Primary Care Management of Upper Respiratory Infections in the Women's Health Care Setting

Upper respiratory infections (URIs) are the most common reason for which individuals seek health care services in the outpatient clinical setting. This case report describes the clinical presentation and management of a woman with a URI. The signs and symptoms of URIs, physical examination, differential diagnoses, and treatment plan options available in the ambulatory care setting are reviewed. Current evidence-based guidelines are discussed, and recommendations for clinical practice are reviewed. Discussion of the incidental treatment of URIs in the specialty care setting is also addressed.

A double-blind, cross-over study of the effects of terodiline in women with unstable bladder

In a double-blind, cross-over study, the effects of terodiline were evaluated in 12 women with motor urge incontinence. The patients were investigated by simultaneous urethro-cystometry before and after treatment fo 2-week periods with placebo and terodiline 12.5 mg twice daily. The effects on subjective symptoms were also assessed. In all patients but one, terodiline increased the bladder capacity and also the bladder volume at which urgency was experienced. No effects on the urethral pressure profile or residual urine were found. Subjective improvement was reported by all but one of the patients. Placebo treatment had no effect on the measured parameters or on the subjective symptoms. No side effects were reported during any of the treatment periods. --It is concluded that terodiline can be used for treatment of female motor urge incontinence, and that it is a promising alternative to drugs presently used for this disorder.

Terodiline inhibition of human bladder contraction. Effects in vitro and in women with unstable bladder

Terodiline, a drug with anticholinergic and calcium antagonistic properties, effectively relaxed carbachol-contracted, isolated human bladder preparations. In the concentrations used, terodiline displaced to the right the concentration-response curve obtained on cumulative addition of carbachol. The maximum response was slightly reduced only at the highest terodiline concentration used (5 microM), suggesting a mainly competitive antimuscarinic effect. Nine patients, aged 12--78 years, suffering from urge urinary incontinence were investigated by simultaneous urethro-cystometry before and after treatment with terodiline 12.5 mg twice or three times daily for 10 days. The patients reported subjective improvement with almost no side effects. Objectively, the number of uninhibited bladder contractions and the amplitude of the contractions decreased. The bladder capacity was almost doubled. There were no marked effects on bladder and urethral pressures at rest, and only two of the investigated patients had slight residual urine after treatment. The results suggest that terodiline is a promising alternative to existing drugs for inhibition of undesired detrusor activity.

ATP-sensitive potassium channel openers and 2,3-dimethyl-2-butylamine derivatives

ATP-sensitive potassium (K(ATP)) channels have important functions through their coupling of cellular energetic networks and their ability to decode metabolic signals, and they are implicated in diseases of many organs. K(ATP) channels are formed by the physical association between the inwardly rectifier potassium channels (Kir6.x) and the regulatory sulfonylurea receptor subunit (SUR), which form a hetero-octameric complex. Different subtypes of K(ATP) channels exist in various tissues. K(ATP) channel openers (KCOs) are classified into nine chemical families according to their molecular structures: (1) benzopyrans, (2) cyanoguanidines, (3) thioformamides, (4) pyrimidine derivatives, (5) pyridine derivatives, (6) benzothiadiazines, (7) dihydropyridines, (8) nicotinamide derivatives, and (9) aliphatic amines. Although the model also predicts that KCOs have four co-binding areas, it was hypothesized that the main contribution lies in the binding domain of hydrophobicity of the side chain. A series of compounds containing the skeleton of the aliphatic secondary amines as a side chain was designed. It was found that N-isopropyl 2,3-dimethyl-2-butylamine (iptakalim, 91) is a novel KCOs. Iptakalim regulates the pore selectively of the inwardly rectifier potassium channel and dilates smaller arteries, but has little effect on vasodilatation of the aorta. Iptakalim administered p.o. has selective and long-lasting antihypertensive effects in hypertensive animals and does not induce tolerance, but has little effect on blood pressure in normotensive animals. Meanwhile, it also reverses cardiovascular remodeling and protects the brain and kidney against damage caused by hypertension in animal models. Iptakalim is in phase II clinical trials now and has a promising future as a treatment for hypertension.

Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials

PURPOSE

We sought to determine the benefits and harms of interventions for children with daytime urinary incontinence.

MATERIALS AND METHODS

Trials of any interventions for children with primary daytime incontinence (the urge syndrome and/or dysfunctional voiding) were identified from the Cochrane Controlled Trials Register, MEDLINE, EMBASE, reference lists of articles, abstracts from conference proceedings and contact with known experts in the field. Once identified, trial quality was assessed, data were extracted and results were expressed in terms of relative risks (RR) with 95% confidence intervals (CI) for individual trials, and summary estimates were obtained using a random effects model. All steps were done by 2 independent reviewers.

RESULTS

Randomized trials of terodiline (2 studies), daytime alarms (1), imipramine (1) and biofeedback/oxybutynin (1) involving 383 children were reviewed. No intervention was demonstrated to be effective. In the latter trial, which was the only one to evaluate a currently used intervention, after 9 months of treatment there was no difference in the proportions of children with unimproved daytime wetting with oxybutynin (RR 0.74, CI 0.26 to 2.13) and biofeedback (0.92, 0.59 to 1.43) compared with placebo.

CONCLUSIONS

No intervention tested in a trial to date has been proved to be of benefit to children with daytime urinary incontinence.

