SEARCH · PubMed Health

Results for “overactive bladder”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 73 records · Page 4Linked to original sources

PubMed2006

[Intravesical treatment of overactive bladder syndrome].

Overactive bladder and urgency incontinence are common conditions generally treated with oral anticholinergic medication. Despite the development of new antimuscarinic substances, many patients are refractory to or cannot tolerate the oral therapy due to severe side effects. Intravesical instillation therapy can provide an alternative method to manage detrusor overactivity. Intravesical instillation of anticholinergics such as oxybutynin and trospium chloride can achieve cholinergic blockade without producing systemic side effects. Botulinum toxin type A injections into the detrusor have been shown to increase bladder capacity and to decrease detrusor overactivity for 6 or more months. Intravesical local anesthetics such as lidocaine and bupivacaine block the conduction of unmyelinated C fibers which results in an increase of functional bladder capacity. Intravesical capsaicin and resiniferatoxin also affect the afferent C fiber innervation of the bladder, leading to a decrease in detrusor overactivity and also an increased bladder capacity. The use of intravesical anticholinergics and of local anesthetic medications, both known for their short-term efficacy, is limited due to the necessity of daily intermittent catheterization. In conclusion, intravesical therapies can provide an alternative treatment for the management of overactive bladder.

Administration, Intravesical↗

PubMed2006

Solifenacin succinate for the treatment of symptoms of overactive bladder.

BACKGROUND: Overactivity of the bladder detrusor muscle can result in urinary urgency, frequency, and incontinence. Antimuscarinic agents are the treatment of choice, as they reduce the contractility of this muscle. Solifenacin succinate (SOL) is a competitive muscarinic-receptor antagonist approved by the US Food and Drug Administration in late 2004 for the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and urinary frequency. OBJECTIVE: This article reviews the current primary literature concerning the pharmacokinetics, efficacy, and tolerability of SOL in the treatment of OAB. METHODS: Pertinent English-language articles were identified through a search of MEDLINE (1966-week 4, 2006), EMBASE (1991-first quarter of 2006), Current Contents/Clinical Medicine (week 10, 2005-week 9, 2006), the Cochrane Database of Systematic Reviews, MICROMEDEX Healthcare Series, and International Pharmaceutical Abstracts (1970-present). The search terms were overactive bladder, urinary incontinence, solifenacin, YM905, pharmacokinetics, and cost. RESULTS: SOL is highly lipophilic (50:1 octanol:water distribution at pH 7.0), completely orally bioavailable, and 98% protein bound. It is metabolized by the cytochrome P450 3A isozyme, and approximately 50% of a dose is eliminated renally as parent compound, with 1 active and 3 inactive metabolites. In two 12-week Phase III studies, patients receiving SOL 5 or 10 mg had significant reductions compared with placebo in the numbers of voids (P < or = 0.01), incontinence episodes (P < or = 0.05), and urgency episodes (P < or = 0.01) per 24 hours; the volume voided per micturition was significantly increased (P < or = 0.01). In a study that compared SOL 5 and 10 mg with tolterodine extended release 4 mg, both agents were associated with significant reductions in the number of voids per 24 hours (-2.45 and -2.24 episodes, respectively; P = 0.004 for noninferiority). In a study of pooled data from two 12-week studies, patients who received SOL 5 or 10 mg reported significant improvements in a number of quality-of-life domains (P < or = 0.05). In a pooled analysis of 4 studies, the most common adverse effects (occurring in > or =3% of any group) in patients receiving SOL 5 mg (n = 266) and 10 mg (n = 612) were dry mouth (10.9% and 27.1%, respectively), constipation (5.3% and 12.9%), and blurred vision (4.5% and 4.7%). CONCLUSIONS: In the studies reviewed, SOL was effective in the treatment of OAB with urge incontinence. Adverse effects included dry mouth, constipation, and blurred vision. Further studies are needed to determine the efficacy and tolerability of SOL in patients with hepatic or renal impairment.

Clinical Trials as Topic↗

PubMed2006

Effects of potassium channel modulators on human detrusor smooth muscle myogenic phasic contractile activity: potential therapeutic targets for overactive bladder.

