Is the bladder a reliable witness for predicting detrusor overactivity?

Catheter-Free Urodynamics Testing: Current Insights and Clinical Potential

Lower urinary tract dysfunction not only interferes with the health-related quality of life of patients but may also lead to acute kidney injury and infections. To assess the bladder, urodynamic studies (UDS) have been implemented but the use of catheters leads to discomfort for the patient. Catheter-free long-term UDS would be useful and a potential solution could be ambulatory wireless devices that communicate via telemetry. Such sensors can detect pressure or volume. Numerous types of potential catheter-free sensors have been proposed for bladder monitoring. Despite substantial innovation in the manufacturing of implantable biomedical electronic systems, such sensors have remained at the laboratory stage due to a number of critical challenges. These challenges primarily concern hermeticity and biocompatibility, sensitivity and artifacts, drift, telemetry, and energy management. Having overcome these challenges, catheter-free ambulatory urodynamic monitoring could combine a synchronized intravesical pressure sensor with a volume analyzer but only the steps of cystometry and volume measurement are currently sufficiently reproducible to simulate UDS results. The measurement of volume by infrared optical sensors, in the form of abdominal patches, appears to be promising and studies are underway to market a telemetric ambulatory urodynamic monitoring system that includes an intravesical pressure sensor. There has been considerable progress in wearable and conformable electronics on many fronts, and continued collaboration between engineers and urologists could quickly overcome current challenges. In addition, to the diagnosis of UDS, such sensors could be useful in the development of a long-term closed-loop neuromodulation system. In this review, we explore the various types of catheter-free bladder sensors, inherent challenges and solutions to overcome these challenges, and the clinical potential of such long-term implantable sensors.

Flat Magnetic Stimulation for Urge Urinary Incontinence

Background and Objectives: Strategies for overactive bladder syndrome (OAB) management involve, among others, strengthening the bladder outlet to suppress urgency and neuromodulating the sacral roots. Magnetic stimulation (MS) is a technology that involves an extracorporeal device that is able to provide an electromagnetic field specifically designed to interact with pelvic floor neuromuscular tissue. The resulting tissue electrical activity induces contraction of the pelvic muscle and neuromodulation of the S2-S4 sacral roots. Flat Magnetic Stimulation (FMS) is a relevant advancement involving homogeneous electromagnetic fields, which are able to optimize the effect on the entire pelvic area. However, the benefits of this new technology for OAB syndrome are poorly known. Consequently, the aim of our study is to analyze the outcomes and quality of life (QoL) impact of FMS with Dr. Arnold (DEKA, Calenzano, Italy) in women suffering from OAB syndrome associated with urinary incontinence. Materials and Methods: This prospective study included patients with OAB, urge urinary incontinence, and no ongoing OAB treatments. At baseline (T0), the Incontinence Impact Questionnaire (IIQ-7), the Female Sexual Function Index (FSFI-19), and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) were collected. Patients underwent 8 FMS sessions of 25 min each in one month. At the termination of the therapy (T1), women repeated the ICIQ-UI SF, FSFI-19, and IIQ-7 tools. Moreover, the Patient Global Impression of Improvement (PGI-I) questionnaire was collected to evaluate the cure rate. Results: Our study enrolled a total of 57 consecutive patients. Most women had at least one second- or third-line treatment before FMS, while the remaining naive patients had contraindications to pharmacological treatments. No women reported adverse effects during the treatment. After the treatment, we observed a decrease in the IIQ-7 (p < 0.001) and ICIQ-UI SF scores (p < 0.001) and an improvement in sexual function (p < 0.001) evaluated with FSFI-19. According to PGI-I scores, 42 (73.7%) women referred to some kind of improvement, scoring ≤ 3 points. Specifically, 8.7% of patients considered themselves very much improved, 29.8% much improved, 35.1% minimally improved, and 26.3% found no changes. FMS was effective in treating OAB symptoms without any adverse effects. The mechanism is supposed to be related to suppressing the initiation of micturition. This makes FMS a promising device for treating naive and refractory urge urinary incontinence. Conclusions: The new FMS represents a promising non-pharmacological option for the treatment of naive and refractory OAB.

Clinical and Urodynamic Determinants of Earlier Time to Failure for the Artificial Urinary Sphincter

OBJECTIVE

To determine clinical, surgical and urodynamic attributes associated with earlier AUS reintervention. The artificial urinary sphincter (AUS) is the gold standard treatment for postprostatectomy stress urinary incontinence. Factors impacting long-term device survival have not been investigated.

MATERIALS AND METHODS

We identified men with post-prostatectomy incontinence who underwent AUS reintervention from 2011 to 2021 at a single center. Urodynamic study, pad weights and voiding diaries are routinely assessed prior to AUS placement. Relationships between clinical, urodynamic and surgical variables and AUS reintervention were assessed using cox regression. Multiple imputation of chained equations was used to handle missing data elements, with truncated linear regression for continuous variables and logistic regression for binary variables.

RESULTS

A total of 524 records were reviewed and 92 met inclusion. Median time to AUS reintervention was 5.7 years (2.3, 9.4). Indications were mechanical failure (38; 41.3%), sub-cuff atrophy (37; 40.2%), erosion/infection (11; 11.9%) and other (6; 6.5%). On univariable testing, earlier intervention was associated with pad weight (P < .01), nocturnal voids (P = .01), bladder capacity (P = .01), bladder volume at strong sensation (P = .03), detrusor overactivity (P < .01) and maximum voiding pressure (P = .02). On multivariable analysis, earlier surgical intervention was associated with detrusor overactivity (HR 1.95, P < .01 CI 1.22-3.1) and pad weight (HR 1.0006, P = .02, CI 1.000-1.001).

CONCLUSIONS

Detrusor overactivity is associated with significantly shorter time to AUS failure. This information may allow for more individualized counseling.

Adherence to Overactive Bladder Syndrome Treatments Recent Developments and Future Perspectives

Overactive bladder (OAB) is a common and distressing condition which is known to have a significant effect on Health-Related Quality of Life (HRQoL). Whilst all patients complaining of overactive bladder symptoms will, in theory, initially benefit from conservative measures, many will require pharmacological therapy. Antimuscarinics currently remain the most commonly used drugs to treat OAB although compliance and persistence can be poor due to concerns regarding adverse events and lack of efficacy. This review will explore the common management strategies for OAB with a particular focus on patient adherence to therapy including compliance and persistence. The role of antimuscarinics and the B3-agonist, mirabegron, will be considered along with barriers to their efficacy and adoption. For those patients in whom conservative and pharmacological treatment proves ineffective or is unsuitable, the management of refractory OAB will also be considered. In addition, the role of current and future developments will be examined.

Correlation between overactive bladder and detrusor overactivity: a retrospective study

INTRODUCTION

The primary objective of this study is to determine the prevalence of overactive bladder (OAB) and detrusor overactivity (DO) in female patients who were referred for urodynamic study (UDS) because of lower urinary tract symptoms (LUTS). The secondary objective is to determine the subjective and objective differences between female OAB patients with and without DO.

MATERIALS AND METHODS

All female patients who underwent UDS for LUTS between June 2016 and September 2019 were retrospectively reviewed. Personal history, medical history, physical examination, and validated questionnaires were collected. One-hour pad test and multichannel urodynamic study was performed. All statistical analyses were conducted by SAS 9.4. P-value < 0.05 was considered statistically significant.

