Long-term efficacy and safety of questionnaire-based initiation of urgency urinary incontinence treatment

Bladder outflow obstruction in women: Clinical and basic evaluation

AIM

Female bladder outflow obstruction is an underdiagnosed and undermanaged condition. This review article aims to illustrate the basic and clinical evaluation of patients who might have this condition.

REVIEW

Clinical evaluation includes clinical history, examination, and basic investigations, including uroflowmetry and postvoid residual, urinalysis and culture, renal function assessment, ultrasound of kidneys and bladder, voiding cystourethrography, and magnetic resonance imaging. Based on the initial evaluation, if the concern of obstruction is high, the clinician might undergo further advanced evaluation.

CONCLUSION

Basic evaluation is the initial step in the diagnosis of female bladder outflow obstruction, the clinician need to have a high index of suspicion and often further advanced evaluation is needed to confirm the diagnosis.

A specialist service evaluation: a cross-sectional survey approach

This article presents the findings of a service evaluation of a specialist urogynaecology service and highlights the implications for nursing practice.

AIMS

To evaluate the overall patient experience and the degree to which individual needs were being met, and make improvements to service delivery.

METHOD

A cross-sectional survey questionnaire was sent to a random sample of women (n=350) who were registered on the electronic patient record system from January to June 2020. Two items on the questionnaire related specifically to communication with patients during the first COVID-19 lockdown in March 2020. Routine service data were collected and included in descriptive statistical analysis. Qualitative themes were thematically analysed.

RESULTS

The response rate was 39% (n=137). More than 90% of respondents felt listened to during consultations with nursing and medical personnel, and had trust and confidence in their clinical expertise, felt involved with decisions about care and felt comfortable with intimate examinations. Negative responses related to poor communication with administration and rescheduling appointments.

CONCLUSION

Findings resulted in a departmental review of admin processes, which resulted in improvements to administrative systems, staff training, communication and information giving, and directly benefited patients.

A lasting impression: telemedicine in urogynecology during the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

Amidst the worldwide coronavirus disease 2019 pandemic, a new medical landscape revolving around telemedicine has arisen. The purpose of this review is to describe and analyze current urogynecologic guidelines for optimizing usage of telemedicine when treating women with pelvic floor disorders.

RECENT FINDINGS

Women managed by urogynecologists are on average older, and hence more likely to have comorbidities that make them susceptible to developing coronavirus disease 2019 with severe symptoms. Telemedicine is key in minimizing exposure without sacrificing treatments and quality of life. Recent studies published prior to the pandemic helped set the stage for successful components of virtual care. Nonsurgical options are crucial to beginning a treatment plan while elective surgeries are still restricted in many hospitals. Medication management and innovative technology, such as smart telephone applications, play a prominent role. The comprehensive literature review discussed here describes the degree of evidence supporting each management option, while also noting the limitations of telemedicine.

SUMMARY

Telemedicine has opened a new door for the field of urogynecology allowing for continued safe, evidence-based care. The pandemic culture has tipped the balance away from surgery and toward nonsurgical treatments while attempting not to sacrifice outcomes or quality of care.

Regenerative potential of human dental pulp stem cells in the treatment of stress urinary incontinence: In vitro and in vivo study

Objectives

To evaluate the regenerative potential of human dental pulp stem cells (hDPSCs) in an animal model of stress urinary incontinence (SUI). SUI, an involuntary leakage of urine, is due to physical stress involving an increase in bladder pressure and a damage of external urethral sphincter affecting muscles and nerves. Conventional therapies can only relieve the symptoms. Human DPSCs are characterized by peculiar stemness and immunomodulatory properties and might provide an alternative tool for SUI therapy.

Materials and methods

In vitro phase: hDPSCs were induced towards the myogenic commitment following a 24 hours pre‐conditioning with 5‐aza‐2′‐deoxycytidine (5‐Aza), then differentiation was evaluated. In vivo phase: pudendal nerve was transected in female rats to induce stress urinary incontinence; then, pre‐differentiated hDPSCs were injected in the striated urethral sphincter. Four weeks later, urethral sphincter regeneration was assayed through histological, functional and immunohistochemical analyses.

Results

Human DPSCs were able to commit towards myogenic lineage in vitro and, four weeks after cell injection, hDPSCs engrafted in the external urethral sphincter whose thickness was almost recovered, committed towards myogenic lineage in vivo, promoted vascularization and an appreciable recovery of the continence. Moreover, hDPSCs were detected within the nerve, suggesting their participation in repair of transected nerve.

Conclusions

These promising data and further investigations on immunomodulatory abilities of hDPSCs would allow to make them a potential tool for alternative therapies of SUI.

Adverse Events Associated with Nonsurgical Treatments for Urinary Incontinence in Women: a Systematic Review

BACKGROUND

Urinary incontinence (UI) is a common malady in women. Numerous nonsurgical treatments are available, each associated with risk of adverse events (AEs).

