Resource use and healthcare costs in patients with overactive bladder who initiate treatment with mirabegron or antimuscarinic monotherapy in Catalonia: the MIRACAT study

INTRODUCTION AND AIM

Overactive bladder (OAB) negatively impacts patient quality of life and may be associated with high resource use. Our aim was to describe the resource use, costs and persistence associated with mirabegron (MB) or antimuscarinic (AM) treatment in patients with OAB.

MATERIALS AND METHODS

Observational retrospective study of medical records in adult patients initiating OAB treatment with MB or AM in Catalonia. Healthcare resource use (visits, hospital stays, tests, medication, absorbent pads) in the first year after treatment initiation was collected. Associated costs were estimated (є, reference year 2019), as well as treatment persistence. Treatment discontinuation was defined as the absence of prescription for at least 45 days or treatment change.

RESULTS

The mean cost per patient (SD) was є 1,640.20 (є 1,227.60) with MB and є 2,159.20 (є 2,264.40) with AM; the associated healthcare resource use cost was lower with MB compared to AM, except for OAB drug costs. Persistence after 12 months of treatment initiation was higher in MB (42.1%) compared to AM (33.0%), as was the median time until treatment discontinuation: 299 (95% CI: 270-328) vs 240 days (95% CI: 230-250).

CONCLUSIONS

Lower healthcare resource use was observed with MB compared to AM in the first year of index treatment, resulting in a lower mean direct cost per patient and year, despite its higher acquisition cost. Increased treatment persistence, as well as rational use of available treatments improves OAB management and, in return, patients' quality of life.

Is there concordance between overactive bladder and detrusor overactivity in men with predominant storage urinary symptoms referred to Functional Urology and Urodynamics Units?

OBJECTIVES

To assess the diagnostic concordance of overactive bladder (OAB) and detrusor overactivity (DO) in male patients with predominant storage lower urinary tract symptoms (LUTS) and evaluate their clinical and urodynamic profile according to DO presence and degree of obstruction.

MATERIAL AND METHODS

Epidemiological, cross-sectional multicenter study. A 3-day bladder diary (3dBD), International Prostate Symptom Score (IPSS) and Bladder Control Self-Assessment Questionnaire (B-SAQ) questionnaires were analyzed. Prostate volume was determined by ultrasound. Urodynamic study (UDS) tests were performed. The prevalence of OAB and DO and the degree of clinical concordance (kappa index) were investigated. Descriptive analysis of clinical variables and UDS results was performed, followed by comparisons based on the presence of DO and degree of obstruction.

RESULTS

A total of 445 patients were included. The mean age was (SD) 54.8 (9.9) years. According to 3dBD, 89.9% presented increased urinary frequency, 87.9% nocturia, 72.1% urgency, and 31.9% urge urinary incontinence (UUI). Obstruction was present in 36.8%. Concomitant OAB and DO were present in 54.5%. The degree of diagnostic concordance between OAB and DO was low (κ = 0.1772). There were more patients with DO presenting urgency (3dBD and B-SAQ; p < 0.001), UUI (3dBD; p = 0.008) and nocturia (B-SAQ; p < 0.001). Differences were found in terms of prostate volume, IPSS-voiding, maximum flow (Qmax) and post-void residual (p < 0.05) according to the obstruction degree.

CONCLUSIONS

Approximately 50% of male patients aged 18-65 years old with predominant storage LUTS, referred to specialized units, have both OAB and DO. Obstruction is present on 1/3. Diagnostic concordance between OAB and DO is poor.

[Transcutaneous stimulation of the posterior tibial nerve modifies the sympathetic skin response and improves overactive bladder syndrome: Case series and possible diagnostic test]

OBJECTIVE

(a) To assess the effect of transcutaneous neuromodulation (TNM) of the posterior tibial nerve plus biofeedback on the sympathetic skin response (SSR). (b) Evaluate its effect on clinical symptoms. (c) Consider SSR as a probable neurophysiological test useful both for diagnosis and for follow-up in patients with overactive bladder (OAB). (d) Evaluate its cost compared to other techniques.

MATERIAL AND METHODS

A prospective quasi-experimental before and after study in 10 OAB patients.

OUTCOME VARIABLES

daytime (DUF) and nighttime (NUF) urinary frequency, strength of the pelvic floor muscles measured by manometry (maximum and mean pressure) and sympathetic skin response (SSR).

RESULTS

DUF improved from 10.3±5.45 to 5.9±2.42 episodes (P=.0050). The NUF improved from 2.4±1.5 to 0.6±0.69 episodes (P=.0012). The maximum pressure ranged from 34.7±16.51 to 39.7±3.65mmHg (P=.0195). The mean pressure of the pelvic floor muscles improved from 6.6±3.65 to 9.3±5.43mmHg (P=.0333). SSR changed from 100% hyperexcitability prior to treatment to 50±14.14% (P=.0000).

CONCLUSION

TNM plus biofeedback could modify SSR and improve clinical and manometry variables in a series of patients with OAB. The probable diagnostic and prognostic utility of this neurophysiological test in OAB and detrusor hyperactivity is reported for the first time. A larger sample study is needed to confirm the promising findings seen in this preliminary study.

Update on sacral neuromodulation and overactive bladder in pediatrics: A systematic review

OBJECTIVES

Sacral electrical stimulation has been used for more than a century as an alternative therapy for adult urinary syndromes. In the literature, several studies have validated the efficacy of this technique based on clinical and urodynamic criteria. Nevertheless, few studies have shown beneficial results in children with overactive bladder.

MATERIAL AND METHODS

We performed a systematic review of studies assessing the impact of sacral electroestimulation treatment on overactive bladder in children. The search identified 389 potentially eligible items. Of them, 14 studies published between 2001and 2019 met the study criteria and were selected for systematic review. RESULTS: All of papers included in this review individually demonstrated a high efficiency rate with good shortterm results, as well as safety in its use due to its minimalrate of adverse effects. However, the comparison of the results obtained in all of them was not possible because the high variety and heterogeneity in the different studies. The main limitation is that there is still no standard protocol for the application of this therapy in the pediatric population.

CONCLUSION

This review revealed the promising benefits of sacral electroneuromodulation in pediatric patients with overactive bladder. However, more studies with strictly meet pediatric overactive bladder diagnosis and management criteria should be done to protocolize and clarify the effectiveness of this therapeutic approach.

