Randomized, double-blind placebo controlled trial of the once daily antimuscarinic agent solifenacin succinate in patients with overactive bladder

PURPOSE

In this phase 3 trial we assessed the efficacy of solifenacin 5 mg and 10 mg daily in patients with symptoms related to overactive bladder. In addition, we assessed the safety and acceptability of solifenacin.

MATERIALS AND METHODS

The study was a multicenter, multinational, randomized, double-blind, placebo controlled trial. Patients were randomized to 12-week once daily treatment with solifenacin 5 mg, solifenacin 10 mg or placebo. The primary efficacy variable was changed from baseline to study end point in mean number of micturitions per 24 hours. Secondary efficacy variables included changes from baseline in mean number of urgency, nocturia and incontinence episodes per 24 hours, and mean volume voided per micturition.

RESULTS

Compared with changes obtained with placebo (-1.59), micturitions per 24 hours were statistically significantly decreased with solifenacin 5 mg (-2.37, p = 0.0018) and solifenacin 10 mg (-2.81, p = 0.0001). A statistically significant decrease was observed in the number of incontinence episodes with both solifenacin doses (5 mg, p = 0.002 and 10 mg, p = 0.016). This effect was also seen for episodes of urge incontinence (5 mg, p = 0.014 and 10 mg, p = 0.042). Of patients reporting incontinence at baseline, fully 50% achieved continence after treatment with solifenacin. Episodes of nocturia were statistically significantly decreased in patients treated with solifenacin 10 mg (-0.71, -38.5%) versus placebo (-0.52, -16.4%, p = 0.036). Episodes of urgency were statistically significantly reduced with solifenacin 5 mg (-2.84, -51%, p = 0.003) and solifenacin 10 mg (-2.90, -52%, p = 0.002). Mean volume voided per micturition was statistically significantly increased with both solifenacin doses (p = 0.0001). Treatment with solifenacin was well tolerated. Dry mouth, mostly mild in severity, was reported in 7.7% of patients receiving solifenacin 5 mg and 23% receiving solifenacin 10 mg (vs 2.3% with placebo).

CONCLUSIONS

In this study treatment with solifenacin 5 mg and 10 mg once daily significantly improved all the major symptoms of overactive bladder including frequency, urgency and incontinence. Solifenacin 10 mg also decreased the frequency of nocturia. Solifenacin therapy was associated with a favorable tolerability profile and a low incidence of dry mouth, especially at the 5 mg starting dose.

Long-term open-label solifenacin treatment associated with persistence with therapy in patients with overactive bladder syndrome

OBJECTIVE

To examine safety and tolerability findings as primary endpoints, and efficacy outcomes as secondary endpoints, of solifenacin treatment over a period of up to 1 year. Long-term efficacy in the treatment of overactive bladder (OAB) syndrome depends in part on the patient's persistence with pharmacologic therapy. Agents with a favourable therapeutic index supporting high levels of patient satisfaction and persistence are needed.

METHODS

The present study was a 40-week open-label extension of two 12-week, placebo-controlled, double-blind studies of solifenacin treatment in patients with OAB. Patients who completed the 12-week studies were offered participation in the open-label extension study. All patients who entered the open-label extension study initially received solifenacin 5 mg daily for 4 weeks, after which a flexible dosing regimen allowed patients to individualise their treatment (5 mg or 10 mg) at each of the 3 study visits. Safety and tolerability assessments (the primary variable) included adverse event reporting. Efficacy data were collected from micturition diaries completed at weeks 16, 28, 40, and 52.

