The pharmacological treatment of urinary incontinence

Hypoxanthine Induces Signs of Bladder Aging With Voiding Dysfunction and Lower Urinary Tract Remodeling

BACKGROUND

Lower urinary tract syndrome (LUTS) is a group of urinary tract symptoms and signs that can include urinary incontinence. Advancing age is a major risk factor for LUTS; however, the underlying biochemical mechanisms of age-related LUTS remain unknown. Hypoxanthine (HX) is a purine metabolite associated with generation of tissue-damaging reactive oxygen species (ROS). This study tested the hypothesis that exposure of the adult bladder to HX-ROS over time damages key LUT elements, mimicking qualitatively some of the changes observed with aging.

METHODS

Adult 3-month-old female Fischer 344 rats were treated with vehicle or HX (10 mg/kg/day; 3 weeks) administered in drinking water. Targeted purine metabolomics and molecular approaches were used to assess purine metabolites and biomarkers for oxidative stress and cellular damage. Biomechanical approaches assessed LUT structure and measurements of LUT function (using custom-metabolic cages and cystometry) were also employed.

RESULTS

HX exposure increased biomarkers indicative of oxidative stress, pathophysiological ROS production, and depletion of cellular energy with declines in NAD+ levels. Moreover, HX treatment caused bladder remodeling and decreased the intercontraction interval and leak point pressure (surrogate measure to assess stress urinary incontinence).

CONCLUSIONS

These studies provide evidence that in adult rats chronic exposure to HX causes changes in voiding behavior and in bladder structure resembling alterations observed with aging. These results suggest that increased levels of uro-damaging HX were associated with ROS/oxidative stress-associated cellular damage, which may be central to age-associated development of LUTS, opening up potential opportunities for geroscience-guided interventions.

The role of facebook support groups for women with benign urologic conditions

OBJECTIVE

To understand the availability and content of patient support groups on social media platforms.

MATERIALS AND METHODS

Five prevalent benign, urologic conditions affecting adult women were selected for analysis. Facebook support groups for these conditions were identified. Groups specific to one urologic condition and with at least 400 members were included, and groups for pediatric and malignant conditions were excluded. Each support group was analyzed for member count, posts per month, and period of activity. The 100 most recent posts in the largest support groups were manually reviewed and further categorized into content subsections.

RESULTS

A total number of 56 Facebook support groups were identified that satisfied the inclusion/exclusion criteria. Interstitial cystitis (IC) had 25 groups (68 466 members; 4825 posts), pelvic organ prolapse (POP) had 14 groups (72 342; 3067), UTI had nine groups (36 414; 3204), overactive bladder and/or urinary incontinence (OAB/UI) had seven groups (8246; 306), urinary retention had one group (1168; 118). Across all groups, post content was predominantly informational support (77.6%). Remaining post content was both informational and emotional support (10.0%), emotional support only (7.6%), or unrelated to either informational or emotional support (4.8%).

CONCLUSION

Individuals with benign urologic conditions are utilizing social media support groups predominantly to seek and share informational support from patient peers. The number of existing groups as well as the level of activity and number of members within individual support groups varies significantly between different urologic conditions. This suggests that there is an unmet need for accessible informational content for patients who suffer with benign urological conditions.

[Short version of the S2k guideline on drug therapy of neurogenic lower urinary tract dysfunction (NLUTD)]

BACKGROUND

In Germany about one million patients suffer from neurogenic lower urinary tract dysfunction (NLUTD). If left untreated, various forms of NLUTD can lead to secondary damage of the lower and upper urinary tract. Thus, the guideline was developed for the drug therapy of patients with NLUTD, who frequently require lifelong care and aftercare.

METHODS

The guideline was developed in a consensus process with several meetings and online reviews, and final recommendations were decided on in online consensus meetings. Ballots were sent to elected officials of the contributing professional societies. Level of consensus was given for each coordinated recommendation ( https://www.awmf.org/leitlinien/detail/ll/043-053.html ). RESULTS/MOST IMPORTANT RECOMMENDATIONS: (Video)urodynamic classification of the NLUTD should be conducted before the use of antimuscarinic drugs (84.2%). Approved oral antimuscarinics should be used as first choice. Contraindications must be respected (100%). If oral treatment is ineffective or in the case of adverse drug reaction (ADRs) alternatively instillation of oxybutynin solution intravesically (83%) or onabotulinumneurotoxine (OBoNT) injection should be offered (89.5%). In case of failure or ADRs of antimuscarinics, β3 sympathomimetic mirabegron can be used to treat neurogenic detrusor overactivity (NDO) (off-label use) (100%). In case of paraplegia below C8 or multiple sclerosis with an expanded disability status scale (EDSS) of ≤ 6.5, OBoNT injection can be offered as an alternative (89.5%). Drug therapy for NDO should be started early in newborns/young children (84.2%). Conservative, nondrug therapy should be considered in frail elderly (94.7%). No parasympathomimetic therapy should be used to treat neurogenic detrusor underactivity (94.7%).

CONCLUSION

Precise knowledge of the neurological underlying disease/sequence of trauma and the exact classification of the NLUTD are required for development of individualized therapy.

Comparison of tolterodine, trospium chloride, solifenacin treatments and its side effects on patients with pure urinary and mixed incontinence

Objective: Urinary incontinence is defined as urinary incontinence that is a social or hygienic problem and can be objectively demonstrated. It is aimed to compare tolterodine, trospium chloride and solifenacin treatments, and its side effects on patients who have complaints of pure urinary and mixed incontinence. Material and Method: Totally 98 patients, who applied to Ankara Etlik Zubeyde Hanım Gynecology Training and Research Hospital, Urogynecology Outpatient Clinic between November 2009 and October 2010 with compliants of urinary incontinence and met the criteria to participate in the research, have been included in this study. Results: A significant improvement in each three of the drug group at third and six months was determined. Solifenacin is generally more effective than the other two treatments. When total values of UDI-6 (Urinary Distress Inventory) survey is analysed, it is seen that each of three antimuscarinic drug group ensured improvement on symptoms at the end of the third month as not to be different from the improvement at the six month. Each three antimuscarinic drug group has a significant therapeutic effect on the IIQ-7 (Incontinence Impact Questionnaire) survey which questions the life quality. Whereas complaints of constipation was seen more at patients that use tolterodine and trospium chloride, there was not a significant difference despite a slight increase in the solifenacin group (p>0.05). It is determined that solifenacin caused desert mouth less than the other two drug groups Conclusion: Tolterodine, trospium chloride and solifenacin as anticholinergic drugs meaningfully reduced the activity of bladder and increased the quality of life. Drug therapy provided an effective and efficient improvement on incontinence.

Treatment strategies for clozapine-induced nocturnal enuresis and urinary incontinence: a systematic review

BACKGROUND

Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug reactions, including nocturnal enuresis and urinary incontinence. This side effect can be burdensome and lead to medication nonadherence and psychotic relapse. Evidence to guide treatment of clozapine-induced nocturnal enuresis and urinary incontinence is sparse. We therefore aimed to synthesize the evidence base to guide management for clinicians, patients, and their carers.

METHODS

We systematically searched PubMed, Embase, PsycInfo, CINAHL, and the Cochrane Trial Registry databases from inception to May 2021 for publications on management of clozapine-induced nocturnal enuresis and urinary incontinence using a PROSPERO preregistered search strategy.

RESULTS

We identified 22 case reports and case series describing 74 patients. Interventions included clozapine dose reduction, nonpharmacological treatment, and pharmacological treatments. Among pharmacological treatments, desmopressin, oxybutynin, trihexyphenidyl, tolterodine, imipramine, amitriptyline, ephedrine, pseudoephedrine, aripiprazole, and verapamil were associated with complete resolution of nocturnal enuresis and urinary incontinence. Balancing evidence for effectiveness against risk of adverse effects, we developed a management framework for clozapine-induced nocturnal enuresis and urinary incontinence.