Is there concordance between overactive bladder and detrusor overactivity in men with predominant storage urinary symptoms referred to Functional Urology and Urodynamics Units?

OBJECTIVE

To assess the diagnostic concordance of overactive bladder (OAB) and detrusor overactivity (DO) in male patients with predominant storage lower urinary tract symptoms (LUTS) and evaluate their clinical and urodynamic profile according to DO presence and degree of obstruction.

MATERIAL AND METHODS

Epidemiological, cross-sectional multicenter study. A 3-day bladder diary (3dBD), International Prostate Symptom Score (IPSS) and Bladder Control Self-Assessment Questionnaire (B-SAQ) questionnaires were analyzed. Prostate volume was determined by ultrasound. Urodynamic study (UDS) tests were performed. The prevalence of OAB and DO and the degree of clinical concordance (kappa index) were investigated. Descriptive analysis of clinical variables and UDS results was performed, followed by comparisons based on the presence of DO and degree of obstruction.

RESULTS

A total of 445 patients were included. The mean age was (SD) 54.8 (9.9) years. According to 3dBD, 89.9% presented increased urinary frequency, 87.9% nocturia, 72.1% urgency, and 31.9% urge urinary incontinence (UUI). Obstruction was present in 36.8%. Concomitant OAB and DO were present in 54.5%. The degree of diagnostic concordance between OAB and DO was low (κ=0.1772). There were more patients with DO presenting urgency (3dBD and B-SAQ; p<0.001), UUI (3dBD; p=0.008) and nocturia (B-SAQ; p<0.001). Differences were found in terms of prostate volume, IPSS-voiding, maximum flow (Qmax) and post-void residual (p<0.05) according to the obstruction degree.

CONCLUSIONS

Approximately 50% of male patients aged 18-65 years old with predominant storage LUTS, referred to specialized units, have both OAB and DO. Obstruction is present on 1/3. Diagnostic concordance between OAB and DO is poor.

Is the addition of vaginal electrical stimulation to transcutaneous tibial nerve electrical stimulation more effective for overactive bladder treatment? A randomized controlled trial

INTRODUCTION AND OBJECTIVES

Overactive bladder (OAB) is a prevalent disorder that increases with age and impairs patients' quality of life. Guidelines recommend behavior modifications as the first-line treatment; however, physiotherapy has also been used with success, safety, and low cost. Transcutaneous tibial nerve electrical stimulation (TTNS) and vaginal electrical stimulation (VS) are being used in clinical physiotherapy practice. This study aimed to verify whether the addition of VS to TTNS is more beneficial than TTNS alone for women with OAB.

PATIENTS AND METHODS

In all, 106 women aged >18 years diagnosed with OAB or mixed urinary incontinence with prevalent OAB symptoms were randomly divided into 2 groups: Group 1: TTNS (n = 52); Group 2: TTNS + VS (n = 54). The 3 day voiding diary, pelvic floor muscle strength (Ortiz Scale), King's Health Questionnaire, and Overactive Bladder Questionnaire were assessed before and after treatment. Urinary frequency was considered the primary outcome, and a reduction of ≥ 3 micturitions/day was considered clinically relevant. Mixed linear models were used to compare the 2groups.

RESULTS

Initially, the groups were similar in age, body mass index, number of pregnancies, time of OAB onset, and prevalence of OAB symptoms. After treatment, a reduction in urinary frequency of 1.5 micturitions was observed in Group 2, which was not clinically relevant despite being statistically significant.

CONCLUSIONS

The addition of VS to TTNS for the treatment of OAB was not more effective than TTNS as a single therapy.

[Symptoms severity profile and expectations in hyperactive bladder patients - VHEXPECTA Study.]

OBJECTIVES

To Evaluate the severity of symptoms in OAB patients and their outcomes expectations, symptoms management and Health-Related Quality of Life (HRQoL).

MATERIAL AND METHODS

Epidemiological, multicentre, non-interventional, cross-sectional study, conducted by 294 physicians in Spain in clinical practice. Female adult patients with OAB symptoms, newly diagnosed or during follow-up were included. B-SAQ, OABq-SF and an ad-hoc patient expectation questionnaire were completed. Association between expectations, symptom severity and prior treatments was analyzed using Chi- Square. The non-parametric Kruskal-Wallis test was used to analyze the relationship between the intensity of the urgency and the impact of OAB symptoms on HRQoL and between expectative and symptoms characteristics and HRQoL.

RESULTS

1.107 patients were included. Mean age was 58 years. 60.6% were newly diagnosed and urinary urgency was the most frequent symptom reported (93.3%). According the B-SAQ score 58.7% suffered moderatedor severe OAB. Expectations in patients without previous treatment about " their symptoms will be cured permanently" were higher than in patients previously treated (p<0.005). The percentage of patients who expected a positive response to treatment decreased while the OAB symptom severity increased (73.9% mild symptoms, 32.5% very severe symptoms; p<0.005). Moreover, patients with higher symptom discomfort were less agreement with all expectations ( p<0.005), and HRQL was higher in patients with higher expectations (p<0.005).

CONCLUSIONS

The expectations of patients with OAB regarding their pathology and the expected outcomes of treatments are related to symptom severity and HRQL.

Quality of life and treatment persistence evaluation in Spanish patients treated with mirabegron. Results of the BELIEVE study

INTRODUCTION AND OBJECTIVE

The BELIEVE study is a European, non-interventional study which includes patients with overactive bladder who were prescribed mirabegron as part of routine clinical practice. Data from the Spanish subpopulation has been obtained for the present study, aiming to analyze health-related quality-of-life (HRQoL) and treatment persistence of these patients.

MATERIALS AND METHODS

Data from 11 Spanish hospitals of the BELIEVE study were analyzed. The primary endpoint was to evaluate change of HRQoL from baseline with overactive bladder questionnaire (OAB-q). Secondary endpoints included treatment persistence, HRQoL based on the EQ-5D-5L questionnaire and adverse events. Study follow-up was 12 months, with two visit windows at 2-4 months and 10-12 months.