RESULTS

A total of 4184 female patients underwent UDS because of LUTS between June 2016 and September 2019; 1524 patients were analyzed for OAB or DO. The occurrence of OAB was 36.4%. The overall incidence of DO in OAB patients was 15.5%; 9.5% of all patients had DO findings on UDS, and 4.6% were incidental findings. There were significant differences among mean age, parity, ICIQ-UI SF, OABSS, POPDI-6, and all UDS parameters (except for maximal urethral pressure and pressure transmission ratio) between patients with and without DO. In patients with DO, there were no significant differences among age, parity, and BMI with or without OAB symptoms. However, there were significant differences among mean OABSS, ICIQ-UI SF, UDI-6, POPDI-6, IIQ-7, and pad test.

CONCLUSIONS

Patients with DO are associated with older age, increased parity, greater urine leakage, and worse storage and micturition functions on UDS. Combinations of subjective and objective measurements are better predictive models for OAB patients.

Acupuncture for the treatment of overactive bladder: A systematic review and meta-analysis

Background

Acupuncture (AT) successfully regulates overactive bladder (OAB) symptoms. However, previous systematic reviews and meta-analyses have not provided sufficient evidence. This review presents the current evidence of the efficacy of AT in the management of OAB symptoms.

Methods and analyses

A total of 12 databases were searched from their inception: PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and AMED databases; five Korean medical databases; and three Chinese medical databases. Study selection, data extraction, and assessment were independently performed by two researchers. The risk of bias was assessed using the Cochrane risk of bias assessment tool. RevMan 5.4.1 software was used for data aggregation, and the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to evaluate the quality of the study outcomes.

Results

A total of 30 studies were included in this review. Compared with the sham AT group, the AT group exhibited significant effects in reducing overactive bladder symptom scores (OABSS) [mean difference (MD): -1.13, 95% confidence interval (CI): -2.01 to -0.26, p = 0.01 I 2 = 67%] and urinary frequency [standardized mean difference (SMD): -0.35, 95% CI: -0.62 to -0.08, I 2 = 0%]. The AT group showed an equivalent effect as drug therapy in reducing OABSS (MD: -0.39, 95% CI: - 1.92 to 1.13, p = 0.61, I 2 = 94%) and urinary frequency (MD: 0.74, 95% CI: -0.00 to 1.48, p = 0.05, I 2 = 71%) with fewer adverse events [risk ratio (RR): 0.38, 95% CI: 0.16-0.92, p = 0.03, I2 = 58%]. The AT plus drug therapy group had a more favorable effect than drug therapy alone for reducing OABSS (MD: -2.28, 95% CI: -3.25 to -1.31, p < 0.00001, I 2 = 84%) and urinary frequency (MD: -2.34, 95% CI: -3.29 to -1.38, p < 0.00001, I 2 = 88%). The GRADE assessment demonstrated that the level of evidence was mostly low or very low given the high risk of bias and small sample sizes.

Conclusion

AT had more favorable effects than sham AT in reducing OAB symptoms. AT improved OAB symptoms as effectively as conventional drug therapy, and the combination of AT and drug therapy had more favorable effects than drug therapy alone. However, more rigorous studies are needed to enhance the level of evidence.

Systematic review registration

http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42014010377, identifier: PROSPERO [CRD42014010377].

Assessing Quality-of-Life of Patients Taking Mirabegron for Overactive Bladder

Lower urinary tract symptoms (LUTS), including urgency, frequency, and urgency incontinence, are highly prevalent in the general population and increase in prevalence with increasing age. All LUTS, but notable urgency and urgency incontinence, are associated with negative impact on quality-of-life (QoL), with multiple aspects of QoL affected. Urgency and urgency incontinence are most commonly caused by overactive bladder (OAB), the clinical syndrome of urinary urgency, usually accompanied by increased daytime frequency and/or nocturia in the absence of infection or other obvious etiology, which may be treated with conservative and lifestyle interventions, bladder antimuscarinic drugs, and, more recently, by mirabegron, a β3 agonist. This narrative review describes the impact of OAB on QoL, quantifies this impact, and outlines the evidence for the use of mirabegron in the treatment of, and improvement in QoL in, people with OAB.

Mechanism of traditional Chinese medicine in treating overactive bladder

Overactive bladder syndrome (OAB) has made increasing progress in mechanism and treatment research. Traditional Chinese medicine (TCM) is a common complementary therapy for OAB, and it has been found to be effective. However, the intervention mechanism of TCM in the treatment of OAB is still unclear. The aim of this review is to consolidate the current knowledge about the mechanism of TCM: acupuncture, moxibustion, herbs in treating OAB, and the animal models of OAB commonly used in TCM. Finally, we put forward the dilemma of TCM treatment of OAB and discussed the insufficiency and future direction of TCM treatment of OAB.

Efficacy, according to urodynamics, of OnabotulinumtoxinA compared with antimuscarinic drugs, for neurogenic detrusor overactivity: a systematic review and network meta-analysis

To summarize the differences in urodynamic outcomes between oral antimuscarinic drugs and OnabotulinumtoxinA, and finding a therapy that maintains good urodynamics in neurogenic detrusor overactivity (NDO). We conducted a literature search of EMBASE and PubMed, with the language limited to English. In the analysis, all of the published randomized trials of OnabotulinumtoxinA or antimuscarinic drugs used to treat NDO were found and the results were finally obtained through Bayesian model analysis. A total of 12 RCTs and 2208 patients were included. OnabotulinumtoxinA 300U was superior to other drugs in terms of MCC, volume at IDC, and Pdet_max endpoints. OnabotulinumtoxinA 200U was more effective on the urodynamic endpoint of BC than other drugs or doses of OnabotulinumtoxinA. According to the MCC urodynamic results, oxybutynin, solifenacin 10 mg, and tolterodine 4 mg also had positive effects. OnabotulinumtoxinA 300U, 200U and 100U were better in improving the urodynamic results of NDO, and the current evidence also shows that selective injection of onabotulinumtoxinA can effectively improve the urodynamic results.

A Feasibility Study to Evaluate Changes in Urinary Metabolites after OnabotulinumtoxinA Injection for Refractory Overactive Bladder

Metabolomics analysis of urine before and after overactive bladder (OAB) treatment may demonstrate a unique molecular profile, allowing predictions of responses to treatment. This feasibility study aimed to correlate changes in urinary metabolome with changes in OAB symptoms after intravesical onabotulinumtoxinA (BTX-A) injections for refractory OAB. Women 18 years or older with non-neurogenic refractory OAB were recruited to complete OAB-V8 questionnaires and submit urine samples before and after 100 units intravesical BTX-A injection. Samples were submitted to CE-TOFMS metabolomics profiling. Data were expressed as percent of change from pre-treatment and were correlated with OAB-V8 score improvement. Urinary metabolite changes in the OAB-V8 groups were compared using the Kruskal–Wallis test, and associations between metabolites and OAB-V8 scores were examined using quantile regression analysis. Of 61 urinary metabolites commonly detected before and after BTX-A, there was a statistically significant decrease in adenosine and an increase in N8-acetylspermidine and guanidinoacetic acid levels associated with OAB score improvement, suggesting that intravesical BTX-A injection modifies the urinary metabolome. These urinary metabolites could provide insight into OAB pathophysiology and help identify patients who would benefit most from chemodenervation.

Overactivity index: A noninvasive and objective outcome measure in overactive bladder in children

INTRODUCTION

Reports showed that observing detrusor overactivity (DO) and maximum cystometric capacity (MCC) may guide rational pharmacotherapy. Since urodynamic studies (UDS) are challenging for both patients and the healthcare system, a non-invasive objective prognostic marker is preferable.

OBJECTIVES

To investigate the value of the overactivity index (OI), a non-invasive measure calculated from the frequency-volume chart (FVC), for predicting the presence of symptoms and abnormal UDS in children with non-neurogenic OAB.