PD0084430: a non-nucleoside inhibitor of human cytomegalovirus replication in vitro

Human cytomegalovirus (HCMV) is a major opportunistic pathogen in immunocompromised individuals. Current therapies target viral DNA replication and accumulate mutations that yield cross-resistance among the approved drugs. A novel, non-nucleoside inhibitor of HCMV replication, PD0084430, was identified in a screening assay using the HCMV beta-galactosidase recombinant RC256. The EC(50) for PD0084430 by inhibition of beta-galactosidase production is 1+/-0.7 microM. This antiviral activity was confirmed by yield reduction and plaque reduction assays using HCMV strain AD169. The TC(50) of PD0084430 as measured by (4C)thymidine incorporation is approximately 30 microM and by XTT is approximately 90 microM. The TC(50) for inhibition of cellular proliferation is approximately 20 microM. Time of addition experiments displayed a similar drop in efficacy for both PD0084430 and GCV when added after the onset of viral DNA replication. The transcomplementation assay for viral DNA replication, using a transfected ori(Lyt) containing plasmid, confirmed that viral DNA synthesis was inhibited at the same concentrations that showed antiviral activity. Western blots showed no apparent block of immediate early or early gene expression. Two ganciclovir (GCV) resistant isolates of HCMV tested showed no cross-resistance to PD0084430. These data suggested a potentially promising novel compound that inhibited HCMV at or before viral DNA replication. However, in vivo testing in mice dosed either orally or intraperitoneally showed rapid glucuronidation on the -OH group. SAR studies on this backbone showed that the -OH group was essential for the antiviral activity in vitro.

Benzonatate for opioid-resistant cough in advanced cancer

Chronic cough is a distressing symptom experienced by approximately 37% of patients with advanced cancer. Palliation of chronic nonproductive cough should always first address the underlying cause but in some patients chronic, nonproductive cough persists and antitussive agents are required. Opioids are the gold standard cough suppressants, of which codeine is the most widely used; patients with an opioid-resistant cough often prove to be a therapeutic challenge. We report three patients with an opioid-resistant cough who achieved symptomatic relief with the peripherally acting nonopioid drug benzonatate.

Inhibitory effects of NS-21, a novel drug for urinary incontinence, and its active metabolite, RCC-36, on L-type calcium currents in isolated guinea pig detrusor smooth muscle cells

The inhibitory effects of NS-21, a newly developed drug for the treatment of urinary frequency and urinary incontinence, and its active metabolite, RCC-36, on L-type Ca2+ currents (ICa) in guinea pig detrusor smooth muscle cells have been compared to those of terodiline by a whole-cell patch-clamp technique. Like terodiline (10 microM), both NS-21 (10 microM) and RCC-36 (10 microM) induced a sizeable decrease in ICa elicited from a holding potential of -60 mV without changing the current-voltage relationship. The three drugs shifted the inactivation curves for ICa in the hyperpolarizing direction by 13 to 20 mV but had no effect on the activation curves for ICa resulting in a decrease in the calcium window current. The inhibitory effects of NS-21 and RCC-36 were greater than those of terodiline. The three drugs inhibited ICa in a concentration- and holding-potential-dependent manner. The IC50 values at a holding potential of -60 mV were 7.9 microM for NS-21, 6.4 microM for RCC-36, and 5.9 microM for terodiline, and at -40 mV they were 1.3, 1.2, and 3.5 microM, respectively. The ratio calculated by dividing the IC50 value at -60 mV by the value at -40 mV was 6.1, 5.3 and 1.7, respectively, indicating that the inhibitory effects of NS-21 and RCC-36 on ICa were more sensitive to voltage than those of terodiline. These results suggest that NS-21 and RCC-36 could be more effective in the treatment of urinary bladder ailments, such as urinary frequency and urinary incontinence.

Concentration dependent cardiotoxicity of terodiline in patients treated for urinary incontinence

OBJECTIVE

Terodiline, an antimuscarinic and calcium antagonist drug, was used to treat detrusor instability but was withdrawn in 1991 after provoking serious ventricular arrhythmias associated with increases in the corrected QT interval (QTc). This research was performed to relate drug induced electrocardiographic changes in asymptomatic recipients to plasma concentrations of the R(+) and S(-) terodiline enantiomers.

SETTING

Urological and geriatric clinics and wards.

SUBJECTS

Asymptomatic patients taking terodiline in stable dose.

METHODS

Electrocardiograms (50 mm/s) were collected from patients while they were taking terodiline and compared with ECGs obtained before or after terodiline. QT interval, heart rate corrected QT interval (QTc), and QT dispersion (QTd) were measured. Drug induced electrocardiographic changes were related to plasma concentrations of R(+) and S(-) terodiline.

RESULTS

During terodiline treatment mean QTc and QTd were prolonged (491(43) and 84 (35) ms 1/2) compared with measurements made off therapy (443 (33) and 42 (17) ms 1/2, paired t tests, P < 0.002 and P < 0.01 respectively) in the 12 patients in sinus rhythm. The mean (95% confidence interval) drug induced increases were 48 (23 to 74) ms 1/2 for QTc and 42 (13 to 70) ms 1/2 for QTd. These increases correlated with total plasma terodiline (QTc: r = 0.77, P < 0.006, QTd: r = 0.68, P < 0.025) and with plasma concentrations of both terodiline enantiomers.

CONCLUSIONS

Terodiline increases QTc and QTd in a concentration dependent manner. It is not clear whether this is a stereoselective effect and, if so, which enantiomer is responsible. The results suggest that drug induced torsade de pointes is a type A (concentration dependent) adverse drug reaction.

