A Primer for the Primary Care Physician: Management of Overactive Bladder Syndrome

Overactive bladder syndrome affects millions of women in the U.S. and is defined by urinary urgency, urinary frequency, and small volume voids, with or without nocturia and incontinence. Overactive bladder is a diagnosis of exclusion, and several therapies exist for the management of this condition. This article outlines a systematic approach that the primary care physician can take when treating a patient with overactive bladder.

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study

Objective

To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence.

Design

Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources.

Methods

Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken.

Results

Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties.

Conclusions

Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

Tibial nerve stimulation to inhibit the micturition reflex by an implantable wireless driver microstimulator in cats

BACKGROUND

Traditional tibial nerve stimulation (TNS) has been used to treat overactive bladder syndrome (OAB), but there are some shortcomings. Thus, a novel alternative is needed for the treatment of OAB. The study investigated the effects of a new type of tibial nerve microstimulator on the micturition reflex in cats.

METHODS

An implantable wireless driver microstimulator was implanted around the tibial nerve in 9 α-chloralose anesthetized cats. Cystometry was performed by infusing 0.9% normal saline (NS) or 0.25% acetic acid (AA) through a urethral catheter. Multiple cystometrograms were performed before, during, and after TNS to determine the inhibitory effect of the microstimulator on the micturition reflex.

RESULTS

TNS at 2 threshold (T) intensity significantly increased the bladder capacity (BC) during NS infusion. Bladder overactivity was irritated by the intravesical infusion of 0.25% AA, which significantly reduced the BC compared with the NS infusion. TNS at 2 T intensity suppressed AA-induced bladder overactivity and significantly increased the BC compared with the AA control.

CONCLUSION

The implantable wireless driver tibial nerve microstimulator appears to be effective in inhibiting the micturition reflex during physiologic and pathologic conditions. The implantable wireless driver tibial nerve microstimulator could be used to treat OAB.

Posterior tibial nerve stimulation using a wirelessly powered system in anesthetized cats

Posterior Tibial Nerve Stimulation (PTNS) is an effective overactive bladder (OAB) therapy where electrical pulses are typically delivered once per week in a 12-week stimulation regime. While the mechanism of action remains unknown, effective long-term delivery of PTNS has recently become a subject of concern. To this end, a multi-contact electrode was surgically placed in the hind limb region of anesthetized cats to (1) investigate the feasibility of using a wirelessly powered system to stimulate PTN afferents and (2) characterize implant-driven effects of stimulation frequency on modulating bladder activity. Using an isovolumetric model, short-duration, supra-threshold stimulation trials were applied with frequencies ranging from 2-20 Hz. The results provide first pre-clinical evidence of frequency-dependent modulation of bladder function supporting the use of a novel therapeutic approach that can be clinically translated to potentially address multiple symptoms of lower urinary tract system.

Temporal summation to thermal stimuli is elevated in women with overactive bladder syndrome

INTRODUCTION

This study sought to provide a preliminary assessment of whether spinally mediated afferent hyperactivity (i.e., central sensitization) might contribute to manifestations of overactive bladder syndrome (OAB) in women as indexed by elevated temporal summation of evoked heat pain stimuli.

METHODS

We recruited 20 adult women with OAB who were planning to undergo interventional therapy for OAB with either onabotulinumtoxinA injection or sacral neuromodulation and 23 healthy controls without OAB symptoms to undergo quantitative sensory testing with cutaneous thermal pain temporal summation. The primary study outcome was the degree of temporal summation, as reflected in the magnitude of positive slope of the line fitted to the series of 10 stimuli at the 49°C target temperatures. Linear regression and analysis of covariance were utilized to compare the degree of temporal summation between study groups.

RESULTS

The standardized slope of temporal summation trials for women with OAB was significantly higher than for controls (β = 3.43, 95% confidence interval = 0.6-6.2, P = 0.017). The adjusted means ±SE of the standardized temporal summation slopes for the full OAB and control groups were 3.0 ± 0.5 (95% confidence interval = 2.0, 4.1) and 1.7 ± 0.5 (95% confidence interval = 0.7, 2.7), respectively.

