Update on the management of overactive bladder

Short-term effect of mirabegron on female sexual function in women with overactive bladder

BACKGROUND

Overactive bladder (OAB) is a common syndrome that can negatively affect patients' daily activities, sleep patterns, mental health, sexual function, and general health. In addition to reducing the frequency of attacks, treatment of OAB can be expected to improve the psychological and sexual health of patients.

AIMS

To evaluate the effects of mirabegron used in the treatment of overactive bladder (OAB) on female sexual function (FSF).

METHODS

This retrospective study includes 48 sexually active women who were diagnosed with overactive bladder and treated with a daily oral dose of 50 mg mirabegron between November 2021 and March 2022. The evaluation of FSF was conducted using female sexual function index (FSFI) along with urinary parameters before the start of the treatment and at the 6th week of the treatment.

RESULTS

In the study, out of 48 participants, 40 (83.3%) were identified with the dry type and 8 (16.7%) with the wet type OAB. The median age when diagnosed was 43.5 years. Although the decrease in the Overactive Bladder Questionnaire (OAB-V8) score did not reach statistical significance in the entire patient group after treatment (p = 0.058), a statistically significant decrease in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score was detected in the wet type OAB group (p < 0.001). During the assessment of sexual function, there was a statistically significant increase in the FSFI score, from 21.4 to 23.05, by the 6th week of treatment (p = 0.017). Specifically, the scores for desire, lubrication, and satisfaction showed a statistically significant post-treatment improvement (p < 0.001, p = 0.049, and p = 0.035, respectively).

CONCLUSION

The study indicates that a 6-week regimen of a daily 50 mg mirabegron dose enhanced sexual function in women. This beneficial impact of mirabegron on sexual health should be taken into account when selecting a treatment for OAB.

Is Cystoscopic Intravesical Injection of OnabotulinumtoxinA Acceptable in an Outpatient Clinic?

PURPOSE

Cystoscopic intravesical onabotulinumtoxinA injection is a safe and effective minimally invasive treatment for refractory overactive bladder. While the procedure can be performed in outpatient clinics under local anesthetic, some clinicians still use sedation or general anesthesia in an operating theatre. Our study aimed to assess acceptability of intravesical onabotulinumtoxinA injection versus widely accepted diagnostic cystoscopy in the outpatient setting via the medium of patient experience.

METHODS

A 16-item patient experience survey was administered following diagnostic cystoscopy or intravesical onabotulinumtoxinA injection in an outpatient clinic. Both procedures were performed using a flexible cystoscope with local anesthetic gel. A visual analogue scale (VAS) assessed intraprocedure pain. Dichotomous questions assessed whether significant pain or postprocedure symptoms were experienced and if these required medical attention. A free-text question assessed which symptoms had occurred.

RESULTS

One hundred responses from 188 patients were received (53.2% response rate). Sixty-eight patients underwent cystoscopic intravesical onabotulinumtoxinA injection and 32 diagnostic cystoscopy. Mean VAS scores were higher for onabotulinumtoxinA injection (24 of 100) than diagnostic cystoscopy (11 of 100) (P=0.002). VAS scores were higher among patients reporting preprocedure anxiety (31 of 100 vs. 14 of 100, P=0.0013). Twenty-four percent of onabotulinumtoxinA injection patients experienced symptoms postprocedure versus 41% for cystoscopy. Medical attention was sought more frequently in the diagnostic cystoscopy group (9.4% vs. 1.5%). Common symptoms following both procedures were dysuria, urinary frequency, urgency, abdominal pain and urine discoloration.

CONCLUSION

Cystoscopic intravesical injection of onabotulinumtoxinA appears more painful than diagnostic cystoscopy. However, as VAS scores were relatively low, this is unlikely to represent clinically significant discomfort burdensome to the patient. There were no significant complications postprocedure. Cystoscopic intravesical onabotulinumtoxinA injection is acceptable in an outpatient setting.

A Prospective Study on the Effectiveness of Sensory and Sub-sensory Stimulation Amplitudes Using eCoin® Implantable Tibial Nerve Stimulation in Reducing Urgency Urinary Incontinence Episodes and Enhancing Quality of Life