METHODS

We systematically reviewed nonsurgical interventions for urgency, stress, or mixed UI in women, focusing on AEs. We searched MEDLINE®, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and Embase® through December 4, 2017. We included comparative studies and single-group studies with at least 50 women. Abstracts were screened independently in duplicate. One researcher extracted study characteristics and results with verification by another independent researcher. When at least four studies of a given intervention reported the same AE, we conducted random effects model meta-analyses of proportions. We also assessed the strength of evidence.

RESULTS

There is low strength of evidence that AEs are rare with behavioral therapies and neuromodulation, and that periurethral bulking agents may result in erosion and increase the risk of voiding dysfunction. High strength of evidence finds that anticholinergics and alpha agonists are associated with high rates of dry mouth and constitutional effects such as fatigue and gastrointestinal complaints. Onabotulinum toxin A (BTX) is also associated with increased risk of urinary tract infections (UTIs) and voiding dysfunction (moderate strength of evidence).

DISCUSSION

Behavioral therapies and neuromodulation have low risk of AEs. Anticholinergics and alpha agonists have high rates of dry mouth and constitutional effects. BTX is associated with UTIs and voiding dysfunction. Periurethral bulking agents are associated with erosion and voiding dysfunction. These AEs should be considered when selecting appropriate UI treatment options. AE reporting is inconsistent and AE rates across studies tended to vary widely. Trials should report AEs more consistently.

An Electronic Health Intervention for Dutch Women With Stress Urinary Incontinence: Protocol for a Mixed Methods Study

BACKGROUND

Stress urinary incontinence (SUI) is a common problem with a great potential influence on quality of life. Although SUI can be treated effectively with pelvic floor muscle training (PFMT), only a minority of women with this complaint seek help. An internet-based electronic health (eHealth) intervention could make care more accessible. The Swedish eHealth intervention Tät-treatment of Stress Urinary Incontinence offers PFMT and has shown to be effective in reducing symptoms in women with SUI. This intervention might be helpful for Dutch women too, but its adoption needs to be studied as the Netherlands differs from Sweden in terms of geographical characteristics and health care organization.

OBJECTIVE

The objective of this protocol is to investigate the barriers and facilitators to the adoption of an eHealth intervention for Dutch women with SUI and the effects of this intervention.

METHODS

We are conducting an explanatory sequential mixed methods study among 800 Dutch women with SUI who participate in the translated version of Tät-treatment of Stress Urinary Incontinence. This eHealth intervention takes 3 months. A pre-post study is conducted using surveys, which are sent at baseline (T0), 3 weeks after baseline (T1), posttreatment (T2), and 3 months posttreatment (T3). After the intervention, semistructured interviews will be held with 15 to 20 participants. The primary outcomes are barriers and facilitators to using the Tät-treatment of Stress Urinary Incontinence. This will also be analyzed among groups that differ in age and severity of incontinence. A thematic content analysis of the qualitative data will be performed. The secondary outcomes are: (1) effect on symptoms of urinary incontinence, (2) effect on quality of life, and (3) factors that are potentially associated with success. Effects will be analyzed by a mixed model analysis. Logistic regression analysis will be used to study what patient-related factors are associated with success.

RESULTS

Enrollment started in July 2018 and will be finished by December 2019. Data analysis will start in March 2020.

CONCLUSIONS

An eHealth intervention for Dutch women with SUI is promising because it can make treatment more accessible. The strength of this study is that it explores the possibilities for an internet-based-only treatment for women with SUI by using both quantitative and qualitative research methodologies. The study elaborates on existing results by using a previously tested and effective eHealth program. Insight into the barriers and facilitators to using this program can enhance the implementation of the intervention in the Dutch health care system.

TRIAL REGISTRATION

Netherlands Trial Registry (NTR) NTR6956; https://www.trialregister.nl/trial/6570.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13164.

Mixed feelings: general practitioners' attitudes towards eHealth for stress urinary incontinence - a qualitative study

BACKGROUND

Stress urinary incontinence (SUI) is the most prevalent subtype of urinary incontinence and is a bothering condition in women. Only a minority of those with SUI consult a general practitioner (GP). EHealth with pelvic floor muscle training (PFMT) is effective in reducing incontinence symptoms and might increase access to care. The role of the GP regarding such an eHealth intervention is unknown. The aim of the study is to gain insight into the attitudes towards a PFMT internet-based, eHealth, intervention for SUI.

METHODS

A qualitative study was conducted. Data were collected through semi-structured interviews among purposively sampled GPs. Audio records were fully transcribed, and analysed thematically.