Randomized double-blind trial of terodiline in the treatment of urge incontinence in women

OBJECTIVE

To evaluate the effects of terodiline in women with urge incontinence.

METHODS

After a 2-week run-in period, 93 women with urinary frequency and urge incontinence were randomized to either placebo or terodiline, 25 mg twice daily, in a double-blind study for 4 weeks. Symptoms were evaluated using daily frequency-volume charts to record voiding frequency, number of incontinent episodes, absorbent pad use, and quality of life.

RESULTS

The terodiline group showed a 70% decrease in the mean (+/- standard deviation) number of incontinent episodes per week (15.8 +/- 24, decreasing to 4.9 +/- 11.9; P < .01), which persisted throughout the study period. The placebo group achieved a 9% reduction in the mean number of incontinent episodes (13.0 +/- 11.3, decreasing to 11.9 +/- 16; P < .05) only in the final week of treatment. Side effects, especially anticholinergic side effects, were more common in the terodiline group, but resulted in only one dropout. Both the treated and placebo groups improved in daytime frequency and quality-of-life indices.

CONCLUSION

Terodiline is well tolerated and effective in reducing urge incontinent episodes in women.

Haloallylamine inhibitors of MAO and SSAO and their therapeutic potential

Based on mechanistic understandings, molecular modeling and extensive quantitative structure-activity relationships, appropriately substituted haloallylamine derivatives were designed as potential mechanism-based inhibitors of MAO and/or SSAO. Potent inhibition of MAO-B and SSAO occurred with fluoroallylamines whereas chloroallylamines, such as MDL 72274A ((E)-2-phenyl-3-chloroallylamine hydrochloride), were selective and potent inhibitors of SSAO. MDL 72974A (E)-2-(4-fluorophenethyl)-3-fluoroallylamine hydrochloride is a potent (IC50 = 10(-9) M) inhibitor of both MAO-B and SSAO, with 190-fold lower affinity for MAO-A. In clinical studies, oral doses as low as 100 micrograms produced substantial inhibition of platelet MAO-B. Essentially complete inhibition occurred at 1 mg with the effect lasting 6-10 days. One or 4 mg MDL 72974A given daily for 28 days to 40 Parkinson's patients treated with L-dopa produced statistically significant reductions in the Unified Parkinson's Disease Rating Scale. MAO-B inhibitors, such as MDL 72974A and L-deprenyl, offer the potential of being neuroprotective in Parkinson's Disease and other neurogenerative disorders. Concommitant inhibition of SSAO may provide additional, but as yet unproven, advantages over pure inhibitors of MAO-B.

Effects of terodiline on urinary incontinence among older non-institutionalized women. Terodiline in the Elderly American Multicenter Study Group

OBJECTIVE

To determine the effectiveness of terodiline, a drug with calcium antagonist and anticholinergic properties, on the frequency of incontinence in older non-institutionalized women.

DESIGN

Randomized, placebo-controlled, parallel-group, double-blind trial.

SETTING

Twelve outpatient clinics across the United States affiliated with programs in either geriatrics, gynecology, or urology.

PARTICIPANTS

Ninety-eight women, age 60 or older, with symptoms of urge incontinence and self-reported frequency of incontinence four or more times per week and involuntary bladder contractions on dual-channel water cystometry.

MAIN OUTCOME MEASURES

Self-reported urinary frequency, urgency, number of incontinence episodes, and number of heavily soaked pads.

RESULTS

Eighty-one women, average age 71, completed the trial, 40 in the active drug group, 41 in the placebo group. Incontinence frequency and the number of heavily soaked pads were reduced in the active drug group by 64% and 55%, respectively, and by 21% (P = 0.002) and 9% (P = 0.04) in the placebo group. No patients dropped out due to adverse effects. An intention-to-treat analysis of all 98 patients yielded the same conclusion.

CONCLUSION

Terodiline is highly effective in reducing incontinence in older, noninstitutionalized women with urge incontinence. Because of its potential association with polymorphic ventricular tachycardia (torsades de pointes), terodiline must undergo further testing to define its safety before it can be recommended for clinical use in the incontinent geriatric population.

Urodynamic effects of intravesical instillation of terodiline in healthy volunteers and in patients with detrusor hyperactivity

The effects of intravesical instillation of terodiline on urodynamic parameters were investigated in 8 healthy volunteers (10(-4) M.) and in 34 patients with detrusor hyperactivity (10(-5) M.) of neurogenic (22) or nonneurogenic (12) origin. The volunteers were investigated with conventional medium-fill cystometry, while in the patients a modified cystometric technique with slow intermittent filling was used. The reproducibility of the procedure was verified in 17 patients. Instillation of terodiline had no effect on the normal bladders nor were any improvements found in the nonneurogenic patients. In 12 patients in the neurogenic group treated with terodiline instillation the bladder capacity increased significantly (p < 0.05) from 289 +/- 32 to 413 +/- 55 ml. Within this group 5 patients were responders. It is suggested that pathophysiological changes may explain the difference between the neurogenic and nonneurogenic groups, and that the number of responders within the neurogenic group may be increased by an optimal drug preparation and increased dosage. Intravesical administration of terodiline may offer an alternative treatment in selected patients with detrusor hyperreflexia.

