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PubMed2004

The wet patient: understanding patients with overactive bladder and incontinence.

Overactive bladder (OAB) is a constellation of lower urinary tract symptoms, including urinary frequency and urgency,which can occur with or without urinary incontinence. Incontinence is present in over half of female patients with OAB. This condition affects more than 33 million Americans and imposes considerable economic, social, and psychological burdens. Although continued improvements in the pharmacologic management of lower urinary tract disorders have led to the availability of well-tolerated, characteristic features, prevalence and epidemiology, effective treatment options, the symptoms of OAB are generally underreported by patients and under treated by healthcare professionals. Heightened awareness of the multifaceted disease burden imposed by OAB and increased understanding of the characteristics of patients who are likely to be most severely affected, in particular those who suffer from incontinence, may improve the timely identification, diagnosis, and clinical management of the syndrome, enhancing both the health and quality of life of these patients. This review will summarize the clinical consequences, and management of OAB, with particular focus on the incontinent patient.

Adult↗

PubMed2005

Tolterodine for the treatment of overactive bladder: a review.

Overactive bladder (OAB) is a prevalent condition. Numerous clinical trials have demonstrated the efficacy and safety of immediate release tolterodine in the treatment of OAB in different patient populations. This review details the characteristics, clinical efficacy and safety of extended release (ER) tolterodine. This formulation yields a flatter serum concentration profile and provides clinically meaningful symptom improvement as early as week 1 of treatment. Tolterodine ER is effective in diverse patient populations with varying levels of symptom severity, and efficacy is maintained with long-term treatment. Tolterodine is an effective, safe, and convenient treatment option for long-term relief of OAB symptoms.

Benzhydryl Compounds↗

PubMedDate not supplied

Correlation between the Overactive Bladder questionnaire (OAB-q) and urodynamic data of Parkinson disease patients affected by neurogenic detrusor overactivity during antimuscarinic treatment.

INTRODUCTION: Parkinson disease (PD) patients present urinary symptoms during the course of the disease, very often suggestive of overactive bladder and sustained by neurogenic detrusor overactivity. These symptoms cause a severe lowering of quality of life determining social withdrawal and they need to be early diagnosed to restore social interaction and prevent urinary tract complications. Today overactive bladder diagnosis is easier, thanks to the availability of new investigative tools, particularly voiding questionnaires. The aim of the present study was to evaluate the reliability of the Overactive Bladder screener (OAB screener/OAB-questionnaire), a new voiding questionnaire specifically developed for the overactive bladder diagnosis in PD subjects suffering from overactive bladder symptoms. Clinical data obtained by the questionnaire were compared with urodynamic outcomes, at basal conditions and after antimuscarinic treatment, to better explorate the questionnaire reliability. MATERIALS AND METHODS: Forty PD patients have been enrolled in the protocol, and submitted to the OAB screener, voiding diary and urodynamic investigation before and after antimuscarinic treatment. OAB-score and urodynamic parameters were statistically analyzed and compared. RESULTS: The OAB-q well correlated with voiding diary and urodynamic data of Parkinson subjects either at baseline or after the antimuscarinic treatment. The study suggests that this clinical tool might be used for neurogenic overactive bladder diagnosis and that it seems to be a useful outcome measure for treatments of neurogenic OAB.

Aged↗

PubMed2005

Improving the tolerability of anticholinergic agents in the treatment of overactive bladder.

Pharmacological treatment for overactive bladder has centred around the interruption of the detrusor activity that is central to urge and incontinence symptoms. The majority of patients with this disorder are treated with antimuscarinic agents. These drugs have been demonstrated to improve urgency, frequency of micturition and urge incontinence, all of which are primary symptoms of overactive bladder; however, they are also commonly associated with anticholinergic adverse effects, most notably dry mouth. Attempts to increase tolerability have included the development of advanced formulations that regulate release of the active ingredient and the development of pharmacological agents that target the desired bladder receptors more specifically and accurately. Although all agents provide good efficacy, tolerability is greatly affected by the formulation used to deliver the active pharmacological agent, as well as the specificity of the targeted receptors. Clinical trials involving a transdermal formulation of oxybutynin have shown that this delivery method may be associated with a lower incidence of anticholinergic adverse events compared with both the immediate-release and the extended-release oral formulations of traditional agents, as well as the most recently approved agents - trospium chloride, solifenacin and darifenacin. Much is still being learned about the function and specificity of muscarinic receptors, which will support the development of agents with sustained efficacy and enhanced tolerability compared with the available formulations to date. These include the S-isomer of oxybutynin, as well as selective muscarinic M2 receptor antagonists.

