Preliminary study of the safety and efficacy of extended-release oxybutynin in children

Treatment modalities for paediatric functional daytime lower urinary tract disorders: an updated review

Paediatric functional bladder disorders especially those causing daytime symptoms are a common cause of significant psychosocial and/or physical morbidity and impaired quality of life. Despite the availability of many therapeutic modalities, a significant number of children appear to be refractory to treatment and continue to have symptoms. In this review, we aim to evaluate the current evidence in the use of existing and novel therapeutic options for the management of daytime lower urinary tract disorders in children. We also aim to highlight the controversies around the terminology and diagnosis of paediatric lower urinary tract dysfunction (LUTD) and specific conditions. The article will then provide a reasonable critique of the existing and emerging treatment modalities in functional daytime LUTD in children including their mode of action, efficacy, indications, and recent advances. These include standard urotherapy, specific urotherapy comprised of biofeedback, alarm therapy and electrical neural stimulation and pharmacotherapy involving selective and non-selective anticholinergics, ß3 adrenergic agonists, alpha blockers and botulinum toxin. A better understanding of this common clinical problem may help clinicians achieve better profiling of these children's diagnoses to further enable specific, targeted treatment.

Neurogenic Lower Urinary Tract Dysfunction

Neurogenic lower urinary tract dysfunction (NLUTD) remains a formidable challenge to pediatric urologists to achieve the goals of renal preservation and the reduction of urinary tract infections as well as the attainment of continence and independence as children grow toward adulthood. Tremendous progress has occurred over the past 50 years which have witnessed an evolution in focus from mere survival to optimal quality of life. This review presents four separate guidelines for the medical and surgical care of pediatric NLUTD, most commonly related to spina bifida, to highlight the change in approach from expectant to more proactive management.

Updates of Overactive Bladder in Pediatrics

Overactive bladder (OAB) is clinically defined as urinary urgency with or without urinary incontinence. It is associated with daytime frequency or constipation and has a prevalence of approximately 5%-12% among 5- to 10-year-olds. The appropriate functional exchange between the pontine micturition center, periaqueductal gray matter, and prefrontal cortex is important for proper micturition control. Several studies on pediatric cases observed a link between OAB and neuropsychiatric problems, such as anxiety, depression, and attention deficit, and treatment of these comorbidities improved patient symptoms. In this review, we present the pathophysiology of OAB, its associated conditions, and aspects related to updates in OAB treatment, and we propose a step-by-step treatment approach following this sequence: behavioral therapy, medical treatment, and invasive treatment. Although anticholinergic drugs are the mainstay of OAB medical treatment, beta-3 agonists and alpha-blockers are now recommended as a result of significant advancements in pharmacologic treatment in the last 10 years. Electrical stimulation techniques and botulinum toxin are also effective and can be used, especially in conventional treatment-refractory cases.

Comprehensive overview of the available pharmacotherapy for the treatment of non-neurogenic overactive bladder in children

INTRODUCTION

Overactive bladder (OAB) is a chronic condition highly prevalent in children and causing bothersome symptoms. It is often associated with deterioration of quality of life and can be devastating for patients and their families. Prompt initiation of conservative measures should be the backbone of treatment. When conservative management fails, pharmacological options must be considered.

AREAS COVERED

Although antimuscarinics are considered the mainstay of pharmacological treatment for OAB, only two agents are currently approved for the pediatric population. Oxybutynin and propiverine are discussed in this review, as well as other non-approved antimuscarinic agents and β3-agonists with related literature to substantiate their use in children. Dual therapy along with medication adherence and persistence is also discussed.

EXPERT OPINION

The treatment of OAB in children is demanding and one must rely on a structured, stepwise approach to achieve success. Discussing conservative measures and prescribing medication is not enough. Clinicians should actively involve children and their families in the treatment, set realistic expectations, and closely monitor side effects and medication adherence to ensure maximal efficacy.

A randomized, crossover trial comparing the efficacy and safety of fesoterodine and extended-release oxybutynin in children with overactive bladder with 12-month extension on fesoterodine: The FOXY study

INTRODUCTION

We sought to assess and compare safety and efficacy of fesoterodine and oxybutynin extended-release in the treatment of pediatric overactive bladder (OAB).

METHODS

We conducted a non-inferiority, randomized, double-blind, crossover trial comparing fesoterodine 4-8 mg and oxybutynin 10-20 mg once daily (QD) in children with OAB aged 5-14 years (2015-2018). Every child received the first medication for eight weeks, followed by crossover to the second antimuscarinic after a three-days washout. Dose up-titration was possible at mid-course. Patients could enter a fesoterodine 12-month extension. Endpoints were assessed through changes on voiding diaries, Patient's Perception of Bladder Condition score (PPBC), adverse events, vital signs, electrocardiogram, post-void residual, urinalysis, and blood tests. The Wilcoxon rank sum and Wilcoxon signed rank tests were used for statistical analysis.

