Refractory Overactive Bladder Symptoms Research Articles

Efficacy and safety of pelvic floor magnetic stimulation combined with mirabegron in female patients with refractory overactive bladder: a prospective study.

To observe the efficacy and safety of pelvic floor magnetic stimulation (PFMS) combined with mirabegron in female patients with refractory overactive bladder (OAB) symptoms. A total of 160 female patients with refractory OAB symptoms were prospectively randomized into two groups. Eighty cases in the combination group accepted PFMS and mirabegron therapy and 80 cases as control only accepted mirabegron therapy (The clinical trial registry number: ChiCTR2200070171). The lower urinary tract symptoms, OAB questionnaire (OAB-q) health-related quality of life (HRQol), symptom bother score and OABSS between two groups were compared at the 1st, 2nd and 4th week ends. All of 160 patients were randomly assigned to two groups, of which 80 patients were included in the combination group and 80 in the mirabegron group. The incidences of LUTS, including urgency, frequent urination, and incontinence episodes, in the 2nd week and the 4th week after combination treatment were significantly lower than those in the mirabegron group (p < 0.05). The incidence of drug-related adverse events between two groups was similar, and there was no statistically significant difference (p > 0.05). With respect to secondary variables, the OAB-q HRQol score in the combination group was statistically superior in comparison with that in the mirabegron group between the 2nd week and the 4th week (p < 0.05). This was consistent with the primary outcome. Meanwhile, from the second to fourth week, the OAB-q symptom bother score and OABSS in the combination group were both lower than in the mirabegron group (p < 0.05). Combination therapy of PFMS and mirabegron demonstrated significant improvements over mirabegron monotherapy in reducing refractory OAB symptoms for female patients, and providing a higher quality of life without increasing bothersome adverse effects. https://www.chictr.org.cn/, ChiCTR-INR-22013524.

MP71-18 PERIPHERAL TIBIAL NERVE STIMULATION DEMONSTRATES LIMITED IMPROVEMENT IN SELF-REPORTED SYMPTOMS FOR PATIENTS WITH OVERACTIVE BLADDER: SINGLE CENTER EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023MP71-18 PERIPHERAL TIBIAL NERVE STIMULATION DEMONSTRATES LIMITED IMPROVEMENT IN SELF-REPORTED SYMPTOMS FOR PATIENTS WITH OVERACTIVE BLADDER: SINGLE CENTER EXPERIENCE Leo D Dreyfuss, Maryam Saghir, Christina Sze, Mary O Strasser, Dean Elterman, Naeem Bhojani, Kevin C Zorn, and Bilal Chughtai Leo D DreyfussLeo D Dreyfuss More articles by this author , Maryam SaghirMaryam Saghir More articles by this author , Christina SzeChristina Sze More articles by this author , Mary O StrasserMary O Strasser More articles by this author , Dean EltermanDean Elterman More articles by this author , Naeem BhojaniNaeem Bhojani More articles by this author , Kevin C ZornKevin C Zorn More articles by this author , and Bilal ChughtaiBilal Chughtai More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003339.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peripheral tibial nerve stimulation (PTNS) is a novel technique for treatment of overactive bladder (OAB), with demonstrated efficacy in reduction of OAB symptoms. We seek to evaluate efficacy of PTNS in self-reported reduction of OAB symptoms at a single academic urologic clinic. METHODS: Single institution cohort was performed of PTNS therapy in men and woman with refractory OAB symptoms. Overactive bladder questionnaire short form (OAB-q SF) was used to track urinary symptoms after each session of PTNS. Descriptive analysis was conducted on baseline characteristics. T-tests were used for continuous variables (or Wilcoxon signed-rank tests, as appropriate). RESULTS: 138 patients (87 women and 51 men) underwent PTNS placement during study period. Median (IQR) PTNS treatments was 11 (6-12) sessions and 56 patients (40.6%) underwent 12 or more sessions. 82 patients (59.9%) had failed previous medical therapy and 97 (70.8%) had failed previous behavioral therapy. Of men, 30 (58.8%) were on concurrent alpha blocker therapy. Pre-procedure OAB-q SF data was available for 88 patients (female, male) and post-procedure data was available for 28 patients. When comparing OAB-q SF responses before and after treatment, no difference was seen for total symptom bother score (survey items 1-6) for all participants (15.9 vs. 15.5, p=0.38), female participants (15.9 vs. 15.5, p=0.38) or male participants (19.0 vs. 18.3, p=0.41). No difference was seen for total HRQOL (survey items 7-19) for all participants (34.9 vs. 34.7, p=0.46), female participants (35.0 vs. 34.7, p=0.46) or male participants (36.1 vs. 34.9, p=0.82). Significant differences were seen for specific items within the symptom bother section of survey including item 1 “Uncomfortable urge to urinate” (female pre 2.8 vs. post 2.2, p=0.02), item 2 “Sudden urge to urinate with little or no warning” (female pre 2.8 vs. post 2.1, p=0.001) and item 5 “Waking up at night because you had urge to urinate” (pre 2.9 vs. post 2.4, p=0.02). No difference was seen for any survey items within male cohort. CONCLUSIONS: In real-world cohort of patients with OAB, PTNS has limited impact on improvement in self-reported symptom bother and quality of life. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1021 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leo D Dreyfuss More articles by this author Maryam Saghir More articles by this author Christina Sze More articles by this author Mary O Strasser More articles by this author Dean Elterman More articles by this author Naeem Bhojani More articles by this author Kevin C Zorn More articles by this author Bilal Chughtai More articles by this author Expand All Advertisement PDF downloadLoading ...

