Overactive bladder - 18 years - Part II

The importance of multimodal diagnostic methods for therapeutic decision making for overactive bladder in women

Background and aim

Despite overactive bladder (OAB) being a symptomatic diagnosis, all patients require a basic assessment to confirm the diagnosis, as well as to exclude any other underlying cause for lower urinary tract dysfunction. While guidelines clearly define different methods of investigations for OAB, there are reasons to believe that these guidelines reflect more of a "one size fits all" model that may not be appropriate for use in all patients. The study aimed to elucidate the complex and advanced multidisciplinary methods of investigation of OAB patients.

Methods

PubMed, ScienceDirect, Cochrane Library, and Google Scholar databases were used to search for scientific publications from 2013 to 2023 using relevant keywords and phrases.

Results

Data from 708 publications were researched and synthesized, a systematic review was carried out and the detailed and coherent results presented the diagnostic aspects of overactive bladder in women. Relevant citations from selected articles were included, and a synthesis of key information was provided.

Conclusion

These discoveries may assist in detecting OAB earlier, allowing for prompt intervention and potentially preventing the condition from progressing to more severe stages and providing healthcare professionals with valuable tools to enhance the diagnosis and treatment of OAB, potentially improving the quality of life for patients affected by this condition.

Sacral and Implantable Tibial Neuromodulation for the Management of Overactive Bladder: A Systematic Review and Meta-analysis

INTRODUCTION

Implantable tibial neuromodulation (iTNM) systems have recently become commercially available in the US, and offer a new method of neurostimulation for the treatment of overactive bladder (OAB). In the absence of head-to-head studies, the aim of this meta-analysis was to indirectly compare the efficacy and safety of sacral neuromodulation (SNM) and implantable tibial neuromodulation (iTNM) for the treatment of OAB.

METHODS

A comprehensive search was performed using terms for OAB and neuromodulation. Primary efficacy measures included a ≥ 50% reduction in urgency urinary incontinence (UUI) episodes, urinary frequency, and/or OAB symptoms. Primary safety measures included the rate of device-related adverse events (AEs).

RESULTS

A total of 20 studies met selection criteria, encompassing 1416 patients treated with SNM and 350 patients treated with iTNM. No comparative or placebo-controlled studies for SNM and iTNM were identified, and therefore the analysis was completed using single-arm results. Weighted averages showed that the UUI responder rate was similar for both SNM and iTNM (71.8% and 71.3%, respectively). Similarly, weighted averages of OAB responder rates were 73.9% for SNM and 79.4% for iTNM. Similar rates of device-related AEs were also observed.

CONCLUSIONS

This meta-analysis found similar efficacy and safety of SNM and iTNM for the treatment of OAB and UUI, including UUI and OAB symptom response rates, reduction in UUI episodes, significant improvements in quality-of-life (QoL), and low rates of procedure and device-related adverse events. Notably, this comparable efficacy was seen without the use of a trial phase of neuromodulation in the iTNM studies versus SNM studies.

Intracellular signaling pathways of muscarinic acetylcholine receptor-mediated detrusor muscle contractions

Acetylcholine plays an essential role in the regulation of detrusor muscle contractions, and antimuscarinics are widely used in the management of overactive bladder syndrome. However, several adverse effects limit their application and patients' compliance. Thus, this study aimed to further analyze the signal transduction of M2 and M3 receptors in the murine urinary bladder to eventually find more specific therapeutic targets. Experiments were performed on adult male wild-type, M2, M3, M2/M3, or Gαq/11 knockout (KO), and pertussis toxin (PTX)-treated mice. Contraction force and RhoA activity were measured in the urinary bladder smooth muscle (UBSM). Our results indicate that carbamoylcholine (CCh)-induced contractions were associated with increased activity of RhoA and were reduced in the presence of the Rho-associated kinase (ROCK) inhibitor Y-27632 in UBSM. CCh-evoked contractile responses and RhoA activation were markedly reduced in detrusor strips lacking either M2 or M3 receptors and abolished in M2/M3 KO mice. Inhibition of Gαi-coupled signaling by PTX treatment shifted the concentration-response curve of CCh to the right and diminished RhoA activation. CCh-induced contractile responses were markedly decreased in Gαq/11 KO mice; however, RhoA activation was unaffected. In conclusion, cholinergic detrusor contraction and RhoA activation are mediated by both M2 and M3 receptors. Furthermore, whereas both Gαi and Gαq/11 proteins mediate UBSM contraction, the activation at the RhoA-ROCK pathway appears to be linked specifically to Gαi. These findings may aid the identification of more specific therapeutic targets for bladder dysfunctions.NEW & NOTEWORTHY Muscarinic acetylcholine receptors are of utmost importance in physiological regulation of micturition and also in the development of voiding disorders. We demonstrate that the RhoA-Rho-associated kinase (ROCK) pathway plays a crucial role in contractions induced by cholinergic stimulation in detrusor muscle. Activation of RhoA is mediated by both M2 and M3 receptors as well as by Gi but not Gq/11 proteins. The Gi-RhoA-ROCK pathway may provide a novel therapeutic target for overactive voiding disorders.