CONCLUSION

In this preliminary study, we demonstrated that women with OAB refractory to primary and secondary therapies exhibited greater thermal cutaneous temporal summation than women without OAB symptoms. This suggests that central sensitization, indexed by temporal summation, may be an underlying factor contributing to OAB in some women. Neurourol. Urodynam. 36:1108-1112, 2017. © 2016 Wiley Periodicals, Inc.

Can Urinary Nerve Growth Factor and Brain-Derived Neurotrophic Factor be used in the Diagnosis and Follow-Up of Voiding Dysfunction in Children?

PURPOSE

We investigated the utility of urinary nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) levels as non-invasive markers for diagnosis and evaluation of treatment efficacy in children with overactive bladder (OAB).

MATERIALS AND METHODS

This prospective study included 24 children with OAB and 30 healthy controls. At the time of diagnosis, micturition disorder symptom scores (MDSS) were determined, blood and urine samples were collected, and anticholinergic therapy was initiated. Clinical responses were evaluated, at the third and sixth month of treatment, by MDSS and urinary NGF, BDNF, and creatinine levels.

RESULTS

The patient group had significantly higher urine NGF/Cr ratio (975 ± 827 and 159 ± 84, respectively, P < .001) and BDNF/Cr ratio (5.98 ± 5.78 and 0.81 ± 0.70, respectively, P < .001) before treatment. Significantly decreased BDNF/Cr ratio was found at the sixth month (5.98 ± 5.78 and 2.24 ± 0.98, respectively, P = .004). NGF/Cr > 360 was found to have 87.5% sensitivity and 100% specificity, and BDNF/Cr > 1.288 was found to have 87.5% sensitivity and 83.3% specificity for OAB diagnosis.

CONCLUSION

In conclusion, urine NGF/Cr and BDNF/Cr ratios may be useful markers for diagnosis of OAB. The BDNF/Cr ratio was found to be more significant in monitoring treatment response.&nbsp.

Urodynamic findings in patients with Creutzfeldt-Jakob disease: a case report

AIM OF STUDY

Urinary dysfunction in Creutzfeldt-Jakob disease (CJD) patients is attributed to functional incontinence, since they often have immobility and loss of motivation. In contrast, previously no urodynamic findings are available in CJD patients.

CASE REPORT

We had 2 CJD patients who had urinary frequency and urinary retention. We performed urodynamics with the spouse's informed consent in order to explore the mechanism of urinary dysfunction in those cases. Case 1 had typical acute cognitive deterioration with incontinence and urinary retention, while case 2 had subacute cognitive deterioration (that started after admission) and nocturia. The urodynamic findings were diverse. One feature was detrusor overactivity during bladder filling in case 1. Another feature of urodynamic finding includes neurogenic change of sphincter EMG in case 1 and decreased bladder sensation in case 2.

CONCLUSION

Urodynamics in our two CJD patients revealed detrusor overactivity and neurogenic sphincter electromyogram, presumably reflecting pathological lesions in the prefrontal cortex/basal ganglia as well as the sacral spinal cord in CJD.

Is vaginal fractional CO2 laser treatment effective in improving overactive bladder symptoms in post-menopausal patients? Preliminary results

OBJECTIVE

To evaluate the role of vaginal fractional CO2 laser treatment in the relief of Overactive Bladder (OAB) symptoms in post-menopausal women.

PATIENTS AND METHODS

Post-menopausal women who complained of one or more symptoms related to vulvo-vaginal atrophy (VVA), who experienced symptoms of OAB and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment T1), vaginal status (using Vaginal Health Index - VHI), subjective intensity of VVA symptoms (using a visual analog scale - VAS) and micturition diary were evaluated. OAB symptoms were also assessed using a validated questionnaire.

RESULTS

Thirty patients were enrolled. A statistically significant improvement in VVA symptoms was observed and in VHI at T1 (p < 0.0001). A significant improvement was also identified in the micturition diary, in number of urge episodes and OAB-q (p < 0.0001). Nine of the 30 patients suffered from incontinence episodes and had improved at T1.

CONCLUSIONS

We showed that fractionated CO2 laser vaginal treatment has proved to be effective in improving OAB symptoms in post-menopausal women. Moreover, it is a safe and efficacious measure for the relief of VVA related conditions. Further long-term studies are needed to confirm these preliminary results.