Introduction Urgency urinary incontinence (UUI), an important subset of overactive bladder (OAB), manifests with symptoms such as urgency, frequency, and incontinence, severely impacting quality of life. Neuromodulation therapies, including sacral nerve stimulation (SNM), percutaneous tibial nerve stimulation (PTNS), and implanted tibial nerve stimulation (ITNS), are FDA-approved for treating UUI. Traditional neuromodulation involves sensory and motor response evoking amplitudes, but emerging evidence suggests that sensory and sub-sensory settings might enhance treatment outcomes by influencing brain activation. Aim This study investigates the efficacy of sensory and sub-sensory programming of the eCoin® ITNS (Valencia Technologies Corporation, Valencia, California, USA) in reducing UUI episodes. The eCoin ITNS is a fully implantable device providing low-duty cycle tibial nerve stimulation. Methods The ESSENCE (Effectiveness of Sensory and Sub-sensory Stimulation Amplitudes Using eCoin Implantable Tibial Nerve Stimulation in Reducing Urgency Urinary Incontinence Episodes) study was conducted as a double-blind, randomized, controlled trial, and 36 subjects with UUI across five U.S. centers were enrolled, aiming to evaluate changes in UUI episodes and quality of life over three months. Participants were randomized to sensory or sub-sensory stimulation groups, with the sensory group activated to the amplitude at which stimulation was first felt and the sub-sensory group set 25% below this threshold. UUI episodes were recorded using three-day voiding diaries, and quality of life was assessed via the Overactive Bladder Symptom Quality of Life Questionnaire (OABq) to assess the primary endpoint of reduction from baseline in the number of UUI episodes per day on the three-day voiding diary. Results Results demonstrated a mean reduction in UUI episodes of 2.1 per day for the sensory group and 2.73 per day for the sub-sensory group from a pooled baseline of 5.53. Both groups reported improvements in health-related quality of life (HRQL) and patient satisfaction. These findings align with previous studies on SNM, demonstrating both sub-sensory and sensory settings are effective, potentially enhancing patient comfort and device longevity. Conclusion The ESSENCE study indicates that both sensory and sub-sensory amplitude settings of eCoin ITNS show a reduction in UUI episodes, improve quality of life, and increase patient satisfaction, offering the potential for optimizing neuromodulation therapies.

Up-and-coming pharmacotherapeutic options for treating patients with refractory overactive bladder

INTRODUCTION

Overactive bladder (OAB) is a prevalent disorder with a significant impact on quality of life. The pathophysiology of OAB is multifactorial and the majority of patients will require treatment with multiple therapies across the course of their disease. First-line treatments include bladder retraining, fluid advice and pelvic floor muscle training. Following this, patients may be offered treatment with anticholinergic and β3 agonist medications. Anticholinergics are known to have high rates of discontinuation due to side effects and there are concerns regarding anticholinergic load and its impact on cognitive function in older adults.

AREAS COVERED

This paper aims to discuss the current and emerging treatment options available for patients who suffer from OAB.

EXPERT OPINION

The management of OAB in the clinical setting remains challenging. The goal of newer pharmacotherapies in OAB would be treatment that provides long-term symptomatic relief with minimal side effects and an improved quality of life. The future of OAB research is promising and should consider the implications of the gut-bladder axis, regenerative medicine, biomarkers and the role of digital health.

Clinical Features and Current Pharmacotherapy of OAB in Practice: Ideal and Reality

INTRODUCTION

The present study aimed to investigate the prescribing patterns of anticholinergics (anti-AChR) or β3-adrenergic agonists (β3A) in the pharmacotherapy of overactive bladder (OAB) and to evaluate the differences in the frequency of adverse events (AEs) between the two types of drugs using a large-scale medical claims database.

METHODS

This cohort study was conducted using the JMDC claims database between May 2015 and April 2023. Patient characteristics, prescription and treatment patterns of anti-AChR and β3A, and the incidence of AEs have been described.

RESULTS

Overall, 70,936 patients were analyzed [mean age, 53.6 (standard deviation: 12.3) years]. Among women (48.5%; 34,439), 21.4% initially received anti-AChR and 27.2% received β3A; among men (51.5%; 36,497), 17.1% initially received anti-AChR and 34.3% received β3A. Most patients (79.6%; women, 83.5%; men, 75.8%) visited clinics. About 10% of patients had a treatment change: 5.6% switched the drug type (change from anti-AChR to β3A or vice versa), and 4.0% had an add-on of another drug type. The incidence rate of treatment change per 100 patient-years was higher with β3A in both women (12.39) and men (13.65). In the multivariable analysis, initial prescription with anti-AChR compared with β3A did not show any association with the risk of AEs.

CONCLUSION

This large-scale database study revealed that treatment for OAB is often initiated with β3A and prescribed mainly at clinics. Changes or additions to initial prescriptions were as low as about 5%, indicating that raising awareness among physicians treating OAB is particularly important to improve the quality of life of patients with OAB. Our study also showed that the incidence of AEs was not associated with the initially prescribed drug type. Continued exploration is warranted to further clarify the risk of AEs with each prescription.

Thread Embedding Acupuncture in Postmenopausal Women with Overactive Bladder: A Prospective, Single-Arm, Before-After Study

Introduction

Overactive bladder is a major public health concern that negatively impacts a patient's quality of life, and it is highly prevalent in menopausal women. Acupuncture has been suggested as a viable therapeutic approach. This study aimed to explore the effectiveness of thread-embedding acupuncture in postmenopausal women with overactive bladder.

