Bladder neck support prosthesis: a nonoperative treatment for stress or mixed urinary incontinence

A double-blind, randomized, placebo-controlled clinical trial evaluating the safety and efficacy of autologous muscle derived cells in female subjects with stress urinary incontinence

PURPOSE

The purpose of the study was to assess safety and efficacy of autologous muscle derived cells for urinary sphincter repair (AMDC-USR) in female subjects with predominant stress urinary incontinence.

METHODS

A randomized, double-blind, multicenter trial examined intra-sphincteric injection of 150 × 10⁶ AMDC-USR versus placebo in female subjects with stress or stress predominant, mixed urinary incontinence. AMDC-USR products were generated from vastus lateralis needle biopsies. Subjects were randomized 2:1 to receive AMDC-USR or placebo and 1:1 to receive 1 or 2 treatments (6 months after the first). Primary outcome was composite of ≥ 50% reduction in stress incontinence episode frequency (IEF), 24-h or in-office pad weight tests at 12 months. Other outcome data included validated subject-recorded questionnaires. Subjects randomized to placebo could elect to receive open-label AMDC-USR treatment after 12 months. Subject follow-up was up to 2 years.

RESULTS

AMDC-USR was safe and well-tolerated with no product-related serious adverse events or discontinuations due to adverse events. Interim analysis revealed an unexpectedly high placebo response rate (90%) using the composite primary outcome which prevented assessment of treatment effect as designed and thus enrollment was halted at 61% of planned subjects. Post hoc analyses suggested that more stringent endpoints lowered placebo response rates and revealed a possible treatment effect.

CONCLUSIONS

Although the primary efficacy finding was inconclusive, these results inform future trial design of AMDC-USR to identify clinically meaningful efficacy endpoints based on IEF reduction, understanding of placebo response rate, and refinement of subject selection criteria to more appropriately align with AMDC-USR's proposed mechanism of action.

Mechanical devices for urinary incontinence in women

BACKGROUND

Incontinence can have a devastating effect on the lives of sufferers with significant economic implications. Non-surgical treatments such as pelvic floor muscle training and the use of mechanical devices are usually the first line of management, particularly when a woman does not want surgery or when she is considered unfit for surgery. Mechanical devices are inexpensive and do not compromise future surgical treatment.

OBJECTIVES

To determine whether mechanical devices are useful in the management of adult female urinary incontinence.

SEARCH METHODS

For this second update 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 21 August 2014), EMBASE (January 1947 to 2014 Week 34), CINAHL (January 1982 to 25 August 2014), and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of mechanical devices in the management of adult female urinary incontinence determined by symptom, sign or urodynamic diagnosis.

DATA COLLECTION AND ANALYSIS

The reviewers assessed the identified studies for eligibility and risk of bias and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 5.3).

MAIN RESULTS

One new trial was identified and included in this update bringing the total to eight trials involving 787 women. Three small trials compared a mechanical device with no treatment and although they suggested that use of a mechanical device might be better than no treatment, the evidence for this was inconclusive. Four trials compared one mechanical device with another. Quantitative synthesis of data from these trials was not possible because different mechanical devices were compared in each trial using different outcome measures. Data from the individual trials showed no clear difference between devices, but with wide confidence intervals. One trial compared three groups: a mechanical device alone, behavioural therapy (pelvic floor muscle training) alone and behavioural therapy combined with a mechanical device. While at three months there were more withdrawals from the device-only group, at 12 months differences between the groups were not sustained on any measure.

AUTHORS' CONCLUSIONS

The place of mechanical devices in the management of urinary incontinence remains in question. Currently there is little evidence from controlled trials on which to judge whether their use is better than no treatment and large well-conducted trials are required for clarification. There was also insufficient evidence in favour of one device over another and little evidence to compare mechanical devices with other forms of treatment.

The role of duloxetine in stress urinary incontinence: a systematic review and meta-analysis

OBJECTIVES

This systematic review determined whether the duloxetine can get more benefits versus placebo in managing women with stress urinary incontinence (SUI) all over the world.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing duloxetine with placebo in these patients. The eligible RCTs were identified from the following electronic databases: Cochrane CENTRAL, Medline and EMBASE. We treated the incontinence episode frequency (IEF) as the main outcome, and the secondary outcomes were cured, average voiding interval, incontinence quality of life (I-QOL), treatment-emergent adverse events (TEAEs) and discontinuation.

