Does COVID-19 cause or worsen LUT dysfunction, what are the mechanisms and possible treatments? ICI-RS 2023

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) and produced a worldwide pandemic in 2020. There have been 770,875,433 confirmed cases and 6,959,316 attributed deaths worldwide until September 19, 2023. The virus can also affect the lower urinary tract (LUT) leading to bladder inflammation and producing lower urinary tract symptoms (LUTS) in both the acute and chronic phases of disease.

METHODS

At the 2023 meeting of the International Consultation on Incontinence-Research Society (ICI-RS), the literature relating to COVID-19 and bladder dysfunction was reviewed. The LUTS reported, as well as the pathophysiology of these bladder symptoms, were the subject of considerable discussion. A number of different topics were discussed including lower LUTS reported in COVID-19, how SARS-CoV-2 may infect and affect the urinary tract, and proposed mechanisms for how viral infection result in new, worsened, and in some persisting LUTS.

CONCLUSIONS

The workshop discussed the interaction between the virus and the immune system, covering current evidence supporting theories underlying the causes of acute and chronic LUTS related to COVID-19 infection. Research questions for further investigation were suggested and identified.

Regular and Irregular Use and Reasons for Discontinuation of Solifenacin Therapy in Patients with Overactive Bladder Managed by Urologists

Solifenacin, a selective muscarinic receptor antagonist, is one of the best-tolerated and most effective medicines that relieve storage symptoms in patients with an overactive bladder (OAB). However, the persistence of solifenacin in daily clinical practice remains far below that reported in clinical trials. This study aimed to analyze the adherence of patients to the therapy and the reasons for solifenacin discontinuation and non-regular use in OAB patients managed by urologists. Data concerning non-compliance and the discontinuation of solifenacin, along with the reasons, were collected during two consecutive visits for 64,049 OAB outpatients. Over the two visits, 81.6% of the patients continued therapy, and 88.6% were taking solifenacin regularly. An age ≥ 75 yrs., the male sex, a rural or small-city dwelling, and a prescription of ≥10 mg predicted therapy continuation. The female sex, a higher education, a short or long duration of an OAB, and a non-idiopathic OAB predicted regular use. The persistence of nycturia and urinary incontinence during therapy predicted both discontinuation and non-regular use. Dissatisfaction with therapy was the most frequent reason for discontinuation. In conclusion, an initial prescription of solifenacin at a low dose reduces the chance of OAB symptom improvement and results in more frequent discontinuation. A high rate of discontinuation related to dissatisfaction suggests unrealistic expectations for OAB patients and insufficient education by urologists.

Association Between Maternal Depression and Lower Urinary Tract Symptoms in Their Primary School-Age Daughters: A Birth Cohort Study

PURPOSE

Although maternal depression is associated with adverse outcomes in women and children, its relationship with lower urinary tract symptoms (LUTS) in offspring is less well-characterized. We examined the association between prenatal and postpartum maternal depression and LUTS in primary school-age daughters.

DESIGN

Observational cohort study.

SUBJECTS AND SETTING

The sample comprised 7148 mother-daughter dyads from the Avon Longitudinal Study of Parents and Children.

METHOD

Mothers completed questionnaires about depressive symptoms at 18 and 32 weeks' gestation and 21 months postpartum and their children's LUTS (urinary urgency, nocturia, and daytime and nighttime wetting) at 6, 7, and 9 years of age. Multivariable logistic regression models were used to estimate the association between maternal depression and LUTS in daughters.

RESULTS

Compared to daughters of mothers without depression, those born to mothers with prenatal and postpartum depression had higher odds of LUTS, including urinary urgency (adjusted odds ratio [aOR] range = 1.99-2.50) and nocturia (aOR range = 1.67-1.97) at 6, 7, and 9 years of age. Additionally, daughters born to mothers with prenatal and postpartum depression had higher odds of daytime wetting (aOR range = 1.81-1.99) and nighttime wetting (aOR range = 1.63-1.95) at 6 and 7 years of age. Less consistent associations were observed for depression limited to the prenatal or postpartum periods only.

CONCLUSIONS

Exposure to maternal depression in the prenatal and postpartum periods was associated with an increased likelihood of LUTS in daughters. This association may be an important opportunity for childhood LUTS prevention. Prevention strategies should reflect an understanding of potential biological and environmental mechanisms through which maternal depression may influence childhood LUTS.

Neodymium Laser Treatment for Overactive Bladder and Vulvodynia in Mayer-Rokitansky-Küster-Hauser Syndrome Patient: A Case Report

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a condition that affects a small proportion of female individuals at birth, resulting in the absence or underdevelopment of reproductive organs. However, this case report introduces overactive bladder (OAB) and vulvodynia, conditions that have not been previously reported in MRKH patients. The 36-year-old patient began developing breast tissue around the age of 12 but never experienced menstruation. Simultaneously, she started experiencing discomfort in the genital region and frequent urination. These symptoms gradually worsened, making it difficult for her to continue her education, and initially, she was misdiagnosed with a developmental disorder. Typically, the general understanding of MRKH syndrome has focused on reproductive anomalies, but this case underscores its diversity. Diagnostic assessments, including ultrasound, MRI, and various tests, revealed that the patient's severe genital discomfort and urinary symptoms were improved through a specialized Neodymium YAG laser therapy named "PIANO mode," resulting in significant symptom relief and improved quality of life. This report emphasizes the importance of comprehensive and individualized approaches to managing MRKH syndrome. It aims to raise awareness that MRKH syndrome, while often associated with reproductive abnormalities, can also involve related symptoms like OAB and vulvodynia, which can significantly impact daily life.

Naturalistic Bladder Filling Reveals Subtypes in Overactive Bladder Syndrome That Differentially Engages Urinary Urgency-Related Brain Circuits: Results From the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN)

PURPOSE

Overactive bladder (OAB) may be attributed to dysfunction in supraspinal brain circuits. Overactive bladder participants enrolled in the LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) study reported sensations of urinary urgency during a bladder-filling paradigm while undergoing brain functional MRI to map supraspinal dysfunction.

MATERIALS AND METHODS

OAB participants and controls (CONs) completed 2 resting-state functional MRI scans following consumption of 350 mL water. Scans were conducted at fuller and emptier bladder states, interleaved with voiding. Urgency ratings (0-10) were assessed. Patterns of urgency during bladder filling were investigated using latent class trajectory models. Clusters of participants encompassing each pattern (ie, subtype) were derived from aggregated groups of OAB and CON independent of diagnosis.

RESULTS

Two distinct patterns of urgency trajectories were revealed: first subtype with OAB and CON who were unresponsive to bladder filling (OAB-1 and CON-1) and second highly responsive subtype predominantly containing OAB (OAB-2). OAB-2 participants scored significantly higher on urinary symptoms but not pain or psychosocial measures. Neuroimaging analyses showed change in urgency due to both bladder filling and voided volume related to multiple loci of brain network connectivity in OAB-2, and in some cases, different than OAB-1 and/or CON-1. Sensorimotor to dorsomedial/dorsolateral prefrontal connectivity mediated the relationship between stimulus (voided volume) and percept (urgency) in OAB-2.