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BackgroundOveractive bladder (OAB) syndrome is a symptom complex affecting 12–14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women’s social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25–40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.MethodsFUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.DiscussionThe FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.Trial registrationISRCTN63268739. Registered on 14 September 2017.

Sacral neuromodulation in patients with refractory overactive bladder symptoms after failed Botulinum toxin therapy: Results in a large cohort of patients.

AimsSacral neuromodulation (SNM) and Botulinum toxin A (BoNT‐A) injections are well‐known third‐line treatment options in patients with refractory overactive bladder (OAB). Our aim is to evaluate the success rate of SNM in patients who received prior therapy with BoNT‐A injections.MethodsAll patients with OAB symptoms referred for SNM between 2006 and 2019 were included. History taking and 3‐day voiding diaries assessed the complaints and suitability for SNM. The success rate of SNM in patients who received prior BoNT‐A was compared with BoNT‐A naive patients. Success was defined as an improvement of 50% or greater in voiding diary parameters. Satisfaction was registered at their most recent visit.ResultsA total of 263 patients underwent SNM test stimulation, of which 75 (16 male/57 female) received prior BoNT‐A and 188 (46 male/142 female) were BoNT‐A naive. Success rate for SNM in BoNT‐A naive patients was 72.9% and in BoNT‐A patients 66.7% (p = 0.316). Success rate after ≤2 BoNT‐A injections was 68.5%, compared to 61.1% after ≥3 injections (p > 0.05). Success rate in patients perceiving lack of efficacy of BoNT‐A was 67.4% (p > 0.05), subjected to temporary CISC was 73.7% (p > 0.05) and with temporary effect of BoNT‐A was 50% (p > 0.05). In 86% of BoNT‐A patients the system was still activated and used to their satisfaction at their last follow‐up visit (mean FU, 40.70 months).ConclusionSNM in patients with refractory OAB who failed prior BoNT‐A is an excellent approach. The number of injections nor reason of BoNT‐A discontinuation have predictive value for success with SNM.

Patient-reported outcomes in the setting of a randomized control trial on the efficacy of transcutaneous stimulation of the posterior tibial nerve compared to percutaneous stimulation in idiopathic overactive bladder syndrome.

To compare the efficacy of transcutaneous tibial nerve stimulation (TTNS) with percutaneous tibial nerve stimulation (PTNS) regarding patient-reported outcomes measures, specifically quality-of-life (QoL) improvement and patient's treatment benefit, on symptoms associated with overactive bladder (OAB). Patients with refractory OAB symptoms and detrusor overactivity were randomized to receive TTNS or PTNS for 12 weeks. Data from self-report OAB questionnaireshort form (q-SF) and incontinence(I)-QoL questionnaires were collected pretreatment and at Weeks 6 and 12. Patients' self-perceived benefits on symptoms (treatment benefit scale, TBS) were also gathered. Mean change in scores within and between groups were estimated. Sixty-eight adult patients (67.6% women) were included in the intention to treat analysis. Of those, 61 completed all questionnaires and were analyzed as per protocol. Statistically significant improvements in OAB-q-SF and I-QoL between baseline and end-of-treatment scores were observed in both TTNS and PTNS groups (p < .001), being the differences much higher than the minimal important difference in both questionnaires. The scores of the OAB-q-SF scales (symptoms bother and health-related QoL) showed no statistically significant differences between the two groups. Similarly, the differences regarding the I-QoL questionnaire were statistically nonsignificant either (p = .607). When assessing the treatment benefit on symptoms, TBS responses between groups showed no statistical differences. A significant improvement of QoL was observed in both TTNS and PTNS groups. However, no patient-reported outcomes measures scores support a difference between the two groups. Therefore, these findings along with TTNS ease of application and less invasiveness may lead to an increased indication of this technique for OAB.