OBJECTIVES: Increased urinary bladder detrusor smooth muscle phasic contractility has been suggested to be associated with idiopathic bladder overactivity (OAB). We examined the role of voltage-dependent L-type calcium channels, adenosine triphosphate-sensitive potassium (K(ATP)) channels, and calcium-activated potassium (BK(Ca) and SK(Ca)) channels in the regulation of human detrusor phasic contractile activity. METHODS: Isolated human bladder strip phasic contractions were measured and quantified as the mean area under the force-time curve, amplitude, and frequency of phasic contractions in 22 bladder samples. RESULTS: Human detrusor strips displayed myogenic phasic contractions in the presence of atropine (10(-6) M), phentolamine (10(-6) M), propranolol (10(-6) M), suramin (10(-5) M), and tetrodotoxin (10(-6) M). The L-type calcium channel inhibitor nifedipine (300 nM) abolished the contractile activity. Blockade of K(ATP) channels by glibenclamide (1 and 10 microM) did not alter myogenic contractions. In contrast, the K(ATP) channel opener pinacidil (10 microM) markedly inhibited phasic contractility. Iberiotoxin (100 nM) and apamin (100 nM), potent and selective inhibitors of BK(Ca) and SK(Ca) channels, respectively, significantly increased the area under the force-time curve and the amplitude of contractions. CONCLUSIONS: Phasic contractions of human detrusor are dependent on calcium entry through L-type calcium channels. BK(Ca) and SK(Ca) channels play a key role in the modulation of human detrusor smooth muscle phasic contractility. Furthermore, these observations support the concept that increasing conductance through K(ATP), BK(Ca), and SK(Ca) channels may represent attractive pharmacologic targets for decreasing phasic contractions of detrusor smooth muscle in OAB.

Calcium Channels, L-Type↗

PubMed2003

[Epidemiology and etiology of overactive bladder].

Bladder overactivity (OAB) is a common disease with a socioeconomic impact comparable to diabetes mellitus. As life expectancy rises in industrialized countries the importance of OAB will further increase. The International Continence Society (ICS) recently reported a modified terminology for lower urinary tract function and established the symptom-based term OAB. The etiology of OAB comprises neurogenic and non-neurogenic detrusor hyperactivity as well as detrusor hypersensitivity. Neurogenic detrusor hyperactivity may be caused by insufficient cortical inhibition, degenerative neuropathies, and spinal cord lesions, whereas bladder aging, bladder outlet obstruction, and chronic bladder irritation (UTI, stones, tumors) are possible causes for non-neurogenic detrusor hyperactivity. Since most epidemiologic surveys focus on urge incontinence without considering urgency frequency without incontinence, epidemiologic data concerning OAB are rare. Two recently published multinational prevalence studies from Europe and Asia show different prevalence values [Europe: 15.6% (men), 17.4% (women); Asia: 53.1%(women)], which may be due to methodological differences. Both studies report an increase of OAB prevalence corresponding with age. The cumulative incidence of OAB is rising faster in aging males than in aging females. Two-thirds of the European and one-fourth of the Asian individuals affected by OAB complained about impaired quality of life, but only 60% of the European and 21% of the Asian sufferers have talked to a doctor or sought treatment. One out of four patients visiting their health care professional for OAB symptoms is currently under medication. To avoid high treatment costs and side effects, pharmacotherapy (e.g., antimuscarinics) should only be given after detailed diagnostic evaluation.

Adolescent↗

PubMed1997

The patient with an overactive bladder--symptoms and quality-of-life issues.

OBJECTIVES: Psychosocial adjustment to illness is an important as the status of the physical disease itself; focusing on this necessitates some measurement of abstract, subjective feelings of "quality of life" (QOL). Assessments of QOL are particularly important for conditions such as urinary incontinence (UI) that have little or no impact on mortality. METHODS: This presentation describes the reasons for, and methods of, measuring lower urinary tract symptoms and disease impact. Validated instruments available for such measurements are reviewed, as are published studies that address the impact of UI (and urge incontinence in particular) on QOL. Potential applications for these new disease measures are discussed. RESULTS: The bladder is an unreliable witness, and symptom assessment is diagnostically disappointing; cystometry is essential if a definitive diagnosis is required. However, objective tests take no account of the patient's perception of the problem. General health status questionnaires have been used to show that urge incontinence is associated with emotional problems, reduced social and recreational activity, and sexual dysfunction. Newly developed, condition-specific instruments have greater specificity and, hence, improved sensitivity for measuring incontinence and its impact. These instruments have the potential for monitoring disease progression and evaluating treatment outcome. CONCLUSIONS: In a proportion of people with bladder overactivity, the disorder has a profound impact on the QOL. Methods of measuring this impact have been developed that may allow identification of this group of individuals while also improving the assessment of treatment efficacy. However, this science is in its infancy and these dimensions await further exploration.