Safety, tolerability, and pharmacokinetics of single and multiple ascending Oral doses of DA-8010 in healthy subjects: First-in-human phase I study

This study assessed the safety, tolerability, and pharmacokinetics of single and multiple oral doses of DA-8010, a muscarinic M₃ receptor antagonist, in healthy subjects. This was a randomized, double-blind, placebo-controlled, ascending single (Part A: 1, 2.5, 5, 20, and 40 mg QD fasted and 10 mg QD fasted and fed) and multiple doses (Part B: 5, 10, and 20 mg QD from Days 1 to 7 fasted), sequential-group study. Safety data were analyzed descriptively, time to maximum plasma concentration (t_max ) nonparametrically, and pharmacokinetic parameters using power and mixed models and ANOVA. Of 109 subjects randomized (Part A = 69 and Part B = 40; each part consisted a female group), 31 (44.9%) in Part A and 29 (72.5%) in Part B experienced treatment-emergent adverse events (TEAEs) in a dose-related manner. Common drug-related TEAEs in Part A and B were dizziness (8.7% and 15.0%), headache (5.8% and 12.5%) and blurred vision (8.7% and 20%). One male (20 mg) and one female (10 mg) from Part B discontinued the study due to a confusional state, and nausea and vomiting. Irrespective of sex, DA-8010 was steadily absorbed following single and multiple doses in the fasted state with increased systemic exposure in a dose-proportional manner with maximum plasma concentration occurring at a median t_max between 4.0 and 6.0 h. A high-fat meal increased systemic exposure. DA-8010 was safe, well tolerated, and well absorbed at lower doses and moderately tolerated at higher doses without any notable effects of food and sex.

Comparison of micro-radiofrequency therapy and tolterodine for the treatment of newly diagnosed overactive bladder: A retrospective cohort study

Purpose

This study aimed to retrospectively compare the efficacy and safety of micro-radiofrequency (RF) therapy through the urethra vs. oral tolterodine tartrate in the treatment of newly diagnosed overactive bladder (OAB).

Materials and methods

In this study, 46 patients who were newly diagnosed with moderate-to-severe OAB were included; 23 of them underwent the micro-RF treatment procedure, and the other 23 patients took tolterodine. Bladder diaries were recorded 3 days before treatment and during the follow-up period on 1, 3, and 7 weeks after micro-RF therapy or oral tolterodine. Micturition parameters including daily voiding times, daily urge urinary incontinence (UI) episodes, daily urgency episodes, mean volume per micturition, post-void residual volume (PVR), maximum urine flow rate (Qmax), overactive bladder symptom score (OABSS), and quality of life (QoL) score were analyzed.

Results

All 46 patients underwent either micro-RF or oral tolterodine treatment, as well as a complete follow-up. The incidence of adverse events in the micro-RF group was 8.7% (2/23), and that in the tolterodine group was 43.5% (10/23). The following two adverse events happened in the micro-RF group: an injury to the urethra during catheterization in a man and a urinary tract infection in a woman, both of which were relieved or disappeared after day 3. The adverse effects in the tolterodine group were mainly dry mouth (4/23), dysuria (5/23), and constipation (8/23), but none of the patients withdrew from the drug therapy. Compared to pre-therapy, all parameters of both groups, including daily voiding times, daily urgency episodes, mean volume per micturition, OABSS, and QoL score, demonstrated significant improvements during follow-up in 7 weeks after therapy, except for daily UI episodes in the tolterodine group, while the above parameters showed bigger improvements in the micro-RF group than in the tolterodine group. Besides, the general treatment efficacy of micro-RF was 73.9% (17/23), which was significantly better than tolterodine (10/23, 43.5%), and the difference was 30.4% [95% CI: 3.4-57.5%, p = 0.036].

