Overactive Bladder in the Elderly

Oxybutynin-associated Cognitive Impairment: Evidence and Implications for Overactive Bladder Treatment

Anticholinergic medications have long been a mainstay of overactive bladder (OAB) treatment. Oxybutynin, a first-generation anticholinergic, still accounts for more than half of all OAB medication prescriptions, despite associations with impaired memory and cognition, as well as mounting evidence that it may increase the risk of incident dementia. This review details the current literature regarding oxybutynin and cognition, including evidence from preclinical, clinical, and real-world studies that show that oxybutynin binds nonspecifically to muscarinic receptors in the brain and is associated with adverse cognitive outcomes. We also discuss society recommendations to reduce use of oxybutynin and other anticholinergics to treat OAB.

Therapeutic dilemmas: cognitive enhancers and risk of falling in older adults-a clinical review

PURPOSE

Cognitive enhancers are the primary pharmacological therapy prescribed to those with dementia, comprising of memantine and the acetylcholinesterase inhibitors (AChEIs). The long-term cognitive and behavioural benefits of these medications, as well as their potential contribution to falls is currently debated, with recent Delphi studies being unable to reach consensus on whether these medications should be deprescribed. In this narrative clinical review, as part of a series on deprescribing in people at risk of falls, we explore the potential falls-related side effects experienced in people taking cognitive enhancers, alongside situations where deprescribing may be appropriate.

METHODS

We undertook a literature search of PubMed and Google Scholar, using terms capturing falls and cognitive enhancers, as well as consulting the British National Formulary and published Summary of Medicinal Product Characteristics. These searches informed the subsequent clinical review.

RESULTS

Cognitive enhancers should be subject to regular review, including confirmation of appropriate treatment indication, and occurrence of side effects in the context of falls. AChEIs, in particular, are associated with a broad range of side effects that can contribute to increased falls risk. These include bradycardia, syncope and neuromuscular effects. Where these have been identified, deprescribing should be considered, as well as alternative treatment options. Deprescribing studies have shown mixed results, likely due to considerable methodological heterogeneity. Several suggested guidelines exist to aid deprescribing decisions, many of which are highlighted in this review.

CONCLUSIONS

The use of cognitive enhancers should be regularly reviewed and decisions to deprescribe made on a case-by-case basis, considering both the risks and benefits of stopping these medications.

Association of decreased grip strength with lower urinary tract symptoms in women: a cross-sectional study from Korea

BACKGROUND

Lower urinary tract symptoms (LUTS) including frequency, nocturia, urgency, and incontinence, are common in women and cause significant discomfort in daily life. However, diagnosis and treatment of LUTS are often delayed because many patients with such symptoms do not complain to the physician of discomfort and do not seek medical attention. LUTS are known to be associated with muscle weakness. We investigated the association between grip strength and LUTS in women of different ages.

METHODS

This study included 4225 women (mean age 48.6 years) who underwent self-referred health screening between April 2015 and December 2019. LUTS were evaluated using a self-reported questionnaire, and the overactive bladder symptom score was used to screen for an overactive bladder. Low muscle strength was defined as a hand grip strength of < 18 kg (decreased grip strength).

RESULTS

We observed decreased grip strength in 13.7% (n = 580) of the participants. Nocturia, urgency, incontinence, and overactive bladder were more common in women with decreased grip strength than in women with normal grip strength. After adjusting for age, comorbidities (hypertension, diabetes, hyperlipidemia), smoking status, alcohol consumption, regular exercise, and stress, nocturia (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.01-1.52), urinary incontinence (OR 1.32, 95% CI 1.01-1.72), and an overactive bladder (OR 1.75, 95% CI 1.35-2.27) were significantly associated with decreased grip strength.

CONCLUSIONS

The findings suggest that LUTS, especially nocturia, incontinence, and an overactive bladder are associated with decreased grip strength in women. Therefore, physicians should be aware that patients may not seek help, even if they are uncomfortable, and it is important to obtain a detailed medical history and perform additional tests, even in the absence of complaints, in patients with low grip strength, who are at high risk of LUTS.

Gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic drugs for overactive bladder treatment

Introduction: Overactive bladder (OAB) has a heterogeneous presentation that varies between individuals and by gender. Treatment with antimuscarinic medications is standard first line pharmacotherapy for most patients with OAB. However, gender specific differences in the pharmacokinetics and pharmacodynamics of antimuscarinic therapy are often overlooked and not discussed.Areas covered: This review will explore differences by gender between the presentation and treatment of OAB. We will discuss the differences between sexes in terms of lower urinary tract anatomy, muscarinic receptors, and hormone variation. The effect of antimuscarinics on males and females as well as adherence and persistence patterns will be reviewed in order to fully review all available literature on the gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic use in the treatment of OAB.Expert opinion: Despite extensive research into various antimuscarinic formulations and therapeutic regimens for the treatment of OAB, identification of gender specific pharmacokinetic and pharmacodynamics considerations remains scant. As our knowledge and understanding of OAB, muscarinic receptors, and antimuscarinic medications evolve, we will hopefully be better able to understand and implement gender-specific and genomic-sprecific treatment regimens and considerations for improved clinical outcomes.