CONCLUSIONS

Our results reveal different OAB subtypes with latent class trajectory models of urgency ratings during natural bladder filling. Functional MRI revealed differences in pathophysiology between subtypes, namely sensorimotor-prefrontal connectivity is a key locus in OAB patients with higher urinary symptoms.

Increase in physiological inhibitory control results in better suppression of unwanted memories

Forgetting or suppressing a memory with unwanted content is just as important as remembering a desirable one. In addition to emphasizing the role of inhibitory control in memory suppression processes, neuropsychological studies have indicated that an intentional inhibition targeting a brain area may exert its inhibitory effects in seemingly unrelated areas through a common inhibitory network. In this study, we aimed to investigate whether the suppression of unwanted memories can be strengthened by recruiting an inhibitory task that can be simultaneously performed with a memory suppression task. Therefore, we manipulated the level of urinary urgency-induced inhibition of participants (N = 180) and test its effect on the suppression of unwanted memories using a Think/No-Think (T/NT) task. The results of our study indicated that individuals with high levels of urinary urgency demonstrated greater memory suppression compared to those with low urinary urgency. Findings and their implications are discussed within the context of cognitive and clinical perspectives, and recommendations are made for future research.

Plain language summary: does treatment with vibegron result in improvements in overactive bladder (OAB) symptoms that are meaningful to people with OAB?

What is this summary about? This is a plain language summary of an article published in the journal Advances in Therapy. In 2020, the US Food and Drug Administration (also called the FDA) approved a medicine called vibegron to treat overactive bladder, also called OAB. The key results used to approve vibegron were from the EMPOWUR study. In the EMPOWUR study, participants who took vibegron had fewer urination episodes, urgency episodes, and bladder leaks each day than those who took a pill containing no medicine, called a placebo. At the end of the study, participants also rated how much their overactive bladder symptoms changed overall during EMPOWUR by responding to a survey. Many participants rated their overactive bladder symptoms as improved overall. This study asked if improvements in the number of urination episodes, urgency episodes, and bladder leaks caused by urgency were associated with feeling better overall. This study also looked at how many participants in the EMPOWUR study had improvements in the number of urination episodes, urgency episodes, and bladder leaks that were big enough to matter. A separate group of people with overactive bladder were asked about the magnitude of improvements that would be important to them. This group had not participated in the EMPOWUR study. What were the results? EMPOWUR participants who reported that taking medicine resulted in their overactive bladder symptoms getting better overall also generally reported fewer daily urinations, urgency episodes, and bladder leaks after treatment. Many had changes in their symptoms that were meaningful. Meaningful was defined for each symptom as: at least 15% fewer urinations, 50% fewer urgency episodes, and 75% fewer bladder leaks. Participants who received vibegron had meaningful reductions in the daily number of episodes of urination, urgency, and bladder leaks more often than those who received the placebo (pill with no active medicine). People with overactive bladder who did not participate in the study were interviewed and said that improvements to those symptoms, similar to those seen in the EMPOWUR study, would be important to them. What do the results mean? This study suggests that the results we measured in the EMPOWUR study may also reflect changes in overactive bladder symptoms that are big enough to be important to people with overactive bladder. Many participants who took vibegron in the EMPOWUR study felt that it helped to improve their individual overactive bladder symptoms. This may also help improve quality of life of participants. Clinical Trial Registration: NCT03492281 (ClinicalTrials.gov).

Urologic view in the management of genitourinary syndrome of menopause

Genitourinary syndrome of menopause (GSM) has a variety of effects on the urinary system and is an important consideration in the care provided to perimenopausal and postmenopausal patients when addressing urinary pathology. Here we discuss the common pathologies of the urinary system related to GSM including lower urinary tract symptoms and recurrent urinary tract infections. Female sexual dysfunction is not to be excluded as a critical part of a urologist's management of GSM but will be discussed elsewhere in this issue.

Development and validation of models predicting treatment patterns in women with urinary urgency and/or urgency incontinence: A Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study

PURPOSE

To develop a tool to predict a woman's treatment pattern for bothersome urinary urgency (UU) and/or UU incontinence over 1 year after presenting for care at urology or urogynecology clinics.

METHODS

The Symptoms of Lower Urinary Tract Dysfunction Research Network observational cohort study enrolled adult women with bothersome UU and/or UU incontinence using the lower urinary tract symptoms (LUTS) Tool who were seeking care for LUTS. Treatments for UU and/or urgency incontinence were ordered from least to most invasive. Ordinal logistic and Cox proportional hazard regression models were fit to predict the most invasive level of treatment during follow-up and overactive bladder (OAB) medication discontinuation, respectively. Binary logistic regression was performed to predict sling treatment during the study follow-up. Clinical tools were then created using the models listed above to predict treatment pattern over 12 months.

RESULTS

Among 349 women, 281 reported UU incontinence, and 68 reported UU at baseline. The highest level of treatment during the study was as follows: 20% no treatment, 24% behavioral treatments, 23% physical therapy, 26% OAB medication, 1% percutaneous tibial nerve stimulation, 3% onabotulinumtoxin A, and 3% sacral neuromodulation. Slings were placed in 10% (n = 36) of participants before baseline and in 11% (n = 40) during study follow-up. Baseline factors associated with predicting the most invasive level of treatment included baseline level of treatment, hypertension, UU incontinence severity, stress urinary incontinence (SUI) severity, and anticholinergic burden score. Less severe baseline depression and less severe UU incontinence were associated with OAB medication discontinuation. UU and SUI severity were associated with sling placement during the study period. Three tools are available to predict: (1) highest level of treatment; (2) OAB medication discontinuation; and (3) sling placement.

CONCLUSIONS

OAB treatment prediction tools developed in this study can help providers individualize treatment plans and identify not only patients at risk for treatment discontinuation but also patients who may not be escalated to potentially beneficial OAB treatments, with the goal to improve clinical outcomes for patients suffering from this chronic and often debilitating condition.

Abnormal Resting-State Network Presence in Females with Overactive Bladder

Overactive bladder (OAB) is a global problem reducing the quality of life of patients and increasing the costs of any healthcare system. The etiology of OAB is understudied but likely involves supraspinal network alterations. Here, we characterized supraspinal resting-state functional connectivity in 12 OAB patients and 12 healthy controls (HC) who were younger than 60 years. Independent component analysis showed that OAB patients had a weaker presence of the salience (Cohen's d = 0.9) and default mode network (Cohen's d = 1.1) and weaker directed connectivity between the fronto-parietal network and salience network with a longer lag time compared to HC. A region of interest analysis demonstrated weaker connectivity in OAB compared to HC (Cohen's d > 1.6 or < -1.6), particularly within the frontal and prefrontal cortices. In addition, weaker seed (insula, ventrolateral prefrontal cortex) to voxel (anterior cingulate cortex, frontal gyrus, superior parietal lobe, cerebellum) connectivity was found in OAB compared to HC (Cohen's d > 1.9). The degree of deviation in supraspinal connectivity in OAB patients (relative to HC) appears to be an indicator of the severity of the lower urinary tract symptoms and an indication that such symptoms are directly related to functional supraspinal alterations. Thus, future OAB therapy options should also consider supraspinal targets, while neuroimaging techniques should be given more consideration in the quest for better phenotyping of OAB.