RESULTS

A total of 62 patients were randomized (two early dropouts). Expected class effects (dry mouth/constipation) were present but no significant difference was observed. There was a 10.1 beats/minute increase in heart rate with fesoterodine (p<0.01) (oxybutynin-1.9 beats/min; p=non-significant [ns]). No life-threatening or serious adverse events occurred. Efficacy was similar for both drugs. Bladder capacity improved over the 16 months of the study; baseline capacity of 125 mL (44.5% expected bladder capacity for age [%EBC]) to 171 mL (53.9 %EBC) at the end of the extension phase. No clinical or statistical difference was shown between efficacy measures for fesoterodine or oxybutynin.

CONCLUSIONS

The use of fesoterodine or oxybutynin appear safe and effective for the treatment of OAB in children. Based on our study, long-term treatment to achieve the ultimate goal of urinary continence is needed in this population.

Pharmacologic therapies for the management of non-neurogenic urinary incontinence in children

Introduction: Non-neurogenic urinary incontinence in children is a common condition that affects the quality of life for both patients and parents. Symptoms may occur in the daytime, nighttime, or both and may be the result of structural and functional anomalies. Evaluation and management of associated co-morbidities, such as constipation is critical to management. Behavioral therapy is a fist line therapy in most cases of non-neurogenic urinary incontinence and pharmacologic therapy a second-line therapy.Areas covered: In this review, the authors cover the pharmacologic agents, FDA approved and commonly used non-FDA approved, available for the treatment of four non-structural etiologies of non-neurogenic urinary incontinence in children. These include nocturnal enuresis, overactive bladder, giggle incontinence, and dysfunctional voiding.Expert opinion: Non-neurogenic causes of urinary incontinence in children represent a complicated medical condition that requires both pharmacologic and non-pharmacologic management. Limited FDA-approved therapies as well as suboptimal results with approved therapies due to a lack in the understanding of the underlying pathophysiology and patient selection may lead to the use of alternative non-FDA approved therapies.

Update on Associated Risk Factors, Diagnosis, and Management of Recurrent Urinary Tract Infections in Children

Recurrent urinary tract infection (rUTI) continues to challenge pediatric care providers. The diagnosis of an rUTI can be difficult, especially in young febrile children. Antibiotic resistance rates continue to rise, which limits oral treatment options. Prophylactic antibiotics are used commonly to manage rUTI, but their use increases the risk of rUTI with antibiotic-resistant strains without significantly reducing renal scarring. Alternative therapies for rUTI include probiotics and anthocyanidins (eg, cranberry extract) to reduce gut colonization by uropathogens and prevent bacterial adhesion to uroepithelia, but efficacy data for these treatments are sparse. The future of rUTI care rests in addressing the following contemporary issues: best diagnostic practices, risk factors associated with rUTI, and the prevention of recurrent infection. In this review, we summarize the state of the art for each of these issues and highlight future studies that will aim to take an alternative approach to managing rUTI.

Pharmacotherapy in overactive bladder

Overactive bladder syndrome (OAB) has a high prevalence within the population and has a negative effect on quality of life. Although the precise pathophysiology has yet to be fully elucidated, pharmacotherapeutic agents have been developed targeting two main pathways, antimuscarinic drugs and β3-adrenoreceptor agonists. Conservative management strategies, for example, bladder training, should be used as first-line treatment, with pharmacotherapy used as an adjunct if this is insufficiently effective. Antimuscarinics have a moderate effect on treating the symptoms of OAB, are associated with side effects, particularly dry mouth, and have low adherence rates in the long term. No single agent has consistently shown superiority over another. Antimuscarinics can affect cognition and may contribute to the anticholinergic burden in elderly patients. Mirabegron, a β3-agonist, appears to be as effective as antimuscarinics in improving symptoms of OAB with fewer side effects and improved adherence, and is currently recommended if treatment with antimuscarinics has failed. A combination of an antimuscarinic and β3-agonist may be worth considering if symptoms remain refractory or to reduce the side-effect profile associated with higher doses of antimuscarinics.

Level of evidence: Not applicable.

Pharmacotherapy for Pediatric Neurogenic Bladder

Neurogenic bladder (NB) is a nonspecific term that may describe conditions ranging from areflectic noncontractile bladder to detrusor overactivity. The most common cause of NB in children is the presence of dysraphic malformations. Urodynamic evaluations make it possible to describe bladder dysfunctions and to plan a therapeutic strategy for each patient. In a child with NB there are two major dangerous functional problems seen in urodynamic investigations: high intravesical pressure in the storage phase and high pressure during urination. The basic goals of urologic treatment for a child with NB are the protection of the urinary tract from complications and improvement of continence. Treatment for a child with NB is usually conservative, and focuses on achieving safe bladder pressures during storage with reliable emptying, via voiding or catheterization. The two most important forms of conservative treatment are clean intermittent catheterization and pharmacological treatment of functional disorders. Some drugs are used in the treatment of functional disorders in children with NB, but none of the drugs are officially approved for small children and babies.