Methods

This was a single-centre, single-arm, open-label study conducted on 20 postmenopausal women with overactive bladder. Participants received thread-embedding acupuncture treatment once a week for 8 weeks. Patients were evaluated using a bladder diary, overactive bladder symptom score (OABSS), and King's Health Questionnaire (KHQ) at three time points: baseline, end of treatment (week 8), and 4 weeks after treatment completion (week 12).

Results

Nineteen participants completed the study. Average daily micturition frequency decreased significantly after thread-embedding acupuncture treatment (week 8: -2.55 ± 0.37, P=0.001, week 12: -2.69 ± 0.37, P=0.001). Daytime and nighttime micturition frequency and OABSS significantly decreased at week 8 and 12. However, no significant differences were observed in urgency, incontinence, or KHQ. No serious adverse events were reported.

Conclusion

Considering that thread-embedding acupuncture was shown to improve daily quality of life by reducing daytime and nighttime episodes, this pilot study suggests that thread-embedding acupuncture is a feasible alternative for treating overactive bladder.

Two-year Pivotal Study Analysis of the Safety and Efficacy of Implantable Tibial Nerve Stimulation With eCoin® for Urgency Urinary Incontinence

OBJECTIVE

To evaluate the continued effectiveness and safety of the eCoin Implantable Tibial Nerve Stimulator system (ITNS) for urgency urinary incontinence (UUI) in patients with overactive bladder (OAB). The 1-year pivotal study was extended through 2 years. The ITNS is a novel and recently FDA-approved therapy.

METHODS

A prospective, multicenter, single-arm trial was conducted on 137 subjects with refractory UUI to evaluate eCoin ITNS therapy. A 3-day voiding diary was collected along with the OAB questionnaire, Patient Global Impression of Improvement, and a custom Likert scale on subject satisfaction. The primary efficacy measure was the proportion of subjects who achieved at least 50% reduction from baseline in number of UUI episodes. The primary safety measure was device-related adverse events (AEs).

RESULTS

Seventy-two subjects completed the 96-week evaluation. Around 78% (95% CI: 67%-87%) experienced at least 50% reduction in UUI episodes; 48% (95% CI, 36%-60%) experienced at least 75% reduction, and 22% (95% CI, 13%-33%) were dry on a 3-day diary. Subjects reported a decrease from baseline in their UUI episodes/day of 2.61 (SD 2.97) and 2.97 (SD 2.64) at 48 weeks and 96 weeks, respectively. Around 91.3% did not require additional medications for OAB. No serious or unanticipated AEs were reported in this extension phase.

CONCLUSION

The eCoin ITNS demonstrated consistent continuing effectiveness and safety in treating OAB patients with UUI. The findings support it as an excellent treatment option for refractory patients.

Efficacy and safety of onabotulinumtoxinA for the treatment of overactive bladder in men and women: A pooled analysis

BACKGROUND

This pooled analysis of randomized controlled studies investigated the safety and efficacy of onabotulinumtoxinA in male and female patients with overactive bladder (OAB).

METHODS

Data were pooled from four similarly designed trials in North America and Europe. Adults with idiopathic OAB for ≥6 months inadequately managed by at least one anticholinergic were randomized 1:1 or 2:1 to receive onabotulinumtoxinA 100 U or matched placebo in Cycle 1 and could request open-label retreatment with onabotulinumtoxinA 100 U at ≥12 weeks. Efficacy outcomes at Week 12 included the primary endpoint of mean urinary incontinence (UI) episodes per day and other variables, such as the proportion of patients with ≥50% reduction in daily UI episodes. Safety was assessed by monitoring treatment-emergent adverse events (TEAEs). Analyses by sex were descriptive. Males were further analyzed by benign prostatic hyperplasia (BPH) diagnosis status.

RESULTS

In the pooled population (N = 1564), there were 194 males (12.4%) and 1370 females (87.6%). Mean number of baseline UI episodes per day was 4.9 in males and 5.5 in females. At Week 12, numerically greater mean reductions from baseline in number of daily UI episodes were observed with the onabotulinumtoxinA 100 U group (females: -3.0; males: -2.2) versus placebo (females: -1.1; males: -1.3). Achievement of ≥50% reduction in daily UI episodes was numerically greater with onabotulinumtoxinA 100 U (females: 64.8%; males: 61.2%) versus placebo (females: 30.6%; males: 44.8%), and numerically higher in males without BPH (onabotulinumtoxinA: 65.1%; placebo: 50.9%) versus with BPH (onabotulinumtoxinA: 54.3%; placebo: 36.6%). A total of 34.7% of males and 39.4% of females experienced at least one TEAE in the first 12 weeks during treatment Cycle 1. Urinary tract infection rate was 13.1% in females and 4.2% in males; incidence of hematuria was 6.8% in males and 1.1% in females. Incidence of urinary retention (defined as incomplete emptying, requiring catheterization) was 2.7% in females and 4.7% in males.

