The female urethra: urethral function throughout a woman's lifetime

INTRODUCTION AND HYPOTHESIS

The objective of this narrative review is to describe changes in urethral function that occur during a woman's lifetime. Evaluation of urethral function includes measurements of urethral closure pressure, at rest and during stress, leak point pressure, and the detailed study of anatomical and histological changes of the urethral sphincteric mechanism.

METHODS

A literature search in MEDLINE, PubMed, and relevant journals from 1960 until 2020 was performed for articles dealing with urethral function and the impact of aging, pregnancy, and childbirth, female hormones, and menopausal transition on the urethral sphincteric mechanism. Longitudinal and cross-sectional epidemiological surveys, studies on histological changes in urethral anatomy during aging, and urodynamic data obtained at different points in a woman's lifetime, during pregnancy, after childbirth, as well as the effects of female hormones on urethral sphincter function are reviewed. Relevant studies presenting objective data are analyzed and briefly summarized.

RESULTS AND CONCLUSIONS

The findings lead one to conclude that a constitutional or genetic predisposition, aging, and senescence are the most prominent etiological factors in the development of urinary incontinence and other pelvic floor disorders. Vaginal childbirth dilates and may damage the compressed pelvic supportive tissues and is invariably associated with a decline in urethral sphincter function. Pregnancy, hormonal alterations, menopausal transition, weight gain, and obesity are at best of secondary influence on the pathology of lower urinary tract dysfunction. The decline of circulating estrogens during menopausal transition may play a role in the transition of fibroblasts to cellular senescence.

A prospective, randomized trial comparing intravesical dimethyl sulfoxide (DMSO) to bupivacaine, triamcinolone, and heparin (BTH), for newly diagnosed interstitial cystitis/painful bladder syndrome (IC/PBS)

INTRODUCTION AND HYPOTHESIS

The primary aim of this study was to compare the effect of bladder instillations using dimethyl sulfoxide (DMSO) with triamcinolone versus bupivacaine, triamcinolone, and heparin (BTH) in women with newly diagnosed interstitial cystitis/painful bladder syndrome. The primary outcome was improvement in symptoms measured using the O'Leary-Sant Interstitial Cystitis Symptoms Index (ICSI) score. Secondary comparisons included changes in urinary frequency, nocturia, and bladder capacity.

MATERIALS AND METHODS

This was a prospective, randomized study. Patients with a recent diagnosis of interstitial cystitis/painful bladder syndrome (IC/PBS) were randomized 1:1 to treatment with either 6 weekly bladder instillations of DMSO with triamcinolone or BTH. During follow-up visits, patients completed the ICSI questionnaire, and bladder capacity was determined through the retrograde filling of the bladder. The χ² test or Student's t test were used for data analysis.

RESULTS

A total of 83 patients were randomized, and final analysis included 70 participants who completed the 6 weekly instillations (42 DMSO, 28 BTH). The groups were similar in baseline demographics and clinical characteristics, except for cystometric maximum capacity (DMSO 338.62± 139.44 mL, BTH 447.43 ± 180.38 mL, p = 0.01). In the DMSO group, 63% of patients had a greater than 29.5% reduction in total ICSI score versus 43% in the BTH group (p = 0.15). Nocturia and pain were significantly reduced in the DMSO group. There was a significant increase from baseline in bladder capacity for both groups.

CONCLUSION

In women with newly diagnosed IC/PBS, bladder instillations with DMSO and triamcinolone provide greater improvement in pain and nocturia compared to BTH.

Nocturia: A Highly Prevalent Disorder With Multifaceted Consequences

Nocturia is a bothersome, multifactorial condition with many underlying causes and contributing factors. Nocturnal polyuria (NP; overproduction of urine at night) is a frequent component. The prevalence of nocturia increases with age; specific estimates of prevalence are influenced by frequency thresholds used to define it. There is a tendency toward higher prevalence in young women than young men, which is reversed in later life. The association between frequency of nocturnal voiding and sleep disruption is well-documented. Nocturia correlates strongly with shorter sleep during the first part (2-4 hours) of the night, during which the first nocturnal void often occurs. A short time to first void after sleep onset (often referred to as "first uninterrupted sleep period") is associated with increased daytime dysfunction and decreased sleep quality and/or sleep efficiency. Adverse health consequences related to nocturia include poor sleep, depression, reduced quality of life, and increased risk of morbidity, mortality, falls, and fractures; studies have been able to establish a causal role for nocturia in only some of these. The potential impact of nocturia on health increases with age. By age 80, 80% of people will rise at least once per night to void. Despite its associated bother, nocturia is often accepted as a natural consequence of aging and many people do not seek help. Women, in particular, may be reluctant to report nocturia. This article reviews the prevalence of nocturia, possible impact on sleep, mortality and morbidity, and falls, and its importance in the elderly/frail population and women.

Vesico-ureteral reflux in women with idiopathic high-pressure detrusor overactivity: prevalence, bladder function, and effect on the upper urinary tract

INTRODUCTION AND HYPOTHESIS

To assess the prevalence of vesico-ureteral reflux (VUR) and upper urinary tract damage in women with idiopathic high-pressure detrusor overactivity (IHPDO) and to characterize their bladder function.

METHODS

A retrospective chart review of women diagnosed with IHPDO (detrusor pressures > 40 cm H2O during involuntary bladder contractions) from 2007 to 2010 was conducted. Women were assessed for VUR by X-ray voiding cysto-urethrogram. Renal ultrasound or CT urogram, serum BUN/creatinine, and urinalyses were performed if reflux reached the renal pelvices. Cystometric and voiding pressure study data were reviewed for detrusor overactivity pressure and volume, voiding dysfunction, urethral relaxation, compliance, and bladder outlet obstruction.