Efficacy of Pudendal Nerve Blocks and Ultrasound-Guided Superior Hypogastric Plexus Blocks for the Management of Refractory Interstitial Cystitis: A Case Series

Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by chronic pelvic, perineal, or bladder pain in addition to lower urinary tract symptoms. The etiology of this condition is not fully understood, which presents a challenge for effective therapeutic intervention. Current treatment guidelines recommend the use of multimodal pain management strategies including behavioral/non-pharmacologic, oral medications, bladder instillations, procedures, and major surgery. However, the safety and efficacy of these modalities vary, and there is currently no optimal treatment for the management of IC/BPS. The pudendal nerves and superior hypogastric plexus, which together mediate visceral pelvic pain and bladder control, are not addressed in the current guidelines but may serve as a therapeutic target. Here, we report improvements in pain, urinary symptoms, and functionality following bilateral pudendal nerve blocks and/or ultrasound-guided superior hypogastric plexus blocks in three patients with refractory IC/BPS. Our findings provide support for the use of these interventions in patients with IC/BPS unresponsive to prior conservative management.

Reduced versus standard intradetrusor OnabotulinumtoxinA injections for treatment of overactive bladder

BACKGROUND

Intradetrusor onabotulinumtoxinA injection is an effective advanced treatment for overactive bladder. While the effective dosages have been well studied, very little data exist on treatment efficacy using differing injection techniques. The objective of this study was to determine whether the efficacy of a reduced injection technique of 5 injection sites was noninferior to the standard technique of 20 injection sites of intradetrusor onabotulinumtoxinA for treatment of overactive bladder.

METHODS

In this randomized noninferiority trial, men and women seeking treatment of overactive bladder with intradetrusor onabotulinumtoxinA injections were randomized to receive 100 units administered via either a reduced injection technique of 5 injection sites or a standard injection technique of 20 injection sites. Subjects completed a series of standardized questionnaires at baseline and at 4-12 weeks postprocedure to determine symptom severity and treatment efficacy. The primary outcome was treatment efficacy as determined by Overactive Bladder Questionnaire-Short Form with a noninferiority margin of 15 points. Secondary outcomes were incidence of urinary tract infection and urinary retention requiring catheterization.

RESULTS

Data from 77 subjects were available for analysis with 39 in the control arm (20 injections) and 38 in the study arm (5 injections). There was a significant improvement in both arms from baseline to follow-up in Overactive Bladder Questionnaire-Short Form and International Consultation on Incontinence Questionnaire scores (p < 0.001). Overall treatment success was 68% with no statistically significant difference between arms. A significant difference between arms was found on the Overactive Bladder Questionnaire-Short Form quality of life survey favoring the control arm (confidence interval [CI]: 0.36-20.5, p = 0.04). However, there were no significant differences between arms in the remaining validated questionnaires. The study arm did not demonstrate noninferiority to the control arm. Subjects in the study arm were significantly more likely to express a willingness to undergo the procedure again (odds ratio = 3.8, 95% CI: 1.42-10.67, p = 0.004). Adverse events did not differ between arms.

CONCLUSIONS

A reduced injection technique for administration of intradetrusor onabotulinumtoxinA demonstrates similar efficacy to the standard injection technique but did not demonstrate noninferiority. Subjects preferred the reduced injection technique over the standard technique. A reduced injection technique is a safe and effective alternative to the standard technique.

The association between overactive bladder and fibromyalgia: A systematic review and meta-analysis

BACKGROUND

Overactive bladder is a common syndrome that significantly affects the quality of life. Fibromyalgia is characterized by widespread pain, impacting patients' lives. The exact mechanisms of the two syndromes remain unknown, but there is an overlap between the suspected pathophysiologies.

OBJECTIVE

To present an overview of the current research on the association between overactive bladder (OAB) and fibromyalgia.

SEARCH STRATEGY

A systematic search of four electronic databases was conducted.

SEARCH STRATEGY

Studies examining the correlation between OAB and fibromyalgia with female patients aged over 18 years were included.

DATA COLLECTION AND ANALYSIS

Two reviewers screened the studies for eligibility. Eligible studies were screened for quality. A meta-analysis was performed for eligible studies.

MAIN RESULTS

Seven studies were included in the final review, of which six presented a positive association between the syndromes. The studies demonstrated a positive association between fibromyalgia and the severity of OAB and an adverse effect on the quality of life related to OAB. A mean effect size of 1.96 (95% confidence interval 0.85-3.06) was calculated.

CONCLUSION

OAB and fibromyalgia are both complex and multifactorial syndromes. The study presents an association between them, but additional studies on the topic should be conducted for a more precise conclusion.

Pelvic Floor Mobility measured by Transperineal Ultrasound Imaging in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

BACKGROUND

Women with urgency/frequency predominant lower urinary tract symptoms (UF-LUTS) may have elevated pelvic floor muscle (PFM) position at rest and limited mobility with PFM contraction and bearing down, but this has not been quantified.

OBJECTIVES

To compare PFM position and mobility using transperineal ultrasound (TPUS) at rest, maximal PFM contraction (perineal elevation), and bearing down (perineal descent) in women with and without UF-LUTS. We hypothesized that women with UF-LUTS would demonstrate elevated resting position and decreased excursion of pelvic landmarks during contraction and bearing down as compared to women without UF-LUTS.

STUDY DESIGN

Case-control study.

METHODS

Women with UF-LUTS were matched 1:1 on age, body mass index and vaginal parity to women without UF-LUTS. TPUS videos were obtained during 3 conditions: rest, PFM contraction, and bearing down. Levator plate angle (LPA) and puborectalis length (PR length), were measured for each condition. Paired t-tests or Wilcoxon signed rank tests compared LPA and PR length between cases and controls.

RESULTS

21 case-control pairs (42 women): Women with UF-LUTS demonstrated greater LPA at rest (66.8 ± 13.2 degrees vs 54.9 ± 9.8 degrees; P=0.006), and less PR lengthening from rest to bearing down (0.2 ± 3.1 mm vs 2.1 ± 2.9 mm; P=.03).

CONCLUSION

Women with UF-LUTS demonstrated more elevated (cranioventral) position of the PFM at rest and less PR muscle lengthening with bearing down. These findings highlight the importance of a comprehensive PFM examination and possible treatment for women with UF-LUTS to include PFM position and mobility.