Cognitive changes in women starting anticholinergic medications for overactive bladder: a prospective study

INTRODUCTION AND HYPOTHESIS

To assess cognitive changes in women 12 months after starting anticholinergic medications for overactive bladder syndrome (OAB).

METHODS

We present a prospective cohort study assessing changes in cognition in women seen in a referral urogynecology practice. We compared women who started anticholinergic OAB medications with women not on anticholinergic OAB medications. The primary outcome was change over time on the Montreal Cognitive Assessment (MOCA) screening score. At enrollment, women completed a baseline MOCA screening, a Geriatric Depression Screen (GDS), and an assessment of medications to create an anticholinergic burden score (ACB). At 3, 6, 9, and 12 months after enrollment women were administered the MOCA, GDS, and a review of their medications and medical problems. Statistical analysis was performed using a linear mixed effects model taking into account correlated error terms given multiple MOCA assessments at various time points per patient.

RESULTS

A total of 106 women were enrolled, 60 in the OAB medication group and 46 in the control (non-OAB medication) group. The mean age was 77 years, 93% of women were Caucasian, and 98% completed high school, with no difference between groups. Over time there was no difference in change of MOCA score between the OAB and control groups when controlling for age, GDS score, and ACB score (p = 0.78). This association did not change when women with a neurological diagnosis were excluded (n = 6). On average MOCA scores for the OAB group increased by 0.76 over 12 months and the control group increased 0.39, with no difference between the groups (p = 0.53).

CONCLUSIONS

We found no changes in MOCA scores between OAB medication and control groups after controlling for age, depression, and polypharmacy after 12 months of follow-up.

International Consultation on Incontinence 2016; Executive summary: Urodynamic testing

AIMS

The International Consultation on Incontinence has published an update of the recommendations for the diagnosis and management of urine incontinence (ICI2016). This manuscript summarizes the consultations committee-recommendations with regard to urodynamic assessment.

METHODS

Expert consensus on the basis of structured evidence assessment has been the basis of the consultations publication and has been summarized by the committee for this manuscript.

RESULTS

Patients that are not satisfied with their initial management on the basis of their reported signs and symptoms of urinary incontinence, as well as all patients with neurological abnormalities that are potentially relevant for the function of the lower urinary tract, may very likely profit from objective diagnosis and staging and grading of their dysfunction, with urodynamic testing, regardless their age, vulnerability and/or comorbidities. The principles and technical innovations as well as the principal recommendations for the utilization of (invasive) urodynamic assessment for women, men, children, and vulnerable elderly, with or without neurogenic lower urinary tract dysfunction with urinary incontinence are provided in this abbreviated ICI recommendations-document.

CONCLUSIONS

The ICI2016 committee on urodynamics presents an executive summary of the most important reasons and recommendations for the use of urodynamic investigations for patients with urinary incontinence.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

Not applicable.

Electronic supplementary material

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

Assessment of inhibitory effects on major human cytochrome P450 enzymes by spasmolytics used in the treatment of overactive bladder syndrome

BACKGROUND

The objective of this study was to examine the inhibitory potential of darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine and trospium chloride on the seven major human cytochrome P450 enzymes (CYP) by using a standardized and validated seven-in-one cytochrome P450 cocktail inhibition assay.

METHODS

An in vitro cocktail of seven highly selective probe substrates was incubated with human liver microsomes and varying concentrations of the seven test compounds. The major metabolites of the probe substrates were simultaneously analysed using a validated liquid chromatography tandem mass spectrometry (LC-MS/MS) method. Enzyme kinetics were estimated by determining IC50 and Ki values via nonlinear regression. Obtained Ki values were used for predictions of potential clinical impact of the inhibition using a static mechanistic prediction model.

RESULTS

In this study, 49 IC50 experiments were conducted. In six cases, IC50 values lower than the calculated threshold for drug-drug interactions (DDIs) in the gut wall were observed. In these cases, no increase in inhibition was determined after a 30 min preincubation. Considering a typical dosing regimen and applying the obtained Ki values of 0.72 µM (darifenacin, 15 mg daily) and 7.2 µM [propiverine, 30 mg daily, immediate release (IR)] for the inhibition of CYP2D6 yielded a predicted 1.9-fold and 1.4-fold increase in the area under the curve (AUC) of debrisoquine (CYP2D6 substrate), respectively. Due to the inhibition of the particular intestinal CYP3A4, the obtained Ki values of 14 µM of propiverine (30 mg daily, IR) resulted in a predicted doubling of the AUC for midazolam (CYP3A4 substrate).

CONCLUSIONS

In vitro/in vivo extrapolation based on pharmacokinetic data and the conducted screening experiments yielded similar effects of darifenacin on CYP2D6 and propiverine on CYP3A4 as obtained in separately conducted in vivo DDI studies. As a novel finding, propiverine was identified to potentially inhibit CYP2D6 at clinically occurring concentrations.

