Emepronium bromide and flavoxate hydrochloride in the treatment of urinary incontinence associated with detrusor instability in elderly women

Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006.

OBJECTIVES

To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.

Flavoxate in urogynecology: an old drug revisited

INTRODUCTION AND HYPOTHESIS

Since its emergence in 1967, flavoxate has been used to treat several urogenital tract disorders irrespective of the etiology of the underlying disease, but the main indications have been overactive bladder and urge symptomatology. With the advances in anticholinergic drugs, its popularity has decreased in recent decades.

METHODS

In this review we summarize the current status of flavoxate in urogynecological practice focusing on its historical background, mechanism of action, efficacy, clinical experiences, outcomes, side effects and tolerability. We reviewed and analyze all the data and draw the major conclusions. We searched MEDLINE and the Cochrane Library using the keyword "flavoxate", and summarized review articles, original studies and case reports published from 1970 to 2013.

RESULTS AND CONCLUSION

We conclude that the minimal side effects and high tolerability of flavoxate make it worthy of consideration for the treatment of several clinical urogynecological conditions. It deserves more clinical studies to assess its efficacy as no randomized controlled trials have been performed with flavoxate during the last decade. More studies and novel drug formulations may reveal or improve its efficacy in daily practice.

Anticholinergic drugs versus other medications for overactive bladder syndrome in adults

BACKGROUND

Overactive bladder syndrome is defined as "urgency with or without urge incontinence, usually with frequency and nocturia". It is a common condition with significant economic and quality of life implications. While the condition's pathophysiology remains to be fully elucidated, pharmacotherapy is the main treatment option. Despite uncertainty as to drug treatment of choice, anticholinergics are increasingly being used in primary and secondary care settings. This review compares anticholinergic drugs with other types or classes of drugs for treating overactive bladder syndromes.

OBJECTIVES

To compare anticholinergic drugs with other types or classes of drugs for treating overactive bladder symptoms.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 20 December 2006) and the reference lists of relevant articles. No language or other limits were imposed.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing anticholinergic drugs with other drugs for the treatment of overactive bladder symptoms. At least one arm of the study used an anticholinergic drug and at least one other arm used a non-anticholinergic drug.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the identified studies for eligibility and methodological quality and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 4.2.8).

MAIN RESULTS

Twelve trials were included in the review. There were seven crossover trials and five parallel group studies. For the comparisons between anticholinergic drugs with tricyclic antidepressants, alpha adrenergic agonists, afferent nerve inhibitors, and calcium channel blocker a single trial was identified for each. Nine trials compared flavoxate with anticholinergics. There was no evidence of a difference in cure rates between anticholinergics and flavoxate. Adverse effects were more frequent in anticholinergic groups versus flavoxate groups (RR 2.28 95% CI 1.45 to 3.56). There was no strong evidence to favour either anticholinergic drugs or the comparators.

AUTHORS' CONCLUSIONS

Many of the drugs considered in trials in this review are no longer used in clinical practice (and this includes the most commonly tested - flavoxate). There is inadequate evidence as to determine whether any of the available drugs are better or worse than anticholinergic medications. Larger randomised controlled trials in clinical settings are required to further establish the role of these medications in the management of overactive bladder syndrome.

Anticholinergic drugs versus other medications for overactive bladder syndrome in adults

BACKGROUND

Overactive bladder syndrome is defined as "urgency with or without urge incontinence, usually with frequency and nocturia". It is a common condition with significant economic and quality of life implications. While the condition's pathophysiology remains to be fully elucidated, pharmacotherapy is the main treatment option. Despite uncertainty as to drug treatment of choice, anticholinergics are increasingly being used in primary and secondary care settings. This review compares anticholinergic drugs with other types or classes of drugs for treating overactive bladder syndromes.

OBJECTIVES

To compare anticholinergic drugs with other types or classes of drugs for treating overactive bladder symptoms.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 20 December 2006) and the reference lists of relevant articles. No language or other limits were imposed.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing anticholinergic drugs with other drugs for the treatment of overactive bladder symptoms. At least one arm of the study used an anticholinergic drug and at least one other arm used a non-anticholinergic drug.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the identified studies for eligibility and methodological quality and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 4.2.8).