The impact of cystocele repair on urge symptoms in women with pelvic organ prolapse

OBJECTIVES

The purpose of this study was to evaluate the impact of cystocele repair on urinary urge symptoms and to determine the likelihood that urge symptoms are caused by cystocele and therefore cured by cystocele repair. The secondary aim was to assess the impact of baseline cystocele stage POP on the improvement of urge symptoms following surgical treatment of POP.

MATERIAL AND METHODS

A total of 321 female patients with cystocele stages II, III or IV (POP), who underwent repair surgery for pelvic organ prolapse, were included. A retrospective analysis was performed to determine the presence of urge symptoms in patients with cystocele and to evaluate how many patients were cured from urge symptoms by the cystocele repair. Postoperative data were obtained by interview during a follow-up examination six weeks after surgery.

RESULTS

Preoperatively, 52.02% of all patients diagnosed with cystocele stages II, III or IV POP experienced urge symptoms. Urge symptoms were cured in 88.62% of patients with cystocele stages II after POP repair (p < 0.005). 88.60% of patients with cystocele stage II POP and 88.68% of patients with cystocele stages III to IV POP reported improvement in urge symptoms (p < 0.005). Despite cystocele repair, 11.4% of patients with preoperative cystocele stage II POP and 11.32% with preoperative cystocele stages III and IV POP reported persistent urge symptoms. 5.84% of the study group who showed no urge symptoms preoperatively, experienced de novo urge symptoms after following surgery (p < 0.005).

CONCLUSIONS

Cystocele repair cured urge symptoms in the majority of patients. Therefore, repair of bladder prolapse may help to differentiate urge symptoms from other urinary tract dysfunctions and assist in determining a proper diagnosis and treatment. However, the severity of POP had no significant influence on the improvement in urge symptoms following cystocele repair. Risk of de novo urge symptoms after anatomical repair still needs to be explored.

Association of Overactive Bladder With Hypertension and Blood Pressure Control: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

The sudden urge to urinate, also known as overactive bladder (OAB), may reflect higher sympathetic activity and associate with higher blood pressure (BP).

METHODS

This cross-sectional analysis utilized data from sixth follow-up exam (2015-2016) of Multi-Ethnic Study of Atherosclerosis to examine the association of OAB with systolic (SBP) and diastolic blood pressure (DBP) levels, hypertension, and BP control. Information on urinary symptoms was obtained with the International Consultation on Incontinence Questionnaire (ICIQ). Sex-stratified regression models were constructed to examine differences in BP, hypertension prevalence, and BP control while adjusting for demographic factors, comorbidities, and medication use.

RESULTS

Among the 1,446 men and 1,628 women who completed the ICIQ (mean age 73.7 years [SD 8.4]), OAB was present in 31.6% of men and 38.9% of women. With no antihypertensive medication use, OAB was not associated with SBP or DBP in both men and women after adjusting for covariates. However, among the 894 men and 981 women on antihypertensive medication, OAB was associated with higher SBP among men (4.04 mm Hg; 95% confidence interval [CI] 1.02, 7.06) but not among women (-0.67 mm Hg; 95% CI -3.79, 2.46) while DBP did not differ by OAB presence in men or women. In addition, OAB was also associated with lower odds of BP control among men (odds ratio [OR] 0.69; 95% CI 0.49, 0.96) but not women (OR 0.96; 95% CI 0.71, 1.30).

CONCLUSIONS

Among men, OAB is associated with lower odds of BP control which suggests that OAB may impede hypertension management.

The Bladder at Night during Hospitalisation: Towards optimal care for elderly patients with nocturia

OBJECTIVE

This study aimed to describe the characteristics of nocturia in older hospitalised patients and to explore knowledge, beliefs and experiences associated with night toileting while in hospital in order to identify unmet care needs.

METHODS

A multisite mixed methods cross-sectional study of older hospitalised adults who were admitted for ≥2 days was conducted using a standardised researcher-administered questionnaire. An additional cohort 16 older hospitalised adults with nocturia >twice per night were interviewed to understand the experience and impact of nocturia during hospitalisation.

RESULTS

Nocturia was experienced by 260 out of 308 participants. In-hospital nocturia was significantly correlated with nocturia in the month preceding admission, high diurnal voiding frequency and nocturnal urinary urgency. Bother was attributed to multiple nocturia episodes. Participants had poor knowledge and understanding of nocturia and believed the symptom to be a normal occurrence; only 20% had discussed management with staff. Disrupted sleep and fear of falling were common in older immobile participants with nocturia.

CONCLUSION

Nocturia is highly prevalent in hospitalised older people. Toileting multiple times at night bothers patients, disrupts sleep, heightens a fear of falling yet is rarely addressed in ward management plans. A screening process to identify, assess, provide education and intervene for nocturia has the potential to improve wellbeing, safety at night and to address risk factors.

Hip and Pelvic Floor Muscle Strength in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

Background

Urgency and frequency are common lower urinary tract symptoms (UF-LUTS) in women. There is limited evidence to guide physical therapist-led treatment.

Objectives

To compare hip and pelvic floor muscle strength between women with and without UF-LUTS. We hypothesized women with UF-LUTS would demonstrate 1) diminished hip external rotator and abductor strength and 2) equivalent pelvic floor strength and diminished endurance compared to controls.

Study Design

A matched case-control study.

Methods

Women with UF-LUTS (cases) and controls were matched on age, body mass index (BMI), vaginal parity. Examiner measured participants' 1) hip external rotator and abductor strength via dynamometry (maximum voluntary effort against fixed resistance) and 2) pelvic floor muscle strength (peak squeeze pressure) and endurance (squeeze pressure over a 10 second hold) via vaginal manometry. Values compared between cases and controls with paired-sample t-tests (hip) or Wilcoxon signed rank tests (pelvic floor).

Results

21 pairs (42 women): Hip external rotation (67.0 ± 19.0 N vs 83.6 ± 21.5 N; P=0.005) and hip abduction strength (163.1 ± 48.1 N vs 190.1 ± 53.1 N; P=0.04) were significantly lower in cases than controls. There was no significant difference in pelvic floor strength (36.8 ± 19.9 cmH₂0 vs 41.8 ± 21.0 cmH₂0; P=0.40) or endurance (234.0 ± 149.6 cmH₂0*seconds vs 273.4 ± 149.1 cmH₂0*seconds; P=0.24).

Conclusion

Women with UF-LUTS had weaker hip external rotator and abductor muscles, but similar pelvic floor strength and endurance compared to controls. Hip strength may be important to assess in patients with UF-LUTS, further research is needed.

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.

Cardiovascular safety of vibegron, a new β3-adrenoceptor agonist, in older patients with overactive bladder: Post-hoc analysis of a randomized, placebo-controlled, double-blind comparative phase 3 study

AIMS

To examine the safety and efficacy of vibegron, a new β3-adrenoceptor agonist, in patients aged ≥65 years, with a focus on the effects on cardiovascular system and overactive bladder (OAB) symptoms.

