantly decreased by nerve growth factor antisense treatment (p <0.01).

CONCLUSIONS

Acetic acid induced bladder overactivity is associated with nerve growth factor over expression in the urothelium and with chemokine up-regulation. Treatment with liposomal antisense suppresses bladder overactivity, and nerve growth factor and chemokine expression. Local suppression of nerve growth factor in the bladder could be an attractive approach for overactive bladder. It would avoid the systemic side effects that may be associated with nonspecific blockade of nerve growth factor expression.