Drug treatment of urological symptoms: estimating the magnitude of unmet need in a community-based sample

Link between circadian rhythm and benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS)

BACKGROUND

Benign prostatic hyperplasia (BPH) is the most common urologic disease in aging males, affecting 50% of men over 50 and up to 80% of men over 80 years old. Its negative impact on health-related quality of life implores further investigation into its risk factors and strategies for effective management. Although the exact molecular mechanisms underlying pathophysiological onset of BPH are poorly defined, the current hypothesized contributors to BPH and lower urinary tract symptoms (LUTS) include aging, inflammation, metabolic syndrome, and hormonal changes. These processes are indirectly influenced by circadian rhythm disruption. In this article, we review the recent evidence on the potential association of light changes/circadian rhythm disruption and the onset of BPH and impact on treatment.

METHODS

A narrative literature review was conducted using PubMed and Google Scholar to identify supporting evidence. The articles referenced ranged from 1975 to 2023.

RESULTS

A clear relationship between BPH/LUTS and circadian rhythm disruption is yet to be established. However, common mediators influence both diseases, including proinflammatory states, metabolic syndrome, and hormonal regulation that can be asserted to circadian disruption. Some studies have identified a possible relationship between general LUTS and sleep disturbance, but little research has been done on the medical management of these diseases and how circadian rhythm disruption further affects treatment outcomes.

CONCLUSIONS

There is evidence to implicate a relationship between BPH/LUTS and circadian rhythm disruptions. However, there is scarce literature on potential specific link in medical management of the disease and treatment outcomes with circadian rhythm disruption. Further study is warranted to provide BPH patients with insights into circadian rhythm directed appropriate interventions.

Pelvic Floor Disorders in Black Women: Prevalence, Clinical Care, and a Strategic Agenda to Prioritize Care

Pelvic floor disorders are a group of common conditions affecting women of all racial and ethnic groups. These disorders are undertreated in all women, but this is especially magnified in Black people who have been historically marginalized in the United States. This article seeks to highlight the prevalence of pelvic floor disorders in Black women, evaluate the clinical care they receive, examine barriers they face to equitable care, and present a strategic agenda to prioritize the care of Black women with pelvic floor disorders.

Sleep Disturbance Among Adults With Overactive Bladder: A Cross-sectional Survey

OBJECTIVE

To examine differences in sleep disturbance, nocturia, and depression among adults with overactive bladder (OAB) by treatment type.

METHODS

A cross-sectional survey of adults with OAB assessed sleep disturbance, nocturia, and depression using patient-reported outcome measures, including the Patient Reported Outcomes Measurement Information System (PROMIS)-29 Profile v2.1 (Sleep Disturbance and Depression domains), Lower Urinary Tract Dysfunction Research Network Symptom Index-10, and PROMIS Sleep Disturbance Short Form 8B. Treatment groups included antimuscarinics, β-3 adrenergic agonists, and no treatment. Analysis of covariance (ANCOVA) was used to test for differences in study endpoints; Bonferroni-adjusted pairwise tests (P < .05/3) were performed to compare differences in least squares means between groups.

RESULTS

One hundred participants were included per treatment group. The overall mean (standard deviation) age across all groups was 47.8 (11.8) years. Symptom scores across all PROMIS domains in all three treatment groups were higher than the US general population. There were no statistically significant differences in outcomes across treatment groups.

CONCLUSION

Adults with OAB reported being affected by sleep disturbance and depression, regardless of treatment. The mirabegron group trended toward the lowest symptom impact across all outcomes, however, comparisons were not significant. Future research should examine temporal associations between OAB treatment, sleep disturbance, and outcomes.

Racial Disparities in Diagnosis and Management of Benign Prostatic Hyperplasia: A Review

PURPOSE OF REVIEW

We sought to perform a contemporary literature review highlighting the racial disparities which exists in the evaluation and management of benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Current literature suggests that racial disparities exist in the diagnosis of BPH and treatment lower urinary tract symptoms (LUTS). This is seen in the presentation and diagnosis of the disease as well as a difference in preventative care with discordant incidences of medical and surgical management among racial groups. The racial disparities that exist in the diagnosis and management of BPH and LUTS require further investigation to better identify the underlying causes. This will ultimately allow for continued improvement in care delivery and a more personalized approach in patient management.