STUDY DESIGN

This was a prospective interventional study on a consecutive sample of 92 children with urgency treated with anticholinergics and standard urotherapy. Data from history, physical examination, bladder diaries, kidneys and bladder ultrasonography, uroflow, urinalysis, urine culture, and UDS was collected at baseline, and after 3 and 6 months. Binary logistic regression was used to evaluate noninvasive parameters as predictors of Overactive Bladder Symptom Score (OABSS) total score >2 and DO and/or small MCC defined as <65% of expected bladder capacity (EBC) for age. OI was calculated as (1 - (median (all voided volumes in FVC in ml))/(0.65 ∗ EBC in ml)) ∗ 100.

RESULTS

At baseline, 26 patients (36.1%) had DO and small MCC, while 21 patients (29.2%) only had DO. In 18 patients (25.0%) only small MCC was found. Seven patients had normal findings and 20 did not perform a urodynamic study. OI ≥ 23 returned as a single significant predictor of OABSS >2 (OR 7.97, 95% 1.97-32.22, p = 0.004) in multivariate regression (R² = 30.8%; AUC = 0.86). OI correlated with "urgency episodes over two weeks" and MCC/EBC with medium (r = 0.45) and large effect (r = -0.56), respectively, p = 0.001.

DISCUSSION

A strong correlation of OI and MCC/EBC ratio is useful, as rise in MCC is predictive of a positive outcome. Also, calculating the OI is more practical than performing UDS. This could contribute to the use of OI as a predictive marker for starting (or continuing) anticholinergic treatment (when OI ≥ 23) or for maintaining urotherapy alone (when OI < 23) in children with OAB. The limitations were lack of external validation of OI, a 37-49% drop-off rate for follow-up visits at 3 and 6 months, respectively, and not performing UDS on all participants at every follow-up visit.

CONCLUSIONS

OI was found to be a significant predictor of the presence of OAB symptoms and correlated with the number of urgency episodes. It could estimate how much MCC differs from EBC.

The effect of vitamin D deficiency in children with overactive bladder related urinary incontinence

Purpose:

Overactive bladder (OAB) is a common syndrome associated with lower urinary tract symptoms (LUTS), especially urinary incontinence in children, which may affect the patient's quality of life (QoL). Vitamin D deficiency has been shown to be associated with OAB syndrome. This study evaluated the relationship between vitamin D status and OAB-related symptoms and QoL in children.

Materials and Methods:

The study included 52 pediatric patients with OAB-related urinary incontinence and 41 healthy children. LUTS were assessed using the Dysfunctional Voiding and Incontinence Symptoms Score (DVISS) questionnaire, and QoL was assessed using the Pediatric Incontinence Questionnaire (PINQ). Oral vitamin D supplementation was given to patients with OAB with vitamin D deficiency. Urinary symptoms and QoL were evaluated before and after vitamin D supplementation.

Results:

Vitamin D deficiency was more common in the OAB group (75%) than in the control group (36.6%). Logistic regression analysis revealed that vitamin D status (<20ng/mL) was a significant predictor of OAB. Both pre-treatment and post-treatment DVISS and PINQ scores showed a positive correlation. After vitamin D supplementation, 8 (23.5%) patients had a complete response and 19 (55.9%) patients had a partial response. Significant improvement in QoL was also achieved.

Conclusions:

Vitamin D deficiency is more common in children with urinary incontinence and OAB than in healthy children. Although vitamin D deficiency is not routinely evaluated for every patient, it should be evaluated in treatment-resistant OAB cases. Vitamin D supplementation may improve urinary symptoms and QoL in patients with OAB.

Learning Curve of Botulinum Toxin Bladder Injection for the Treatment of Refractory Overactive Bladder

PURPOSE

Intradetrusor botulinum toxin injections is an established second-line treatment for patients with refractory overactive bladder syndrome (OAB). We aimed to evaluate the learning curve of intradetrusor injections with botulinum toxin for the treatment of refractory OAB.

PATIENTS AND METHODS

This retrospective study analyzed all women with idiopathic and refractory OAB who underwent botulinum toxin bladder injections performed by residents with no previous experience with operative cystoscopy under consultant supervision. Baseline International Consultation on Incontinence Questionnaire-Short Form questionnaire (ICIQ-SF) and Euroqol (EQ-5D) questionnaires were collected. Procedural data (operative time, number of valid injections, complications, subjective easiness, perceived tolerability) and patients' outcomes (Patients Global Impression of Improvement (PGI-I), ΔICIQ-SF, ΔEQ-5D, need for self intermittent catheterization, duration of efficacy) were considered as markers to evaluate learning curves for each resident.

RESULTS

Twenty-seven patients underwent intravesical injection of botulinum toxin performed by residents. Only a grade 1 Clavien-Dindo complication occurred, and none of the patients had urinary retention. PGI-I was very satisfactory, scoring 1.4 ± 0.9. Both ICIQ-SF and EQ-5D 2-2 were statistically improved (p < 0.00001 and p = 0.04, respectively). The mean duration of efficacy resulted to be 8.0±4.3 months. A positive effect of the learning curve was observed only for operative time, subjective easiness, and perceived tolerability.

CONCLUSION

Intradetrusor botulinum toxin injection for the treatment of refractory OAB is characterized by high efficacy and very low complications even at the very beginning of the learning curve when performed under proper mentorship.

Is there concordance between overactive bladder and detrusor overactivity in men with predominant storage urinary symptoms referred to Functional Urology and Urodynamics Units?

OBJECTIVES

To assess the diagnostic concordance of overactive bladder (OAB) and detrusor overactivity (DO) in male patients with predominant storage lower urinary tract symptoms (LUTS) and evaluate their clinical and urodynamic profile according to DO presence and degree of obstruction.

MATERIAL AND METHODS

Epidemiological, cross-sectional multicenter study. A 3-day bladder diary (3dBD), International Prostate Symptom Score (IPSS) and Bladder Control Self-Assessment Questionnaire (B-SAQ) questionnaires were analyzed. Prostate volume was determined by ultrasound. Urodynamic study (UDS) tests were performed. The prevalence of OAB and DO and the degree of clinical concordance (kappa index) were investigated. Descriptive analysis of clinical variables and UDS results was performed, followed by comparisons based on the presence of DO and degree of obstruction.

RESULTS

A total of 445 patients were included. The mean age was (SD) 54.8 (9.9) years. According to 3dBD, 89.9% presented increased urinary frequency, 87.9% nocturia, 72.1% urgency, and 31.9% urge urinary incontinence (UUI). Obstruction was present in 36.8%. Concomitant OAB and DO were present in 54.5%. The degree of diagnostic concordance between OAB and DO was low (κ = 0.1772). There were more patients with DO presenting urgency (3dBD and B-SAQ; p < 0.001), UUI (3dBD; p = 0.008) and nocturia (B-SAQ; p < 0.001). Differences were found in terms of prostate volume, IPSS-voiding, maximum flow (Qmax) and post-void residual (p < 0.05) according to the obstruction degree.

CONCLUSIONS

Approximately 50% of male patients aged 18-65 years old with predominant storage LUTS, referred to specialized units, have both OAB and DO. Obstruction is present on 1/3. Diagnostic concordance between OAB and DO is poor.

Evaluation of the effect of 100U of Onabotulinum toxin A on detrusor contractility in women with idiopathic OAB: A multicentre prospective study

Aims

Intradetrusor injection of Onabotulinum Toxin A (BTX‐A) is a third‐line treatment for overactive bladder (OAB). Voiding dysfunction and the need for intermittent catheterization are potential complications, consequent to bladder contractility (BC) decrement.