CONCLUSION

OnabotulinumtoxinA 100 U was efficacious and well tolerated in men and women with OAB, including in males with and without BPH. No new safety findings were identified when data were analyzed by sex.

A wireless, battery-free device for electrical neuromodulation of bladder contractions

Lower urinary tract dysfunction (LUTD) is a prevalent condition characterized by symptoms such as urinary frequency, urgency, incontinence, and difficulty in urination, which can significantly impair patient's quality of life and lead to severe physiological complications. Despite the availability of diverse treatment options, including pharmaceutical and behavioral therapies, these approaches are not without challenges. The objective of this study was to enhance treatment options for LUTD by developing a wireless, battery-free device for managing bladder contractions. We designed and validated a compact, fully implantable, battery-free pulse generator using the magnetic induction coupling mechanism of wireless power transmission. Weighing less than 0.2 g and with a volume of less than 0.1 cubic centimeters, this device enables precise stimulation of muscles or neurons at voltages ranging from 0 to 10 V. Wireless technology allows real-time adjustment of key stimulation parameters such as voltage, duration, frequency, pulse width, and pulse interval. Our findings demonstrate that the device effectively controlled bladder contractions in mice when used to stimulate the Major Pelvic Ganglion (MPG). Additionally, the device successfully managed micturition in mice with bilateral transection of the pudendal nerve. In conclusion, the development of this innovative wireless pulse generator provides a safer and more cost-effective alternative to conventional battery-powered neurostimulators for bladder control, addressing the limitations of such devices. We anticipate that this novel technology will play a pivotal role in the future of electrical stimulation therapies for voiding dysfunctions.

Evaluation of transurethral GreenLight laser-selective vaporization for refractory overactive bladder in women

Background

Refractory overactive bladder (OAB) in women is a common yet challenging condition for which traditional treatments have been unsatisfactory. This study aimed to evaluate the efficacy and safety of transurethral bladder mucosal GreenLight laser-selective vaporization for treating refractory OAB in women.

Methods

The female patients with refractory OAB who were admitted to the Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University between May 2022 and July 2023 were examined retrospectively in this study. Transurethral bladder mucosal GreenLight laser-selective vaporization was used to treat the patients, and the perioperative and postoperative parameters were reviewed and compared. Bladder mucosa was examined by immunohistochemical staining to explore the expressions of TRPV1, P2X3, tumor necrosis factor alpha (TNF-α), and interleukin 6 (IL-6) before and after treatments.

Results

Surgeries were performed successfully for all 32 patients in 57.38±11.22 minutes with minimal intraoperative bleeding. Twelve weeks post-surgery, there was a significant decrease (P<0.05) in the patients' Overactive Bladder Symptom Score (OABSS), 3-day bladder diary (daytime frequency, nocturia, urgency, and urgency incontinence), and Overactive Bladder questionnaire Short Form (OAB-qSF) score. After treatments, both first desire to void (FDV) and maximum bladder pressure capacity (MCBC) increased significantly (P<0.05). The immunohistochemical analysis revealed that the GreenLight laser significantly reduced the expressions of TRPV1, P2X3, TNF-α, and IL-6 in the bladder mucosa (P<0.05). No severe complications were observed after interventions.

Conclusions

For female patients with refractory OAB who have shown poor response to conventional treatment approaches, transurethral bladder mucosal GreenLight laser-selective vaporization may represent a promising alternative treatment option.

Deprescribing as a Way to Reduce Inappropriate Use of Drugs for Overactive Bladder in Primary Care (DROP): Protocol for a Cluster Randomized Controlled Trial With an Embedded Explanatory Sequential Mixed Methods Study

BACKGROUND

Potentially inappropriate medication remains a significant concern in general practices, particularly in the context of overactive bladder (OAB) treatment for individuals aged 65 years and older. This study focuses on the exploration of alternative options for treating OAB and the deprescribing of anticholinergic drugs commonly used in OAB. The research aims to comprehensively evaluate the efficiency of deprescribing through a mixed methods approach, combining quantitative assessment and qualitative exploration of perceptions, experiences, and potential barriers among patients and health care personnel.

OBJECTIVE

This study aims to evaluate the efficiency and safety of the intervention in which health care staff in primary care encourage patients to participate in deprescribing their drugs for OAB. In addition, we aim to identify factors contributing to or obstructing the deprescribing process that will drive more informed decisions in the field of deprescribing and support effective and safe treatment of patients.