Conclusion

In this retrospective study, we found that micro-RF therapy is safe and more effective than oral tolterodine for newly diagnosed moderate-to-severe OAB in a short-term follow-up. Stronger evidence would be provided through a well-designed, prospective, randomized controlled trial.

The effectiveness of different electrical nerve stimulation protocols for treating adults with non-neurogenic overactive bladder: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Electrical nerve stimulation is a widely used treatment for overactive bladder but there is no consensus regarding the best placement of electrodes or protocols. We hypothesised that some non-implanted neurostimulation protocols would be more effective compared to others for treating urinary symptoms and improving quality of life among adults diagnosed with non-neurogenic overactive bladder.

METHODS

A systematic review and meta-analyses of randomized clinical trials were performed in five electronic databases: PubMed/MEDLINE, Lilacs, CINAHL, Web of Science, and PEDro. The main outcome was urinary symptoms-frequency, nocturia, and urgency-and the secondary outcome quality of life. Some protocol characteristics were extracted, e.g., frequency, pulse width, intensity, intervention time, and electrode placement.

RESULTS

Nine randomized controlled trials were included. Tibial neurostimulation showed better results than sacral neurostimulation for urge incontinence (mean difference = 1.25 episodes, 95% CI, 0.12-2.38, n = 73). On the pooled analysis, the different neurostimulation protocols-intravaginal, percutaneous tibial, and transcutaneous tibial nerve stimulation-demonstrated similar results for urinary frequency, nocturia, and urgency as well as quality of life. In general, effect sizes from meta-analyses were low to moderate. The best reported parameters for percutaneous tibial nerve stimulation were 20-Hz frequency and 200-μs width, once a week.

CONCLUSIONS

There was evidence that tibial neurostimulation is more effective than sacral neurostimulation for urge incontinence symptoms among patients with non-neurogenic overactive bladder. Overall, there was no superiority of an electrical nerve stimulation electrode placement and protocol over others considering urinary symptoms and quality of life. Further studies with three-arm trials are necessary. This study was registered at PROSPERO: CRD4201810071.

Comparison of antimuscarinic drugs to beta adrenergic agonists in overactive bladder: A literary review

BACKGROUND

The purpose of this study was to carry an extended literature review to compare antimuscarnics with beta adrenergic agonists (mirabegron) in treatment of overactive bladder.

MATERIALS AND METHODS

A literature review was carried out, using key words in different databases including MEDLINE, PUBMED, and EMBASE. All relevant published articles during last 5 years with full texts available were included in this review for critical analysis and evaluation. In total, there were 20 studies including 7 systemic reviews, 6 retrospective cohort, 3 prospective cohort, 2 randomized controlled trials, and 2 cross sectional studies.

RESULTS

After critical evaluation the results were considered under parameters of efficacy, adverse effects, adherence and persistence, tolerability, cost-effectiveness. In 9 studies efficacy was evaluated, 5 studies dealt with adverse effects, same number evaluated adherence and persistence. Cost effectiveness was compared in 3 and same number of studies also compared tolerability.

CONCLUSIONS

To conclude, we found mirabegron is as efficacious as any other antimuscarnics, has better tolerability (including elderly), has better adverse effect profile, is cost effective, has better persistence and adherence rates at 12 months.

The Relationship between Overweight and Overactive Bladder Symptoms

BACKGROUND

Several authors have investigated the relationship between obesity - assessed only by body mass index (BMI) - and overactive bladder (OAB) symptoms.

OBJECTIVES

The objective of this study was to determine the relationship between body fat percentage (BFP) and the severity of OAB symptoms with an impact on quality of life.

