The neurogenic overactive bladder. Classification based on urodynamics

The aetiology and pathogenesis of bladder overactivity are very variable and the classification is rather crude. By careful interpretation of clinical findings and urodynamic assessments, refinement of the diagnosis is possible. From a therapeutic and prognostic stand-point, it is of interest to distinguish between "idiopathic detrusor instability" and the "uninhibited overactive bladder". Based on neurological investigation and cystometric recordings, including the ice water test, characteristics of the 2 entities are described.     

The effect of overactive bladder treatment with anticholinergics on female sexual function in women: a prospective observational study

International Urology and Nephrology - The aim of the study was to determine the effect of anticholinergics used for overactive bladder treatment on the sexual function of women. Between January...     

Anticholinergics [corrected] in patients with overactive bladder: Assessment of ambulatory urodynamics and patient perception

AIMS: The aim of this study was to evaluate whether ambulatory urodynamic monitoring (AUM) may reflect patient perception of bladder condition and treatment benefit in patients with overactive bladder (OAB). METHODS: A total of 33 women and 7 men 23 to 72 years old who were undergoing AUM were included in this study. At baseline, patients were asked to complete the following information in the micturition chart for 3 consecutive days. Patients were given anticholinergics once daily for the 2 weeks. Two weeks after the treatment, all patients received an identical repeat study. RESULTS: Most parameters of AUM, micturition chart and patient perception were improved 2 weeks after treatment. However, when Spearman correlation coefficients were performed, all AUM parameters did not correlate with patient perception of bladder condition after treatment although some AUM parameters regarding incontinence were associated with patient perception of bladder condition at baseline. In addition, when patients were divided as the 'no or some benefit' group (n = 25) and the 'much benefit' group (n = 15), all AUM parameters except total voided volume (P = 0.004) were not significantly different in the two groups. CONCLUSIONS: Because patients with pelvic floor dysfunction have widely varying expectations from treatment, the patient's goal for treatment is highly subjective. Our findings suggest that AUM does not take into account the patient perception of disease severity, and correlations between the patient view of treatment outcome and objective measures are poor. Therefore, strategies for assessing OAB should incorporate self-perceived disease condition.     

Efficacy and safety of anticholinergics for children or adolescents with idiopathic overactive bladder: systematic review and meta-analysis

Introduction and hypothesis

Anticholinergics have been established for their efficacy and safety in adults with idiopathic overactive bladder syndrome (OAB-s) but not in children and adolescents. This study was aims to investigate the efficacy and safety of anticholinergics in children and adolescents with idiopathic OAB-s.

Method

A total of nine studies with 11 trials comprising of 1801 subjects (1116 experimental and 685 controls) were included. Inclusion criteria were idiopathic OAB-s in children or adolescents. Overall SMD of change in diurnal urge incontinence per week, change in mean voiding frequency per 24 h, change in mean voided volume, and incidence of adverse events compared with placebo were investigated.

Results

Overall SMD of diurnal urge incontinence per week for the anticholinergic group (experimental group) vs. the placebo group (control group) was ??0.15 (95% CI ??0.31, 0.01). Overall SMD of mean voiding frequency per 24 h was ??0.16 (95% CI ??0.33, 0.02). Overall SMD of mean voided volume was 0.49 (95% CI 0.10, 0.88). The overall incidence of any AEs of anticholinergics compared with placebo was OR?=?1.06 (95% CI 0.84–1.34) (p?=?0.637). Among each AEs, the only incidence of urinary tract infection showed a higher incidence rate for anticholinergics (OR?=?1.92, 95% CI 1.06–3.49) than for placebo.

Conclusions

Apart from oxybutynin, other anticholinergics showed efficacy including an increase in mean voided volume. Moreover, there was no significant difference in the incidence of overall adverse events between anticholinergics and placebo.

     

The impact of urodynamics on treatment and outcomes in women with an overactive bladder: a longitudinal prospective follow-up study

Introduction and hypothesis

The aim of this study was to establish if the management of women with overactive bladder (OAB) and patient-reported outcomes differed based on the findings of urodynamics (UDS).