METHODS

The drugs for overactive bladder in primary care (DROP) study uses a rigorous research design, using a randomized controlled trial (RCT) with an embedded sequential explanatory mixed methods approach. All general practices within the North Denmark Region will be paired based on the number of general practitioners (GPs) and urban or rural locations. The matched pairs will be randomized into intervention and control groups. The intervention group will receive an algorithm designed to guide the deprescribing of drugs for OAB, promoting appropriate medication use. Quantitative data will be collected from the RCT including data from Danish registries for prescription analysis. Qualitative data will be obtained through interviews and focus groups with GPs, staff members, and patients. Finally, the quantitative and qualitative findings are merged to understand deprescribing for OAB comprehensively. This integrated approach enhances insights and supports future intervention improvement.

RESULTS

The DROP study is currently in progress, with randomization of general practices underway. While they have not been invited to participate yet, they will be. The inclusion of GP practices is scheduled from December 2023 to April 2024. The follow-up period for each patient is 6 months. Results will be analyzed through an intention-to-treat analysis for the RCT and a thematic analysis for the qualitative component. Quantitative outcomes will focus on changes in prescriptions and symptoms, while the qualitative analysis will explore experiences and perceptions.

CONCLUSIONS

The DROP study aims to provide an evidence-based intervention in primary care that ensures the deprescription of drugs for OAB when there is an unfavorable risk-benefit profile. The DROP study's contribution lies in generating evidence for deprescribing practices and influencing best practices in health care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06110975; https://clinicaltrials.gov/study/NCT06110975.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56277.

Isolated bladder training or in combination with other therapies to improve overactive bladder symptoms: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Bladder training (BT), the maintenance of a scheduled voiding regime at gradually adjusted intervals, is a common treatment for overactive bladder (OAB).

OBJECTIVES

To assess the effects of isolated BT and/or in combination with other therapies on OAB symptoms.

METHODS

A systematic review of eight databases was conducted. After screening titles and abstracts, full texts were retrieved. Cochrane RoB 2 and the GRADE approach were used.

RESULTS

Fourteen RCTs were included: they studied isolated BT (n = 11), BT plus drug treatment (DT; n = 5), BT plus intravaginal electrical stimulation (IVES; n = 2), BT plus biofeedback and IVES (n = 1), BT plus pelvic floor muscle training and behavioral therapy (n = 2), BT plus percutaneous tibial nerve stimulation, and BT plus transcutaneous tibial nerve stimulation (n = 1). In a meta-analysis of short-term follow-up data, BT plus IVES resulted in greater improvement in nocturia (mean difference [MD]: 0.89, 95% CI: 0.5, 1.20), urinary incontinence (UI; MD: 1.93, 95% CI: 1.32, 2.55), and quality of life (QoL; MD: 4.87, 95% CI: 2.24, 7.50) than isolated BT, while DT and BT improved UI (MD: 0.58, 95% CI: 0.23, 0.92) more than isolated BT.

CONCLUSION

In the short term, BT plus IVES improves the OAB symptoms of nocturia and UI while improving QoL. The limited number of RCTs and heterogeneity among them provide a low level of evidence, making the effect of BT on OAB inconclusive, which suggests that new RCTs should be performed.

Radiofrequency as the New Opportunity in Treating Overactive Bladder and Urge Urinary Incontinence-A Single-Arm Pilot Study

Background and Objectives: Until now, overactive bladder (OAB) with or without urge urinary incontinence (UUI) has been treated mainly in two ways: with behavioral methods and patient education, or using antimuscarinic drugs and/or beta-3 adrenergic receptor agonists. Unfortunately, these drugs may cause side effects in some women or are insufficiently effective, so patients abandon them. Therefore, in this pilot study, radiofrequency was evaluated as a new option in the treatment of OAB and UUI. Materials and Methods: Nineteen patients were enrolled in this pilot study using radiofrequency (RF), where the level of OAB and UUI was assessed using the validated ICIQ-OAB questionnaire. RF was applied four times for 20 min, once a week. Two weeks after treatment, the level of OAB and UUI was reassessed and processed statistically and the treatment effect evaluated. Results: Using the ICIQ-OAB, the severity of OAB and UUI was assessed: 0-3 mild symptoms; 4-7 moderate symptoms; 8-11 severe symptoms; 12-16 very severe symptoms. Before treatment, 10.5% of patients had mild symptoms, 21.1% moderate symptoms, 63.2% severe symptoms and 5.3% very severe symptoms. After treatment, 42.9% had mild symptoms, 50% moderate symptoms and 7% severe OAB and UUI symptoms. All four main symptoms-frequency, nocturia, urgency and incontinence-decreased statistically significantly, with the best results being found in urgency (p = 0.002). Conclusions: Based on this pilot study, RF seems a very promising method in the treatment of OAB and UUI. To extend our initial findings, it is necessary to perform a prospective, randomized and placebo-controlled study in order to obtain reliable results and to determine for how long one set of treatment maintains the results obtained immediately after the end of that treatment. In this way, we may determine how often the treatment needs to be repeated, if necessary, and when.