Administration, Oral↗

PubMedDate not supplied

Overactive bladder--a practical approach to evaluation and management.

The overactive bladder (OAB) is a highly prevalent condition characterized by the combination of urgency and frequency with or without urge incontinence. The pathophysiology is multifactorial; the background is complicated and not yet fully understood. The basic diagnostic workup comprises symptoms assessment, targeted physical examination, urine analysis, post-void residual urine estimation which mostly allows to make a working diagnosis and to find out which patients can be treated also by the nonspecialist. The bladder diary is an optimal diagnostic instrument with a lot of information, whereas urodynamics are expensive and somewhat unverified in their value. The symptom-focused diagnosis is absolutely sufficient to start nonoperative therapy for OAB symptoms. The OAB presents a treatment challenge, as the management of OAB patients is not standardized. An algorithm should include an initial period of at least 6 weeks of conservative therapy consisting of antimuscarinic drugs in combination with behavioral therapy including pelvic floor exercises. If this combination is not successful, the primary diagnosis should be questioned and additional diagnostic tests may be required. If the therapy is successful after 8 weeks, a continuation should be considered in case the symptoms occur after stopping pharmacological therapy. Further therapy depends on the severity of the initial symptoms, the presence of side effects and the motivation of the patient. If pharmacotherapy is not successful or additional therapy desirable, electrical neuromodulation can be added for another period of 6 weeks for up to 3-6 months considering firstly non-invasive therapeutic modalities before recommending invasive sacral neuromodulation. Neuromodulation should be discussed before more invasive procedures, such as bladder augmentation, are considered. There are potentially promising new therapies on the horizon for the OAB. The use of intravesical agents, which decrease the afferent-sensory input, may herald a new therapeutic paradigm for the treatment of the OAB. Refinements in the techniques and the delivery vehicle for electrical stimulation may offer an even less invasive method of neuromodulation. Finally, ongoing research in biotechnology and tissue engineering may produce a functional, stable, compatible tissue substitute suitable for bladder augmentation. The objectives are (1) to define the overactive bladder, (2) to understand the prevalence of the overactive bladder and its impact on the quality of life, (3) to review the basic evaluation of the patient with symptoms suggestive of the overactive bladder and how to differentiate the overactive bladder from other types of urinary dysfunction, and (4) to understand the rationale for and the approach to therapy for the overactive bladder.

Cognitive Behavioral Therapy↗

PubMed2002

Conservative therapy for overactive bladder: pelvic floor exercises.

Overactive bladder affects the lives of millions of people. Anticholinergic medications are traditionally used to treat this condition, but some patients find these agents difficult to tolerate and ineffective. Conservative treatment with pelvic floor exercises, with or without biofeedback, electric stimulation, and behavioral modification, are excellent modalities that can be effective in the motivated patient. This review describes the available literature supporting the efficacy of pelvic floor exercises in the treatment of overactive bladder and guidelines for patient selection.

Electric Stimulation Therapy↗

PubMed2006

Botulinum toxin for the treatment of idiopathic and neurogenic overactive bladder: state of the art.

The pharmacologic treatment of overactive bladder and detrusor overactivity, whether idiopathic or neurogenic, has centered around blocking muscarinic receptors on the detrusor muscle. Although newer agents have been developed with better tolerability and safety, the basic mechanism by which the "irritable" detrusor is treated has not changed in decades. Although effective in many cases of idiopathic and neurogenic detrusor overactivity and overactive bladder, antimuscarinic agents fall short in many other cases because of lack of efficacy and/or tolerability. For the past several years, there has been increasing evidence to support the use of botulinum toxin for the treatment of detrusor overactivity and overactive bladder syndrome not effectively treated by anticholinergics. From early open-label studies to the more recent randomized, controlled trials, efficacy and tolerability data have been very encouraging. Botulinum toxin is not yet approved by the US Food and Drug Administration for the treatment of detrusor overactivity and overactive bladder, but the positive results seen thus far cannot be ignored.

Journal Article↗

PubMed2006

Urgency is the core symptom of female overactive bladder syndrome, as demonstrated by a statistical analysis.