CONCLUSIONS

Following assessment of urological, psychiatric, pharmacological, and common comorbid medical issues, first-line treatments should be nonpharmacological, including bathroom alarms, voiding before bedtime, and nocturnal fluid restriction. If these interventions do not provide adequate relief, aripiprazole should be trialed. Desmopressin may be considered for severe refractory cases, but monitoring for hyponatremia is essential.

Reviving Cav1.2 as an attractive drug target to treat bladder dysfunction

Inhibition of bladder contraction with antimuscarinics is a common approach to treat bladder hyperactivity, and the L-type voltage-gated calcium channel α_1C (Cav1.2) is crucial for bladder contractility. Therefore, strategies aimed at inhibiting Cav1.2 appear warranted. However, multiple clinical trials that attempted to treat bladder overactivity with calcium channel blockers (CCBs) have been unsuccessful, creating an unsolved mystery. In contrast, cardiologists and epidemiologists have reported strong associations between CCB use and bladder hyperactivity, opposing expectations of urologists. Recent findings from our lab offer a potential explanation. We have demonstrated that ketamine which can cause cystitis, functions, like nifedipine, as a Cav1.2 antagonist. We also show that a Cav1.2 agonist which potentiates muscle contraction, rather than antagonizing it, can increase the volume of voids and reduce voiding frequency. This perspective will discuss in detail the unsuccessful urological trials of CCBs and the promise of Cav1.2 agonists as potential novel therapies for bladder dysfunctions.

Chronic Urinary Infection in Overactive Bladder Syndrome: A Prospective, Blinded Case Control Study

Objectives

To investigate whether women with overactive bladder (OAB) symptoms and no evidence of clinical infection by conventional clean-catch midstream urine cultures have alternative indicators of sub-clinical infection.

Patients/Subjects Materials & Methods

The study was a prospective, blinded case-control study with 147 participants recruited, including 73 OAB patients and 74 controls. The OAB group comprised female patients of at least 18 years of age who presented with OAB symptoms for more than 3 months. Clean-catch midstream urine samples were examined for pyuria by microscopy; subjected to routine and enhanced microbiological cultures and examined for the presence of 10 different cytokines, chemokines, and prostaglandins by ELISA.

Results

The mean age and BMI of participants in both groups were similar. No significant difference in the number of women with pyuria was observed between OAB and control groups (p = 0.651). Routine laboratory cultures were positive in three (4%) of women in the OAB group, whereas the enhanced cultures isolated bacteria in 17 (23.2%) of the OAB patients. In the control group, no positive cultures were observed using routine laboratory cultures, whereas enhanced culture isolated bacteria in 8 (10.8%) patients. No significant differences were observed in the concentrations of PGE2, PGF2α, MCP-1, sCD40L, MIP-1β, IL12p70/p40, IL12/IL-23p40, IL-5, EGF and GRO-α between the OAB and control groups.

Conclusions

Patients with OAB symptoms have significant bacterial growth on enhanced culture of the urine, which is often not detectable through routine culture, suggesting a subclinical infection. Enhanced culture techniques should therefore be used routinely for the effective diagnosis and management of OAB.

Desmopressin versus desmopressin + oxybutynin in the treatment of children with nocturnal enuresis

INTRODUCTION

Enuresis is identified as voluntary or involuntary leakage of urine for at least three consecutive months in the daytime and/or nighttime on clothes for children older than five. Monosymptomatic nocturnal enuresis (MNE) describes nighttime wetting without daytime leakage of urine in children with no pathology in the urinary system and it is 80% more common than enuresis. Desmopressin is the most common medical treatment for MNE. The aim of this study is to retrospectively compare the effectiveness of desmopressin as monotherapy and desmopressin + oxybutynin as a combination therapy in the treatment of nocturnal enuresis.

MATERIAL AND METHOD

This study retrospectively evaluated 183 patients who applied to pediatrics, pediatrics surgery and urology clinics with the complaint of nocturnal enuresis and diagnosed with primary monosymptomatic nocturnal enuresis between January 2014 and December 2019. The patients were divided into two groups (91 patients) who only received desmopressin therapy (Group 1), and those (92 patients) who received desmopressin and oxybutynin combination therapy (Group 2). Response to treatment, compliance and recurrence ratios were determined in the evaluation. Complete response was accepted as 90-100% decrease in the number of nighttime wetting, partial response was accepted as 50-90% decrease in the number of nighttime wetting and those below 50% were regarded as non-response. The 1st, 3rd, and 6th months of control data of treatment effectiveness of both groups were evaluated and their responses to treatment and the side effects of drugs were examined.

RESULTS

The mean age 183 patients of whom 103 were male and 80 were female was 10 (6-16) year. In the first month of control of Group 1, 71.4% had a complete cure, 8.8% had a partial cure and 19.8% had no response to treatment. In the third month of control of Group 1, 74.73% gave a complete response and were cured, 5.5% gave a partial response and 19.78% had no response. In the sixth month of Group 1, 70 patients were evaluated as complete response (79.5%), and 5 patients were evaluated as partial response (5.6%). In the first month of control of Group 2, 75% gave a complete response, 10.9% gave a partial response, 14.1% had no response to treatment. In the third month of control of Group 2, 86.9% gave a complete response, 6.52% gave a partial response, and 6.52% had no response. In the sixth month of the control of Group 2, the number of patients who did not come for control and could not be reached was 2, 83 patients out of 90 patients were evaluated as complete response (92.2%), 6 patients were evaluated as partial response (6.6%).

CONCLUSION

Desmopressin is the only FDA approved pharmacologic treatment for nocturnal enuresis. Desmopressin reduces urine production and the anticholinergic agent allows the bladder to store more urine. Therefore, combined therapy can be recommended in the MNE treatment for specially selected cases.

A uro-protective agent with restorative actions on urethral and striated muscle morphology

PURPOSE

Aging increases oxidative stress, which can have delirious effects on smooth and striated muscle resulting in bladder dysfunction. Consequently, in women aged over 60 years, urinary incontinence (UI) is a prevalent health problem. Despite the prevalence and consequences, UI continues to be undertreated simply because there are few therapeutic options.

METHODS

Here we investigated whether 8-aminoguanine (8-AG), a purine nucleoside phosphorylase (PNPase inhibitor), would restore urethra and external sphincter (EUS) muscle morphology in the aged rat. Aged (> 25 months) female Fischer 344 rats were randomized to oral treatment with 8-AG (6 weeks) or placebo, and the urethra and EUS were evaluated by electron microscopy and protein expression (western immunoblotting).

RESULTS

Aging was associated with mitochondrial degeneration in smooth and striated muscle cells as compared to young rats. We also observed a significant increase in biomarkers such as PARP, a downstream activator of oxidative/nitrosative stress. Treatment of aged rats with 8-AG normalized all abnormalities to that of a younger state.

CONCLUSIONS

8-AG, a potent inhibitor of PNPase, reverses age-related lower urinary tract morphological and biochemical changes. Our observations support the concept that 8-AG will reverse age-induced lower urinary tract disorders such as UI. These initial findings could have therapeutic implications for the prevention and treatment of age-related UI.