Management of Neurogenic Bladder

This article provides a comprehensive summary of the clinical approach, investigative modalities and management of a child with neurogenic bladder disease due to myelodysplasia. It is aimed at pediatric physicians and surgeons working in developing nations. The methodologies suggested are simple and can be practised even in resource poor regions. The goal of management is avoidance of Chronic kidney disease and for this, meticulous bladder management is the key.

Overactive bladder in children

Overactive bladder (OAB) is a highly prevalent disorder in the pediatric population. This condition is especially troublesome for pediatric patients and their families when associated with incontinence, since it negatively affects self-esteem and impairs children's development. From the patient's perspective, urgency and urge incontinence can have a significant impact, negatively affecting their quality of life. For a therapy to have true benefit, changes must not only be statistically significant, but must also be perceived as meaningful by the patient. A stepwise approach is favoured to treat this pathology, starting with behavioural therapy, followed by medical management, and eventually more invasive procedures. Antimuscarinic agents are the mainstay of medical treatment for OAB. Oxybutynin is the most commonly used antimuscarinic in the pediatric population. However, some patients have a suboptimal response to antimuscarinics and many experience bothersome side effects, which have been documented with all antimuscarinics to a significantly higher degree than placebo. Although there have been reports about the use of tolterodine, fesoterodine, trospium, propiverine, and solifenacin in children, to date, only oxybutynin has been officially approved for pediatric use by medical authorities in North America. This review will address alternative treatment options for pediatric patients presenting with OAB, from conservative measures to more invasive therapies.

Single center experience with oxybutynin transdermal system (patch) for management of symptoms related to non-neuropathic overactive bladder in children: an attractive, well tolerated alternative form of administration

OBJECTIVE

Oxybutynin is the current gold standard drug for management of overactive bladder (OAB) in children, but can have significant side effects or be difficult to administer in multiple daily doses. Herein, we report our experience with transdermal oxybutynin patch (TOP) as an alternative in a selected patient population without neuropathic compromise.

MATERIALS AND METHODS

Consecutive patients assessed in a pediatric urology clinic over a 1-year period, diagnosed with OAB with minimum follow-up of 3 months, were included. TOP starting dose was 3.9 mg/day based on product design (Oxytrol). Demographics and outcomes data were retrospectively collected. Symptomatic response was defined as improvement or resolution of lower urinary tract symptoms.

RESULTS

35 children met inclusion criteria (mean age 8 years, range 4-16). Overall, 97% reported good symptom response. The main side effect was skin irritation at TOP site (35%), leading to discontinuation in 20%. There were no reports of other significant side effects. Mean bladder capacity increased from 104 ml to 148 ml at follow-up.

CONCLUSIONS

Our data suggest that TOP is a viable alternative for children with non-neuropathic OAB who do not tolerate other formulations of oxybutynin. These findings highlight the potential benefit of transdermal drug delivery in the pediatric setting.

Oxybutynin and tolterodine for treatment of neurogenic detrusor overactivity: a pharmacoeconomic evaluation in the Brazilian context

Antimuscarinic agents are the first-line choice for the treatment of neurogenic detrusor overactivity (NDO). The currently available antimuscarinic drugs have been widely studied in patients presenting idiopathic detrusor overactivity; however, investigations evaluating the effects of these drugs on NDO are scant, particularly with regard to cost-effectiveness analyses. A pharmacoeconomic evaluation was performed to compare the costs and effectiveness of oxybutynin and tolterodine in two different formulations, extended (ER) and immediate-release (IR), for the treatment of NDO (based on Brazilian maximal consumer price index). A systematic review of literature was conducted in order to obtain significant clinical and urodynamic data (based on expert opinion), concerning the effects of these drugs in the neurogenic population. Furthermore, a pharmacoeconomic evaluation was performed and costs involved were calculated based on percentage effectiveness obtained for the timeframes of one month and of one year. The best cost-effectiveness ratio (CER) was observed with oxybutynin IR for the urodynamic parameters. In terms of clinical parameters, oxybutynin IR and ER showed the best CER. Based on the key urological parameters analyzed, oxybutynin IR was considered the most cost-effective antimuscarinic agent.

New strategies for medical management of overactive bladder in children

PURPOSE OF REVIEW

The medical treatment of children with non-neurogenic overactive bladder syndrome (OAB) is still limited to a small number of drugs approved for use in childhood according to the national regulations of each country.