RESULTS

Sixty-five women were diagnosed with IHPDO, and 50 completed an X-ray voiding cysto-urethrogram. The median (range) detrusor overactivity pressure was 65 (41-251) cm H2O. Four (8.0%) women had IHPDO; none had upper urinary tract deterioration. The majority of women exhibited urethral relaxation with voiding, impaired compliance, and bladder outlet obstruction.

CONCLUSIONS

Women with IHPDO are at risk of low-grade vesico-ureteral reflux. However, most women with IHPDO are likely protected from reflux by intermittent exposure to high detrusor pressures and the ability to decompress the bladder by urethral relaxation.

Efficacy and safety of oxybutynin topical gel 3% in patients with urgency and/or mixed urinary incontinence: a randomized, double-blind, placebo-controlled study

AIMS

To assess the efficacy and safety of oxybutynin transdermal gel 3% (OTG3%), with propylene glycol for enhanced skin permeation, in patients with urinary incontinence (UI).

METHODS

In this phase 3 study, 626 patients ≥18 years old with urgency and/or mixed UI symptoms and predominantly urgency UI for ≥3 months were randomized 1:1:1 to receive 12 weeks of OTG3% 84 mg, OTG3% 56 mg, or placebo gel applied once daily to abdomen, inner/upper thigh, or upper arm/shoulder. Primary efficacy endpoint was change from baseline to Week 12 in weekly UI episodes recorded in 3-day bladder diaries. Results were compared using analysis of covariance. Adverse events (AEs) were monitored.

RESULTS

Efficacy was assessed in 601 (intent-to-treat) and safety in 626 patients. At 12 weeks, OTG3% 84 mg/day achieved significantly greater improvement versus placebo in weekly UI episodes (mean change from baseline: -20.4 vs. -18.1; P < 0.05(a)), daily urinary frequency (-2.6 vs. -1.9; P = 0.001(b)), and urinary void volume (32.7 vs. 9.8; P < 0.0001(b)). Dry mouth, the most common treatment-related AE, occurred more often with OTG3% 84 mg/day (26/214 [12.1%]) vs. placebo (10/202 [5.0%]) (P = 0.028); 4 OTG3% patients withdrew because of dry mouth. Application site erythema occurred more often with OTG3% 84 mg/day (8/214 [3.7%]) versus placebo (2/202 [1.0%]) (P = NS); 12 OTG patients withdrew because of skin irritation. No serious treatment-related AEs occurred.

CONCLUSIONS

OTG3% 84 mg/day was well tolerated and effective in improving urge incontinence or mixed UI symptoms with a predominance of UI in adults with overactive bladder.

The diagnosis and management of lower urinary tract symptoms in multiple sclerosis patients

Sixty-five percent of multiple sclerosis patients have moderate to severe urinary symptoms and up to 14% initially present with urinary symptomatology. Urinary retention, neurogenic detrusor overactivity, and detrusor sphincter dyssynergia, all increase the risk for urinary tract infections in patients with multiple sclerosis, and these infections may exacerbate their immune response, leading to symptom progression. Fewer than half of the patients with urinary symptoms have seen a specialist and only half have been treated for their neurogenic detrusor overactivity. Several treatments including pelvic floor muscle therapy, pelvic floor electrical stimulation, anticholinergics, desmopressin, sacral nerve neuromodulation, posterior tibial nerve stimulation, cannabinoids, and intravesical therapy with vanniloids, as well as botulinum toxin, have all been shown to be effective in treating urinary symptoms in those with multiple sclerosis. Clean intermittent catheterization is invaluable in patients with persistent urinary retention to avoid infection and upper tract dysfunction. Indwelling transurethral catheterization should be avoided because of the high risk of infection. Identification and successful treatment of these urinary conditions will improve the health and quality of life for these men and women.

Efficacy and safety of low dose desmopressin orally disintegrating tablet in women with nocturia: results of a multicenter, randomized, double-blind, placebo controlled, parallel group study

PURPOSE

Previous studies suggest a lower dose of desmopressin orally disintegrating tablet may be effective in females compared to males with nocturia. We confirm the efficacy and safety of 25 μg desmopressin orally disintegrating tablet compared to placebo in female patients.

MATERIALS AND METHODS

In this 3-month, randomized, double-blind, parallel group study 25 μg desmopressin once daily was compared to placebo in women with nocturia (2 or more nocturnal voids). The co-primary efficacy end points were change from baseline in mean number of nocturnal voids and proportion of patients achieving at least a 33% reduction from baseline in the mean number of nocturnal voids (33% responders).

RESULTS

The full analysis set comprised 261 patients (age range 19 to 87 years). Desmopressin significantly reduced the mean number of nocturnal voids and increased the odds of a 33% or greater response compared to placebo during 3 months, assessed by longitudinal analysis (-0.22, p = 0.028 and OR 1.85, p = 0.006, respectively). Desmopressin increased the mean time to first nocturnal void by 49 minutes compared to placebo at 3 months (p = 0.003). The response to desmopressin was seen by week 1 of treatment and was sustained throughout the trial. Significant increases in health related quality of life and sleep quality were observed compared to placebo. Desmopressin was well tolerated. Serum sodium levels remained greater than 125 mmol/L throughout the trial and 3 transient decreases to less than 130 mmol/L were recorded.

CONCLUSIONS

At a dose of 25 μg, desmopressin orally disintegrating tablet is an effective and well tolerated treatment for women with nocturia. Treatment provides rapid and sustained improvement in nocturia and quality of life.