A Systematic Review of Racial/Ethnic Disparities in Female Pelvic Floor Disorders

Numerous studies have investigated the influence of health disparities among women with pelvic floor disorders with varied results. Racial/ethnic disparities, in particular, inconsistently indicate differences in prevalence of disease, disease severity, and treatment outcomes. We aim to review the body of literature examining racial/ethnic disparities in pelvic floor disorders, including overactive bladder, stress urinary incontinence, pelvic organ prolapse, and interstitial cystitis. A better understanding of these disparities may help guide clinicians, researchers, and advocates in providing improved education, outreach opportunities, and access to care in minority women with pelvic floor disorders.

Axonics® system for treatment of overactive bladder syndrome and urinary urgency incontinence

Introduction: Overactive bladder and urge urinary incontinence affect millions of women and men and results in billions of dollars in health-care expenses. First- and second-line therapy includes behavioral modifications and/or pharmacotherapies however, many patients' symptoms remain or progress on these treatments. There has been concern regarding the detrimental side effects of the most widely prescribed medications for these bladder symptom management.Areas covered: As a result, there has been increased interest in continuous sacral neuromodulation, an FDA approved therapy for refractory urinary urgency and urge urinary incontinence. In this article, we specifically review current research on the efficacy and patient/provider satisfaction and safety profile of the Axonics® System. In addition, we address the current state of sacral neuromodulation and potential future direction and applicability.Expert opinion: The Axonics® system is a safe effective device for the treatment of overactive bladder and urinary urge incontinence. Additionally, it affords patient's the convenience of a rechargeable, compact, MRI safe system. It should be noted that the rechargeable system, while allowing for approximately 15 years of battery and lead life, may have its challenges in terms of charge burden. Furthermore, this system is easily adapted for experienced implanters of sacral neuromodulating devices.

Tamsulosin dispensation patterns in the United States: a real-world, longitudinal, population claims database analysis

Background

Tamsulosin remains the single most popular uroselective alpha adrenoceptor antagonist approved for the treatment of lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH). Over the last 3 decades, the utilization of tamsulosin has extended to conditions beyond its original indication. To identify potential changes to prescribing patterns and the extent of tamsulosin use for conditions beyond its original indication, we evaluated tamsulosin dispensing patterns in the United States using a large, multi-payer claims database.

Methods

We conducted a retrospective analysis using IMS PharMetrics Plus™. Patients with a tamsulosin dispensation/BPH diagnosis code (index dates), identified during a 12-month selection period (October 2012-September 2013), were included if continuously enrolled in a health plan during the 18-month analysis period (12 months pre-index-6 months post-index). Patient and provider characteristics were evaluated using descriptive statistics and were contrasted with previously reported data from the literature.

Results

Of 133,977 patients dispensed tamsulosin during the analysis period, 72,583 (54.2%) were new users [59,197 (81.6%) men; 13,386 (18.4%) women]. Tamsulosin was newly initiated in men and women mostly by primary care physicians (PCPs; 31.6%) and emergency medicine physicians (21.6%). During the analysis period, 35,071 (59.2%) male new tamsulosin users did not receive a BPH diagnosis code during the analysis period. Of 199,468 men with a BPH diagnosis code, 143,444 (71.9%) were newly diagnosed, mostly [70,412 (49.1%)] by urologists. Few men received hypotension diagnosis: 252 (0.4%) new tamsulosin users within 1 month of starting tamsulosin and 640 (0.4%) within 1 month of a new BPH diagnosis.

Conclusions

Tamsulosin was prescribed in patients without a recorded diagnosis of BPH and in women. Physicians were comfortable prescribing tamsulosin in the presence of comorbidity and polypharmacy, and PCPs and emergency medicine physicians were the primary prescribers. These results have important implications for future retrospective research for tamsulosin.

Management of Male Lower Urinary Tract Symptoms in a Simulated, Over-the-Counter Setting: An Exploratory Study of Tamsulosin

BACKGROUND

Lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH) are common in men, considerably affecting quality of life.

AIMS

The self-directed use of over-the-counter (OTC) tamsulosin (0.4 mg) and potential safety risks were evaluated in an open-label, uncontrolled, exploratory, 8-week OTC-simulated study.