METHODS

A post-hoc subgroup analysis was performed of a randomized, placebo-controlled, double-blind comparative phase 3 study of vibegron, including those assigned to receive either vibegron 50 mg (V50), vibegron 100 mg (V100), or placebo for 12 weeks. Subjects were stratified into two subgroups based on age: a <65-year subgroup and a ≥65-year subgroup. Safety (changes in systolic and diastolic blood pressure, pulse rate, and residual urine volume) and efficacy (changes in the numbers of micturitions, urgency episodes, urgency urinary incontinence [UUI] episodes, and the voided volume/micturition) were assessed in the subgroups treated with vibegron vs. placebo.

RESULTS

There were no significant differences in the cardiovascular outcomes (blood pressure and pulse rate), nor in the changes in residual urine volume, between the V50/100 and placebo groups in the <65-year or ≥65-year subgroup after 12-week treatment. Adverse events were slightly increased in the ≥65-year subgroup. In the efficacy analysis, V50/100 demonstrated similar efficacy in the <65-year and ≥65-year subgroups; an increasing trend in the voided volume/micturition was observed in subjects aged ≥65 years compared to subjects aged <65 years.

CONCLUSIONS

Vibegron was suggested to be similarly effective in patients ≥65 and <65 years and to have minimal influence on cardiovascular parameters.

Effects of intravesical prostaglandin E2 on bladder function are preserved in capsaicin-desensitized rats

Prostaglandin E2 (PGE2) instilled into the bladder generates symptoms of urinary urgency in healthy women and reduces bladder capacity and urethral pressure in both humans and female rats. Systemic capsaicin desensitization, which causes degeneration of C-fibers, prevented PGE2-mediated reductions in bladder capacity, suggesting that PGE2 acts as an irritant (Maggi CA, Giuliani S, Conte B, Furio M, Santicioli P, Meli P, Gragnani L, Meli A. Eur J Pharmacol 145: 105-112, 1988). In the present study, we instilled PGE2 in female rats after capsaicin desensitization but without the hypogastric nerve transection that was conducted in the Maggi et al. study. One week after capsaicin injection (125 mg/kg sc), rats underwent cystometric and urethral perfusion testing under urethane anesthesia with saline and 100 µM PGE2. Similar to naïve rats, capsaicin-desensitized rats exhibited a reduction in bladder capacity from 1.23 ± 0.08 mL to 0.70 ± 0.10 mL (P = 0.002, n = 9), a reduction in urethral perfusion pressure from 19.3 ± 2.1 cmH2O to 10.9 ± 1.2 cmH2O (P = 0.004, n = 9), and a reduction in bladder compliance from 0.13 ± 0.020 mL/cmH2O to 0.090 ± 0.014 mL/cmH2O (P = 0.011, n = 9). Thus, changes in bladder function following the instillation of PGE2 were not dependent on capsaicin-sensitive pathways. Further, these results suggest that urethral relaxation/weakness and/or increased detrusor pressure as a result of decreased compliance may contribute to urinary urgency and highlight potential targets for new therapies for overactive bladder.

Do Older Adults with Overactive Bladder Demonstrate Impaired Executive Function Compared to Their Peers Without OAB?

Background

Maintaining urinary continence is not an automatic process, but relies on continuous processing of sensory signals from the bladder and suppression of the desire to void. Urinary incontinence (UI) and lower urinary tract symptoms (LUTS), including urinary urgency, frequency, and nocturia are highly prevalent among the general population. This prevalence rises in association with increasing age, and this may be in part due to changes in the central nervous system rather than the urinary tract. The aim of this study was to assess if older adults with overactive bladder (OAB) had demonstrable impairment in executive function.

Methods

This was a cross-sectional study comparing the performance of adults aged 65 and over with and without OAB on two cognitive tests, the Trail Making Test B (TMT-B) and simple reaction time (SRT). OAB was defined as urgency, with at least weekly urgency incontinence and a daytime urinary frequency of 8 or more. The control group were defined as a Bladder control Self-Assessment Questionnaire (B-SAQ) score of ≤4.

Results

56 participants were recruited, of whom 35 met criteria for OAB. The OAB group took significantly longer to complete the TMT-B than the control group (103s vs. 77s, p = .003). There was no difference in the SRT.

Conclusions

In this sample of older adults, OAB was associated with measurable slower performance on the TMT-B, suggesting that impaired executive function is associated with OAB.

Vaginal estrogen therapy is associated with increased Lactobacillus in the urine of postmenopausal women with overactive bladder symptoms

BACKGROUND

Previous work has shown that the vaginal microbiome decreases in Lactobacillus predominance and becomes more diverse after menopause. It has also been shown that estrogen therapy restores Lactobacillus dominance in the vagina and that topical estrogen is associated with overactive bladder symptom improvement. We now know that the bladder contains a unique microbiome and that increased bladder microbiome diversity is associated with overactive bladder. However, there is no understanding of how quickly each pelvic floor microbiome responds to estrogen or if those changes are associated with symptom improvement.

OBJECTIVE

This study aimed to determine if estrogen treatment of postmenopausal women with overactive bladder decreases urobiome diversity.

STUDY DESIGN

We analyzed data from postmenopausal participants in 2 trials (NCT02524769 and NCT02835846) who chose vaginal estrogen as the primary overactive bladder treatment and used 0.5 g of conjugated estrogen (Premarin cream; Pfizer, New York City, NY) twice weekly for 12 weeks. Baseline and 12-week follow-up data included the Overactive Bladder questionnaire, and participants provided urine samples via catheter, vaginal swabs, perineal swabs, and voided urine samples. Microbes were detected by an enhanced culture protocol. Linear mixed models were used to estimate microbiome changes over time. Urinary antimicrobial peptide activity was assessed by a bacterial growth inhibition assay and correlated with relative abundance of members of the urobiome.

RESULTS

In this study, 12 weeks of estrogen treatment resulted in decreased microbial diversity within the vagina (Shannon, P=.047; Richness, P=.043) but not in the other niches. A significant increase in Lactobacillus was detected in the bladder (P=.037) but not in the vagina (P=.33), perineum (P=.56), or voided urine (P=.28). The change in Lactobacillus levels in the bladder was associated with modest changes in urgency incontinence symptoms (P=.02). The relative abundance of the genus Corynebacterium correlated positively with urinary antimicrobial peptide activity after estrogen treatment.

CONCLUSION

Estrogen therapy may change the microbiome of different pelvic floor niches. The vagina begins to decrease in diversity, and the bladder experiences a significant increase in Lactobacillus levels; the latter is correlated with a modest improvement in the symptom severity subscale of the Overactive Bladder questionnaire.