RESULTS

The review contained ten trials including 5,738 women who were randomized to take duloxetine or placebo. All arms in individual trials were comparable for various baseline characteristics. Individual studies showed a significantly greater decrease in IEF than placebo group. The total IEF responders (defined as a woman who had at least a 50 % decrease in IEF with treatment) within the duloxetine-treated women were more than the placebo-treated women (52.5 vs. 33.7 %; RR = 1.56; 95 %CI, 1.46-1.66; p < 0.00001). TEAEs were commonly experienced by both two groups (62.7 vs. 45.3 %) though they were not critical.

AUTHORS' CONCLUSIONS

Our meta-analysis showed that significant efficacy can be found in women treated with a certain dose of duloxetine. The adverse events like nausea, constipation, dry mouth, fatigue etc. are common.

Mechanical devices for urinary incontinence in women

BACKGROUND

ncontinence can have a devastating effect on the lives of sufferers with significant economic implications. Non-surgical treatments such as pelvic floor muscle training and the use of mechanical devices are usually the first line of management, particularly when a woman does not want surgery or when she is considered unfit for surgery. Mechanical devices are inexpensive and do not compromise future surgical treatment.

OBJECTIVES

To determine the effects of mechanical devices in the management of adult female urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 23 June 2010), EMBASE (January 1947 to 2010 Week 24), CINAHL (January 1982 to 11 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of mechanical devices in the management of adult female urinary incontinence determined by symptom, sign or urodynamic diagnosis.

DATA COLLECTION AND ANALYSIS

The reviewers assessed the identified studies for eligibility and risk of bias and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 5.0.25).

MAIN RESULTS

One new trial was identified and included in this update bringing the total to seven trials involving 732 women. Two small trials compared a mechanical device with no treatment and although they suggested that use of a mechanical device might be better than no treatment, the evidence for this was inconclusive. Four trials compared one mechanical device with another. Quantitative synthesis of data from these trials was not possible because different mechanical devices were compared in each trial using different outcome measures. Data from the individual trials showed no clear difference between devices, but with wide confidence intervals. One new trial compared three groups: a mechanical device alone, behavioural therapy (pelvic floor muscle training) alone and behavioural therapy combined with a mechanical device. While at three months, there were more withdrawals from the device-only group, at 12 months group differences between the groups were not sustained on any measure.

AUTHORS' CONCLUSIONS

The place of mechanical devices in the management of urinary incontinence remains in question. Currently there is little evidence from controlled trials on which to judge whether their use is better than no treatment and large well-conducted trials are required for clarification. There was also insufficient evidence in favour of one device over another and little evidence to compare mechanical devices with other forms of treatment.

Reductions in stress urinary incontinence episodes: what is clinically important for women?

AIM

To expand our understanding of the clinical importance to patients with stress urinary incontinence (SUI) of reductions in incontinence episode frequency (IEF) that fall short of a complete cure.

METHODS

We used an integrated database that included data from 1,913 women with SUI who were enrolled in four randomized, placebo-controlled pharmaceutical clinical trials and examined the relationship between various levels of reduction in IEF and minimally clinical important difference (MCID) levels established for the validated Incontinence Quality of Life (I-QOL) questionnaire. The first decile of IEF reduction to exceed the within-group MCID was considered to be the point at which the reduction in IEF first became clinically important. The between-group MCID was then used to determine when further reductions in incontinence represented clinically relevant incremental improvements for patients.

RESULTS

Improvements in condition-specific quality of life were not clinically important until the fifth decile of IEF reduction, representing a reduction in IEF >40% to <or=50%. Patients appreciated incremental clinically important benefits when IEF reductions exceeded 70%, with progressive improvements in condition-specific quality of life with higher levels of IEF reduction. The difference between a >70% to <or=80% reduction and a >90% to <or=100% reduction was clinically important.

CONCLUSION

Reductions in IEF <or=40% do not appear to be clinically important for women with SUI. Patients appear to recognize important clinical value at reductions of approximately 50% and important incremental clinical value at reductions of approximately 75% and 90-100%. These thresholds may not apply to women seeking non-pharmaceutical treatments for SUI.

Duloxetine versus placebo for the treatment of women with stress predominant urinary incontinence in Taiwan: a double-blind, randomized, placebo-controlled trial

BACKGROUND

This manuscript compares the efficacy and safety of duloxetine with placebo in Taiwanese women with SUI.

METHODS

Taiwanese women with SUI were were randomly assigned to placebo (n = 61) or duloxetine 80 mg/day (n = 60) in this double-blind, 8-week, placebo-controlled study. Outcome variables included: incontinence episode frequency (IEF), Incontinence Quality of Life questionnaire (I-QOL) scores, and Patient Global Impression of Improvement rating (PGI-I).