RESULTS

Ninety-one percent (1637/1802) of patients who completed the two 12-week randomised studies chose to participate in the long-term open-label extension study. A total of 81% of patients completed 40 weeks of open-label treatment. Solifenacin treatment was safe and well tolerated, and rates of anticholinergic side effects were relatively low. Only 4.7% of patients discontinued treatment owing to adverse events. Improvements in major symptoms of OAB were noted for all patients for up to 52 weeks of treatment. In patients randomised to solifenacin in the double-blind studies, there were small incremental improvements in all efficacy parameters (reductions in episodes per 24 hours of urgency, reductions in frequency and urge incontinence, and increases in volume voided per micturition) over the course of the extension study. Efficacy was confirmed when outcomes were assessed as a function of total solifenacin exposure. Patient satisfaction with solifenacin tolerability (85%) and efficacy (74%) were high. These results indicate that long-term treatment with solifenacin was well tolerated and associated with improvements in efficacy parameters based on patient diary data recorded over the 12-month treatment period. Moreover, the high level of patient satisfaction reported appeared to correlate well with the quantified improvements in key symptoms demonstrated in this study.

CONCLUSIONS

Long-term therapy with solifenacin resulted in a favourable tolerability profile, and was associated with improvements in efficacy parameters based on diary data recorded over a 12-month period. This balance of tolerability and efficacy with solifenacin was associated with excellent persistence with therapy. These results suggest that solifenacin may be useful for the long-term treatment of the chronic symptoms associated with OAB.

Antidiuresis: a new concept in managing female daytime urinary incontinence

OBJECTIVE

To investigate the efficacy of desmopressin nasal spray on daytime urinary incontinence in women.

PATIENTS AND METHODS

A multicentre, multinational, randomized, double-blind, placebo-controlled, cross-over exploratory study of women (aged 18-80 years) complaining of severe daytime urinary incontinence was conducted in three centres (King's College Hospital; Boras County Hospital and Skejby Hospital). Seventy-five patients were screened of whom 64 were randomized. In all, 60 women received study medication (safety population) and 57 completed the study. The intention-to-treat population comprised 59 patients and there were 41 in the per protocol analysis. The primary efficacy endpoint was the number of periods with no leakage for 4 h after dosing. Women were instructed to take the drug at a time of their choosing, but >/= 4 h before bedtime. Secondary efficacy variables included the time to first void or incontinence episode, volume leaked per incontinence episode, total volume voided and number of periods with no leakage. All measurements were made over 7 days on desmopressin and 3 days on placebo.

RESULTS

There was a higher mean (sd) incidence of periods with no leakage in the first 4 h on desmopressin, at 62 (35)%, than on placebo, at 48 (40)%, and during the first 8 h, at 55 (37)% vs 40 (41)%. There was also a higher frequency of dry days on desmopressin than on placebo; 36% of patients had no leakage on virtually all treatment days (6 or 7) for 4 h after dosing. At 4-8 h the incidence of periods with no leakage on desmopressin was 68 (35)% vs 63 (41)% on placebo, and thereafter the incidence was similar. The time from dosing to first incontinence episode was longer on desmopressin, at 6.3 (2.5) h, vs 5.2 (3.3) h, whilst the volume leaked per incontinence episode was lower on desmopressin than placebo. The total volume voided was consistently lower on desmopressin, at 1180 (58) mL vs 1375 (57) mL, over the 24-h period after administration. There were no serious or severe adverse events reported. Seven women (11%) withdrew from the study, of whom five did not attend for the final visit and two (3%) because of mild adverse events.

CONCLUSIONS

The results of this exploratory study suggest that desmopressin is an effective and safe treatment in women with daytime urinary incontinence, and allows them to choose when they need treatment, thus improving motivation, which may aid compliance with therapy.

Correlating structure and function: three-dimensional ultrasound of the urethral sphincter

OBJECTIVE

Three-dimensional (3D) ultrasound facilitates assessment of the anatomy of the urethral sphincter, a decrease in sphincter volume being associated with stress incontinence. Urethral pressure profilometry (UPP) is used to assess urethral sphincter function although it is not diagnostic of stress incontinence. The aim of this pilot study was to determine whether 3D sphincter volume can be correlated with the area under the UPP curve.

METHODS

Primigravid women were recruited antenatally between 32 and 42 weeks' gestation. 3D transvaginal ultrasound scans of the urethra were performed in modified lithotomy position with a comfortably full bladder. Length and cross-sectional area were measured allowing the sphincter volume to be calculated. UPP measurements were performed with a Gaeltec solid-state pressure transducer and the area under the curve mapped out and calculated. All scans and measurements were repeated between 3 and 6 months postpartum.