Oxybutynin: past, present, and future

Oxybutynin chloride is primarily indicated for the treatment of overactive bladder syndrome (OAB). It remains the most widely prescribed compound for OAB in the world. OAB is defined as the presence of urinary urgency, usually accompanied by daytime urinary frequency and nocturia, with or without urgency urinary incontinence, in the absence of infection or other identifiable etiology. This is a significant problem for men and women said to affect over 33 million adults in the USA, with the prevalence increasing with age. These symptoms can alter quality of life, with both physical and psychological impairment, as well as cause significant financial burden including the cost of sanitary supplies and decreased work productivity. Both pharmacological and non-pharmacological methods may be employed to aid in the treatment of OAB. The mainstay of treatment for OAB relies on pharmacological management, most specifically treatment with antimuscarinic medications. These medications are thought to prevent involuntary bladder contractions and/or urgency by inhibiting the muscarinic receptors within the urothelium and detrusor muscle. Currently, there are six different medications approved by the US Food and Drug Administration (FDA) for the treatment of OAB, with more than nine formulations including immediate- and extended-release tablets, transdermal patch and gel, vaginal ring, and suppository. This review will focus specifically on oxybutynin chloride, which has been used to treat OAB for four decades in numerous formulations.

Transforming growth factor beta1 gene expression during vaginal wound healing in a rabbit menopause model

OBJECTIVE

Surgical outcome following reconstructive pelvic surgery is largely dependent on the vaginal wound healing process. As peri- and post-menopausal women are the most likely candidates to undergo these surgeries, it is important to understand the effect of estrogen deficiency on this process. Transforming growth factor beta (TGFβ) is an important mediator of wound healing. We sought to assess TGFβ1 gene expression during the vaginal incisional wound healing process in a rabbit menopause model.

DESIGN

Animal study.

SETTING

Animal laboratory.

SAMPLE

Sixty-three rabbits were used for this study.

METHODS

Twenty-one underwent bilateral oophorectomy, 21 underwent a sham surgery, and 21 served as controls. Eight weeks later, standardised full-thickness 6-mm diameter circular segments were excised from the vagina of all rabbits. Animals were killed sequentially, before wounding, and at 0, 4, 7, 14, 21 and 35 days after wounding, and the wounds were harvested.

MAIN OUTCOME MEASURES

Wound closure and TGFβ1 gene transcription, as measured by real-time polymerase chain reaction (PCR).

RESULTS

Wound closure was significantly protracted (P < 0.02), whereas TGFβ1 gene expression was significantly increased (P < 0.0001) during the wound healing process in oophorectomised rabbits, as compared with both control and sham groups.

CONCLUSION

Oophorectomised rabbits show protracted incisional vaginal wound healing associated with increased TGFβ1 gene transcription.

Expression of platelet-derived growth factor-B mRNA during vaginal vs. dermal incisional wound healing in the rabbit

OBJECTIVE

The outcome of pelvic reconstructive surgery is largely dependent on the vaginal wound healing process, but this process has not yet been fully elucidated. Platelet-derived growth factor (PDGF) is an important mediator of the wound healing process in cutaneous tissue. We sought to compare PDGF-B mRNA expression in vaginal versus cutaneous incisional wound healing in a rabbit model.

STUDY DESIGN

Bilateral 6 mm full-thickness circular segments were excised from the vagina and abdominal skin in 36 New Zealand-White female rabbits. Animals were euthanized sequentially before, on the day of and 4, 7, 10, 14, 21, 28 and 35 days after wounding. Their wounds were evaluated for surface area and PDGF-B mRNA expression using real time PCR.

RESULTS

In both tissues PDGF-B mRNA expression increased constantly after wounding, reaching peak levels on day 10, and declined immediately thereafter, reaching minimal values on day 21. In both tissues, the expression of PDGF-B mRNA significantly correlated with the wound closure rate.

CONCLUSION

PDGF-B mRNA expression significantly correlates with incisional vaginal and cutaneous wound closure, suggesting that this factor plays an important role in the wound healing process of both tissues.

Pharmacokinetics of oxybutynin chloride topical gel: effects of application site, baths, sunscreen and person-to-person transference

BACKGROUND

Oxybutynin chloride topical gel (OTG; Gelnique®) is an approved formulation for the transdermal administration of oxybutynin, an established antimuscarinic therapy for overactive bladder (OAB). Transdermal administration of oxybutynin minimizes plasma concentrations of the active metabolite N-desethyloxybutynin (N-DEO), which can have anticholinergic adverse effects.

OBJECTIVES

In four phase I studies, we separately assessed the effects of OTG application site selection on oxybutynin bioavailability (site-to-site study); the effects of post-application showering on oxybutynin steady-state pharmacokinetics (showering study); the effects of sunscreen application on oxybutynin absorption (sunscreen study); and the person-to-person transfer of oxybutynin through skin-to-skin contact at the application site (transference study).

METHODS

All four studies were open-label, randomized, phase I studies. The site-to-site and showering studies involved repeated administration of OTG to establish steady-state plasma concentrations of oxybutynin and N-DEO; the other two studies involved single doses. Clinical visits were required for pharmacokinetic sampling, supervision of OTG self-application on pharmacokinetic sampling days, showering, sunscreen application and transference experiments. The study included healthy subjects aged 18-45 years. Subjects with conditions requiring medical therapy or interfering with the application of OTG or the interpretation of pharmacokinetic results were excluded. Participants applied OTG (1 g containing oxybutynin chloride 10%, 1.14 mL/dose) once daily to the abdomen, upper arm/shoulder or thigh. Showering occurred 1-6 hours after dosing. Sunscreen was applied 30 minutes before or after OTG application. Abdomen-to-abdomen contact with movement for 15 minutes between treated and untreated participants was conducted 1 hour after dosing. Time points of serial blood sampling for pharmacokinetic analyses varied among studies. Plasma concentrations of oxybutynin and N-DEO (except transference study) were measured. Bioequivalence was tested with ANOVA models for log(e)-transformed plasma exposure (area under the plasma concentration-time curve [AUC]) and maximum plasma concentration (C(max)) to generate 90% confidence intervals (CIs).