Regular and Irregular Use and Reasons for Discontinuation of Solifenacin Therapy in Patients with Overactive Bladder Managed by Urologists

Solifenacin, a selective muscarinic receptor antagonist, is one of the best-tolerated and most effective medicines that relieve storage symptoms in patients with an overactive bladder (OAB). However, the persistence of solifenacin in daily clinical practice remains far below that reported in clinical trials. This study aimed to analyze the adherence of patients to the therapy and the reasons for solifenacin discontinuation and non-regular use in OAB patients managed by urologists. Data concerning non-compliance and the discontinuation of solifenacin, along with the reasons, were collected during two consecutive visits for 64,049 OAB outpatients. Over the two visits, 81.6% of the patients continued therapy, and 88.6% were taking solifenacin regularly. An age ≥ 75 yrs., the male sex, a rural or small-city dwelling, and a prescription of ≥10 mg predicted therapy continuation. The female sex, a higher education, a short or long duration of an OAB, and a non-idiopathic OAB predicted regular use. The persistence of nycturia and urinary incontinence during therapy predicted both discontinuation and non-regular use. Dissatisfaction with therapy was the most frequent reason for discontinuation. In conclusion, an initial prescription of solifenacin at a low dose reduces the chance of OAB symptom improvement and results in more frequent discontinuation. A high rate of discontinuation related to dissatisfaction suggests unrealistic expectations for OAB patients and insufficient education by urologists.

Efficacy and safety of an alternative onabotulinumtoxinA injection paradigm for refractory overactive bladder

AIMS

In studies utilizing a 20-injection-site paradigm of onabotulinumtoxinA treatment for overactive bladder (OAB), some patients performed clean intermittent catheterization (CIC). An alternative injection paradigm of fewer injections targeting the lower bladder may reduce the need for CIC by maintaining upper bladder function. This study evaluated the efficacy and safety of an unapproved alternative 10-injection-site paradigm targeting the lower bladder.

METHODS

In this phase 4, double-blind, parallel-group study, patients with OAB and urinary incontinence (UI) for ≥6 months with ≥3 episodes of urinary urgency incontinence (no more than 1 UI-free day) and ≥8 micturitions per day over 3 days during screening were randomized 2:1 to onabotulinumtoxinA 100 U or placebo injected at 10 sites in the lower bladder.

RESULTS

Of 120 patients, 78 in the onabotulinumtoxinA group and 39 in the placebo group had efficacy assessments. In the double-blind phase, mean change from baseline at week 12 in daily frequency of UI episodes was greater with onabotulinumtoxinA (-2.9) versus placebo (-0.3) (least squares mean difference [LSMD]: -2.99, p < 0.0001). Achievement of 100% (odds ratio [OR]: 6.15 [95% confidence interval, CI: 0.75-50.37]), ≥75% (OR: 7.25 [2.00-26.29]), and ≥50% improvement (OR: 4.79 [1.87-12.28]) from baseline in UI episodes was greater with onabotulinumtoxinA versus placebo. Reductions from baseline in the daily average number of micturitions (LSMD: -2.24, p < 0.0001), nocturia (LSMD: -0.71, p = 0.0004), and urgency (LSMD: -2.56, p < 0.0001) were greater with onabotulinumtoxinA than with placebo. Treatment benefit was improved or greatly improved in the onabotulinumtoxinA group (74.0% of patients) versus placebo (17.6%) (OR: 13.03 [95% CI: 3.23-52.57]). Mean change from baseline in Incontinence Quality of Life score was greater with onabotulinumtoxinA versus placebo (LSMD: 24.2, p = 0.0012). Two of 78 (2.6%) patients in the onabotulinumtoxinA group used CIC during the double-blind period; no females used CIC during the double-blind period. Commonly reported adverse events (≥5%) were urinary tract infection (UTI), dysuria, and productive cough for both groups; rate of UTI was higher with onabotulinumtoxinA versus placebo.

CONCLUSION

In patients treated with onabotulinumtoxinA for OAB with UI, an unapproved alternative injection paradigm targeting the lower bladder demonstrated efficacy over placebo, with a low incidence of CIC.

The Effects of Age, Gender, and Postvoid Residual Volume on Catheterization Rates After Treatment with OnabotulinumtoxinA for Overactive Bladder

Background

Transient increases in postvoid residual urine volume (PVR) requiring clean intermittent catheterization (CIC) have occurred with onabotulinumtoxinA treatment for overactive bladder (OAB).

Objective

To evaluate onabotulinumtoxinA safety and the effect of age, gender, and maximum PVR (PVRmax) on CIC initiation in adults with OAB and urinary incontinence (UI).