DESIGN

Cross-sectional study. The sample consisted of 206 overweight women; they were university students (BMI = 25.8 ± 3.0) with an average age of 30.6 ± 2.4 years. Body composition analysis was used, including assessment of BFP, visceral fat area (cm2/level), and other parameters. OAB symptoms were evaluated with an OAB questionnaire (OAB-q), voiding diary, and quality of life scale (I-QoL).

RESULTS

Ninety women had a BFP >32% and 116 had a BFP <32%. The voiding diary and OAB-q confirmed significant differences in 24-h daytime and nighttime frequency of voiding and average urine volume during the day. The OAB-q symptom score was lower in the group with BFP <32%. I-QoL recorded significantly worse parameters in the group with BFP >32% (p < 0.01). The Patient Perception of Intensity of Urgency Scale significantly correlated with BFP (r = 0.466, p < 0.001). Women with a BFP above 32% had a 1.95 times greater chance of developing OAB (odds ratio = 1.95, 95% CI = 1.09-3.52, p < 0.02).

CONCLUSION

Young women with a BFP >32% were 95% more likely to have OAB than other young women with a BPF <32%.

Effect of an exercise programme for reducing abdominal fat on overactive bladder symptoms in young overweight women

INTRODUCTION AND HYPOTHESIS

The effect of exercise in relation to overweight and overactive bladder (OAB) in young women has not been sufficiently supported by studies. The objective of our study was to reduce symptoms of OAB through a 3-month exercise programme in young overweight women with OAB. The sample consisted of 70 women (mean age 26.7 ± 4.8 years), 36 being treated and 34 in the control group.

METHODS

We used a body composition analyser with the assessment of skeletal muscle mass (SMM) (kg), body fat mass (BFM) (kg), body fat percentage (BFP) (%), visceral fat area (VFA) (cm²/level) and the waist/hip circumference index (WHR). OAB symptoms were evaluated using a voiding diary, the overactive bladder questionnaire (OAB-q) and the Patient Perception of Intensity of Urgency Scale (PPIUS). The intervention was a programme for the reduction of abdominal fat (PRAF), with elements of aerobic training, strengthening of the abdominal muscles and stretching.

RESULTS

In the OAB symptoms assessed through the voiding diary (number of voidings per 24 h, nocturia, mean voided volume) as well as in the OAB-q and PPIUS scales after training, significant differences were reported in favour of the treatment group [number of voidings per 24 h: treatment vs. control group, baseline 9.1 ± 0.3 vs. 8.6 ± 0.3, final 6.9 ± 0.2 vs. 8.1 ± 0.2, p < 0.0001; mean voided volume per 24 h (ml): treatment vs. control group, baseline 154.2 ± 9.1 vs. 162.2 ± 9.3, final 201.3 ± 9.3 vs. 164.1 ± 9.6, p < 0.0001] with a large effect size (ES). In the body composition analysis after training, significant differences were also reported in favour of the treatment group in the reduction of body mass index (BMI), BFP and VFA (p < 0.0001), with a large ES.

CONCLUSIONS

Body composition analysis confirmed a reduction of BMI, body weight, body fat percentage, visceral abdominal fat, the WHR index and waist circumference in favour of the treatment group after the 12-week PRAF exercise programme. A reduction in OAB symptoms was also objectively confirmed following the PRAF exercise programme.

Comparison of body composition and overactive bladder symptoms in overweight female university students

OBJECTIVES

To compare body composition in young overweight women with OAB compared to women without OAB, and to determine the severity of the symptoms of OAB, as well as to investigate the impact of OAB on quality of life.

STUDY DESIGN

Cross-sectional study. The sample consisted of 1932 enrolled women classed as overweight (BMI:25-29.9).From this sample, 276 women were recruited. Of these, 206 women with an average age of 30.6 ± 20.4 years and an average BMI of 25.8 ± 3.0 were confirmed to be overweight. We used the Voiding Diary, the Overactive Bladder Questionnaire(OAB-q),and the Incontinence Quality of Life (I-QoL) scale. Body composition was measured using direct segmental multi-frequency bioelectrical impedance analysis, with assessment of: skeletal muscle mass(kg)(SMM), body fat mass (kg)(BFM), body fat percentage (%)(BFP), visceral fat area (cm²/level)(VFA), and waist to hip ratio(WHR).

