Treatment Of Refractory Overactive Bladder Research Articles

MP31-04 SHORTENED 6-WEEK PERCUTANEOUS TIBIAL NERVE STIMULATION FOR REFRACTORY OVERACTIVE BLADDER. A RANDOMISED CONTROLLED TRIAL

INTRODUCTION AND OBJECTIVE: Although the standard 12-weeks percutaneous tibial nerve stimulation (PTNS) for refractory overactive bladder (OAB) is effective, standard PTNS is costly. We aim to compare the efficacy of shortened PTNS versus sham for refractory OAB. METHODS: 57 non-neurogenic OAB adult patients were randomized to 6 weeks PTNS group or sham group. The PTNS group (25 patients) was treated with active PTNS, the sham group (25 patients) received a placebo treatment using a 34 gauge needle placed in the medial part of the gastrocnemius muscle. both groups had one session, lasted 30 minutes, performed 3 times weekly for 2 weeks. The primary outcome to assess symptoms improvements assessed by Homma and Blaivas OAB symptoms scores as well as 3-day voiding diaries at baseline, 7th week, 3rd, and 6th month. RESULTS: Patients baseline characteristics were comparable between groups (table 1). The 7th week, 3rd and 6th month OABSS demonstrated that PTNS achieved statistically significant improvement with 52% of patients reported voiding dairy (p <0.001) . Compared to sham group, the voiding dairy improved in patients with previous Botox with PTNS with p <0.001 (table 2). CONCLUSIONS: A shortened 6-week treatment protocol with PTNS appears to be successful and more effective than sham in the treatment of refractory OAB. 6-week treatment PTNS would make it more acceptable and cost effective for patients.Source of Funding: No

Sleep disturbance changes in women after treatment of refractory overactive bladder with sacral neuromodulation.

PurposeThe aim of this study is to evaluate changes in sleep disturbance following treatment of overactive bladder with sacral neuromodulation.Materials and MethodsThis is a sub-analysis of data collected from an institutional review board approved retrospective cohort study evaluating women with Patient-Reported Outcomes Measurement Information System–Sleep Disturbance (PROMIS-SD) before and after sacral neuromodulation for overactive bladder between March 2016 and October 2017. Data collected included demographics, clinical characteristics, and additional PROMIS item banks. Within-group analysis was performed with paired t-tests. Groups based up on PROMIS-SD improvement (change <0) were then compared using Fisher's exact test, t-test, or Mann–Whitney U-test as appropriate.ResultsThose with improved sleep disturbance (n=7) noted a significant mean improvement of −3.99 (95% confidence interval, −6.32, −1.65; p<0.01). Both pre- and post-procedure PROMIS-Physical Function (38.86±2.35 vs. 34.13±5.58, p=0.07 and 37.14±5.10 vs. 35.44±4.74, p=0.53), Pain Interference (60.04±6.34 vs. 65.50±6.20, p=0.13 and 57.89±5.08 vs. 64.73±7.35, p=0.07), Depression (44.2±4.73 vs. 61.29±9.53, p=0.17 and 54.29±6.25 vs. 57.96±11.42, p=0.47) t-scores were similar between sleep response groups.ConclusionsThose with improved sleep disturbance reported significant changes after sacral neuromodulation for overactive bladder. However, no significant differences were identified between those with and without improvement. Further investigation of changes in sleep disturbance and factors affecting change are needed within this population.

Efecto de la electroestimulación del nervio tibial en la musculatura del piso pélvico de pacientes con síndrome de vejiga hiperactiva

Antecedentes y Objetivos: El Síndrome de Vejiga Hiperactiva (svh) presenta alteraciones motoras como hipertonía de la musculatura del piso pélvico (mpp). El objeto del estudio es demostrar las características de la electromiografía de superficie (emgs) del mpp en el svh tratados con electro-estimulación percutánea del nervio tibial (ptns).&#x0D; Material y Método: Estudio prospectivo, observacional, controlado. Se realizó emgs de mpp a 17 voluntarios con svh rebelde a tratamiento, antes, durante la ptns y 72 horas después. Se asignaron 2 grupos: Catorce voluntarios del grupo ptns, y 3 voluntarios del grupo placebo. Se incluyeron pacientes con evolución mínima de 6 meses, frecuencia urinaria de 8 o más, sin toma de medicamentos. Se excluyeron pacientes con urocultivo/espermocultivo positivos, litiasis, biopsia y/o cirugía de órganos pélvicos ó cáncer pélvico, y lesiones del snc. Las variables se analizaron mediante Anova y Tukey pos hoc test, 95% ic, usando el software spss 10.1.&#x0D; Resultados: Media de edad 34.23±12.90 años, media del tiempo de evolución 19.58±12.08 meses, sin diferencia estadística en entre grupos. La diferencia de las medias en el promedio de emg (avgemg) del grupo ptns pre vs trans de 0.125 µV y de pre vs 72 horas de 0.171 µV fueron significativas (p&lt;0.05), mientras que en el grupo placebo la diferencia de las medias avgemg de 0.013 µV y 0.006 µV sin diferencia estadística (p&gt;0.05).&#x0D; Conclusiones: El cambio inmediato sobre la mpp que permanece hasta 72 horas después de la ptns, es un posible mecanismo de acción de neuroplasticidad de la neuromodulación del nervio tibial.