Cycling Versus Continuous Mode In Neuromodulator Programming: A Crossover, Randomized, Controlled Trial

This is a randomized, controlled, blind, crossover trial comparing cycling versus continuous programming of a sacral neuromodulator in women diagnosed with overactive bladder (OAB). At 6 months, treatment order significantly affected Overactive Bladder Questionnaire - Short Form (OABq-SF) symptom scores. The cycling followed by continuous stimulation group had superior OABq-SF scores (p > 0.02).

[Prevalence and initial management of overactive bladder in France: A cross-sectional study]

AIMS

To determine the prevalence of overactive bladder (OAB) syndrome in France and gather data about initial patient trajectories in the healthcare system.

METHODS

A dedicated questionnaire (41 questions) has been sent to a 12,000 sample of people representative of the global population. The following data were investigated: social and demographic features, medical history, Urinary Symptom Profile questionnaire, bother, history of symptoms, care seeking and treatments received. Patient were considered having OAB in case if presenting at least two episodes of urgency per week, or being under treatment of OAB. OAB prevalence was the main outcome, and associated factors were characterized by univariate and multivariate analysis.

RESULTS

Based on 8842 available questionnaires, the global prevalence of OAB was estimated to be 14.4%. Prevalence was significantly higher in women, older age groups, as well as obesity, irritable bowel syndrome, urinary tract infections, enuresia, constipation, anxiety/depression, neurological diseases, sleep apnea syndrome, asthma, chronic obstructive pulmonary disease, diabetes and hypertension. Only 34.6% of patients with OAB had visited a health practitioner for this problem. General practitioners were most frequently implicated in patient primary care and evaluation. Seventy-two percent of patients with OAB had had additional investigations (mostly a urine culture) and only 6% of patients had to complete a bladder diary. The most frequent treatment option was oral antimuscarinics. Physical therapy and rehabilitation have been prescribed in 26% of cases, as well as dietary advice.

CONCLUSIONS

OAB is a frequent syndrome. Its prevalence increases with age, and OAB frequently concern elderly frail people with many other associated diseases.

LEVEL OF EVIDENCE

3.

[Animated biofeedback for the dysfunctional voiding syndrome]

OBJECTIVES

To analyze clinical and electromyographic treatment outcome of dysfunctional voiding (DV) with animated Biofeedback (Bfb). Clinical or electromyographic variables associated with higher success rate were checked.

PATIENTS AND METHODS

Cross-sectional study of patients with DV, that in 2010- 2015 followed animated Bfb program. Efficacy was measured with Uroflowmetry, Electromyography (EMG) and validated clinical questionnaire. Inclusion criteria: no myelodysplasia, no anatomical malformations and a minumin of 3 Bfb sessions. Clinical variables: age, number of sessions, daytime leaks, nocturnal enuresis, constipation, UTI, VUR. Flow measurement variables: morphology of curves, electromyogram, flows, and elevated post void residual (PVR).

RESULTS

Of 37 patients who received Bfb, 27 girls who met inclusion criteria were selected. Mean age: 7.8 years (2.5). Twelve (44%) had detrusor overactivity on urodynamics concomitantly. Globally, all clinical and flowmetry parameters improved. Clinically 33.5% had complete resolution of symptoms, 37% improved (> 50% of symptoms according to criteria ICCS) and 29% had no improvement. In EMG, 74% achieved normal perineal relaxation. Constipation at baseline is associated with lower rates of success (cure: 13 vs. 58%, p = 0.019; cure + improvement: 60% vs. 83% p> 0.05). The absence of RPM at the end of the study was associated with clinical improvement (cure: 66.7% vs. 0%, p = 0.012; cure + improvement: 89% vs. 60%, p> 0.05).

CONCLUSIONS

Bfb in DV provides cure or improvement and electromyographic resolution are 69 and 74% respectively. The absence of constipation is associated with higher success rates. The High RPM correlates with persistence of clinics.

Electrical stimulation with non-implanted electrodes for overactive bladder in adults

BACKGROUND

Several options exist for managing overactive bladder (OAB), including electrical stimulation (ES) with non-implanted devices, conservative treatment and drugs. Electrical stimulation with non-implanted devices aims to inhibit contractions of the detrusor muscle, potentially reducing urinary frequency and urgency.