EAU-ESPU guidelines recommendations for daytime lower urinary tract conditions in children.

The objective is to review the literature related to lower urinary tract (LUT) conditions in children to conceptualize general practice guidelines for the general practitioner, pediatrician, pediatric urologist, and urologist. PubMed was searched for the last 15-year literature by the committee. All articles in peer-review journal-related LUT conditions (343) have been retrieved and 76 have been reviewed extensively. Prospective trials were few and the level of evidence was low. Most of the recommendations have been done by committee consensus after extensive discussion of literature reports. History taking is an integral part of evaluation assessing day- and nighttime urine and bowel control, urgency, and frequency symptoms. Exclusion of any neurogenic and organic cause is essential. Uroflowmetry and residual urine determination are recommended in all patients to evaluate bladder emptying. Urodynamic studies are reserved for refractory or complicated cases. Urotherapy that aims to educate the child and family about bladder and bowel function and guides them to achieve normal voiding and bowel habits should initially be employed in all cases except those who have urinary tract infections (UTI) and constipation. Specific medical treatment is added in the case of refractory overactive bladder symptoms and recurrent UTIs.Conclusion: Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.What is Known:• Symptoms of the lower urinary tract may have significant social consequences and sometimes clinical morbidities like urinary tract infections and vesicoureteral reflux. In many children, however, there is no such obvious cause for the incontinence, and they are referred to as having functional bladder problems.What is New:• This review aims to construct a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist, and urologist for LUTS in children. Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.

Introduction to sacral neuromodulation therapy for urinary bladder dysfunction using an InterStim system.

Sacral neuromodulation is an internationally endorsed therapy recognised by the National Institute for Health and Care Excellence for patients who have refractory overactive bladder symptoms and/or idiopathic non-obstructive urinary retention when conservative treatments have failed or when patients have been unable to tolerate them. The Medtronic InterStim System used at the Queen Elizabeth Hospital Birmingham received CE mark approval in 1995 for bladder indications. To date, over 300 000 patients worldwide have been treated, with 61-90% reporting satisfaction with treatment (Sutherland et al, 2007; Leong et al, 2011). It is a safe and effective intervention that can positively impact upon the management of both of these conditions, in particular overactive bladder. This highly prevalent condition is distressing to the individual and has an economic burden to society comparable in magnitude with that of breast cancer and osteoporosis (Hu and Wagner, 2005).

Factors associated with overactive bladder symptom improvement after 1 year of monthly percutaneous tibial nerve stimulation therapy.

To investigate patient characteristics associated with overactive bladder (OAB) symptom improvement after 1 year of monthly percutaneous tibial nerve stimulation (PTNS) therapy. This was a retrospective chart review of women who underwent PTNS for refractory OAB symptoms between January 2011 and December 2017 in our tertiary center. Patients who received 12 monthly PTNS maintenance treatments after achieving success with 12 weekly PTNS treatments were included in the study. Reports on subjective changes in urinary frequency, nocturia, and urgency urinary incontinence were submitted at each visit. Patients were categorized to symptom improve and no improve groups. A multivariate analysis was performed to identify patient characteristics that predicted symptomatic improvement. Sixty-six patients were identified. Average subjective improvement after 12 monthly sessions compared with 12 weekly sessions was 5.2% on a scale of -100% to +100%. A history of urogynecologic surgery remained a significant negative predictor of symptom change from 12 weekly sessions to 12 monthly treatment sessions (odds ratio, 0.19; P = .01). OAB symptoms remain relatively stable after 12 monthly treatments of PTNS, as compared with the 12-week time point. A history of urogynecologic surgery was a negative predictor of OAB symptom improvement in patients receiving monthly PTNS for at least 12 months.