Female↗

PubMed1998

Change in bladder contractility associated with bladder overactivity in rats with cerebral infarction.

PURPOSE: To evaluate the contractile properties of overactive bladder from rats in the chronic stage of experimental cerebral infarction. MATERIALS AND METHODS: Cystometry was performed in conscious male S-D rats after inducing occlusion of the left middle cerebral artery. Bladder muscle strips were evaluated for force development in response to field stimulation, acetylcholine and KCl. By measuring the contractile response to field stimulation after adding atropine and alpha,beta-methylene-ATP, contributions of cholinergic and purinergic transmission were determined. RESULTS: Bladder capacity of cerebral-infarcted rats was <50% of the capacity of sham-operated rats and significantly less than that of sham-operated rats even 4 months after surgery. There was no significant difference in bladder weight between sham-operated rats and cerebral-infarcted rats. No differences in the contractile response of detrusor strips to field stimulation and acetylcholine, or in the relative contribution of cholinergic and purinergic transmission to the contractile response, were observed over time or between strips from sham-operated rats and cerebral-infarcted rats. KCl induced significantly less contraction in strips from 4 month infarcted rats than in strips from 4 month sham-operated rats, 2 week infarcted rats and 2 month infarcted rats. CONCLUSIONS: This animal model will be useful for chronic studies on the mechanism of detrusor hyperactivity (DH).

Animals↗

PubMed2004

Role of glutamate receptors in the development and maintenance of bladder overactivity after cerebral infarction in the rat.

PURPOSE: To investigate the role of glutamate receptors in overactive bladder (OAB) caused by cerebral infarction (CI) we examined the effects of 2 different types of receptors antagonists on OAB induced by left middle cerebral artery (MCA) occlusion. MATERIALS AND METHODS: Female rats were intravenously injected with dizocilpine, an NMDA (N-methyl-D-aspartate) receptor antagonist, or NBQX (2,3-dioxo-6-nitro-1,2,3,4-tetrahydrobenzo(f)quinoxaline-7-sulfonamide), an AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor antagonist, before or after MCA occlusion. Awake rats were cystometrically examined for 8 hours. Detrusor strips were evaluated for force development in response to dizocilpine and NBQX. RESULTS: In CI rats without pretreatment bladder capacity (BC) was significantly decreased after MCA occlusion and remained consistently below half that of pre-occlusion capacity. Dizocilpine (0.5 mg/kg intravenously) administered before MCA occlusion blocked the decrease in BC in awake rats 5 to 8 hours after MCA occlusion. In CI rats pretreated with NBQX (10 or 30 mg/kg intravenously) BC was not different from that in rats without pretreatment. Increasing doses of dizocilpine (0.01 to 10 mg/kg) or NBQX (0.1 to 30 mg/kg) increased rat BC 2 hours after MCA occlusion. NBQX did not change the BC of sham operated rats. No differences in the contractile response to dizocilpine or NBQX of detrusor strips from sham operated and CI rats were observed. CONCLUSIONS: These results indicate that NMDA receptor has an essential role in the development of OAB after CI. AMPA receptor antagonist cannot block the development of OAB. However, AMPA receptor antagonist temporally inhibits OAB after it is established by CI.

Animals↗

PubMed2005

Effects on sleep of anticholinergics used for overactive bladder treatment in healthy volunteers aged > or = 50 years.

