Identifying and treating urinary incontinence. The crucial role of the primary care physician

The Relation between Postvoid Residual and Occurrence of Urinary Tract Infection after Stroke in Rehabilitation Unit

Objective

To determine the relation between postvoid residual (PVR) and the occurrence of urinary tract infection (UTI) in stroke patients.

Method

One hundred and eighty-eight stroke patients who were admitted to an inpatient rehabilitation unit and who did not have UTI on admission (105 males, 83 females, mean age 67.1 years) were included in this study. The PVR was measured 3 times within 72 hours after admission. Mean PVR, demographic variables, K-MMSE (Korean Mini-Mental State Examination), initial K-MBI (Korean Modified Barthel Index), Foley catheter indwelling time and stroke type were defined and the relation to the occurrence of UTI was analyzed.

Results

UTI occurred in 74 patients (39.4%) during admission to the rehabilitation unit. There were significant differences between the UTI and non-UTI groups in K-MMSE, K-MBI, Foley catheter indwelling time (p<0.01). However, age, gender, stroke location and type were not associated. The occurrence of UTI was 4.87 times higher in the patients with a mean PVR over 100 ml than in those with a mean PVR <100 ml. The mean PVR was 106.5 ml in the UTI group, while it was 62.7 ml in the non-UTI group (p<0.01). PVR was not associated with age.

Conclusion

The UTI rate is higher when the mean PVR is over 100 ml irrespective of gender and age. Close monitoring of PVR and appropriate intervention is needed to reduce the occurrence of UTI in stroke patients.

Current and emerging investigational medical therapies for the treatment of overactive bladder

Overactive bladder (OAB) is a chronic distressing condition characterised by urinary urgency with or without urge incontinence, usually with frequency (voiding at least eight times daily) and nocturia. It affects millions of people worldwide independent of age, sex and race. The prevalence increases with age and is relatively higher in women compared with men. The treatment of OAB is aimed at reducing the debilitating symptoms so as to improve the overall quality of life for patients. Anticholinergic agents targeting the muscarinic receptors in the bladder represent the mainstay of pharmacotherapy for the treatment of OAB. Besides their status as the current standard of care, use of antimuscarinic drugs is limited by certain side effects, particularly dry mouth and constipation; therefore, various attempts have been made to improve the organ selectivity of these drugs to overcome the side effects. These include the development of new antimuscarinic agents with structural modifications and the use of innovative drug delivery methods. The advancement in the drug delivery systems extends to the long-term therapeutic efficacy with improved tolerability and patient compliance; however, future prospective therapies are aimed at novel targets with novel mechanisms of action, including beta3-adrenoceptor agonists, K+ channel openers, 5-HT modulators and botulinum toxin, which are currently under different stages of clinical development. Among other investigational therapies, neurokinin receptor antagonists, alpha-adrenoceptor antagonists, nerve growth factor inhibitors, gene therapy and stem cell-based therapies are of considerable interest. The future for the development of new modalities for the treatment of OAB looks promising.

Elevated postvoid residual in women with pelvic floor disorders: prevalence and associated risk factors

A retrospective case-control study was designed to assess risks for elevated post void residual (PVR) in women with pelvic floor disorders. The 1,399 women underwent evaluation including standardized questionnaire, examination, and catheterized PVR. Elevated PVR was defined as > or =100 ml and anterior and apical prolapse was defined as at or beyond the hymen. Overall, the prevalence of elevated PVR was 11%. After matching, the absence of stress incontinence symptoms (OR 0.55, CI 0.33-0.92), the symptoms of vaginal bulge (OR 2.19, CI 1.38-3.48), pelvic pressure (OR 1.79, CI 1.14-2.86), urinary splinting (OR 2.89, CI 1.24-6.74), and presence of prolapse (OR 2.60 CI 1.62-4.18) were significantly associated with an elevated PVR. Only prolapse (OR 1.96 CI 1.37-2.79) maintained a significant association after multivariate analysis. Symptoms alone do not predict which women may have an elevated PVR, but the finding of prolapse at or beyond the hymen is associated with incomplete emptying. Elevated post void residuals cannot be predicted based on symptoms alone; however, prolapse beyond the hymen may help identify women with incomplete bladder emptying.

Postpartum Urinary and Anal Incontinence: A Population-Based Study of Quality of Life of Primiparous Women in Quebec

OBJECTIVE

To describe the quality of life of primiparous women with urinary or anal incontinence.

METHODS

A questionnaire was mailed at six months postpartum to 2492 primiparous women living in Quebec. The prevalence of urinary incontinence was assessed at six months postpartum through the FPSUND severity score index; the prevalence of anal incontinence was assessed by the grading system of Vaizey et al.; the quality of life of women who developed incontinence was assessed using the Shumaker's I-QOL for urinary incontinence and Lowry's quality of life instrument for anal incontinence. Descriptive analysis, t-test, analysis of variance, and linear regression were used.