RECENT FINDINGS

Over the last few years, there were several studies on the use of antimuscarinics other than oxybutynin in children, as well as some on the use of extended release oxybutynin and tolterodine and transdermal oxybutynin. It was shown that the combination of two different anticholinergics might be a well tolerated and successful option in children with OAB refractory to monotherapy, as well as administration of a receptor-selective antimuscarinic such as solifenacin. European studies showed promising outcomes using propiverine, and good results were achieved in the majority of patients by injection of botulinum toxin into the detrusor.

SUMMARY

After exhaustion of conservative standard treatment (i.e. urotherapy), medical treatment should be considered for children with non-neurogenic OAB. Oxybutynin or off-label use of an agent that has been shown to be well tolerated and effective should be given preference over the use of medication that has not yet been evaluated in children. Randomized controlled studies on newer and receptor-selective anticholinergics, combination therapy, and botulinum toxin in children are needed.

Treatment of non-monosymptomatic nocturnal enuresis by transcutaneous parasacral electrical nerve stimulation

OBJECTIVE

To evaluate the effectiveness of transcutaneous parasacral electrical stimulation (TCPSE) in the treatment of non-monosymptomatic nocturnal enuresis (NMNE). Also, we evaluated possible pretreatment predictors of TCPSE failure.

MATERIALS AND METHODS

Nineteen children diagnosed with NMNE who underwent TCPSE were studied prospectively. There were 6 boys and 13 girls with a mean age of 9.05 ± 3.153 years (range 5-17 years). The sessions were performed three times per week for a maximum of 20 sessions, for 20 min each and at a frequency of 10 Hz.

RESULTS

For eight children (42%) the nocturnal enuresis resolved, four (21%) presented a reduction in nocturnal episodes to less than one a week, six (32%) presented no change and one (5%) had increased frequency of NMNE. Symptoms present before treatment, such as daytime incontinence, frequency, constipation and occurrence of urinary tract infection, were not predictors of failure after TCPSE.

CONCLUSION

TCPSE can be an effective treatment for NMNE, but about a third of patients will need another kind of treatment. No pretreatment factor was determined that predicted TCPSE failure.

Prospective open label study of solifenacin for overactive bladder in children

PURPOSE

We evaluated the effect of solifenacin for urinary incontinence in children with overactive/neurogenic bladder refractory to oxybutynin or tolterodine.

MATERIALS AND METHODS

Pediatric patients presenting with refractory overactive bladder with incontinence were offered the opportunity to enter a prospective, open label protocol using adjusted dose regimens of 1.25 to 10 mg solifenacin. Study inclusion criteria were absent correctable neurological anomalies on magnetic resonance imaging, failure of symptoms to improve on intensive behavioral and medical (oxybutynin or tolterodine) therapy, and/or significant side effects of those agents. Followup consisted of a voiding diary, post-void residual urine measurement, urine culture, ultrasound and urodynamics. Families were questioned about continence, side effects, compliance, behavior change and quality of life. The primary end point was efficacy for continence and secondary end points were tolerability and safety.

RESULTS

Enrolled in the study were 42 girls and 30 boys. Of the patients 27 with neurogenic bladder, of whom 11 were on clean intermittent catheterization, and 45 with overactive bladder completed a minimum 3-month followup. Patients were on solifenacin a mean of 15.6 months. Mean age at study initiation was 9.0 years. Mean ± SD urodynamic capacity improved from 146 ± 64 to 311 ± 123 ml and uninhibited contractions decreased from 70 ± 29 to 20 ± 19 cm H(2)O (p <0.01). Continence improved in all patients, including 24 who were dry, and 42 and 6 who were significantly and moderately improved, respectively. Of the patients 50 reported no side effects while 15 had mild and 3 had moderate side effects. Four patients withdrew from the protocol due to intolerable side effects. Four patients had significant post-void residual urine (greater than 20 ml).

CONCLUSIONS

In children with overactive bladder refractory to oxybutynin or tolterodine solifenacin is an effective alternative to improve symptoms. Tolerability was acceptable and the adjusted dose regimen appeared safe.

Non-neurogenic elimination disorders in children

Non-neurogenic elimination disorders cover a wide spectrum of lower urinary tract and bowel dysfunctions, observed in the absence of a neurological background or lower urinary tract malformation. We reviewed conditions responsible for incontinence during bladder filling with normal voiding patterns (such as overactive bladder, giggle incontinence, post-void dribbling), and dysfunctional voiding syndromes. Dysfunctional elimination syndrome usually includes detrusor-sphincter dyscoordination, small-capacity overactive bladder or decompensated large poorly contractile bladder, and large-volume post-micturition residuals, occasionally associated with bowel dysfunction. At the most severe end of the spectrum lies the non-neurogenic neurogenic bladder syndrome, characterized by the association of a severe impairment of the upper urinary tract with a dysfunctional elimination syndrome. It must be emphasized that if the term 'non-neurogenic' relates to the absence of a neurological lesion, it is however conceivable that these conditions actually do have an underlying neurological cause that remains to be identified.

