Effectiveness of BTX-A and neuromodulation in treating OAB with or without detrusor overactivity: a systematic review

Retrospective Observational Study of Treatment Patterns and Efficacy of onabotulinumtoxinA Therapy in Patients with Refractory Overactive Bladder in Clinical Practice

This study aimed to evaluate the treatment patterns and long-term efficacy of onabotulinumtoxinA injections in a clinical setting. This single-center retrospective study was conducted on patients with refractory overactive bladder (OAB) aged 18 years or older who received onabotulinumtoxinA 100 IU administered between April 2012 and May 2022. The primary endpoint was the treatment pattern, including the retreatment rate and OAB medication prescription pattern. The duration and effectiveness of onabotulinumtoxinA treatment were analyzed using the overactive bladder symptom score and voiding diaries. A total of 216 patients were enrolled in this study, and the overall patient satisfaction rate was 55.1%. After the first injection, 19.9% received a second treatment, and 6.1% received three or more injections. The median duration until the second injection was 10.7 months. Among the patients, 51.4% resumed OAB medications after 2.96 months. The presence of urodynamic detrusor overactivity was observed only in female patients (odds ratio, 23.65; 95% CI, 1.84 to 304.40), which was associated with a good response. In contrast to clinical trials, the degree of improvement and retreatment rate did not meet expectations. Our findings provide valuable insights into the effectiveness of onabotulinumtoxinA injections in patients with refractory OAB symptoms in real-world practice.

Development of a prediction model in female pure or predominant urge urinary incontinence: a retrospective cohort study

Background:

Urinary incontinence is a prevalent form of pelvic floor dysfunction, with a non-negligible impact on a patient’s quality of life. There are several treatment options, varying from conservative to invasive. The aim of this study is to predict treatment outcomes of pure or predominant urge urinary incontinence (UUI) in women to support shared decision-making and manage patient expectations.

Methods:

Data on patient characteristics, disease history, and investigations of 512 consecutive women treated for UUI in three hospitals in the Netherlands were retrospectively collected. The predicted outcome was the short-term subjective continence outcome, defined as patient-reported continence 3 months after treatment categorized as cure (no urinary leakage), improvement (any degree of improvement of urinary leakage), and failure (no improvement or worsening of urinary leakage). Multivariable ordinal regression with backward stepwise selection was performed to analyze association between outcome and patient’s characteristics. Interactions between patient characteristics and treatment were added to estimate individual treatment benefit. Discriminative ability was assessed with the ordinal c-statistic.

Results:

Conservative treatment was applied in 12% of the patients, pharmacological in 62%, and invasive in 26%. Subjective continence outcome was cure, improvement, and failure in 20%, 49%, and 31%, respectively. Number of incontinence episodes per day, voiding frequency during the day, subjective quantity of UI, coexistence of stress urinary incontinence (SUI), night incontinence, and bladder capacity and the interactions between these variables were included in the model. After internal validation, the ordinal c-statistic was 0.699.

Conclusions:

Six variables were of value to predict pure or predominant UUI treatment outcome in women. Further development into a comprehensive set of models for the use in various pelvic floor disorders and treatments is recommended to optimize individualized care. This model requires external validation before implementation in clinical practice.

Botulinum toxin for treating overactive bladder in men: A systematic review

PURPOSE

We sought to systematically review the literature on the use of botulinum toxin (BTX-A) injections in the bladder to treat overactive bladder (OAB) in men.

MATERIALS AND METHODS

A systematic review was performed to identify clinical trials on efficacy and safety of BTX-A injections in the detrusor for treatment of OAB in men published from inception to October 2020. Quality assessment was performed using the Cochrane Collaboration's tool for assessing risk of bias and study characteristics were extracted by two reviewers independently.