OBJECTIVES

To determine the effectiveness of: ES with non-implanted electrodes compared with placebo or any other active treatment for OAB; ES added to another intervention compared with the other intervention alone; different methods of ES compared with each other.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 10 December 2014). We searched the reference lists of relevant articles and contacted specialists in the field. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials of ES with non-implanted devices compared with any other treatment for OAB in adults. Eligible trials included adults with OAB with or without urgency urinary incontinence (UUI). Trials whose participants had stress urinary incontinence (SUI) were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data from eligible trials and assessed risk of bias, using the Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

We identified 51 eligible trials (3443 randomised participants). Thirty-three trials did not report the primary outcomes of subjective change in OAB symptoms. The majority of trials were deemed to be at low or unclear risk of selection and attrition bias and unclear risk of performance and detection bias. Lack of clarity with regard to risk of bias was largely due to poor reporting.Twenty-three trials (1654 participants) compared ES with no active treatment, placebo or sham treatment. Moderate-quality evidence indicated that OAB symptoms were more likely to improve in people receiving ES than with no active treatment, placebo or sham treatment (relative risk (RR) for no improvement 0.54, 95% confidence interval (CI) 0.47 to 0.63). Moderate-quality evidence indicated that similar numbers of people receiving ES and no active treatment, placebo or sham treatment experienced adverse effects.Eight trials (542 participants) compared ES with conservative treatment. Very low-quality evidence suggested no evidence of a difference between ES and PFMT or PFMT plus biofeedback in OAB symptoms (RR for no improvement 0.79, 95% CI 0.51 to 1.21 and 0.97, 95% CI 0.60 to 1.57 respectively). There was no evidence of a difference between ES and conservative treatment with regard to adverse effects.Sixteen trials (894 participants) compared ES with drug treatment (probanthine, tolterodine, oxybutynin, propantheline bromide, solifenacin succinate, terodiline, trospium chloride, terodiline). Moderate-quality evidence indicated that OAB symptoms were more likely to improve with ES than drug treatment (RR for no improvement 0.66, 95% CI 0.48 to 0.90). Low-quality evidence suggested a greater risk of adverse effects with oxybutynin (RR 1.26, 95% CI 1.07 to 1.49) and with tolterodine (RR 1.51, 95% CI 1.21 to 1.89) than with ES. There was insufficient evidence of a difference between ES and trospium hydrochloride (RR 0.73, 95% CI 0.43 to 1.25).Eight trials (252 participants) compared ES combined with another treatment versus the other treatment alone, two trials (48 participants) compared ES plus conservative treatment with no active treatment, placebo or sham treatment and six trials (361 participants) compared different types of ES. None of these comparisons had sufficient evidence to indicate any differences between the treatment groups in terms of OAB or adverse effects.Moderate-quality evidence suggested that ES improved OAB-related quality of life more than no active treatment, placebo or sham treatment. There was insufficient evidence of any difference between ES and any other treatment with regard to quality of life.There was insufficient evidence to determine if the benefits of ES persisted after the active treatment period stopped.

AUTHORS' CONCLUSIONS

Electrical stimulation appeared to be more effective than both no treatment and drug treatment for OAB. There was insufficient evidence to determine if ES was more effective than conservative treatment or which type of ES was more effective. This review underlines the need to conduct well-designed trials in this field measuring subjective outcomes and adverse effects.

Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial

Background

Somatic afferent nerve stimuli are used for treating an overactive bladder (OAB), a major cause of nocturia in the elderly. Clinical evidence for this treatment is insufficient because of the lack of appropriate control stimuli. Recent studies on anesthetized animals show that gentle stimuli applied to perineal skin with a roller could inhibit micturition contractions depending on the roller’s surface material. We examined the efficacy of gentle skin stimuli for treating nocturia.

Methods

The study was a cross-over, placebo-controlled, double-blind randomized clinical study using two rollers with different effects on micturition contractions. Participants were elderly women (79–89 years) with nocturia. Active (soft elastomer roller) or placebo (hard polystyrene roller) stimuli were applied to perineal skin by participants for 1 min at bedtime. A 3-day baseline assessment period was followed by 3-day stimulation and 4-day resting periods, after which the participants were subjected to other stimuli for another 3 days. The primary outcome was change in the frequency of nighttime urination, for which charts were maintained during each 3-day period.