Methods

A prospective, longitudinal observational study conducted in urogynaecology clinics in 22 UK hospitals participating in the Diagnostic Accuracy of Bladder Ultrasound Study (BUS). A total of 687 women with OAB symptoms or urgency-predominant mixed urinary incontinence were recruited into a diagnostic study that used UDS as the reference standard. Detailed clinical history and International Consultation on Incontinence OAB Short Form (ICIQ-OAB sf) questionnaire responses were obtained before the UDS test was carried out. These questionnaires were subsequently collected at a mean of 7 and 20 months, along with patient global impression of improvement and details on medical and surgical treatments. The relationship between UDS diagnosis and treatment was examined using a multinomial regression model; logistic and repeated measures regressions were used to examine other outcomes.

Results

We recruited 687 women and the response rate was 69% at 20 months. Treatment subsequent to UDS was highly associated with diagnosis (p < 0.0001). Women who received treatment concordant with their UDS findings were more likely to report an improvement in bladder symptoms (57% vs 45%; p = 0.02) and ICIQ-OAB sf scores (0.5 points, 95%CI: 0.1 to 0.9; p = 0.02).

Conclusions

Urodynamics influenced treatment decisions made by clinicians in determining treatment pathways in women presenting with OAB. Women treated based on UDS diagnoses appear to have greater reductions in symptoms than those who do not.

     

The overactive bladder: Epidemiology and morbidity

The International Continence Society recognizes the overactive bladder (OAB) as a "symptom syndrome suggestive of lower urinary tract dysfunction" that is defined as "urgency, with or without urge incontinence, usually with frequency and nocturia." Patients who have OAB are often sleep deprived and their sexual life is hindered. These patients have a restricted social life and an increased risk for depression. Accurate prevalence figures are difficult to obtain because most patients consider OAB an inevitable part of aging and some patients are too embarrassed to seek diagnosis. Primary care physicians need to be educated about the importance of identifying this clinical problem and managing it in a way that will minimize morbidity and maximize quality-of-life improvement. This article describes the various aspects of OAB, with special emphasis on epidemiology and morbidity.     

The bladder epithelium and overactive bladder: What we know

Although the urothelium has been traditionally thought of as a passive barrier between urine and detrusor muscle, new studies have shown that the urothelium is a highly specialized structure involved in antigen presentation, micturition reflex, metabolic secretion, inflammatory regulation, and sensory afferent functioning. Data from several laboratories have shown that the urothelium can respond to thermal, mechanical, and chemical stimuli. The earlier findings (activation of urothelial transient receptor potential channel vanilloid 1 producing the second messenger nitric oxide, which in turn triggers suburothelial sensory nerves) demonstrate how the urothelium acts as a transducer, releasing chemicals that target adjacent bladder cells and sensory neurons. We now know that bladder urothelium acts also as a transducer whereby afferent neurons, via urothelial mechanoafferent transduction, are involved in the micturition process and the pathogenesis of bladder disorders. This paper highlights the important role that the urothelium has in bladder pathophysiology.     

Overactive bladder and men: Indications for anticholinergics

Similar to bladder outlet obstruction (BOO), overactive bladder (OAB) symptoms are very common and increase in prevalence as men age. Whether or not OAB symptoms are thought to be secondary to BOO, the goal of treatment of symptoms should result in an improved quality of life and ultimately prevent clinical deterioration. A common dilemma when treating men with obstruction and OAB is the risk of acute urinary retention or morbidities related to increasing postvoid residuals. In this article, the relationship of OAB to BOO is examined and the role of urodynamics and data on the use of anticholinergics in men with OAB and obstruction are reviewed. An algorithm for managing men with OAB also is proposed. In men with OAB without evidence of obstruction (including OAB after treatment for BOO), first-line medical therapy with anticholinergics is indicated. However, in men with OAB and concomitant BOO, nomogram has been developed to assist in the management of patients at risk for urinary retention. Men with significant obstruction should be appropriately treated to decrease bladder outlet resistance before adding anticholinergics for the treatment of OAB.     