Prospective study of transcutaneous parasacral electrical stimulation for overactive bladder in children: long-term results

PURPOSE

We evaluated the long-term success of transcutaneous parasacral electrical stimulation for overactive bladder in children.

MATERIALS AND METHODS

We prospectively evaluated children who underwent transcutaneous parasacral electrical stimulation for overactive bladder. All patients had symptoms of overactive bladder, bell curve in uroflowmetry and low post-void residual urine. The procedure was performed using a frequency of 10 Hz for 20-minute sessions 3 times weekly for a maximum of 20 sessions. Initial and long-term (more than 6 months) success rates were evaluated.

RESULTS

Transcutaneous parasacral electrical stimulation was performed in 36 girls and 13 boys with a mean age of 10.2 years (range 5 to 17). Mean followup was 35.3 months (range 6 to 80). Before treatment urgency, daytime incontinence and urinary tract infection were seen in 100%, 88% and 71% of cases, respectively. Initial success (full response) was demonstrated in 79% of patients for urgency, 76% for incontinence and 77% for all symptoms. Continued success was seen in 84% of patients for urgency, 74% for daytime incontinence and 78% for all symptoms. If the 30 patients with at least 2 years of followup were considered, treatment was successful in 73%. Recurrence of symptoms after a full response was seen in 10% of cases. Two of 33 patients (6%) with urinary tract infection before the procedure still had infection after treatment.

CONCLUSIONS

Transcutaneous parasacral electrical stimulation is well tolerated, and demonstrates short and long-term effectiveness in treating overactive bladder in children. Symptoms eventually will recur in 10% of patients.

Diagnosis and management of urinary incontinence and functional fecal incontinence (encopresis) in children

The ability to maintain normal continence for urine and stools is not achievable in all children by a certain age. Gaining control of urinary and fecal continence is a complex process, and not all steps and factors involved are fully understood. While normal development of anatomy and physiology are prerequisites to becoming fully continent, anatomic abnormalities, such as bladder exstrophy, epispadias, ectopic ureters, and neurogenic disturbances that can usually be recognized at birth and cause incontinence, will require specialist treatment, not only to restore continence but also to preserve renal function. Most forms of urinary incontinence are not caused by an anatomic or physiologic abnormality and, hence, are more difficult to diagnose and their management requires a sound knowledge of bladder and bowel function.

The neurogenic bladder: medical treatment

Neurogenic bladder sphincter dysfunction (NBSD) can cause severe and irreversible renal damage and bladder-wall destruction years before incontinence becomes an issue. Therefore, the first step in adequate management is to recognize early the bladder at risk for upper- and lower-tract deterioration and to start adequate medical treatment proactively. Clean intermittent catheterization combined with anticholinergics (oral or intravesical) is the standard therapy for NBSD. Early institution of such treatment can prevent both renal damage and secondary bladder-wall changes, thereby potentially improving long-term outcomes. In children with severe side effects or with insufficient suppression of detrusor overactivity despite maximal dosage of oral oxybutynin, intravesical instillation is an effective alternative. Intravesical instillation eliminates systemic side effects by reducing the first-pass metabolism and, compared with oral oxybutynin, intravesical oxybutynin is a more potent and long-acting detrusor suppressor. There is growing evidence that with early adequate treatment, kidneys are saved and normal bladder growth can be achieved in children so they will no longer need surgical bladder augmentation to achieve safe urinary continence in adolescence and adulthood.

The effects of anticholinergic drugs on attention span and short-term memory skills in children

AIMS

Studies have shown cognitive problems in adults treated with anticholinergics. It is unclear if children are also susceptible to anticholinergic adverse effects. This study evaluates the effects of long-acting oxybutynin and tolterodine on short-term memory and attention in children with urgency and urge incontinence.

METHODS

Children with urgency or urge incontinence were recruited to take part in a prospective, randomized double-blinded placebo controlled trial using long-acting oxybutynin or tolterodine. Patients underwent a baseline test of their memory/recall ability and attention span using a standardized developmental/neuropsychological assessment tool. They were then randomized to either medication or placebo with retesting in 2 weeks, at which time they were crossed. They were retested after the second 2 weeks.

RESULTS

Fourteen children (9 boys and 5 girls), ranging in age from 5 to 11 (M = 7.7) participated in the study. Attention and memory scores increased over time in all children, however, the analyses showed no significant negative effects of anticholinergic medications on attention or memory. Indeed, though not statistically significant, trends were for improvement in test scores in both areas.