Outcomes for Intravesical Abobotulinumtoxin A (Dysport) Treatment in the Active Management of Overactive Bladder Symptoms—A Prospective Study

ObjectiveTo present the results our active management protocol for bothersome overactive bladder (OAB) symptoms using abobotulinumtoxinA (Dysport) over a 9-year period. Material and MethodsData from consecutive patients with OAB symptoms due to urodynamically-proven idiopathic detrusor overactivity who had failed maximum-dose pharmacotherapy and bladder drill were reviewed. All patients completed the Overactive Bladder Symptom Score (OABSS) and Likhart quality of life indices before treatment and again at review 6 weeks post-treatment. Two hundred and fifty units of abobotulinumtoxinA were injected under general anaesthesia. Repeat treatment was offered only after failed resumption of pharmacotherapy with bladder drill. ResultsThe results of 299 treatments in 170 patients were reviewed. OABSS and quality of life indices improved by a mean of 35% (P ˂.001) and 41% (P ˂.001), respectively, with the OABSS improving by 2 or more points in 65% of cases. While urgency incontinence was completely abolished in 26%, the severity of incontinence was reduced in 44%. Pharmacotherapy was resumed after a mean of 10.2 months, and the mean interval between repeat abobotulinumtoxinA injection treatments was 21.3 months. De-novo self-catheterization was required in 18.2% of cases due to high postvoid residuals. ConclusionThe use of abobotulinumtoxinA is safe and highly effective treatment option for patients with refractory OAB symptoms. Our data show similar outcomes to onabotulinumtoxinA in terms of symptom score improvement and self-catheterization rates.

Urinary Nerve Growth Factor Can Predict Therapeutic Efficacy in Children With Overactive Bladder

To assess urinary nerve growth factor (NGF) in children with overactive bladder (OAB) and to investigate the relationship between urinary NGF/creatinine (Cr) levels and OAB. Thirty-five children (27 boys and 8 girls) with OAB and 11 children (6 boys and 5 girls) without OAB or any other urinary symptoms, who served as controls, were included in this study. Urinary NGF levels were measured using enzyme-linked immunosorbent assay. The total urinary NGF levels were adjusted with the concentration of urinary creatinine (NGF/Cr level). Refractory OAB was defined as little improvement in OAB symptoms despite at least 3 months of urotherapy and anticholinergic agent treatment. Urinary NGF/Cr was compared between the children with OAB and the controls. The relationship between urinary NGF/Cr and treatment outcomes was also evaluated. Urinary NGF/Cr was significantly higher in the children with OAB when compared with those in the control group (0.65 ± 0.82 vs 0.11 ± 0.09, P = .0007). Improvement of OAB symptoms was observed in 26 out of 35 children (74%). The remaining 9 children showed refractory OAB symptoms (the refractory group). Urinary NGF/Cr was significantly higher in the refractory group than in the improved group (1.28 ± 1.34 vs 0.44 ± 0.39, P = .027). Urinary NGF/Cr was significantly higher in the children with OAB than in the controls, and was significantly higher in the refractory group than in the improved group. Urinary NGF/Cr could not only be a potential biomarker for children with OAB, but also a predictor of therapeutic efficacy in children with OAB.

Editorial Comment to Urodynamic findings in women with refractory overactive bladder symptoms.

Editorial Comment to Urodynamic findings in women with refractory overactive bladder symptoms.

Urodynamic findings in women with refractory overactive bladder symptoms.

To assess: (i) the correlation between overactive bladder symptoms and urodynamic findings in female patients; and (ii) the association of urinary symptoms with the presence of detrusor overactivity and/or bladder outlet obstruction. The present retrospective study included female patients with overactive bladder symptoms who underwent urodynamic evaluation by a single physician. Patients with previous anti-incontinence surgery or neurogenic bladder were excluded. Spearman's correlation coefficients were calculated to correlate overactive bladder symptoms with the urodynamic findings. Univariate and multivariate logistic regression analyses were used to determine the independent factors for detrusor overactivity and bladder outlet obstruction. Overall, 1737 reports were analyzed. All patients had urgency with or without urgency urinary incontinence. Urgency, urgency urinary incontinence and nocturia correlated with detrusor overactivity. The severity of frequency, nocturia and slow stream correlated with bladder outlet obstruction. In contrast, stress urinary incontinence showed an inverse, but weak, correlation with bladder outlet obstruction. Stress urinary incontinence correlated moderately with urine leak. Storage symptoms showed an inverse, but weak, correlation with maximum cystometric capacity. Multivariate analysis data showed that age, urgency, urgency urinary incontinence and nocturia were independent predictors of detrusor overactivity, whereas the severity of frequency was a predictor of bladder outlet obstruction. As overactive bladder symptoms increase in severity, female patients tend to have a smaller bladder capacity and a higher incidence of detrusor overactivity. A significant number of these patients have bladder outlet obstruction.