RESULTS

Nineteen women participated in the study. Antenatal and postnatal data were available in all cases. There was a statistically significant correlation between antenatal sphincter volumes and area under the UPP curve although this relationship was lost following delivery.

CONCLUSIONS

There appears to be a correlation between structural anatomy and functional anatomy in the antenatal period although following delivery this is lost.

Morbidity after ambulatory urodynamics

AIMS

To identify urinary symptoms and morbidity after ambulatory urodynamics.

METHODS

One hundred consecutive women underwent ambulatory urodynamics for a variety of urinary complaints. Urinary symptom questionnaires were collected before investigation and again 48 hours later, reporting dysuria and haematuria. Women were screened for urinary tract infection before investigation and again 48 hours later.

RESULTS

Of the 91 women who completed the study, 1 (1.1%) had a positive urinary culture after the investigation but was asymptomatic. Seventeen women reported mild to moderate de novo dysuria.

CONCLUSIONS

Urinary symptoms and morbidity after ambulatory monitoring is low.

Does the menopause influence the risk of bacteriuria?

The objective of this study was to test the hypothesis that the risk of bacteriuria is increased as a result of estrogen deprivation following the menopause. All midstream urine samples (MSU) sent to the King's College Hospital department of microbiology by general practitioners in 1997 were assessed. Bacteriuria was diagnosed when the bacterial count was >10(5) organisms/ml. Logistic regression analysis was performed to investigate the effects of age and sex on the likelihood of having a positive result. Non-linear effects of age were investigated, with interest focusing in particlar on the time around the menopause. There were 15,392 MSU samples analyzed; 11,811 (77%) were from women and 3581 (23%) from men. In both sexes the proportion of positive results increased with increasing age (P<0.0001). The specimens taken from women were significantly more likely to be positive than those taken from a man of the same age (P<0.0001). In women there was no evidence of any non-linear relationship between age and the log odds of a positive result. A plot of the proportion of positive results versus age did not suggest any departure from a linear relationship at or following the menopause. In conclusion, the increased risk of bacteriuria which occurs as women get older appears to happen gradually as a result of the aging process, rather than as the result of pathophysiological changes in the urogenital tract that take place at or following the menopause.

Pharmacological management of detrusor instability

Urinary incontinence and lower urinary tract dysfunction remain an important cause of morbidity, affecting at least 14% of women over the age of 30 years. Whilst the etiology and pathophysiology of detrusor instability remains to be elucidated drug therapy remains important in the management of women with the irritative symptoms of urgency, frequency and urge incontinence. The number of drugs which have been developed illustrates the point that none are ideal, often having systemic adverse effects limiting their therapeutic usage and affecting compliance. This review aims to assess the current pharmacological management of detrusor instability as well as examining recent progress in the development of new agents, some of which may prove to be efficacious.

Urodynamic techniques

Appropriate investigation is essential to a full evaluation of any patient with urinary incontinence, as accurate diagnosis leads to correct treatment. This paper describes the various investigations for lower urinary tract dysfunction, and their main indications. They include the pad test, uroflowmetry, subtracted cystometry, and more complex investigations such as videocystourethrography, ambulatory urodynamics, urethral pressure profilometry, magnetic resonance imaging and electromyography. Although not every patient requires extensive investigation, appropriate use of tests of lower urinary tract function provides useful information on which to base appropriate treatment.