Primary aim: to evaluate BC variation after BTX‐A detrusor injection in women with idiopathic OAB.

Methods

A prospective multi‐institutional observational study was conducted. Medical history, bladder diary, 24‐h pad test, and invasive urodynamic parameters were recorded before and 4–6 weeks after BTX‐A 100U administration. BC was measured as Modified Projected Isovolumetric Pressure (PIP1), that is, maximum flow rate (Qmax) + detrusor pressure at Qmax (PdetQmax).

Continuous variables were expressed as median and interquartile range. We compared continuous variables using Wilcoxon test and proportions between two times with Fisher exact test.

Results

No changes in PIP1 were observed (p > 0.05) in 45 women enrolled between January 2018 and September 2019. Median age was 54.6 years. At baseline, 91.1% had urge urinary incontinence, with 4.9 ± 2.6 daily pads used and a 24‐h pad test of 205.4 ± 70.8 g. Baseline detrusor contractility was normal in all the patients.

Postoperatively, an improvement in the 24‐h pad test (p < 0.01), daily voids (p < 0.01), and nocturia (p < 0.01) occurred. Urodynamics pointed out a significant reduction of detrusor overactivity rate (p < 0.01) and an increase of median maximum cystometric capacity (p < 0.01). No difference was observed in median Qmax (p > 0.05), PdetQmax (p > 0.05), and PVR (p > 0.05). No patient needed postoperative catheterization.

Conclusions

The current series provides evidence that detrusor injection of botulinum toxin is an effective option for treating OAB, without causing voiding dysfunction and BC impairment.

Update on the management of overactive bladder

Overactive bladder (OAB) syndrome is a common condition characterised by urinary urgency, with or without urgency incontinence, frequency and nocturia, in the absence of any other pathology. Clinical diagnosis is based upon patient self-reported symptomology. Currently there is a plethora of treatments available for the management of OAB. Clinical guidelines suggest treatment via a multidisciplinary pathway including behavioural therapy and pharmacotherapy, which can be commenced in primary care, with referral to specialist services in those patients refractory to these treatments. Intradetrusor botulinum A and sacral neuromodulation provide safe and efficacious management of refractory OAB. Percutaneous tibial nerve stimulation and augmentation cystoplasty remain available and efficacious in a select group of patients. Unfortunately, there remains a high rate of patient dissatisfaction and discontinuation in all treatments and thus there remains a need for emerging therapies in the management of OAB.

Is there concordance between overactive bladder and detrusor overactivity in men with predominant storage urinary symptoms referred to Functional Urology and Urodynamics Units?

OBJECTIVE

To assess the diagnostic concordance of overactive bladder (OAB) and detrusor overactivity (DO) in male patients with predominant storage lower urinary tract symptoms (LUTS) and evaluate their clinical and urodynamic profile according to DO presence and degree of obstruction.

MATERIAL AND METHODS

Epidemiological, cross-sectional multicenter study. A 3-day bladder diary (3dBD), International Prostate Symptom Score (IPSS) and Bladder Control Self-Assessment Questionnaire (B-SAQ) questionnaires were analyzed. Prostate volume was determined by ultrasound. Urodynamic study (UDS) tests were performed. The prevalence of OAB and DO and the degree of clinical concordance (kappa index) were investigated. Descriptive analysis of clinical variables and UDS results was performed, followed by comparisons based on the presence of DO and degree of obstruction.

RESULTS

A total of 445 patients were included. The mean age was (SD) 54.8 (9.9) years. According to 3dBD, 89.9% presented increased urinary frequency, 87.9% nocturia, 72.1% urgency, and 31.9% urge urinary incontinence (UUI). Obstruction was present in 36.8%. Concomitant OAB and DO were present in 54.5%. The degree of diagnostic concordance between OAB and DO was low (κ=0.1772). There were more patients with DO presenting urgency (3dBD and B-SAQ; p<0.001), UUI (3dBD; p=0.008) and nocturia (B-SAQ; p<0.001). Differences were found in terms of prostate volume, IPSS-voiding, maximum flow (Qmax) and post-void residual (p<0.05) according to the obstruction degree.

CONCLUSIONS

Approximately 50% of male patients aged 18-65 years old with predominant storage LUTS, referred to specialized units, have both OAB and DO. Obstruction is present on 1/3. Diagnostic concordance between OAB and DO is poor.

Diagnostic value of nerve growth factor in detrusor overactivity: a study on women with mixed urinary incontinence

OBJECTIVE

Urinary incontinence has a profound impact on women's quality of life. Studies have shown that changes in urinary protein levels could be a potential diagnostic biomarker in some urological diseases. The aim of present study is to determine the diagnostic value of nerve growth factor (NGF) in women with mixed urinary incontinence (MUI) as a diagnostic biomarkers of detrusor overactivity (DO).

METHODS

Seventy women aged between 20 and 75 years with MUI were enrolled in this prospective study. All participants underwent urodynamic study. Urine NGF levels were measured using an ELISA method. NGF level was compared between groups using Mann-Whitney U test. Receiver Operator Characteristic (ROC) analysis was employed to evaluate the diagnostic performance of urinary NGF.

RESULTS

The results showed that the median (min, max) of NGF in patients with DO was significantly higher in comparing to its level in women without DO [184.10 (31, 346.60) pg/ml vs. 151.80 (21, 210.70)], respectively (P = 0.035). Using receiver-operator characteristics analysis, the threshold urinary NGF value of 102.00 pg/ml provided a sensitivity of 88% and specificity of 40% in diagnosing DO, PPV of 39.1%, and NPV of 88.2%, positive likelihood ratio 2.18 and negative likelihood ratio of 0.45 (P = 0.02).

CONCLUSION

Based on high sensitivity and low specificity, we can conclude that NGF can be a good tool for ruling out the OAB when the test is negative. However, the future investigations are needed to expand the observed correlation in larger groups of women with DO.

Bacterial Colonization as a Possible Source of Overactive Bladder Symptoms in Pediatric Patients: A Literature Review

Overactive Bladder (OAB) is a common condition that is known to have a significant impact on daily activities and quality of life. The pathophysiology of OAB is not completely understood. One of the new hypothetical causative factors of OAB is dysbiosis of an individual urinary microbiome. The major aim of the present review was to identify data supporting the role of bacterial colonization in overactive bladder symptoms in children and adolescents. The second aim of our study was to identify the major gaps in current knowledge and possible areas for future clinical research. There is a growing body of evidence indicating some relationship between qualitative and quantitative characteristics of individual urinary microbiome and OAB symptoms in adult patients. There are no papers directly addressing this issue in children or adolescents. After a detailed analysis of papers relating urinary microbiome to OAB, the authors propose a set of future preclinical and clinical studies which could help to validate the concept in the pediatric population.

Shifting the treatment paradigm in idiopathic overactive bladder

PURPOSE

Overactive Bladder (OAB) is a common condition that is known to have a significant impact on Health Related Quality of Life (HRQoL). Whilst all patients will initially benefit from lifestyle modifications and behavioural therapy in the first instance drug therapy remains integral in management pathways. The purpose of this review paper is to reappraise the evidence based approach to the management of OAB in addition to exploring a new treatment algorithm for the escalation of treatment in those patients with refractory symptoms.

DESIGN

Literature Review RESULTS: Antimuscarinic drugs are currently the most commonly used medication although the introduction of mirabegron, a β3 agonist, has provided an alternative and also allowed combination therapy in those patients who have failed to improve on primary therapy or who have troublesome side effects. For those patients with symptoms of refractory OAB more invasive therapies including OnabotulinumtoxinA, sacral neuromodulation and Percutaneous Tibial Nerve Stimulation (PTNS) may be indicated.