CONCLUSIONS

Our results in a double blinded cross-over trial suggest that long-acting oxybutynin and tolterodine do not have a deleterious effect on children's attention and memory. Other cognitive functions may be affected.

Long-Term Tolerability of Tolterodine Extended Release in Children 5–11 Years of Age: Results from a 12-Month, Open-Label Study

OBJECTIVE

To evaluate the long-term tolerability of tolterodine extended release (ER) in children (aged 5-11 yr) with urgency urinary incontinence (UUI).

METHODS

This was a multicenter, open-label extension of a 12-wk, double-blind, placebo-controlled study of tolterodine ER. Patients had UUI suggestive of detrusor overactivity (>/=1 diurnal incontinence episode per 24h for >/=5 of 7 d) and >/=6 voids per 24h at baseline and had completed the 12-wk double-blind study. Patients received tolterodine ER (2mg once daily) for 12 mo. The primary end points were the incidence and severity of adverse events (AEs) and the incidence and reasons for withdrawals. Visits were scheduled at 3, 6, 9, and 12 mo, and investigators were instructed to report all AEs. At 6 and 12 mo, vital signs were recorded and a physical examination was performed.

RESULTS

A total of 318 patients were enrolled (double-blind tolterodine ER, n=221; placebo, n=97). The majority of patients were white (90%), mean+/-SD age was 7.6+/-1.5 yr, and 54% were boys. Forty-nine percent of patients reported >/=1 AE during the study, similar to that observed in the preceding 12-wk study (42%). The most frequent AEs were urinary tract infection (7%), nasopharyngitis (5%), headache (5%), and abdominal pain (4%); 111 (35%) patients withdrew. The most common reasons for withdrawal were lack of efficacy (12%), symptom improvement (8%), and withdrawn consent (6%). Ten patients (3%) withdrew because of AEs.

CONCLUSION

Long-term treatment with tolterodine ER was well tolerated in children with UUI.

Improved efficacy of extended release oxybutynin in children with persistent daytime urinary incontinence converted from regular oxybutynin

OBJECTIVES

To examine the response to conversion from regular oxybutynin (Ditropan) to an extended-release form (Ditropan XL) in children with persistent daytime urinary incontinence.

METHODS

A retrospective review of patients with daytime wetting who switched from Ditropan to Ditropan XL included patient age, sex, reason for the change in medication, uroflowmetry findings before and after the change, side effects, and duration and dosage of the medication. The data were analyzed using a paired, two-tailed t test, with P <0.05 considered significant.

RESULTS

Twenty-seven patients were followed up for an average of 35.8 months. A lack of improvement (n = 11), convenience (n = 6), side effects (n = 2), and a dislike of the taste (n = 2) were identified as reasons for changing to the extended release form. The mean dosage of Ditropan and Ditropan XL did not differ significantly (0.40 and 0.38 mg/kg/day, respectively). After the change to Ditropan XL, 6 patients had a resolution of side effects and 7 developed new side effects. Of the 27 patients, 13 became dry or had significant improvement by the first visit after the change to Ditropan XL. Significant increases in voided volume (38% versus 53%; P <0.01) and total bladder capacity (55% versus 70%; P = 0.03), normalized for age-expected bladder capacity, occurred by the first clinic visit after beginning Ditropan XL. No significant changes in the postvoid residual urine volume occurred.

CONCLUSIONS

The frequency of wetting decreased and the voided volume and bladder capacity increased after a change to Ditropan XL in children with persistent wetting when taking Ditropan.

Oxybutynin in Detrusor Overactivity

Oxybutynin has been used for the management of detrusor overactivity for over 30 years and has withstood medical scrutiny and the test of time throughout the world. Although several agents in the class of bladder relaxants have only recently been studied, oxybutynin's effectiveness in reducing urinary frequency and urge urinary incontinence is unquestioned in the medical literature. Oxybutynin is extremely safe and effective in almost every population including children, the elderly, and those who have neurogenic bladder. With more preparations available and more dosing flexibility than any other anticholinergic medication on the market, oxybutynin remains the "gold standard" for first-line therapy for patients who have detrusor overactivity.

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study

OBJECTIVE

To report a series of children with lower urinary tract dysfunction (LUTD) whose urge syndrome was treated by electrical stimulation, and their voiding dysfunction by biofeedback; none of the children were using anticholinergic drugs during treatment.

PATIENTS AND METHODS

In all, 36 children who presented with symptoms of urinary urgency and/or daily incontinence completed the treatment and were prospectively evaluated. The mean (range) follow-up was 13.8 (4-24) months, and their mean age 7 (3-14) years, 17 children were aged <5 years. The children were divided into two groups: group 1, with urge syndrome treated with superficial parasacral electrical stimulation, and group 2, with voiding dysfunction, treated with biofeedback.