The role of estrogen supplementation in lower urinary tract dysfunction

The female lower urinary and genital tracts both arise from the primitive urogenital sinus and develop in close anatomical proximity. Sex hormones have a substantial influence on the female lower urinary tract throughout adult life, with fluctuations in their level leading to macroscopic, histological and functional changes. Urinary symptoms may therefore develop during the menstrual cycle, in pregnancy and following the menopause. Estrogen deficiency, particularly when prolonged, is associated with a wide range of urogenital complaints, including frequency, nocturia, incontinence, urinary tract infections and the 'urge syndrome'. Estrogen supplementation subjectively improves urinary stress incontinence but there is no objective benefit when given alone; however, estrogen given in combination with phenylpropanolamine may be clinically more useful. Hormone replacement therapy does appear to treat postmenopausal irritative urinary symptoms such as frequency and urgency, possibly by reversing urogenital atrophy, and there is also evidence to suggest that estrogens can provide prophylaxis against recurrent urinary tract infections. However, the 'best' type of estrogen, route of administration and duration of therapy are at present unknown.

Retropubic urethropexy (Burch colposuspension)

Many varied procedures have been described for the surgical treatment of female stress incontinence. Over the years these have had enthusiastic proponents, but not until the recent publication of two systematic literature reviews did their relative efficacies become apparent. At present it would appear that open suprapubic urethropexy is the current 'gold standard' procedure. Many new minimal-access techniques aimed at reducing the morbidity of a Burch colposuspension have been proposed. However, careful analysis of the medium- to long-term success of these procedures and their associated complications is needed before they are adopted universally.

A new intravaginal device for stress incontinence in women

OBJECTIVE

To compare two versions of the same type of disposable intravaginal device (the Conveen Continence Guard, CCG, and the Contrelle Continence Tampon, CCT, Coloplast a/s, Humlebaek, Denmark) for treating stress incontinence in women.

PATIENTS AND METHODS

Women with the predominant symptom of stress incontinence were recruited from four centres in Denmark, Australia and the UK. The women were assessed using a 24-h pad-test, uroflowmetry, postvoid residual urine volume and a voiding diary before treatment, and after 5 weeks using each of the two devices. Vaginal swabs and specimens of urine were sent for culture, and a questionnaire about the subjective effect and adverse events completed at each visit. In all, 94 women were recruited, of whom 62 (66%) completed the study.

RESULTS

Both devices reduced the amount of leakage significantly, but the CCT reduced urine loss significantly more than the CCG. Uroflowmetry values and residual urine volume were unchanged when using the two devices. Vaginal culture showed no abnormality during the study period, and only one woman was treated for a urinary tract infection. Side-effects were few and not serious. The women found both devices easy to prepare, insert and use; two-thirds preferred the CCT to the CCG.

CONCLUSION

The new intravaginal device (CCT) is more effective for treating stress incontinence than the currently available version (CCG), and patient acceptability of the new device seems to be superior.

The impact of the menstrual cycle on urinary symptoms and the results of urodynamic investigation

Four hundred and eighty-three consecutive women referred for videocystourethrography completed a structured questionnaire about their menstrual status and urinary symptoms. Women were included in the study if they were premenopausal, had a regular menstrual cycle and were not taking hormonal therapy. One hundred and thirty-three women satisfied the inclusion criteria of whom 55 (41%) complained that their urinary symptoms were cyclical. The times at which symptoms were said to be at their worst were reported by the women as follows: during a period (n = 20; 36%); just after a period (n = 4; 7%); middle of the month (n = 8; 15%); just before a period (n = 23; 42%). The prevalence of abnormal detrusor activity on videocystourethrography increased significantly with time from the last menstrual period (chi2 for trend = 6.56, P = 0.01) and might reflect increases in the circulating level of progesterone following ovulation. This study provides further indirect evidence that progesterone could have an adverse effect on female lower urinary tract function. In addition, it might be necessary to consider the stage within the menstrual cycle when interpreting the results of urodynamic investigation.