RESULTS

153 Spanish patients were enrolled in the study. In the Full Analysis Set (FAS), 63.1% were women, and the mean age was 66 years. Symptom bother and HRQoL improved from baseline to 2-4 months and 10-12 months. EQ-5D-5L questionnaire also showed an improved patients' HRQoL. Treatment persistence was high, as 49% of patients remained with mirabegron at 10-12 months. Adverse events were consistent with previous safety profile results of mirabegron, and no unexpected safety issues were observed.

CONCLUSIONS

Spanish patients treated with mirabegron in real clinical practice reported improvements in HRQoL, with a good tolerability and persistence to treatment.

Precise characterization of urinary tract innervation using three-dimensional reconstruction: A contemporary review

A precise understanding of the autonomic innervation of the urinary tract is crucial to successful management of urologic disease given the important role that neurophysiology plays in genitourinary pathology. Recent studies using a combination of contemporary histopathology and imaging technologies have furthered our understanding of the spatial nerve distribution in the kidneys, ureters, and bladder. The findings of these recent studies may have important clinical applications in expanding our knowledge of the etiology and treatment of disease processes affecting the urinary tract. In this narrative review, our goal is to provide an overview of the autonomic innervation of the urinary tract. Specifically, we aim to provide a three-dimensional gender-specific description of renal, ureteral and vesical innervation. We also highlight some possible opportunities for clinical and investigational application of this new knowledge.

Lower urinary tract symptoms and obstructive sleep apnea syndrome: Urodynamic evolution before and after one year of treatment with continuous positive airway pressure

OBJECTIVE

To report the clinical evolution and the urodynamic behaviour of several lower tract urinary symptoms in patients with obstructive sleep apnea syndrome before and after the treatment with continuous positive airway pressure (CPAP) devices.

METHODS

A prospective study was performed; patients with recent diagnosis of sleep apnea confirmed by nocturnal sleep polygraphy and absence of medical urological past history. In order to discard important lower urinary tract conditions, urological examinations were previously performed. Urinary symptoms were evaluated using the IPSS and OAB-V8 validated questionnaires, three-day Bladder Diary and invasive urodynamic examinations with a gap of one year before and one year after using the CPAP.

RESULTS

84 urodynamic studies were carried out in 43 patients. The IPSS score decreased by 3.58 points. The OAB-V8 score decreased by 2.87 points. Nocturia episodes decreased to one per night. The percentage of patients with nocturnal polyuria went down to 26%. The bladder compliance significantly increased (97.39 vs 200.40ml/cm H2O). The presence of detrusor overactivity decreased from 11 (before CPAP) to 5 patients (after CPAP).

CONCLUSION

The proper treatment with CPAP showed a statistical and clinical improvement of several LUTS with limited urodynamic modifications.

Clinical and urodynamic impact of detrusor overactivity in women with overactive bladder

OBJECTIVE

To evaluate the clinical and urodynamic differences (associated with the presence or absence of detrusor overactivity [DO]) in women with overactive bladder (OAB) referred to Functional Urology and Urodynamic Units in Spain.

MATERIAL AND METHODS

Observational, cross-sectional, multicenter and prospective study conducted in Spain in women with clinical diagnosis of OAB, who had been referred to urodynamic study (UDS) of which centralized reading was performed. Patients completed the 3-day voiding diary (DM3d) with the PPIUS scale (Patient Perception of Intensity of Urgency Scale), the B-SAQ (Bladder Self-Assessment Questionnaire) and the OABq-SF (Overactive Bladder Questionnaire Short Form). The questionnaires and UDS variables of women with OAV, with or without DO, were compared using the Mann-Whitney test (continuous variables) and the chi-square test (χ²) (categorical variables).

RESULTS

A total of 247 women with OAB were evaluated, and 103 of them had DO. According to the presence or absence of DO, significant differences were observed in the number of episodes of urge urinary incontinence (UUI), urinary frequency, nocturia, mean micturition volume and number of pads (P<.05 for all comparisons). A higher percentage of patients with OAB and DO presented reduced bladder capacity, urgency, urge urinary incontinence (UUI) and lower volume for first voiding desire, strong desire to void and maximum cystomanometric capacity in UDS compared with patients without DO (P<.05 for all comparisons). The only significant differences between both groups were regarding the B-SAQ symptoms scale (P=.011).

CONCLUSIONS

The presence of DO in women with OAB is related to a more severe alteration of the bladder filling phase.

Cognitive function assessment in elderly patients with overactive bladder treated with transdermal oxybutynin

INTRODUCTION AND OBJECTIVES

Older patients with overactive bladder under antimuscarinic treatment are especially susceptible to cognitive impairment. The aim was to assess short term changes in cognitive function in elderly patients with overactive bladder treated with transdermal oxybutynin.

MATERIALS AND METHODS

Observational, retrospective, multicentre study in patients with overactive bladder aged 65-80 years undergoing treatment with transdermal oxybutynin. Before and after one month of treatment, cognitive function using the Memory Alteration Test and Clock-Drawing Test, changes in symptoms with validated questionnaires, patient perception of treatment response using Treatment Benefit Scale and treatment adherence with the modified Morisky-Green test, were assessed.

RESULTS

From 85 eligible patients, 70 completed the assessment (mean age: 71.4±4.5; BMI: 28.7±3.1kg/m2). No cognitive impairment was observed after one month with transdermal oxybutynin: Memory Alteration Test (+1 point; 95%CI: 0.0-1.5), Clock-Drawing Test (0 points; 95%CI: 0.0-0.0). A statistically significant improvement (P<.001) was observed in all urinary storage symptoms, except stress urinary incontinence. There was an improvement in the Bladder Control Self-Assessment Questionnaire (symptom score: -2.27; 95%CI: -2.8, -1.7; P<.001; bother score: -2.73; 95%CI: -3.3, -2.1; P<.001). 70% of patients reported either a stable or improved bladder condition according to the Patient Perception of Bladder Condition questionnaire. 72.8% of patients reported that their urinary problems had improved or greatly improved with an 84.3% treatment adherence.

CONCLUSIONS

No cognitive impairment was observed in elderly patients after one month of treatment with transdermal oxybutynin; urinary urgency symptoms improved and there was adequate treatment adherence.

[Cost effectiveness of Mirabegron and antimuscarinic drugs in patients with hiperactive bladder.]

OBJECTIVE

To evaluate the costeffectivenessof mirabegron in comparison to theantimuscarinic drugs tolterodine, solifenacin andfesoterodine, in the treatment of urgency, increasedmicturition frequency and urinary incontinence in patientswith overactive bladder (OAB).