Purine nucleoside phosphorylase inhibition ameliorates age-associated lower urinary tract dysfunctions

In the aging population, lower urinary tract (LUT) dysfunction is common and often leads to storage and voiding difficulties classified into overlapping symptom syndromes. Despite prevalence and consequences of these syndromes, LUT disorders continue to be undertreated simply because there are few therapeutic options. LUT function and structure were assessed in aged (>25 months) male and female Fischer 344 rats randomized to oral treatment with a purine nucleoside phosphorylase (PNPase inhibitor) 8-aminoguanine (8-AG) or vehicle for 6 weeks. The bladders of aged rats exhibited multiple abnormalities: tactile insensitivity, vascular remodeling, reduced collagen-fiber tortuosity, increased bladder stiffness, abnormal smooth muscle morphology, swelling of mitochondria, and increases in urodamaging purine metabolites. Treatment of aged rats with 8-AG restored all evaluated histological, ultrastructural, and physiological abnormalities toward that of a younger state. 8-AG is an effective treatment that ameliorates key age-related structural and physiologic bladder abnormalities. Because PNPase inhibition blocks metabolism of inosine to hypoxanthine and guanosine to guanine, likely uroprotective effects of 8-AG are mediated by increased bladder levels of uroprotective inosine and guanosine and reductions in urodamaging hypoxanthine and xanthine. These findings demonstrate that 8-AG has translational potential for treating age-associated LUT dysfunctions and resultant syndromes in humans.

Off-label uses of drugs for depression

The prescription of drugs for depression is rising rapidly. One of the reasons for this trend is their many off-label uses. Up to one third of all prescriptions are for non-indicated use, which in addition to drug repurposing includes different dosing or duration than those recommended. In this review, we elaborate on what antidepressants can treat besides depression. The five classes of drugs for depression are introduced, and their mechanisms of action and serious side effects are described. The most common off-label uses of antidepressants are discussed, with a special focus on treating eating disorders, sleep problems, smoking cessation and managing chronic pain. Depression is often a comorbidity when antidepressants are chosen as therapy, but good therapeutic effects have been observed for other conditions also when depression is not involved. Finally, a new type of antidepressant developed from the hallucinogenic "party drug" ketamine is briefly introduced. This recent development suggests that antidepressants will keep playing a central role in medicine for years to come.

Targetable purinergic receptors P2Y12 and A2b antagonistically regulate bladder function

Abnormalities in purine availability or purinergic receptor density are commonly seen in patients with lower urinary tract symptoms (LUTS), but the underlying mechanisms relating altered receptor function to LUTS are unknown. Here we provide extensive evidence for the reciprocal interplay of multiple receptors responding to ATP, ADP (adenosine diphosphate), and adenosine, agonists that regulate bladder function significantly. ADP stimulated P2Y12 receptors, causing bladder smooth muscle (BSM) contraction, whereas adenosine signaling through potentially newly defined A2b receptors, actively inhibited BSM purinergic contractility. The modulation of adenylyl cyclase-cAMP signaling via A2b and P2Y12 interaction actively regulated bladder contractility by modulating intracellular calcium levels. KO mice lacking the receptors display diametrically opposed bladder phenotypes, with P2Y12-KO mice exhibiting an underactive bladder (UAB) phenotype with increased bladder capacity and reduced voiding frequency, whereas A2b-KO mice have an overactive bladder (OAB), with decreased capacity and increased voiding frequency. The opposing phenotypes in P2Y12-KO and A2b-KO mice not only resulted from dysregulated BSM contractility, but also from abnormal BSM cell growth. Finally, we demonstrate that i.p. administration of drugs targeting P2Y12 or A2b receptor rescues these abnormal phenotypes in both KO mice. These findings strongly indicate that P2Y12 and A2b receptors are attractive therapeutic targets for human patients with LUTS.

Alarm therapy and desmopressin in the treatment of patients with nocturnal enuresis

PURPOSE

The purpose of this study was to compare the rates of success, relapse, and compliance to treatment in patients undergoing alarm therapy or receiving desmopressin for primary monosymptomatic nocturnal enuresis (PMNE).

MATERIALS AND METHODS

This retrospective study was performed by reviewing the medical files of patients undergoing alarm therapy (Group 1) or receiving desmopressin (Group 2) for PMNE, between January 2010 and July 2014. Patients undergoing treatment in the 3^rd and 6^th month as well as 1^st year follow-up data were analyzed. Two groups were compared with regard to treatment success, relapse rate, and compliance to treatment.

RESULTS

Group 1 included 64 and Group 2 included 70 children. Relapse rates at the 3^rd month, 6^th month, and 1^st year were 67.2%, 71.9%, and 17.0% for Group 1 and 74.3%, 80.0%, and 21.4% for Group 2, respectively. There was no statistically significant difference between relapse rates at any point of follow-up.

CONCLUSIONS

Alarm therapy and desmopressin have the same success rate and relapse rates for PMNE. Compliance with alarm therapy is higher and we recommend it as the first-line treatment. On the other hand, desmopressin has low side effects and can also be used.

An investigation of factors predicting the type of bladder antimuscarinics initiated in Medicare nursing homes residents

Background

To examine factors predicting type of bladder antimuscarinics (BAM) initiated in nursing home (NH) residents.

Methods

Incident BAM initiators following NH admission were identified by constructing a retrospective cohort from Medicare files and Minimum Data Set (MDS). Participants included all residents 65 years and older admitted in Medicare-certified NH between January 1, 2007 and December 31, 2008 who were prescribed BAM and had continuous Medicare (Part A, B, and D) enrollment. Patient characteristics, medications, and comorbidities were derived from Medicare enrollment and claims. NH characteristics and health status were derived from MDS assessments. The outcome was defined as type of BAM initiated after admission (selective, non-selective extended release, non-selective immediate release). Multinomial logistic regression using generalized estimating equation methodology determined which factors predicted the type of BAM initiated.

Results

Twelve thousand eight hundred ninety-nine NH residents initiating BAM therapy were identified; 13.38% of new users were prescribed selective BAM, 45.56% non-selective extended release, and 41.07% non-selective immediate release medications. In both sexes, significant predictors of BAM included region of nursing home, body mass index, cognitive performance score, frailty measures, activities of daily living, and measures of bladder continence. In women, history of fracture and fall-related injuries were significant predictors of type of BAM use, while race and indicators of balance were significant predictors of type of BAM use in men. Non-pharmacological continence management strategies were not predictive of type of BAM initiation.

Conclusions

Several factors are important in predicting type of BAM initiation in both women and men, but other factors are sex-specific. Some observed factors predicting the type of BAM initiated, such as other medications use, body mass index, or provider-related factors are potentially modifiable and could be used in targeted interventions to help optimize BAM use in this population.

Trial registration

Not applicable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0690-2) contains supplementary material, which is available to authorized users.

Big-conductance Ca2+-activated K+ channels in physiological and pathophysiological urinary bladder smooth muscle cells

Contraction and relaxation of urinary bladder smooth muscle cells (UBSMCs) represent the important physiological functions of the bladder. Contractile responses in UBSMCs are regulated by a number of ion channels including big-conductance Ca²⁺- activated K⁺ (BK) channels. Great progress has been made in studies of BK channels in UBSMCs. The intent of this review is to summarize recent exciting findings with respect to the functional interactions of BK channels with muscarinic receptors, ryanodine receptors (RyRs) and inositol triphosphate receptors (IP₃Rs) as well as their functional importance under normal and pathophysiological conditions. BK channels are highly expressed in UBSMCs. Activation of muscarinic M₃ receptors inhibits the BK channel activity, facilitates opening of voltage-dependent Ca²⁺ (Ca_V) channels, and thereby enhances excitability and contractility of UBSMCs. Signaling molecules and regulatory mechanisms involving RyRs and IP₃Rs have a significant effect on functions of BK channels and thereby regulate cellular responses in UBSMCs under normal and pathophysiological conditions including overactive bladders. Moreover, BK channels may represent a novel target for the treatment of bladder dysfunctions.