METHODS

Men (≥ 18 years) were recruited via mass advertising about bothersome LUTS. In a working retail environment, respondents reviewed the product and decided whether it was appropriate for them to use (self-selection phase). After purchasing the product, participants' ability to use it as directed by the proposed drug facts label (DFL) was assessed (home-use phase).

RESULTS

Of 1446 eligible men, 679 completed the self-selection phase, and 73.9% (502/679) self-selected to use tamsulosin correctly according to the DFL. Of 369 participants who purchased tamsulosin and entered the home-use phase, 321 took one or more doses of tamsulosin and participated in at least one telephone interview. In total, 85.4% (274/321) of participants adhered to the 'Stop Use' and 'Directions' instructions in the DFL. Overall, 139 (39.6%) participants experienced one or more adverse events (AEs); 65 (18.5%) were deemed drug-related, including dizziness (11 [3.1%]), ejaculation disorder (6 [1.7%]), and semen volume decrease (6 [1.7%]). No unexpected AEs were reported.

CONCLUSIONS

Of the men interested in self-managing their LUTS, a majority had moderate-to-severe LUTS of long duration. Most men were able to appropriately self-select and use tamsulosin in concordance with DFL instructions and directions. No unexpected AEs were reported during self-directed use. With further label refinement, an over-the-counter tamsulosin option might be feasible.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01726270.

Is there a relationship between phosphodiesterase type 5 inhibitors and biochemical recurrence after radical prostatectomy: a systematic review and meta-analysis

PURPOSE

Conduct a systematic review and meta-analysis of studies to evaluate the association between the use of PDE5I and biochemical recurrence (BCR) after radical prostatectomy (RP).

METHODS

We searched Embase (from 1996 to Feb 2018), PubMed (from 1996 to Feb 2018), and Cochrane library (from 1999 to Feb 2018), then manually searched the reference lists of key retrieved articles. Original studies that reported the risk of postoperative BCR for PDE5I users, as compared with non-PDE5I users, were included. Data including the characteristic of participants, the risk of BCR after RP and key criteria of study quality were collected. The pooled relative risks (RRs) were calculated with random-effects model.

RESULTS

A total of 5 cohort studies and 1 case-control study were conducted for data analysis (a total of 17752 participants). Only 1 cohort study reported adjusted RR greater than 1 (range for all derived RRs, 0.7-1.47). The meta-analysis revealed that the PDE5I users had no higher risk of BCR after RP (RR = 1.04, 95% confidence interval [CI], 0.79-1.36). Sensitivity analysis showed that the remaining pooled RR and 95% CI were not changed significantly by omitting each study. In addition, the 5-year BCR rate had no significant difference between PDE5I users and non-PDE5I users.

CONCLUSIONS

Our meta-analysis indicated that PDE5I treatment in men following RP did not increase the risk of BCR. The results preliminarily suggested that the use of PDE5I for erectile dysfunction after RP was oncologically safe. Nevertheless, more large sample cohort studies are needed to validate this conclusion.

Over-the-counter medication availability could augment self-management of male lower urinary tract symptoms

In this review, we focus on current trends in the management of male lower urinary tract symptoms (LUTS), defined here as LUTS, namely, storage, voiding, and post-micturition symptoms presumed secondary to benign prostatic hyperplasia (BPH), and discuss possible novel approaches toward better care. According to results of a PubMed database search covering the last 10 years and using keywords pertaining to male LUTS, this condition continues to be globally undiagnosed or diagnosed late, partly because of men's hesitation to seek help for perceived embarrassing problems or problems considered a normal part of aging. In addition, the prevalence of male LUTS is continually increasing because of a constantly aging population. Male LUTS can be bothersome and affect the quality of life (QoL) and sexual function. Additional effective alternatives for managing this condition need to be identified and incorporated into the current care model. Considering that most male LUTS such as frequency, hesitancy, urgency, and intermittency are easy to self-identify, a self-management approach toward male LUTS is proposed. Limited evidence supports the efficacy of phytotherapies and herbals as self-management options for male LUTS. However, introducing over-the-counter (OTC) medication with proven efficacy, accompanied by lifestyle and behavioral modifications, may be a promising approach that will encourage more men to treat their symptoms in a timely manner. Formal guidelines, along with appropriate education programs for patients and support from the healthcare community, will be needed to ensure that the promise of this approach is fully materialized.

