Efficacy and safety of fesoterodine 8 mg in subjects with overactive bladder after a suboptimal response to tolterodine ER

AIMS

To assess fesoterodine 8 mg efficacy over time and vs. placebo in subjects with overactive bladder (OAB) who responded suboptimally to tolterodine extended release (ER) 4 mg.

METHODS

In a 12-week, double-blind trial, subjects with self-reported OAB symptoms for ≥ 6 months, mean of ≥ 8 micturitions and ≥ 2 to < 15 urgency urinary incontinence (UUI) episodes/24 h, and suboptimal response to tolterodine ER 4 mg (defined as ≤ 50% reduction in UUI episodes during 2-week run-in) were randomised to fesoterodine (4 mg for 1 week, 8 mg for 11 weeks) or placebo once daily. Change from baseline to week 12 in UUI episodes (primary end-point) was analysed in step-wise fashion: first, baseline vs. week 12 for fesoterodine; if significant, then change from baseline to week 12 for fesoterodine vs. placebo.

RESULTS

By week 12, subjects receiving fesoterodine 8 mg had significantly greater improvement from baseline vs. placebo in UUI episodes, urgency episodes and scores on the Patient Perception of Bladder Control, Urgency Perception Scale and OAB Questionnaire Symptom Bother and Health-Related Quality of Life scales and domains (all p < 0.05). 50% and 70% UUI responder rates were also significantly higher with fesoterodine 8 mg vs. placebo at week 12 (p < 0.05). Dry mouth (placebo, 4%, 12/301; fesoterodine, 16.6%, 51/308) and constipation (placebo, 1.3%, 4/301; fesoterodine, 3.9%, 12/308) were the most frequent adverse events.

CONCLUSIONS

Subjects who responded suboptimally to tolterodine ER 4 mg showed significant improvements in UUI and other OAB symptoms and patient-reported outcomes, with good tolerability, during treatment with fesoterodine 8 mg vs. placebo.

Urgency and pain in patients with overactive bladder and bladder pain syndrome. What are the differences?

BACKGROUND

The Overactive Bladder Syndrome (OAB) and the Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) are different urological conditions sharing 'urgency' as a common symptom. The aim of this review is to address our existing knowledge and establish how these symptoms are interrelated and to determine whether or not there is a common link between both symptoms complexes that help to distinguish one from the other.

METHODS

Pubmed was used to obtain references for this non-systematic review aiming to discuss differences between OAB and BPS/IC. Guidelines of several professional associations and discussions based on expert opinion from the authors were implemented.

RESULTS

Whilst in BPS the hallmark symptom is pain on bladder filling, urgency is the defining symptom of OAB. Whilst it is likely that the pain in BPS/IC arises from local inflammation in the bladder wall, the nature of urgency as a symptom, its origin, and the relationship between urgency and pain, as well as the different afferent mechanisms associated with the genesis of these sensory symptoms, remains unknown. Although the aetiology of both OAB and PBS/IC is unclear, the influence of environmental factors has been suggested. Both are chronic conditions with very variable symptom resolution and response to therapy. The relationship with voiding dysfunction, gynaecological causes of chronic pelvic pain or the possible alteration of the hypothalamic-pituitary-adrenal axis and psychological disorders has not been established. Inflammation has been suggested as the common link between OAB and BPS/IC.

CONCLUSIONS

OAB and BPS/IC are different symptoms complexes that share urgency as a common symptom. None of them have a specific symptom although pain on bladder filling is the hallmark symptom in BPS/IC. Bladder pain with urgency should be a trigger for referral to the provider with appropriate knowledge and expertise in this disease state, whereas the management of OAB should be part of normal routine care in the community.

Urogenital Prolapse and Atrophy at Menopause: A Prevalence Study

For 285 subjects referred to a menopause clinic data were prospectively collected on the time elapsed since the onset of menopause (menopausal age), sexual activity, dyspareunia, smoking, chronic cough and constipation. Prolapse and atrophy were sought on examination. FSH assay confirmed menopausal status. We found an anterior wall prolapse in 51% of the subjects, of which 6% were protruding beyond the introitus. Posterior wall prolapse was present in 27% and apical prolapse in 20%; none was protruding beyond the introitus. No trend was noted between prolapse and menopausal age. Atrophy was evident in 34% of the women, and this was related to menopausal age (P<0.001). Forty per cent of the sexually active women admitted to dyspareunia, of which 2/3 were superficial. This correlated with advancing menopausal age (P<0.02). In conclusion, genital prolapse was frequent in the population of postmenopausal women, predominantly cystocele, but the prevalence did not correlate with menopausal age.