Results

Twenty-four participants were randomized, of which 22 completed all study protocols. One participant discontinued treatment because of an adverse event (abdominal discomfort). In participants with OAB (n = 9), change from baseline in the mean frequency of urination per night during the active stimuli period (mean ± standard deviation, −0.74 ± 0.7 times) was significantly greater than that during placebo stimuli periods (−0.15 ± 0.8 times [p < 0.05]). In contrast, this difference was not observed in participants without OAB (n = 13).

Conclusions

These results suggest that gentle perineal stimulation with an elastomer roller is effective for treating OAB-associated nocturia in elderly women. Here the limitation was a study period too short to assess changes in the quality of sleep and life.

Trial Registration

UMIN Clinical Trial Registry (CTR) UMIN000015809

Overactive bladder - 18 years - Part II

Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics - pillars of the overactive bladder pharmacotherapy - started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning - as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder - 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Gender differences in overactive bladder

Overactive bladder (OAB) is a common condition in both women and men. Although prevalence's are similar in both genders, sex specific differences do exist in relation to individual OAB symptoms as well as degree of bother and quality of life. The added effect of prostatic enlargement in men leads to slightly different evaluation and treatment regimens in both genders. This review will examine the gender differences in OAB related to epidemiology, OAB evaluation, investigation and treatment. This information will assist the primary care physician in assessing and initiating treatment in patients with OAB. It will further the understanding of the spectrum of treatments available for OAB and assist in determining the appropriateness and timing of referral of such patients to a urologist.

Communicating with mismatch and tension: treatment provision experiences of primary care doctors treating patients with overactive bladder in Hong Kong

BACKGROUND

Overactive bladder (OAB) is a common chronic bladder dysfunction worldwide. As the first contact point of health care, primary health care providers are often consulted by patients seeking initial consultation for OAB. The relatively short history of the existence of OAB in medicine and low public awareness of OAB in Hong Kong, however, often serve as a challenge to primary health care providers in treating patients with OAB. The experiences of patients and health care providers are often influenced by the interaction between these two groups, hence both health care providers and patients are key determinants of the entire treatment experience, and the perspectives of health care providers should not be overlooked. However, patient experiences have been the main focus of related studies, few of which have examined the treatment provision experiences and perspectives of health care providers. This research gap is notable considering that the satisfaction and morale of health care providers can influence treatment outcome.

METHODS

This study adopted a qualitative research approach by conducting semistructured individual interviews with 30 private practice primary care doctors in Hong Kong between November 2013 and May 2014.

RESULTS

Lacking confidence in treating OAB patients, encountering mismatch with patients in treatment expectations and communication style, and feeling embarrassed when communicating with OAB patients were the experiences reported by the sampled doctors.

CONCLUSION

The sampled doctors' treatment provision experiences revealed a general lack of knowledge about OAB among primary care doctors in Hong Kong. Furthermore, the negative stereotype of and lack of trust in private practice doctors created tension between the doctors and patients. This lack of mutual trust was particularly unfavourable for the doctors to provide long-term treatment and support to patients with OAB. The embedded distrust of private practice doctors also affected the prescribing behaviour of the doctors, who prescribed medication only to satisfy patient demands, which may lead to antibiotic abuse and resistance. Finally, the expectations of doctor professionalism and behaviour in Chinese cultures and the cultural perceptions of urinary diseases caused challenging treatment provision experiences for the sampled doctors.

[Overactive bladder syndrome--a public health challenge]

Overactive bladder is a highly prevalent clinical syndrome affecting up to 17% of women. It is often associated with urodynamic detrusor overactivity, leads to embarrassment and is frequently under-diagnosed and insufficiently treated. Its pathophysiology is complex and the numerous treatment modalities, some of them of poor evidence, aim to improve quality of life. When physiotherapy fails, anticholinergics are recommended as first-line medical treatment. They can be combined with or replaced by beta3-adrenergic agonists whereas sacral neuromodulation or posterior tibia nerve stimulation are considered an efficient alternative. Addidtionally, cystoscopic injection of botulinum toxine in the bladder has recently been validated in Switzerland as a treatment option for idiopathic overactive bladder.