Design setting and participants

This was a pooled post hoc analysis of four placebo-controlled, multicenter randomized trials that included adults with idiopathic OAB after first onabotulinumtoxinA treatment (NCT00910845, NCT00910520, NCT01767519, NCT01945489). Patients had at least three urgency UI episodes over 3 d and at least eight micturitions per day, had inadequate management with at least one anticholinergic agent, and were willing to use CIC.

Outcome measurements and statistical analysis

We measured the following outcomes: PVRmax within 12 wk after first treatment; CIC incidence; estimated functional capacity; PVR ratio (PVR/estimated functional capacity).

Results and limitations

Of 1504 patients, 87.7% were women and 88.8% were White. The mean age was 60.5 yr across 10-yr age groups, baseline PVR was 13.8-35.0 ml, and estimated functional capacity was 293.5-475.7 ml. Mean baseline PVR was 21.3 ml overall versus 34.0 ml in the group that started CIC. The CIC incidence was 6.2% for women (range 1.1-8.4%) and 10.5% for men (range 0-14.6%). Higher CIC rates were observed for PVRmax >350 ml (women 91.9%, men 84.6%) in comparison to PVRmax of 201-350 ml (women 32.5%, men 17.4%) and PVRmax <200 ml (women 1.2%, men 1.6%). Overall, 2/1504 patients (both women) were unable to void spontaneously. The mean PVR ratio was highest at week 2. Some subgroups had small sample sizes.

Conclusions

CIC incidence was low overall, was less frequent for women, was rare with PVRmax ≤200 ml, and did not appear to correlate with baseline PVR.

Patient summary

After onabotulinumtoxinA treatment for OAB, patients sometimes insert a catheter to help in emptying their bladder after urinating. In this study, few patients needed a catheter, especially when less urine volume remained after urination.

Inhibition of Contractility of Isolated Caprine Detrusor by the Calcium Channel Blocker Cilnidipine and Reversal by Calcium Channel Openers

Background

Cilnidipine is a fourth-generation calcium channel blocker that is clinically used to treat hypertension. It is a dihydropyridine that blocks L- and N-type calcium channels. The inhibitory effect of cilnidipine on isolated detrusor muscle contractility has not been studied. This study investigated the inhibitory effect of cilnidipine on isolated caprine (goat) detrusor muscle contractility and the reversal of the inhibition by calcium channel openers.

Methods

Fourteen caprine detrusor strips were made to contract using 80 mM potassium chloride before and after addition of three concentrations (20, 40, and 60 µM) of cilnidipine. Two reversal agents, the L-type calcium channel opener FPL64716, and the N-type calcium channel opener GV-58, were investigated for their ability to reverse the inhibitory effect of 40 µΜ cilnidipine on potassium chloride-induced detrusor contractility.

Results

Cilnidipine caused a dose-dependent and statistically significant inhibition of detrusor contractility at all concentrations of cilnidipine used (20, 40, and 60 µΜ). The inhibitory effect of 40 µM cilnidipine on detrusor contractility was significantly reversed by the addition of FPL64716 and GV-58.

Conclusions

Cilnidipine inhibits the contractility of the isolated detrusor by blocking L- and N-type calcium channels. Cilnidipine could be evaluated for treating clinical conditions requiring relaxation of the detrusor such as overactive bladder.

Treating and Managing Urinary Incontinence: Evolving and Potential Multicomponent Medical and Lifestyle Interventions

Incontinence is defined by either ICS 2002 or IUGA/ICS 2010 as the involuntary loss of urine and includes urgency urinary incontinence (UUI), stress urinary incontinence (SUI) or mixed urinary incontinence (MUI). It has a high worldwide prevalence with an associated impact on quality of life. Despite existing management options for the management of urinary incontinence, patients continue to be troubled by symptoms or side effects of existing treatment. There is therefore a requirement for ongoing research into treatment options for the management of UUI and SUI, that are more effective and tolerable to patients. Advances in treatment of UUI include a more selective beta 3 agonist, Vibegron, which has less impact on cardiac function than Mirabegron. Hormonal treatment, including Ospemifene and Prasterone, may improve GSM and in turn symptoms of UUI. There are advances in the types of neuromodulators available, including those that are rechargeable at home and are MRI safe. Laser has shown promising initial results. There is developing interest in the microbiome, and how this may impact future treatment modalities. Advances in treatment of SUI include the use of mobile health applications to support delivery of pelvic floor muscle training. Litoxetine, a selective serotonin reuptake inhibitor, has shown promising results at phase III trials. Functional magnetic stimulation is being developed to improve contractility of pelvic floor muscles. We also discuss interventions that improve tissue elasticity and regeneration, such as platelet rich plasma, autologous stem cell transplantation, laser therapy and radiofrequency treatment, which show short term benefits.