CONCLUSION

We propose a new, evidence based, treatment algorithm for the management of OAB in patients who remain refractory to first line therapy.

Cognitive components of behavioral therapy for overactive bladder: a systematic review

INTRODUCTION AND HYPOTHESIS

Behavioral therapy is the first-line treatment for overactive bladder (OAB); however, the cognitive components of behavioral therapy for OAB have not been evaluated. The purposes of this systematic review were to describe the cognitive components of behavioral therapy for OAB and evaluate their effectiveness as well as to describe their rationale and origins.

METHODS

Searches were conducted on the PubMed, CINAHL, Web of Science, Cochrane and PEDro databases. Inclusion criteria were single-arm or randomized controlled trials on OAB treatment that utilized behavioral therapy, with a description of a cognitive component of the behavioral therapy. Study participants were neurologically intact adults (n = 1169). Study methodological quality was assessed with the PEDro and Newcastle-Ottawa scales.

RESULTS

Five studies were included, published between 2009 and 2020. Methodological quality was variable. All studies reported a reduction of symptoms in participants receiving behavioral therapy. Cognitive components of behavioral therapy were not extensively described. Distraction was the most common cognitive strategy for managing urgency. The relative impact of the cognitive aspect of behavioral therapy could not be evaluated, and the cognitive aspects of behavioral therapy appear to be accepted wisdom, traceable to several key authors, that has not been subjected to scientific investigation.

CONCLUSIONS

Behavioral therapy for OAB appears useful, but its cognitive components are not well described, their relative importance has not been evaluated or ascertained, nor have they been rigorously studied.

Lower Urinary Tract Functional Assessment of Men Undergoing Radical Prostatectomy: Correlation of Preoperative Clinical and Urodynamic Parameters

PURPOSE

To assess baseline clinical and urodynamic profiles of a contemporary cohort of men undergoing radical prostatectomy (RP) as part of the ROSE (Robotic and Open Surgery for Prostate Cancer: A Prospective, Multi-centre, Comparative Study of Functional and Oncological Outcomes) study.

METHODS

Men with localized prostate cancer undergoing RP were prospectively recruited to undergo clinical assessment and urodynamic testing prior to surgery as part of a clinical trial. The International Prostate Symptoms Score (IPSS) was used to determine participants' degree of lower urinary tract symptoms (LUTS).

RESULTS

Eighty-five men with a median age of 64.5 years and a median prostate-specific antigen level of 6.3 ng/mL were prospectively recruited. Of patients with complete baseline data, 36 (50.7%), 28 (39.4%), and 7 (9.9%) had mild (IPSS<8), moderate (IPSS 8-19), and severe (IPSS>20) LUTS, respectively. Obstruction was identified in 18 men (29.5%), and 9 (14.8%) showed detrusor underactivity. Of the 15 patients with detrusor overactivity, 12 (80%) reported overactive bladder (OAB). Of men with urodynamic obstruction, 5 (31.3%), 10 (62.5%), and 1 (6.3%) reported mild, moderate, and severe LUTS, respectively. Of men without OAB, 4 (11.8%, P=0.002) showed filling phase abnormalities, 13 (46.4%, P=0.611) had flow rates of <15 mL/sec, and 7 (30.4%, P=0.767) showed obstruction. Of men with mild or no LUTS, 5 (20%, P=0.072) showed obstruction and 4 (16%, P=0.524) showed poor contractility.

CONCLUSION

LUTS and OAB were common in men with localized prostate cancer undergoing RP. Detrusor overactivity and urodynamic filling phase abnormalities were strongly correlated with OAB. IPSS did not show a strong correlation with bladder outflow obstruction or detrusor underactivity. Urodynamic filling abnormalities were found in 11.8% of men without OAB. Symptomatic and functional assessment may therefore have a role in the preoperative counselling of patients and possibly guide postoperative management of LUTS, especially if OAB is present.

Testing a new, intensified infusion-withdrawal protocol for urinary urgency provocation in brain-bladder studies

INTRODUCTION

The brain's role in bladder control has become an important area of study in the last 15 years. Typically, the brain's role in urinary urgency has been studied by repeated infusion and withdrawal of fluid, per catheter, to provoke urgency sensation during a whole brain magnetic resonance imaging (MRI) scan. Since this technique generally requires a large group size, we tested a more intense infusion-withdrawal protocol in an attempt to improve signal to noise ratio and repeatability of the signal which would, in turn, allow us to further probe subtypes of urgency urinary incontinence.

METHODS

A total of 12 women over the age of 60 were recruited to test a new "intense" infusion withdrawal protocol. They underwent this new protocol during a functional brain MRI scan. The primary outcome was comparison of activity within the insula, medial pre-frontal cortex and dorsal anterior cingulate cortex/supplementary motor area (dACC/SMA). Immediate test-retest repeatability was measured using intraclass correlation. Secondary exploratory evaluation of differences in the whole brain between protocols was conducted.

RESULTS

There was no significant difference in signal in any of the a priori regions of interest between protocols. Test-retest repeatability in the new protocol was poor compared to the original protocol, and variability was higher. Three participants were not able to tolerate the "intense" protocol.

CONCLUSION

The small improvement in signal to noise ratio of the new protocol was not sufficient to overcome the poorly tolerated intense filling protocol.

Overactive bladder syndrome - focus onto detrusor overactivity

INTRODUCTION AND HYPOTHESIS

To determine in patients with overactive bladder (OAB), urodynamic differences as well to compare the characteristics of patient's, with presence of detrusor overactivity on urodynamics with those with absence of detrusor overactivity.

METHODS

Taking into account the urodynamic findings, the patients with OAB symptoms were categorized into one of two groups: group 1 (with detrusor overactivity) or group 2 (without detrusor overactivity), and comparative analyses for both groups were performed (epidemiological data, patient history, urodynamic criteria, bladder diaries, IC-OAB, IC-OABqol - questionnaires).

RESULTS

There was a significant difference in age as well in the disease duration between group 1 and group 2. Although the mean number of micturitions and nocturia episodes was comparable, the numbers of urgency episodes differed significantly. The number of 'wet' patients was significantly higher in the group 1 with the significantly higher number of incontinence episodes. Group 1 demonstrated higher OAB symptom scores and higher impact on the patients' quality of life.

CONCLUSIONS

More than half of the patients complaining of urgency-frequency do not have detrusor overactivity upon urodynamic testing, and only half have detrusor overactivity that correlates with urge perception. The patients with no detrusor overactivity appear to be significantly younger and have fewer symptoms, with a less pronounced impact on quality of life. They also have significantly higher maximal bladder capacity. This data supports the hypothesis that both conditions are different phases (early and late) of the same pathological state, or may be two different subtypes of OAB.

The cognitive safety of antimuscarinics in the treatment of overactive bladder

INTRODUCTION

Overactive bladder is a common problem women suffer from, with its incidence increasing with age. The mainstay of treatment is antimuscarinic medication. There is growing evidence that antimuscarinics may increase the risk of cognitive impairment, dementia, and even death.

AREAS COVERED

This review explores the evidence that antimuscarinics increase the risk of cognitive impairment, dementia, and death. It evaluates how best to treat overactive bladder the older woman.

EXPERT OPINION

The evidence suggests that antimuscarinics increase the risk of cognitive impairment and dementia in the older adult. Care should be taken to use an antimuscarinic that is less likely to cross the blood-brain barrier and thus reduce the risk of these significant adverse events. A patient's anticholinergic load also needs to be considered when treating this group. Other treatment options such as fluid management, bladder retraining, vaginal estrogens, mirabegron, Onabotulinum toxin A and neuromodulation can be used instead.