Transcutaneous posterior tibial nerve stimulation versus extended release oxybutynin in overactive bladder patients. A prospective randomized trial

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the effectiveness of transcutaneous posterior tibial nerve stimulation (T.C. PTNS) versus extended release oxybutynin (E.R.O.) in patients with overactive bladder.

MATERIALS AND METHODS

Seventy female patients were randomized to receive either 10mg E.R.O. daily or T.C. PTNS, using a TENS machine program with the 20Hz, 200 cycles/s, and normal stimulation setting for two 30-min sessions, each week for a 12-week period. Pre-treatment and after the 12-week intervention, each patient completed a 3-day voiding diary and a self-report quality of life questionnaire (OAB-q). Statistical analysis was performed using Stata V12.1.

RESULTS

Sixty-four patients completed the treatment protocol. There were no significant differences between study groups in terms of age, body mass index, past hormone replacement therapy, smoking habits, menopause status, and parity. Prior to treatment, there were also no significant differences in the analysis of the 3-day voiding diary or in the OAB-q questionnaire results. Following the 12-week study, there was a statistically significant reduction in frequency of urination, urgency episodes, and urge incontinent episodes compared to pre-treatment values. However, there were no significant differences in these values between intervention groups after 12-weeks of therapy. There was a similar improvement in OAB-q scores in both treatment groups following therapy, and the T.C. PTNS group showed a statistically significant improvement over the E.R.O. in domain 2 of the OAB-q questionnaire. The other two domains showed similar improvement in both study groups.

CONCLUSION

T.C. PTNS and E.R.O. demonstrated similar improvements in subjects with OAB in a 12-week study.

Effectiveness of pelvic floor muscle training on symptoms and uroflowmetry parameters in female patients with overactive bladder

BACKGROUND/AIM

To evaluate the effects of pelvic floor muscle training (PFMT) on symptoms of overactive bladder (OAB) as well as uroflowmetry parameters and functional bladder capacity.

MATERIALS AND METHODS

Fifty-nine female patients with OAB symptoms were included. Patients were assessed by SEAPI-QMM, uroflowmetry, and abdominal ultrasound. A specially designed PFMT program using a Pilates ball was generated for patients. The training period was 1-h sessions twice a week for 6 weeks and aerobic home exercises to be performed at home 4 or 5 times every other day. Following training, subjects were reevaluated for body mass index, SEAPI questionnaire, and uroflowmetry.

RESULTS

Initial mean SEAPI score, mean maximum and average flow rates, and mean voided volume were 9.8 ± 7.2, 29.8 ± 16.4 mL/s, 16.3 ± 8.7 mL/s, and 211.6 ± 173.5 mL, respectively. After completion of the training program, SEAPI scores improved significantly to 3.4 ± 6.4 (P < 0.05). Maximum and average flow rate results did not show significant changes, whereas voided volume seemed to have improved in conjunction with patients' symptom scores (Pearson correlation coefficient: 0.86).

CONCLUSION

According to. our results, we think that proper PFMT results in increase of functional bladder capacity as well as improvement in OAB symptoms and can be recommended as first-line therapy or in conjunction with medical therapy in severe cases.

Effectiveness of Short Term Percutaneous Tibial Nerve Stimulation for Non-neurogenic Overactive Bladder Syndrome in Adults: A Meta-analysis

AIM

to evaluate the effectiveness of short-term PTNS for non-neurogenic OAB in adults systematically by comparing with sham procedure and other treatments.

METHODS

we performed a systematic review of cohort study. Data sources were MEDLINE, EMBASE, CINAHL, National Library for Health, Cochrane, and google scholar from 2005 through 2015. Meta-analysis was performed using the random effects model. Heterogeneity of effects was assessed by calculating I2 statistic. Statistical analysis was performed using Review Manager 5.3 for RCT meta-analysis.

RESULTS

we analized 11 randomised controlled trial (RCT) and five prospective non-comparative studies with variable success rate. Based on percentage of responders, the results were 37.3% - 81.8% in PTNS group, 0% - 20.9% in sham group, 54.8% in anti-muscarinic group, and 89.7% in multimodal group. The decrease of voiding symptoms episodes per day was found in PTNS (0.7-4.5), sham (0.3-1.5), and anti-muscarinic (0.6-2.9) groups. In meta-analysis of four RCTs, the results favour PTNS over sham procedure with overall risk ratio of 7.32 (95% CI of 1.69-32.16), p=0.09, I2=54%.