Management of urinary incontinence

Urinary incontinence is a common problem affecting 25-45% women. Effective management can have a huge impact on a patient's quality of life and many treatments are available. Management should be dictated by the degree of bother the symptoms are having, and vary depending on the type on incontinence. Conservative measures should always be initiated, including optimisation of body mass index and smoking cessation. Overactive bladder and urge urinary incontinence can be improved with bladder retraining and avoidance of bladder stimulants. Medical treatment then includes anticholinergic medications or Mirabegron. More invasive options include Botulinum Toxin A (Botox®) injections, sacral nerve stimulation or urological surgery. Stress urinary incontinence should be managed initially with pelvic floor exercises, and input from a specialist nurse or physiotherapist is beneficial. The surgical options for managing stress incontinence have changed considerably over the years, but include bladder neck injections, mid-urethral slings, colposuspension or autologous fascial slings. Mixed urinary incontinence is more challenging to manage, but all conservative measures should be started. Further treatment is directed towards the predominant symptom, but overactivity should be controlled before surgical measures for stress urinary incontinence are performed.

Enduring impact of childhood adversity on lower urinary tract symptoms in adult women

AIMS

To determine whether childhood adversity is associated with self-reported lower urinary tract symptoms (LUTS) among older adult women.

METHODS

A convenience sample of women (≥55 years old) who presented to an academic urology practice or who had participated in a previous bladder health prevention study completed questionnaires including the LUTS Tool (on frequency and bother of LUTS), the Adverse Childhood Experiences (ACEs) Questionnaire, the Spielberger State-Trait Anxiety Inventory, and the Center for Epidemiologic Studies Depression Scale.

RESULTS

The average age (SD) of participants (N = 151) was 64.7 (6.9) years. The total number of ACEs predicted the total number of LUTS, β = .39 (95% confidence interval [CI] = 0.14, 0.64), P = .003, as well as LUTS frequency, β = .09 (95% CI = 0.04, 0.13), P < .001. ACEs predicted bother for nocturia, β = 0.12 (95% CI = 0.03, 0.22), P = .008. Negative affect symptoms did not mediate the relationship between the total number of ACEs and the total number of LUTS. Rather, ACEs predicted LUTS and negative affect symptoms through (at least partially) independent pathways. Analyses controlled for tobacco use, number of vaginal deliveries, hypertension, overactive bladder medication use, body mass index, income, and race because these variables were significantly associated with the total number of ACEs or total number of LUTS.

CONCLUSIONS

Childhood adversity has an enduring impact on risk for LUTS in adulthood even when controlling for potential confounds and this relationship cannot be explained by negative affect symptoms.

Evaluating the safety and potential activity of URO-902 (hMaxi-K) gene transfer by intravesical instillation or direct injection into the bladder wall in female participants with idiopathic (non-neurogenic) overactive bladder syndrome and detrusor overactivity from two double-blind, imbalanced, placebo-controlled randomized phase 1 trials

Aims

Two phase 1 trials were performed in healthy women with the overactive bladder (OAB) syndrome and urodynamically demonstrated detrusor overactivity (DO), with the aim to demonstrate the safety and potential efficacy of URO‐902, which comprises a gene therapy plasmid vector expressing the human big potassium channel α subunit.

Methods

ION‐02 (intravesical instillation) and ION‐03 (direct injection) were double‐blind, placebo‐controlled, multicenter studies without overlap in enrollment between studies. Active doses were administered and evaluated sequentially (lowest dose first) for safety. ION‐02 participants received either 5000 µg or 10 000 µg URO‐902, or placebo. ION‐03 participants received either 16 000 or 24 000 µg URO‐902, or placebo, injected directly into the bladder wall using cystoscopy. Primary outcome variables were safety parameters occurring subsequent to URO‐902 administration; secondary efficacy variables also were evaluated.

Results

Among the safety outcomes, there were no dose‐limiting toxicities or significant adverse events (AEs) preventing dose escalation during either trial, and no participants withdrew due to AEs. For efficacy, in ION‐02 (N = 21), involuntary detrusor contractions on urodynamics at 24 weeks in patients receiving URO‐902 (P < .0508 vs placebo) and mean urgency incontinence episodes in the 5000 µg group (P = .0812 vs placebo) each showed a downward trend. In ION‐03 (N = 13), significant reduction versus placebo in urgency episodes (16 000 µg, P = .036; 24 000 µg, P = .046) and number of voids (16 000 µg, −2.16, P = .044; 24 000 µg, −2.73, P = .047) were observed 1 week after injection.

Conclusion

Promising safety and efficacy results in these preliminary phase 1 studies suggest gene transfer may be a promising therapy for OAB/DO, warranting further investigation.

Association between urinary urgency and falls among rural dwelling older women

AIM

To examine the association between urinary urgency and falls in older women living in rural areas in South Korea.

DESIGN

A secondary analysis was conducted using cross-sectional data.

METHODS

This study used dataset obtained from 246 women aged 65 years or older living in 15 rural mountain communities in South Korea between February 2016-March 2016. Falls were measured by self-reports including the number, location, reasons of falls during the past year. Frequency of urinary urgency and nocturia were assessed by self-reports. Covariates included age, body mass index, self-reported health problems. Mixed-effects negative binomial regression was used to analyse the association between urinary urgency and the number of falls.

RESULTS

The mean age of the 246 women was 77.3 years. Among the sample, 30.1% experienced at least one fall in the past year and 16% had required hospital treatments. The analysis showed that urinary urgency and osteoporosis were significantly associated with a greater number of falls after adjusting for other covariates. Among those who had experienced falls, nearly 60% reported that the reasons for falls were environmental factors, such as slippery floors or uneven sidewalks/thresholds.

CONCLUSION

Improving urinary urgency may be a strategy to decrease the fall risk in older women. Accordingly, community nurses can provide intervention programs on lifestyle and behavioural changes such as bladder training, dietary modification and pelvic floor muscle training. Interventions for fall prevention need to be developed while considering the unique features of indoor and outdoor environments.

IMPACT

The findings have implications for healthcare providers and policy makers with regard to the development of safer indoor and outdoor environments for older women living in rural areas by remodelling their residential spaces and neighbourhoods. In addition, more prospective studies using larger samples are needed to investigate the causal mechanism between urinary urgency and falls.

Does successful treatment of overactive bladder improve co-morbidities in patients with nocturia?

OBJECTIVE

To investigate whether treatment of overactive bladder (OAB), one comorbidity of nocturia, could reduce waking to void and improve other co-existing symptoms.

METHODS

A prospective cohort study was conducted at Royal Melbourne Hospital. Participants received 12 weeks of standard treatment, including lifestyle interventions and pharmacotherapy. Outcome measures were nocturia episodes, severity of urinary urgency/incontinence, sleep quality, daytime somnolence, anxiety and depression scores, quality of life and change in blood pressure.

RESULTS

Twenty participants completed the study. Nocturia frequency improved by one void per night. Overactive Bladder Symptom Score, sleep quality, first uninterrupted sleep time and systolic blood pressures improved. There were no significant changes in daytime somnolence, mood or quality of life.