A systematic review of estrogens for recurrent urinary tract infections: third report of the hormones and urogenital therapy (HUT) committee

Our objective was to apply a meta-analysis to the available data to evaluate the effect of estrogen supplementation in the prevention of recurrent urinary tract infections in postmenopausal women. The literature review incorporated articles based on a search of Excerpta Medica, Medline, Science Citation Index and a manual search of commonly read journals in the fields of urology, gynecology, gerontology and primary healthcare, from January 1969 to December 1998. The search was not limited to English-language publications. Inclusion criteria were peer-reviewed articles containing original data with a primary outcome of symptomatic urinary tract infections and an estrogen-treated group. Articles were categorized into randomized controlled trials, case-control studies and self-controlled series. Of the articles reviewed, five were randomized controlled trials, two were case-control studies and three were self-control series. Meta-analysis of data from 334 subjects revealed a significant benefit from estrogen over placebo (odds ratio = 2.51, 95% confidence interval = 1.48 4.25). The most convincing results were obtained using the vaginal route of administration. A variety of different estrogen preparations have been employed in the few published reports, making comparison of the data difficult. However, vaginal administration seems to be effective in the prevention of recurrent urinary tract infections in postmenopausal women.

How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study

OBJECTIVE

To determine the prevalence of chronic and debilitating symptoms of the overactive bladder, defined here as the presence of chronic frequency, urgency and urge incontinence (either alone or in any combination), and presumed to be caused by involuntary detrusor contractions. Subjects and methods Data were collected using a population-based survey (conducted by telephone or direct interview) of men and women aged >/= 40 years, selected from the general population in France, Germany, Italy, Spain, Sweden and the United Kingdom, using a random stratified approach. The main outcome measures were: prevalence of urinary frequency (> 8 micturitions/24 h), urgency and urge incontinence; the proportion of participants who had sought medical advice for symptoms of an overactive bladder; and current or previous therapy received for these symptoms.

RESULTS

In all, 16 776 interviews were conducted in the six European countries. The overall prevalence of overactive bladder symptoms in individuals aged >/= 40 years was 16.6%. Frequency (85%) was the most commonly reported symptom, followed by urgency (54%) and urge incontinence (36%). The prevalence of overactive bladder symptoms increased with advancing age. Overall, 60% of respondents with symptoms had consulted a doctor but only 27% were currently receiving treatment. Conclusion Symptoms of an overactive bladder, of which frequency and urgency are as bothersome as urge incontinence, are highly prevalent in the general population. However, only a few affected individuals currently receive treatment. Taken together, such findings indicate that there is considerable scope for improvement in terms of how physicians diagnose and treat this condition.

Three-dimensional ultrasound: a novel technique for investigating the urethral sphincter in the third trimester of pregnancy

OBJECTIVES

To measure urethral sphincter volume by three-dimensional (3D) ultrasound. To assess the reproducibility of this measurement technique and to compare volumes obtained using 3D ultrasound with volumes calculated from a formula based on 2D ultrasound measurements.

METHODS

Women were recruited as part of an ongoing study of changes to the pelvis resulting from pregnancy and childbirth. One hundred and eleven women in the third trimester of pregnancy (between 32 and 41 completed weeks' gestation) underwent a 3D transvaginal ultrasound scan of the urethra. In 10 cases the scan was analyzed twice by different observers to assess the reproducibility of the measurements from the scans and the results were analyzed using limits of agreement.

RESULTS

The interobserver error was consistent between all the linear, 2D and 3D measurements obtained from the area scanned. There was a significant difference between volumes calculated directly by 3D ultrasound and the approximated volumes from conventional 2D measurements.

CONCLUSIONS

Three-dimensional ultrasound appears to be a useful tool in measuring urethral sphincter volume. The error is consistent with that of linear and 2D imaging. However, the increase in normal range generated by biological variation in all three planes makes 3D ultrasound a more sensitive method of evaluating change to the urethral sphincter.

A comparison of the objective and subjective outcomes of colposuspension for stress incontinence in women

OBJECTIVES

To investigate the impact of colposuspension for stress incontinence on the symptoms and quality of life of women undergoing both primary and repeat surgery for genuine stress incontinence and in addition to assess the use of a condition specific quality of life questionnaire as an outcome measure following surgery.

DESIGN

Prospective case series: videocystourethrography performed before and between six and twelve months after surgery. Validated condition specific quality of life (QoL) questionnaires completed by women before and six to twelve months after surgery.

SETTING

A tertiary referral Urogynaecology Unit in a teaching hospital.