PURPOSE: We determined overactive bladder symptoms in combination with other lower urinary tract symptoms and illustrated their relationships using a statistical analysis. Furthermore, we also describe the potential contributory factors and adaptation strategies in patients that are associated with overactive bladder subtypes. MATERIALS AND METHODS: A total of 1,930 women with a mean age +/- SD of 46 +/- 15 years (range 15 to 91) with troubling lower urinary tract symptoms were successfully interviewed with a validated questionnaire at the urology and urogynecology clinics at 14 medical centers in Taiwan. The questionnaire was constructed to evaluate 6 lower urinary tract symptoms and 7 adaptation strategies. A log linear statistical model and multiple logistic regression analysis were used to assess the associations among lower urinary tract symptoms and the potential overactive bladder contributory factors, respectively. RESULTS: No single or isolated symptom presented in patients with overactive bladder. Most patients reported a combination with other lower urinary tract symptoms. These female patients can be categorized into 3 groups, including 1 is associated with dry symptoms (urgency, frequency and nocturia), 1 associated with wet symptoms (urgency, urge incontinence and mixed stress incontinence) and a small group that may have overactive bladder symptoms combined with voiding difficulty symptoms. in contrast to patients with dry overactive bladder (urgency associated with frequency and/or nocturia without urge incontinence), after multiple logistic regression analysis patients with wet overactive bladder (urgency with urge incontinence) had a greater average age and higher body mass index, and made more adaptation efforts (p <0.05). CONCLUSIONS: We used statistical analysis to determine and suggest that urgency is the core symptom of female overactive bladder syndrome and there are 3 distinctive overactive bladder subtypes, which differ in their symptom combinations. Different symptom combinations and patient characteristics affect female adaptation to overactive bladder syndrome.

Adolescent↗

PubMed2005

Solifenacin and darifenacin for overactive bladder.

Darifenacin (Enablex) and solifenacin (VESIcare) are 2 new oral anticholinergics available for once-daily symptomatic treatment of overactive bladder. Overactive bladder is a common condition in older patients. The 5 drugs currently approved for treatment are modestly effective but also cause anticholinergic adverse effects such as dry mouth and constipation and can cause confusion in the elderly. In some experimental studies, the new drugs particularly target bladder receptors, but the clinical significance of these findings is unknown.

Benzofurans↗

PubMed2000

Lower urinary tract symptoms, benign prostatic obstruction and the overactive bladder.

Lower urinary tract symptoms (LUTS), benign prostatic obstruction (BPO), and the overactive bladder have increasing prevalence with age in both men and women (with the obvious exception). The question is, are they interrelated or independently related to age? The specific issue is whether BPO causes the overactive bladder. There are two pieces of evidence that might appear to suggest such a cause and effect. First, the overactive bladder is more common in men than in women of the same age, although physiologically, men are 5-10 years older at the same biological age. Second, the overactive bladder resolves in two-thirds of individuals after surgical interventions such as transurethral prostatectomy. The symptoms suggestive of an overactive bladder are the most troublesome, even though they may not be the most prevalent. Long-term follow-up studies with repeated urodynamic investigations have shown that the incidence of the overactive bladder and its attendant symptoms increases despite there being no deterioration in outlet obstruction over follow-up periods of 10 and 20 years. These data, and others, indicate that the situation is not as straightforward as some believe. The statement that 'the overactive bladder is secondary to BPO' cannot be made, as there are too many unanswered questions and pieces of the puzzle that do not fit. The overactive bladder is undoubtedly associated with BPO, and it leads to the most troublesome LUTS in older men. Epidemiological research, coupled with urodynamic evaluation, may provide further evidence. We also need better and more relevant models (e.g. ageing animals), together with further histological and other biological data before the waters become crystal clear.

Aging↗

PubMed2005

Elimination of rat spinal neurons expressing neurokinin 1 receptors reduces bladder overactivity and spinal c-fos expression induced by bladder irritation.

Substance P (SP) binding to neurokinin 1 receptors (NK1R) in the spinal cord reportedly plays an important role in the micturition reflex as well as in nociceptive responses. We therefore investigated the effect of ablation of NK1R-expressing neurons in the spinal cord using saporin, a ribosome-inactivating protein, conjugated with [Sar9, Met (O2)11]SP, a specific ligand of NK1R (SSP-saporin), on the micturition reflex in rats. In female Sprague-Dawley rats, SSP-saporin (1.0 or 1.5 microM) or saporin (1.5 microM) only was injected through an intrathecal catheter implanted at the L6-S1 level of the spinal cord. Three weeks after intrathecal administration of SSP-saporin, NK1R immunoreactivity in lamina I of the spinal cord was significantly reduced, but cystometric parameters in awake rats were not altered. Instillation of capsaicin (15 microM) into the bladder of normal rats induced bladder overactivity. This response to capsaicin was significantly suppressed in SSP-saporin-treated animals. SSP-saporin treatment also decreased c-fos expression in the dorsal horn of the spinal cord induced by instillation of capsaicin into the bladder. These data indicate that NK1R-expressing neurons in the superficial layer of the dorsal horn play an important role in transmission of nociceptive afferent information from the bladder to induce bladder overactivity and spinal c-fos expression elicited by bladder irritation. Toxin-induced damage of NK1R-expressing neurons in the lumbosacral spinal cord may provide an effective modality for treating overactivity and/or nociceptive responses in the bladder without affecting normal micturition.