Electrical stimulation for the treatment of lower urinary tract dysfunction after spinal cord injury

Electrical stimulation for bladder control is an alternative to traditional methods of treating neurogenic lower urinary tract dysfunction (NLUTD) resulting from spinal cord injury (SCI). In this review, we systematically discuss the neurophysiology of bladder dysfunction following SCI and the applications of electrical stimulation for bladder control following SCI, spanning from historic clinical approaches to recent pre-clinical studies that offer promising new strategies that may improve the feasibility and success of electrical stimulation therapy in patients with SCI. Electrical stimulation provides a unique opportunity to control bladder function by exploiting neural control mechanisms. Our understanding of the applications and limitations of electrical stimulation for bladder control has improved due to many pre-clinical studies performed in animals and translational clinical studies. Techniques that have emerged as possible opportunities to control bladder function include pudendal nerve stimulation and novel methods of stimulation, such as high frequency nerve block. Further development of novel applications of electrical stimulation will drive progress towards effective therapy for SCI. The optimal solution for restoration of bladder control may encompass a combination of efficient, targeted electrical stimulation, possibly at multiple locations, and pharmacological treatment to enhance symptom control.

Altered detrusor gap junction communications induce storage symptoms in bladder inflammation: a mouse cyclophosphamide-induced model of cystitis

Lower urinary tract symptoms (LUTS) include storage, voiding and post-micturition symptoms, featuring many urological diseases. Storage symptoms are the most frequent among these and associated with overactive bladder and non-bacterial bladder inflammation such as interstitial cystitis/bladder pain syndrome (IC/BPS). Gap junction, a key regulator of hyperactive conditions in the bladder, has been reported to be involved in pathological bladder inflammation. Here we report involvement of gap junction in the etiology of storage symptoms in bladder inflammation. In this study, cyclophosphamide-induced cystitis was adapted as a model of bladder inflammation. Cyclophosphamide-treated mice showed typical storage symptoms including increased urinary frequency and reduced bladder capacity, with concurrent up-regulation of connexin 43 (GJA1), one of the major gap junction proteins in the bladder. In isometric tension study, bladder smooth muscle strips taken from the treated mice showed more pronounced spontaneous contraction than controls, which was attenuated by carbenoxolone, a gap junction inhibitor. In voiding behavior studies, the storage symptoms in the treated mice characterized by frequent voiding were alleviated by 18α-glycyrrhetinic acid, another gap junction inhibitor. These results demonstrate that cyclophosphamide-induced mouse model of cystitis shows clinical storage symptoms related with bladder inflammation and that gap junction in the bladder may be a key molecule of these storage symptoms. Therefore, gap junction in the bladder might be an alternative therapeutic target for storage symptoms in bladder inflammation.

Managing overactive bladder symptoms in a palliative care setting

BACKGROUND

The combined symptoms of urinary frequency, urgency, nocturia, and incontinence (overactive bladder) are common symptoms within an elderly population but are also seen in palliative care patients and are most often due to detrusor muscle overactivity. These symptoms can lead to a marked reduction in quality of life and pharmacological management is traditionally with anticholinergic drugs. These medications carry a high risk of side effects and are often poorly tolerated by palliative care patients. Other management approaches, however, such as the use of urisheaths may markedly improve quality of life without adding to symptom burden in patients nearing the end of life.

OBJECTIVES

This article highlights two cases in palliative care where overactive bladder symptoms prove difficult to manage with anticholinergic drugs.

CONCLUSIONS

The discussion will give an overview of treatment strategies to help aid the clinician in managing these difficult symptoms in patients with a terminal illness.

Calcium Antagonists Use and Its Association with Lower Urinary Tract Symptoms: A Cross-Sectional Study

Background

Lower urinary tract symptoms (LUTS) have been reported amongst the side effects of calcium antagonists (CA). CAs act on the bladder by affecting the ability of the detrusor muscle to create enough contractile force to overcome obstruction to normal voiding. We aimed to determine the relationship between CA use and LUTS in general medical inpatients.

Methods and Findings

In this cross-sectional study we recruited 278 medical inpatients (including 85 CA users) aged ≥40 (72.1±13.7) years. LUTS was assessed using the International Prostate Symptoms Score (IPSS) questionnaire. A Logistic regression model using a ‘backwards-elimination’ strategy was used to identify variables associated with LUTS and for calculating the adjusted odds ratios and the 95% confidence intervals (CI). After adjusting for other risk factors and drugs, patients on amlodipine/nifedipine and diltiazem/verapamil (compared to non-users) were more likely to suffer from severe LUTS [Males: 12.45(CI: 1.57–98.63) and Females: 7.75(CI: 0.94–63.94)] and moderate-to-severe LUTS [Males: 17.43(CI: 2·26–134.39) and Females: 47.8(CI: 6.22–367.37)]. Patients on felodipine/lercanidipine were less likely to suffer from either severe or moderate-to-severe LUTS. Further, 19 (22.4%) CA-users were on treatment for LUTS compared to 18 (9.3%) of the non-users group, p = 0.003. Both male and female CA-users were three times more likely to be on alpha-blockers than non-users, p<0.001. CA-users were more likely to have undergone urinary tract-related surgery (Males: two times, p = 0.07 and females: nine times, p = 0.029). The study was limited by the fact that a causal relationship could not be established between CA use and LUTS.

Conclusions

Our results demonstrate an association between CA use and an increasing severity of LUTS. They also demonstrate that CA-users are more likely to have medical or surgical treatment for LUTS. However, these CA’s effects on LUTS vary, and the use of highly vascular selective agents does not appear to pose significant risk.

Muscarinic agonists and antagonists: effects on the urinary bladder

Voiding of the bladder is the result of a parasympathetic muscarinic receptor activation of the detrusor smooth muscle. However, the maintenance of continence and a normal bladder micturition cycle involves a complex interaction of cholinergic, adrenergic, nitrergic and peptidergic systems that is currently little understood. The cholinergic component of bladder control involves two systems, acetylcholine (ACh) released from parasympathetic nerves and ACh from non-neuronal cells within the urothelium. The actions of ACh on the bladder depend on the presence of muscarinic receptors that are located on the detrusor smooth muscle, where they cause direct (M₃) and indirect (M₂) contraction; pre-junctional nerve terminals where they increase (M₁) or decrease (M₄) the release of ACh and noradrenaline (NA); sensory nerves where they influence afferent nerve activity; umbrella cells in the urothelium where they stimulate the release of ATP and NO; suburothelial interstitial cells with unknown function; and finally, other unidentified sites in the urothelium from where prostaglandins and inhibitory/relaxatory factors are released. Thus, the actions of muscarinic receptor agonists and antagonists on the bladder may be very complex even when considering only local muscarinic actions. Clinically, muscarinic antagonists remain the mainstay of treatment for the overactive bladder (OAB), while muscarinic agonists have been used to treat hypoactive bladder. The antagonists are effective in treating OAB, but their precise mechanisms and sites of action (detrusor, urothelium, and nerves) have yet to be established. Potentially more selective agents may be developed when the cholinergic systems within the bladder are more fully understood.

Can sacral neuromodulation improve minor incontinence symptoms in doubly incontinent patients successfully treated for major incontinence symptoms?

OBJECTIVE

To describe the effect of sacral nerve modulation (SNM) on less severe types of incontinence in patients who were successfully implanted for either urinary or fecal incontinence, and who presented with double incontinence. When conservative treatments fail, SNM is a first-line treatment for patients with urge urinary or fecal incontinence.

METHODS

All patients who received SNM between 2005 and 2010 at 5 hospitals and who still had the implant were included in our survey. All received a urinary and fecal change and quality of life questionnaire by mail to complete.

RESULTS

Of the 51 questionnaires sent out, 37 were returned, for a 72.5% response rate. The population was composed of 97.3% women, with a mean age of 56.8 years (SD 14). The main indication for SNM was urge urinary incontinence in 15 patients (40.5%) and fecal incontinence in 22 patients (59.5%). Eighteen patients (48.7%) had improvements in both urinary and fecal incontinence symptoms. The percentage increased to 53.3% (16/30) in the group of patients with urge urinary incontinence associated with fecal incontinence. Patients who reported an improvement in double incontinence symptoms complained more often of urge urinary incontinence than other patients (P=.04).