A patient-reported, non-interventional, cross-sectional discrete choice experiment to determine treatment attribute preferences in treatment-naïve overactive bladder patients in the US

PURPOSE

Many pharmacotherapeutic treatment options are available for the symptoms of overactive bladder (OAB), each offering varying efficacy, safety, and tolerability profiles that must be carefully considered when selecting treatment. The objective of the present study was to characterize pharmacotherapy treatment preferences of individuals with symptoms of OAB and to examine how preferences differ by both patient characteristics and disease burden metrics.

PATIENTS AND METHODS

Patient preferences for OAB treatment attributes were examined using a discrete choice experiment (DCE). Attributes were identified through literature review, clinical relevance, and input from patients. Eligible respondents were required to be ≥18 years of age, have a self-reported physician OAB diagnosis or have self-reported symptoms of OAB, and be naïve to pharmacotherapy or invasive OAB treatments. A hierarchical Bayesian random-effects-only model was used to estimate the mean relative preference weights and mean relative importance scores of treatment attributes. Multivariable linear regression models with backward selection were used to analyze the differences in relative importance scores by demographic characteristics and disease burden-related metrics.

RESULTS

In total, 514 individuals participated in the study. Most respondents were <65 years of age (66.0%), female (68.5%), and reported moderate/severe OAB symptoms (64.2%). Overall, respondents placed the greatest importance on drug delivery method, with a preference for oral and patches over injectables, followed by efficacy defined as reduced daytime micturition and out-of-pocket cost. Multivariable linear regression analyses revealed that females were less likely to select injectables, that symptom control of incontinence was the most important to respondents who reported greater work productivity loss, and that out-of-pocket cost was the most important to respondents with moderate/severe OAB.

CONCLUSION

OAB treatment preferences vary depending on individual patient characteristics and disease severity. Overall, drug delivery method, reduced daytime micturition, and out-of-pocket costs were the most important treatment attributes among treatment-naïve individuals with symptoms of OAB. Preferences for OAB treatment were also found to vary depending on patient demographics and disease comorbidities, which has previously not been examined.

Sociodemographic patterns in pharmacy dispensing of medications for erectile dysfunction in Sweden

Purpose

The purpose of this study is to investigate the relationship between sociodemographic factors and pharmacy dispensing of medications for erectile dysfunction (ED) in the general population of middle-aged and elderly men. By considering a number of medical conditions that could promote or contraindicate use of ED medication, the analysis could help capture prescription patterns that might not be explained by medical needs.

Methods

Individual-level pharmacy dispensing data from 2006 for a population-based cohort of 216,148 men aged 45–79 years in the county Scania, Sweden, were analysed. Multiple logistic regression was applied, and area under the receiver operating characteristic curve (AUC) was calculated to quantify the discriminatory accuracy (DA) of the associations. National trends in pharmacy dispensing of ED medication between 2006 and 2016 were also analysed.

Results

Pharmacy dispensing of ED medication increased between 2006 and 2016, particularly among men aged 65–79 years (from 6.8 to 9.2%). Dispensing of ED medication was positively associated with higher socioeconomic position, and divorced and widowed men were more likely to fill a prescription with ED medication than married men. These associations remained after adjusting for medical conditions. The DA of the associations was, however, rather low (AUC = 0.69 among 45–64 year olds and AUC = 0.65 among 65–79 year olds).

Conclusions

Pharmacy dispensing of ED medication seem linked to the individuals socioeconomic position, age and marital status suggesting sociodemographic disparities in the pharmacy dispensing targeting sexual function. However, the low DA of the associations shows the limited capacity of these factors to predict ED medication use at the individual level.

Future Directions of Research and Care for Urinary Incontinence: Findings from the National Institute of Diabetes and Digestive and Kidney Diseases Summit on Urinary Incontinence Clinical Research in Women

PURPOSE

Female urinary incontinence is prevalent, costly and morbid. Participants in a NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) sponsored summit reviewed findings from NIH (National Institutes of Health) funded clinical research on urinary incontinence in women and discussed the future of urinary incontinence research.

MATERIALS AND METHODS

The NIDDK convened the Summit on Urinary Incontinence Clinical Research in Women on March 14, 2014. Participants representing a broad range of clinical expertise reviewed completed NIH sponsored urinary incontinence related studies, including results from community based epidemiological studies such as the BACH (Boston Area Community Health) Survey and from randomized clinical trials such as PRIDE (Program to Reduce Incontinence by Diet and Exercise), and studies conducted by the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network.