Animals↗

PubMed2006

[Epidemiology and pathophysiology of overactive bladder].

According to the new ICS classification overactive bladder (OAB) is defined as a complex of symptoms such as frequency, nocturia, and urgency with or without urge urinary incontinence. Urgency is the key symptom that leads to the diagnosis. The prevalence of overactive bladder in the general adult population is approximately 17%. This number increases with advancing age. Incontinence events are reported in approximately one-third of these patients. Symptoms of overactive bladder have a negative impact on quality of life in every second patient and on sexuality in every fourth patient. In addition to neurogenic and myogenic factors, nowadays urothelial dysfunction is being discussed in the etiology of OAB.

Age Distribution↗

PubMed2004

Post-void residual urine volume in women with overactive bladder symptoms.

PURPOSE: Most patients with overactive bladder symptoms initially present to their primary care provider for treatment. It is currently recommended that post-void residual urine (PVR) should be measured during the assessment of women complaining of overactive bladder symptoms and anticholinergic medication should be used if PVR is low. However, many primary care providers are reluctant to measure PVR and, therefore, they may delay treatment or even inappropriately treat patients who have a high PVR. We identified clinical factors that are associated with increased PVR that could be used to select which patients are at risk for this. MATERIALS AND METHODS: The charts of women presenting to our clinic with complaints of urinary frequency, urgency and/or urge incontinence were retrospectively reviewed. Patient demographics, physical examination and PVR were analyzed to determine if any factor was associated with increased PVR (100 ml or greater). RESULTS: The charts of 201 patients with complete data were reviewed. Patient age was 20 to 90 years (mean 55). Overall 19% of patients were found to have elevated PVR. Univariate analysis identified that older age, prior incontinence surgery, history of multiple sclerosis, greater American Urological Association Symptom Score, vaginal parity greater than 2, greater pad use and stage 2 or greater vaginal prolapse were associated with elevated PVR. Multivariate analysis identified age older than 55 years, prior incontinence surgery, a history of multiple sclerosis and vaginal prolapse stage 2 or greater as independent predictors of elevated PVR. CONCLUSIONS: It is possible to identify patients with overactive bladder symptoms who are at risk for elevated PVR based on history and physical examination. This could result in fewer patients needing PVR measurement prior to initiating treatment.

Adult↗

PubMed2000

Intravesical neuromodulatory drugs: capsaicin and resiniferatoxin to treat the overactive bladder.

Current pharmacologic treatment of the overactive bladder relies on anticholinergic drugs. However, these drugs often have troublesome side effects and frequently are given in doses insufficient to restore continence in patients with detrusor instability. We present the background and basic and clinical research dealing with intravesical instillation of capsaicin and resinfferatoxin as treatments for the overactive bladder. Capsaicin is the main pungent ingredient in "hot" peppers of the genus Capsicum. It is a specific neurotoxin that desensitizes C-fiber afferent neurons, which may be responsible for the signals that trigger detrusor overactivity. Studies with capsaicin over the past 8 years have demonstrated clinical efficacy with minimal long-term complications. Most of these studies have also shown that the acute pain and irritation associated with capsaicin are a major deterrent to widespread use. Resiniferatoxin (RTX), an ultrapotent analog of capsaicin that appears to have similar efficacy but with much less acute side effects may be more useful. Intravesical instillation of capsaicin or resiniferatoxin is a promising treatment for the overactive bladder.

Administration, Intravesical↗

PubMed1999

Intravesical capsaicin and resiniferatoxin therapy: spicing up the ways to treat the overactive bladder.