RESULTS

Oxybutynin and N-DEO exposures (AUCs) from time zero to 24 hours (AUC(24)) were similar for the three application sites, with N-DEO/oxybutynin mean AUC(24) ratios of approximately 0.9. The 90% CIs for thigh-to-abdomen ratios of oxybutynin AUC(24) (0.93, 1.23) and C(max) (0.85, 1.16) were within the interval required for bioequivalence (0.8, 1.25); the other application site ratios for oxybutynin had boundaries slightly outside this interval. Showering 1-6 hours and sunscreen application 30 minutes before or after OTG application had minor effects on oxybutynin concentrations. After vigorous skin contact between treated and untreated participants at the application site, the mean ± SD AUC from time zero to 48 hours (AUC(48)) of oxybutynin in 12 untreated participants was 29.8 ± 24.5 ng · h/mL, approximately one-quarter of the exposures generally seen in subjects treated with a single dose of OTG. Oxybutynin AUC(48) after clothing-to-skin contact was undetectable in 12 of 14 untreated participants and very low (mean ± SD 0.4 ± 0.8 ng · h/mL) in two untreated female participants.

CONCLUSION

The bioavailability of oxybutynin and its pharmacokinetic profile are not greatly affected by application site selection, post-application showering or sunscreen use shortly before or after dosing with OTG. Oxybutynin transference to untreated persons is essentially prevented by avoiding direct skin-to-skin contact with the application site.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery

INTRODUCTION AND HYPOTHESIS

A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery.

METHODS

This report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus).

RESULTS

A terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/complication).

CONCLUSION

A consensus-based terminology and classification report for prosthesis and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.

Once-daily trospium chloride 60 mg extended release in subjects with overactive bladder syndrome who use multiple concomitant medications: Post hoc analysis of pooled data from two randomized, placebo-controlled trials

BACKGROUND

Overactive bladder syndrome (OAB) is associated with various co-morbidities; treatment of these frequently results in multiple medication use (MMU) and the potential for drug-drug interactions, which may lead to adverse events and altered efficacy. With the aging population, the prevalence of MMU is likely to increase in the overall population, an increase due in part to treatment of co-morbidities that are more common in the elderly.

OBJECTIVE

To assess safety and efficacy outcomes with once-daily trospium chloride 60 mg extended release (XR) in subjects with OAB who were taking multiple concomitant medications.

STUDY DESIGN

Post hoc analysis of pooled data from two 12-week randomized, placebo-controlled studies.

SETTING

Urology, urogynaecology, and primary care offices/clinics.

PATIENTS

Subjects aged ≥18 years with OAB for ≥6 months who had baseline urinary frequency of ≥30 toilet voids/3 days; ≥1 'severe' urgency severity rating/3 days (on the Indevus Urgency Severity Scale); and pure urge urinary incontinence (UUI) or mixed incontinence with predominant UUI, with ≥3 UUI episodes/3 days. This analysis utilized data from subjects taking concomitant medications, focusing on those taking seven or more.

INTERVENTION

Once-daily trospium chloride 60 mg XR or placebo.

MAIN OUTCOME MEASURE

Predictors of treatment-emergent adverse events (TEAEs) identified by multivariate logistic regression analysis.

RESULTS

Concomitant medications were being taken by 1135 subjects (placebo, n = 576; trospium chloride XR, n = 559); 427 were taking seven or more (placebo, n = 199; trospium XR, n = 228). Among subjects taking seven or more concomitant medications, there was no significant difference between trospium chloride XR and placebo in the proportion of subjects experiencing one or more TEAEs (64.5% vs 58.3%). Logistic regression analysis indicated that the odds of experiencing a TEAE were influenced by concomitant medication use, but not by randomization assignment to trospium chloride XR or to placebo, suggesting that concomitant drugs contribute more to TEAEs than trospium chloride XR. Compared with subjects taking one to two concomitant medications, the adjusted odds ratio (OR) for experiencing any TEAE was 3.39 (95% CI 2.39, 4.80; p < 0.0001) for subjects taking seven or more concomitant medications. The adjusted OR for experiencing any TEAE for subjects randomized to active treatment compared with placebo was 1.19 (95% CI 0.85, 1.67; p = 0.31). Efficacy in subjects taking seven or more concomitant medications was similar to that in the overall pooled study population.

CONCLUSIONS

Trospium chloride XR does not increase the likelihood of a TEAE compared with placebo. The probability of experiencing a TEAE was significantly influenced by use of multiple concomitant medications. Trospium chloride XR was as effective in subjects with OAB taking seven or more concomitant medications as in the overall pooled study population. The data support the conclusion that trospium chloride XR is safe and effective in patients with OAB taking multiple concomitant medications.

Long-term safety, tolerability, and efficacy of fesoterodine treatment in men and women with overactive bladder symptoms

OBJECTIVE

To evaluate long-term safety, tolerability, and efficacy of fesoterodine for men and women with overactive bladder (OAB) symptoms.