PARTICIPANTS

A consecutive series of 83 women undergoing colposuspension between March 1995 and December 1997. Pre-operative assessment and surgery was performed by, or was under the direct supervision of, the unit director.

INTERVENTION

Modified Burch colposuspension.

MAIN OUTCOME MEASURES

Objective results of surgery assessed with videocystourethrography. Subjective results evaluated using a condition specific QoL tool, the Kings Health Questionnaire (KHQ). Symptom severity was evaluated as a component of the condition specific QoL questionnaire.

RESULTS

Objective cure was demonstrated in 92% of women undergoing primary surgery with an 8% incidence of de-novo detrusor instability and a 10% incidence of voiding difficulties. In the group of women having repeat surgery the objective cure rate was 81% with no de-novo detrusor instability and a 6% incidence of post-operative voiding difficulties. QoL scores improved in 95% of women. Improvements of over 25% were seen in 70% of women and of over 50% in 28%. However, 2.4% of women recorded a deterioration in QoL scores.

CONCLUSIONS

Colposuspension performed in this setting, assessed using both objective and standardised subjective measures, completed by women themselves, appears to produce good objective and subjective results and leads to enhanced quality of life in the great majority of women.

[Coxitis due to multidrug resistant Mycobacterium tuberculosis in a HIV negative patient]

A case of an HIV negative female patient with coxofemoral arthritis of tuberculous etiology, multidrug-resistant strain, and connective tissue disease associated to glucocorticoid therapy is reported. The patient was treated with cycloserine, ethambutol, p-aminosalicylic acid and ofloxacin, with improvement of the joint lesions. Previous publications on this subject are reviewed.

Evaluating ambulatory urodynamics: a prospective study in asymptomatic women

OBJECTIVE

To identify abnormal detrusor contractions in asymptomatic women undergoing ambulatory urodynamics, to standardise the investigation technique for women with urinary symptoms for clinical practice.

DESIGN

Prospective observational study.

SETTING

Two tertiary referral urogynaecology units: one in London, UK and one in Varese, Italy.

METHODS

Women without urinary symptoms were recruited into the study. Ambulatory urodynamics was performed according to the King's College Hospital protocol. All the traces were analysed in four different ways: 1. without the second bladder transducer measurements displayed on the screen and without the diary; 2. as in 1. but with the diary; 3. with the second bladder sensor displayed on the screen but without the diary; 4. as in 3. but with the diary. The diary was always interpreted at the end of the test with the woman present. For each method we reported the total number of detrusor contractions and whether the woman would have been diagnosed as having abnormal detrusor contraction. Cochran's Q test was used for statistical analysis.

RESULTS

Twenty-six women (mean age 31.7 years) were recruited. Ambulatory urodynamic testing lasted an average of 3.57 hour. The diagnosis of abnormal detrusor contraction varied by 65.4% depending on the method of analysis used. The diary and the women's symptoms during the test were the most discriminating factors. A significant difference between the diagnoses was obtained when comparing the four different ways of analysis. According to our protocol only three women (11.5%) had abnormal detrusor contractions.

CONCLUSIONS

Using our protocol almost 90% of asymptomatic women have a stable bladder on ambulatory urodynamics. This is similar to the results of labouratory urodynamic testing of asymptomatic women but is in contrast to previous reports of ambulatory urodynamics of asymptomatic women. The technique used during ambulatory urodynamics determines the tests ability to detect detrusor instability with an accurate symptom diary being the most important.

Genuine stress incontinence: colpocystourethropexy versus sling procedures

Both colpocystourethropexy (colposuspension) and sling operations have been shown to be effective in treating female stress incontinence. The present review discusses the literature available and compares the results and complications of both procedures. Colposuspension can give excellent results as both primary and secondary surgery. Slings also give excellent results, but are prone to complications relating to the sling material and postoperative voiding difficulties. Slings are arguably best reserved for women in whom vaginal scarring makes colposuspension impossible. Colposuspension remains the gold standard operation against which new techniques should be compared.