Terodiline in the treatment of nocturnal enuresis in children

The effect of terodiline was investigated in 17 children with nocturnal enuresis. Twelve of them were evaluated urodynamically before treatment and 6 of these were proved to have detrusor instability with or without provocation. Terodiline in a daily dose of 12.5 mg was administered for 4 weeks. After treatment the number of wet nights per week has significantly decreased. Urodynamically, maximum cystometric capacity has statistically increased and in 2 patients involuntary contraction has disappeared. During these periods no serious side effects were encountered. Terodiline could improve urodynamic parameters in nocturnal enuresis. These changes appear to be favourable in clinical improvement.

[Clinical study of terodiline hydrochloride for the treatment of urinary frequency and urinary incontinence, and its cardiovascular adverse effects]

We evaluated the effectiveness and side effects of terodiline hydrochloride in 109 patients with urinary frequency and urinary incontinence. The drug was administered at a dose of 24 mg once a day or 12 mg twice a day for 4 weeks. Symptoms such as urinary frequency and urinary incontinence were alleviated in 101 out of 109 patients (92.7%). Mild side effects such as thirst, dysuria, sense of residual urine, orthostatic hypotension and arrhythmia were observed in 9 out of 109 patients (8.2%). Side effects such as orthostatic hypotension and arrhythmia were observed on the 28th day or the 20th day of the administration, but these symptoms disappeared with discontinued use of this medicine. The results obtained from this study suggest that terodiline hydrochloride may be greatly useful for the patients with urinary frequency and urinary incontinence. But we must take account of the side effects such as orthostatic hypotension and arrhythmia.

Terodiline causes polymorphic ventricular tachycardia due to reduced heart rate and prolongation of QT interval

Recent reports have suggested an association between terodiline hydrochloride and cardiac arrhythmias. We report 4 patients presenting over a six month period who developed polymorphic ventricular tachycardia (polymorphic VT) while receiving treatment with this agent. In each case there was prolongation of QT interval on electrocardiogram (ECG). Two patients had hypokalaemia associated with diuretic therapy. In the 3 cases in which follow-up ECG was available, QT interval returned to normal after discontinuation of terodiline. In order to define the effects of terodiline on corrected QT interval (QTc) and heart rate in the elderly, a prospective study was performed in 8 elderly in-patients treated with terodiline for urinary incontinence. After 7 days treatment with terodiline 12.5 mg twice daily, there was a significant increase in QT by a mean of 29 ms, QTc by 15 ms and a decrease in resting heart rate by a mean of 6.7 beats.min-1. Terodiline increases QTc and reduces resting heart rate in elderly patients. Both these effects may be associated with polymorphic VT, a potentially life threatening arrhythmia. This drug should be avoided in patients with other known risk factors for polymorphic VT, particularly hypokalaemia and cardiac disease.

[Polymorph ventricular tachycardia with torsades de pointes caused by administration of terodiline (Mictrol)]

A 63-year-old female was admitted to the hospital because of collapse. She had no history of cardiovascular disease. Prior to admission she used co-trimoxazole, paracetamol, calcium tablets and 50 mg terodiline (Mictrol) daily because of bladder instability. Electrocardiography showed QT prolongation and polymorphous ventricular tachycardia with torsades de pointes. During admission she developed ventricular fibrillation, needing defibrillation. After withdrawal of terodiline and treatment with isoprenaline the symptoms and all ECG abnormalities disappeared. In this case terodiline was suspected of having been the causative agent. Terodiline shows structural resemblance to the anti-arrhythmic agent prenylamine, a known cause of torsades de pointes. Recently terodiline has been temporarily withdrawn from the worldwide market in order to investigate the causal relationship between this drug and cardiac arrhythmia and conduction disturbances.

Terodiline with bladder retraining for treating detrusor instability in elderly people

OBJECTIVE

To compare terodiline with bladder retraining against placebo with bladder retraining in the treatment of detrusor instability in frail elderly patients.

DESIGN

Randomised, double blind, parallel group study. Treatment lasted for six weeks. Frequency of micturition and episodes of incontinence recorded on diary chart by patients.

SETTING

Incontinence clinic and a geriatric day hospital at two teaching hospitals.

PATIENTS

37 frail but ambulant patients, mean (range) age 80.4 (70-89) years with urinary frequency and urge incontinence, due to detrusor instability. Two patients withdrew before the first assessment (one in each group) and one could not complete the diary chart (placebo group).

INTERVENTIONS

19 patients received bladder retraining and terodiline 25 mg daily and 18 bladder retraining and placebo.

MAIN OUTCOME MEASURES

Change in urinary frequency and number of episodes of incontinence after six weeks' treatment. Patient's subjective evaluation of symptoms.

RESULTS

Little difference was found in the results of treatment with terodiline and placebo. The change in episodes of incontinence per 24 hours was no different in the two groups (95% confidence interval -0.6 to 1.2; p = 0.75) and the difference between treatments in the change in frequency of micturition per 24 hours (-0.2) was not significant (-1.1 to 1.2; p = 0.76). Ten patients taking terodiline thought they had improved compared with seven receiving placebo; this difference was not significant.

CONCLUSION

Although the number of patients in each group was small and may have been insufficient to detect a drug effect, the possible benefit of terodiline is likely to be small.