Outcomes of Sacral Nerve Stimulation for Treatment of Refractory Overactive Bladder Among Octogenarians

Sacral nerve stimulation (SNS) is an effective treatment for refractory overactive bladder (OAB). However, advanced age is often cited as a reason to avoid SNS in the elderly. This study evaluates the safety and efficacy of SNS for refractory OAB among our octogenarian population. A retrospective review from a single institution was performed on all SNS lead placements from December 1998 to June 2017 for refractory OAB. Octogenarians were characterized as 80 years of age or older at the time of Stage I. Efficacy and safety were determined by the rate of progression to Stage II, subsequent need for multimodal therapy, and rate of surgical revision and explantation. All patients were followed for a minimum of 12 months. Of 374 patients in this study, 37 (9.9%) were octogenarians. There was no difference in gender, race, smoking history, or prior OAB treatment regimens between cohorts. The rate of progression to Stage II was 56.8% for octogenarians compared to 60.5% for nonoctogenarians (p = 0.66). The rate of surgical revision, explantation, and need for multimodal therapy did not differ between groups. Subgroup analysis of octogenarians did not reveal any significant differences between successful and nonsuccessful Stage I patients. The safety and efficacy of SNS was similar between cohorts. This result suggests that SNS is a safe and effective therapy that should be considered among the treatment options for refractory OAB in octogenarian patients. Further studies are needed to determine predictive factors of Stage I success in elderly patients.

Intraoperative Tips and Tricks for Successful Sacral Neuromodulation

Sacral neuromodulation (SNM) is an effective, minimally invasive treatment for refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. Although the treatment is 80% successful, optimal outcomes over time are achieved only by applying precise surgical technique. In this review, we will present the surgical technique for optimal SNM documented in the literature, as well as provide tips for ideal placement based on the authors’ experience. The technique of SNM placement has greatly evolved over the last 10 years with the routine use of fluoroscopy as well as the introduction of the curved, tined lead. With these developments, surgeons have begun to pay more attention to motor thresholds needed to achieve anal bellows and toe flexion responses during staged lead implants. By achieving lower motor thresholds, ideally less than 2 mA, patients have a lower risk of future lead revision and may benefit from longer battery life and greater reprogramming options. Ideal lead placement for SNM includes superior medial entry into the S3 foramen, with a lateral curvature of the distal lead to follow the S3 nerve root. Specific fluoroscopic findings, along with low motor thresholds for anal bellows and toe flexion, confirm ideal lead placement. Surgeons should make every effort to achieve the ideal lead. In patients with inadequate response to therapy, the lead can be checked on x-ray for ideal characteristics, and a revision should be considered if there is room for improvement.

What uro-gynecologists should know about sacral neuromodulation (SNM) for the treatment of refractory overactive bladder.

To inform uro-gynecologists about the current standards and latest developments of sacral neuromodulation (SNM) in women with overactive bladder (OAB). Literature search in the PubMed database for articles published between 1988 and 2019 on SNM for OAB in women. In total, 361 articles were identified and 51 articles retrieved for the review. SNM shows an objective success rate of 70-80%, OAB cure rate of 17-47% and a subjective satisfaction rate of 80-90%. These benefits have to be weighed against an adverse event rate of approx. 40%. SNM is significantly more successful than switching to another antimuscarinic after failed antimuscarinic drug therapy. Efficacy of SNM is slightly lower compared to bladder wall injections with 200U botulinum toxin in the first months but efficacy of both treatments appears to be similar after 24months. MRI examinations of patients with a sacral neurostimulator should only be performed after radiologist consultation. Sacral neurostimulators in patients with another pacemaker system should only be implanted after interdisciplinary consultation. The sacral neuromodulator should be turned off during pregnancy and delivery. SNM for OAB in patients with concomitant female sexual dysfunction or fecal incontinence seems to be beneficial. SNM is a successful and recommended second-line treatment of OAB. Sacral neurostimulators should preferably be implanted in SNM-centers because complications and the frequency of revisions are significantly reduced with increasing experience of the surgeon.