Psychological characteristics and motivation of women seeking labiaplasty

BACKGROUND

Labiaplasty is an increasingly popular surgical intervention but little is known about the characteristics and motivation of women who seek the procedure or the psychosexual outcome.

METHOD

A total of 55 women seeking labiaplasty were compared with 70 women who did not desire labiaplasty. Various general measures of psychopathology as well as specific measures (Genital Appearance Satisfaction; Cosmetic Procedure Screening for labiaplasty) were used. Labia measurements of the women seeking labiaplasty were also obtained.

RESULTS

Women seeking labiaplasty did not differ from controls on measures of depression or anxiety. They did, however, express increased dissatisfaction towards the appearance of their genitalia, with lower overall sexual satisfaction and a poorer quality of life in terms of body image. Women seeking labiaplasty reported a significantly greater frequency of avoidance behaviours on all the domains assessed, and greater frequency of safety-seeking behaviours for most of the domains. Key motivations reported for labiaplasty were categorized as cosmetic, functional or sexual. Of the 55 women seeking labiaplasty, 10 met diagnostic criteria for body dysmorphic disorder.

CONCLUSIONS

This is the first controlled study to describe some of the characteristics and motivations of women seeking labiaplasty. We identified a wide range of avoidance and safety-seeking behaviours, which occurred more frequently in the labiaplasty group than the control group. These could be used clinically as part of a psychological intervention for women seeking labiaplasty.

Estabilidade oxidativa e perfil de ácidos graxos do leite de vacas suplementadas com óleo de linhaça na dieta associado ou não ao selenito de sódio injetável

Avaliou-se o efeito da suplementação com óleo de linhaça na dieta, com ou sem injeção de selenito de sódio, sobre o perfil de ácidos graxos e sobre a estabilidade oxidativa do leite de vacas leiteiras. Catorze vacas foram distribuídas em três tratamentos: as do grupo 1, que receberam diariamente 400mL de óleo de linhaça (LIN); as do grupo 2, 400mL de óleo de linhaça + 0,2mg/kg de selenito de sódio IM (LINSe); e as do grupo 3 (controle), que não foram tratadas (C). O óleo foi fornecido diariamente após 15 dias da aplicação única de selenito de sódio, e o experimento teve duração de quatro semanas. Os animais suplementados com o óleo de linhaça produziram leite com altas porcentagens de ácido linoleico conjugado (CLA) e de ômega 3, contudo mais suscetível à oxidação. A aplicação injetável de selenito de sódio mostrou-se eficaz ao impedir a oxidação prematura do leite. Concluiu-se que a inclusão do óleo de linhaça na dieta de vacas leiteiras resulta em aumento do CLA, do ômega 3 e, consequentemente, da oxidação do leite, necessitando, assim do uso de substâncias antioxidantes ou promotores antioxidantes, como o selenito de sódio injetável.

Management of refractory overactive bladder

Overactive bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence and is usually associated with frequency and nocturia. It is a common, under-diagnosed and therefore under-treated condition which can have a detrimental effect on physical functioning and psychological well-being. Initial treatment of OAB includes lifestyle advice, behavioural modifications, bladder retraining and pelvic floor muscle training, usually in combination with antimuscarinic agents. However, approximately 40% either do not achieve an acceptable level of therapeutic benefit or remain completely refractory to treatment. Our review will focus on the management of this challenging group of women with refractory OAB. For those women with persistent symptoms following conservative therapy, a thorough clinical assessment and appropriate investigations are required. Treatment of any underlying pathology should be considered. The introduction of bladder selective antimuscarinic agents, extended release formulations, alternative routes of administration or use of other drugs could be explored. Modalities such as intravesical Botulinum toxin, neuromodulation (peripheral or sacral) may be offered. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion (suprapubic or transurethral) can be considered as a last resort.

Use of nutrition literacy scale in elderly minority population

OBJECTIVES

The major objective of our paper was to test and validate the nutritional literacy scale (NLS) in a pre-dominantly African-American geriatric population.