[Clinical evaluation of terodiline hydrochloride in patients with urinary frequency or incontinence]

A clinical trial with the collaboration of 15 department of urology was performed to determine the usefulness of terodiline hydrochloride in 99 patients whose chief complaints were of pollakisuria or incontinence due to neurogenic bladder, psychogenic disease or chronic cystitis. The patients were orally given 24 mg once daily for 4 weeks. The final global improvement rate was 88.5% and the effective rates on subjective symptoms were; 66.2% for diurnal urinary frequency, 68.0% for nocturnal urinary frequency, 68.8% for urinary incontinence and 78.3% for nocturnal enuresis. Even for the cases having mild bladder outlet obstructive disease, the clinical effective rates were good. Mild side effects were observed in 10 patients, which were dry mouth and others. The results obtained from this trial suggest that terodiline hydrochloride may be useful for the treatment of urinary frequency and incontinence caused by detrusor instability.

Terodiline. A review of its pharmacological properties, and therapeutic use in the treatment of urinary incontinence

Terodiline has both anticholinergic and calcium antagonist properties and, as a result, effectively reduces abnormal bladder contractions caused by detrusor instability. When administered to adult patients with urge incontinence (generally as a 25mg twice-daily dose) terodiline reduces diurnal and nocturnal micturition frequency and incontinence episodes. In studies also assessing cystometric parameters, bladder volume at first urge and bladder capacity are increased. Children with diurnal enuresis respond similarly to a daily 25mg dose. Several studies have shown that terodiline 50 mg/day is preferred by patients when compared with emepronium 600 mg/day or flavoxate 600 mg/day, and tends to reduce voluntary micturition frequency and episodes of incontinence more effectively than these drugs. Terodiline is well tolerated in short and long term (up to 3.5 years) studies. Anticholinergic effects are most commonly reported; other adverse effects occur equally during terodiline and placebo treatment. Thus, terodiline is effective and well tolerated in patients with urge incontinence or neurogenic bladder dysfunction, and will claim an important place in the treatment of such patients in light of the limitations of alternative therapies.

[Clinical effect of terodiline hydrochloride on pollakisuria and urinary incontinence]

Efficacy and safety of terodiline hydrochloride were studied by treating 38 patients who complained of pollakiuria and incontinence with this drug. Terodiline hydrochloride in a dose of 24 mg once or 12 mg twice a day was administered to these patients for 4 weeks and the conditions of the patients before and after the treatment were evaluated. According to the subjective symptoms, pollakisuria during the daytime and at night, incontinence, anischuria at night and frequency of urination were all reduced significantly. Objective symptoms detected after the treatment a tendency of increase (p less than 0.1) in the bladder volume at the time of maximum micturition. However, no change in the urination volume and the maximum urine flow was observed before and after the administration. A significant decrease (p less than 0.05) in residual urine was noted after the treatment. The results were favorable with overall improvement of 78.4% and efficacy of 75.7%. Side effects were observed in 3 of the 38 cases (7.9%), but all the symptoms were slight.

[Terodiline in the treatment of stress incontinence in women]

Terodiline combines simultaneously a parasympatholytic and a calcium antagonistic effect and can be used positively for the treatment of urge-incontinence of women. 44 female patients with an urge-incontinence have been examined urodynamically before and after a six-week treatment with terodiline. After therapy the urodynamic parameters ameliorated significantly. A subjective amelioration or even a healing of the urge symptomatic occurred in 86.4% of the patients. The side effects were minor.

Terodiline: a dose titrated, multicenter study of the treatment of idiopathic detrusor instability in women

Idiopathic detrusor instability is a common cause of lower urinary tract symptoms at all ages and in both sexes. Treatment initially is conservative and often includes drug therapy. Terodiline has the theoretical advantage of being a drug with anticholinergic and calcium channel blocking effects. Theoretically, by using a drug with dual action the beneficial effect of reduced detrusor overactivity might occur at a dosage below that likely to lead to the troublesome side effects experienced by patients who take pure anticholinergic agents. A total of 70 female patients completed a study characterized by extremely strict inclusion criteria and a tight protocol. Other novel elements to the study were the extensive use of urinary diaries for symptom evaluation, standardized urodynamic studies agreed upon by the participating centers and the dose titration design of the trial. Terodiline has been demonstrated to be a safe, well tolerated and effective drug in the treatment of idiopathic detrusor instability. Drug treatment led to significant decreases in urinary frequency and incontinence episodes. Pre-micturition symptoms, such as urgency, were markedly reduced and the voided volume was significantly increased. Although there were consistent trends towards greater improvement in the urodynamic measurements, when the terodiline and placebo groups were compared these did not reach statistical significance, partly due to a large improvement in the placebo group. Nevertheless, terodiline has been shown to be a useful drug for conservative management of patients with detrusor instability.

[Clinical studies on terodiline hydrochloride in nocturnal enuresis]

The clinical effect of terodiline hydrochloride was studied in 10 patients with enuresis. Terodiline hydrochloride was adminisered at a dose of 12 mg once a day for 4 weeks. In 8 of the 10 patients (80%), the enuresis rate was reduced. There were no side effects in our cases. These results indicate that terodiline hydrochloride is an effective drug to treat enuresis.

Diagnosis and management of female urinary incontinence in general practice

In response to an invitation sent to women who had complained previously of regular incontinence, 65 women with regular incontinence were seen by their general practitioner. A diagnosis was made using a personally administered questionnaire and appropriate examination. Patients were placed in one of three diagnostic/management categories--stress, urge or stress/urge incontinence--and were given an appropriate treatment programme. Fifty six women were recruited as matched controls from non-responders while attending the surgery for other reasons. They underwent identical entry procedures but were not offered a treatment programme. All the patients were reassessed after 12 weeks at which time significant improvement in incontinence was reported by the treated women in the stress and urge categories compared with the controls. There was no significant difference in reported efficacy of treatment between age groups and treatment was shown to be effective irrespective of the duration of incontinence. This study shows that for the majority of women reporting incontinence the condition can be diagnosed by a general practitioner and significantly improved by appropriate intervention.