Overactive bladder - 18 years - Part II

Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics - pillars of the overactive bladder pharmacotherapy - started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning - as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder - 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Practical points in the medical treatment of overactive bladder and nocturia in the elderly

The prevalence of overactive bladder (OAB) increases with age. Degeneration of the central nervous system in the elderly has been proposed as one of the pathogenic factors of OAB. Antimuscarinic therapy is effective in the treatment of OAB; however, intolerable systemic adverse events and cognitive dysfunction during treatment with nonselective antimuscarinic agents is of growing concern in elderly patients. The newly developed beta-3 adrenoceptor agonist mirabegron does not adversely affect flow rate and detrusor pressure, and its therapeutic efficacy and tolerability are similar in patients aged > 65 years and > 75 years, suggesting it might be the therapeutic choice in older patients with OAB. Nocturia can cause sleep deprivation at night and increase daytime sleepiness and loss of energy in the elderly. Desmopressin add-on therapy is effective in improving nocturia and storage symptoms. However, elderly patients with a baseline serum sodium level below the normal range are at high risk of developing significant hyponatremia.

Treatment of Overactive Bladder in the Elderly Female: The Case for Trospium, Oxybutynin, Fesoterodine and Darifenacin

Overactive bladder (OAB) is a common constellation of lower urinary tract storage symptoms that causes a significant impact on a person's quality of life. The elderly may be disproportionally impacted by these symptoms due to concomitant poor mobility, comorbid conditions such as diabetes and heart failure, and polypharmacy. While behavioral modification and pelvic floor muscle training should be considered first-line treatment options, pharmacotherapy remains the backbone of the therapeutic regimen. Trospium, oxybutynin, fesoterodine, and darifenacin all have unique properties that may confer certain advantages in the elderly population. The hydrophilicity and quaternary amine structure of trospium may limit its ability to cross the blood-brain barrier and thus minimize impact on cognition in the elderly. In its oral form, oxybutynin may have the most significant effect on cognition; however, the transdermal preparations may be favorable in the elderly population due to the ability to avoid first-pass metabolism and its limited antimuscarinic adverse effects. Fesoterodine may be the most extensively studied OAB medication in the elderly population. Darifenacin has a strong affinity for the M3 receptor in the bladder, while having a weak affinity for the M1 receptor commonly found in the brain. It must be noted that all muscarinic receptor antagonists are associated with common adverse effects to some degree, and frequent re-evaluation of the elderly patient is necessary to confirm the proper benefit-to-risk profile.

Antimuscarinic use among individuals with urinary incontinence who reside in long-term care facilities

PURPOSE

To assess appropriateness of antimuscarinic use in long-term care facilities (LTCFs) among treated and untreated urinary incontinence (UI) residents from 2007 to 2009.

METHODS

We conducted a retrospective analysis using the AnalytiCare(SM) database consisting of minimum data sets (MDS) assessments and prescription records of 90,660 residents from 2007 to 2009. UI (MDS H1b ≥ 1) residents with ≥ 14-day LTCF stay were identified and categorized as treated if they had ≥ 1 antimuscarinic prescription and untreated if they had no antimuscarinics. A random sample of untreated residents was matched based on treated residents' type of MDS assessment. We defined appropriate antimuscarinic use if residents had adequate cognitive function [≤ 4 on the cognitive performance scale (0 = intact to 6 = very severe impairment)] and mobility [scoring <4 on mobility for toileting scale (MDS item G1iA 0 = independent to 4 = total dependent)]. Chi-square tests were used to detect statistical difference between cohorts.

RESULTS

A total of 5,327 residents (2,840 treated; 2,487 untreated) were selected [mean age (standard deviation) 80 (8), 81 (8) years; female (76, 65 %), respectively]. On study-defined MDS assessment, 63 % of treated and 69 % of untreated residents had UI (P < 0.01). Approximately 84 % of treated and 74 % of untreated residents may have had cognitive function and mobility sufficient for appropriate antimuscarinic use (P < 0.01).

CONCLUSIONS

Our study identified a high percentage of LTCF residents with UI who may have been candidates for antimuscarinics. However, due to the MDS limitation, we were unable to identify overactive bladder patients among these untreated residents with UI. It is possible that untreated control residents had UI due to other factors not amenable to treatment with antimuscarinic agents. Therefore, choice of treatment for each resident needs to be individualized and carefully monitored for efficacy and adverse effects. This retrospective analysis requires prospective confirmation. Proper patient selection for antimuscarinic treatment requires careful assessment of underlying physical status including cognitive function, mobility, and comorbidities.

A comparative analysis of pelvic floor muscle strength in women with stress and urge urinary incontinence

AIMS

To assess pelvic floor muscle (PFM) strength in women with stress urinary incontinence (SUI) and urge urinary incontinence (UUI).