Changes in urinary nerve growth factor and prostaglandin E2 in women with overactive bladder after anticholinergics

Introduction and hypothesis

The aim of this study is to investigate changes in urinary nerve growth factor (NGF) and prostaglandin E₂ (PGE₂) in women with overactive bladder (OAB) following anticholinergic treatment.

Methods

A total of 30 female patients with OAB were enrolled and the control group included 15 healthy women who did not present any bladder symptoms. All subjects with OAB recorded voiding diaries, underwent urodynamic study, and were evaluated for urgency grade. They received anticholinergic treatment for 4 weeks, after which they were again evaluated for urinary urgency grade and voiding diaries. OAB patients were classified into three groups according to the change on the 5-point Urinary Sensation Scale after the treatment: group 1 (no change in urgency grade), group 2 (1 point of improvement), and, group 3 (more than 2 points of improvement). Urinary NGF and PGE₂ levels between controls and OAB patients (before and after treatment in groups 1, 2, and 3) were compared.

Results

Urinary NGF and PGE₂ levels were significantly higher in OAB patients than in the controls. NGF levels were not significantly different between pre- and post-treatment in groups 1 and 2. However, in group 3, NGF levels were significantly decreased after treatment. PGE₂ levels were not significantly different between pre- and post-treatment in either group.

Conclusions

NGF and PGE₂ have important roles in the development of OAB symptoms in women. Initial reduction of urgency severity after anticholinergic treatment in women with OAB could be associated with decreasing urinary NGF levels.     

The electrovesicogram in the overactive bladder: role in determining pathogenesis and diagnostic significance

We investigated the hypothesis that the abnormal contractility of the smooth musculature of the overactive bladder (OAB) may be due to derangement of its electrical activity. Percutaneous electrovesicography was performed in 22 patients (mean age 46.3 years, 12 men, ten women) with OAB and 14 healthy volunteers (mean age 45.6 years, eight men, six women). Recording was performed with the bladder full and empty. Three electrodes were applied suprapubically and one reference electrode was applied to a lower limb. Reproducible regular triphasic slow waves (SWs) were recorded in the volunteers. The pattern of the full and empty bladder were similar except for the higher amplitude of the waves in the former (P<0.05). The OAB patients showed a dysrhythmic pattern with irregular frequency, amplitude and conduction velocity in both the empty and full bladders. We obtained tachyrhythmic, bradyrhythmic and arrhythmic areas in the same recording. The OAB exhibited a dysrhythmic electrical pattern with areas of different electrical activity in the same recording. The tachyrhythmic, bradyrhythmic and arrhythmic areas are suggested to explain the abnormal vesical contractions and clinical manifestations of OAB. Further studies are required to investigate the cause of the dysrhythmic pattern and the electrovesicogram is suggested as an investigative tool in OAB diagnosis.     

Comparison of darifenacin and oxybutynin in patients with overactive bladder: assessment of ambulatory urodynamics and impact on salivary flow

OBJECTIVES: To evaluate the effects of darifenacin, an M3 selective receptor antagonist, compared with oxybutynin, on ambulatory urodynamics, salivary flow, heart rate and visual nearpoint in patients with overactive bladder (OAB). METHODS: A double-blind, randomized, crossover study (n=65) with three treatment cohorts: darifenacin immediate release (IR) 2.5 mg three times a day (t.i.d.) or oxybutynin 2.5 mg t.i.d.; darifenacin controlled release (CR) 15 mg once daily (q.d.) or oxybutynin 5 mg t.i.d.; darifenacin CR 30 mg q.d. or oxybutynin 5 mg t.i.d. Within cohorts, patients received 7 days' treatment with each agent separated by 14 days' washout. RESULTS: All active treatments improved urodynamic parameters. Both darifenacin CR doses had significantly less effect on salivary flow than oxybutynin. Effects on urodynamic parameters, heart rate and visual nearpoint were comparable. CONCLUSION: Ambulatory urodynamics appears to be an innovative and potentially useful investigative tool in the evaluation of the efficacy of new therapeutic agents. Darifenacin CR is an efficacious therapy for OAB with comparable effects on urodynamic parameters but producing significantly less dry mouth than oxybutynin.