PD31-02 LONG-TERM RESULTS OF SAFETY, EFFICACY, QUALITY OF LIFE AND SATISFACTION OF PATIENTS TREATED FOR REFRACTORY OAB USING AN IMPLANTABLE TIBIAL NEUROSTIMULATION SYSTEM: RENOVA ISTIM™ SYSTEM

INTRODUCTION AND OBJECTIVES:Neuromodulation is an accepted third line therapy for the treatment of refractory overactive bladder (OAB). The only commercially available neuromodulation systems optio...

A comparison of sacral neuromodulation vs. transvaginal electrical stimulation for the treatment of refractory overactive bladder: the impact on quality of life, body image, sexual function, and emotional well-being.

Overactive bladder syndrome (OAB) is defined by the presence of urinary urgency, with or without urge incontinence, usually accompanied by an increase in urinary frequency and nocturia in the absence of urinary tract infections (UTI) or other diseases. The overall prevalence of OAB symptoms in the female population is reported to be 16.6% and increases with advancing age and menopause. The aetiology of OAB is not fully understood and is likely to affect a heterogeneous population of patients due to changes to their central and peripheral nervous systems. Although OAB is frequently associated with female sexual dysfunction (FSD), its real impact on sexual function in women has been evaluated only in a few studies. The first line of treatment for OAB includes behavioural modification and physical therapy, either as monotherapies or in combination. Many patients who have not had success in managing their symptoms with more conservative therapies may decide to resort to third-line treatments for refractory OAB. These treatments include neuromodulation therapies, particularly transvaginal electrical stimulation (TES) and sacral neuromodulation (SN). The aim of this short commentary is to provide an overview of the effectiveness of these treatments and of their impact on quality of life, body image, sexual function, and emotional well-being.

Sacral neuromodulation for refractory overactive bladder

Sacral neuromodulation (SNM) is aminimally invasive, established treatment modality for overactive bladder (OAB) as well as for other pelvic functional disorders, such as non-obstructive urinary retention and fecal incontinence. Apacemaker implanted in the upper buttocks delivers mild electrical pulses to the sacral nerves thereby modulating pathological afferent signals from pelvic end organs. The current article conveys the current knowledge on the indications, contraindications, mechanism of action, implantation technique, efficacy and complications of SNM for the treatment refractory OAB.

Statewide Success of Staged Sacral Neuromodulation for the Treatment of Urinary Complaints in California (2005-2011).

Sacral neuromodulation (SNS) is approved by the Food and Drug Administration as a third-line treatment for refractory overactive bladder, idiopathic urinary retention, and fecal incontinence. Prior to implantation of an implantable pulse generator, all patients undergo a trial phase to ensure symptom improvement. The published success rates of progression from the test phase to permanent implant vary widely (range, 24% to >90%). We sought to characterize success rates using a statewide registry. Using nonpublic data, we identified SNS procedures using the California Office of Statewide Planning and Development ambulatory surgery database from 2005 to 2011. A successful trial was defined as receiving a stage 2 generator implantation after trial lead placement. Multivariable logistic regression was performed to identify factors associated with staged success. During the study period, 1396 patients underwent a staged SNS procedure, with 962 (69%) subsequently undergoing generator placement. Successful trial rates were 72% for overactive bladder wet, 69% for urgency/frequency, 68% for interstitial cystitis, 67% for neurogenic bladder, and 57% for urinary retention. On multivariate logistic regression, only male sex (odds ratio, 0.51) and urinary retention [odds ratio, 0.54) were significantly associated with lower odds of success, whereas age, race/ethnicity, medical insurance, and placement at an academic or high-volume institution had no association. The "real world" success rates for staged SNS implantation in California are less than those observed by some academic centers of excellence but better than previously reported for Medicare beneficiaries. Successful trial rates for interstitial cystitis and neurogenic voiding dysfunction are similar to refractory overactive bladder.

Transcutaneous tibial nerve stimulation: 2years follow-up outcomes in the management of anticholinergic refractory overactive bladder.