PD27-02 DOES PATIENT AGE AFFECT THE OUTCOMES AND PATIENT REPORTED HEALTH RELATED QUALITY OF LIFE (HRQOL) AFTER SACRAL NEUROMODULATION?

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Incontinence - Therapy I1 Apr 2015PD27-02 DOES PATIENT AGE AFFECT THE OUTCOMES AND PATIENT REPORTED HEALTH RELATED QUALITY OF LIFE (HRQOL) AFTER SACRAL NEUROMODULATION? Tyler Lu, Jaspreet Singh Parihar, Bianca Chendrimada, and Hari S.G.R. Tunuguntla Tyler LuTyler Lu More articles by this author , Jaspreet Singh PariharJaspreet Singh Parihar More articles by this author , Bianca ChendrimadaBianca Chendrimada More articles by this author , and Hari S.G.R. TunuguntlaHari S.G.R. Tunuguntla More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.446AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Sacral nerve neuromodulation is an established treatment option for refractory overactive bladder symptoms (OAB, urinary frequency, urgency and urgency incontinence) as well as non-obstructive urinary retention (NOR). In this retrospective cohort study, we aim to determine whether patient age plays a significant role in the outcomes following sacral neuromodulation. METHODS From 2009-2013, all consecutive patients with refractory OAB and NOR treated by a single surgeon were included. Patient symptom severity and satisfaction with therapy were assessed three months postoperatively. Patients were asked on whether they preferred keeping the device or wanted removal (patient reported HRQOL). Patients were categorized into 3 groups (Group 1 [20-40 years]; Group 2 [41-60 years]; and Group 3 [61-80 years]). Each of these 3 groups was subsequently subdivided into 2 subgroups (subgroup a, OAB; subgroup b, NOR). These subgroups are designated as 1a, 1b, 2a, 2b, 3a, and 3b. Descriptive statistics including frequency of distribution and central tendency were calculated for each category. RESULTS A total of 78 patients were included in the study. There was a total of 13 patients in Group 1; 11/13 (85%) presented with OAB and 2/13 (15%) with NOR. In group 1a only, 1 (9.1%) patient requested explant while none requested explant in group 1b. Group 2 comprised of 29 patients with 16 (55%) presenting with OAB symptoms and 13 (45%) with NOR. 3 patients (18.8%) in group 2a and 2 patients (15.4%) in group 2b requested explant. Group 3 comprised of 36 patients with 22 (61%) presenting OAB and 14 (39%) with NOR. 4 patients (18.2%) in group 3a and 1 patient (7.1%) in group 3b had their implants removed. CONCLUSIONS Our study demonstrates that age does not adversely affect the outcomes following sacral neuromodulation in patients with urinary frequency, urgency, urgency incontinence and non-obstructive urinary retention. Group 1 Group 1 Group 2 Group 2 Group 3 Group 3 a [OAB] (n=11) b [NOR] (n=2) a [OAB] (n=16) b [NOR] (n=13) a [OAB] (n=22) b [NOR] (n=14) Implant remained 10 2 13 11 18 13 Implant removed 1 0 3 2 4 1 Rate of device explantation (%) 9% 0% 19% 15% 18% 7% Group 1 [20-40 years-old] (n=13 ), Group 2 [41-60 years-old] (n=29), Group 3 [61-80 years-old] (n=36) © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e571-e572 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tyler Lu More articles by this author Jaspreet Singh Parihar More articles by this author Bianca Chendrimada More articles by this author Hari S.G.R. Tunuguntla More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A pilot study of the use of fesoterodine in the management of men with refractory overactive bladder symptoms after surgery for bladder outlet obstruction