CONCLUSIONS

Of the doubly incontinent patients who were successfully implanted for a predominant type of incontinence (ie, urinary or fecal incontinence), 48.7% had an improvement in the other type of incontinence. Patients with urge urinary incontinence associated with fecal incontinence were more likely to report an improvement in double incontinence than the other patients.

The role of sacral neuromodulation in double incontinence

AIM

Urinary and faecal incontinence are common conditions that are frequently associated. When conservative treatments fail, sacral nerve modulation (SNM) is considered to be a first-line treatment for patients with urge urinary incontinence and for patients with faecal incontinence. This article aims to determine the effect of SNM on the treatment of double incontinence (i.e. urinary and faecal incontinence).

METHOD

We searched for relevant articles in MEDLINE, PubMed and Embase, and for reviews in the Cochrane database. Articles were restricted to the English language.

RESULTS

Only a few studies have studied the efficacy of SNM for double incontinence and in a limited number of patients. Between 30% and 100% of patients with double incontinence experience improvement in urinary and faecal incontinence at medium-term follow up.

CONCLUSION

Further prospective trials are needed to determine which patients with combined problems will benefit from SNM at a long-term follow up.

Urinary incontinence is associated with lower psychological general well-being in community-dwelling women

OBJECTIVE

There are few studies documenting the impact of urinary incontinence (UI) on well-being in women. The aim of this study was to evaluate the relationships between different types of UI and general well-being in women in the community.

METHODS

A cross-sectional survey of 542 community-dwelling women, aged 24 to 80 years, was conducted in July 2006. A detailed self-administered questionnaire was mailed to the study participants. UI was assessed using the Questionnaire for Urinary Incontinence Diagnosis, and well-being was assessed using the Psychological General Well-being Index (PGWBI). The relationships between types of UI and PGWBI scores were assessed using multiple regression analyses while adjusting for potential confounders.

RESULTS

A total of 506 (94%) women provided data for analysis. Women with incontinence had a lower total PGWBI score (76.9 +/- 16.5) than did women with no UI (81.6 +/- 15.3; P = 0.001). The total PGWBI mean score was significantly lower in women with stress-only UI (77.8 +/- 16.2; P = 0.05) and mixed UI (74.2 +/- 17.8; P < 0.001) compared with women with no UI. There was no significant difference in the mean total scores between women with urge UI and women without UI. Stress-only UI was negatively associated with the PGWBI subdomains of self-control, general health, and vitality, whereas those with mixed UI had lower scores for all the PGWBI subdomains. The associations for UI remained significant after adjustment for age, systemic hormone therapy use, menopause status, smoking status, and regular exercise.

CONCLUSIONS

Not only is UI associated with a significant reduction in well-being in community-dwelling women, but also, the relationship between different types of UI and well-being seems to differ.

[Significance of phosphodiesterase isoenzymes in the control of human detrusor smooth muscle function. An immunohistochemical and functional study]

OBJECTIVES

The use of inhibitors of phosphodiesterase (PDE) isoenzymes 1 and 5 to treat overactive bladder has been suggested. To further evaluate the significance of PDE isoenzymes in detrusor smooth muscle relaxation, we investigated the effects of selective PDE inhibitors on the tension induced by carbachol of isolated human detrusor tissue. Using immunohistochemical methods, the expression of PDE1, PDE4, and PDE5 in human detrusor was also investigated.

MATERIAL AND METHODS

The expression of PDE1, PDE4, and PDE5 was evaluated by means of conventional immunohistochemistry (IHC). Using the organ bath technique, the effects of the PDE inhibitors vinpocetine, rolipram, sildenafil, tadalafil, and vardenafil on the tension induced by the muscarinic agonist carbachol (1 microM) were investigated.

RESULTS

The tension induced by carbachol was dose-dependently reversed by the PDE inhibitors; the maximum reversal of tension ranged from 7% (tadalafil) to 34% (vardenafil). IHC revealed that the expression of PDE isoenzymes was limited to the smooth musculature of the detrusor. While there was prominent expression of PDE4 and PDE5, immunoreactions indicating the presence of PDE1 were less abundant.

CONCLUSION

Despite the fact that inhibitors of PDE1, PDE4, and PDE5 exerted only a weak relaxant response on detrusor strips precontracted by carbachol, our findings indicate that both the cAMP and cGMP pathways might be involved in the relaxation mechanism of human detrusor smooth muscle.

Comparison of the effect of anti-muscarinic agents on bladder activity, urinary ATP level, and autonomic nervous system in rats

We compared the effect of 4 anti-muscarinic agents on bladder activity, urinary ATP levels, and autonomic nervous system in rats. Rats were divided into the following 5 groups (control group, oxybutynin group, propiverine group, tolterodine group, imidafenacin group), and were administered daily the designated anti-muscarinic agent or distilled water into the stomach. After 2 weeks, we performed 1) continuous cystometry with physiological saline and 0.1% acetic acid solution, 2) measurement of urinary ATP level before and after bladder stimulation, and 3) measurement of the heart rate, blood pressure and plasma catecholamines. The maximum bladder contraction pressure increased and the interval between contractions became shorter during cystometry with acetic acid solution in the control group, but not in the 4 anti-muscarinic agent groups. The urinary ATP level increased after bladder stimulation in all groups, but the increase was smaller in the propiverine and imidafenacin groups. The plasma noradrenaline and dopamine levels of the propiverine group were higher. Taken together, all anti-muscarinic agents inhibited the bladder activity without changing the heart rate and blood pressure. Especially, the inhibitory effect of propiverine and imidafenacin on bladder activity may be partly due to blocking an increase of ATP release from the bladder urothelium.

Association of change in estradiol to lower urinary tract symptoms during the menopausal transition

OBJECTIVE

To estimate the relationship between changes in estradiol (E2) levels over time and lower urinary tract symptoms in premenopausal women as they transition to menopause.

METHODS

A self-administered validated questionnaire to measure lower urinary tract symptoms was administered to 300 women at the 11th assessment period on an ongoing longitudinal Penn Ovarian Aging cohort study. The association between the change in E2 over time through the menopausal transition and lower urinary tract symptoms (urinary incontinence, filling symptoms, voiding dysfunction) was determined. Risk factors associated with lower urinary tract symptoms were determined by univariable analysis and multivariable linear regression.

RESULTS

Estradiol levels and menopausal stage at one point in time were not associated with lower urinary tract symptoms. Women with a sharp decline in E2 levels over time had significantly lower urinary incontinence scores in comparison with women without a change in E2 levels through the study period (mean+/-standard deviation 3.11+/-2.86 compared with 2.08+/-2.43, adjusted mean difference -0.93, 95% confidence interval [CI] -1.8 to -0.02). Women between the ages of 45 years to 49 years had significantly higher urinary incontinence scores than women woman age older than 55 years (1.59+/-1.86 compared with 3.04+/-2.93, adjusted mean difference 1.0, 95% CI 0.01-2.1). Women with a body mass index greater than 35 also had significantly higher urinary incontinence scores than women in the normal weight range, (3.53+/-3.16 compared with 1.98+/-2.52, adjusted mean difference 1.5, 95% CI 0.59-2.3) after adjusting for changes of E2 through the menopausal transition. High anxiety was associated with worsening scores in all three lower urinary tract symptoms domains (incontinence, filling, voiding).

CONCLUSION

Women with a sharp decline in E2 through the menopausal transition have significantly lower urinary incontinence scores. Urinary filling symptoms and voiding dysfunction were not associated with changes in E2 through the menopausal transition.

LEVEL OF EVIDENCE

II.