RESULTS

After screening 75 abstracts, 12 trials were included in the qualitative synthesis, of which 6 were conducted exclusively in men (mean age: 66.7 years). Only two were randomized controlled studies and the remaining were observational studies, mostly case series. Total number of participants in each study ranged from 28 to 146. Therapeutic response to intravesical BTX-A injection was assessed differently across the studies, which used quality-of-life symptom questionnaires and voiding diary parameters. Urodynamics findings were reported separately for men before and after intravesical injection of BTX-A in two studies only. Pooling of outcome data was possible with adverse events reported after BTX-A by seven studies, which showed urinary tract infection, urinary retention, increased postvoid residual, de novo interstitial cystitis, and hematuria rates of 29.8%, 20.0%, 37.3%, 28.3%, and 12.4%, respectively.

CONCLUSIONS

Limited information regarding the efficacy and safety of BTX-A bladder injections for male OAB from relatively low evidence is available. Further research is needed to better understand the risk-benefit profile of BTX-A in the male population.

Is urodynamic evaluation able to change and improve the management of women with idiopathic overactive bladder?

BACKGROUND

For women with overactive bladder (OAB), current guidelines recommend the use of urodynamic studies (UDS) only in complicated cases. This study aimed to investigate whether UDS can also be helpful in uncomplicated cases. Specific aims of the study were: 1) to evaluate objective benefit and subjective patient satisfaction with tailored treatment based on the UDS diagnosis compared to the outcomes of the pharmacological treatment only based on the symptoms; 2) to investigate the correlation between symptoms and UDS findings in women with uncomplicated idiopathic OAB symptoms; 3) to assess the ability of UDS to modify management decisions in these patients.

METHODS

Women presenting to our clinic with a history of uncomplicated OAB symptoms for the past three months or more, and who completed the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), were considered for this study. We proposed UDS to all participants. In women who accepted UDS (group 1), management decisions were made on the basis of urodynamic findings and post-treatment evaluation was scheduled at three months. The outcomes of treatments in these patients were compared to the results in women who did not accept UDS and who received pharmacological treatment symptoms-based (group 2). Objective outcomes were based on completion of a 3-day micturition diary. Subjective outcomes were captured using the Overactive Bladder Questionnaire Short Form (OABq-SF), the Patient Global Impression of Improvement (PGI-I) scale, and a patient satisfaction scale.

RESULTS

A total of 680 women were enrolled in the study; 478 underwent UDS and 202, at the contrary, declined UDS. In 53.6% of cases, UDS led to modification of the proposed management approach. At the 3-month follow-up, the overall patient satisfaction rate in group 1 and group 2 was 77% and 65.8%, respectively (P=0.003).

CONCLUSIONS

We showed that OAB management tailored according to the UDS diagnosis results in higher subjective satisfaction if compared with a pharmacological treatment symptoms-based. Our study confirmed a lack of correlation between OAB symptoms and the urodynamically proven diagnosis of detrusor overactivity (DO). It also suggested that UDS can determine the underlying pathophysiology of every woman with OAB syndrome, whether complicated or uncomplicated, allowing treatment to be appropriately tailored with better results.

Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy

The ideal treatment for overactive bladder is still elusive. In those where medication fails to improve symptoms options include invasive treatments such as botulinum toxin-A, sacral neural stimulation or posterior tibial nerve stimulation. Scientific professional society guidelines advise percutaneous posterior tibial nerve stimulation as a third line treatment option only after multi-disciplinary team review as well as failure of both conservative and pharmacological management. The aim of this article is to review all techniques for tibial nerve stimulation and their efficacy.

A Preliminary Study on the Impact of Detrusor Overactivity on the Efficacy of Selective Bladder Denervation for the Treatment of Female Refractory Overactive Bladder

OBJECTIVE

To determine whether the presence of detrusor overactivity (DO) is associated with the 12-week and 12-month clinical outcomes of selective bladder denervation (SBD) in women with refractory overactive bladder (OAB).

METHODS

Prospective single institutional study of refractory OAB females who underwent a urodynamic study and were categorized according to DO status (DO- vs DO+) prior to receiving SBD.