ObjectiveTo assess the efficacy of long-acting fesoterodine on persistent lower urinary tract symptoms in men who have had previous surgical treatment for bladder outlet obstruction (BOO). Materials and methodsSeventeen patients with overactive bladder (OAB) secondary to BOO, persisting for 3 months after the obstruction was surgically relieved, were treated with fesoterodine. Follow up was performed at 2 months, 3 months, and 7 months. The primary endpoint was change in the International Prostate Symptom Score (IPSS). The secondary endpoints were change in the maximum flow rate (Qmax) and postvoid residual (PVR). ResultsPatients receiving fesoterodine demonstrated trends for improvement in mean nocturia episodes (3.2–2.6, p = 0.065), IPSS irritative subscore (6.2–2.0, p = 0.066), and quality of life score (4.2–3.5, p = 0.067) over 7 months of follow up. There was also a reduction in the mean IPSS score which was not significant over time (18.8–15.1, p = 0.183). There was no significant change observed in Qmax or PVR. Six patients (33%) had significant side effects and did not complete the study. ConclusionPatients with persistent OAB symptoms after surgical treatment of BOO displayed possible reductions in the IPSS, IPSS irritative subscore, and mean number of nocturia events after 7 months of follow up, as well as trends for an increased quality of life when treated with fesoterodine. Larger trials are needed to help characterize the utility of fesoterodine in the treatment of persistent lower urinary tract symptoms after surgical treatment of benign prostatic hyperplasia.

Urinary retention rates after intravesical onabotulinumtoxinA injection for idiopathic overactive bladder in clinical practice and predictors of this outcome.

The purpose of this study was to find the rate of urinary retention in clinical practice after treatment with onabotulinumtoxinA (BTN/A) for refractory overactive bladder (OAB) symptoms and determine factors that predict this outcome. This is a retrospective study of BTN/A for treatment of non-neurogenic, refractory OAB symptoms. Patients were analyzed with respect to their first and second BTN/A injections. The primary outcome measure was postoperative urinary retention. Statistical significance was assessed with multivariate logistic regression. Based on inclusion and exclusion criteria, the study population was 160. Mean age was 64 ± 13.2 years and 24% of the patients were men. The rate of urinary retention was 35% (n = 56). For the first BTN/A treatment, multivariate analysis revealed that preoperative PVR (post-void residual volume) (OR 1.27, 95% CI 1.13-1.43, P < 0.001) and preoperative bladder capacity (OR 1.05, 95% CI 1.01-1.08, P = 0.005) were associated with postoperative urinary retention. In patients with a preoperative PVR of ≥100 ml, 94% (n = 17) went into urinary retention. For those who underwent a second BTN/A treatment, preoperative PVR, BTN/A units injected and retention after the first BTN/A were associated with an increased rate of postoperative retention. Increased preoperative PVR was associated with urinary retention. The retention rate is higher than that reported in recent clinical trials. The inclusion of patients with a preoperative PVR ≥100 ml and a lower threshold to initiate clean intermittent catheterization contributed to this high rate of retention.

The importance of cystoscopy and bladder biopsy in women with refractory overactive bladder: the urogynaecologist's point of view?

ObjectivesTo assess the sensitivity, specificity, positive and negative predictive value of cystoscopy and the clinical value of bladder biopsy in women with refractory overactive bladder (OAB) symptoms. Study designProspective observational study carried out in a tertiary referral urogynaecology unit in London. Consecutive women with OAB resistant to pharmacotherapy who underwent cystoscopy, hydrodistention and bladder biopsy were studied. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cystoscopy as well as histological findings for chronic cystitis were evaluated. Results106 women aged 22–91 years were studied. Histopathology showed chronic cystitis in 94 women, follicular cystitis 3, acute and chronic cystitis in 2, transitional cell carcinoma in 6 and no abnormality in 1 woman. Trabeculations and increased vascularity were the most common cystoscopic findings, seen in 71% and 72% of women respectively. Haemorrhages on first filling and haemorrhages on refilling had specificities of 86.6% and 80% respectively for chronic cystitis. Their sensitivities were 9.8% and 13.1% respectively. Trabeculations and increased vascularity had sensitivities of 68.1% and 68.1% and their specificities were 11.6% and 4.5% respectively. Trabeculations, increased vascularity, haemorrhages on first filling and haemorrhages on refilling all had a PPV over 80% for chronic cystitis. ConclusionsMore than 90% of women with refractory OAB symptoms have chronic cystitis on histopathology. Cystoscopy alone is useful, but not always adequate to diagnose chronic cystitis. Antibiotic therapy in those women might be beneficial before starting anticholinergics. Larger randomised controlled trials are mandatory to confirm our hypothesis.