RESULTS

In group 1, the mean (range) number of electrical stimulation sessions was 13.1 (4-20). Of the 19 children treated, 12 had a complete clinical improvement, six a significant improvement, and one a mild improvement. In group 2, the mean (range) number of biofeedback sessions was 6 (4-14). Of the 17 children treated, there was complete improvement of symptoms in 10, significant improvement in two and mild improvement in five. Six children who had no resolution of symptoms after biofeedback had salvage therapy with electrical stimulation, after which four had complete improvement of symptoms, and two a 90% and 40% improvement, respectively. Taking the two groups together, after treatment, four children developed isolated episodes of urinary tract infection. Of 21 children with nocturnal enuresis, bed-wetting continued in 13 (62%) after treatment.

CONCLUSION

In this short-term follow-up, the nonpharmacological treatment of voiding dysfunction using biofeedback, and of urge syndrome by electrical stimulation, was effective for treating LUTD in children.

TOLTERODINE TREATMENT FOR CHILDREN WITH SYMPTOMS OF URINARY URGE INCONTINENCE SUGGESTIVE OF DETRUSOR OVERACTIVITY: RESULTS FROM 2 RANDOMIZED, PLACEBO CONTROLLED TRIALS

PURPOSE

We report the results of the first 2 large randomized controlled trials designed to evaluate the efficacy and safety of tolterodine extended release in children 5 to 10 years old with symptoms of urinary urge incontinence suggestive of detrusor overactivity.

MATERIALS AND METHODS

Two double-blind, placebo controlled trials were conducted sequentially. Children 5 to 10 years old with incontinence suggestive of detrusor overactivity (1 or more diurnal incontinence episodes per 24 hours) were randomized to tolterodine (2 mg daily) or placebo for 12 weeks. The primary end point was the change from baseline to week 12 in the number of incontinence episodes per week. Changes from baseline in the number of voids per 24 hours and volume of urine per void were also evaluated. Exploratory analyses were conducted to determine whether particular subsets of patients showed differential responses to treatment.

RESULTS

A total of 224 and 487 children (mean age 8 years) were randomized to placebo and tolterodine, respectively. Differences in the number of incontinence episodes per week, voids per 24 hours, and volume of urine per void between tolterodine and placebo did not reach statistical significance. This finding may be explained by a high placebo response and under dosage of tolterodine among children with greater body weight. Tolterodine was well tolerated.

CONCLUSIONS

Analysis of the primary efficacy outcome did not reveal a statistically significant effect of treatment. However, secondary analyses demonstrated that tolterodine was well tolerated among 5 to 10-year-old children with diurnal incontinence. Exploratory analyses also showed that children weighing 35 kg or less with detrusor overactivity characterized by incontinence and/or frequent voiding benefited most from tolterodine treatment, suggesting that a weight adjusted dosing regimen may be required for optimal response among older and heavier children.

Oxybutynin Extended-Release

The OROS-based oxybutynin extended-release (ER) formulation (Lyrinel XL; Ditropan XL) represents a new form of oral delivery for oxybutynin, a muscarinic receptor antagonist used in the treatment of overactive bladder (OAB). The release of oxybutynin from oxybutynin ER occurs in a sustained manner, resulting in a smoother plasma concentration-time profile and a lower maximum plasma concentration than those seen with oxybutynin immediate-release (IR). The ER formulation has been developed with the aim of improving the tolerability of oxybutynin therapy and facilitating once-daily administration. Moreover, oxybutynin ER offers greater flexibility in dosage (5-30 mg/day) than the other available treatment options. At dosages of 5-30 mg once daily, oxybutynin ER produced significant decreases from baseline in weekly urinary urge incontinence in patients with OAB. In addition, there were significant decreases in weekly total incontinence episodes and micturition frequency. In two randomised, double-blind studies in patients with OAB, the improvement in all the symptoms with once-daily oxybutynin ER 5-30 mg/day was similar to that produced by oxybutynin IR 5-20 mg/day given one to four times daily. Once-daily oxybutynin ER 10 mg was superior to tolterodine IR 4 mg/day given as two daily doses and as effective as once-daily tolterodine ER 4 mg/day in decreasing urinary incontinence; the decreases in micturition frequency with oxybutynin ER were significantly greater than those seen with either of tolterodine formulations. Oxybutynin ER was well tolerated in all the trials, with adverse events usually being mild to moderate and transient. In direct comparisons, the overall tolerability profile of oxybutynin ER was better than that of oxybutynin IR. Oxybutynin ER was similar to tolterodine (IR and ER) with respect to the incidence of clinically important dry mouth. A large 12-month tolerability study demonstrated no significant risks associated with the long-term use of oxybutynin ER. A few noncomparative studies have shown promising results with oxybutynin ER in the treatment of adult and paediatric patients with neurogenic bladder dysfunction secondary to neuronal injury. Long- and short-term studies have reported significant improvements in health-related quality of life with oxybutynin ER therapy. In addition, pharmacoeconomic studies have suggested that oxybutynin ER is more cost effective than oxybutynin IR and at least as cost effective as tolterodine IR. In conclusion, oxybutynin ER shows excellent efficacy in the treatment of symptoms associated with OAB in adults and the elderly with a good tolerability profile over a prolonged period of use (12 months). The ER formulation of oxybutynin provides a smooth plasma concentration profile over the 24-hour dosage interval, facilitating once-daily administration. Hence, given its overall efficacy/tolerability profile and dosage flexibility, oxybutynin ER provides an excellent treatment option in the first-line pharmacotherapy of OAB.