RESULTS

Decrease in IEF was significantly greater in duloxetine-treated than placebo-treated women (69.98% vs 42.56%, P < .001). No treatment differences in I-QOL scores were significant. There were significant differences in PGI-I rating. Treatment-emergent adverse events (TEAEs) were experienced by more duloxetine-treated than placebo-treated women (80.0% vs 44.3%; P < .001). Discontinuations due to adverse events were significantly greater for duloxetine-treated than placebo-treated women (26.7% vs 6.6%; P = .003).

CONCLUSION

Data provide evidence for the safety and efficacy of duloxetine for the treatment for Taiwanese women with SUI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00475358.

Dilemmas in the management of female stress incontinence: the role of pelvic floor muscle training

Treatment options for female stress urinary incontinence include pelvic floor muscle training, lifestyle interventions, bladder retraining, pharmacotherapy, anti-incontinence devices and surgery. Several consensus statements recommend pelvic floor muscle training as first line treatment. The aim of this review is to analyse all the currently available data and propose a treatment algorithm for clinical practice. A literature-based critical presentation of all treatment modalities, methods of assessing efficacy and comparison between them using a patient-centered approach was made. Many of the studies are observational, non-randomized with several methodological problems that lead to confusion. Emphasis was made to high quality randomized trials. The proposed treatment algorithm established only on evidence-based data. Management strategy however, must identify patient expectations and involve them in the decision-making more than traditional measures of treatment success.

Mechanical devices for urinary incontinence in women

BACKGROUND

Incontinence can have a devastating effect on the lives of sufferers with significant economic implications. Non-surgical treatments such as pelvic floor muscle training and the use of mechanical devices are usually the first line of management. The latter more so when a person did not want surgery or when considered unfit for surgery. Mechanical devices are inexpensive and do not compromise future surgical treatment.

OBJECTIVES

To determine the effects of mechanical devices in the management of adult female urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (7 December 2005). The register contains trials identified from MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL and handsearching of journals and conference proceedings.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of mechanical devices in the management of adult female urinary incontinence determined either by symptom classification or by urodynamic diagnosis.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the identified studies for eligibility and methodological quality and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 4.2).

MAIN RESULTS

There were six trials involving a total of 286 women. Two small trials compared a mechanical device with no treatment and although they suggested that use of a mechanical device might be better than no treatment, the evidence for this was inconclusive. Five trials compared one mechanical device with another. Quantitative synthesis of data from these trials was not possible because different mechanical devices were compared in each trial using different outcome measures. Data from the individual trials showed no clear difference between devices, but with wide confidence intervals. There were no trials comparing a mechanical device with another type of treatment.

AUTHORS' CONCLUSIONS

The place of mechanical devices in the management of urinary incontinence remains in question. Currently there is little evidence from controlled trials on which to judge whether their use is better than no treatment and a large well-conducted trial is required for clarification. There was also insufficient evidence in favour of one device over another and no evidence to compare mechanical devices with other forms of treatment.

Minimal clinically important differences in Incontinence Quality-of-Life scores in stress urinary incontinence

OBJECTIVES

To determine the clinically relevant reference points for the Incontinence Quality of Life (I-QOL) questionnaire scores in women with stress urinary incontinence and compare them with the treatment effects observed with duloxetine and placebo.

METHODS

Using data from 1133 women with predominant stress urinary incontinence in two randomized, placebo-controlled duloxetine studies, the within-treatment and between-treatment minimal clinically important differences (MCIDs) were obtained by anchoring the I-QOL scores to the validated Patient Global Impression of Improvement scale (PGI-I). The within-treatment MCID (mean I-QOL for women rating their condition "a little better" with treatment) and between-treatment MCID (difference in scores between the group ratings of "no change" and "a little better") were derived. The treatment effects were compared with these MCIDs. Real-time urinary diaries were completed, along with the I-QOL and PGI-I.

RESULTS

The within-treatment and between-treatment MCID for the I-QOL total score was 6.3 and 2.5, respectively. The total and subscale scores had almost identical MCIDs. Duloxetine 80 mg significantly improved the I-QOL total and subscale scores. Treatment differences in the I-QOL scores exceeded the between-treatment MCID and the duloxetine I-QOL treatment effect exceeded the within-treatment MCID. The number of patients needed to treat to gain an additional I-QOL responder was 6.8.