MATERIAL AND METHODS

A Markov model in Excel,with a time horizon of 5 years was developed fromthe National Health System and societal perspective.Clinical effectiveness was estimated from a clinical trial(SCORPIO) and a network meta-analysis. Unit costswere obtained from Spanish sources. The effectivenessof the treatments was measured as quality adjusted lifeyears(QALY). Deterministic and probabilistic sensitivityanalyses were performed.

RESULTS

For the 5-year time horizon, the incrementalcost per patient with mirabegron 50 mg versustolterodine was € 195.52 and € 157.42, from theNational Health System (NHS) and societal perspectivesrespectively, with a gain of 0.0127 QALY withmirabegron. Consequently, the cost of gaining a QALYwith mirabegron versus tolterodine was 15,432 € and12,425 € respectively. The probability that mirabegronwould be cost-effective at a willingness to pay thresholdof € 30,000 was: 70% (NHS) and 71% (society)versus tolterodine; 94% (NHS and society) versussolifenacin 5 mg; 84% (NHS) and 84.5% (society)versus solifenacin 10 mg; 96% (NHS and society)versus fesoterodine 4 mg; 98% (NHS) and 99% (society)versus fesoterodine 8 mg. The highest probability thatmirabegron would be cost-effective at a willingness topay threshold of € 20.000 and € 25.000 per QALYgained, is obtained versus fesoterodine 4 mg and 8 mgfrom both NHS and society perspectives.

CONCLUSIONS

The treatment of patients with OABwith mirabegron 50 mg is likely to be cost-effectivecompared to treatment with antimuscarinics.

Impact of overactive bladder symptoms on work activity: The ACTIVHA study

OBJECTIVES

To analyse the impact of overactive bladder (OAB) symptoms on the work activity of patients in Spain.

METHOD

An observational, multicentre cross-sectional study was conducted with 149 urologists and 131 gynaecologists of Spain and included patients diagnosed with OAB, according to clinical judgment, who were of working age (18-65 years). We collected sociodemographic, clinical and work activity data. The patients filled out the Bladder Control Self-Assessment Questionnaire (B-SAQ) and the Work Productivity and Activity Impairment Questionnaire-General Health (WPAI-GH). The effect of each symptom on the daily and occupational activity was assessed. The results were stratified according to sex and the presence of emergency and urinary incontinence (UI) according to the B-SAQ.

RESULTS

We assessed 768 patients (89% women), with a mean (SD) age of 52.5 (9.3) years and 2.6 (2.6) years of OAB progression. The most common symptoms according to the patients were urgent urination (89.8%), nocturia (75.7%), urge incontinence (68.5%) and frequent urination (68.2%). Ninety-six percent of the patients adopted adaptive measures for their OAB. According to the B-SAQ, 543 patients (71%) presented urgent urination; of these, 294 (54%) showed UI. The symptom that most affected work activity was frequent urination (59.8%). According to the WPAI-GH, the patients reported an impact of 32% during the workday (41% in patients with urgent urination and UI) and a loss of work time of 6.5% (9.9% in patients with urgent urination and UI).

CONCLUSIONS

The symptoms of OAB negatively affect work activity, especially in patients who have urgent urination and UI.

Transcutaneous stimulation of the posterior tibial nerve for treating refractory urge incontinence of idiopathic and neurogenic origin

OBJECTIVE

To assess the efficacy of treatment with transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with urge urinary incontinence, of neurogenic or nonneurogenic origin, refractory to first-line therapeutic options.

MATERIAL AND METHODS

We included 65 patients with urge urinary incontinence refractory to medical treatment. A case history review, a urodynamic study and a somatosensory evoked potentials (SEP) study were conducted before the TPTNS, studying the functional urological condition by means of a voiding diary. The treatment consisted of 10 weekly sessions of TPTNS lasting 30minutes.

RESULTS

Some 57.7% of the patients showed abnormal tibial SEPs, and 42% showed abnormal pudendal SEPs. A statistically significant symptomatic improvement was observed in all clinical parameters after treatment with TPTNS, and 66% of the patients showed an overall improvement, regardless of sex, the presence of underlying neurological disorders, detrusor hyperactivity in the urodynamic study or SEP disorders. There were no adverse effects during the treatment.

CONCLUSIONS

TPTNS is an effective and well tolerated treatment in patients with urge incontinence refractory to first-line therapies and should be offered early in the treatment strategy. New studies are needed to identify the optimal parameters of stimulation, the most effective treatment protocols and long-term efficacy, as well as its applicability to patients with a neurogenic substrate.

[Prevalence and characterization of overactive bladder detected in a population in Madrid with self-administered OAB-V3 questionnaire in Primary Care]

Objetivo

Determinar la prevalencia de síntomas sugestivos de vejiga hiperactiva (VH) en una población española y evaluar su impacto en el bienestar y la productividad laboral de esta población.

Diseño

Estudio transversal.

Emplazamiento

Atención primaria, Madrid, España.

Participantes

Varones y mujeres > 30 años.

Intervenciones

Clasificación con el instrumento abreviado Overactive Bladder Awareness Tool (OAB-V3). Sujetos con puntuación ≥ 3 y una población control similar con puntuación < 3 fueron investigados clínicamente.

Mediciones principales

Anamnesis, exploración física, análisis de orina, ecografía, escala de bienestar general y cuestionarios PPBC, OAB-q y WPAI-SHP.

Resultados

Se cribaron 923 sujetos, 209 (22,6%) de los cuales —35% hombres y 65% mujeres— presentaron probable VH. La distribución por edad aumentó del 11,1% en la cuarta década al 44,4% en la novena década. El coeficiente kappa entre probable VH y diagnóstico definitivo fue de 0,83. El área bajo la curva ROC para el diagnóstico según el cuestionario OAB-V3 y la constatación de molestias percibidas y estrategias de afrontamiento fue del 92%. Los sujetos clasificados por OAB-V3 ≥ 3 tuvieron peor bienestar, mayor puntuación PPBC y peores parámetros en las puntuaciones OAB-q total y transformadas para cada subescala OAB-q (p < 0,0001). Su productividad laboral no se vio afectada (p = 0,14), pero sí la capacidad de realizar actividades cotidianas (p < 0,0001).