To evaluate long-term use, efficacy and tolerability of transcutaneous tibial nerve stimulation (TTNS) in the treatment of refractory overactive bladder (OAB). We performed a prospective observational study and included all patients treated in a single center for OAB persisting after first-line anticholinergic treatment, with ≥ 24months follow-up. The protocol consisted of daily stimulation at home. The primary outcome was treatment persistence. Amelioration was defined as an improvement in urinary symptom profile (USP) score. We assessed 84 consecutive patients. After a mean follow-up of 39.3months and a mean treatment use of 8.3months, almost two-thirds of patients (71.8%) had discontinued TTNS. Treatment continuation was > 12months for 28 patients (33.3%) and > 18months for 16 patients (19%). TTNS was successful following 3months of treatment in 60 (71%) patients. Mean USP score stayed significantly lower than baseline until 12months of treatment, but was not significant anymore after 18months. Discontinuation therapy reasons were a lack of sufficient symptom relief for 59 (70%) patients, compliance difficulty for 5 (6%) patients and becoming asymptomatic for 6 (8%) patients. No serious adverse events occurred. The present study confirms the utility of TTNS as a treatment option for patients with resistant OAB. In the long-term use, few patients continued with therapy, mostly because of a decreased effectiveness with time.

Sacral nerve stimulation versus intravesical botulinum toxin injections for medically refractory overactive bladder: A contemporary review of UK treatment from both clinician and patients’ perspectives

Introduction: In the UK, 10,000 refractory overactive bladder patients per year receive intravesical onabotulinum toxin A treatment and 300 receive sacral nerve stimulation implants. Current National Institute for Health and Care Excellence guidelines propose using onabotulinum toxin A before sacral nerve stimulation whilst the European Association of Urology (EAU) and American Urological Association (AUA) suggests both be offered with equipoise. The aim of this study was to ascertain both patients and clinician views regarding these two treatments. Subjects/methods: Fifty consecutive overactive bladder patients who were refractory to behavioural and medical therapy anonymously completed a structured questionnaire about their treatment preferences. Additionally, 100 UK consultant urologists anonymously completed a separate questionnaire about their treatment preferences and which treatment modalities they had available for use in their Trusts. Results: Of patients, 60% preferred sacral nerve stimulation over onabotulinum toxin A, of whom 80% would happily randomise into a trial between the two treatments. Ninety-seven per cent of 100 consultant urologists in the UK have access to onabotulinum toxin A in their hospitals, but only 39% have access to sacral nerve stimulation. Of clinicians given access to all available options, 71% would use onabotulinum toxin A as their first choice treatment for refractory overactive bladder. Conclusion: There appears to be a significant disparity between current UK overactive bladder guidance, National Health Service accessibility to onabotulinum toxin A and sacral nerve stimulation therapies, the views of clinicians, and patient preferences for treatment. Level of evidence: 5

Strategy of clinical diagnosis and treatment in women with lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) are common in women. The etiology , clinical manifestation, diagnosis and management of LUTS in women are different from those in men. A detailed history, a physical examination and a urine analysis are essential components of the initial evaluation of lower urinary tract symptoms in the female. Thoroughly treating urinary tract infection is very important in management of frequency . In addition, management of fluid intake, behavioral and drug therapies are often used in combination to optimize patient symptom and the quality of life. Intravesical injection of onabotulinumtoxinA is highly effective, but often requires repeated treatments. Sacral neuromodulation is an effective, minimally invasive surgical treatment for refractory overactive bladder in carefully selected, cognitively capable patients. Detrusor underactivity is a common cause of LUTS in women. Female bladder outlet obstruction was divided into two categories, anatomical and functional obstruction. So far, there is no uniform urodynamic standard for diagnosing bladder outlet obstruction in women . The clinical manifestations are various in different types of obstruction , so is the management. It is important to find out the causes of obstruction, and only in this way can we get correct diagnosis, thus treating patients successfully. Key words: Lower urinary tract symptoms; Female; Diagnosis; Treatment

SNS Retention Rates in the Treatment of Refractory OAB, Urinary Retention, and Idiopathic Fecal Incontinence [7G