Terodiline treatment of detrusor hyperreflexia in sclerosis multiplex

A single-blind placebo controlled study on the efficacy of the anticholinergic and calcium blocking agent terodiline (Mictrol) on detrusor hyperreflexia has been done in 10 patients with multiple sclerosis in a stable state. The patients were evaluated by means of micturition charts, uroflowmetry and cystourethrometry, including electromyography of the periurethral sphincter in females and the bulbocavernosus muscle in males. After 6 weeks on terodiline 25 mg twice a day, the volume per voluntary micturition increased 23 per cent. The number of incontinence episodes decreased. Bladder volume at first urge increased 55 per cent, the maximum cystometric capacity increased 52 per cent, and the detrusor pressure of the first involuntary contraction decreased 27 per cent. The number of voluntary micturitions and voided volume per 24-hour, maximum and average flow, residual urine and urethral pressure at first urge remained unaltered. Terodiline is an alternative drug in the treatment of detrusor hyperreflexia. A follow-up investigation indicates that an increase in terodiline dosage may improve the results.

Terodiline in the treatment of children with unstable bladders

A double-blind study of terodiline compared with placebo was performed in 58 children aged 6 to 14 years with urgency or urge incontinence. All had an unstable bladder at cystometry. A bladder regimen was emphasised during the study. Continence was improved according to micturition charting and a pad test in both groups. Terodiline at 25 mg/day, however, gave significantly better results than placebo. In patients with a subnormal bladder capacity (less than or equal to 150 ml), a significant increase in capacity was recorded on cystometry during medication with terodiline but not with placebo. The improved continence seen in the placebo group was probably due to the non-specific bladder training achieved by the child's increased awareness and adult involvement during treatment. The even better results attained in the terodiline group shows this drug to be a valuable adjunct to a bladder regimen in children with urge incontinence, particularly since no important adverse effects were noted during an 8-week period.

[Clinical study of terodiline hydrochloride on nervous pollakisuria]

TD-758 (12 mg tablets) was given in two tablets daily to 19 patients with nervous pollakisuria. The changes in frequency of daily micturition and in subjective symptoms were studied referring to the diary kept by each patient, along with the occurrence of side effects. Before the medication, urodynamic studies were made on each patient and all the cases were thus confirmed being free from detrusor instability or uninhibited contraction. The wash-out period of other drugs and control observation period, each one week, were set before the medication period which lasted for four weeks. The frequency of micturition per day showed a significant decrease from the first week of the medication period (p less than 0.05), and at the fourth week there was noted a significant reduction by twice per day on the average (p less than 0.001). Subjective efficacy was noted as follows: excellent in 3 cases (15.8%), good in 9 cases (47.7%), unchanged in 7 cases (36.8%), and thus 12 cases (63.2%) showed an efficacy of the rating of good or higher. In four cases dry mouth and in two cases sense of abdominal distention were noted out of the total of 19 cases, but no side effects of severe degree to stop the medication were noted during the medication period. In conclusion TD-758 is a clinically useful remedy for treatment of nervous pollakisuria.

Terodiline in the treatment of diurnal enuresis in children

Efficacy and tolerance of the anticholinergic and calcium antagonistic drug terodiline (Mictrol) were investigated in comparison to placebo in 42 children with diurnal enuresis. The study was double-blind with a modified cross-over design with 2 treatment periods of 4 weeks. Terodiline in a daily dose of 25 mg was well tolerated. A statistically significant decrease in the number of wet episodes per day was found with terodiline when compared to placebo. In addition a high patient preference for terodiline was observed. This study shows that terodiline is effective in the treatment of daytime enuresis in children. The low incidence of side-effects also favours the use of terodiline in children.

Terodiline, emepronium bromide or placebo for treatment of female detrusor overactivity? A randomised, double-blind, cross-over study

In a randomised, double-blind study, 20 women with idiopathic detrusor instability and associated symptoms were treated with terodiline 25 mg bd, placebo, and emepronium bromide 200 mg tds--each drug being given for 3 weeks with placebo as wash-out period before cross-over. The results were evaluated according to drug preference, frequency charts and elimination of detrusor instability on cystometry. Serum levels of both drugs were monitored as control of tablet intake. The preference for terodiline to placebo was statistically significant: 14/3 women (P less than 0.05), and the majority of women (12/4) preferred terodiline to emepronium. Terodiline also gave a small but significant reduction in 24 h micturition frequency and eliminated detrusor instability in almost 50% of the patients (P less than 0.05). Side effects were frequent but mild in all three treatment periods. It was concluded that terodiline offers an alternative in the treatment of female detrusor instability.