MAIN RESULTS

Thirteen trials were included in the review. There were eight crossover trials and five parallel group studies. For the comparisons between anticholinergic drugs with tricyclic antidepressants, alpha adrenergic agonists, afferent nerve inhibitors, and calcium channel blocker a single trial was identified for each. Ten trials compared flavoxate with anticholinergics. There was no evidence of a difference in cure rates between anticholinergics and flavoxate. Adverse effects were more frequent in anticholinergic groups versus flavoxate groups (RR 2.28 95% CI 1.45 to 3.56). There was no strong evidence to favour either anticholinergic drugs or the comparators.

AUTHORS' CONCLUSIONS

Many of the drugs considered in trials in this review are no longer used in clinical practice (and this includes the most commonly tested - flavoxate). There is inadequate no evidence as to whether any of the available is better or worse than anticholinergic medications. Larger randomised controlled trials in clinical settings are required to further establish the role of these other medications in the management of overactive bladder syndrome.

Anticholinergic drugs versus placebo for overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (urgency with frequency and/or urge incontinence). The prevalence increases with age. Anticholinergic drugs are commonly used to treat this condition.

OBJECTIVES

To determine the effects of anticholinergic drugs for the treatment of overactive bladder syndrome.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 14 June 2005) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug with placebo treatment or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewer authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005).

MAIN RESULTS

Sixty -one trials, 42 with parallel-group designs and 19 crossover trials were included (11,956 adults). Most trials were described as double-blind but were variable in other aspects of quality. The crossover trials did not present data in a way that allowed inclusion in the meta-analysis. Nine medications were tested: darifenacin; emepronium bromide or carrageenate; oxybutynin; propiverine; propantheline; tolterodine; trospium chloride; and solifenacin. One trial included the newer, slow release formulation of tolterodine. At the end of the treatment period, cure or improvement (relative risk (RR) 1.39, 95% CI 1.28 to 1.51), difference in leakage episodes in 24 hours (weighted mean difference (WMD) -0.54; 95% CI -0.67 to -0.41) and difference in number of voids in 24 hours (WMD -0.69; 95% CI -0.84 to -0.54) were statistically significant favouring medication. Statistically significant but modest sized improvements in quality of life scores were reported in recently completed trials. There was three times the rate of dry mouth in the medication group (RR 3.00 95% CI 2.70 to 3.34) but no statistically significant difference in withdrawal (RR 1.11, 95% CI 0.91 to 1.36). Sensitivity analysis, while limited by small numbers of trials, showed little likelihood that the effects were modified by age, sex, diagnosis, or choice of drug.

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in statistically significant improvements in symptoms. Recent trials suggest that this is associated with modest improvement in quality of life. Dry mouth is a common side effect of therapy but did not seem to have an effect on the numbers of withdrawals. It is not clear whether any benefits are sustained during long-term treatment or after treatment stops.

Current and future pharmacological treatment for overactive bladder

PURPOSE

Urinary incontinence and overactive bladder are important and common conditions that have received little general medical attention. We reviewed the magnitude and impact of these conditions, and discuss pharmacotherapy as well as new drugs under investigation.

MATERIALS AND METHODS

The main emphasis of this review is pharmacological therapy for the bladder. We discuss currently available agents, drugs under development and pharmacological targets that would be suitable targets for treating overactive bladder. Drugs such as duloxetine that target not bladder smooth muscle, but rather central nervous system control of the micturition reflex are undergoing clinical trials. We also discuss intravesical therapy and alternative drug delivery methods, such as intravesical capsaicin and botulinum toxin, with special emphasis on approaches to modulate bladder afferent nerve function for preventing overactive bladder.

RESULTS

There are many advantages to advanced drug delivery systems, including long-term therapeutic efficacy, decreased side effects and improved patient compliance. Future speculation such as gene therapy holds great promise for overactive bladder because it is possible to access all genitourinary organs via endoscopy and other minimally invasive techniques that are ideally suited for gene therapy.

CONCLUSIONS

Traditional anticholinergic therapies are limited in their effectiveness. There is great hope for future research regarding voiding dysfunction and urinary incontinence through a focus on afferent nerve intervention for preventing overactive bladder.

Anticholinergic drugs versus placebo for overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (urgency with frequency and/or urge incontinence). The prevalence increases with age. Anticholinergic drugs are commonly used to treat this condition.

OBJECTIVES

To determine the effects of anticholinergic drugs for the treatment of overactive bladder syndrome.

SEARCH STRATEGY

The Cochrane Incontinence Group trials register was searched to January 2002.

SELECTION CRITERIA

Randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug with placebo treatment or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook.