RESULTS

Among the 23 patients, 10 were DO- and 13 were DO+. Both groups reported improvement at 12 weeks on the 24-hour pad weight test, in urgency urinary incontinence (UUI) and urgency. At 12 months, both groups still reported improvement in urgency, but only the DO- group reported reduction on the pad weight test and only the DO+ group maintained improvement in the UUI rate. Clinical success (≥50% reduction in UUI) was achieved by all DO- and by 69% of DO+ patients at 12 weeks, and by 60% of DO- and 92% of DO+ patients at 12 months. Treatment benefit (Treatment Benefit Scale ≤2) was reported in 90% of DO- and 85% of DO+ patients at 12 weeks, and in 60% of DO- and 85% of DO+ patients at 12 months. When directly comparing both group outcomes, the only significant difference was the greater reduction of UUI in the DO- group at 12 weeks (-9.0 vs -6.5; P = .045).

CONCLUSION

Refractory OAB females appear to be effectively treated by SBD regardless of baseline DO status. DO status does not seem to be associated with the 12-week and 12-month outcomes of SBD.

Botulinum toxin A for refractory OAB and idiopathic urinary retention: Can phenotyping improve outcome for patients: ICI-RS 2019?

AIMS

Botulinum toxin A (BTX-A) is a well-established treatment for refractory idiopathic overactive bladder (OAB). It has also been used with short-term success in treating idiopathic urinary retention. However, efficacy and complication rates are variable and predicting those likely to benefit most from treatment would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society (ICI-RS) meeting in 2019 a Think Tank addressed the question of how we can improve the way we phenotype patients undergoing BTX-A treatment.

METHODS

The Think Tank conducted a literature review and expert consensus meeting focussing on how advances in basic science research of the mechanism of action of BTX-A, as well as assessment of psychological comorbidity, can be translated into clinical practice to improve patient selection for therapy.

RESULTS

Idiopathic OAB and idiopathic urinary retention are heterogenous conditions encompassing several phenotypes with multiple potential pathophysiological mechanisms. Animal models have demonstrated a central nervous system mechanism of action of intravesically injected BTX-A and this has been confirmed in human functional MRI studies, but whether this tool can be used to predict outcome from treatment remains to be determined. Phenotyping based on psychological comorbidity using validated screening tools should be studied as a way to potentially optimize patient selection for therapy.

CONCLUSIONS

Advances in basic science research into the mechanism of action of BTX-A have improved our understanding of the pathophysiology of OAB and may lead to novel ways to phenotype patients. Psychological assessment is another way in which phenotyping may be improved. Areas for further research are proposed.

Urodynamic Mechanisms Underlying Overactive Bladder Symptoms in Patients With Parkinson Disease

PURPOSE

To assess the urodynamic findings in patients with Parkinson disease (PD) with overactive bladder symptoms.

METHODS

We performed a retrospective chart review of all PD patients who were seen in an outpatient clinic for lower urinary tract symptoms (LUTS) between 2010 and 2017 in a single-institution. Only patients who complained of overactive bladder (OAB) symptoms and underwent a video-urodynamic study for these symptoms were included. We excluded patients with neurological disorders other than PD and patients with voiding LUTS but without OAB symptoms.

RESULTS

We included 42 patients (29 men, 13 women, 74.5±8.1 years old). Seven patients (16.7%) had a postvoid residual (PVR) bladder volume >100 mL and only one reported incomplete bladder emptying. Detrusor overactivity (DO) was found in all 42 patients (100%) and was terminal in 19 (45.2%) and phasic in 22 patients (52.4%). Eighteen patients had detrusor underactivity (DU) (42.3%). Later age of PD diagnosis was the only parameter associated with DU (P=0.02). Patients with bladder outlet obstruction (BOO) were younger than patients without BOO (70.1 years vs. 76.5 years, P=0.004), had later first sensation of bladder filling (173.5 mL vs. 120.3 mL, P=0.02) and first involuntary detrusor contraction (226.4 mL vs. 130.4 mL, P=0.009).