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.

Managing overactive bladder

Overactive bladder (OAB) is a common and distressing condition which is known to increase with age and has a significant effect on quality of life. Whilst OAB is a symptomatic diagnosis, many patients will require basic investigations prior to initiating the appropriate management. This article will review the initial clinical assessment and management of women complaining of OAB including conservative measures and drug therapy, and will also focus on the role of estrogen. In addition, the management of refractory OAB will also be discussed including more invasive strategies such as neuromodulation, Botulinum Toxin, and reconstructive surgery.

Novel implantable pressure and acceleration sensor for bladder monitoring

OBJECTIVES

To test the hypothesis that an implantable sensing system containing accelerometers can detect small-scale autonomous movements, also termed micromotions, which might be relevant to bladder physiology.

METHODS

We developed a 6-mm submucosal implant containing a pressure sensor (MS5637) and a triaxial accelerometer (BMA280). Sensor prototypes were tested by implantation in the bladders of Gottingen minipigs. Repeated awake voiding cystometry was carried out with air-charged catheters in a standard urodynamic set-up as comparators. We identified four phases of voiding similar to cystometry in other animal models based on submucosal pressure. Acceleration signals were separated by frequency characteristics to isolate linear acceleration from the baseline acceleration. The total linear acceleration was calculated by the root mean square of the three measurement axes. Acceleration activity during voiding was investigated to adjacent 1-s windows and was compared with the registered pressure.

RESULTS

We observed a total of 19 consecutive voids in five measurement sessions. A good correlation (r > 0.75) was observed between submucosal and catheter pressure in 14 of 19 premicturition traces. The peak-to-peak interval between maximum total linear acceleration was correlated with the interval between submucosal voiding pressure peaks (r = 0.760, P < 0.001). The total linear acceleration was higher during voiding compared with pre- and postmicturition periods (start of voiding/phase 1).

CONCLUSIONS

To the best of our knowledge, this is the first report of bladder wall acceleration, a novel metric that reflects bladder wall movement. Submucosal sensors containing accelerometers can measure bladder pressure and acceleration.

New participant stratification and combination of urinary biomarkers and confounders could improve diagnostic accuracy for overactive bladder

Overactive bladder (OAB) is a highly prevalent symptom complex characterised by symptoms of urinary urgency, increased frequency, nocturia, with or without urge incontinence; in the absence of proven infection or other obvious pathology. The underlying pathophysiology of idiopathic OAB is not clearly known and the existence of several phenotypes has been proposed. Current diagnostic approaches are based on discordant measures, suffer from subjectivity and are incapable of detecting the proposed OAB phenotypes. In this study, cluster analysis was used as an objective approach for phenotyping participants based on their OAB characteristic symptoms and led to the identification of a low OAB symptomatic score group (cluster 1) and a high OAB symptomatic score group (cluster 2). Furthermore, the ability of several potential OAB urinary biomarkers including ATP, ACh, nitrite, MCP-1 and IL-5 and participants’ confounders, age and gender, in predicting the identified high OAB symptomatic score group was assessed. A combination of urinary ATP and IL-5 plus age and gender was shown to have clinically acceptable and improved diagnostic accuracy compared to urodynamically-observed detrusor overactivity. Therefore, this study provides the foundation for the development of novel non-invasive diagnostic tools for OAB phenotypes that may lead to personalised treatment.

Is coexistent overactive-underactive bladder (with or without detrusor overactivity and underactivity) a real clinical syndrome? ICI-RS 2019

AIMS

Lower urinary tract symptoms (LUTS) can be classified into symptom syndromes based on which symptoms are predominant. Overactive bladder (OAB) syndrome, a storage dysfunction, and underactive bladder (UAB) syndrome, a voiding dysfunction, are common syndromes, which urodynamic tests may show to be caused by detrusor overactivity (DO) and detrusor underactivity (DU), but can also be associated with other urethro-vesical dysfunctions. Sometimes OAB and UAB can coexist in the same patient and, if so, need a specific approach beyond treatment of the single and apparently opposing syndromes.

METHODS

During its 2019 meeting in Bristol, the International Consultation on Incontinence Research Society held a literature review and expert consensus discussion focused on the emerging awareness of the coexisting overactive-underactive bladder (COUB).

RESULTS

The consensus considered whether COUB is the combination of OAB and UAB syndromes, or a real unique clinical syndrome in the same patient, possibly with a common etiology. Definitions, pathophysiology, diagnosis, and treatment were discussed, and high-priority research questions were identified.

CONCLUSIONS

COUB (with or without urodynamic evidence of DO and DU) may be considered a real clinical syndrome, because it differs from single OAB and UAB, and may not be the combination of both syndromes. Urodynamic tests may be necessary in unclear cases or in cases not responding to initial treatment of the most troublesome symptoms. It is pivotal to define the evolution of the syndrome and the characteristic population, and to recognize predictive or phenotyping factors to develop a specific approach and adequate outcome measures.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 1 - Female population

Although, until a few years ago, the diagnostic power of urodynamic testing had never been questioned, recent studies in the literature have raised some doubts on the routine use of this tool. The benefits of the urodynamic studies (UDS) should be weighted against costs, time-consumption and patient discomfort. These recommendations are intended to guide clinicians in the right selection of the female patients to submit to a urodynamic evaluation. We reviewed the literature, regarding the use of UDS in female adults with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction. Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and uro-gynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in female population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with lower urinary tract symptoms and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

Are there different patterns of detrusor overactivity which are clinically relevant? ICI-RS 2018

INTRODUCTION

Different patterns of detrusor overactivity (DO) have been described and included in several standardization terminology documents. However, it is unclear if these different patterns have any clinical significance.

METHODS

This is a report of the proceedings of Proposal 3: "Are there different patterns of detrusor overactivity which are clinically relevant?" from the annual International Consultation on Incontinence-Research Society (ICIRS) meeting, which took place from 14 to 16 June 2018, in Bristol, UK.

RESULTS

We have collected and discussed, as a committee, the evidence about different urodynamic (UD) patterns of detrusor overactivity and their potential clinical significance. We reviewed the important previous basic research and clinical studies and compiled summaries. The discussion focused on clinical relevance of different UD patterns of DO and what further research is required.

CONCLUSIONS

There are several UD definitions of patterns of detrusor overactivity, however the clinical relevance of these definitions remains unclear. Future research should concentrate on defining the pattern of DO in relation to clinical diagnosis, gender, age, and treatment outcomes.

Wireless intravesical device for real-time bladder pressure measurement: Study of consecutive voiding in awake minipigs

Traditional urodynamics have poor correlation with urological symptoms. Ambulatory urodynamics may improve this correlation but the need for a transurethral catheter and the time-consuming nature of this examination limits its use. Therefore, the objective of this study was to develop a wireless real-time bladder pressure measurement device for repeated and prolonged-term measurement of bladder behavior in awake pigs. The Bladder Pill is an intravesical device with a pressure microsensor and a 3-dimensional inductive coupling coil for energy supply. A corresponding external coil provides wireless power transmission and real-time communication of bladder pressure data. To test the correlation between the pressure data measured by the device and by standard methods, we compared static water column pressures with this device and water-filled urodynamic catheter systems. In vivo assessment of awake voiding by the pill was done by introducing the bladder pill into the bladder of Göttingen minipigs. An air-charged urodynamic catheter was introduced transurethrally as control for pressure measurements. The optimal physical configuration of the pill was investigated to maximize the containment in the bladder. We used two versions of external signal receivers (one waistband and one rectangular frame) to test the optimal external signal capture. Next to that, we performed short-term and medium-term comparative pressure studies. The in vitro static pressure measurement demonstrated a mean difference of less than 1 cm H₂O between the methods. The optimal design of the pill for maximal retainment in the bladder proved to be a pigtail configuration. The bending of the device during bladder contractions caused offset of 2.7 +/- 1.4 cm H₂O (mean +/- SD) on the pressure measurements. The rectangular frame performed signal capture during 5 consecutive voids with a good correlation of the pressure measurements. The device can be inserted through the urethra and is retrieved using string or endoscopic extraction. In conclusion, wireless long-term measurement of bladder pressure is demonstrated and yields comparable results to current available catheter methods of measurement in a pig model.