CONCLUSIONS

In this pilot study, nocturia and other co-morbid dysfunctions appeared to improve when the severity of OAB was reduced. Treatment of OAB co-morbid with nocturia reduces urinary symptoms and may improve sleep parameters and positively impact return to health.

Urinary Urgency in Working Women: What Factors Are Associated with Urinary Urgency Progression?

BACKGROUND

Urinary urgency is the primary symptom of overactive bladder (OAB). This study aimed to identify targets for effective intervention to delay progression of urinary urgency.

MATERIAL AND METHODS

Secondary analyses of data from a study conducted with female employees of a large academic medical center were conducted. Women were ≥18 years and nonpregnant at the time of the survey. An online questionnaire obtained demographic information, presence of lower urinary tract symptoms, and toileting behaviors. Bivariate analyses and multivariate logistic regression were applied to explore factors related to different stages of urinary urgency.

RESULTS

Four stages of urinary urgency were constructed: (1) Stage 1: no urinary symptoms (n = 20), (2) Stage 2: continent but urinary urgency reported (n = 19), (3) Stage 3: nonsevere urgency urinary incontinence (UUI) (incontinent but leakage ≤1/day, n = 74); and (4) Stage 4: severe UUI (leakage ≥1/day, n = 26). In multivariate analyses, older women were more likely to be in Stage 3 than in Stage 2 (aOR 1.053, 95% CI 1.012-1.096). Women who lost urine with defecation were more likely to be in Stage 4 than Stage 3 (aOR 3.828, 95% CI 1.921-7.629). Women who habitually strained to empty the bladder faster were more likely to be in Stage 4 than in Stage 3 (aOR 6.588, 95% CI 1.317-32.971).

CONCLUSIONS

Losing urine with defecation and making the bladder empty faster by pushing down should be explored as intervention targets to prevent women from progressing from Stage 3 to Stage 4.

OAB without an overactive bladder in the acute prostaglandin E2 rat model

Intravesical prostaglandin E2 (PGE2) was previously used to induce overactive bladder (OAB) symptoms, as it reduces bladder capacity in rats and causes a "strong urgency sensation" in healthy women. However, the mechanism by which this occurs is unclear. To clarify how PGE2 reduces bladder capacity, 100 µM PGE2 was administered intravesically during open, single-fill cystometry with simultaneous measurement of sphincter EMG in the urethane-anesthetized female Wistar rat. PGE2 was also applied to the urethra or bladder selectively by use of a ligature at the bladder neck before (urethra) or during (bladder) closed-outlet, single-fill cystometry. Additional tests of urethral perfusion with PGE2 were made. PGE2 decreased bladder capacity, increased voiding efficiency, and increased sphincter EMG during open cystometry compared with saline controls. The number of nonvoiding contractions did not change with PGE2; however, bladder compliance decreased. During closed-outlet cystometry, PGE2 applied only to the bladder or the urethra did not decrease bladder capacity. Urethral infusion of PGE2 decreased urethral perfusion pressure. Taken together, these results suggest that intravesical PGE2 may decrease bladder capacity by targeting afferents in the proximal urethra. This may occur through urethral relaxation and decreased bladder compliance, both of which may increase activation of proximal urethra afferents from distension of the proximal urethra. This hypothesis stands in contrast to many hypotheses of urgency that focus on bladder dysfunction as the primary cause of OAB symptoms. Targeting the urethra, particularly urethral smooth muscle, may be a promising avenue for the design of drugs and devices to treat OAB.

The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda

BACKGROUND

There is a well-recognised association between falls and lower urinary tract symptoms (LUTS) in older adults, with estimates of odd ratios for falls in the presence of LUTS ranging between 1.5 and 2.3. Falls and LUTS are both highly prevalent among older people and both are markers of frailty, with significant associated morbidity, mortality, and healthcare resource cost. This association is not well examined or explained in the literature.

AIMS

We aimed to outline current knowledge of the association between falls and lower urinary tract symptoms and suggest a research program to further investigate this.

MATERIALS AND METHODS

A consensus conference of experts in the field was convened to review the current literature and brainstorm potential future investigative avenues.

RESULTS AND DISCUSSION

Despite the recognition of this association, there has been little research to examine its potential causes, and no intervention trial has established if reducing LUTS or urinary incontinence can reduce the risk of falls. The commonly held assumption that urgency causes falls through rushing to the toilet is likely incorrect. Falls and LUTS are both symptoms of frailty and have many common causes. Gait, balance, and continence are all processes requiring cognitive input, and the concept of dual tasking may be a further link.

CONCLUSION

The significant association between lower urinary tract symptoms and falls is currently unexplained, and further research into the potential causes of this association is needed.

Rotigotine Effects on Bladder Function in Patients with Parkinson's Disease

Background

The objective of this study was to assess the effect of rotigotine treatment on bladder function in patients with Parkinson's disease (PD) who have urinary urgency.

Methods

in total, 20 patients with PD underwent urodynamic evaluation and completed International Prostate Symptoms questionnaires in off-rotigotine condition and after 3 months of rotigotine patch monotherapy administration. In both sessions, clinical motor condition was evaluated with the Unified Parkinson Disease Rating Scale, Part III (motor part).

Results

Rotigotine administration significantly ameliorated the first sensation of bladder filling, the neurogenic detrusor overactive contractions threshold and bladder capacity compared with the off-treatment condition. Moreover, the total score on the International Prostate Symptoms questionnaire revealed a decrease of filling (irritative) symptoms after rotigotine treatment compared with the off-treatment condition.

Conclusion

The positive effects of rotigotine may be due to its balanced agonism to D1 and D2 receptors and in particular to its stimulation of D1 receptors in the anterior cingulate cortex and insula, which are known as areas involved in bladder-inhibitory functions.

Non-invasive characterization of real-time bladder sensation using accelerated hydration and a novel sensation meter: An initial experience

AIMS

The purpose of this investigation was to develop a non-invasive, objective, and unprompted method to characterize real-time bladder sensation.

METHODS

Volunteers with and without overactive bladder (OAB) were prospectively enrolled in a preliminary accelerated hydration study. Participants drank 2L Gatorade-G2® and recorded real-time sensation (0-100% scale) and standardized verbal sensory thresholds using a novel, touch-screen "sensation meter." 3D bladder ultrasound images were recorded throughout fillings for a subset of participants. Sensation data were recorded for two consecutive complete fill-void cycles.

RESULTS

Data from 14 normal and 12 OAB participants were obtained (ICIq-OAB-5a = 0 vs. ≥3). Filling duration decreased in fill2 compared to fill1, but volume did not significantly change. In normals, adjacent verbal sensory thresholds (within fill) showed no overlap, and identical thresholds (between fill) were similar, demonstrating effective differentiation between degrees of %bladder capacity. In OAB, within-fill overlaps and between-fill differences were identified. Real-time %capacity-sensation curves left shifted from fill1 to fill2 in normals, consistent with expected viscoelastic behavior, but unexpectedly right shifted in OAB. 3D ultrasound volume data showed that fill rates started slowly and ramped up with variable end points.