RESEARCH DESIGN AND METHODS

This was a post hoc analysis of data pooled from two open-label extensions (NCT00220402, NCT00220376) of double-blind studies. All subjects began open-label treatment with fesoterodine 8 mg once daily, with voluntary dose reduction to 4 mg and re-escalation to 8 mg each permitted once annually. Maximum allowable duration of open-label treatment ranged from 24 to 36 months.

MAIN OUTCOME MEASURES

Safety and discontinuations were assessed throughout treatment; subject-reported treatment tolerability and 3-day bladder diaries were evaluated at open-label baseline and months 1, 4, 8, 12, and 24.

RESULTS

A total of 185 men and 705 women enrolled; 83 men (45%) and 356 women (50%) continued open-label treatment for ≥ 24 months. Most men (84%) and women (75%) remained on fesoterodine 8 mg throughout open-label treatment. No new or unexpected safety signals were observed. Dry mouth was the most common treatment-emergent adverse event (men, 24%; women, 32%), rates of discontinuation due to dry mouth were low (men, 1%; women, 2%). Most men and women (≥ 91%) reported at least 'good' tolerance. For men and women, statistically significant improvements in urgency urinary incontinence episodes, micturitions, urgency episodes, and mean voided volume per micturition achieved between double-blind baseline and open-label baseline were sustained or further improved through month 24; significant improvements in most OAB symptoms were observed between double-blind baseline and month 24 when subjects were stratified by double-blind treatment (placebo, tolterodine extended release 4 mg, fesoterodine 4 mg, fesoterodine 8 mg). Limitations include the lack of a placebo control and that subjects completing double-blind treatment may have been more likely to tolerate or respond to long-term fesoterodine treatment.

CONCLUSIONS

Long-term fesoterodine treatment was well tolerated and associated with sustained improvements in OAB symptoms in men and women.

Once-daily trospium chloride 60 mg extended-release provides effective, long-term relief of overactive bladder syndrome symptoms

AIMS

Once-daily extended-release (XR) trospium chloride has been evaluated for the treatment of overactive bladder syndrome (OAB) in two 12-week randomized, double-blind, placebo-controlled studies. This pooled analysis of the 9-month open-label extensions to these studies evaluated the long-term efficacy and tolerability of trospium XR.

METHODS

Following double-blind treatment, subjects with OAB could enter the open-label period, during which they received trospium 60 mg XR once daily for 36 weeks. The primary efficacy variables were changes from baseline in the number of toilet voids and urgency urinary incontinence (UUI) episodes per day at Week 48. Adverse events (AEs) were also recorded.

RESULTS

Of the 1,027 subjects who completed double-blind treatment, 944 (92%) continued into the open-label period (placebo-to-trospium, N = 483; trospium-to-trospium, N = 461); 332 (68.7%) and 335 (72.7%), respectively, completed the open-label period. At Week 48, the mean change from baseline in the number of toilet voids/day was -3.21 in the placebo-to-trospium group and -3.35 in the trospium-to-trospium group, and the median change from baseline in the number of UUI episodes/day was -2.33 in both groups. Efficacy was maintained relative to Week 12 in trospium-to-trospium subjects, while improvement was seen following trospium initiation in placebo-to-trospium subjects. Improvement from baseline was also observed on secondary efficacy parameters at Week 48. Trospium was well tolerated; dry mouth and constipation were the most common class treatment-emergent AEs. Central nervous system AEs were rare and did not increase with long-term treatment.

CONCLUSIONS

Long-term treatment of OAB with once-daily trospium 60 mg XR is effective and well tolerated.

Effect of baseline symptom severity on continence improvement mediated by oxybutynin chloride topical gel

Background

In a recent placebo-controlled Phase III study, oxybutynin chloride topical gel (OTG) significantly improved urinary continence in patients with overactive bladder. In this post hoc analysis, the effect of incontinence severity on OTG-mediated improvement in continence was evaluated.

Methods

Change from baseline in the number of incontinence episodes was evaluated in patients with two to three incontinence episodes/day (moderate incontinence) and those with more than three incontinence episodes/day (severe incontinence).

Results

In patients with moderate (n = 171) and severe (n = 556) incontinence, reduction in incontinence episodes (mean ± standard deviation) was greater (P < 0.01) with OTG (moderate, −1.7 ± 1.4; severe, −3.6 ± 3.0) than with placebo (moderate, −1.2 ± 1.3; severe, −3.1 ± 3.4). Continence achievement rate with OTG was 48.2% (placebo, 24.4%) among patients with moderate incontinence and 17.8% (placebo, 12.1%) among those with severe incontinence.

Conclusion

Absolute placebo-adjusted reduction in incontinence episodes with OTG was not affected by baseline incontinence severity. Continence achievement was more likely if symptoms were less severe.

Trospium chloride once-daily extended release is efficacious and tolerated in elderly subjects (aged ≥ 75 years) with overactive bladder syndrome

OBJECTIVE

• To evaluate the safety and efficacy of once-daily trospium chloride extended release (ER) in overactive bladder syndrome (OAB) in subjects aged ≥ 75 years.

SUBJECTS AND METHODS

• The analysis included subjects ≥ 75 years of age with OAB. • A subgroup analysis of pooled data was performed for subjects aged ≥ 75 years from two randomized, double-blind, multicenter studies of subjects with OAB receiving once-daily trospium 60 mg extended release (ER) or placebo for 12 weeks, followed by 9-month open-label extension periods during which all subjects received trospium ER. A total of 143 of the 1165 subjects from two phase III registration trials who were aged ≥ 75 years (85 trospium ER, 58 placebo; mean age 79 years and ranging up to 90 years; 73% female) were evaluated. • Dual primary efficacy variables were the changes from baseline in the average number of toilet voids per day and urge urinary incontinence episodes per day.