The bladder is an unreliable witness: The case for urodynamic investigations in female stress urinary incontinence

For some years, the role of urodynamics (UDS) in female stress urinary incontinence (SUI) has been a topic of intense debate. The findings of the VaLUE and VUSIS-II randomised clinical trials (RCTs) published in 2012 appeared to suggest that UDS is not useful in women with uncomplicated SUI, with the result that several authoritative guidelines were amended and the routine use of UDS in this setting fell sharply. However, many experts have raised concerns about the design of these two RCTs and their subsequent interpretation - including the inappropriate generalisation of the findings beyond uncomplicated cases, which represent only a small minority of the overall patient population. In this paper, we consider a range of issues and confounding factors which raise doubts about how influential these RCTs should have been and reflect on the potential value of UDS both for objective diagnosis and patient counselling in female SUI.

The role of urodynamics in females with lower urinary tract symptoms

Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used.

Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: ‘female urology’, ‘lower urinary tract symptoms’, ‘urodynamic’, ‘incontinence’, ‘overactive bladder’, ‘bladder outlet obstruction’. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society.

Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS.

Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity.

Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence

Urinary Biomarkers in Overactive Bladder: Revisiting the Evidence in 2019

CONTEXT

In overactive bladder (OAB), after an initial outbreak of research, it is more consensual that biomarkers may be better used to phenotype patients. Herein, we revisit this topic, including some of the most promising biomarkers.

OBJECTIVE

To provide a comprehensive analysis of the actual role of biomarkers in OAB.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted, including the most relevant articles published in the last 15 yr, on nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), adenosine triphosphate (ATP), genomics, and microbiota as OAB biomarkers. Articles with no full text available or not written in English were excluded. Additional reviews were included.

EVIDENCE SYNTHESIS

Urinary NGF, BDNF, and ATP are increased in many OAB patients. These biomarkers can help identify OAB phenotypes and select the ideal candidates for new therapies directed to neurotrophic and purinergic pathways. Circulating urinary miRNA may be useful for establishing the ideal moment for bladder outlet obstruction relief and will eventually lead to the development of therapeutic agents that inhibit or reverse fibrotic pathways in the bladder. Urinary microbiota seems to be related to OAB symptoms, in particular urgency urinary incontinence, and may have strong implications in the prevention, diagnosis, and treatment of OAB.

CONCLUSIONS

In the future, physicians may consider the use of biomarkers to identify distinct OAB phenotypes, with distinct causal mechanisms, selecting patients for specific target therapies with expected better outcomes.

PATIENT SUMMARY

Overactive bladder biomarkers can be useful for phenotype patients and for selecting more effective target therapies.

Clinical and urodynamic impact of detrusor overactivity in women with overactive bladder

OBJECTIVE

To evaluate the clinical and urodynamic differences (associated with the presence or absence of detrusor overactivity [DO]) in women with overactive bladder (OAB) referred to Functional Urology and Urodynamic Units in Spain.

MATERIAL AND METHODS

Observational, cross-sectional, multicenter and prospective study conducted in Spain in women with clinical diagnosis of OAB, who had been referred to urodynamic study (UDS) of which centralized reading was performed. Patients completed the 3-day voiding diary (DM3d) with the PPIUS scale (Patient Perception of Intensity of Urgency Scale), the B-SAQ (Bladder Self-Assessment Questionnaire) and the OABq-SF (Overactive Bladder Questionnaire Short Form). The questionnaires and UDS variables of women with OAV, with or without DO, were compared using the Mann-Whitney test (continuous variables) and the chi-square test (χ²) (categorical variables).

RESULTS

A total of 247 women with OAB were evaluated, and 103 of them had DO. According to the presence or absence of DO, significant differences were observed in the number of episodes of urge urinary incontinence (UUI), urinary frequency, nocturia, mean micturition volume and number of pads (P<.05 for all comparisons). A higher percentage of patients with OAB and DO presented reduced bladder capacity, urgency, urge urinary incontinence (UUI) and lower volume for first voiding desire, strong desire to void and maximum cystomanometric capacity in UDS compared with patients without DO (P<.05 for all comparisons). The only significant differences between both groups were regarding the B-SAQ symptoms scale (P=.011).

CONCLUSIONS

The presence of DO in women with OAB is related to a more severe alteration of the bladder filling phase.

Urodynamic and Bladder Diary Factors Predict Overactive Bladder-wet in Women: A Comparison With Overactive Bladder-dry

Purpose

To identify factors predicting the presence of overactive bladder syndrome (OAB)-wet, compared with OAB-dry.

Methods

Between September 2007 and September 2013, the medical records of 623 women with OAB who completed a 3-day bladder diary and underwent urodynamic studies in a medical center were retrospectively reviewed. OAB-wet was diagnosed in patients who complained of at least one episode of urgency incontinence in the previous month; otherwise, OAB-dry was diagnosed. Multivariable logistic regression analysis was used to predict the presence of OAB-wet.

Results

Age (odds ratio [OR], 1.05; P<0.001), maximal flow rate (Qmax) (OR,1.06; P<0.001), voided volume (OR, 0.996; P=0.001), detrusor pressure at maximal flow rate (PdetQmax) (OR, 1.02; P=0.003), urgency episodes (OR, 1.04; P<0.001) and urodynamic stress incontinence (OR,1.78; P=0.01) were independent predictors for the presence of OAB-wet vs. OAB-dry. If we use bladder contractility index as a variable for multivariable logistic regression analysis, bladder contractility index (OR, 1.012; P<0.001) become an independent predictor for OAB-wet.

Conclusions

A smaller bladder capacity and more frequent urgency episodes were predictors of OAB-wet, and the above findings indicate that OAB-wet and OAB-dry might be a continuum of OAB. Old age, high Qmax, high PdetQmax and urodynamic stress incontinence were also predictors for OAB-wet, and the above results reveal that OAB-wet and OAB-dry have partially different clinical and urodynamic features. Further studies might be performed to elucidate whether different treatment strategies between OAB-dry and OAB-wet can improve treatment efficacy.

Where can urodynamic testing help assess male lower urinary tract symptoms?

Urodynamic studies assess the function of the bladder and bladder outlet. They are often useful in the assessment and diagnosis of patients presenting with lower urinary tract symptoms (LUTS). The evidence regarding the value and risks of invasive urodynamics remains insufficient. However, men with LUTS who are assessed by invasive urodynamics are more likely to have their management changed and less likely to undergo surgery. This review discusses the role of urodynamic diagnosis and application in the diagnosis and treatment of male LUTS.

Is submucosal bladder pressure monitoring feasible?