DESIGN

Completion of the 2 literacy scales Short Test of Functional Health Literacy in Adults (STOHFLA) and nutritional literacy scale (NLS) during a 5-month period from September 2008 to January 2009.

SETTING

The Rosa Parks Geriatric Center at Detroit Medical Center/Wayne State University.

PARTICIPANTS

The study cohort consisted of elderly (>65 years old) 150 patients that had presented to the geriatric clinic.

MEASUREMENTS

NLS and STOHFLA were simultaneously given to the patients. The NLS consists of 28 questions regarding organic foods; calorie intake etc. and questions in each section were arranged from easier to more difficult ones. The baseline characteristics were stratified according to the NLS (< 25 and ≥ 25) and STOHFLA (< 35 and ≥ 35) scores. Additionally we also collected data on demographic information, educational experience, blood pressure recordings from 3 consecutive clinic visits.

RESULTS

The patients with a higher NLS score were younger (72 ± 9) as compared to those with lower NLS score (76 ± 9) (p = 0.005), and also had more years of education (16 ± 3 years v/s 13 ± 3 years; p <0.001). A higher proportion of patients with lower score on NLS had hypertension (95.10 % for NLS < 25 v/s 77.08 % for NLS > 25; p =0.001).

CONCLUSION

We validated a potentially useful nutritional literacy tool that might prove to be useful intervention aimed at identifying individuals with lower levels of education and insight regarding their nutritional behaviors.

Prognostic research and its potential role in modern gynaecology: a call for more prognostic research in urogynaecology

Over the last 30 years, many researchers have focussed on therapeutic and aetiological studies. Randomised controlled trials (RCT) are considered the 'gold standard' in research circles ( Ward et al. 2004 ). Prognostic research has been neglected probably due to a combination of a lack of perception of its importance and also a failure to produce good quality trials. The word 'prognosis' means the ability to foresee or predict an outcome or an event. Prognostic research in medicine is the ability to predict the likelihood of outcomes from a number of clinical variables. There are two main forms of prognostic research. One form identifies the prognostic value of a single risk factor (e.g. a tumour marker). The second one focuses on the development of a model based on multiple variables and is called multivariable prognostic modelling. The planning and powering of prognostic studies is managed differently from traditional randomised controlled trials.

Role of composite endpoints as an outcome assessment tool in urogenital prolapse

Our aim was to assess the role of composite endpoints as outcome assessment tools in urogenital prolapse. Women undergoing surgery for urogenital prolapse were recruited and followed-up over 1 year. 'Cure' following surgery was defined as: (1)

OBJECTIVE

POP-Q ordinal = 0 (pelvic organ prolapse quantification system); (2) Subjective: PGI-I = 1 or 2 (patient global impression of improvement); (3) Composite endpoint of cure: POP-Q ordinal = zero and patient goal achievement = 60%. Our results showed 'Composite cure' of POP was in 88.7%, while objective and subjective cure were 85.3% and 95.5%, respectively. Defining 'success' or 'failures' based on PGI-I scores was most discriminatory. Quality of life (QoL) was similar in treatment success or failure groups, where cure was measured objectively or using the composite endpoint. Composite endpoints should accurately represent cure as they combine objective measures and patient goals. However, these were not demonstrated as valid methods in defining success of prolapse surgery.

Persistence and adherence in the treatment of overactive bladder syndrome with anticholinergic therapy: a systematic review of the literature

Overactive bladder syndrome (OAB) is a chronic condition that has an impact on patients' daily activities and health-related quality of life (HRQL). Anticholinergic therapy is often prescribed following insufficient results with behaviour modification alone; however, rates of treatment discontinuation are consistently high. This study systematically reviewed persistence and adherence data in patients with OAB treated with anticholinergic therapy. A search focused on the intersection of OAB, persistence/adherence, and anticholinergic therapy was conducted in MEDLINE and EMBASE. Articles published after 1998 were reviewed and selected for inclusion based on prespecified criteria. A total of 147 articles and two abstracts were included in the review. Results from 12-week clinical trials showed high rates of discontinuation, ranging from 4% to 31% and 5% to 20% in treatment and placebo groups, respectively. Unsurprisingly, rates of discontinuation found in medical claims studies were substantially higher, with 43% to 83% of patients discontinuing medication within the first 30 days and rates continuing to rise over time. Findings from medical claims studies also suggest that over half of patients never refill their initial prescription and that adherence levels tend to be low, with mean/median medication possession ratio (MPR) values ranging from 0.30 to 0.83. The low levels of persistence and adherence documented in this review reveal cause for concern about the balance between the efficacy and tolerability of anticholinergic agents. Strategies should be identified to increase persistence and adherence. New agents and non-pharmacologic alternatives with good efficacy and minimal side effects should be explored.

Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence (SUI) through systematic review and economic modelling.

DATA SOURCES

The Cochrane Incontinence Group Specialised Register, electronic databases and the websites of relevant professional organisations and manufacturers, and the following databases: CINAHL, EMBASE, BIOSIS, Science Citation Index and Social Science Citation Index, Current Controlled Trials, ClinicalTrials.gov and the UKCRN Portfolio Database.

STUDY SELECTION

The study comprised three distinct elements. (1) A survey of 188 women with SUI to identify outcomes of importance to them (activities of daily living; sex, hygiene and lifestyle issues; emotional health; and the availability of services). (2) A systematic review and meta-analysis of non-surgical treatments for SUI to find out which are most effective by comparing results of trials (direct pairwise comparisons) and by modelling results (mixed-treatment comparisons - MTCs). A total of 88 randomised controlled trials (RCTs) and quasi-RCTs reporting data from 9721 women were identified, considering five generic interventions [pelvic floor muscle training (PFMT), electrical stimulation (ES), vaginal cones (VCs), bladder training (BT) and serotonin-noradrenaline reuptake inhibitor (SNRI) medications], in many variations and combinations. Data were available for 37 interventions and 68 treatment comparisons by direct pairwise assessment. Mixed-treatment comparison models compared 14 interventions, using data from 55 trials (6608 women). (3) Economic modelling, using a Markov model, to find out which combinations of treatments (treatment pathways) are most cost-effective for SUI.

DATA EXTRACTION

Titles and abstracts identified were assessed by one reviewer and full-text copies of all potentially relevant reports independently assessed by two reviewers. Any disagreements were resolved by consensus or arbitration by a third person.

RESULTS

Direct pairwise comparison and MTC analysis showed that the treatments were more effective than no treatment. Delivering PFMT in a more intense fashion, either through extra sessions or with biofeedback (BF), appeared to be the most effective treatment [PFMT extra sessions vs no treatment (NT) odds ratio (OR) 10.7, 95% credible interval (CrI) 5.03 to 26.2; PFMT + BF vs NT OR 12.3, 95% CrI 5.35 to 32.7]. Only when success was measured in terms of improvement was there evidence that basic PFMT was better than no treatment (PFMT basic vs NT OR 4.47, 95% CrI 2.03 to 11.9). Analysis of cost-effectiveness showed that for cure rates, the strategy using lifestyle changes and PFMT with extra sessions followed by tension-free vaginal tape (TVT) (lifestyle advice-PFMT extra sessions-TVT) had a probability of greater than 70% of being considered cost-effective for all threshold values for willingness to pay for a QALY up to 50,000 pounds. For improvement rates, lifestyle advice-PFMT extra sessions-TVT had a probability of greater than 50% of being considered cost-effective when society's willingness to pay for an additional QALY was more than 10,000 pounds. The results were most sensitive to changes in the long-term performance of PFMT and also in the relative effectiveness of basic PFMT and PFMT with extra sessions.

LIMITATIONS

Although a large number of studies were identified, few data were available for most comparisons and long-term data were sparse. Challenges for evidence synthesis were the lack of consensus on the most appropriate method for assessing incontinence and intervention protocols that were complex and varied considerably across studies.

CONCLUSIONS

More intensive forms of PFMT appear worthwhile, but further research is required to define an optimal form of more intensive therapy that is feasible and efficient for the NHS to provide, along with further definitive evidence from large, well-designed studies.

Pelvic organ prolapse and overactive bladder

AIMS

In this review we try to shed light on the following questions: *How frequently are symptoms of overactive bladder (OAB) and is detrusor overactivity (DO) present in patients with pelvic organ prolapse (POP) and is there a difference from women without POP? *Does the presence of OAB symptoms depend on the prolapsed compartment and/or stage of the prolapse? *What is the possible pathophysiology of OAB in POP? *Do OAB symptoms and DO change after conservative or surgical treatment of POP?

METHODS

We searched on Medline and Embase for relevant studies. We only included studies in which actual data about OAB symptoms were available. All data for prolapse surgery were without the results of concomitant stress urinary incontinence (SUI) surgery.

