How does the lower urinary tract contribute to bladder sensation? ICI-RS 2023

AIM

Bladder sensation is critical for coordinating voluntary micturition to maintain healthy bladder function. Sensations are initiated by the activation of sensory afferents that innervate throughout the bladder wall. However, the physiological complexity that underlies the initiation of bladder sensory signaling in health and disease remains poorly understood. This review summarises the latest knowledge of the mechanisms underlying the generation of bladder sensation and identifies key areas for future research.

METHODS

Experts in bladder sensory signaling reviewed the literature on how the lower urinary tract contributes to bladder sensation and identified key research areas for discussion at the 10th International Consultation on Incontinence-Research Society.

RESULTS

The importance of bladder sensory signals in maintaining healthy bladder function is well established. However, better therapeutic management of bladder disorders with exaggerated bladder sensation, including overactive bladder syndrome (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS) is limited by a lack of knowledge in a number of key research areas including; the contribution of different nerves (pudendal, pelvic, hypogastric) to filling sensations in health and disease; the relative contribution of stretch sensitive (muscular) and stretch-insensitive (mucosal) afferents to bladder sensation in health and disease; the direct and indirect contributions of the muscularis mucosae to bladder contraction and sensation; and the impact of manipulating urothelial release factors on bladder sensation.

CONCLUSION

Disturbances in bladder sensory signaling can have severe consequences for bladder sensation and function including the development of OAB and IC/BPS. Advancing therapeutic treatments for OAB and IC/BPS requires a deeper understanding of the mechanisms underlying the generation of bladder sensation, and key areas for future research have been identified.

Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013

BACKGROUND

Evidence-based guidelines for the management of neurological disease and lower bowel dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance.

AIMS

To update clinical management of neurogenic bowel dysfunction from the recommendations of the 4th ICI, 2009.

MATERIALS AND METHODS

A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and modifications applied to deliver evidence based conclusions and recommendations for the scientific report of the 5th edition of the ICI in 2013.

RESULTS

The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic bowel dysfunction. The pathophysiology is described in terms of spinal cord injury, multiple sclerosis, and Parkinson's disease. Assessment requires detailed history and clinical assessment, general investigations, and specialized testing, if required. Treatment primarily focuses on optimizing stool consistency and regulating bowel evacuation to improve quality of life. Symptom management covers conservative and interventional measures to promote good habits and assist stool evacuation, along with prevention of incontinence. Education is essential to achieving optimal bowel management.

DISCUSSION

The review offers a pragmatic approach to management in the context of complex pathophysiology and varied evidence base.

Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence?

Overactive bladder and urgency incontinence are common and distressing conditions in older people, for which the first-line pharmacological treatment is a bladder antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first-line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first-line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in particular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people.

Flexible dosing with fesoterodine 4 and 8 mg: a systematic review of data from clinical trials

AIMS

To systematically review dose-escalation data from flexible-dose studies of fesoterodine and summarise factors associated with dose-escalation decisions.

METHODS

A PubMed search was conducted using the terms (fesoterodine AND flexible dose), with no limits. Articles were included if they contained fesoterodine dose-escalation data for efficacy or safety outcomes or factors associated with dose-escalation decisions.

RESULTS

Of 13 articles identified by the search, 10 articles (six clinical studies) met inclusion criteria. In flexible-dose trials of fesoterodine, 51-63% of subjects initially receiving fesoterodine 4 mg opted for dose escalation to fesoterodine 8 mg. Escalators generally reported significantly more severe overactive bladder (OAB) symptoms, greater OAB symptom bother and worse health-related quality of life at baseline than non-escalators. Escalators demonstrated less treatment benefit with fesoterodine 4 mg than non-escalators. Non-escalators generally had a higher rate of dry mouth and constipation with fesoterodine 4 mg than escalators. The decision to escalate appeared to be determined by the efficacy/tolerability responses; fesoterodine escalators demonstrated a lower sensitivity (less efficacy and fewer adverse events) before their decision to escalate. By study end (8-11 weeks after escalation decision), the efficacy and tolerability profiles were similar in escalators and non-escalators.

CONCLUSIONS

Data from flexible-dose studies provide strong evidence that fesoterodine provides treatment benefit to individual subjects with OAB because of its true dose-response effect. In clinical practice, it can be worthwhile to escalate to fesoterodine 8 mg in individual subjects who require additional efficacy benefit.

Development and psychometric evaluation of a dutch questionnaire for the assessment of anorectal and lower urinary tract symptoms

BACKGROUND AND STUDY AIMS

Epidemiological studies have shown a frequent coexistence of symptoms and diseases affecting the anorectum and lower urinary tract. To further investigate combined symptoms and pathology of both pelvic viscera we developed a self-reported questionnaire, in Dutch, which extensively evaluates habits, complaints and symptoms of both viscera. We describe the construction and the psychometric properties of this questionnaire.

PATIENTS AND METHODS

This prospective study was conducted in 56 patients with anorectal symptoms, 41 patients with lower urinary tract symptoms and in a control group of 91 people. The following psychometric properties of the questionnaire were evaluated: content validity, construct validity, criterion validity, test-retest reliability and internal consistency.

RESULTS

The questionnaire covered all important domains, was well interpreted and showed good acceptability (content validity). The questionnaire clearly differentiated the patient populations (construct validity). The criterion validity of the questionnaire was excellent. The test-retest reliability of the questionnaire was acceptable in all three the study populations (overall median kappa: 0.64; Inter Quartile Range: 0.56-0.75; mean agreement: 88%). The internal consistency of both anorectal and lower urinary tract symptom questions was high (Crohnbach's alpha of 0.78 and 0.80 respectively).

CONCLUSIONS

This questionnaire is a valid and reliable instrument for the assessment of anorectal and lower urinary tract symptoms. It can provide further insights into the epidemiology of concomitant bowel and bladder disorders and, accordingly, can contribute to a more efficient diagnostic and therapeutic approach in patients with such disorders.

Neurological patients need evidence-based urological care

AIMS

To report the conclusion of the Think Thank on Neurourology discussions during the first ICI-RS meeting in 2009.

METHODS

During a 3-day meeting a group of specialists discussed evidence-based medicine in neurourology and made suggestions for future research.

RESULTS

In the vast majority of patients with neurological disease bladder dysfunction occurs. The actual rules of diagnosis and treatment lack a study related evidence base. From a long list of possible research subjects, prevalence, detrusor pressure, imaging, catheterization and surgery have been first discussed.

CONCLUSION

In each of these subjects, research items are suggested which can help to improve the care in this patient group.