Conclusiones

OAB-V3 es un cuestionario simple para el cribado de VH con buena exactitud de predicción en atención primaria y que conlleva implicaciones importantes en la calidad de vida relacionada con la salud.

Comparative study of the B-SAQ, OAB-V8 and OAB-V3 questionnaires as screening tools for overactive bladders in clinical practice

OBJECTIVE

To compare the capacity shown by 3 self-assessment questionnaires validated in Spanish (B-SAQ, OAB-V8 and OAB-V3) for the screening of patients with overactive bladder (OAB) in clinical practice.

MATERIAL AND METHOD

A noninterventional observational study was conducted of men and women older than 30 years evaluated in primary care consultations. The clinical diagnosis of OAB was conducted through a case history review, physical examination, urine analysis, ultrasonography and voiding diary. The presence of coping strategies and discomfort was investigated. The differential diagnosis was established in patients with symptoms not due to OAB. We assessed the correlation between the clinical tests and diagnosis (kappa <.4 poor; .4-.6 moderate; >.6 good; >.8 excellent) and ROC curves to define the capacity to screen the assessed questionnaires.

RESULTS

A total of 411 patients were investigated. OAB was detected in 207 (50.4%) patients, other causes for the lower urinary tract symptoms were detected in 63 (15.3%), and 141 (34.3%) patients had no diagnosis. The voiding diary suggested OAB in 197 (47.9%) patients. The correlation between the clinical diagnosis and the diagnosis based on the voiding diary was .702. The correlation between the clinical diagnosis and B-SAQ, OAB-V8 and OAB-V3 was .59, .673 and .732, respectively. The area under the curve (AUC) was .799 for B-SAQ; .837 for OAB-V8 and .867 for OAB-V3 (OAB-V3 vs. OAB-V8, P=.02; OAB-V3 vs. B-SAQ, P<.0001). The AUC for the voiding diary was .852 (OAB-V3 vs. diary, P=.47).

CONCLUSIONS

OAB-V3 is a simple questionnaire with excellent performance for screening OAB in a specific population and that is superior to the OAB-V8 and B-SAQ. The accuracy of the voiding diary for the same indication is equivalent to that of the OAB-V3 in our setting.

Cultural adaptation to Spanish (Spain) of the "Overactive Bladder - Family Impact Measure (OAB-FIM)" questionnaire

OBJECTIVE

The OAB-FIM was developed as a measure of the impact of an overactive bladder (OAB) on relatives who live with the patient. The objective of this study was conduct a cultural adaptation to Spanish (Spain) of the OAB-FIM questionnaire.

METHODS

The adaptation included a conceptual and linguistic validation phase, as well as a phase for measuring the psychometric properties in 25 relatives [mean age, 63.0 years (SD, 14.3); 44% women] who regularly live with patients with OAB, who are of either sex and 18 years of age or older. We measured conceptual and linguistic equivalence, internal reliability, construct validity and content validity. We assessed the applicability and administration load.

RESULTS

The OAB-FIM was conceptually and linguistically equivalent to the original, maintaining its 6 domains: social, travel, worry, irritability, sleep and sex. The interagreement correctly placed all items in their domain, except for number 10, which was placed more in worry than in irritability, motivates its reformulation. Some 2.95% of the items were missing. The floor and ceiling effects of the items varied, respectively, between 20-28%, and 0-16%. The mean time for completing the questionnaire was 5.2minutes (SD, 2.8), and 24% of the participants required some type of assistance. The α-Cronbach coefficient varied between 0.948-0.839. The correlations with similar scales in the family were moderate-high (0.407-0.753) or small-moderate with those administered to the patient (0.004-0.423).

CONCLUSION

We obtained a Spanish (Spain) version of the OAB-FIM that was conceptually and linguistically equivalent to the original. The questionnaire showed good internal consistency, content and construct validity and applicability.

Impact of daily number of urgency urinary incontinence episodes on overactive bladder patient reported outcomes

OBJECTIVE

To explore the impact of urgency urinary incontinence (UUI) on well-being in non-institutionalized patients with overactive bladder (OAB) in a community sample.

METHODS

A cross-sectional web-based study was conducted in the general population, including males and females, >18 years of age. Patients with probable OAB were identified using a validated algorithm together with a score ≥8 on the OAB-V8 scale. Presence of coping behavior was considered determinant for the clinical diagnosis of OAB. Individual well-being was determined through a battery of patient-reported outcomes (PRO) measurements including assessment of health-related quality of life (EQ-5D), sleep disturbances (MOS Sleep), and life satisfaction (LISAT-8). Patients were grouped according to the number of daily UUI episodes (UUI severity): 0 (dry OAB),1, 2-3, or ≥4. Multivariate analysis to evaluate factors independently affecting quality of life was undertaken.

RESULTS

A total of 396 patients (52.5% women, mean age: 55.3 [11.1] years, OAB-V8 mean score: 14.5 [7.9]) out of 2035 subjects participating from the general population met the criteria for OAB: 203 (51.3%) with 0episodes, 119 (30.1%) with 1, 52 (13.1%) with 2 or 3, and 22 (5.6%) with ≥4 episodes. A statistically significant linear adjusted association was found between number of UUI episodes and PRO scores. Participants with more episodes had poorer health profiles and self-evaluated quality of life, worse life satisfaction, and more sleep disturbances and fewer hours of sleep per night. Number of incontinence episodes was independent factor to affect quality of life using both LISAT-8 and MOS questionnaires.

CONCLUSION

Severity of UUI was significantly associated with poorer individual well-being in subjects with OAB in a community sample in Spain.

Persistence and concomitant medication in patients with overactive bladder treated with antimuscarinic agents in primary care. An observational baseline study

OBJECTIVE

To assess therapeutic persistence and its relationship with concomitant medication in patients treated with fesoterodine versus tolterodine and solifenacin for overactive bladder (OAB) in standard clinical practice conditions.

MATERIAL AND METHODS

An observational, multicentre retrospective study was performed based on medical registries of patients followed-up in primary care (PC). Three study groups were analysed. Persistence was defined as the time (in months) without withdrawing from the initial therapy or without changing to another medication for at least 30 days after the initial prescription. The concomitant medications were antidepressants, anxiolytic/hypnotic agents, antibiotics, antiseptic agents, laxatives and skin products. We employed the SPSSWIN program version 17 (statistical significance, P<.05).