RESULTS

BACH Survey results improved our understanding of precursors, incidence, prevalence and natural history of urinary incontinence in a diverse group of women. The Pelvic Floor Disorders Network study found that anticholinergic medications and onabotulinumtoxinA are efficacious for treating urge urinary incontinence, and Burch colposuspension and retropubic mid urethral polypropylene slings are efficacious for decreasing stress urinary incontinence following pelvic organ prolapse surgery in women with potential stress urinary incontinence. The Urinary Incontinence Treatment Network study found that fascial slings were better than colposuspension, and that retropubic and transobturator mid urethral polypropylene slings were equivalent for stress urinary incontinence. In patients with stress urinary incontinence a preoperative urodynamic study was noninferior to basic office examinations for surgical outcome. The addition of behavioral intervention did not allow female patients to discontinue antimuscarinics for urge urinary incontinence. PRIDE showed that modest weight reductions significantly decreased urinary incontinence.

CONCLUSIONS

Strategies for future research on urinary incontinence should include a focus on early disease, risk factor identification, better phenotyping, incorporation of new technologies, patient centered research and prevention.

The Burden of Overactive Bladder on US Public Health

Overactive bladder (OAB) is a highly prevalent symptom condition that affects millions of US men and women. Not only can the symptoms of OAB be very bothersome, but OAB can have significant detrimental effects on many aspects of individuals' lives, representing a particularly impactful health burden to quality of life and productivity. Estimates of the individual and societal costs for the management of OAB continue to rise, particularly as effective treatments remain elusive. As such, OAB represents a significant public health burden to the USA.

Treatment status and progression or regression of lower urinary tract symptoms in a general adult population sample

PURPOSE

We report progression and regression of lower urinary tract symptoms in a population based cohort by race/ethnicity, gender, age and lower urinary tract symptom medication use.

MATERIALS AND METHODS

The BACH (Boston Area Community Health) Survey enrolled 5,502 participants 30 to 79 years old of black, Hispanic or white race/ethnicity. The 5-year followup interviews were completed by 1,610 men and 2,534 women for a conditional response rate of 80%. Population weighted estimates of lower urinary tract symptoms severity were assessed using the AUASI (American Urological Association symptom index) and analyzed using multivariate models.

RESULTS

Symptom progression (increase in AUASI score of 3 or more points) was reported by 21% to 33% of participants and regression (decrease 3 or greater) by 30% to 44% of participants, most commonly women and Hispanic participants. Age and higher body mass index were associated with progression (p <0.01), but not with regression. Lower urinary tract symptom medication use at baseline only was associated with improved symptoms scores 5 years later (multivariate adjusted OR 3.10, 95% CI 1.28-7.51, compared to nonusers), whereas using medication at baseline and followup was associated with similar rates of progression and regression as observed among participants not using lower urinary tract symptom medication at either point.

CONCLUSIONS

Lower urinary tract symptoms persisted at followup for approximately half of the population experiencing symptoms at baseline, including many men and women using lower urinary tract symptom medications. However, overall lower urinary tract symptom medication use and surgical treatment appeared beneficial for symptom control at 5-year followup. Age and body mass index were associated with symptom worsening, and Hispanic ethnicity was associated with greater symptom fluctuation. Clinicians should consider the higher likelihood of lower urinary tract symptom progression for older or heavier patients, and monitor responsiveness to lower urinary tract symptom medication.

Coexisting lower urinary tract symptoms and erectile dysfunction: a systematic review of epidemiological data

OBJECTIVE

Assess and categorise the available prevalence data on coexistent LUTS and ED in the general population and among individuals consulting a healthcare provider for any reason or when seeking treatment for LUTS and/or ED.

METHODS

Literature search of English-language articles published during the last 15 years.