MATERIALS AND METHODS

51 women were prospectively divided into two groups, according to the symptoms as SUI (G1 = 22) or UUI (G2 = 29). Demographic data, such as number of pads/ 24 hours, number of micturations/ 24 hours and nocturia, delay time of urgent void (i.e., the time period for which an urgent void could be voluntarily postponed), number of parity and vaginal deliveries were obtained using a clinical questionnaire. Objective urine loss was evaluated by 60-min. Pad Test, subjective urine stream interruption test (UST) and visual survey of perineal contraction. Objective evaluations of PFM were performed in all patients (vaginal manometry).

RESULTS

Median of age, mean number of pads / 24 hours, nocturia and warning time were significantly higher in UUI comparing to SUI group. During UST, 45.45% in G1 and 3.44%, in G2, were able to interrupt the urine stream (p < 0.001). The 60-min. Pad Test was significantly higher in G2 compared to G1 women (2.7 ± 2.4 vs 1.5 ± 1.9 respectively, p = 0.049). Objective evaluation of PFM strength was significantly higher in the SUI than in the UUI patients. No statistical difference was observed regarding other studied parameters.

CONCLUSION

Pelvic floor muscle weakness was significantly higher in women with UUI when compared to SUI.

Mirabegron: β3-Adrenergic Receptor Agonist for the Treatment of Overactive Bladder

OBJECTIVE

To review the place in therapy of mirabegron, a new oral β3-adrenergic receptor agonist, for the treatment of overactive bladder (OAB).

DATA SOURCES

A literature search of MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations Databases (1996-April 2013) was conducted using the key words mirabegron, receptor, adrenergic, beta-3; adrenergic beta-3 receptor; beta-3 receptor, and overactive bladder; urinary bladder; overactive. All published articles regarding mirabegron were included. References of selected articles, data from poster presentations, and abstract publications were additionally reviewed.

STUDY SELECTION AND DATA EXTRACTION

Available English-language data from reviews, abstracts, presentations, and clinical trials of mirabegron in humans were reviewed; relevant clinical data were selected and included.

DATA SYNTHESIS

Mirabegron is the newest option for treatment of OAB with symptoms of urge incontinence. As a β3-receptor agonist, it reduces bladder muscle contractions. In two 12-week, randomized, double-blind, placebo-controlled Phase 3 studies, mirabegron significantly reduced the number of incontinence episodes per 24 hours from baseline (−1.47, −1.63, and −1.13; p < 0.05; and −1.57, −1.46, and −1.17; p < 0.05; all values for mirabegron 50 mg, 100 mg, and placebo). Micturitions per 24 hours were also reduced from baseline (−1.66, −1.75, and −1.05; p < 0.05; and −1.93, −1.77, and −1.34; p < 0.05; all values for mirabegron 50 mg, 100 mg, and placebo). A 12-month trial found mirabegron to have a safety and efficacy profile similar to that of tolterodine.

CONCLUSIONS

Treatment of OAB initially includes lifestyle and nonpharmacologic intervention; for patients with persistent symptoms despite these treatments, drug therapy represents a next-step approach for symptom control. Mirabegron alleviates symptoms of OAB while having a mechanism of action that provides an alternative for patients who are intolerant of or who have contraindications to anticholinergic agents. The place in therapy of mirabegron relative to anticholinergics in the treatment of urge incontinence has not yet been established.

Muscarinic agonists and antagonists: effects on the urinary bladder

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

Brain penetration of the OAB drug trospium chloride is not increased in aged mice

Purpose

To analyse whether the permeability of the blood–brain barrier to the antimuscarinic drug trospium chloride is altered with ageing. This is a relevant question for elderly patients with overactive bladder syndrome who are treated with trospium chloride as the occurrence of adverse effects on the central nervous system (CNS) highly depends on the absolute drug concentration in the brain.

Methods

Trospium chloride at 1 mg/kg was intravenously administered to adult, middle-aged, and aged mice at 6, 12, and 24 months of age, respectively, and the absolute drug concentrations in the brain were analysed after 2 h. Furthermore, mRNA expression levels of relevant markers of blood–brain barrier integrity (occludin, claudin-5, and the drug efflux carrier P-glycoprotein) were analysed in brain samples from adult and aged mice.

Results

The absolute brain concentrations of the drug were identical in adult and middle-aged mice (13 ± 2 ng/g vs. 13 ± 2 ng/g) and were slightly, but significantly, lower in aged mice (8 ± 4 ng/g). The brain/plasma drug concentration ratios were not different between the age groups and demonstrated the generally low capability of trospium chloride in permeating the blood–brain barrier. Occludin, claudin-5, and P-glycoprotein showed identical mRNA expression levels in the brains of adult and aged mice.

Conclusion

Based on our in vivo data in a mouse model, we conclude that trospium chloride permeation across the BBB is not increased in ageing per se, and therefore, the occurrence of adverse CNS drug effects is also not expected to increase with ageing.