INTRODUCTION: Sacral nerve stimulation (SNS) has proven to be an effective treatment of refractory overactive bladder (OAB), urinary retention, and idiopathic fecal incontinence. Many studies assessing the effectiveness of this treatment, however, often focus on the short- to medium-term effectiveness (less than 24 months) with a few studies extending up to five years. The purpose of this study is to determine whether patients continue to retain SNS 5 years after implantation. METHODS: This study was performed using health insurance claims data from Clinformatics DataMart. Data were collected between January 1st, 2002 and September 30th, 2014. Diagnoses and procedures were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes. Data were initially screened for patients who had completed SNS implantation (n=2248). Inclusion criteria included women aged 18-65 who had had continuous insurance enrollment in the prior year (n=1231). Patients were excluded if they had had procedures associated with SNS treatment in the prior year (n=884). For each year, we assessed the number of patients who still had the SNS implant compared to the number of patients who had the SNS implant removed during follow-up. RESULTS: At year one, 85.8% of patients had retained the SNS implant (549/640). At year two, 81.4% (341/419). At year three, 78.1% (210/269). At year four, 79.0% (124/157). And at year five, 72.0% (67/93). CONCLUSION: The retention rate for SNS as a treatment for refractory OAB, urinary retention, and idiopathic fecal incontinence continues to be high at five years follow-up.

Financial Impact of Percutaneous Tibial Nerve Stimulation (PTNS) Treatment [10G

INTRODUCTION: To estimate average quarterly medication and physician visit costs for patients with refractory overactive bladder, before and after 12 sessions of Percutaneous Tibial Nerve Stimulation (PTNS) treatment. METHODS: This is a retrospective case series for patients undergoing PTNS for the treatment of refractory overactive bladder. 23 patients had 12 weekly sessions of initial PTNS treatment; 18 met the criteria for 3-month follow-up before and after treatment. Number of follow-up visits, PTNS maintenance visits, and medications were collected quarterly for a year before and after treatment. Using known medication and visit costs, we calculated mean quarterly costs, and standard deviations for patients, and measured their significance using a 2-tailed paired t-test. RESULTS: The average quarterly medication cost decreased from $656.40 ±292.45 to $375.51 ±331.80 after PTNS (p=0.01). The average number of quarterly provider follow-up visits decreased from 1.34 ±0.78 to 0.40 ±0.63 (p=0.001). The average quarterly total provider cost was calculated using the cost of follow-up visits in addition to PTNS maintenance visits. The average quarterly total provider cost increased from $136.96 ±81.50 to $ 181.04 ±146.34 (p=0.286). However, the total provider cost for the last quarter decreased from $169.04 ±103.69 to $55.14 ±94.62 (p=.005). CONCLUSION: PTNS treatment significantly reduced the average quarterly cost of medications and the average number of provider follow-up visits on patients with refractory overactive bladder. The average total provider cost initially increased in the first three quarters following PTNS and decreased the last quarter due to a higher number of PTNS maintenance visits immediately after treatment.

Somatosensory evoked potentials as a screening tool for diagnosis of spinal pathologies in children with treatment refractory overactive bladder.

To evaluate the usefulness of somatosensory evoked potential as a screening tool for spinal pathologies in patients with treatment refractory overactive bladder. This prospective study was performed between January 2011 and January 2014. Children >5years old with treatment refractory overactive bladder were enrolled after exclusion of anatomical and neurological causes of incontinence. All patients underwent urodynamic studies, spinal MRI, and somatosensory evoked potential (SEP). Sensitivity, specificity, PPV, and NPV were calculated for SEP. Thirty-one children (average age 8.3±2.9years) were included in the study. SEP was abnormal in 13 (41.9%), and MRI was abnormal in 8 (25.8%) patients. SEP was found to have a sensitivity of 87.5%, a specificity of 73.9%, positive predictive value of 53.85%, and negative predictive value (NPV) of 94.4%. In patients with treatment refractory OAB, SEP is an important tool for the screening of tethered cord/spinal pathologies. Our results suggest that a child with a normal SEP study in this group of patients may not require further investigation with MRI.

A Prospective, Multicenter, Double-Blind, Randomized Trial of Bladder Instillation of Liposome Formulation OnabotulinumtoxinA for Interstitial Cystitis/Bladder Pain Syndrome