A benefit-risk assessment of extended-release oxybutynin

Oxybutynin is a muscarinic receptor antagonist, which has been available for a number of years in its original immediate-release (IR) formulation. While oxybutynin IR has proven effective for the treatment of overactive bladder, its extended use can be limited by adverse effects, particularly dry mouth. An extended-release (ER) formulation of oxybutynin based on the OROS system has recently become available, which allows once daily administration. In direct comparison to oxybutynin IR, oxybutynin ER has an increased oral bioavailability for the parent compound oxybutynin which is accompanied by a reduced bioavailability for the active metabolite N-desethyl-oxybutynin. The latter has been implicated in mediating a major part of the adverse effects of oxybutynin treatment. Two double-blind, placebo-controlled, randomised studies in patients with overactive bladder have demonstrated that oxybutynin ER has a similar efficacy as oxybutynin IR but with improved tolerability. This is in line with clinical pharmacological studies demonstrating a smaller impairment of saliva production with oxybutynin ER than with oxybutynin IR. Thus, the ER formulation of oxybutynin maintains the therapeutic benefits and concomitantly improves tolerability.

Conservative management in neurogenic bladder dysfunction

PURPOSE OF REVIEW

A few decades ago, urinary diversion, usually with an ileal conduit, was the ultimate outcome for most children with spina bifida. The revolutionary institution of clean intermittent catheterization has changed the algorithm totally. Furthermore many new drugs have been developed during the past decade and have decreased the need for surgery dramatically. In this article, we will focus on the most recent data on new modalities of therapy to help avoid urinary diversion or bladder augmentation.

RECENT FINDINGS

In addition to clean intermittent catheterization and oxybutynin treatment, a new generation of anticholinergic medications, such as tolterodine, has been developed. For patients who drop out because of the side-effects of oral administration, new methods of administration are now available, including extended release and intravesical instillation. For those unresponsive, botulinum-A toxin and resiniferatoxin are two relatively new drugs in the field, administered as intravesical injection and instillation, respectively. Intravesical or transdermal electrical stimulation, sacral nerve stimulation and biofeedback therapy are under development, but as currently administered, are not yet completely successful.

SUMMARY

Although life-saving in many respects, bladder augmentation introduces life-long risks of its own. Our goal in describing 'conservative' management is to prevent this step. Many alternatives to surgery are available now and more effective strategies are under development.

Neurogenic bladder dysfunction in patients with myelomeningocele

PURPOSE OF REVIEW

The general management strategies in children with myelodysplasia are widely accepted, however diagnostic and therapeutic details still need to be discussed and clarified.

RECENT FINDINGS

Ten articles are reviewed. Two articles are dealing with general clinical aspects; one underlines the need for urodynamics as a prerequisite for an adequate treatment strategy, the other recommends to evaluate adolescents and adults with myelodysplasia, because only the ultimate outcome allows a judgement of how effective our efforts are to achieve the goals. Increased excretion of glycosaminoglycan in myelodysplasia children above 5 years of age could become a marker for beginning bladder damage and deserves further interest. The question whether children with normal urodynamics after closing the spinal cord should be followed or not is clearly answered in a further article which also discusses the results of detethering in these patients. Four articles report on pharmacotherapy with new substances or new ways of application (intravesical oxybutynin, extended release oxybutynin formulation, intravesical resiniferatoxin). The results of collagen injections in children with neurogenic sphincter underactivity clearly demonstrate that the long-term results are disappointing. Last, but not least, a retrospective review on acute abdominal symptoms and signs in children with myelodysplasia clearly shows that these patients should be transferred to a centre because of complex reasons and treatment modalities.

SUMMARY

Urodynamics - abnormal or normal - are a prerequisite for adequate treatment and follow-up in children with myelodysplasia. More studies should focus on adolescents and adults with myelodysplasia to judge the effectiveness of our diagnostic and therapeutic efforts. New ways of application and new developments in pharmacotherapy to relax the overactive detrusor may possibly further decrease the need for surgery in the future. With regards to sphincter underactivity, results with collagen injections in this group of patients are disappointing and provide no alternative to operative treatment options.