Once-daily trospium chloride 60 mg extended release in subjects with overactive bladder syndrome who use multiple concomitant medications: Post hoc analysis of pooled data from two randomized, placebo-controlled trials

BACKGROUND

Overactive bladder syndrome (OAB) is associated with various co-morbidities; treatment of these frequently results in multiple medication use (MMU) and the potential for drug-drug interactions, which may lead to adverse events and altered efficacy. With the aging population, the prevalence of MMU is likely to increase in the overall population, an increase due in part to treatment of co-morbidities that are more common in the elderly.

OBJECTIVE

To assess safety and efficacy outcomes with once-daily trospium chloride 60 mg extended release (XR) in subjects with OAB who were taking multiple concomitant medications.

STUDY DESIGN

Post hoc analysis of pooled data from two 12-week randomized, placebo-controlled studies.

SETTING

Urology, urogynaecology, and primary care offices/clinics.

PATIENTS

Subjects aged ≥18 years with OAB for ≥6 months who had baseline urinary frequency of ≥30 toilet voids/3 days; ≥1 'severe' urgency severity rating/3 days (on the Indevus Urgency Severity Scale); and pure urge urinary incontinence (UUI) or mixed incontinence with predominant UUI, with ≥3 UUI episodes/3 days. This analysis utilized data from subjects taking concomitant medications, focusing on those taking seven or more.

INTERVENTION

Once-daily trospium chloride 60 mg XR or placebo.

MAIN OUTCOME MEASURE

Predictors of treatment-emergent adverse events (TEAEs) identified by multivariate logistic regression analysis.

RESULTS

Concomitant medications were being taken by 1135 subjects (placebo, n = 576; trospium chloride XR, n = 559); 427 were taking seven or more (placebo, n = 199; trospium XR, n = 228). Among subjects taking seven or more concomitant medications, there was no significant difference between trospium chloride XR and placebo in the proportion of subjects experiencing one or more TEAEs (64.5% vs 58.3%). Logistic regression analysis indicated that the odds of experiencing a TEAE were influenced by concomitant medication use, but not by randomization assignment to trospium chloride XR or to placebo, suggesting that concomitant drugs contribute more to TEAEs than trospium chloride XR. Compared with subjects taking one to two concomitant medications, the adjusted odds ratio (OR) for experiencing any TEAE was 3.39 (95% CI 2.39, 4.80; p < 0.0001) for subjects taking seven or more concomitant medications. The adjusted OR for experiencing any TEAE for subjects randomized to active treatment compared with placebo was 1.19 (95% CI 0.85, 1.67; p = 0.31). Efficacy in subjects taking seven or more concomitant medications was similar to that in the overall pooled study population.

CONCLUSIONS

Trospium chloride XR does not increase the likelihood of a TEAE compared with placebo. The probability of experiencing a TEAE was significantly influenced by use of multiple concomitant medications. Trospium chloride XR was as effective in subjects with OAB taking seven or more concomitant medications as in the overall pooled study population. The data support the conclusion that trospium chloride XR is safe and effective in patients with OAB taking multiple concomitant medications.

Urological Disorders in Men

Urinary incontinence (UI) and benign prostatic hyperplasia (BPH) are 2 common urogenital problems in men. UI is associated with involuntary leakage of urine and lower urinary tract symptoms (LUTS) of urgency, frequency, and nocturia. Types of UI include functional, urge, stress, and overflow. Treatment for UI is based on the type of incontinence, patient-specific factors, and treatment preferences of both patients and health care providers. Options for the management of UI include environmental modifications, disposable incontinence products, pelvic floor exercises, pharmacotherapy, surgically implanted devices, and intermittent catheterization. BPH may be also associated with LUTS. Patient symptoms, assessed with a measurement tool such as the American Urological Association Symptom Index (AUASI), serve as the basis for determining treatment. Management approaches for BPH include pharmacotherapy, surgery, and minimally invasive procedures. Anticholinergic drugs as well as α-receptor antagonists and 5-α reductase inhibitors, either alone or in combination, are effective and useful for LUTS unresponsive to traditional pharmacotherapy. Transurethral resection of the prostate (TURP) can eliminate symptoms of BPH but is associated with relatively more complications than other available surgical and minimally invasive procedures.

Review of cognitive impairment with antimuscarinic agents in elderly patients with overactive bladder

Overactive bladder (OAB) will become an increasingly prevalent problem as the proportion of older people in the population increases over the next 20 years. In addition to the urological symptoms (urinary urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia), OAB is associated with other problems in older patients, especially an increased risk of falls and fractures. The bother caused by OAB needs not be an inevitable consequence of ageing, because the symptoms can usually be alleviated, even in frail older people. Pharmacological treatment for OAB involves the use of antimuscarinic agents, whose efficacy and safety profiles depend on their interactions with muscarinic receptors that are widely distributed throughout the body. Interactions between antimuscarinics and M(1) receptors in the central nervous system may have the potential to cause cognitive impairment in older people, depending on muscarinic receptor binding profiles, lipophilicity and the ability to cross the blood brain barrier. Concerns over the possibility of cognitive impairment have contributed to an under-utilisation of antimuscarinics in the geriatric population, despite the high prevalence and severity of OAB in older subjects. Antimuscarinic agents should be actively considered for elderly patients with OAB, but it is desirable to establish the cognitive risk for every type of antimuscarinic, using robust cognition assessment methods.