RESULTS

Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP. No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms. All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms. It is unclear what predicts whether OAB symptoms disappear or not. When there is concomitant DO and POP, following POP surgery DO disappear in a proportion of the patients. Bladder outlet obstruction is likely to be the most important mechanism by which POP induces OAB symptoms and DO signs. However, several other mechanisms might also play a role.

CONCLUSIONS

There are strong indications that there is a causal relationship between OAB and POP.

Urinary urgency - translating the evidence base into daily clinical practice

AIM

To consider the currently available knowledge and understanding of the symptom of urgency.

MATERIALS & METHODS

Each faculty member reviewed the literature base of a different aspect of urgency and along with their personal clinical experience provided a base of evidence for discussion.

RESULTS

This overview summarises relevant published literature and the current clinical experience of the authors.

DISCUSSION

Whilst the mechanisms producing the sensation of urgency are still not fully understood and we are working within a definition that may complicate measurement and treatment, our pressing need is to effectively manage our patients for whom the practical nature of urgency can be all too apparent.

CONCLUSION

Health care professionals have an important role to play today in helping to alleviate the widespread problem of urgency and its consequences.

Current trends in management of ectopic pregnancy in the United Kingdom

The potential advantages of laparoscopic management of ectopic pregnancy include lower morbidity, faster return to work, and less impact on reproductive health. This study aimed to investigate the current management of ectopic pregnancy in the United Kingdom. Thirty-five per cent of ectopic pregnancies are currently managed laparoscopically. Units that tended to operate laparoscopically were more likely to attempt to preserve the fallopian tube at surgery. Ninety per cent of units in the UK feel that they potentially could manage ectopic pregnancies laparoscopically but in practice only 60% managed any of the last three ectopic pregnancies by this technique.

Neurobiology of stress urinary incontinence: New insights and implications for treatment

Stress urinary incontinence (SUI) is a significant problem for millions of women, many of whom remain untreated for years, sometimes for life. One reason for this is the lack of effective pharmacologic therapy. The drugs used for urge incontinence have little or no effect on leakage occurring without detrusor contraction under conditions of increased intra-abdominal pressure. Recent studies suggest that extrinsic urethral sphincter closure may be controlled by enhancing neurotransmission in pudendal pathways. A new agent, duloxetine, which inhibits serotonin-norepinephrine re-uptake in these pathways, is now in clinical trials and appears to be the first effective pharmacologic therapy for SUI.

Baseline incontinence severity is predictive of the percentage of patients continent after receiving once-daily trospium chloride extended release

OBJECTIVE

It has been assumed that a patient's underlying baseline overactive bladder (OAB) incontinence severity is predictive of the resulting efficacy of pharmacological treatment. The objective of this study was to stratify and analyse the effects of baseline incontinence disease severity on the treatment outcome of the percentage of patients continent (PPC) during treatment with once-daily trospium chloride 60 mg extended release (XR).

METHODS

A post hoc analysis was conducted on pooled data from two 12-week, randomised, double-blind phase III studies in the USA in which 1165 patients with baseline urgency, and an average of >or= 1 urge urinary incontinence (UUI) episode/day and >or= 10 toilet voids/day on a 3-day bladder diary, received once-daily trospium chloride 60 mg XR (n = 578) or placebo (n = 587). Patients were stratified by the mean number of UUIs/day (1.0, > 1.0-2.0, > 2.0-5.0 or > 5.0) at baseline. The efficacy parameter that was analysed was complete continence (defined as no UUIs on a 3-day bladder diary collected at week 12 of treatment).

RESULTS

Baseline UUI levels were inversely correlated with the week 12 PPC (p < 0.0001). Post-treatment PPCs were higher with trospium chloride XR vs. placebo at all degrees of severity. Complete continence was achieved in 75% of trospium chloride XR recipients with 1.0 UUI/day at baseline and 48% of those with > 1.0-2.0 UUIs/day at baseline.

CONCLUSIONS

These findings support the assumption that baseline incontinence severity affects the likelihood of achieving continence from OAB therapy, and that patients with less severe OAB (e.g. 1 UUI/day) can expect higher 'dry rates' following treatment (e.g. up to 75%) than those with more severe OAB. This information can provide a useful tool for the physician and patient in establishing expectations during therapy.