There has been recent interest in placing pressure-sensing elements beneath the bladder mucosa to facilitate chronic bladder pressure monitoring. Wired submucosal sensors with the wires passed through detrusor have been demonstrated in vivo, with limited chronic retention, potentially due to the cable tethering the detrusor. Published studies of submucosal implants have shown that high correlation coefficients between submucosal and lumen pressures can be obtained in caprine, feline, and canine models. We have developed a wireless pressure monitor and surgical technique for wireless submucosal implantation and present our initial chronic implantation study here. Pressure monitors were implanted (n = 6) in female calf models (n = 5). Five devices were implanted cystoscopically with a 25-French rigid cystoscope. One device was implanted suprapubically to test device retention with an intact mucosa. Wireless recordings during anesthetized cystometry simultaneous with catheter-based reference vesical pressure measurements during filling and manual bladder compressions were recorded. Individual analysis of normalised data during bladder compressions (n = 12) indicated high correlation (r = 0.85-0.94) between submucosal and reference vesical pressure. The healing response was robust over 4 weeks; however, mucosal erosion occurred 2-4 weeks after implantation, leading to device migration into the bladder lumen and expulsion during urination. Wireless pressure monitors may be successfully placed in a suburothelial position. Submucosal pressures are correlated with vesical pressure, but may differ due to biomechanical forces pressing on an implanted sensor. Fully wireless devices implanted beneath the mucosa have risk of erosion through the mucosa, potentially caused by disruption of blood flow to the urothelium, or an as-yet unstudied mechanism of submucosal regrowth. Further investigation into device miniaturisation, anchoring methods, and understanding of submucosal pressure biomechanics may enable chronic submucosal pressure monitoring. However, the risk of erosion with submucosal implantation highlights the need for investigation of devices designed for chronic intravesical pressure monitoring.

Audiovisual stimulus during urodynamics to provoke detrusor overactivity: A randomized trial

OBJECTIVE

This study estimated the effect of adding an audiovisual (AV) intervention during urodynamic evaluation (UDE) on increasing detrusor contractions (DO) versus routine UDE testing without AV cues.

METHODS

A randomized trial was conducted of women with overactive bladder (OAB) undergoing UDE with and without AV intervention. The AV intervention was a 1-minute video on continuous loop showing common OAB triggers. A continuous running waterfall provided auditory stimulation. The primary outcome was the proportion of patients who had DO on UDE, interpreted by masked clinicians. Secondary outcomes included the number, amplitude, and duration of DO and urinary leakage associated with DO. A sample size of 109 per group was calculated to have 80% power to detect a 20% difference with a significance level of 0.05.

RESULTS

In all, 109 women each were randomized to standard UDE and to the AV intervention. There was no difference in the proportion of patients with DO on UDE between the intervention and control groups (35% vs 32%, respectively; P = 0.8). Furthermore, there were no differences between the intervention and control groups in leakage with DO on UDE (24% vs 21%, respectively), mean duration of detrusor contractions (23.9 vs 25.3 s, respectively), or mean maximum detrusor pressure during involuntary contractions (18.1 vs 20.6 cm H₂ O, respectively). Clinical severity of OAB symptoms was not associated with the detection of DO or other UDE parameters.

CONCLUSIONS

Addition of AV intervention during UDE did not increase the finding of detrusor contractions. The relationship between OAB triggers, urge incontinence, and urodynamic findings remains unclear.

Management of Overactive Bladder Symptoms After Radical Prostatectomy

PURPOSE OF REVIEW

Post-prostatectomy overactive bladder (OAB) is a common and challenging condition to manage. The aim of the present report was to review the recent evidences regarding OAB symptoms that develop in men after prostatectomy and how to manage them.

RECENT FINDINGS

The prevalence of OAB after radical prostatectomy may range from 15.2 to 37.8%. Recent studies have highlighted the role of the urethrogenic mechanism (facilitation of the urethrovesical reflex due to stress urinary incontinence (SUI)) in the genesis of post-prostatectomy OAB in a significant proportion of patients. Several other pathophysiological factors such as iatrogenic decentralization of the bladder, defunctionalized bladder due to severe SUI, detrusor underactivity, or bladder outlet obstruction might be involved. The evaluation should aim to identify the underlying mechanism to tailor the treatment, which could range from SUI surgery, to fixing a urethral stricture, improving bladder emptying or using the conventional spectrum of OAB therapies. There is a paucity of data for OAB therapies specific to post-prostatectomy patients, with the exception of solifenacin, tolterodine, and botulinum toxin. There is currently no data on how preoperative management or surgical technique may prevent post-prostatectomy OAB.

Effect of urodynamic preoperative detrusor overactivity on the outcomes of transurethral surgery in patients with male bladder outlet obstruction: a systematic review and meta-analysis

OBJECTIVE

To investigate the effect of urodynamic detrusor overactivity (DO) on the outcomes of transurethral surgery in patients with male bladder outlet obstruction (BOO).

MATERIALS AND METHODS

We systematically searched the PubMed, Embase, and Cochrane Library databases for articles published between January 1989 and June 2017. All results of eligible studies were synthesized.

RESULTS

Nine articles met the eligibility criteria. These studies included a total of 932 patients with a median number of 92 patients per study (range 40-190). Of the nine studies, the conventional transurethral prostatectomy was adopted in four studies, photoselective vaporization of prostate in three studies, and other surgical modalities in two studies. In patients with DO positive, the pooled mean difference (MD) was not significant for a better or poorer improvement in the International Prostate Symptom Score [pooled MD, - 0.27; 95% confidence interval (CI), - 1.75 to 1.22; studies, 9; participants, 827], quality-of-life score (pooled MD, - 0.14; 95% CI, - 0.46 to 0.18; studies, 7; participants, 734), maximal flow rate (pooled MD, 0.79; 95% CI, - 1.57 to 3.14; studies, 8; participants, 781), and post-void residual volume (pooled MD, 2.81; 95% CI, - 4.70 to 10.32; studies, 6; participants, 509) compared to patients with DO negative. Some comparisons showed between-study heterogeneity despite the strict criteria of the eligible studies. However, there was no clear evidence of publication bias in the funnel plots.

CONCLUSIONS

Our meta-analysis results demonstrated that preoperative urodynamic DO has no diagnostic role in the prediction of surgical outcomes in patients with male BOO.

OAB score: a clinical model that predicts the probability of presenting overactive detrusor in the urodynamic study

Purpose

To create a predictive model of involuntary detrusor contraction (IDC) to improve the diagnostic accuracy of overactive detrusor (OAD), associating overactive bladder (OAB) symptoms with other clinical parameters in the female population.

Materials and Methods

A total of 727 women were studied retrospectively. In all of them, urodynamic study was conducted for urogynecological causes. Demographics information, personal history, symptoms, physical exam, a 3-day frequency/volume chart and urinary culture, were collected in all patients and they subsequently underwent uroflowmetry and urodynamic studies. A logistic regression model was performed in order to determine independent predictors of presence of IDC. Odd ratio (OR) estimation was used to assign a score to each one of the significant variables (p≤0.05) in the logistic regression model. We performed a ROC curve in order to determine the predictive ability of the score in relation to the presence of OAD.

Results

presence of OAD was evident in 210 women (29%). In the logistic regression analysis, independent predictors of OAD were urgency, urgency incontinence, nocturia, absence of SUI symptoms, diabetes mellitus, reduction of vaginal trophism and bladder capacity below 150 mL. The probability of IDC diagnosis increases as the score raises (Score 0: 4% until Score ≥10: 88%). Sensitivity was 71% and specificity 72%. The area under the curve of OAB score was 0.784 (p>0.001).

Conclusions

OAB score is a clinical tool that shows higher diagnostic accuracy than OAB symptoms alone to predict overactive detrusor.