The potential of hormones and selective oestrogen receptor modulators in preventing voiding dysfunction in rats

OBJECTIVE

To investigate whether oestrogen, selective oestrogen receptor modulators (SERMs), and growth hormone (GH) can prevent the development of voiding dysfunction in a postpartum postmenopausal rat model of voiding dysfunction.

MATERIALS AND METHODS

Immediately after spontaneous delivery, nine primiparous Sprague-Dawley rats served as uninjured controls (sham group) and 54 underwent intravaginal balloon dilation. On day 7, the 54 subject rats underwent bilateral ovariectomy. A week later, six treatment groups of nine rats were randomized to receive: normal saline (injured control group), 17beta-oestradiol (E(2)), raloxifene, levormeloxifene, GH, or GH + E(2). The treatment groups received daily subcutaneous injections for 3 weeks. The effects of hormone treatment were examined by conscious cystometry at the end of the study. Voiding dysfunction was defined to include overactive bladder and sphincter deficiency.

RESULTS

The sham rats had a mean (sd) voiding frequency of 3 (0.87) times in 10 min and a bladder capacity of 0.43 (0.13) mL with smooth cystometry curves. The number of rats in each treatment group (each group contained nine rats) that had voiding dysfunction was as follows: E(2), three; raloxifene, six; levormeloxifene, four; and controls, four (P > 0.05 among the groups). Only one rat in the GH-treated group and no rats in the GH + E(2)-treated group had voiding dysfunction, which was significantly less in the GH + E(2)-treated group than in the controls (P = 0.041).

CONCLUSION

This functional data suggest that the development of voiding dysfunction can be prevented by short-term administration of GH and GH + E(2) in our rat model. SERMs and E(2) alone seem to have no therapeutic effect.

Patient perspectives in the management of overactive bladder, focus on transdermal oxybutynin

Overactive bladder syndrome (OAB) is a constellation of distressing symptoms that significantly impair quality of life, sexual function, and work productivity, and imposes a significant economic burden to society. Pharmacological treatment with antimuscarinic agents, behavioral modification, bladder retraining, and/or pelvic floor exercises are often used alone or in combination as the mainstay treatment in the management of OAB. Oxybutynin has been used in the treatment of OAB for over 20 years with proven efficacy and is often the comparator in drug treatment trials. Oral formulations of oxybutynin have proven efficacy, but not without significant antimuscarinic effects, which reduce patient persistence with medical treatment. Low levels of patient persistence with oral formulations of oxybutynin provided an impetus for the development of a transdermal oxybutynin delivery system. The oxybutynin transdermal formulation has been found to have side effects similar to that of a placebo in randomized controlled trials while providing excellent efficacy. Patient persistence with therapy, improved quality of life, sexual function and interpersonal relationships have been observed with use of the transdermal oxybutynin delivery system. Its twice weekly dosing, low side effect profile, and high efficacy have made it a good choice for initial treatment of overactive bladder syndrome.

Comparative studies of ZD0947, a novel ATP-sensitive K(+) channel opener, on guinea pig detrusor and aortic smooth muscles

The effects of ZD0947, a novel urinary bladder selective ATP-sensitive potassium channel (K(ATP) channel) opener, on carbachol-induced contractions of isolated guinea pig urinary bladder strips were investigated to compare its ability to relax norepinephrine-induced contraction of the aorta. Electrophysiological techniques were also utilized to compare the effects of ZD0947 on membrane currents between guinea pig detrusor and aortic myocytes. ZD0947 caused a significant reduction of the carbachol-induced contractile activity, demonstrating a biphasic relaxation (the first and second components). Although glibenclamide antagonized the effects of two components for the ZD0947-induced relaxation, gliclazide, a selective sulphonylurea receptor 1 (SUR1) antagonist, reduced the effects of the first component but not the second component of the ZD0947-induced relaxation. ZD0947 also reduced the norepinephrine-induced contraction of the aorta. ZD0947 reduced electrical excitability of detrusor smooth muscles, inhibiting spike discharges and also hyperpolarizing the membrane as measured with microelectrodes. In conventional whole-cell configuration, ZD0947 caused a glibenclamide-sensitive K(+) current (i.e., K(ATP) current) at a holding potential of -60 mV in guinea pig detrusor and aortic myocytes. The current density of ZD0947-induced K(ATP) currents in guinea pig detrusor myocytes was significantly larger than that in aortic smooth muscle cells. These results show that ZD0947 caused a significant relaxation through the activation of K(ATP) channels in detrusor muscle.

Actions of two main metabolites of propiverine (M-1 and M-2) on voltage-dependent L-type Ca2+ currents and Ca2+ transients in murine urinary bladder myocytes

The anticholinergic propiverine (1-methyl-4-piperidyl diphenylpropoxyacetate), which is used for the treatment of overactive bladder syndrome, has functionally active metabolites [M-1 (1-methyl-4-piperidyl diphenylpropoxyacetate N-oxide) and M-2 (1-methyl-4-piperidyl benzilate N-oxide)], but the site of actions of these metabolites is uncertain. Propiverine is rapidly absorbed after oral administration and is extensively biotransformed in the liver, giving rise to several active metabolites (M-1 and M-2). This study determines the effect of M-1 and M-2 on voltage-dependent nifedipine-sensitive inward Ca(2+) currents (I(Ca)) using patch-clamp techniques and fluorescent Ca(2+) imaging [after electrical field stimulation (EFS) and acetylcholine (ACh)] in the murine urinary bladder. In conventional whole-cell recording, propiverine and M-1 but not M-2 inhibited the peak amplitude of I(Ca) in a concentration-dependent manner at a holding potential of -60 mV (propiverine, K(i) = 10 microM; M-1, K(i) = 118 microM). M-1 shifted the steady-state inactivation curve of I(Ca) to the left at -90 mV by 7 mV. Carbachol (CCh) reversibly inhibited I(Ca). This inhibition probably occurred through muscarinic type 3 receptors, coupling with G-proteins, because nanomolar concentrations of 4-diphenylacetoxy-N-methyl-piperidine greatly reduced this inhibition, whereas pirenzepine or 11-([2-[(diethylamino)methyl]-1-piperdinyl]acetyl)-5,11-dihydro-6H-pyrido[2,3-b][1,4]benzodiazepine-6-one (AF-DX 116) at concentrations up to 1 microM was almost ineffective. In the presence of M-2, the CCh-induced inhibition of I(Ca) was blocked. In fluorescent Ca(2+) imaging, M-2 inhibited EFS-induced and ACh-induced Ca(2+) transients. These results suggest that M-1 acts, at least in part, as a Ca(2+) channel antagonist (as it inhibited I(Ca)), whereas M-2 has more direct antimuscarinic actions.

Randomized Trial of Oxybutynin Extended Versus Immediate Release for Women Aged 65 and Older with Overactive Bladder: Lessons Learned from Conducting a Trial

OBJECTIVE

This trial was designed to investigate the effectiveness of extended release versus immediate release oxybutynin in reducing symptoms of overactive bladder in a community-dwelling female population over the age of 65.

METHODS

This was a prospective randomized 12-week, open-label study. The primary outcome was number of micturitions per 24 hours, 12 weeks after treatment. The a priori sample size estimate was 60 patients per group.

RESULTS

Of the 318 women approached, only 72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely because of recruitment difficulties and an interim analysis revealing the need for a much larger sample than had been estimated to show a significant difference between treatments. After 12 weeks of treatment, there was no difference between the oxybutynin extended release and immediate release groups in the number of micturitions per 24 hours or in other outcomes.