RESULTS

• At week 12 of the double-blind period, trospium ER produced greater improvements from baseline than placebo in voiding diary parameters, OAB Patient Global Assessment, and quality of life. • Efficacy and tolerability persisted among subjects receiving open-label trospium ER for up to 1 year.

CONCLUSIONS

• Once-daily trospium chloride 60 mg ER demonstrated efficacy vs placebo and was tolerated in subjects aged ≥ 75 years with OAB. • For subjects who continued into the open-label treatment period, efficacy and tolerability were observed for up to 1 year.

Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary incontinence and for fecal incontinence. Part 1: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients

AIMS

The members of The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing' provide an executive summary of the chapter 'Dynamic Testing' that discusses (urodynamic) testing methods for patients with signs and or symptoms of urinary incontinence. Testing of patients with signs and or symptoms of faecal incontinence is also discussed.

METHODS

Evidence based and consensus committee report.

RESULTS

The chapter 'Dynamic Testing' is a continuation of previous Consultation-reports added with a new systematic literature search and expert discussion. Conclusions, based on the published evidence and recommendations, based on the integration of evidence with expert experience and discussion are provided separately, for transparency.

CONCLUSION

This first part of a series of three articles summarizes the committees recommendations about the innovations in urodynamic study techniques 'in general', about the test characteristics and normal values of urodynamic studies as well as the assessment of female with signs and or symptoms of incontinence and includes only the most recent and relevant literature references.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

INTRODUCTION

Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two international organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Appropriate core clinical categories and a subclassification were developed to give an alphanumeric coding to each definition. An extensive process of 15 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A terminology report for female pelvic floor dysfunction, encompassing over 250 separate definitions, has been developed. It is clinically based with the six most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific imaging (ultrasound, radiology, and MRI) has been a major addition while appropriate figures have been included to supplement and help clarify the text. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Extended-release trospium chloride improves quality of life in overactive bladder

OBJECTIVES

Overactive bladder syndrome (OAB) is a urinary condition that often exerts detrimental effects on an individual's quality of life (QoL). A once-daily, extended-release (ER) formulation of the quaternary amine trospium chloride has recently been developed for the treatment of OAB. The pooled health-related QoL (HRQoL) data from two multicenter, parallel-group, double-blind Phase III studies with trospium chloride ER 60 mg were analyzed.

METHODS

Subjects aged>or=18 years with urinary urgency, frequency, and an average of >or=1 urge urinary incontinence episode per day on a 3-day bladder diary were randomized (1:1) to receive once-daily trospium 60 mg ER or placebo for 12 weeks. HRQoL was assessed at baseline and at Week 12 using the King's Health Questionnaire (KHQ) and the OAB questionnaire (OAB-q).

RESULTS

Overall, 1165 subjects were randomized (trospium ER, n=578; placebo, n=587). Trospium ER produced significantly greater improvements from baseline than placebo in seven of the nine KHQ domains. At Week 12, the improvement in mean OAB-q HRQoL total score (from approximately 52 at baseline) was significantly greater with trospium ER than with placebo (+25.8 vs. +20.7; P=0.0003). Improvements from baseline were seen with trospium ER on all eight of the OAB-q symptom bother scales.

CONCLUSIONS

Once-daily trospium 60 mg ER improved the QoL of subjects with OAB, as assessed using the KHQ and the OAB-q, in two large Phase III clinical trials.

Trospium chloride once-daily extended release is effective and well tolerated for the treatment of overactive bladder syndrome: an integrated analysis of two randomised, phase III trials

BACKGROUND

Trospium chloride is an antimuscarinic agent with a hydrophilic polar quaternary amine structure that is minimally metabolised by hepatic cytochrome P450 and is actively excreted in the urine, each of which confers a potential benefit with regard to efficacy and tolerability.

PURPOSE

We analysed pooled data from two identically designed phase III trials of a once-daily, extended-release (XR) formulation of trospium chloride (trospium XR 60-mg capsules) in subjects with overactive bladder syndrome (OAB).

METHODS

Adults with OAB of > or = 6 months' duration with urinary urgency, frequency and > or = 1 urge urinary incontinence (UUI) episode/day were enrolled in these multicentre, parallel-group, double-blind trials. Participants were randomised (1 : 1) to receive trospium XR 60 mg or placebo for 12 weeks. Primary efficacy variables were changes in urinary frequency and the number of UUI episodes/day. Adverse events (AEs) were recorded throughout.

RESULTS

In total, 1165 subjects were randomised (trospium XR, 578; placebo, 587). At baseline, subjects averaged 12.8 toilet voids/day and 4.1 UUI episodes/day. Compared with placebo, subjects treated with trospium XR had significantly greater reductions from baseline in the mean number of toilet voids/day (-1.9 vs. -2.7; p < 0.001) and UUI episodes/day (-1.8 vs. -2.4; p < 0.001) at week 12. The most frequent AEs considered possibly related to study treatment were dry mouth (trospium XR, 10.7%; placebo, 3.7%) and constipation (trospium XR, 8.5%; placebo, 1.5%). Notably, rates of central nervous system (CNS) AEs were lower with trospium XR vs. placebo (dizziness: 0.2% vs. 1.0%; headache: 1.4% vs. 2.4%).

CONCLUSIONS

Treatment with trospium XR resulted in statistically significant improvements in both of the dual primary and all of the secondary outcome variables. Trospium XR demonstrated favourable rates of AEs, particularly CNS AEs (numerically lower than with placebo) and dry mouth (lower than previously reported with trospium immediate-release, although not compared in a head-to-head study).

