OnabotulinumtoxinA Treatment for Overactive Bladder in the Elderly: Practical Points and Future Prospects

Association of cancer with overactive bladder and impact of overactive bladder on mortality among cancer survivors: NHANES 1999-2018

BACKGROUND

Cancer is one of the leading causes of death worldwide. There is little knowledge on the association between cancer and risk of overactive bladder (OAB). Additionally, the impact of OAB on mortality among cancer survivors remains unknown. We aimed to examine the association between cancer and risk of OAB and investigate OAB associations with mortality outcomes in cancer survivors.

METHODS

We analyzed data of the National Health and Nutrition Examination Survey from 1999 to 2018. Cancer status was identified through the NHANES questionnaire. OAB was diagnosed with a cumulative OAB Symptom Score ≥  3. Multivariable logistic analysis was performed to examine the relationship between cancer and OAB. Cox regression analysis was carried out to investigate the relationship between OAB and mortality in subjects with cancer.

RESULTS

In total, this study included a cohort of 32,166 participants. Within the study population, the occurrence of cancer was observed in 9.606%, and OAB was prevalent in 20.167%. The findings from the logistic regression analyses indicated a heightened risk of OAB among individuals with cancer in comparison to those devoid of cancer. Results from subgroup analyses also revealed affirmative correlations between cancer and OAB. Furthermore, the diagnosis of cancer, irrespective of whether it was genitourinary, non-genitourinary, pelvic, or non-pelvic in nature, was found to be correlated with an increased risk of OAB. Within the cohort comprising 3,090 participants diagnosed with cancer, a total of 850 all-cause deaths were recorded during a median follow-up duration of 76 months. After accounting for multiple covariates, OAB was linked to an elevated risk of all-cause and cancer-specific mortality. Moreover, the influence of OAB on mortality from all causes was observed across various cancer types, including both genitourinary and non-genitourinary, as well as pelvic and non-pelvic cancers.

CONCLUSIONS

The investigation identified a noteworthy positive correlation between cancer and the likelihood of OAB. Moreover, OAB was significantly correlated with an elevated risk of mortality among individuals who had received a cancer diagnosis.

Evaluating the Efficacy and Safety of Botulinum Toxin in Treating Overactive Bladder in the Elderly: A Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials

Overactive bladder (OAB) significantly impairs quality of life in the elderly. Although the intradetrusor injection of botulinum toxin type A (BoNT-A) is a treatment option, its effects on older adults remain uncertain. This study aimed to evaluate the efficacy and safety of BoNT-A intradetrusor injections in elderly OAB patients through a systematic review and meta-analysis. A comprehensive literature search was conducted using the PubMed, Embase, Cochrane Library, Scopus, and CINAHL databases from inception to 30 May 2024. The primary outcomes were improvements in daily urinary incontinence (UI) episodes and patient-reported outcomes, while the secondary outcomes focused on potential adverse events. Four randomized controlled trials with 803 participants were included. BoNT-A injections significantly reduced daily UI episodes at 4-6 weeks (mean difference [MD]: -3.82; 95% confidence interval [CI]: -6.29 to -1.35) and at 12 weeks (MD: -2.17; 95% CI: -3.22 to -1.12). However, BoNT-A was associated with an increased risk of elevated post-void residual (Risk Difference [RD]: 0.154; 95% CI: 0.058 to 0.251) and urinary tract infection (RD: 0.111; 95% CI: 0.005 to 0.217), with no significant difference observed in the initiation of catheterization or hematuria. Trial sequential analysis confirmed a sufficient sample size and statistical power. In conclusion, while BoNT-A effectively manages OAB in the elderly, careful post-injection monitoring is warranted due to its potential risks.

Lower urinary tract dysfunction in the central nervous system neurogenic bladder and the real-life treatment outcome of botulinum toxin A

Neurogenic lower urinary tract dysfunction (NLUTD) is common in patients with central nervous system (CNS) lesions. Cases of cerebrovascular accidents (CVA), Parkinson's disease, dementia, and other intracranial lesions develop poor bladder control with or without urinary difficulty due to loss of cortical perception of bladder filling sensation and poor coordination of urethral sphincter relaxation during reflex micturition. Patients with CNS lesions usually have overactive bladder (OAB) symptoms, including urgency, frequency, incontinence, voiding symptoms of dysuria, large postvoid residual volume, and retention. In elderly patients with severe CNS disease the OAB symptoms are usually difficult to adequately relieve by medical treatment, and thus, their quality of life is greatly. Botulinum toxin A (BoNT-A) is currently licensed and has been applied in patients with idiopathic and neurogenic OAB due to spinal cord injury or multiple sclerosis. However, the application of BoNT-A in the treatment of urinary incontinence due to NLUTD in chronic CNS lesions has not been well-documented. Although cohort studies and case series support BoNT-A treatment for neurogenic OAB, chronic urine retention after intravesical BoNT-A injection for OAB and exacerbated urinary incontinence after urethral BoNT-A injection for voiding dysfunction have greatly limited its application among patients with NLUTD due to CNS lesions. This article reviews the pathophysiology and clinical characteristics of NLUTD in patients with CNS lesions and the clinical effects and adverse events of BoNT-A injection for patients with NLUTD. A flowchart was created to outline the patient selection and treatment strategy for neurogenic OAB.

Bladder Dysfunction in Older Adults: The Botulinum Toxin Option

Bladder dysfunction, which involves inadequacies of urine storage or emptying, increases with age. Conventional medications may have insufficient efficacy for patients with refractory lower urinary tract symptoms, and their concomitant adverse events (AEs) may be intolerable for the older adult population. For decades, the botulinum toxin type A (BoNT-A) injection has been an option for managing urine frequency, urge incontinence, and voiding dysfunction in the general population refractory to conventional management. This review focuses on studies of BoNT-A application in the management of bladder dysfunction in older adult patients aged ≥ 65 years. In this target population, intravesical BoNT-A injections provide similar efficacy in idiopathic overactive bladder to that in younger adults. Good clinical response has also been demonstrated in older adult patients presenting with storage dysfunction and with various concomitant underlying neurological diseases. However, caution must be taken for the AEs that occur after intravesical BoNT-A injection, including increased post-void residual urine, acute urine retention, and urinary tract infection. Most evidence shows that age is not a major determinant of AEs after adjusting for other factors. In contrast to its application in storage dysfunction, evidence for voiding dysfunction in older adults is scarce. In general, BoNT-A may be a reasonable option for older adult patients with refractory storage dysfunction because of its promising clinical response without significant systemic AEs. Overall, clinicians should be aware of the balance between the therapeutic efficacy of BoNT-A and local AEs in vulnerable members of this population.