OBJECTIVE: To study the influence of oxybutynin, tolterodine or trospium chloride, anticholinergics used to treat bladder overactivity, on sleep and the cognitive skills of healthy volunteers aged > or = 50 years. SUBJECTS AND METHODS: In a randomized, double-blind, placebo-controlled study with a crossover design, 24 healthy sleepers (12 men and 12 women) aged 51-65 years underwent polysomnographic recordings and cognitive tests in a sleep laboratory. Study medications were given as a single dose containing the total recommended daily dose. RESULTS: There was a significant reduction in rapid-eye movement (REM) sleep of approximately 15% and a slightly (but not significantly) greater REM latency after oxybutynin and tolterodine than with placebo. After trospium chloride, REM duration and latency were comparable with placebo. There was no effect of the tested anticholinergics on cognitive and subjective sleep variables. CONCLUSION: Individuals aged > or = 50 years had a more distinct impairment of REM sleep after oxybutynin and tolterodine than had young people, but the reduction in REM sleep did not reach a pathological degree in this single-dose study. There was no apparent impairment of concentration or cognitive function, but impairment of cognitive function and neuropsychological side-effects cannot be excluded, especially when elderly patients with impaired REM sleep from various psychiatric diseases (e.g. depression) and/or sleep disturbances are given oxybutynin or tolterodine in long-term treatment.

Aged↗

PubMed1999

Tolterodine, a new antimuscarinic drug for treatment of bladder overactivity.

Tolterodine is a nonsubtype selective antimuscarinic agent recently approved as therapy in patients with overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence. It acts by muscarinic receptor blockade in the bladder wall and detrusor muscle. Despite short terminal disposition half-lives of 2-3 and 3-4 hours for tolterodine and its active 5-hydroxy metabolite, respectively, twice/day dosing is effective due to the drug's prolonged pharmacodynamic effects. Dosage adjustment is recommended in the presence of hepatic impairment and during concurrent therapy with drugs that inhibit cytochrome P450 2D6 and 3A4 isozymes. Tolterodine significantly reduces clinically relevant end points such as number of micturitions and number of incontinence episodes/day. In general, it is superior to placebo and equivalent to oxybutynin in this regard. As might be expected from its pharmacologic profile, the principal adverse effects of the drug are anticholinergic. In clinical trials, tolterodine was tolerated significantly better than oxybutynin. Its relative merits as a first- or second-line agent for patients intolerant of oxybutynin are unclear. Until pharmacoeconomic analyses are conducted that clearly justify use of this more expensive agent, tolterodine is perhaps best reserved for patients who are intolerant of or fail oxybutynin therapy.

Benzhydryl Compounds↗

PubMed1999

Electrical stimulation of the overactive bladder.

Bladder overactivity is a significant health-care problem. Electrical stimulation has been shown to be a safe and effective treatment option. Careful patient selection may improve results obtained with this technique. Further studies are required to determine optimal treatment parameters.

Algorithms↗

PubMed2004

Effects of metabolic stress and ischaemia on the bladder, and the relationship with bladder overactivity.

The bladder wall becomes to ischaemic when intravesical pressure rises above capillary pressure. This will occur routinely in bladders with outflow obstruction. Experiments in vitro show that the detrusor normally uses anaerobic as well as aerobic metabolism. Anoxic conditions result in an initial reduction in contractility, but significant contractile ability persists. Substrate removal causes a slow progressive fall in contractility as glycogen stores deplete. Removal of substrate and oxygen causes rapid loss of contractile ability and permanently damages intrinsic nerves, although the detrusor recovers well. In vivo ischaemia in animal models results in bladder overactivity and the expression of apoptotic markers in intrinsic neurons in the bladder wall. In humans, bladders from patients with bladder instability show patchy denervation, suggesting that periodic ischaemia and neuronal death may predispose to overactivity.

Adenosine Triphosphate↗

PubMed2003

[Physiology and evaluation of overactive bladder].

Detrusor overactivity is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked. There are certain patterns of detrusor overactivity. Phasic detrusor overactivity is defined by a characteristic wave form and may or may not lead to urinary incontinence. Terminal detrusor overactivity is defined as a single involuntary detrusor contraction occurring at cystometric capacity, which cannot be suppressed. Neurogenic detrusor overactivity is qualified as neurogenic when it is a relevant neurological condition (old term is "detrusor hyperreflexia"), idiopathic detrusor overactivity when there is no defined cause (this term replaces "detrusor instability"). In neurogenic patients, detrusor overactivity is secondary to various pathophysiologic factors: interruption of inhibitor pathways issued from cerebral regions, activation de novo of vesical C reflex mediated by unmyelinated capsaicin fibers, and ultrastructural modifications of bladder urothelium. Bladder overactivity treatment is necessary to avoid renal complications and improve quality of life of neurogenic patients.