RESULTS

Thirteen GPs were interviewed, nine females and four males. Three themes emerged: appraisal of eHealth as a welcome new tool, mixed feelings about a supportive role, and eHealth is no cure-all. GPs welcomed eHealth for SUI as matching their preferences for PFMT and having advantages for patients. With eHealth as stand-alone therapy GPs were concerned about the lack of feedback, and the loss of motivation to adhere to the intervention. Therefore, GPs considered personal support important. The GP's decision to recommend eHealth was strongly influenced by a woman's motivation and her age. GPs' treatment preferences for elderly are different from those for young women with SUI; both PFMT and eHealth are perceived less suitable for older women.

CONCLUSION

EHealth with PFMT fits into the GPs' routine practice of SUI and adds value to it. Although there is evidence that eHealth as a stand-alone intervention is effective, GPs consider personal support important to supplement the perceived shortcomings. Probably GPs are not aware of, or convinced of the existing evidence. Training should address this issue and should also focus on common misunderstandings about regular care for women with SUI, such as the idea that PFMT is not suitable for the elderly. Improving GPs' knowledge that eHealth can be a stand-alone therapy for SUI facilitates the implementation in daily care.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

CONTEXT

The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016.

OBJECTIVE

We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination.

EVIDENCE ACQUISITION

Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria.

EVIDENCE SYNTHESIS

The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/.

CONCLUSIONS

These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances.

PATIENT SUMMARY

Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

Impact of Dry Mouth on Fluid Intake and Overactive Bladder Symptoms in Women taking Fesoterodine

PURPOSE

We investigated the long-term relationships between dry mouth, fluid intake and overactive bladder symptoms in women undergoing treatment with fesoterodine. We hypothesized that women who experienced dry mouth would increase their fluid intake and worsen their urinary symptoms.

MATERIALS AND METHODS

We conducted a prospective ancillary study to a 9-month open-label trial of fesoterodine for women with urgency urinary incontinence. Fluid intake was measured and compared according to reported dry mouth. Multivariable analysis was used to study the interaction between dry mouth, fluid intake and urinary symptoms.

RESULTS

During the study 407 women without dry mouth significantly reduced their fluid intake (mean decrease 172.1 ml, median 118.3 ml, p = 0.02), while 91 women with dry mouth did not (mean decrease 95.8 ml, median 118.3 ml, p = 0.54). On univariable analysis a greater proportion of women who experienced dry mouth reported improvement in their urinary symptoms compared to women without dry mouth (60.5% vs 47.2%, p = 0.03). On multivariable analysis black women were less likely to report dry mouth (OR 0.4, 95% CI 0.2-0.9, p = 0.03) and older women were less likely to report improvement in urinary symptoms (OR 0.98, 95% CI 0.96-0.99, p = 0.003). Factors not associated with improvement in urinary symptoms on multiple regression were dry mouth, baseline fluid intake volume, change in fluid intake volume and caffeine intake volume.

CONCLUSIONS

In women with overactive bladder receiving fesoterodine dry mouth may prevent restriction of fluid intake but does not diminish treatment efficacy.

Fesoterodine clinical efficacy and safety for the treatment of overactive bladder in relation to patient profiles: a systematic review

OBJECTIVE

To summarize published evidence on the pharmacology, efficacy, and safety of fesoterodine for the treatment of overactive bladder (OAB) symptoms in relation to patient clinical and demographic profiles.

METHODS

A systematic review of published articles on fesoterodine was conducted via a PubMed search. Articles were identified using the search term fesoterodine, with limits of human species and abstract available. Review and meta-analysis articles, validation studies, articles focused on treatment compliance/adherence, meeting abstracts, and articles not focused on oral fesoterodine administration in human subjects were excluded. Data from retained articles were summarized descriptively.

RESULTS

Of 137 articles identified, 61 (15 articles on the pharmacology and 46 articles on the efficacy and/or safety of fesoterodine) met inclusion criteria. Superiority trials demonstrated the additional efficacy of fesoterodine 8 mg versus fesoterodine 4 mg and tolterodine extended release 4 mg in treating OAB. Prospective trials in specific patient populations indicated beneficial effects of fesoterodine in elderly patients, vulnerable elderly patients, patients dissatisfied with or with a suboptimal response to previous antimuscarinic therapy, patients with urge urinary incontinence (UUI) or nocturnal urgency, and men with persistent LUTS during alpha-blocker treatment. With two effective doses, the fesoterodine dose can be adjusted to achieve optimal efficacy and tolerability in individual patients. The most common adverse events during fesoterodine treatment are dry mouth and constipation.

CONCLUSIONS

Extensive evidence demonstrates the efficacy and safety of fesoterodine in relieving OAB symptoms, including urgency, urinary frequency, UUI, and nocturnal urgency, in patients with various clinical and demographic profiles. Trial results provide valuable information on fesoterodine treatment in specific patient populations, including both elderly and vulnerable elderly patients. Potential limitations of this review are that only English language articles in PubMed were searched and included.