CONCLUSION

DO is almost universal in all patients with PD complaining of OAB symptoms (97.1%). However, a significant percentage of patients also had BOO (36.8%), DU (47%), and increased PVR (16.7%) indicating that neurogenic DO may not be the only cause of OAB symptoms in PD patients.

A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment

CONTEXT

Current literature suggests that several pathophysiological factors and mechanisms might be responsible for the nonspecific symptom complex of overactive bladder (OAB).

OBJECTIVE

To provide a comprehensive analysis of the potential pathophysiology underlying detrusor overactivity (DO) and OAB.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted in April 2018, to identify randomised controlled trials, prospective and retrospective series, animal model studies, and reviews.

EVIDENCE SYNTHESIS

OAB is a nonspecific storage symptom complex with poorly defined pathophysiology. OAB was historically thought to be caused by DO, which was either "myogenic" (urgency initiated from autonomous contraction of the detrusor muscle) or "neurogenic" (urgency signalled from the central nervous system, which initiates a detrusor contraction). Patients with OAB are often found to not have objective evidence of DO on urodynamic studies; therefore, alternative mechanisms for the development of OAB have been postulated. Increasing evidence on the role of urothelium/suburothelium and bladder afferent signalling arose in the early 2000s, emphasising an afferent "urotheliogenic" hypothesis, namely, that urgency is initiated from the urothelium/suburothelium. The urethra has also recently been regarded as a possible afferent origin of OAB-the "urethrogenic" hypothesis. Several other pathophysiological factors have been implicated, including metabolic syndrome, affective disorders, sex hormone deficiency, urinary microbiota, gastrointestinal functional disorders, and subclinical autonomic nervous system dysfunctions. These various possible mechanisms should be considered as contributing to diagnostic and treatment algorithms.

CONCLUSIONS

There is a temptation to label OAB as "idiopathic" without obvious causation, given the poorly understood nature of its pathophysiology. OAB should be seen as a complex, multifactorial symptom syndrome, resulting from multiple potential pathophysiological mechanisms. Identification of the underlying causes on an individual basis may lead to the definition of OAB phenotypes, paving the way for personalised medical care.

PATIENT SUMMARY

Overactive bladder (OAB) is a storage symptom syndrome with multiple possible causes. Identification of the mechanisms causing a patient to experience OAB symptoms may help tailor treatment to individual patients and improve outcomes.

Outcomes of intradetrusor onabotulinum toxin A injection in patients with Parkinson's disease

OBJECTIVE

To assess the safety and efficacy of intradetrusor onabotulinum toxin A injections for the treatment of overactive bladder (OAB) in patients with Parkinson's disease (PD).

METHODS

All PD patients who underwent intradetrusor injections of onabotulinum toxin A (BoNT-A) for storage symptoms between 2010 and 2017 were included in a retrospective study. A 100 U dose of BoNT-A (Botox®, Allergan Irvine, CA) was used for the first injection in all patients. The primary endpoint was clinical success defined as any subjective improvement in OAB symptoms self-assessed by the patients 4 weeks after the injections.

RESULTS

Out of 24 patients analyzed, 19 reported improvement of their OAB symptoms 4 weeks after the first injection (79.2%) with complete resolution of urgency urinary incontinence in seven patients (29.1%; P < 0.001). The average post-void residual (PVR) increased significantly after the first injection from 17.6 to 125.3 mL (P < 0.001). Three of the patients had to start clean intermittent catheterization (CIC) after the first injection (12.5%). Out of 49 injections in total, only five caused incomplete bladder emptying requiring the use of CIC (10.2%). Higher pre-injection PVR was significantly associated with both a lower chance of symptomatic improvement (P = 0.04) and a higher risk of incomplete bladder emptying with institution of CIC (P = 0.047).

CONCLUSION

Intradetrusor injections of BoNT-A 100 U appeared as a safe and effective option in PD patients with OAB symptoms and a low PVR before the injection. Higher preoperative PVR was the strongest predictor of both treatment failure and postoperative urinary retention requiring CIC.