RESULTS

We selected 3094 patients for the study. The median age was 54.0 years and 62.2% were women. The patients treated with fesoterodine shown greater treatment persistence (12 months) when compared with those who took solifenacin and tolterodine (40.2% vs. 34.7% and 33.6%, respectively; P=.008). They also showed a lower use of concomitant medication (1.1 vs. 1.2 and 1.2 drugs, respectively; percentages: 61.6% vs. 67.1% and 70.1%, respectively; P<.03).

CONCLUSIONS

The patients undergoing OAB treatment with fesoterodine, when compared with those taking solifenacin and tolterodine, were associated with greater treatment persistence and a reduced use of concomitant medication.

How should we address the diagnosis of overactive bladder in women?

OBJECTIVE

Determine the degree of completion, agreement and diagnostic performance of various instruments for assessing the presence and intensity of urgency and other symptoms of idiopathic overactive bladder (OAB) and determine which is the best diagnostic combination.

MATERIAL AND METHODS

Observational, noninterventional, cross-sectional multicentre study on 247 women aged 18 years or older, with a clinical diagnosis of OAB, evaluated in 55 functional urology and urodynamic units. The women completed the Patient Perception of Intensity of Urgency Scale questionnaire, an independent bladder control self-assessment questionnaire (B-SAQ), the Overactive Bladder Questionnaire Short-Form and a 3-day voiding diary (VD3d), and they underwent a urodynamic study (UDS). The degree of completion and agreement among the instruments was assessed using the Kappa index (95% CI) and Cramér's V. The diagnostic performance of each tool and their combination was studied using absolute frequencies of positive cases for each OAB symptom.

RESULTS

The patients mean age was 57.66 years (SD, 13.43). There was a high degree of completion (>85%). The agreement among the instruments was poor or moderate, and there was no agreement with the UDS. The best combination of tools for the diagnosis of OAB in women was the B-SAQ and VD3d.

CONCLUSIONS

The degree of completion of all instruments was high, the agreement between them was poor-moderate and not significant for the UDS. The instruments that had the best diagnostic performance for assessing urgency and other OAB symptoms, providing data on their severity and discomfort, were the B-SAQ and the VD3d.

The value of oxybutynin in transdermal patches for treating overactive bladder

CONTEXT

There is currently a broad therapeutic arsenal of drugs for treating overactive bladder syndrome (OAB). However, there is still a need for new compounds and for improving known drugs in terms of efficacy, compliance and tolerability.

OBJECTIVE

To report the scientific evidence on the safety and efficacy of transdermal oxybutynin (OXY-TDS) for treating OAB.

MATERIAL AND METHODS

A systematic review without time restrictions was conducted until May 2015 in the MEDLINE/PubMed database. We also performed a manual review of abstracts published in international urogynaecology congresses.

RESULTS

The evaluated studies show that patients treated with OXY-TDS experience a significant reduction in urinary incontinence episodes compared with placebo, which is comparable to that observed in patients treated with oral oxybutynin or with tolterodine. In all of the studies, we observed improvements in symptoms from the second or third week of treatment and in a sustained manner until the end of treatment (6, 12 or 24 weeks). The clinical practice study also showed improved quality of life, achieving benefits in numerous patient profiles, with an efficacy independent of previous treatments. The safety of the drug was demonstrated in the various patient profiles.

CONCLUSIONS

OXY-TDS represents an effective alternative for the symptomatic treatment of adult patients with OAB, which, thanks to its pharmacokinetic profile, better tolerability, different administration method and dosage, could represent an added value in treating special populations.

[Consensus document on overactive bladder in older patients]

Overactive nladder (OAB) is a clinical entity with a high prevalence in the population, having a high impact on quality of life, especially when it occurs with urge urinary incontinence. It is very important to highlight the low rate of consultation of this condition by the older population. This appears to depend on several factors (educational, cultural, professional), and thus leads to the low percentage of older patients who receive appropriate treatment and, on the other hand, a large percentage of older patients with a significant deterioration in their quality of life. Therefore, Scientific societies and Working Groups propose the early detection of OAB in their documents and clinical guidelines. Its etiology is not well known, but is influenced by cerebrovascular processes and other neurological problems, abnormalities of the detrusor muscle of bladder receptors, and obstructive and inflammatory processes of the lower urinary tract. Its diagnosis is clinical, and in the great majority of the cases it can be possible to establish its diagnosis and etiopathogenic orientation, without the need for complex diagnostic procedures. Currently, there are effective treatments for OAB, and we should decide the most appropriate for each elderly patient, based on their individual characteristics. Based on the main clinical practice guidelines, a progressive treatment is proposed, with the antimuscarinics being the most recommended drug treatment. Therefore, a group of very involved professionals in clinical practice for the elderly, and representing two scientific Societies (Spanish Society of Geriatrics and Gerontology [SEGG], and the Spanish Society of Primary Care Physicians [SEMERGEN]) developed this consensus document with the main objective of establishing practices and valid strategies, focused to simplify the management of this clinical entity in the elderly population, and especially to improve their quality of life. The recommendations presented in this consensus document are the result of a comprehensive review and critical discussion of articles, documents and clinical guidelines on OAB, both nationally and internationally. Are, where possible, levels of evidence and grades of recommendation are included.

Adherence to fesoterodine in women with overactive bladder in routine clinical practice

OBJECTIVES

To assess the short-term compliance with fesoterodine treatment and to identify the reasons for lack of adherence and discontinuation in routine clinical practice. The secondary aim was to estimate the patient-reported outcomes.

METHODS

This was an observational retrospective, multicenter study conducted in a sample of women with overactive bladder on fesoterodine treatment for at least three months. Adherence to medication was assessed using the Morisky-Green test. Patient-reported outcomes were assessed using the Incontinence Questionnaire Short Form (ICIQ-SF), Overactive Bladder Questionnaire Short Form (OAB-qSF), and Treatment Benefit Scale (TBS).