RESULTS

The prevalence of urinary incontinence was 29.6% and of anal incontinence was 20.6%. Quality of life was affected significantly by the presence of urinary incontinence or both forms of incontinence (P 0.001) and by the type of urinary incontinence (P < 0.001). Women with all types of anal incontinence had significantly lower quality of life scores for access to toilet (P < 0.001), lifestyle (P < 0.01), self-esteem (P = 0.037), and total score (P < 0.001). Quality of life correlated with the severity of both urinary incontinence and anal incontinence: the more severe the urinary or anal incontinence, the lower the quality of life score.

CONCLUSION

Women who have urinary or anal incontinence, or both, have significant reductions in indicators of quality of life. Research is needed to evaluate strategies for preventing and treating these problems.

The synthesis and structure-activity relationships of 1,3-diaryl 1,2,4-(4H)-triazol-5-ones: a new class of calcium-dependent, large conductance, potassium (maxi-K) channel opener targeted for urge urinary incontinence

A series of 1,3-diaryl 1,2,4-(4H)-triazol-5-ones was prepared and shown by electrophysiological analysis to activate a cloned maxi-K channel mSlo (or hSlo) expressed in Xenopus laevis oocytes. The effects of these structurally novel maxi-K channel openers on bladder contractile function were studied in vitro using isolated rat bladder strips pre-contracted with carbachol. Several 1,3-diaryl 1,2,4-(4H)-triazol-5-one derivatives were found to be potent smooth muscle relaxants but this activity did not completely correlate with maxi-K channel opening.

Acute urinary retention and urinary incontinence

AUR is a commonly seen genitourinary emergency. It has many etiologies, including obstructive, neurogenic, pharmacologic, and extraurinary causes. Treatment is immediate bladder decompression by transurethral catheterization and treatment of the provoking etiology. Urinary incontinence is less commonly seen as a presenting complaint in the ED. For the emergency physician, the key lies in recognizing its underlying cause. Neurologic and pharmacologic causes need to be considered in all patients. Urinary incontinence that is not caused by a neurologic emergency can be referred for further outpatient evaluation.

Immediate-release oxybutynin versus tolterodine in detrusor overactivity: a population analysis

We evaluated adherence to treatment with immediate-release (IR) oxybutynin (515 patients) and tolterodine (505 patients) for detrusor overactivity through retrospective analysis of a pharmacy claims database. Outcomes included percentage of patients continuing therapy for 6 months, medication possession ratios, and time to discontinuation of therapy. The proportion of patients continuing therapy for 6 months was statistically superior for tolterodine (32%) compared with IR oxybutynin (22%, p<0.001). Medication possession ratios were also superior for patients in the tolterodine group (medians 0.83 and 0.64, ranges 0.11-1.15 and 0.07-1.13, respectively, p<0.001). Oxybutynin was discontinued significantly earlier (mean 45 days) than tolterodine (mean 59 days, p<0.001) and was switched to another therapy more commonly than tolterodine (19% and 14%, respectively). Tolterodine was favored over oxybutynin for several measurements of patient adherence. However, less than one-third of patients continued therapy with either agent for 6 months. The clinical relevance of these differences is unknown.

Design and SAR of novel potassium channel openers targeted for urge urinary incontinence. 1. N-Cyanoguanidine bioisosteres possessing in vivo bladder selectivity

A structurally novel series of adenosine 5'-triphosphate-sensitive potassium (K(ATP)) channel openers is described. As part of our efforts directed toward identifying novel, bladder-selective potassium channel openers (KCOs) targeted for urge urinary incontinence (UUI), we found that bioisosteric replacement of the N-cyanoguanidine moiety of pinacidil (1, Figure 1) with a diaminocyclobutenedione template afforded squaric acid analogue 2, the prototype of a novel series of K(ATP) channel openers with unique selectivity for bladder smooth muscle in vivo. Further modification of the heterocyclic ring to give substituted aryl derivatives (3) afforded potent KCOs that possessed the desired detrusor selectivity when administered orally. The effects of these potassium channel agonists on bladder contractile function was studied in vitro using isolated rat detrusor strips. Potent relaxants were evaluated in vivo in a rat model of bladder instability. Lead compounds were evaluated concomitantly in normotensive rats for their effects on mean arterial blood pressure (MAP) and heart rate as a measure of in vivo bladder selectivity. (R)-4-[3,4-Dioxo-2-(1,2, 2-trimethyl-propylamino)-cyclobut-1-enylamino]-3-ethyl-benzo nitrile (79) met our potency and selectivity criteria and represents an attractive development candidate for the treatment of UUI. Electrophysiological studies using isolated rat bladder detrusor myocytes have demonstrated that compound 79 produces significant hyperpolarization which is glyburide-reversed, thus consistent with the activation of K(ATP). The design, synthesis, structure-activity relationships (SAR), and pharmacological activity associated with this series of novel KCOs will be discussed.