Humans↗

PubMed2005

Overactive bladder.

The overactive bladder is a common condition, which has significant effects on quality of life. The aetiology in most cases is unknown, and treatment outcomes have until recently been unsatisfactory. Management includes excluding pathology and implementing behavioural changes such as caffeine reduction, bladder and pelvic floor training, as well as antimuscarinic drug therapy. Compliance is often problematic, and this can be improved with some of the newer antimuscarinics with fewer side-effects, and a good therapist/patient relationship. In the majority of cases this 'treatment package' is successful, but in those where it is not, intravesical therapies have been introduced, e.g. neuromodulation, alternative drug therapies (e.g. vanilloids, botox) and surgery. With a better understanding of the aetiology and identification of risk factors better outcomes from treatment are likely.

Behavior Therapy↗

PubMed2003

Multinational study of reliability and validity of the King's Health Questionnaire in patients with overactive bladder.

OBJECTIVE: Overactive bladder (OAB) has substantial impact on health-related quality of life (HRQoL). The purpose of this research was to evaluate the psychometric properties of the King's Health Questionnaire (KHQ). METHODS: The KHQ (n = 1284) was administered at baseline and 12 weeks post-treatment in a multinational, double-blind, randomized clinical trial of tolterodine for treatment of OAB. Country-specific psychometric analyses of HRQoL instruments were performed. Countries demonstrating marginal psychometric properties on the KHQ were pooled with same-language countries, re-evaluated, and aggregate analysis performed on the pooled data. RESULTS: Internal consistency of the KHQ was high, item characteristics were good, most assumptions of summed scales were met, and it is externally valid and consistent. Few problems with the KHQ were noted although the performance of the personal relationships domain was complicated by the 'not applicable' response category. CONCLUSIONS: Psychometric testing supports the reliability and validity of the KHQ as an OAB-specific measure of HRQoL.

Aged↗

PubMed2005

Solifenacin in the management of the overactive bladder syndrome.

Overactive bladder (OAB) is the term used to describe the symptom complex of urinary frequency and urgency, with or without urge incontinence. Whilst antimuscarinic drug therapy has proven to be effective in the management of patients with symptoms of the OAB syndrome, compliance with medication is often affected by the bothersome antimuscarinic adverse effects of dry mouth, constipation, somulence and blurred vision. The development of bladder selective M3 specific antagonists offers the possibility of increasing efficacy whilst minimising adverse effects. At present, there are no M3 specific antagonists currently available, although solifenacin and darifenacin are under development and are due to be registered in 2004-2005. The purpose of this article is to review the pharmacology and clinical trial data available for solifenacin in addition to examining its emerging role in the treatment of the OAB syndrome.

Clinical Trials as Topic↗

PubMed2006

Solifenacin in overactive bladder syndrome.

Overactive bladder (OAB) syndrome is a prevalent condition, increasingly recognised as a cause of reduced quality of life that places a substantial economic burden on healthcare provision. While antimuscarinic agents are the therapy of choice for OAB, their use is associated with a number of drawbacks, not least of which is the high rate of adverse events, which is intimately linked with poor compliance with treatment. Solifenacin succinate is a novel antimuscarinic agent approved in Europe and the US for the treatment of men and women with OAB. The recommended starting dose of solifenacin is 5 mg once daily and, if needed, the dose may be increased to 10 mg once daily. In multiple clinical trials, solifenacin treatment has been associated with statistically significant reductions in all key symptoms of OAB (notably frequency, urgency and incontinence) as well as increases in volume voided. Solifenacin has been shown to be well tolerated, producing few adverse effects, which are usually mild in nature. Furthermore, possibly because of this favourable efficacy and tolerability, solifenacin treatment has been associated with a high rate of patient persistence with therapy, with 81% of 1802 patients who completed 12-week, double-blind trials enrolling in and completing a 40-week open-label extension study. Solifenacin has been shown to display selectivity for bladder versus salivary tissue in vitro, and studies in healthy men have shown that absorption is slow but extensive with an absolute bioavailability of 88%. Solifenacin is a well tolerated and efficacious agent for the treatment of OAB, significantly reducing symptoms and improving patients' quality of life.