CONCLUSION

This study did not demonstrate differences between oxybutynin extended release and immediate release and in reducing symptoms of overactive bladder or quality of life, possibly because the study did not reach the necessary sample size. The difficulty in recruiting subjects for the trial likely resulted from the onerous study requirements (4 study visits required over 12 weeks) and the downtown location of the study centres: these factors would cause particular difficulties for women over age 65 with overactive bladder, for whom travelling may be a problem. Evidence is needed to guide prescribing for older patients, but designing research to obtain adequate sample sizes is difficult. Studies in older subjects should ensure that a much larger budget is allocated for recruitment than would be allocated for studies in younger subjects, that meticulous attention is paid to issues of transport and access, and that support is provided for subjects who agree to take part research.

Chapitre C-l A - Traitement pharmacologique de l’hyperactivité détrusorienne neurologique : per os, en patch, en instillation endo-vésicale

Functional rehabilitation of neurourological patients always starts with patient education, retraining, and occupational therapy, possibly completed by medical treatments. In the light of a systematic review of the literature, the authors describe the various treatments that can be used orally and by intravesical instillation in these patients. They also describe treatments such as desmopressin or agents that increase sphincter pressure, which can sometimes be very useful to obtain stable clinical results that are satisfactory for the patient.

A standardised mini pig model for in vivo investigations of anticholinergic effects on bladder function and salivation

PURPOSE

The objective was to validate an in vivo model for evaluation of pharmacological effects on bladder function taking the most predominant anticholinergic side effect (hyposalivation) into account. Therefore, two anticholinergic properties (propiverine hydrochloride and tolterodine-L(+)-tartrate) were used to test the in vivo model. Sacral anterior root stimulation (SARS) was performed to induce reproducible and standardized bladder contractions. To evaluate hyposalivation standardised salivavary flow measurements by stimulating the lingual nerve was performed in addition to SARS.

MATERIALS AND METHODS

10 male mini pigs were anaesthetised. The carotid artery was cannulated for blood pressure measurement and the jugular vein for administration of propiverine 0.4 mg kg(-1) b.w. and tolterodine 0.06 mg kg(-1) b.w. For stimulation-induced salivary flow measurements both lingual nerves were exposed and a cuff electrode was placed around the nerves. The bladder was exposed and a cystostomy catheter was inserted to performed cystometrographic measurements during SARS.

RESULTS

In all experiments, for each animal reproducible intravesical pressure values (pves) and salivary flow rates were elicited during electrostimulation before administration of the drug. Bladder pressure: After administration of propiverine, neurostimulation-induced rise in pves had fallen by 60% from the initial value. After administration of tolterodine pves had fallen by about 50%. After additional administration of atropine pves decreased to about 15% of the initial value for both drugs. Salivation: After propiverine salivary flow had fallen by 61%. Inhibition of salivary flow under tolterodine was about 56%. Additional administration of atropine led in both drugs to a nearly complete blockade of salivation. Heart rate (HR) and blood pressure (BP): Directly following intravenous administration of both drugs, a short-term and reversible period of mild but significant fluctuations in HR was observed. There was also a slight but non-significant rise in blood pressure.

CONCLUSIONS

This model allows comparative investigations of various drugs with bladder inhibitory properties in terms of acute efficacy and side effects.

The role of the prostacyclin receptor antagonist RO3244019 in treating neurogenic detrusor overactivity after spinal cord injury in rats

OBJECTIVE

To determine the effects of the prostacyclin receptor (IP) antagonist RO3244019 on neurogenic detrusor overactivity (NDO) in spinal cord-injured (SCI) neurogenic bladder of the rat.

MATERIALS AND METHODS

Female Sprague-Dawley rats with SCI were divided into four treatment groups of eight each: vehicle (200 mm Tris base), indomethacin (3 mg/kg), RO3244019 (at 1 and 5 mg/kg). The conscious rats were assessed by cystometry, by slowly infusing the bladder with physiological normal saline at 0.04 mL/min. After 1 h of cystometry one of the four compounds was administered intravenously to the rats and changes in cystometrogram tracings recorded. Seven voiding variables were calculated before and after administering each compound: the intercontractile interval (ICI) for all contractions, voiding ICI, amplitude of all contractions, amplitude of voiding contractions, time to first void (TFV), voided volumes (VVs), and first VV. Data were analysed using a paired t-test for each of the experiments.

RESULTS

At 1 mg/kg, the RO compound was associated with a statistically significant difference in the voiding ICI and VVs (both P < 0.05). The mean (sd) voiding ICI increased from 621 (140) to 889 (119) s (43% increase) and the VVs from 0.53 (0.13) to 0.72 (0.09) mL (36% increase). However, there was no statistically significant difference in the TFV or the first VVs. Increasing the dose to 5 mg/kg was more effective in improving the voiding ICI and the VVs (both P < 0.01). The voiding ICI increased from 716 (130) to 1346 (159) s (88% increase) and the VVs from 0.60 (0.11) to 1.05 (0.12) mL (75% increase). In addition, the higher dose had a statistically significant difference in the TFV (P < 0.05). There was more than a four-fold increase in the TFV, from 807 (138) to 3239 (883) s. At 5 mg/kg, the difference in the first VV before and after administering the compound was also almost statistically significant (P = 0.057); the first VV increased from 0.56 (0.14) to 1.01 (0.21) mL. There were no statistically significant differences in the amplitude of contractions or the ICI for all contractions for either of the dosages. Indomethacin at 3 mg/kg was the most effective compound for improving all of the voiding variables and was the only one to show a significant difference in the first VV. However, the IP antagonist at 5 mg/kg was almost as effective as indomethacin when comparing other variables, e.g. the voiding ICI and the VV. There was no statistically significant difference in any of the seven voiding variables before and after administering the vehicle.

CONCLUSION

The IP antagonist RO3244019 was effective in treating NDO in SCI bladders. While RO3244019 at 1 mg/kg significantly increased the voiding ICI and VVs, 5 mg/kg appeared to be more effective, suggesting a dose-dependent effect of the drug. The RO compound at 5 mg/kg was almost as effective as indomethacin in improving all of the voiding variables.

A gap junction blocker inhibits isolated whole bladder activity in normal rats and rats with partial bladder outlet obstruction

We examined the effect of 18alpha-glycyrrhetinic acid (18alpha-GA), a gap junction blocker, or propiverine hydrochloride on the activity of isolated whole bladders obtained from intact rats and rats with partial bladder outlet obstruction (BOO). Thirty-two female Sprague-Dawley rats were divided into an intact group and a BOO group. The whole bladder was harvested from each rat and isovolumetric cystometry was performed in Krebs solution. Changes of bladder activity were recorded after addition of 18alpha-GA or propiverine hydrochloride to the perfusate. Propiverine hydrochloride inhibited the amplitude and duration of contraction in both intact and BOO groups. Propiverine hydrochloride also reduced the baseline bladder pressure in the BOO group, but not in the intact group. In contrast, 18alpha-GA inhibited the amplitude and duration of bladder contraction, and also reduced the baseline pressure, in both intact and BOO groups. BOO bladders showed inhibition of the amplitude and duration of bladder contraction at lower concentrations of 18alpha-GA than intact bladders. A gap junction blocker suppressed the in vitro activity of BOO bladders more effectively than that of intact bladders. Therefore, inhibition of intercellular communication in the bladder via gap junctions may be useful for treating detrusor overactivity, as well as propiverine hydrochloride.