Nocturia

Nocturia is a common symptom in women which has profound negative impact on the quality of life. With the increase in aging population, nocturia is becoming an important clinical problem. A proper understanding of cardio-respiratory, metabolic, and neurological patho-physiology of nocturia is imperative for appropriate management of nocturia. When managing a patient with nocturia it is important to evaluate the patient as a whole rather than from urological perspective only. In this article we attempt to discuss the definition, etiology, clinical features and management of nocturia so that a comprehensive approach to management can be adopted when faced with a woman complaining of nocturia.

Perspectives on overactive bladder in the elderly population

INTRODUCTION

Overactive bladder (OAB) represents a disruption in the storage function of the lower urinary tract. This bothersome condition occurs more commonly in the elderly. Since population forecasts predict a worldwide increase in the proportion of people aged over 65 years, it is reasonable to expect that the healthcare burden associated with OAB will also increase. The pathophysiology of OAB in the elderly is thought to be multifactorial, with an abnormality occurring in the nervous supply and/or the structure/function of the urothelium or bladder smooth muscle, leading to bladder hypersensitivity, abnormalities in bladder sensation (urgency) and involuntary detrusor contraction.

METHODS

A review of some of the key aspects relating to management of this growing population was undertaken.

RESULTS

The potential for an elderly patient to present with a number of concomitant conditions means that careful characterization of their overall status is required before deciding on the most appropriate management option for their urinary tract pathology. Lifestyle interventions and pharmacological agents have shown success in treating OAB in the elderly, but as this patient group often has many concomitant conditions they are more likely to be seen by a non-urology specialist.

CONCLUSIONS

It is therefore important to raise awareness of the condition and an appreciation of its impact among healthcare professionals to ensure the most appropriate care.

Trospium and cognition in patients with late onset Alzheimer disease

OBJECTIVES

Cholinesterase inhibitors for the treatment of Alzheimer's Disease (AD) and antimuscarinic agents for the treatment of urge urinary incontinence (UUI) may reduce the potential effect of each other in the patients with both diseases. Trospium has a relatively low lipophilicity and low CNS penetration, and galantamine, a cholinesterase inhibitors, has also allosterically modulates nicotinic cholinergic receptors. This study was designed to evaluate the effects of dual use of trospium and galantamine for 6 months in the elderly patients with AD and UUI.

SETTING/PARTICIPANTS

One hundred and seventy eight elderly patients: 99 UUI patients (Group I, treated with trospium), 43 AD patients (Group II, treated with galantamine) and 36 AD and UUI patients (Group III, treated with galantamine and trospium) were evaluated by geriatric assessments, the Global Perception Index (GPI), Patients' Satisfaction Question (PSQ), Estimated Patients' Improvement (EPI), nocturia and pads/day at baseline and in the 6th month.

RESULTS

Trospium increased the satisfaction of the patients in Groups I and III according to the EPI, PSQ, GPI, number of nocturia and pads/day. Decreasing in the GDS score was significant in the Group I and III (p < 0.05). Decreasing in the ADL score was significant in the Group III (p < 0.05). The MMSE scores were not significantly changed in the all groups during the 6 months.

CONCLUSION

Consequently, we have thought that a combination of trospium and galantamine could be recommended for the management of the elderly patients with UUI and AD, which are common problems in the elderly.

Tolterodine extended release is well tolerated in older subjects

OBJECTIVES

To investigate the tolerability of tolterodine extended release (ER) in older subjects with overactive bladder (OAB).

METHODS

This was a retrospective analysis of pooled data from five large, randomised, double-blind, placebo-controlled trials. Subjects with OAB symptoms, including urinary frequency and urgency (and nocturia in two studies) with or without urgency urinary incontinence, received qd treatment with tolterodine ER (4 mg) or placebo for 8-12 weeks. Data were stratified post hoc by age group: < 65 (n = 2531), 65-74 (n = 1059) and > or = 75 years (n = 573). Tolerability was assessed by evaluating the occurrence of adverse events (AEs). AE occurrences from each study were mapped to the MedDRA coding dictionary of preferred terms.

RESULTS

Discontinuation rates were slightly higher among subjects > or = 75 years of age vs. those < 65 years of age; however, this was observed in subjects treated with placebo as well as tolterodine ER. Overall, there were no significant differences in the occurrence of dry mouth, headache, constipation, nausea, urinary tract infection, blurred vision, dry eye, dizziness and micturition disorder in older (65-74 or > or = 75 years) vs. younger (< 65 years) subjects treated with tolterodine ER relative to placebo (treatment x age; all p > 0.1). Dry mouth was the only AE consistently associated with tolterodine ER treatment (< 65 years, 17%; 65-74 years, 16%; > or = 75 years, 15%). The occurrence of all other AEs was < or = 5% in most age and treatment cohorts. Most AEs were mild or moderate in all age and treatment cohorts.