CONCLUSIONS

Improvements in I-QOL scores should be greater than the within-treatment MCID, and differences between two treatments should be greater than the between-treatment MCIDs, for statistically significant differences to be considered clinically meaningful. We propose 2.5 points as a reasonable guide for the I-QOL between-treatment MCID and 6.3 points for the within-treatment MCID.

Mechanical devices for urinary incontinence in women

BACKGROUND

Incontinence can have a devastating effect on the lives of sufferers with significant economic implications. Non-surgical treatments such as pelvic floor muscle training and the use of mechanical devices are usually the first line of management. The latter more so when a person did not want surgery or when considered unfit for surgery. Mechanical devices are inexpensive and do not compromise future surgical treatment.

OBJECTIVES

To determine the effects of mechanical devices in the management of adult female urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (7 December 2005). The register contains trials identified from MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL and handsearching of journals and conference proceedings.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of mechanical devices in the management of adult female urinary incontinence determined either by symptom classification or by urodynamic diagnosis.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the identified studies for eligibility and methodological quality and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 4.2).

MAIN RESULTS

There were six trials involving a total of 286 women. Two small trials compared a mechanical device with no treatment and although they suggested that use of a mechanical device might be better than no treatment, the evidence for this was inconclusive. Five trials compared one mechanical device with another. Quantitative synthesis of data from these trials was not possible because different mechanical devices were compared in each trial using different outcome measures. Data from the individual trials showed no clear difference between devices, but with wide confidence intervals. There were no trials comparing a mechanical device with another type of treatment.

AUTHORS' CONCLUSIONS

The place of mechanical devices in the management of urinary incontinence remains in question. Currently there is little evidence from controlled trials on which to judge whether their use is better than no treatment and a large well-conducted trial is required for clarification. There was also insufficient evidence in favour of one device over another and no evidence to compare mechanical devices with other forms of treatment.

Pharmacological treatment of women awaiting surgery for stress urinary incontinence

OBJECTIVE

Duloxetine, a serotonin/norepinephrine reuptake inhibitor, has been effective in the treatment of mild and moderate stress urinary incontinence. The aim of this trial was to assess its efficacy for women with severe stress urinary incontinence.

METHODS

One hundred nine women, aged 33-75 years, enrolled into this double-blind, randomized, placebo-controlled study. Subjects had to have a predominant symptom of stress urinary incontinence with an incontinence episode frequency 14 per week or more, pure urodynamic stress urinary incontinence, and continence surgery already scheduled. Women were randomized to placebo (n = 54) or duloxetine 80 mg/d (n = 55) for 4 weeks, escalated to 120 mg/d for 4 weeks. Assessment variables included incontinence episode frequency, continence pad use, the Incontinence Quality of Life (I-QOL) questionnaire, and the Willingness to Consider Surgery rating. A responder was defined as a subject with an incontinence episode frequency reduction of 50% or more.

RESULTS

There were significant improvements with duloxetine compared with placebo in incontinence episode frequency (-60% versus -27%, P <.001), I-QOL score (+10.6 versus +2.4, P =.003), and pad use (-34.5% versus -4.8%, P =.008). At the conclusion of the 8-week study, 10/49 (20%) duloxetine-treated women were no longer interested in surgery, compared with 0/45 placebo-treated women (P =.001). Duloxetine-treated subjects were significantly more likely to be classified as responders (relative risk 4.68, 95% confidence interval 2.27-9.66). The number of subjects-needed-to-treat to gain an additional incontinence episode frequency responder with duloxetine was 2.02. All duloxetine responses were observed within 2 weeks. Side effects and discontinuations because of side effects were significantly more common with duloxetine.

CONCLUSION

The data support duloxetine's efficacy in women with severe stress urinary incontinence and suggest that some women responding to duloxetine may reconsider their willingness to undergo surgery.

Conservative management for urinary incontinence

Gynaecologists have become increasingly aware of the need to offer conservative therapy for genuine stress incontinence. There is good objective evidence from randomized controlled trials to support the use of supervised pelvic floor exercises. The efficacy of biofeedback therapy, vaginal cone weights and electrostimulation therapy is variable and requires further study to identify those women who will benefit the most. The mainstay of therapy for detrusor instability/sensory urgency remains bladder training, which has proven objective efficacy, but new treatments such as transcutaneous electrical nerve stimulation (TENS) offer promise. Finally, for certain groups of women with mixed stress and urge leak, a new range of vaginal and urethral devices provide useful additional options. The specific requirements for future research are discussed.

A magnetic device for increasing the urethral resistance to flow: an experimental study in female dogs

OBJECTIVE

To test a new magnetic device for increasing the urethral resistance to flow in a dog model, and thus provide a potential mechanical device for the treatment of incontinence in women.