RESULTS

One hundred and twenty women with a mean age [standard deviation (SD)] of 62.2 (12.0) years with severe OAB [mean (SD) ICIQ-SF score 13.2 (4.0)] were included. 42.1% of the patients were considered compliant with fesoterodine treatment. The main causes for non-compliance/discontinuation stated by the remaining 57.9% of the patients were adverse events (62.2%) and lack of clinical benefits (20.0%). The illness status as well as the patient-perceived bother occasioned by the OAB symptoms and their impact on the quality of life improved significantly after three months on fesoterodine treatment (p<0.0001). Most of the patients stated that the current state of their urinary problems had greatly improved/ improved.

CONCLUSION

In routine clinical practice, a high percentage of patients were adherent to fesoterodine and perceived the benefit that the treatment provided them three months after starting treatment. However, more than half of the study population failed to comply or discontinued the treatment mainly due to intolerance or lack of efficacy.

Cost-effectiveness analysis of main diagnosis tools in women with overactive bladder. Clinical history, micturition diary and urodynamic study

OBJECTIVES

The aim of the present clinical research is to analyze, in the light of the best scientific evidence, the performance and the cost of the main diagnostic tools for overactive bladder (OAB).

METHODS

It is an exploratory transversal study in which 199 women diagnosed of OAB between 2006 and 2008 were selected and underwent to following prospective analyses: physical examination, urine analysis, micturition diary (MD) and urodynamic study (UDS). A percentage of 80% was assumed as highly sensitive and a diagnostic difference among tests of 10% would be considered clinically relevant. Tests' sensitivity for diagnosis of OAB was statistically established by two ways: isolated and combined. Besides, the direct and indirect costs of these tests performance were conducted. Cost-effectiveness study of clinical history (CH), MD and US for the diagnosis of OAB was performed.

RESULTS

Overall sensitivity for OAB diagnosis is low for the 3 tests used in isolated way, whilst the combination of any two tests shows good overall sensitivity. The combination of CH and MD has appeared as the most cost-effective alternative to OAB diagnosis.

CONCLUSIONS

For OAB diagnosis, CH-DM combination shows the same sensitivity than the association of either of them with the UDS, but unlike to these, it shows the lowest cost.

Use of health care resources and associated costs in non-institutionalized vulnerable elders with overactive bladder treated with antimuscarinic agents in the usual medical practice

OBJECTIVE

To evaluate the use of resources and health costs in vulnerable elderly institutionalized patients with overactive bladder (OAB) treated with fesoterodine, tolterodine or solifenacin in routine medical practice.

MATERIAL AND METHODS

A multicenter retrospective study, from the records of patients treated during 2008-2010 in three geographical locations and starting treatment with antimuscarinic (fesoterodine, solifenacin and tolterodine) for OAB. The attribute of vulnerability was based on collecting at least 3 of the Vulnerable Elders Survey criteria-13, age>75 years, poor/average age for health and difficulty in at least one daily physical activity.

MAIN MEASURES

morbidity, persistence and resource use and costs. Monitoring of patients was conducted over 52 weeks. A general linear model with covariates and bootstraping (1000) at random was used to construct the 95% CI of the cost differences between drugs.

RESULTS

Records of 552 patients (50.8% women, mean age: 80.2 years) were analyzed. Treated with fesoterodine (N=58), solifenacin (N=252) or tolterodine (N=212). The use of absorbent was 20.7%, 29.4% and 33.0% (P=.186), respectively. Persistence to treatment was slightly greater with fesoterodine. The patient healthcare costs/year were lower with fesoterodine, €1,775 (1550-2014) vs. solifenacin €2,062 (1911-2223) and tolterodine €2,149 (1,978-2,307), P=.042, as a result of lower utilization visits and concomitant medication.

CONCLUSIONS

Despite the potential limitations of the study, the vulnerable elderly non institutionalized patients with OAB treated with fesoterodine, compared to solifenacin or tolterodine were associated with lower resource utilization and healthcare costs.

Expert consensus on scientific evidence available on the use of botulinum toxin in overactive bladder

OBJECTIVES

Overactive bladder (OAB) is a pathology impairing patients' quality of life and with a high percentage of patients who are refractory to medication. In this paper, technical opinion of an «expert panel» is assessed in order to gain the most reliable professional consensus on scientific evidence available on the criteria of use of Onabotulinumtoxin A (OnabotA) in OAB.

MATERIAL AND METHODS

according to DELPHI method, 42 panelists answered a survey of 93 items divided into four strategic areas including clinical criteria and recommendations in order to improve, at different levels, the current approach to patients with OAB. The recent advances in the field, areas of controversy and their real application possibilities in the different areas of our health care system were taken into consideration.

RESULTS

Two rounds of the questionnaire were completed by all experts. In the first round, a criteria consensus was reached for 64 of 93 (68.8%) questions analyzed; in the second round the consensus reached was for 83 items evaluated (89.25%). An agreement among panelist was reached for: 1) definition, classification, detection and differential diagnosis; 2) medical treatment; 3) surgical treatment; 4) role of OnabotA in the treatment of OAB.

CONCLUSIONS

the consensus is broadly in line with the latest scientific evidence on OAB. The panelists believe that it is necessary to propose a change in the current definition of OAB and that it seems necessary to improve the screening tools too. Medical treatment of OAB must be tailored to each patient, staged and progressive. The use of OnabotA (Botox(®)) could imply therapeutic advantages with respect to other treatments, and positions itself as a safe and effective alternative to treat drug refractory OAB.

The effect of hyperactive bladder severity on healthcare utilization and labor productivity

OBJECTIVE

To explore the relationship between the severity of urinary urge incontinence (UUI) on healthcare resources utilization (HRU) and loss of labor productivity of subjects with overactive bladder (OAB) in the general population in Spain.

METHODS

Secondary analysis of a cross-sectional web-based study conducted in the general population >18 years, through a battery of HRU questions asked using an online method. Probable OAB subjects were identified using a previously validated algorithm and a score >8 in the OAB-V8 questionnaire. HRU questions included an assessment of concomitant medication used as a consequence of OAB/UUI, pad utilization, and medical office visits. Patients were grouped according to the number of UUI episodes into 0, 1, 2-3 or 4+ episodes.