Intravesical instillation of liposomal formulated botulinum toxin A (lipotoxin) has shown therapeutic effects as treatment of refractory overactive bladder without needle injections. We assessed lipotoxin to treat refractory interstitial cystitis/bladder pain syndrome. This 2-center, double-blind, randomized, placebo controlled, physician initiated study enrolled patients with refractory interstitial cystitis/bladder pain syndrome. A total of 31 patients were assigned to intravesical instillation of lipotoxin (onabotulinumtoxinA 200 U with 80 mg sphingomyelin), 28 were assigned to onabotulinumtoxinA 200 U in normal saline and 31 were assigned to normal saline alone. The primary end point was the average change in O'Leary-Sant symptom scores, including ICSI (Interstitial Cystitis Symptom Index) and ICPI (Interstitial Cystitis Problem Index) between baseline and 4 weeks after treatment. Other end points included the average changes in a 3-day voiding diary, a visual analog scale for pain and a global response assessment of patient satisfaction. Improvements in the pain scale and O'Leary-Sant symptom scores occurred in all 3 groups by 4 weeks after treatment. Lipotoxin instillation was associated with a statistically significant decrease in O'Leary-Sant symptom scores (mean ± SD 7.38 ± 8.75), ICSI (4.00 ± 4.28), ICPI (3.35 ± 5.11) and the visual analog scale pain scale (1.64 ± 2.52), and an increase in the global response assessment (1.35 ± 1.28). However, there was no difference in improvement among the 3 groups. No significant adverse events were found in any group. Lipotoxin failed to demonstrate a positive proof of concept compared to onabotulinumtoxinA or placebo. However, a single intravesical instillation of lipotoxin was associated with decreased interstitial cystitis/bladder pain syndrome symptoms compared to baseline in patients with moderate to severe interstitial cystitis/bladder pain syndrome. The effect was likely due to a significant placebo effect.

Efficacy and safety of a first intradetrusorial injection of botulinum toxin-A for the treatment of refractory overactive bladder in 54 elderly patients

Intradetrusorial injection of botulinum toxin A (IDBT) is a validated treatment for neurogenic and non-neurogenic refractory overactive bladder. In the elderly, muscarinic antagonists have many side effects, in particular in cognition. An alternative treatment is, for that reason, interesting in this frail population with multiple medication use. The question of efficacy is remaining. Indeed, bladder dysfunction is most of the time a multifactorial issue in the elderly. The objective of this study was to evaluate prospectively the efficacy and safety of IDBT in this population. All patients aged more than 65 years who received a first IDBT were included. The clinical effects, anti-muscarinic drug intake, urodynamic parameters and adverse events were assessed before and 3 months after IDBT. The number of IDBT, the dose injected and their efficacy were also recorded. From April 2002 to February 2016, 54 elderly patients (23 male and 31 female) were enrolled, mean age of 71 years + –4.7. Forty-four patients (81%) had a neurological disease. The doses injected were: 50UBotox ( n = 2), 100U ( n = 5), 150U ( n = 2), 200U ( n = 24), 300U ( n = 21). Two patients were lost to follow-up, three had not been evaluated yet. 50% of patients had a complete subjective improvement, incomplete for 27%. After repeated IBTD, 64.5% had a complete improvement, incomplete for 8.3%. Incontinent patients decreased from 88% to 47.8% ( p < 105). Anti-muscarinic drug intake decreased from 79.0% patients to 23.3% ( p = 0.008). After repeated IDBT, 53.6% patients had complete clinical efficacy for the dose of 300UBotox, 39.3% for 200UBotox and 7.1% for 100U Botox. 36.3% patients had complete urodynamic efficacy after the first IDBT, and 65.2% after repeated IDBT. One severe side effect had been reported (hematuria). Over the 16 patients with spontaneous micturition, 9 had to start intermittent catheterizing after IDBT, but 4 had previous post-void residual volume >100 mL. IDBT is a safe and efficient treatment for refractory overactive bladder that can be proposed in the elderly, as an alternative to muscarinic antagonists in order to reduce side effects in this frail population. Clean intermittent catheterizing can be necessary, but is not a contraindication even in this population.

Neuromodulation and female pelvic disorders.

Sacral neuromodulation is a Food and Drug administration approved therapy for the treatment of refractory overactive bladder, urinary retention, and fecal incontinence. The objective of this manuscript is to review the recent literature regarding clinical outcome data and current management strategies for sacral neuromodulation. There have been significant advances in therapy techniques as well as long-term data supporting this therapy for both urinary and fecal incontinence. These include the InSite trial and the long-term follow-up of the fecal incontinence registry trial. In addition, the development of surgical techniques to reduce infection, improvements in programmability of the implantable pulse generator, as well as deciding on best stimulation parameters will be discussed. Finally, introduction of a new animal model to test a chronically implanted lead and stimulator in a large animal model opens the door to many future studies. These data help to inform us on the most recent clinical outcomes for sacral neuromodulation, as well as recommendations for best practices for implant technique.

Overactive bladder - 18 years - Part II.

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