CONCLUSION

there is an evidence of effectiveness of short term PTNS in treatment of non-neurogenic OAB. PTNS is proven significantly better than sham procedure.

Urodynamic outcome of parasacral transcutaneous electrical neural stimulation for overactive bladder in children

OBJECTIVE

To evaluate the urodynamic changes immediately after the first session (acute effect) and after the last session of parasacral TENS in children with idiopathic OAB.

MATERIALS AND METHODS

We performed urodynamic evaluation immediately before and after the first session of parasacral TENS and immediately after the last session (7 weeks later). Only children with idiopathic isolated OAB were included. Patients with dysfunctional voiding were not included.

RESULTS

18 children (4 boys and 14 girls, mean age of 8.7) were included in the first analysis (urodynamic study before and immediately after the first session) and 12 agreed to undergo the third urodynamic study. Urodynamic before and immediately after the first session: There was no change in the urodynamic parameters, namely low MCC, low bladder compliance, presence of IDC, the average number of IDC, or in the maximum detrusor pressure after the first exam. Urodynamic after the last session: The bladder capacity improved in most patients with low capacity (58% vs. 8%). Detrusor overactivity was observed in 11 (92%) before treatment and 8 (76%) after. There was not a significant reduction in the average number of inhibited contractions after TENS (p=0.560) or in the detrusor pressure during the inhibited contraction (p=0.205).

CONCLUSION

There was no change in the urodynamic parameters immediately after the first session of stimulation. After the last session, the only urodynamic finding that showed improvement was bladder capacity.

Communicating under medical patriarchy: gendered doctor-patient communication between female patients with overactive bladder and male urologists in Hong Kong

BACKGROUND

Gender differences between patients and doctors markedly influence the quality of communication in treatment processes. Previous studies have shown that communication between patients and doctors of the same gender is usually more satisfactory, particularly for female patients. However, in Hong Kong, where urology is a male-dominated specialty, female patients typically require medical care from male doctors for diseases such as overactive bladder (OAB). The literature about gender-related doctor-patient communication predominantly involves people in non-Chinese communities, with few studies conducted with Chinese populations. However, the differences between Western and Chinese cultures are expected to result in different treatment and communication experiences. Furthermore, OAB has received little attention in many Chinese communities; few studies in the literature address the communication quality between OAB patients and their urologists in Chinese communities, particularly regarding female OAB patients' experiences when seeking treatment from male urologists. This study, therefore, investigated the doctor-patient communication between female OAB patients and male urologists in Hong Kong.

METHODS

This study adopted a qualitative research approach by conducting semistructured interviews with 30 female OAB patients on an individual basis from April 2012 to July 2012. The participants were purposively sampled from a patient self-help group for OAB patients in Hong Kong.

RESULTS

The participants' communication experiences with male urologists were unpleasant. Embarrassment, feelings of not being treated seriously, not being understood, and not being given the autonomy to choose treatment approaches prevailed among the participants. Furthermore, the perceived lack of empathy from their urologists made the participants' communication experiences unpleasant.

CONCLUSIONS

The gender and power differential between the participants and their urologists, which was contributed by the social and cultural values of patriarchy and doctors' dominance in Hong Kong, made the participants' communication with the urologists unpleasant and difficult. Poor doctor-patient communication can endanger patients' treatment compliance and thus the treatment outcome. Although altering such social and cultural values would be difficult, providing complementary chronic care services, such as nurse-led clinics as well as support and sharing from patient self-help groups, might be a possible solution.

Physician Use of Sacral Neuromodulation Among Medicare Beneficiaries With Overactive Bladder and Urinary Retention

OBJECTIVE

To identify physician-level factors associated with high rates of sacral neuromodulation testing.

MATERIALS AND METHODS

We performed a retrospective cohort study using a 20% sample of national Medicare claims to identify physicians who performed sacral neuromodulation procedures between 2005 and 2010. Physician-level rates of device testing were determined based on the number of patients seen for overactive bladder and urinary retention diagnoses in the office in each calendar year. These rates were then used to fit a Poisson model to examine factors associated with high rates of device testing.