RESULTS

Of a total of 2,035 subjects participating from the general population, 396 patients [52.5% women, mean age: 55.3 (11.1) years, OAB-V8 mean score: 14.5 (7.9)] were analyzed; 203 (51.3%) with 0 episodes, 119 (30.1%) with 1, 52 (13.1%) with 2 or 3, and 22 (5.6%) with 4 or more episodes. A linear and significant adjusted association was observed between the number of UUI episodes and HRU; the higher the number of daily episodes the higher the HRU. Subjects with more episodes had medical visits more frequently at the primary care (P = .001) and specialist (P = .009) level as well. Consumption of day (P < .001) and night (P < .001) urinary absorbents, anxiolytic medicines (P = .021) and antibiotics (P = .05) was higher in patients with more UUI episodes.

CONCLUSION

The severity of OAB in terms of frequency of daily urge incontinence episodes was significantly and linearly associated with higher healthcare resources utilization and a decrease in labor productivity in subjects with probable OAB in Spain.

Therapeutic benefit in patients switching tolterodine to other novel antimuscarinic agents

OBJECTIVES

To explore in the daily clinical practice setting that antimuscarinic, Fesoterodine or Solifenacin, provides a greater clinical benefit after changing their prior Overactive Bladder (OAB) therapy with tolterodine extended-release (ER) to other novel antimuscarinic agents.

MATERIAL AND METHODS

A post-hoc analysis of data from an observational multicenter, cross-sectional, retrospective study. Adult patients of both sexes, with OAB and OAB-V8 score≥8, who switched to fesoterodine or solifenacin within the 3-4 months before study visit from their prior tolterodine-ER-based therapy due to poor response were included. 92 patients were selected for each treatment group, matched (1:1) according to conditioned probability using the propensity score. Benefit of treatment change perceived by the physician and patient was evaluated by means of the Clinical Global Impression of Improvement subscale (CGI-I) and Treatment Benefit Scale (TBS), respectively. Degree of worry, bother and interference with daily living activities due to urinary symptoms, level of satisfaction, and preference for current treatment were also assessed.

RESULTS

Fesoterodine provided a significantly greater improvement than solifenacina in terms of therapeutic benefit perceived by the physician according to ICG-I. 96.7% of the patients on fesoterodine treatment vs. 81.6% of the solifenacin group showed a score of improvement in TBS (P<.05). Fesoterodine was also better rated than solifenacin with regard to satisfaction and preference for the new treatment (93.4 vs. 78.2% P<.05).

CONCLUSIONS

In daily clinical practice the switch from tolterodine LP to fesoterodine seems to provide greater benefits both from the physician's and the patient's point of view compared with those provided by solifenacin.

Evidence available on the use of the selective β3-adrenoceptor agonist mirabegron for the treatment of overactive bladder

CONTEXT

Mirabegron, the selective β3-adrenoceptor agonist, heralds the latest development for the treatment of overactive bladder (OAB).

OBJECTIVE

To present the evidence available on the efficacy and tolerability of mirabegron and to discuss this treatment's potential in our setting.

EVIDENCE ACQUISITION

We reviewed 11 studies conducted with mirabegron in patients with OAB (2 phase II, 9 phase III), all studies were compared to placebo with 6 studies also including tolterodine as an additional arm. Greater emphasis shall be given to the main phase III trials performed in Europe, the USA and Australia evaluating efficacy and safety after 12 weeks (NCT00662909, NCT00689104, NCT00912964) and safety after 12 months (NCT00688688). The combined analyses of these 12 week studies is also available, with emphasis on global efficacy (FAS), efficacy with regard to incontinence (FAS i) and safety (SAF). More than 50% of patients had previously discontinued anticholinergics medication for OAB, thus allowing us to obtain data on the effectiveness of mirabegron in patients already treated with anticholinergics.

EVIDENCE SYNTHESIS

Mirabegron is an efficacious drug which presents a statistically significant reduction in the number of incontinence episodes and in urinary frequency as of 4 weeks, with a higher percentage of dry patients and a higher percentage of patients with reduction ≥50% in the number of incontinence episodes than placebo. The efficacy of mirabegron 50 and 100mg in the reduction of incontinence episodes occurs in de novo patients and who have received antimuscarinics, with adjusted mean difference and improvement in urinary frequency greater in treated patients. Its tolerability is very similar to placebo particularly for the adverse effects of the antimuscarinics (dry mouth, constipation and blurred vision). A minimal, non-clinically significant change is observed in systolic and diastolic blood pressure and pulse. Its efficacy is long-term. Mirabegron at the doses of 50 and 100mg presents an improvement versus placebo in patient satisfaction, health-related quality of life (HRQoL), symptom bother and patient's perception of bladder condition (PPBC). In the 12 week Phase III European study tolterodine delivered a lesser degree of improvement than mirabegron versus placebo in patient satisfaction, HRQoL, symptom bother and PPBC.

CONCLUSIONS

Mirabegron is the first of a new class of compounds with a novel mechanism of action that is different to the antimuscarinics. It presents significant and clinically important efficacy in the treatment of the symptoms of OAB. It has advantages with regard to the results described by the patient in treatment satisfaction. Studies on its combined use with anticholinergics are ongoing.

Validation of the Spanish version of the questionnaire «Benefit, satisfaction and willingness to continue the treatment» in patients with overactive bladder

OBJECTIVES

To perform the linguistic and psychometric validation of the Spanish version of the BSW (Benefit, Satisfaction and Willingness to continue) questionnaire.

MATERIAL AND METHODS

Epidemiologic, observational, multicenter, prospective (October 2008-February 2009) study in patients ≥40 years old with de novo overactive bladder syndrome who start treatment with antimuscarinics by physicians assessment. Data was recorded at baseline (face-to-face) and the follow-up of the study after 1 and 3 months (closed surveys by phone). Morisky-Green questionnaire was used to assess compliance. Bladder Control Self-assessment Questionnaire (B-SAQ) and BSW questionnaire were completed, performing the validation of BSW.

RESULTS

312 evaluable patients were recruited, 93 remained until the 3 months visit. 65% and 71% of patients were not compliant with treatment at 1 and 3 months, respectively. The correlation between the BSW and the B-SAQ questionnaires after 1 and 3 months was moderate and statistically significant. The internal consistency between the BSW questionnaire items was high (Cronbach alpha: 0,89 at 1 month and 0,84 at 3 months). 92% of patients understood the questions and 84% were able to fill the BSW questionnaire without need of previous instructions (N=25).

CONCLUSIONS

The BSW questionnaire has been shown to be a feasible, valid and reliable tool to know the patient self-assessment of the treatment, according to its psychometric properties.