Patients with medication-refractory OAB symptoms should be further treated with neuromodulation

Overactive bladder (OAB) is a condition defined by the International Continence Society (ICS) as urgency with or without urgency incontinence, usually with increased daytime frequency and nocturia.1 Patients with OAB have significantly reduced quality of life.2 Population-based surveys done in Canada have shown high prevalence (14%) in both sexes.3 In a survey of over 19 000 adults in Canada and Europe, the overall prevalence of OAB was 12.8% in women and 10.8% in men.4 The similar study in United States showed that overall, 16.5% of the U.S. population aged ≥18 years (about 33 million people) have symptoms of OAB.5 The initial treatment of the OAB includes anticholinergic medications. Compliance and satisfactory results, however, are low after 1 year and range from 18% to 65%.6,7 Patients with medication refractory OAB have the option of sacral neuromodulation (SNM), intravesical injection of Botulinum Toxin type A (BTX A) or surgery, such as bladder augmentation or diversion. I strongly belief the most appropriate option for these patients is SNM. It is the most innovative treatment modality developed in recent years for the management of OAB and other voiding dysfunctions; it has also been approved by Health Canada for this indication since 1999. The ideal treatment should be effective, safe and financially sound. There is no question that SNM is effective. Brazzelli and colleagues systematic review found that 80% (4 randomized controlled trials) and 67% (30 case series) of patients became dry or achieved a >50% improvement in symptoms after implantation.8 Our own data showed 84.8% success rate with a median follow-up of 50 months (Fig. 1).10 Furthermore, in a recent study, overall satisfaction was reported as high as 90%.9 There are very little initial complications with the device. The infection rate is under 5%; in our series of 96 implants, no infection was reported at all. There is a possibility of seroma formation which was described occasionally. In our experience, the reoperation rate due to malfunction of the device or lack of improvement was initially high at 40%. The main reason for revisions (50%) was poor response. The second most common indication (17%) for revision was local pain from the device. The median time for revision was 24 months. Review of the literature of 855 patients, showed 33% revision rate. Most of the studies, including ours, consist of sacral nerve stimulation non-tined lead data, which have higher complication rates associated with the open fasciotomy procedure and lead migration.10 With the advances in the equipment and surgical technique, this rate was reduced to 26% with a combined revision rate of 32% in our experience. The biggest improvement was in the introduction of the tined-lead which can be implanted through percutaneus, minimal invasive technique. Some patients also complained of unpleasant sensations or pain. This, however, was usually resolved with reprogramming. Patients are followed on a regular basis the third and sixth month mark, and then yearly. The battery life was on average 113 months. Fig. 1. Kaplan-Meier graph of sacral neuromodulation retention (SNM) rate. The black curve indicates urge urinary incontinence. Dotted curve indicates bladder pain syndrome. Grey curve indicates IUR. Adapted from Al-zahrani et al.10.10 Patients with refractory OAB symptoms, other than SNM, have very few options left. Ileocystoplasty or diversion can be a very extensive surgery associated with complications and severe consequences; also, it has an overall low satisfaction rate. Other treatments available for these pateints include BTX A, which is still considered investigational in Canada. It is not approved in Canada for OAB and its use is off-label. The satisfaction rate, although in the 60% to 70% range, not long-lasting. One of the limiting factors with BTX A is urinary retention, which ranges from 0 to 44%11,12 or high post-void residual requiring intermittent catheterizations in 5% to 43% of patients.13 Urinary tract infections are in the range of 13% to 44%. On average, OAB patients require repeat bladder BTX A injections every 6 to 9 months. There are no Canadian studies on the cost-effectiveness of SNM and BTX A. Recently, European researchers concluded that SNM treatment is cost-effective after 5 years compared to BTX A in most cases.14 However, when local anesthesia is used for BTX A treatment and if a peripheral nerve evaluation is not a stage procedure or bilateral test, SNM was not cost-effective. These are, however, European data which are difficult to extrapolate to the Canadian health care environment. There are some reports from United States which suggest the use of SNM instead of medication for patients with OAB symptoms.15 This suggestion must also be placed within the Canadian health care context. In conclusion, SNM remains the obvious alternative for patients with refractory OAB symptoms.