MATERIALS AND METHODS

The study comprised 12 female mongrel dogs; three dogs were used to study the effect on urethral resistance of inserting a vaginal magnet (control experiment) and five were assessed in a urodynamic study. With the animals under general anaesthesia, the bladder and the urethra were exposed by a low midline incision. One magnet, embedded in a silicon layer, was placed on the anterior side of the urethra 3 cm distal to the bladder neck and fixed with a few sutures. To increase the urethral resistance as required, a second magnet was inserted into the vagina and the device activated. Urethral pressure profiles and leak-point pressures were recorded in the anaesthetized animals under resting conditions and after the urethra was compressed between the magnets. Recordings were also made after pharmacological blockade of the urethral musculature. In four additional dogs, chronic experiments were conducted to evaluate the effect of continuous compression of the urethra and the vaginal wall for 14 days.

RESULTS

Urethral compression between the magnets resulted in a doubling of the maximal pressure in the proximal urethra and in a threefold increase of the leak-point pressure. After pharmacological denervation of the urethra the differences between the control pressures and those after activating the device were even greater, although not significantly so. After 2 weeks of continuous compression of the vaginal wall and the urethra between the magnets there was no detectable tissue damage.

CONCLUSION

These results suggest that the magnetic device can efficiently increase urethral pressure and that prolonged compression caused no apparent damage to the urethra or vagina. It may therefore be a useful potential method of providing urinary continence in women.

Efficacy of an external urethral device in women with genuine stress urinary incontinence

The efficacy of a new external anti-incontinence device in patients with a videourodynamic diagnosis of genuine stress incontinence (GSI) in an open longitudinal study is reported. Fourteen women with GSI underwent assessment before and after 3-4 weeks of device use. Assessment consisted of visual analog scores (VAS), quality of life (QOL) questionnaires, urine for culture and a 1 hour pad test. VAS scores showed a significant improvement for the symptom of stress incontinence (P<0.05). QOL scores improved significantly by 38% (P<0.05) and 29% (P<0.01) for the Incontinence Impact Questionnaire and Urogenital Distress Inventory, respectively. The mean pad weight decreased by 47% (P=0.056). Of the 9 women who had a positive pad test (>2 g) without the device, 5 were dry (<2 g) with the device (P<0.05). These preliminary data suggest that this device is effective in women with GSI.

Office management of female urinary incontinence

The majority of incontinent women are manageable using office-based techniques. This article reviews the basic causes of per urethram urinary incontinence, and summarizes how to optimally evaluate them from a clinical and urodynamic standpoint in the office setting. Emphasis is made on the progress and efficiency of the wide range of ambulatory treatment options, which include behavioral treatments, pharmacotherapy, periurethral injection of bulking agents, anti-incontinence devises, and the use of absorbent products. The economy-driven trend to decrease hospital management of disease and patient interest in noninvasive techniques will continue to increase the importance of the key role played by the office urologist in the management of female urinary incontinence.

Clinical value of vaginal cones for the management of female stress incontinence

In women with mild stress incontinence (mean urine loss of 3.7 g/h), pelvic floor training using vaginal cones resulted in a subjective success rate of 70% (19/27), that is complete cure or reduction by >50% of the original severity. However, in women with severe stress incontinence (mean urine loss of 20.7 g/h) cone therapy was successful in only 14% (7/50). The predictive value of six parameters (age, parity, urine loss by pad test, frequency of incontinence, contractile strength of the vagina, and perceived problems) was analyzed and two showed significant prognostic values: a smaller amount of urine loss and less frequent incontinence. It is concluded that vaginal cone therapy is one physical treatment option for stress incontinence but is of no clinical effect for those with severe incontinence.

Introl bladder neck support prosthesis: international clinical experience

The Introl bladder neck support prosthesis is a ring-shaped silastic device with two prongs located at one side such that when placed within the vaginal canal the bladder neck is suspended in a fashion similar to a surgical urethropexy. Since its initial description in 1988 the device has undergone clinical trials in the US and Japan, documenting its effectiveness in the treatment of stress and mixed incontinence in women. Introl is available for clinical use in the United States and has been well accepted by practicing clinicians. In Japan, exposure has occurred through clinical trials, which resulted in a high efficacy rate, i.e. 81% of the patients had either maximum benefit or benefit in the global usefulness rating, and 26% experienced minor adverse effects. This paper will summarize Introl clinical study findings and describe various clinical observations made during increased clinical usage.