RESULTS

Of 23 relevant studies identified, 12 used both the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) as assessment tools and 11 used alternative approaches. In studies using both IPSS and IIEF, overall prevalence of coexistent LUTS/ED of any severity was not assessable for men in the general population, but rates ranged from 14-37% based on alternative assessments. In the general male population, 13-29% had moderate to severe LUTS and 8-35% had moderate to severe ED. In studies using both IPSS and IIEF, overall prevalence of coexistent LUTS and ED of any severity was 71-80% among men seeking treatment for LUTS, and 74% based on alternative assessments. Among men who sought treatment for either condition, 67-100% had moderate to severe LUTS and 43-59% had moderate to severe ED. Coexistence of LUTS and ED increased with age, ranging from 59-86% among men aged 40s to 60s in primary care to 79-100% in treatment-seeking men with LUTS aged 50s to 70s. Impact on QoL varied, but health-related QoL was generally worse in treatment-seeking men compared with men in the general population.

CONCLUSIONS

Although less than one-third of middle-aged and older men in the general population have coexisting LUTS and ED, most men seeking treatment for either LUTS or ED have both conditions. Symptom severity and impact on QoL in each condition increase when LUTS and ED coexist.

Cohort profile: the Boston Area Community Health (BACH) survey

The Boston Area Community Health (BACH) Survey is a community-based, random sample, epidemiologic cohort of n = 5502 Boston (MA) residents. The baseline BACH Survey (2002-05) was designed to explore the mechanisms conferring increased health risks on minority populations with a particular focus on urologic signs/symptoms and type 2 diabetes. To this end, the cohort was designed to include adequate numbers of US racial/ethnic minorities (Black, Hispanic, White), both men and women, across a broad age of distribution. Follow-up surveys were conducted ∼5 (BACH II, 2008) and 7 (BACH III, 2010) years later, which allows for both within- and between-person comparisons over time. The BACH Survey's measures were designed to cover the following seven broad categories: socio-demographics, health care access/utilization, lifestyles, psychosocial factors, health status, physical measures and biochemical parameters. The breadth of measures has allowed BACH researchers to identify disparities and quantify contributions to social disparities in a number of health conditions including urologic conditions (e.g. nocturia, lower urinary tract symptoms, prostatitis), type 2 diabetes, obesity, bone mineral content and density, and physical function. BACH I data are available through the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Central Repositories (www.niddkrepository.org). Further inquiries can be made through the New England Research Institutes Inc. website (www.neriscience.com/epidemiology).

Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) survey

AIMS

To compare the descriptive epidemiology of overactive bladder (OAB) of presumed neurologic origin (NOAB) to OAB of non-neurologic origin (N-NOAB).

METHODS

Five thousand five hundred three community-dwelling persons aged 30-79 were interviewed regarding urologic symptoms (2002-2005). NOAB was defined as symptoms of urgency and/or urgency incontinence among those with a self-reported history of healthcare provider diagnosed stroke (N = 98), multiple sclerosis (N = 21), or Parkinson's disease (N = 7). N-NOAB was defined identically but occurring among those not reporting neurologic disease (ND). Prevalence estimates were weighted to reflect sampling design; chi-square, Fisher's exact, or t-tests were used to test differences. Urologic symptom interference was assessed using the Epstein scale, while the impact of urinary incontinence (UI) on health-related quality-of-life (HRQOL) was measured using a modification of the Incontinence Impact Questionnaire-7.

RESULTS

Forty-five (31.0%) of 125 persons with ND and 994 (16.7%) of 5378 persons without ND reported OAB symptoms. The overall prevalence of NOAB and N-NOAB was 0.6% and 16.4%, respectively. Persons with NOAB had higher (worse) mean American Urologic Association Symptom Index scores (13.0 vs. 10.0, P = 0.09) compared to those with N-NOAB, and were significantly more likely to have diabetes, high blood pressure, cardiac disease, and fair/poor self-reported health (all P < 0.05). Mean symptom interference and UI HRQOL scores were significantly higher (worse) in the NOAB group compared to persons with N-NOAB (all P < 0.05).

CONCLUSIONS

Persons with NOAB appeared to have a greater burden of urologic illness with respect to symptom interference and HRQOL compared to persons with N-NOAB.