[Clinical effects of terodiline hydrochloride on urinary frequency and sense of residual urine--a double blind clinical trial using flavoxate hydrochloride as a control]

A double blind clinical trial was performed as a multicenter study to determine the usefulness of terodiline hydrochloride (HCl), an anticholinergic and calcium antagonistic agent, for urinary frequency or sense of residual urine in patients with psychogenic diseases, chronic prostatitis or chronic cystitis. Either 24 mg of terodiline HCl a day or 600 mg of flavoxate HCl a day was given for 4 weeks. One hundred and ninety-nine patients completed the test. The final global improvement rating was 70% in patients given terodiline HCl and 48% in patients given flavoxate HCl. The difference was statistically significant (p less than 0.01). Diurnal and nocturnal urinary frequency and urinary incontinence were less in patients given terodiline HCl than in patients given flavoxate HCl (p less than 0.01). No difference was noted between the two agents in relieving sense of residual urine. Compared with the control period, the average urinary frequency decreased 2.0 times a day in patients given terodiline HCl and 0.7 times in patients given flavoxate HCl. The difference was statistically significant (p less than 0.01). Adverse effects were observed in 12% of the patients given terodiline HCl and in 16% of the patients given flavoxate HCl. They included thirst, difficult urination, constipation, slight increase of serum GOT, GPT or alkaline phosphatase, and so forth. They disappeared with discontinued use of the agent. The global utility rating was 68% in patients given terodiline HCl and 45% in patients given flavoxate HCl, the difference being significant (p less than 0.01). These results indicate that terodiline HCl is useful for the treatment of urinary symptoms in patients with psychogenic diseases, chronic prostatitis or chronic cystitis.

[Clinical effects of terodiline hydrochloride for urinary frequency and sense of residual urine]

The clinical effects of terodiline hydrochloride were evaluated in forty-four patients with urinary frequency and/or sense of residual urine. After a four-week treatment with 24 mg terodiline hydrochloride once daily, subjective symptoms were improved and micturition frequency was decreased significantly. Slight dysuria was reported as a side effect only in one patient. Terodiline hydrochloride is considered to be superiorly effective and safe for the treatment of urinary frequency and sense of residual urine.

[Clinical evaluation of long-term administration with terodiline hydrochloride for the treatment of patients with neurogenic bladder]

Terodiline HCl was administered in a long-term study to 20 patients with neurogenic bladder and pollakisuria. Its efficacy on urinary frequency and urinary incontinence was studied together with its safety and changes in blood concentration. The dosing period extended from 2 through 53 weeks (21 weeks on the average). The drug was found effective in 62% of diurnal urinary frequency patients, 71% of nocturnal urinary frequency, 73% of urinary incontinence, and 69% of nocturnal enuresis. Side effects of dizziness and nasal obstruction were seen in only one case. The drug was judged to be useful in 75% of the patients studied. Terodiline HCl showed no further increase in plasma concentration due to the long-term administration, and it disappeared from plasma within one to two months after the last dosing.

[Clinical evaluation of long-term administration of terodiline hydrochloride for the treatment of patients with pollakisuria and incontinence]

We evaluated the effectiveness and side effects of long-term administration of terodiline hydrochloride in patients with chief complaints of pollakisuria or incontinence or both due to unstable bladder or neurogenic bladder associated with uninhibited contraction. The dose was 24 mg once daily. The symptoms such as pollakisuria and incontinence improved in 31 out of 41 patients (76%). Mild side effects were observed in 12 out of 47 patients (26%), which were thirst, dizziness, dysuria, urticaria and gastrointestinal symptoms. An increasing tendency of both maximum desire to void and compliance (p less than 0.10), and significant difference in maximum static pressure (p less than 0.05) were observed on urodynamic examinations before and after administration of this medicine. The results obtained from this study suggest that terodiline hydrochloride may be greatly recommended for patients with such symptoms as pollakisuria and incontinence.

[Clinical effect of terodiline hydrochloride (TD-758) in patients with urinary disturbances]

We evaluated the efficacy of terodiline hydrochloride (TD-758) in 23 patients with psychosomatic bladder, chronic prostatitis and chronic cystitis. The drug was administered at a dose of 24 mg once a day for 4 weeks. In 78% of the patients the symptoms such as urinary frequency and sense of residual urine improved. Only mild side effects such as thirst were noted. We concluded that terodiline hydrochloride was effective in this trial.

A calcium blocking and anticholinergic agent (terodiline) in the treatment of detrusor hyperreflexia: a placebo-controlled, cross-over trial

In 25 neurological patients with detrusor hyperreflexia terodiline reduced the number of total micturitions during daytime. Bladder capacity was increased and amplitude of the bladder contractions was reduced. An increase in residual urine was also observed. Mild anticholinergic side-effects were measured on pupillary motility and on heart rate variation. It is concluded that terodiline is a useful alternative in treatment of patients with detrusor hyperreflexia.

[Clinical effect of terodiline hydrochloride on nervous pollakisuria or irritative bladder]

The clinical effect of terodiline hydrochloride (TD-758) was studied in 95 patients with nervous pollakisuria or irritative bladder. TD-758 was given per os randomly at a dose of 24 mg or 12 mg once a day for 4 weeks. The symptoms such as urinary frequency, urinary incontinence and sense of residual urine were improved in 74% of the patients taking 24 mg, and in 51% of the patients taking 12 mg. The difference was statistically significant. Side effects such as dry mouth, constipation and heart burn were observed in 15% of the patients in each group and were not serious. The results of this study indicate that TD-758 is useful for these patients and its optimal dosage is 24 mg once a day.

Management of urinary incontinence in children with myelomeningocele

Several forms of treatment of lower urinary tract functional disorders have been attempted in children with myelomeningocele (MMC). Intravesical electrical stimulation was attempted in 10 patients. Urinary control was achieved in one and in the remaining 9 either the bladder was resistant to stimulation or the children discontinued the treatment due to loss of interest. A combined anticholinergic and calcium blocking agent, terodiline, was tested in 8: symptoms improved in 4, but bladder compliance was unchanged. Clean intermittent catheterization, either alone or in combination with medication, seems to be the most beneficial treatment.