A treatment prediction strategy for overactive bladder using a machine learning algorithm that utilized data from the FAITH study

AIMS

To use machine learning algorithms to develop a model to accurately predict treatment responses to mirabegron or antimuscarinic agents in patients with overactive bladder (OAB), using real-world data from the FAITH registry (NCT03572231).

METHODS

The FAITH registry data included patients who had been diagnosed with OAB symptoms for at least 3 months and were due to initiate monotherapy with mirabegron or any antimuscarinic. For the development of the machine learning model, data from patients were included if they had completed the 183-day study period, had data for all timepoints and had completed the overactive bladder symptom scores (OABSS) at baseline and end of study. The primary outcome of the study was a composite outcome combining efficacy, persistence, and safety outcomes. Treatment was deemed "more effective" if the composite outcome criteria for "successful," "no treatment change," and "safe" were met, otherwise treatment was deemed "less effective." To explore the composite algorithm, a total of 14 clinical risk factors were included in the initial data set and a 10-fold cross-validation procedure was performed. A range of machine learning models were evaluated to determine the most effective algorithm.

RESULTS

In total, data from 396 patients were included (266 [67.2%] treated with mirabegron and 130 [32.8%] treated with an antimuscarinic). Of these, 138 (34.8%) were in the "more effective" group and 258 (65.2%) were in the "less effective" group. The groups were comparable in terms of their characteristic distributions across patient age, sex, body mass index, and Charlson Comorbidity Index. Of the six models initially selected and tested, the decision tree (C5.0) model was chosen for further optimization, and the receiver operating characteristic of the final optimized model had an area under the curve result of 0.70 (95% confidence interval: 0.54-0.85) when 15 was used for the min n parameter.

CONCLUSIONS

This study successfully created a simple, rapid, and easy-to-use interface that could be further refined to produce a valuable educational or clinical decision-making aid.

Establishment of an overactive bladder model in mice

BACKGROUND

Overactive bladder (OAB) is a syndrome characterized by symptoms of urinary urgency, often accompanied by frequent urination and nocturia or urge incontinence.

METHODS

Twenty female ICR mice were randomly divided into pBOO (partial bladder outlet obstruction) and control groups. The mouse OAB model was constructed by ligating the bladder outlet. Eight weeks after the operation, the methods of voiding spot on paper (VSOP), isolated detrusor muscle, and HE staining were used for analysis and research.

RESULTS

After the operation, two mice in the experimental and one in control died, and one in the control groups had an abnormal bladder size, so it was excluded from the statistical analysis. Eight weeks after the operation, there was an insignificant difference (P = 0.15) in the body weight of mice in the pBOO (26.54 ± 2.62 g) and the control group (24.84 ± 1.76 g). The number of urinations in 12 h was significantly higher (P < 0.001) in the pBOO (7.63 ± 1.19) than in the control group (4.13 ± 0.99). Also, the 12-h urine volume of pBOO (1491.23 ± 94.72 μL) was significantly greater (P = 0.006) than that of the control group (1344.86 ± 88.17 μL). The isolated bladder of the pBOO mice was significantly heavier than that in the control group (53.16 ± 1.79 mg vs. 24.54 ± 1.80 mg, P < 0.001), the horizontal and vertical length of the bladder in pBOO group were larger than those in the control group (P < 0.001). The detrusor thickness of pBOO group (357.50 ± 11.88 µm) was significantly thicker than that of control group (258.52 ± 17.22 µm, P < 0.001), and the isolated muscle strip was more sensitive to carbachol stimulation. According to HE staining, the bladder wall of the pBOO mice was significantly thickened.

CONCLUSIONS

A pBOO-mediated mouse OAB model was successfully established by ligating the bladder outlet.

Physical Agent-Based Treatments for Overactive Bladder: A Review

Almost one-fifth of the people in the world experience a decrease in quality of life due to overactive bladder (OAB) syndrome. The main bothersome symptoms are urgency accompanied by urinary frequency and nocturia. This chronic, disabling condition is first managed by reducing fluid intake and pelvic floor muscle training, supplemented with antimuscarinic drugs, if necessary. However, refractory cases often still occur. In more severe cases, invasive surgical interventions can be considered; yet, the success rate is still inconsistent, and there is a high complication rate. This condition is frustrating for patients and challenging for the medical staff involved. Although its pathophysiology has not been fully elucidated, peripheral autonomic somatic and sensory afferent receptors are considered to be involved in this condition. Hence, currently, physical agent-based treatments such as neuromodulation have taken a significant place in the third-line therapy of OAB. The efficacy and safety profiles of electrical and magnetic stimulation continue to evolve. Physical-based agents provide an appealing option owing to their effectiveness and minimal side effects. In addition, more physical therapies using light and shock energy are currently being investigated. Thus, a comprehensive understanding of these modalities is an extremely important aspect to provide the most suitable modalities for patients.