Outcomes of Intravesical Botulinum Toxin for Idiopathic Overactive Bladder Symptoms: A Systematic Review of the Literature

We systematically reviewed the evidence for the efficacy and safety of botulinum toxin in the management of overactive bladder. We performed a systematic review of the literature to identify articles published between 1985 and March 2009 on intravesical botulinum toxin-A injections for the treatment of refractory idiopathic overactive bladder in men and women. Databases searched included MEDLINE, CENTRAL and Embase. Data were tabulated from case series and from randomized controlled trials, and data were pooled where appropriate. Our literature search identified 432 titles and 23 full articles were included in the final review. Three randomized placebo controlled trials addressing the use of botulinum toxin-A were identified (99 patients total). The pooled random effects estimate of effect across all 3 studies was 3.88 (95% CI -6.15, -1.62), meaning that patients treated with botulinum toxin-A had 3.88 fewer incontinence episodes per day. Urogenital Distress Inventory data revealed significant improvements in quality of life compared with placebo with a standardized mean difference of -0.62 (CI -1.04, -0.21). Data from case series demonstrated significant improvements in overactive bladder symptoms and quality of life, despite heterogeneity in methodology and case mix. However, based on the randomized controlled trials there was a 9-fold increased odds of increased post-void residual after botulinum toxin-A compared with placebo (8.55; 95% CI 3.22, 22.71). Intravesical injection of botulinum toxin resulted in improvement in medication refractory overactive bladder symptoms. However, the risk of increased post-void residual and symptomatic urinary retention was significant. Several questions remain concerning the optimal administration of botulinum toxin-A for the patient with overactive bladder.

Cost-Effectiveness of Sacral Neuromodulation Versus Intravesical Botulinum A Toxin for Treatment of Refractory Urge Incontinence

We determined the cost-effectiveness of sacral neuromodulation vs intravesical botulinum toxin A for the treatment of refractory urge incontinence. We developed a Markov decision model using a societal perspective to compare costs (2008 U.S. dollars) and effectiveness (quality adjusted life-years) of sacral nerve stimulation and botulinum toxin A. Our primary outcome was the incremental cost-effectiveness ratio, which was defined as (sacral nerve stimulation cost - botulinum toxin A cost)/(sacral nerve stimulation quality adjusted life-year - botulinum toxin A quality adjusted life-year). Sensitivity analyses were performed to assess the impact of varying efficacy, costs and adverse event rates over the range of reported values. In the base case scenario sacral nerve stimulation was more expensive ($15,743 vs $4,392) and more effective (1.73 vs 1.63 quality adjusted life-years) than botulinum toxin A during a 2-year period. The incremental cost-effectiveness ratio was $116,427 per quality adjusted life-year. Using conventional incremental cost-effectiveness ratio thresholds of $50,000 and $100,000 per quality adjusted life-year, sacral nerve stimulation was not cost-effective. In sensitivity analyses intravesical botulinum generally remained cost-effective. During a 2-year period botulinum toxin A was cost-effective compared to sacral neuromodulation for the treatment of refractory urge incontinence. Additional data regarding time to failure after botulinum toxin A injections, long-term efficacy with repeat botulinum toxin A injections and long-term complications with both therapies will be helpful for future cost-effectiveness studies.

Botulinum Toxin A for Overactive Bladder and Detrusor Muscle Overactivity in Patients With Parkinson's Disease and Multiple System Atrophy

Urinary disturbances are common in patients with Parkinson's disease and multiple system atrophy. We investigated the effectiveness and safety of botulinum toxin type A injected into the detrusor muscle in patients with Parkinson's disease and multiple system atrophy who had refractory overactive bladder symptoms and detrusor overactivity. All participants underwent clinical and urodynamic assessment, and completed a quality of life questionnaire before botulinum toxin type A treatment, and 1 and 3 months thereafter. Four patients with Parkinson's disease and 2 with multiple system atrophy were enrolled in the study. All patients received 200 U botulinum toxin type A injected into the detrusor muscle at 20 sites under cystoscopic guidance at a single session on an inpatient basis. Outcome measures were clinical assessment (a voiding diary including daytime and nighttime urinary frequency, and episodes of urgency and urge urinary incontinence), urodynamic assessment (including first volume and maximum pressure of uninhibited detrusor contractions, and maximum cystometric capacity) and pressure flow studies. One and 3 months after botulinum toxin type A injection all patients reported that daytime and nighttime urinary frequency had decreased and quality of life scores improved. No patients had further episodes of urgency and urge urinary incontinence during the 5-month followup. Urodynamics showed improvement in all urinary function variables tested. No systemic side effects were recorded during or after treatment. In all patients post-void urinary residual volume increased and intermittent catheterization was required only in those with multiple system atrophy. The new beneficial effect that we report in a small study sample encourages larger trials to confirm botulinum toxin type A injection into the detrusor muscle as an effective and safe treatment for refractory overactive bladder symptoms and detrusor overactivity related to Parkinson's disease and multiple system atrophy.