Mixed urinary incontinence: Are there effective treatments?

The aim of this debate article is to discuss whether effective treatments are available for mixed urinary incontinence (MUI). Because patients with MUI have both stress and urgency urinary incontinence (SUI and UUI) episodes and current treatment guidelines currently recommend treating the predominant symptom first, this article presents standard and emerging treatments for both SUI and UUI before discussing how well these treatments meet the medical needs of patients with MUI. Standard treatments presented include noninvasive options such as lifestyle changes and pelvic floor exercises, pharmacological agents, and surgery. Treatment of all three types of urinary incontinence (UI) is usually initiated with noninvasive options, after which treatment options diverge based on UI subtype. Multiple pharmacological agents have been developed for the treatment of UUI and overactive bladder, whereas surgery remains the standard option for SUI and stress-predominant MUI. The divide between UUI and SUI options seems to be propagated in emerging treatments, with most novel pharmacological agents still targeting UUI and even having SUI and stress-predominant MUI as exclusion criteria for participation in clinical trials. Considering that current treatment options focus almost exclusively on treating the predominant symptom of MUI and that emerging pharmacological treatments exclude patients with stress-predominant MUI during the development phase, effective treatments for MUI are lacking both in standard and emerging practice. Ideally, agents with dual mechanisms of action could provide symptom benefit for both the stress and urgency components of MUI.

Clinical Utility of β3-Adrenoreceptor Agonists for the Treatment of Overactive Bladder: A Review of the Evidence and Current Recommendations

This nonsystematic review provides a summary of current evidence on the use of β₃-adrenoreceptor agonists (β₃-ARAs) for the treatment for lower urinary tract symptoms. Soon after their discovery in 1989, β₃-ARs were identified as a predominant adrenoreceptor subtype in the human urinary bladder. Although it is widely believed that β₃-ARAs cause detrusor relaxation, the effect on bladder afferent signaling likely plays an important role in their mechanism of action as well. In 2011 and 2012, mirabegron was approved for clinical use in overactive bladder (OAB) patients. Pooled analysis of data from prospective randomized studies on >60,000 OAB patients showed that when compared to placebo, mirabegron was superior with respect to reducing the frequency, number, and severity of urgency episodes, number of incontinence episodes and increasing dry rate, but not in reduction of nocturia episodes. The only side effect showing significantly higher incidence than placebo was nasopharyngitis. Mirabegron is approved for OAB treatment in all age-groups and in pediatric patients with neurogenic bladder. Vibegron is another β₃-ARA approved for OAB treatment in the US and Japan. Several large, multicenter, double-blind, randomized trials have documented statistically significant superiority of vibegron over placebo on all efficacy end points. Other β₃-ARAs are being developed; however, to date none has been introduced to clinical use. All β₃-ARAs provide efficacy similar to anticholinergics. They have a favorable safety profile and are well tolerated. Due to their different mechanisms of action, combination of β₃-ARAs with anticholinergic compounds allows for increased efficacy.

Pharmacological Management of Urinary Incontinence: Current and Emerging Treatment

Pharmacological management of urinary incontinence (UI) is currently based on antimuscarinic and beta-3-agonist drugs. Botulinum toxin A detrusor injections represent an effective but more invasive alternative. This review covers the latest developments of the currently available drugs and the emerging compounds for the treatment of UI. Evidence shows that new antimuscarinics and beta-3-agonists with improved safety profiles may offer unique options to patients intolerant to currently available drugs. Combination therapy proved to be a non-invasive alternative for patients refractory to first-line monotherapy. Exciting advances are ongoing in the research to improve the efficacy/tolerability profile of botulinum toxin, through innovative routes of administration. Several new agents emerged from preclinical studies, some of which have now entered the clinical phase of development and could represent, in the coming years, a new way for the treatment of UI. Recent evidence on the existence of different overactive bladder phenotypes could be the key to tailored treatment. Rather than discovering new molecules, reaching the ability to identify the right drug for the right patient could be the real gamechanger of the future.

Mirabegron improves erectile function in men with overactive bladder and erectile dysfunction: a 12-week pilot study

Phosphodiesterase type 5 inhibitors (PDE5i) is the only approved oral treatment for erectile dysfunction (ED) in the US, and alternative management remains necessary when this treatment fails or is contraindicated. Targeting other pathways than the NO-cGMP pathway and/or combining this approach with PDE5i may introduce new treatments for men who are unresponsive to PDE5i. This study aims to evaluate whether Mirabegron improves erectile function in men with concurrent overactive bladder and mild to moderate ED. Twenty subjects, 40-70 years old, registering International Index of Erectile Function (IIEF) score 11-25 and International Prostate Symptom Score 8-20, were treated with Mirabegron therapy for 12 weeks. Study participants were re-administered IIEF and OAB-q questionnaires on weeks 2, 4, 8, and 12 and assessed for adverse events. The primary and secondary endpoints were an increase in the IIEF-5 score of 4 units and a decrease in the Overactive Bladder questionnaire (OAB-q) symptom severity score of 10 units between study time points. Thirteen men completed the 12-week study. Mirabegron treatment improved the IIEF-5 scores in five patients (38.4%) by 4 points or more, whereas IIEF-5 scores were not affected by Mirabegron treatment in eight patients (61.5%). There were no clinically relevant decreases in the IIEF-5 score. Significant improvements were observed in intercourse satisfaction at week eight compared to baseline (p = 0.01). Orgasmic function and sexual desire were not affected by Mirabegron treatment. As expected, Mirabegron treatment reduced OAB symptoms based on OAB-q short form (p = 0.006) and OAB-q total health-related quality of life (HRQL) scores compared to baseline (p = 0.03). Residual bladder volumes were not affected by treatment. No serious side effects were reported during the study period. This study suggests that Mirabegron may improve both EF and OAB-related symptoms in some individuals without causing serious adverse events.

Management of Urgency and Mixed Urinary Incontinence

Urinary incontinence (UI) is a prevalent disorder that significantly affects quality of life. This article reviews management of urgency and mixed UI by breaking the management algorithm down into observation, lifestyle and behavioral changes, pharmacologic therapy, and procedural management. Stress UI is best managed with mid-urethral slings and is covered in other chapters. Behavioral and pharmacologic management are equally efficacious for urgency UI, but procedural therapy is superior. Mixed UI is conventionally treated by first managing whichever UI subtype is most bothersome. The management of overflow UI is directed at its underlying etiology: detrusor underactivity or bladder outlet obstruction.