CONCLUSION

The nature and frequency of AEs associated with tolterodine ER treatment were similar across age groups in subjects with OAB, suggesting that tolterodine ER was not associated with an increased risk of AEs in older vs. younger subjects and, thus, is a suitable first-line pharmacotherapy treatment for OAB in this population.

Trospium chloride treatment of overactive bladder

OBJECTIVE

To review the pharmacology, pharmacokinetics, safety, and clinical application of trospium chloride for the management of overactive bladder (OAB).

DATA SOURCES

Clinical literature including both primary sources and review articles was accessed through MEDLINE, International Pharmaceutical Abstracts, and Cochrane databases from 1980 through January 8, 2009. Search terms included overactive bladder, urge urinary incontinence, muscarinic receptor antagonists, and urinary frequency. Further data sources were identified from bibliographies of selected articles.

STUDY SELECTION AND DATA EXTRACTION

Basic pharmacology data were extracted from animal studies and pharmacokinetic data were gathered from human studies. Multicenter, parallel, randomized, double-blind, placebo-controlled studies were included to describe the efficacy and adverse effects of trospium.

DATA SYNTHESIS

Trospium chloride is an antimuscarinic agent indicated for the treatment of OAB with symptoms of urge urinary incontinence, urgency, and urinary frequency. Trospium has 3 chemical and pharmacokinetic properties unique among antimuscarinic agents: it is a positively charged quaternary ammonium compound with minimal central nervous system penetration; it is not metabolized by the cytochrome P450 system, resulting in a lower tendency for drug interactions; and it is excreted mainly unchanged in the urine as the active parent compound, providing local activity to achieve early onset of clinical effect and prolonged efficacy. In two 12-week, randomized, placebo-controlled clinical studies in adults with OAB, trospium 20 mg twice daily was more effective than placebo in reducing the number of micturitions per 24 hours, reducing the number of urge incontinence episodes per week, and increasing the volume of urine voided per micturition. Placebo-controlled trials report efficacy with trospium in treatment of OAB; comparative trials with other anticholinergic agents are limited. Current therapy of OAB consists primarily of anticholinergic drugs such as oxybutynin, which are associated with therapy-limiting adverse effects. Because the prevalence of OAB is greatest among the elderly, safety considerations regarding renal function must be noted, with dosage adjustment required in patients with severe renal impairment.

CONCLUSIONS

Whether the pharmacodynamic properties of trospium make it superior to other therapies will require considerable additional experience with the drug. For now, it appears to be a feasible alternative for patients who cannot tolerate oxybutynin.

Efficacy and safety of duloxetine in elderly women with stress urinary incontinence or stress-predominant mixed urinary incontinence

OBJECTIVES

To evaluate the efficacy and safety of duloxetine in community-dwelling women > or =65 years with stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (S-MUI) versus placebo.

METHODS

Patients were randomly assigned for 12 weeks to placebo (N=134) or duloxetine (N=131) (20mg twice daily [BID] for 2 weeks and 40 mg BID for an additional 10 weeks), followed by a double-blind 4-week dose de-escalation/discontinuation phase. The primary efficacy variable was the percent change in incontinence episode frequency (IEF) from baseline to endpoint. Other variables included absolute IEF change, responder rate, changes in mean time between voids (MTBV), weekly continence pad usage, the impact of treatment on quality of life, patient's global impression of improvement (PGI-I), and changes in depression and cognition.

RESULTS

Duloxetine-treated patients had a significantly greater decrease from baseline to endpoint in mean IEF/week than placebo-treated patients (-52.47% vs. -36.70%, P<0.001). The IEF responder rate (> or =50% reduction in IEF/week) was 57.1% in the duloxetine group and 35.2% in the placebo group (P<0.001). Significant benefits of duloxetine were also demonstrated for weekly continence pad usage (P=0.011), MTBV (P<0.001), incontinence quality of life questionnaire (I-QOL) scores (P<0.001), and PGI-I ratings (P<0.001). Patients with depressive symptoms and cognitive impairments were few and changes were insignificant. The proportion of patients with > or =1 treatment-emergent adverse event (TEAE) was similar with both treatments, but dry mouth, fatigue, constipation, and hyperhidrosis were significantly more common in women taking duloxetine.

CONCLUSIONS

Duloxetine is a safe and effective treatment for elderly women with symptoms of SUI or S-MUI.

Long-term darifenacin treatment for overactive bladder in patients aged 65 years and older: analysis of results from a 2-year, open-label extension study

OBJECTIVES

This analysis evaluated the long-term safety, tolerability and efficacy of darifenacin, a muscarinic M3 selective receptor antagonist, in the treatment of overactive bladder (OAB) in patients > or = 65 years of age.

METHODS

Patients who completed one of two 12-week, placebo-controlled, double-blind, feeder studies received once-daily (o.d.) treatment with darifenacin 7.5 mg for the first 2 weeks of the 2-year, open-label extension study. The dose could be subsequently adjusted (7.5 or 15 mg o.d.) according to need. Safety and tolerability were assessed, and efficacy variables/endpoints were evaluated from patient diary data.