Animals↗

PubMed2004

Benefit-risk assessment of tolterodine in the treatment of overactive bladder in adults.

Overactive bladder is associated with symptoms of urgency, with or without urge incontinence, usually with daytime frequency and nocturia in the absence of local pathological factors. Muscarinic receptor antagonists (antimuscarinics) are the first-line pharmacotherapy. Tolterodine, a competitive, nonselective antimuscarinic specifically developed for the treatment of overactive bladder, demonstrated tissue selectivity for the bladder over the parotid gland in an animal model. As of March 5, 2003, the immediate-release (IR) formulation had been approved in 72 countries and the extended-release (ER) formulation had been approved in 28 countries, and tolterodine had been administered to 5 million patients. This review evaluates the benefit-risk profile of tolterodine in the treatment of adults with overactive bladder, summarising clinical trial and postmarketing surveillance data. Tolterodine has been found to significantly reduce micturition frequency, urgency perception and the number of episodes of urge incontinence and increase the volume voided per micturition. Dry mouth, an antimuscarinic class effect, is the most commonly reported adverse effect but is mostly mild to moderate in severity. Serious adverse effects are reported infrequently. Based on summary and review of postmarketing surveillance and clinical trial safety data received by the market authorization holder and contained in the Periodic Safety Update Reports for tolterodine, several monitored serious events of the gastrointestinal tract (e.g. ileus or haemorrhage), nervous system (e.g. syncope, convulsions and memory disorders) and cardiovascular system (e.g. ventricular arrhythmia, atrial fibrillation, palpitations, bradycardia, transient ischaemic attacks and hypertension) were not considered related to tolterodine. QT or corrected QT (QTc) prolongation was not observed in any of the five cases of verified ventricular arrhythmia in patients administered tolterodine; there is insufficient evidence to indicate that tolterodine causes ventricular arrhythmia or extrasystoles or any specific type of cardiac rhythm abnormality. The safety profile of tolterodine is similar in patients aged > or =65 years and in younger adults. Clinically relevant drug interactions are limited to cytochrome P450 3A4 inhibitors, such as ketoconazole, and co-administration with such agents warrants a tolterodine dosage decrease. In addition, tolterodine IR 2mg twice daily is similar in efficacy to oxybutynin IR 5mg three times daily, and tolterodine ER 4 mg once daily is similar in efficacy to oxybutynin ER 10mg once daily. Dry mouth occurred less frequently with tolterodine than oxybutynin, and moderate to severe dry mouth occurred more than three times less frequently. Based on the low frequency of adverse events, the absence of unexpected adverse events and the very low frequency of serious adverse events, we conclude that tolterodine is a well tolerated treatment for overactive bladder in adults, in whom it should be considered as first-line therapy.

Adult↗

PubMed2002

The use of biodegradable PGA stents to judge the risk of post-TURP incontinence in patients with combined bladder outlet obstruction and overactive bladder.

OBJECTIVE: For patients with the combination of severe bladder outlet obstruction (BOO) and severe overactive bladder (OB), no straightforward and safe treatment exists due to the risk of urge incontinence after TURP. In this study we have used a biodegradable polyglycolic stent to simulate the status after TURP and register the risk for urge incontinence. METHODS: A total of 37 patients with severe OB, combined with moderate to severe BOO, were asked if they wanted to participate. Under cystoscopic vision a polyglycolic biodegradable stent was inserted in the prostatic urethra. RESULTS: Twenty-five of the patients noticed no or only minor leakage and 19 of these have been subjected to TURP with good results. Three patients are on the waiting-list for TURP. Twelve of 37 patients were found to have major leakage after stent insertion. During the stent period, we noted five cases of complications, due to UTI, stent crash and irritation. All of these patients recovered within three weeks. CONCLUSIONS: A biodegradable PGA stent seems to be a new and unique tool to test the risk for post-TURP incontinence in patients with combined BOO and severe OB.

Absorbable Implants↗