RESULTS

The voiding diary and OAB-q results confirmed OAB in 102 women. There was no significant difference in BMI between groups. The body composition analysis showed significant differences in BFP, VFA, and WHR, with higher values in the OAB group(p < 0.01). SMM, however, was higher in the group without OAB(p < 0.01). Recorded I-QoL scores showed worse parameters in the OAB group(p < 0.001). Women with a body fat percentage above 32% have a 1.95 times greater chance of developing OAB. Odds ratio [OR] = 1.95,(95%CI:1.09-3.52,p < 0.02).

CONCLUSION

Body fat percentage, visceral fat area, and waist to hip ratio were significantly higher in overweight women with OAB, compared with women without OAB and a comparable BMI.

Management of neurogenic bladder in patients with Parkinson's disease: A systematic review

AIMS

To assess the different treatment methods in management of neurogenic bladder (NGB) in patients with Parkinson's disease (PD).

METHODS

A systematic search was performed in Cochrane library, EMBASE, Proquest, Clinicaltrial.gov, WHO, Google Scholar, MEDLINE via PubMed, Ovid, ongoing trials registers, and conference proceedings in November 11, 2017. All randomized controlled trials (RCTs) or quasi-RCTs comparing any treatment method for management of NGB in patients with PD were included. The titles and abstracts of all identified studies were evaluated independently by two investigators. Once all of the potential related articles were retrieved, each author separately evaluated the full text of each article and the quality of the methodology of the selected studies using the Cochrane appraisal risk of bias checklist and then the data about the patient's outcomes was extracted. We registered the title in Joanna Briggs Institute (JBI) that is available in http://joannabriggs.org/research/registered_titles.aspx.

RESULTS

We included 41 RCTs or quasi-RCTs or three observational study with a total of 1063 patients that evaluated pharmacological, neurosurgical, botulinum toxin, electrical neuromodulation, and behavioral therapy effects on NGB. Among the included studies only solifenacin succinate double-blind, randomized, placebo-controlled study was assessed as low risk of bias, and treatment led to an improvement in urinary incontinence.

CONCLUSIONS

Although several interventions are available for treatment NGB in patients with PD, at present there is little or no evidence that treatment improves patient outcomes in this population. Additional large, well designed, randomized studies with improved methodology and reporting focused on patient-centered outcomes are needed.

High Frequency Stimulation of the Pelvic Nerve Inhibits Urinary Voiding in Anesthetized Rats

Urge Urinary Incontinence: “a sudden and uncontrollable desire to void which is impossible to defer” is extremely common and considered the most bothersome of lower urinary tract conditions. Current treatments rely on pharmacological, neuromodulatory, and neurotoxicological approaches to manage the disorder, by reducing the excitability of the bladder muscle. However, some patients remain refractory to treatment. An alternative approach would be to temporarily suppress activity of the micturition control circuitry at the time of need i.e., urgency. In this study we investigated, in a rat model, the utility of high frequency pelvic nerve stimulation to produce a rapid onset, reversible suppression of voiding. In urethane-anesthetized rats periodic voiding was induced by continuous infusion of saline into the bladder whilst recording bladder pressure and electrical activity from the external urethral sphincter (EUS). High frequency (1–3 kHz), sinusoidal pelvic nerve stimulation initiated at the onset of the sharp rise in bladder pressure signaling an imminent void aborted the detrusor contraction. Urine output was suppressed and tone in the EUS increased. Stimulating the right or left nerve was equally effective. The effect was rapid in onset, reversible, and reproducible and evoked only minimal “off target” side effects on blood pressure, heart rate, respiration, uterine pressure, or rectal pressure. Transient contraction of abdominal wall was observed in some animals. Stimulation applied during the filling phase evoked a small, transient rise in bladder pressure and increased tonic activity in the EUS, but no urine output. Suppression of micturition persisted after section of the contralateral pelvic nerve or after ligation of the nerve distal to the electrode cuff on the ipsilateral side. We conclude that high frequency pelvic nerve stimulation initiated at the onset of an imminent void provides a potential means to control urinary continence.