RESULTS

214 patients (65-89 years) entered and 137 (64.0%) completed the 2-year extension study, amounting to 308 patient-years' drug exposure. Darifenacin was well tolerated with no new safety concerns. The most common adverse events (AEs) were dry mouth and constipation, which infrequently resulted in discontinuation (2.3% and 4.2%, respectively). Darifenacin produced significant improvements in OAB symptoms that were maintained over the 2-year period (median reduction from feeder-study baseline to 2 years: -11.0 [-83.7%] for incontinence episodes/week and -1.2 [-12.4%] for micturitions/day, both p < 0.05), with 44.4% patients achieving > or = 90% reduction in incontinence episodes at 2 years.

CONCLUSIONS

Darifenacin demonstrated good tolerability and safety in older patients with OAB. The improvement in OAB symptoms was sustained throughout the 2-year extension, resulting in high treatment persistence rates. Results were comparable with those in the overall OAB population from this study, indicating that darifenacin treatment is effective and well tolerated irrespective of age.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Extrapyramidal signs, primitive reflexes and incontinence in fronto-temporal dementia

According to the diagnostic consensus criteria [1] akinesia, rigidity and tremor as well as primitive reflexes and incontinence support the diagnosis of fronto-temporal dementia (FTD). However, the prevalence of extrapyramidal signs (EPMS), primitive reflexes and incontinence in FTD has not yet been systematically studied. In the present study, thirty-one patients with mild or moderate FTD without previous or present antipsychotic medication underwent a detailed neurological exam including the motor part of the Unified Parkinson's Disease Rating Scale (UPDRS). The average total score on the motor subscale of the UPDRS was 14.0 points. Akinesia and Parkinsonian gait or posture were found frequently but were mild in most instances. Rigidity was found in 36% of the patients. Resting tremor was a rare symptom. The only primitive reflex that occurred was a positive palmomental that was found in 7% of the patients. Urinary incontinence was present in 26%. The results have to be confirmed with larger or pooled patient samples from different ascertainment scenarios. If the results of the present study can be replicated, a revision of the consensus criteria from 1998 might be considered.

Psychological morbidity and female urinary incontinence

Female urinary incontinence is a common yet distressing condition. It affects women of all ages, but is especially common in the elderly. Its prevalence ranges from 15 to 55%, depending on age and population studied. Despite the ubiquity of female urinary incontinence, many incontinent women do not voice their suffering, and urinary incontinence has therefore been dubbed 'the silent epidemic'. The physical impact and social isolation associated with urinary incontinence lead to impairment of quality of life and psychological well-being. It is the aim of this review to discuss the epidemiology and psychological impact of urinary incontinence. The recognition and management of incontinence-related psychological morbidity are also explored.

Solifenacin provides effective antimuscarinic therapy for the complete management of overactive bladder

Solifenacin is an antimuscarinic agent, administered once daily, which has been newly approved for the treatment of overactive bladder (OAB). Solifenacin administered at 5- and 10-mg once-daily doses shows efficacy for all the symptoms of OAB in both 'wet' and 'dry' patients, including improvements in patient quality of life and satisfaction. These improvements are observed as early as week 2 of treatment and are maintained over 12-week and 1-year time periods, without being compromised by the age or gender of the patient. Solifenacin demonstrates a favourable tolerability profile, with mild dry mouth as the most common adverse event associated with its use, both at the 5- and 10-mg doses; this allows for flexibility in the dosing regimen, in which physicians can administer solifenacin 5 mg, with the option to safely increase the dose to 10 mg if necessary based on the severity of patient's symptoms. The favourable efficacy and safety profile of solifenacin, coupled with its dose flexibility, are consistent with solifenacin being a convenient treatment option for patients with OAB.

New transdermal bioadhesive film containing oxybutynin: In vitro permeation across rabbit ear skin

Oxybutynin is used extensively in the treatment of patients with overactive bladder. The aim of this work was to realize and test in vitro a new transdermal bioadhesive film containing oxybutynin. Transdermal films were prepared by dissolving in water an adhesive (Plastoid), a film-forming polymer (polyvinyl alcohol), a plasticizer (sorbitol) and the drug. The mixture was then spread on siliconized paper and oven-dried. Permeation experiments were conducted in Franz-type diffusion cells using rabbit ear skin as barrier. The donor compartment contained a water solution, the prepared film (with or without backing) or the commercial patch (Oxytrol). The experiments were performed for 24h. Oxybutynin showed good permeation characteristics across the skin. When the film was applied in occlusive conditions the release profiles were much higher than in non-occlusive conditions, reaching 50% of drug permeated after 24h. Compared to the commercial patch Oxytrol, the film was more efficient suggesting that a smaller area or a lower drug loading could be employed. The results obtained show that the bioadhesive film can be a promising and innovative therapeutic system for the transdermal administration of oxybutynin.