MAIN RESULTS

Fifty one trials, 32 parallel designs and 19 crossover designs were included (6713 adults). Most trials were described as double-blind, but were variable in other aspects of quality. The crossover trials did not present data in a way that allowed inclusion in the meta-analysis. Seven medications were tested: darifenacin; emepronium bromide or carrageenate; oxybutynin chloride; propiverine; propantheline; tolterodine; and trospium chloride. One trial included the newer, slow release, formulation of tolterodine. After treatment, cure/improvement (RR 1.41, 95%CI 1.29 to 1.54), changes in leakage episodes in 24 hours (WMD -0.56, 95%CI -0.73 to -0.39), number of voids in 24 hours (WMD -0.59, 95%CI -0.83 to -0.36), maximum cystometric volume (WMD 53.85 ml, 95%CI 42.28 to 65.41), and volume at first contraction (WMD 52.25 ml, 95%CI 37.45 to 67.06), were significantly in favour of medication. Medication was associated with significantly higher residual volumes (WMD 4.06 ml, 95%CI 0.73 to 7.39) and more than two and a half times the rate of dry mouth (RR 2.61, 95% CI 2.27 to 3.00). Sensitivity analysis, while limited by small numbers of trials, showed little likelihood that these effects were modified by age, sex, diagnosis, or choice of drug.

REVIEWER'S CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in statistically significant improvement in symptoms. However, the clinical significance of these differences is uncertain, and the longer-term effects are not known. Dry mouth is a common side effect of therapy.

Pharmacologic management of pelvic floor dysfunction

Pharmacologic therapy is an important part of the treatment armamentarium for urogynecologic disorders. Current and future research will determine the utility of such therapy as medications with fewer side effects and more targeted efficacy are developed.

Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients

Medications to treat lower urinary tract dysfunction in older adults are selected to alter specific physiologic parameters. Pharmacotherapy alone results in modest clinical improvement. Because of the high prevalence of adverse drug reactions and polypharmacy in the geriatric population, medication should be used for those conditions that do not respond sufficiently to behavioral therapy. For stress incontinence, medications with alpha-adrenergic agonist properties are the mainstay of pharmacotherapy because they increase outlet resistance. Pharmacotherapy of urinary frequency and urge incontinence aims to decrease detrusor irritability and increase bladder capacity by inhibiting cholinergic stimulation of the bladder. In addition to these medications, in postmenopausal women, estrogen seems to have an additive effect for both urge and stress incontinence. More randomized, placebo-controlled, double-blinded clinical trials are needed that compare various pharmacologic agents and combinations, as well as pharmacotherapy with other forms of treatment for lower urinary tract dysfunction.

Urinary incontinence in the elderly

Urinary incontinence is a prevalent problem among the elderly and has a significant clinical, social, psychological, and economical impact. In spite of these consequences, often very little is done to evaluate the problem. Furthermore, patients may be reluctant to bring their complaint to the attention of their health care provider. This broad review will discuss the anatomy, physiology, and pathophysiology of urinary incontinence. The initial evaluation and treatment options will also be outlined. As the aged population continues to grow, physicians can expect to see this problem with greater frequency. It is hoped that this discussion will facilitate the evaluation and management of this common but frequently neglected problem.

A review of flavoxate hydrochloride in the treatment of urge incontinence

This article provides a review of the use of flavoxate hydrochloride in the treatment of urge incontinence. It outlines the pharmacology, mode of action, toxicology and pharmacokinetic studies which have been carried out, and then reviews the clinical studies, including those involving patients with benign prostatic hypertrophy. The effects of dosages of 600-1200 mg/day are compared, particularly regarding safety and tolerability factors. Finally, alternative therapies to flavoxate hydrochloride (alpha-adrenergic receptor blockers, oxybutinin chloride, terodiline hydrochloride, emepronium bromide and imipramine) are summarized. The article is written in the knowledge of recent evidence which indicates that flavoxate hydrochloride exhibits only weak anticholinergic activity on receptors involved in the control of the lower urinary tract.

Urinary incontinence in the elderly: etiology and treatment

Urinary incontinence is a common, though often hidden, medical problem among the elderly. Urinary continence requires integrity of the neural, muscular, and hormonal systems. Five distinct types of urinary incontinence can be distinguished based on patient symptoms. A variety of factors can impair continence, including aging, environmental barriers, and medications. Both pharmacological and nonpharmacological measures are useful in the treatment of incontinence.