Patient-reported Goal and Goal Achievement: The Most Individualized Method of Outcome Assessment in Patients with Lower Urinary Tract Symptoms

Patients with lower urinary tract diseases often have a constellation of symptoms, and the degree of distress due to individual symptoms varies. In particular, some symptoms are more bothersome to patients and lead to treatment. However, traditional outcomes, such as urodynamic data, voiding diaries, and standardized patient-reported outcomes, may fail to address the individual factors. In contrast, patient-centered outcomes rely on patients to assess treatment outcomes in terms of their concerns or goals. Goal achievement is a patient-centered outcome that was pioneered in prolapse surgery. Recently, this most individualized outcome measure has been evaluated in the context of lower urinary tract symptoms (LUTS). According to the studies, most patients with LUTS have symptom-related goals. After treatment, goal achievement in patients with overactive bladder or benign prostatic obstruction was low even when there were significant improvements in symptom severity in terms of traditional outcome measures. On the other hand, most women with stress incontinence achieved their treatment goals after midurethral sling surgeries. There are ongoing efforts to develop valid and reliable methods for assessing goal achievement that can facilitate the complex rating process and have responsiveness. Goal achievement shows a limited correlation with standardized patient-reported outcomes and no significant correlation with objective outcomes. Thus, at the moment, it can be used as a complimentary outcome measure along with other traditional methods. Further research is needed to reveal the correlation between goal achievement and overall patient satisfaction and, ultimately, to determine if assessing goal achievement can enhance patient satisfaction.

Novel biomarkers for overactive bladder

Biomarkers constitute any objectively measurable indicator of a biological process. The classic biomarker used in the diagnosis of overactive bladder (OAB) has been detrusor overactivity, which is assessed urodynamically. In the search for a reliable, noninvasive alternative to urodynamics, interest has focused on genetic, imaging, and urinary factors. Along with other cytokines detectable in urine, prostaglandin E2 and nerve growth factor are indicators of low-grade inflammation. Although they correlate with OAB symptom severity, they have not been shown to have independent prognostic benefit. Imaging biomarkers have been investigated since the earliest days of video urodynamics. Despite extensive research on the ultrasonographic estimation of bladder wall thickness, further standardization of the technique is required before conclusions can be reached regarding diagnostic accuracy. Genetic factors contribute approximately half of the total risk for urgency incontinence. Functional polymorphisms of the cytochrome P450 IID6 gene significantly alter the metabolism of some commonly used anticholinergic drugs, but no genetic loci that influence risk of OAB have been definitively identified. The first genome-wide association studies for OAB are in progress, and should identify new susceptibility genes. Although current putative biomarkers correlate with OAB severity, much future work is required to assess their prognostic value, and establish their role in clinical practice.

Patient-selected goals in overactive bladder: a placebo controlled randomized double-blind trial of transdermal oxybutynin for the treatment of urgency and urge incontinence

OBJECTIVE

To assess patient selected goal improvement with transdermal oxybutynin, in a representative population of adult women with overactive bladder (OAB).

SUBJECTS AND METHODS

Adult women with ≥ 3 month history of OAB symptoms, with or without urgency urinary incontinence, were recruited from a tertiary referral urogynaecology unit. Participants were allocated to either transdermal oxybutynin 3.9 mg/day or matching placebo patches in a double-blind, randomized parallel group design, over 4 weeks. Patient-selected goal achievement was defined as the primary outcome measure. Participants selected their own goals for treatment at baseline, and subsequently scored achievement of these goals on a visual analogue scale. They completed 3-day bladder diaries incorporating the Patients Perception of Intensity of Urgency Scale (PPIUS) to assess urgency and urgency incontinence episodes. Quality of life was assessed using the King's Health Questionnaire (KHQ).

RESULTS

A total of 96 women were randomized; 78 (81.3%) participants completed 4 weeks double-blind treatment. There was no significant difference between mean goal achievement in the transdermal oxybutynin and placebo groups (41.9% (SD 31.3) vs 32.2% (SD 27.3), P= 0.203). Transdermal oxybutynin was associated with significant improvements in urgency episodes (-1.23 episodes/day (SD1.40) vs -0.21 episodes/day (SD 1.58), P= 0.01). Both groups made non-significantly different improvements in KHQ scores; 18 (38.2%) patients in the transdermal oxybutynin group experienced either erythema or pruritus, with 7 (14.9%) experiencing at least one systemic adverse event.

CONCLUSIONS

In women with OAB, in comparison with placebo, transdermal oxybutynin 3.9 mg/day leads to significant objective improvements in urinary urgency, but with no significant difference observed in achievement of patients' own goals for therapy, or improvement in disease specific quality of life.