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. Appropriate core clinical categories and a subclassification were developed to give an alphanumeric coding to each definition. An extensive process of 15 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A terminology report for female pelvic floor dysfunction, encompassing over 250 separate definitions, has been developed. It is clinically based with the six most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific imaging (ultrasound, radiology, and MRI) has been a major addition while appropriate figures have been included to supplement and help clarify the text. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible.

CONCLUSIONS

A consensus-based terminology report for female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Impact of transdermal oxybutynin on work productivity in patients with overactive bladder: results from the MATRIX study

BACKGROUND

Overactive bladder syndrome (OAB) is a common condition affecting a significant number of working adults, resulting in increased healthcare utilization, reduced quality of life and decreased work productivity. The MATRIX study was a large, prospective, community-based, observational US study aimed at evaluating the impact of oxybutynin transdermal system (OXY-TDS). In this paper, we report on productivity findings among working adults in MATRIX.

METHODS

This study enrolled 2878 adults (aged > or =18 years) with symptoms of OAB from 327 practice sites throughout the US. All subjects received OXY-TDS (3.9 mg/day up to 6 months). Baseline versus end-of-study productivity was measured using the Work Productivity Questionnaire (WPQ). The WPQ includes a subset of questions from the Work Limitations Questionnaire (WLQ) and consists of four scales: (i) physical; (ii) time management; (iii) mental; and (iv) output demands. Overall productivity was measured by the work productivity index score (WPQ Index; a summary score based on scales) and work productivity loss score (WPLS; a measure of reduced output compared with healthy workers). Psychometric performance of the WPQ instrument is also reported, since this study represents the first use of the tool.

RESULTS

Of the participants, 52% were of working age (18-65 years) and 38.6% were employed. A total of 1112 working adults participated in MATRIX and were included in this analysis. They had a mean age of 52.4 years; 92.2% were female and 80.9% were Caucasian. Subjects who reported that they were most affected by OAB were also most impaired at work. After OXY-TDS treatment, participants experienced significant improvements in mean scores for all four WPQ scales (p < or = 0.0002) and the mean WPQ Index decreased from 8.2 to 5.5 (p < 0.0001). In addition, the WPLS decreased from 7.7% to 5.2% (p < 0.0001), indicating improvement in work function with OXY-TDS treatment.

CONCLUSION

OAB contributes to decreased work productivity due to job interruptions as well as fatigue. OXY-TDS may result in productivity improvement when patients receive 3.9 mg/day via twice weekly patch application for up to 6 months.

Predictors of persistent detrusor overactivity after transvaginal sling procedures

OBJECTIVE

Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence

STUDY DESIGN

Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models.

RESULTS

Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001).

CONCLUSION

When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.

Evolving trends in the successful management of interstitial cystitis/painful bladder syndrome

OBJECTIVE

To provide an overview of interstitial cystitis (IC), including the presentation of patients with the disorder, and to explore diagnostic and treatment options.

STUDY DESIGN

Current literature concerning the history, etiology, diagnosis and treatment of IC was used to support expert recommendations regarding patient management. Experts discussed the literature surrounding IC, focusing on diagnostic tools and currently available treatment modalities.

RESULTS

Diagnosis of IC may often be delayed or missed due to the similarity of symptoms with a number of other conditions. A detailed medical history and careful physical examination are key for diagnosis, and a variety of screening and diagnostic tools are also available. Once a patient is diagnosed with IC, multimodal treatment through pharmacological and nonpharmacological approaches is recommended.

CONCLUSION

The involvement of both the patient and physician in determining the therapeutic approach, the use of multimodal therapies, regular follow-up and staff involvement in care can bring relief to a substantial number of patients with this condition.

Association between response to pentosan polysulfate sodium therapy for interstitial cystitis and patient questionnaire-based treatment satisfaction

OBJECTIVE

To evaluate the relationship between symptom reduction and satisfaction with pentosan polysulfate sodium (PPS) therapy in subjects with interstitial cystitis (IC).

METHODS

A secondary analysis was conducted in 128 subjects treated with PPS 300 mg/day (US Food and Drug Administration-approved dose) from a 32-week multicenter, randomized, double-blind study of 380 subjects with IC who were treated with PPS 300 mg/day, 600 mg/day, or 900 mg/day. Self-rated outcome measures included the O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and a treatment satisfaction questionnaire. Treatment responders were defined as subjects having > or =30% reduction in ICSI from baseline to study end point.

RESULTS

A reduction in IC symptoms was associated with significantly higher satisfaction with PPS (p < 0.05). Compared with nonresponders, subjects achieving a > or = 30% reduction in ICSI were more likely to be pleased with PPS for IC symptoms, to have benefited from PPS for their IC symptoms, to recommend PPS for IC symptoms to others with the same condition, and to say that PPS provides better relief, based on prior experience with other IC treatments. Among all subjects at week 32, 75% said they would recommend PPS therapy for IC symptoms to others with the condition.

CONCLUSION

Despite limitations (lack of placebo control, use of a nonvalidated instrument), this analysis demonstrated significantly increased treatment satisfaction with PPS therapy among treatment responders versus nonresponders. There was a significant positive correlation between ICSI scores and response on the treatment satisfaction questionnaire. Treatment response and patient satisfaction with treatment are important clinical considerations in the management of patients with IC.

Impact of hysterectomy on stress urinary incontinence: an identical twin study

OBJECTIVE

This study uses the unique properties of twin research design to evaluate whether hysterectomy impacts stress urinary incontinence (SUI).

STUDY DESIGN

As part of the Evanston Twins Sister Study, we performed bivariate and multivariate analyses on 83 identical twin pairs discordant for hysterectomy.