RESULTS

The number of physicians performing test procedures increased 4-fold from 2005 to 2010. Average rates of test procedures increased from 4.0 to 6.4 procedures per physician per year (P <.001), whereas rates of device implantation remained stable (P = .23). Physicians who had higher rates of device testing were associated with lower rates of device implantation (estimate, -1.76, P <.01). Other predictors of physicians with higher test rates included more recent calendar year, testing done in any setting other than an ambulatory surgery center, gynecology subspecialty, and geographic location in the South and West (all P values <.01).

CONCLUSION

Over time, physicians are testing more patients but are not implanting more devices. Additionally, there is an inverse relationship between rates of device testing and implantation, suggesting opportunities to improve efficiency and resource utilization.

Heterogeneity in post-intervention prolapse and urinary outcome reporting: a one-year review of the International Urogynecology Journal

INTRODUCTION

This review aimed to examine post-intervention prolapse, incontinence, and overactive bladder outcome measures published in the International Urogynecology Journal over the previous year and to report on the heterogeneity in outcome reporting.

METHODS

All original article abstracts published in the print version of the International Urogynecology Journal in 2014 were reviewed for possible inclusion. Those reporting on prolapse and/or incontinence and/or overactive bladder outcomes following a urogynecological intervention were analyzed. Articles were reviewed for all reported outcomes. Outcomes were categorized as primary or secondary and objective or subjective.

RESULTS

Of 117 original articles published, 45 were reviewed. Among primary outcomes, 9 different outcomes were reported for prolapse and 11 for incontinence and overactive bladder. For prolapse, 6 different objective and 13 subjective outcomes were reported. For incontinence, 21 objective and 36 subjective outcomes were reported. Three different definitions were used for the outcome of "prolapse cure," 3 for "prolapse recurrence," and 4 for "stress incontinence cure." Several validated and non-validated questionnaires in addition to single unvalidated questions were used to measure subjective outcomes.

CONCLUSIONS

This research highlights the diversity in outcome reporting for prolapse, incontinence, and overactive bladder after an intervention in the last year of publications alone. This can lead to serious challenges in the generation of higher order evidence, such as systematic reviews and meta-analyses. As a subspecialty, we need to aim for more cohesive reporting so as to allow for robust comparison and evidence dissemination.

Transcutaneous parasacral electrical stimulation vs oxybutynin for the treatment of overactive bladder in children: a randomized clinical trial

PURPOSE

We determined the effectiveness of 2 methods to treat overactive bladder in children using intragroup and intergroup comparisons in a randomized clinical trial.

MATERIALS AND METHODS

Nine boys and 19 girls with a mean ± SD age of 6.4 ± 2.18 years were randomly divided into group 1-parasacral transcutaneous electrical stimulation with placebo drug and group 2-oxybutynin with sham scapular electrical therapy. Success was assessed by 1) the rate of complete symptom resolution, 2) a visual analog scale of 0 to 10, 3) the dysfunctional voiding score system, 4) voiding diary records, 5) Rome III criteria and 6) side effect frequency in each group.

RESULTS

A total of 13 and 15 patients were randomized to groups 1 and 2, respectively. Symptoms completely resolved in 6 patients in group 1 (46%) and 3 in group 2 (20%) (p = 0.204). A statistically significant improvement was found in the 2 groups in the dysfunctional voiding score system and voiding diary records. However, no statistically significant difference was found between the groups in the visual analog scale score, voiding frequency, and maximum and mean voided volume (p = 0.295, 0.098, 0.538 and 0.650, respectively). Constipation improved in 100% of group 1 patients but in only 55% in group 2 (p = 0.031 vs 0.073). Group 1 showed no side effects while dry mouth, hyperthermia and hyperemia developed in 58%, 25% and 50% of group 2 patients (p = 0.002, 0.096 and 0.005, respectively). Treatment was discontinued by 13.3% of patients in group 2.

CONCLUSIONS

Parasacral transcutaneous electrical stimulation was as effective as oxybutynin to treat overactive bladder in children. However, transcutaneous parasacral electrical stimulation was more effective against constipation and showed no detectable side effects. Oxybutynin was more effective for decreasing voiding frequency.