CONCLUSIONS

This study establishes a non-invasive means to evaluate real-time bladder sensation using a two-fill accelerated hydration protocol and a sensation meter. Verbal thresholds were inconsistent in OAB, and the right shift in OAB %capacity-sensation curve suggests potential biomechanical and/or sensitization changes. This methodology could be used to gain valuable information on different forms of OAB in a completely non-invasive way.

Overactive bladder

Overactive bladder syndrome is highly prevalent, and increasingly so with aging. It is characterized by the presence of urinary urgency, and can be associated with incontinence, increased voiding frequency, and nocturia. Assessment needs to exclude serious medical disorders that might present with similar symptoms, and a bladder diary is an invaluable part of understanding the presentation. Initial management is conservative, comprising education, bladder training, and advice on fluid intake. Drug therapy options include antimuscarinic medications and beta-3 adrenergic receptor agonists. Persistent overactive bladder syndrome, despite initial therapy, requires a review of the patient’s understanding of conservative management and compliance, and adjustment of medications. For refractory cases, specialist review and urodynamic testing should be considered; this may identify detrusor overactivity or increased filling sensation, and needs to exclude additional factors, such as stress incontinence and voiding dysfunction. Botulinum neurotoxin-A bladder injections can be used in severe overactivity, provided the patient is able and willing to do intermittent self-catheterisation, which is necessary in about 5% of treated patients. Sacral nerve stimulation and tibial nerve stimulation are other approaches. Major reconstructive surgery, such as augmentation cystoplasty, is rarely undertaken in modern practice but remains a possibility in extreme cases.

Clinical use of the β3 adrenoceptor agonist mirabegron in patients with overactive bladder syndrome

Mirabegron is a β3 adrenoceptor agonist licensed for the treatment of overactive bladder symptoms, such as urinary urgency or urgency incontinence. β3 adrenoceptor activation causes detrusor muscle relaxation, but mirabegron may also act by binding other targets in the bladder, and it may also reduce activity in sensory nerves. Phase III clinical trials (SCORPIO, ARIES, and CAPRICORN) evaluated mirabegron at various doses, demonstrating reduction from baseline to endpoint in mean incontinence episodes and mean number of micturitions per 24 h (coprimary endpoints), along with health-related quality of life and a range of secondary measures. Efficacy was seen in many patients who had previously discontinued antimuscarinic therapy on the grounds of lack of efficacy or poor tolerability. Treatment emergent adverse effects were documented in a long-term study (TAURUS), mostly being of mild or moderate severity. The most frequent adverse effects were hypertension, dry mouth, constipation, and headache, with a lower incidence of dry mouth than for the antimuscarinic active comparator. Efficacy and safety are not substantially different in older patients. A urodynamic safety study in men showed no consistent effect on voiding function, but a small increase in postvoid residual. Use of mirabegron in combination with α-adrenergic blockers does not appear to increase adverse effects. Dose reduction is needed in people with severe renal failure, or moderate hepatic failure. Dose adjustment is not needed in relation to food intake. Ongoing research is evaluating the potential for combination therapy with antimuscarinics.

α-adrenergic blockers for the treatment of lower-urinary-tract symptoms and dysfunction in women

OBJECTIVE

To evaluate the efficacy and safety of α-adrenergic blockers in the treatment of female lower-urinary-tract symptoms and dysfunction.

DATA SOURCES

Literature searches were conducted using EMBASE (1974 to January 2014), International Pharmaceutical Abstracts (1970 to January 2014), and MEDLINE (1946 to January 2014) to identify clinical trials evaluating the effects of α-adrenergic blockers in the treatment of women with lower-urinary-tract dysfunction. Bibliographies from relevant research articles were also reviewed for inclusion.

STUDY SELECTION AND DATA EXTRACTION

All original research articles available in the English language were identified from the data sources. Primary literature evaluating outcomes related to urinary dysfunction and associated symptoms in women were included in this review. Articles describing the use of α-adrenergic blockers in other medical conditions or in men were excluded.

DATA SYNTHESIS

A total of 15 clinical studies were identified and evaluated. Many studies showed an improvement in female lower-urinary-tract symptoms and dysfunction using α-adrenergic blockers. Most studies also reported adverse drug events of α-adrenergic blockers such as dizziness and hypotension. However, limitations of the studies conducted to date include small sample sizes, inconsistent study designs, and short duration of therapy.

CONCLUSIONS

The role of α-adrenergic blockers in the treatment of urinary dysfunction and associated symptoms in women remains unclear. The majority of evidence suggests that these agents may have a place in therapy for female lower-urinary-tract symptoms and/or bladder outlet obstruction; however, data are conflicting. Clinicians should be aware of the potential clinical benefits but also recognize the potential adverse drug effects of α-adrenergic blockers.

Self-induced plantar-flexion objectively reduces wave amplitude of detrusor overactivity and subjectively improve urinary urgency: a pilot study

AIMS

To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO).

METHODS

Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS).

RESULTS

The mean peak detrusor pressure without plantar-flexion was 58 cmH2 O (95% CI: 46.3-69.7) compared to 31 cmH2 O (95% CI: 23.1-38.9) with plantar-flexion (P < 0.001). All patients reported a reduced degree of urgency during plantar-flexion reflected in a significant reduction in mean VAS score from 9.3 (95% CI: 9-9.5) to 4.7 (95% CI: 3.9-5.4; P < 0.0001).

CONCLUSIONS

Self-performed plantar-flexion maneuver might reduce the severity of urinary urgency and the magnitude of overactive detrusor contractions, which may have a role in the conservative therapy of detrusor overactivity.

Oxybutynin topical gel in the treatment of overactive bladder

Overactive bladder (OAB), often accompanied by urinary incontinence, is most prevalent among the elderly, but also affects many middle-aged men and women in the US. OAB may severely impair quality of life, and its overall economic costs to society are substantial. Although antimuscarinic agents relieve OAB symptoms effectively, treatment persistence generally is low. This has been attributed in part to the occurrence of dry mouth and other anticholinergic adverse events. High plasma concentrations of N-desethyloxybutynin (DEO), an active metabolite of oxybutynin, have been identified as the major cause of anticholinergic adverse effects associated with oral oxybutynin. Transdermal formulations of oxybutynin generate much lower DEO plasma concentrations compared with oral formulations. In a placebo-controlled US Phase III study in patients with OAB, the recently approved oxybutynin topical gel (OTG) was efficacious and well tolerated. Dry mouth occurred in 6.9% of patients treated with OTG and 2.8% of patients on placebo. Incidences of other anticholinergic events were low and similar for OTG and placebo. OTG rarely caused application site skin reactions. OTG provides significant benefits to patients with OAB, particularly those who are sensitive to anticholinergic adverse effects.