RESULTS

In bivariate analysis, SUI was less common in women who had prior hysterectomy (P =0.028). Multivariate analysis suggested that SUI was significantly less common after hysterectomy (odds ratio [OR], 0.55, confidence interval [CI], 0.30 to 1.00). Exclusion of twin pairs with a history of pelvic floor defect surgery eliminated the statistical relationship between hysterectomy and SUI (OR, 0.79, CI, 0.4 to 1.40).

CONCLUSION

Hysterectomy, when analyzed with all cases, was associated with reduced SUI. When concurrent pelvic floor defect surgeries were excluded from the analysis, we found no relationship between hysterectomy and the risk of SUI afterward.

Evaluation and treatment of female urinary incontinence

Urinary incontinence is a very common and bothersome condition among women and can affect up to 50% of women during their lifetime. Older women are disproportionately affected and often view urinary incontinence as a normal part of aging, thus precluding contact with medical professionals. Physicians must therefore include questions regarding urinary incontinence as part of routing examinations. A simple, yet thorough history and physical examination along with basic testing can often aid the physician in making an accurate diagnosis and initiating effective treatment. Several interventions are available and are often chosen based on type and severity of urinary incontinence. These include conservative measures, pharmacotherapy, and surgical intervention. Also, innovative treatment modalities are constantly being investigated to manage urinary incontinence further expanding treatment options available to women.

Evaluation and treatment of female urinary incontinence

Urinary incontinence is a very common and bothersome condition among women and can affect up to 50% of women during their lifetime. Older women are disproportionately affected and often view urinary incontinence as a normal part of aging thus precluding contact with medical professionals. Physicians must, therefore, include questions regarding urinary incontinence as part of routine examinations. A simple, yet thorough history and physical examination along with basic testing can often aid the physician in making an accurate diagnosis and initiating effective treatment. Several interventions are available and are often chosen based on type and severity of urinary incontinence. These include conservative measures, pharmacotherapy, and surgical intervention. Also, innovative treatment modalities are constantly being investigated to manage urinary incontinence further expanding treatment options available to women.

Multicenter prospective randomized 52-week trial of calcium hydroxylapatite versus bovine dermal collagen for treatment of stress urinary incontinence

OBJECTIVES

To evaluate the safety and effectiveness of soft-tissue augmentation of the urethral sphincter with calcium hydroxylapatite (CaHA; Coaptite) compared with glutaraldehyde cross-linked bovine collagen (Contigen) in female patients with stress urinary incontinence due to intrinsic sphincter deficiency and without associated urethral hypermobility.

METHODS

This 12-month prospective, randomized, comparative, multicenter, single-blind, parallel, clinical trial of CaHA and collagen for soft-tissue augmentation of the urethral sphincter in the treatment of stress urinary incontinence enrolled 296 women. Up to five injections were performed in the first 6 months of the trial. Twelve-month postinjection efficacy data were available for 231 patients.

RESULTS

The results indicated that CaHA and collagen were both well tolerated in this study. No systemic adverse events were observed with either product. We used the Stamey Urinary Incontinence Scale to grade the improvement, which was the primary endpoint of the study. At 12 months, 83 (63.4%) of 131 CaHA patients compared with 57 (57.0%) of 100 collagen patients showed improvement of one Stamey grade or more (P = 0.34). More CaHA patients required only one injection (n = 60; 38.0%) during the study compared with the Contigen patients (n = 36; 26.1%; P = 0.034). Also, the average total volume of material injected during the course of the study was less for CaHA than for collagen (4.0 mL versus 6.6 mL, respectively; P <0.0001).

CONCLUSIONS

The results of the study have demonstrated that Coaptite is an appropriate and well-tolerated treatment for patients with incontinence due to intrinsic sphincter deficiency. This new soft-tissue augmentation material has a good safety profile and appears to provide durable improvement.

Safety and tolerability of extended-release oxybutynin once daily in urinary incontinence: combined results from two phase 4 controlled clinical trials

Early studies of extended-release oxybutynin in patients with overactive bladder used adjusted-dose regimens ranging from 5 to 30 mg/day to achieve an optimal balance of efficacy and tolerability. The safety and tolerability of extended-release oxybutynin at a fixed dose of 10 mg once daily (commonly prescribed in clinical practice) is reported using pooled data from 2 multicenter, randomized, double-blind, parallel-group trials with a similar study design. One study compared extended-release oxybutynin with immediate-release tolterodine 2 mg bid. The other study compared extended-release oxybutynin with extended-release tolterodine 4 mg qd. In total, 576 patients received extended-release oxybutynin, 399 received extended-release tolterodine, and 193 received immediate-release tolterodine. The incidence of adverse events (AEs) was similar in the three treatment groups (extended-release oxybutynin, 70%; extended-release tolterodine, 64%; and immediate-release tolterodine, 79%). The most common adverse event was dry mouth (extended-release oxybutynin, 29%; extended-release tolterodine, 22%; and immediate-release tolterodine, 33%). Other AEs occurring in more than 5% of patients in any treatment group included constipation, diarrhea, headache, urinary tract infection, pain, dyspepsia, and peripheral edema, with no apparent difference across treatment groups. Most AEs (>90%) were mild or moderate in intensity in all treatment groups. The proportion of patients who discontinued study medication due to AEs was 6.1, 4.8, and 7.8% in the extended-release oxybutynin, extended-release tolterodine, and immediate-release tolterodine groups, respectively. In total, 1.2, 1.0, and 1.6% of patients in the extended-release oxybutynin, extended-release tolterodine, and immediate-release tolterodine groups, respectively, discontinued study medication due to dry mouth.