Propiverine and metabolites: differences in binding to muscarinic receptors and in functional models of detrusor contraction

Propiverine is a commonly used antimuscarinic drug used as therapy for symptoms of an overactive bladder. Propiverine is extensively biotransformed into several metabolites that could contribute to its spasmolytic action. In fact, three propiverine metabolites (M-5, M-6 and M-14) have been shown to affect various detrusor functions, including contractile responses and L-type calcium-currents, in humans, pigs and mice, albeit with different potency. The aim of our study was to provide experimental evidence for the relationship between the binding of propiverine and its metabolites to human muscarinic receptor subtypes (hM(1)-hM(5)) expressed in chinese hamster ovary cells, and to examine the effects of these compounds on muscarinic receptor-mediated detrusor function. Propiverine, M-5, M-6 and M-14 bound to hM(1)-hM(5) receptors with the same order of affinity for all five subtypes: M-6 > propiverine > M-14 > M-5. In HEK-293 cells expressing hM(3), carbachol-induced release of intracellular Ca(2+) ([Ca(2+)](i)) was suppressed by propiverine and its metabolites; the respective concentration-response curves for carbachol-induced Ca(2+)-responses were shifted to the right. At higher concentrations, propiverine and M-14, but not M-5 and M-6, directly elevated [Ca(2+)](i). These results were confirmed for propiverine in human detrusor smooth muscle cells (hDSMC). Propiverine and the three metabolites decreased detrusor contractions evoked by electric field stimulation in a concentration-dependent manner, the order of potency being the same as the order of binding affinity. We conclude that, in comparison with the parent compound, loss of the aliphatic side chain in propiverine metabolites is associated with higher binding affinity to hM(1)-hM(5) receptors and higher functional potency. Change from a tertiary to a secondary amine (M-14) results in lower binding affinity and reduced potency. Oxidation of the nitrogen (M-5) further lowers binding affinity as well as functional potency.

Muscarinic receptors: their distribution and function in body systems, and the implications for treating overactive bladder

1. The effectiveness of antimuscarinic agents in the treatment of the overactive bladder (OAB) syndrome is thought to arise through blockade of bladder muscarinic receptors located on detrusor smooth muscle cells, as well as on nondetrusor structures. 2. Muscarinic M3 receptors are primarily responsible for detrusor contraction. Limited evidence exists to suggest that M2 receptors may have a role in mediating indirect contractions and/or inhibition of detrusor relaxation. In addition, there is evidence that muscarinic receptors located in the urothelium/suburothelium and on afferent nerves may contribute to the pathophysiology of OAB. Blockade of these receptors may also contribute to the clinical efficacy of antimuscarinic agents. 3. Although the role of muscarinic receptors in the bladder, other than M3 receptors, remains unclear, their role in other body systems is becoming increasingly well established, with emerging evidence supporting a wide range of diverse functions. Blockade of these functions by muscarinic receptor antagonists can lead to similarly diverse adverse effects associated with antimuscarinic treatment, with the range of effects observed varying according to the different receptor subtypes affected. 4. This review explores the evolving understanding of muscarinic receptor functions throughout the body, with particular focus on the bladder, gastrointestinal tract, eye, heart, brain and salivary glands, and the implications for drugs used to treat OAB. The key factors that might determine the ideal antimuscarinic drug for treatment of OAB are also discussed. Further research is needed to show whether the M3 selective receptor antagonists have any advantage over less selective drugs, in leading to fewer adverse events.

Antimuscarinic drugs for the treatment of female urinary incontinence

Overactive bladder syndrome, urge syndrome or urgency-frequency syndrome is defined as 'urgency with or without urge incontinence, usually with frequency and nocturia'. Although this definition indicates that these symptoms are suggestive of detrusor overactivity (the observation of involuntary detrusor contractions during the filling phase of cystometry), a urodynamic demonstration of detrusor overactivity is not necessary in order to make the diagnosis. Nevertheless, patients with overactive bladder syndrome represent a substantial proportion of patients suffering with urinary symptomatology, and approximately a third of individuals with overactive bladder suffer from incontinence. Furthermore, as compared with those patients with stress urinary incontinence, women with urge incontinence have a poorer overall quality of life, perhaps related to both the volume of urine lost as well as the unpredictable nature of the leakage. When combined with behavioral modification, antimuscarinic pharmacotherapy remains the mainstay of treatment for this condition. A number of these agents are available for the treatment of overactive bladder-related incontinence, each with unique pharmacokinetic and pharmacodynamic properties. In order to optimize therapy for patients suffering from this type of incontinence, it is necessary to understand the mechanism of action of these agents, as well as to be familiar with the differences between them with respect to efficacy, safety and tolerability.

Urinary incontinence in women

Urinary incontinence is common in women, but is under-reported and under-treated. Urine storage and emptying is a complex coordination between the bladder and urethra, and disturbances in the system due to childbirth, aging, or other medical conditions can lead to urinary incontinence. The two main types of incontinence in women, stress urinary incontinence and urge urinary incontinence, can be evaluated by history and simple clinical assessment available to most primary care physicians. There is a wide range of therapeutic options, but the recent proliferation of new drug treatments and surgical devices for urinary incontinence have had mixed results; direct-to-consumer advertising has increased public awareness of the problem of urinary incontinence, but many new products are being introduced without long-term assessment of their safety and efficacy.

The role of venlafaxine and duloxetine in the treatment of depression with decremental changes in somatic symptoms of pain, chronic pain, and the pharmacokinetics and clinical considerations of duloxetine pharmacotherapy

Chronic pain is among the most common conditions to initiate medical care; 40% of patients victimized by chronic pain are not under the supervision of a physician, and about 70% of patients with severe pain are receiving pain medical care. About dollar 100 billion is an annual estimated cost representing loss of productivity, increased medical costs, and income loss. Major depressive disorder is not infrequently encountered in daily clinical practice often presenting with somatic complaints that include varieties of pain, and these may be so prominent as to direct the treatment to the somatic complaint evaluation to the exclusion of underlying psychopathology. Anxiety disorders and other psychiatric disorders may also present with such a somatization evaluation focus. Serotonin noradrenergic reuptake inhibitors (SNRIs), ie, venlafaxine and duloxetine, offer benefits over tricyclic antidepressants and serotonin reuptake inhibitors. Years of experience with venlafaxine representing a first-line pharmacotherapy for depression and anxiety have benefited patients presenting with somatic symptoms with a robust onset. A more rapid achievement by venlafaxine of remission and a high-quality pharmacokinetic and pharmacodynamic profile lead to patient compliance and facilitate both fewer relapses and recurrences. Duloxetine is broadly discussed, revealing pharmacokinetic, pharmacodynamic, adverse/side effects, cautions with requisite patient-specific selection, and laboratory monitoring. The management of somatic pain complaints of physical and psychiatric origin is discussed.

Comparisons of urodynamic characteristics between female patients with overactive bladder and overactive bladder plus stress urinary incontinence

OBJECTIVES

To determine and compare the urodynamic characteristics in patients with overactive bladder (OAB) and patients with OAB plus stress urinary incontinence (OAB+SUI).

METHODS

A total of 120 patients (60 each in OAB and OAB+SUI groups) who underwent urodynamic study between January and April 2003 were recruited. A detailed history, physical examination, and multichannel urodynamic data, including uroflowmetry, filling and voiding cystometry, stress urethral pressure profile, and 20-minute pad test were obtained for each patient. The urodynamic findings of each patient were analyzed and the results compared between the two groups.

RESULTS

The median age of both groups was 51 years (interquartile range 43 to 64) with a parity of 3 (interquartile range 2 to 4); 54% (n = 65) were menopausal. The urodynamic parameters of bladder storage function showed premature filling sensation with decreased bladder capacity. Additionally, 60 (50%) had genuine stress incontinence, 3 (3%) had idiopathic detrusor overactivity, 11 (9%) mixed type incontinence, and 12 (11%) had voiding dysfunction. Among the urodynamic parameters between the two groups, first desire, strong desire, urgency, functional urethral length, maximal urethral pressure, maximal urethral closure pressure, pad test, and percentage of genuine stress incontinence in the OAB+SUI group were significantly lower statistically than those in the OAB group (P <0.03); the differences in age, parity, and percentage of menopausal status were also statistically significant (P <0.03).

CONCLUSIONS

Our data showed that patients in the OAB+SUI group had more impaired urodynamic parameters than those in the OAB group. Age, parity, and menopausal status were contributory factors.