PURPOSE: Pharmacological treatment of the overactive bladder relies on partially blocking the efferent parasympathetic innervation to the detrusor with anticholinergic drugs. However, often these drugs have troublesome side effects and doses are insufficient to restore continence in patients with detrusor instability. We present the background, basic and clinical research with intravesical instillation of capsaicin and resiniferatoxin as treatments for the overactive bladder. MATERIALS AND METHODS: Capsaicin, the main pungent ingredient in hot peppers of the genus Capsicum, is a specific neurotoxin that desensitizes C fiber afferent neurons which may be responsible for signals that trigger detrusor overactivity. RESULTS: In the last 6 years studies have demonstrated encouraging improvement in lower urinary tract symptoms with minimal long-term complications. Most of these studies have also demonstrated that the acute pain and irritation associated with capsaicin are major deterrents to widespread use. Therefore, resiniferatoxin, an ultra-potent analogue of capsaicin which appears to have similar efficacy but less acute side effects, may be more useful. CONCLUSIONS: Intravesical capsaicin and resiniferatoxin are novel and promising treatments for the overactive bladder, with profound basic and clinical implications.

Administration, Intravesical↗

PubMed2004

Retrospective analysis of efficacy and tolerability of tolterodine in children with overactive bladder.

OBJECTIVE: To evaluate the efficacy and tolerability of tolterodine in children with an overactive bladder, treated in a single incontinence centre. MATERIALS AND METHODS: A retrospective analysis of a database of a total of two hundred and fifty-six patients (175 boys and 81 girls, age range 3 years to 17 years, mean age 8.33 years) with urodynamically confirmed bladder overactivity was performed. All children received tolterodine tartrate (dose range of 0.5-4 mg orally). In group I (n=205) tolterodine tartrate replaced anticholinergic drugs (AC) (oxybutinin chloride or oxyphencyclimin hydrochloride). A subgroup of patients switched because of intolerance due to serious adverse events (60.4%) or because of lack of improvement in micturition variables (39.6%). In group II tolterodine was prescribed as initial therapy (n=51). Tolerability was assessed by a standardised questionnaire on adverse events at every outdoor clinic visit. Efficacy assessment was based on micturition diary variables, mean change of maximum bladder capacity and number of incontinence episodes/24 h. RESULTS: The mean treatment time was 9.32 months with a range from 1.5 months to 23.4 months. The final dose was 0.1mg/kg orally daily divided into two doses. In group I central nervous system disorders (81%) were the most common adverse events, 26.2% showed flushing, 12.2% accommodation problems and 25.2% had gastrointestinal complaints (constipation, encopresis, abdominal pain). Withdrawal of the non-selective antimuscarinic drug resulted in total recovery from adverse events. Introduction of tolterodine in group I and II caused no serious adverse events. Nine patients (3.5%) reported side-effects and only two discontinued treatment. There were no reports of flushing, troubles of visual accommodation, hyperpyrexia. In group I we observed a mean decrease in urgency by 38.7%, a mean increase in maximal bladder capacity by 33.6% and the number of incontinence episodes decreased by 64.8%. In group II we observed equivalent values with a significant (p<0.001) change in maximal bladder capacity (49.7%), incontinence episodes (64.8%) and micturition episodes/24 h. CONCLUSIONS: The results of this retrospective analysis suggest that tolterodine is well tolerated in children and offers an effective treatment for urinary symptoms due to overactive bladder. Tolterodine is superior to non-selective antimuscarinic drugs, with respect to adverse events, allowing more compliance and more effective treatment in children.

Adolescent↗

PubMed2006

The puzzle of overactive bladder: controversies, inconsistencies, and insights.

Overactive bladder (OAB) affects millions of individuals and may severely impair the quality of life of those affected. The contribution of human behavior to manifestations of this symptom complex remains poorly understood. Continued evolution of our understanding of the pathophysiology of OAB has identified contributory mechanisms, which in turn may open new therapeutic avenues. Recent improvements in drug delivery systems represent advances in the management of OAB. However, more complete symptom control with greater tolerability is desirable; this awaits the development of agents specific for newly emerging and as yet unidentified pathophysiologic pathways. Importantly, as understanding of outcomes assessment in OAB matures, refined assessments of disease severity, response to intervention, and patient preference should be possible.

Animals↗

PubMed2005

Bladder augmentation using Pelvicol implant for intractable overactive bladder syndrome.

The objective of the study was to evaluate the effectiveness of an implant of porcine dermis to augment the bladder in women with refractory overactive bladder syndrome (OAB). Twelve women underwent a Pelvicol bladder augmentation. A visual analogue score for severity of incontinence and a quality of life questionnaire was carried out pre-operatively and at 12 months post-operatively. Follow up cystoscopy was carried out in three women in addition. Three women were dry and cured; five women were significantly improved; two women were slightly improved and the procedure was unsuccessful in the remaining two women. There were no significant complications and voiding was spontaneous in every case. A bladder augmentation using porcine dermis may have a role in the surgical management of non-neuropathic women with OAB that has failed to respond to conservative therapy.

Adult↗