Terodiline in the treatment of women with urgency and motor urge incontinence. A clinical and urodynamic double-blind cross-over study

In a consecutive double-blind cross-over study, 18 females with detrusor instability were treated with an anticholinergic and calcium antagonistic agent terodiline 25 mg bid or placebo for 3 weeks; cross-over took place after a wash-out period of 1 week. The efficacy of the drug was investigated at the end of each treatment period by means of drug preference, micturition charts, pad usage, bladder and urethral mucosal perception threshold and bulbocavernosus reflex latency measurement. Serum levels of terodiline were estimated at the end of each treatment period and all side effects were reported. The preference for the drug was statistically significant (P less than 0.01): 14 patients preferred the drug, one preferred the placebo and three had no preference. A small but statistically significant reduction was found in 24-h micturition frequency (P less than 0.05). Cystometry showed an increase in volume at first sensation, an increase in volume at detrusor contraction and a tendency towards an increase in bladder capacity, whereas detrusor contraction pressure was unchanged. Median serum levels of the drug were 559 ng/ml (range 203-1117). No serious side effects were reported. It was concluded that terodiline should be considered as an alternative drug in the treatment of motor urge incontinence.

Innervation of the child urinary bladder

Muscle strips from the fundus, trigonum and distal ureters obtained from children at operations for vesico-ureteric reflux were studied using histochemical and immunohistochemical methods, and electrical nerve stimulation in an organ bath. A rich supply of cholinergic nerves was found and despite a partial atropine resistance the neurophysiological experiments indicated that the transmitter causing contraction of the detrusor muscle is acetylcholine. Imipramine, which is used in the treatment of enuresis, had no anticholinergic effect on the bladder in the doses used clinically. The adrenergic innervation was very sparse except around the ureter orifices. No contractile alpha-adrenoceptors could be detected but beta receptor mediated relaxation was found, which was neither of the beta 1 nor beta 2 type. A third type of beta receptor is postulated. Peptidergic nerves containing vasoactive intestinal peptide, VIP, were demonstrated in a few nerve terminals running along bundles of smooth muscle. No nerves containing enkephaline, somatostatine or substance P were found. VIP affected the detrusor muscle indicating a possible role as a modulator of transmitter action, while substance P had no effect. The anticholinergic and calcium antagonistic drug terodiline inhibited all muscle activity, whether it was induced by nerve stimulation, cholinergic drugs or a potassium rich solution, making it suitable for treatment of diurnal enuresis.

Bladder training and terodiline in females with idiopathic urge incontinence and stable detrusor function

Twenty consecutive female patients with urge incontinence and stable detrusor function on provocative rapid fill CO2-cystometry were treated as out-patients with a bladder training programme and with terodiline/placebo in a double-blind cross-over design. Frequency and incontinence episodes decreased significantly, while first sensation and cystometric bladder capacity increased. Both objectively and subjectively terodiline was significantly better than placebo with 50% (95% confidence limits 18-82) more patients improved on terodiline than on placebo. Thirty percent of the patients (95% confidence limits 12-54) relapsed after withdrawal of terodiline. At 3 months follow-up the remaining 70% were satisfied with the outcome of the training programme. Side effects were mild and reversible. Serum creatinine and alkaline phosphatase increased slightly on terodiline and the diastolic blood pressure was probably also increased by terodiline. In conclusion, female patients with idiopathic urge incontinence and stable detrusor function did respond to treatment as do female patients with urge incontinence and proven instability.

The effect of terodiline treatment in women with motor urge incontinence. Results from a double-blind study and long-term treatment

The effects of terodiline were evaluated in 24 women with genuine motor urge incontinence: Twelve patients participated in a double-blind crossover study and 12 in a subsequent long-term study. All patients were investigated by simultaneous urethrocystometry before and after treatment. During the controlled study the subjects were treated with placebo or 37.5 mg of terodiline daily for two 3-week periods. The long-term study covered a period from 6 months to 3 years. A significantly higher increase in both bladder volume at urinary leakage (from 170 to 270 ml, p less than 0.001) and bladder capacity (from 320 to 390 ml, p less than 0.01) was registered after terodiline treatment compared to placebo. In the long-term study the effects on these parameters were still more pronounced with an increase in bladder volume at leakage (from 180 to 300 ml, p less than 0.001) and in bladder capacity (from 290 to 430 ml, p less than 0.0001). Subjective improvement with terodiline treatment was reported by all but two patients in the double-blind study and by all in the long-term study. Side effects such as dryness of the mouth were reported by four patients receiving terodiline in the double-blind study and by six in the long-term study. No patient discontinued the treatment. Terodiline seems to be a promising alternative for treatment of motor urge incontinence in women.

The effects of terodiline and meladrazine on severe motor urge incontinence in geriatric patients

Twenty-five geriatric patients with severe motor urge incontinence were treated with terodiline and meladrazine separately and in combination. Because of poor general state of health and serious concomitant diseases the frequency of dropouts was high. Separate administration of the drugs improved the majority of the patients subjectively, but not sufficient for complete continence. Urodynamically, however, significant improvement was found only with terodiline. On combined administration with both drugs, seven of 15 patients became completely continent, seven were improved, and one remained unchanged, but additional urodynamic improvement was not demonstrated. Meladrazine caused a high incidence of side effects; therefore, treatment with terodiline separately is recommended for geriatric patients who have severe motor urge incontinence.