Botulinumtoxin in der Therapie der überaktiven Blase – ein Überblick

This article shall give a state-of-the-art review about the treatment of neurogenic and idiopathic detrusor overactivity with botulinum toxin injections into the detrusor muscle. We searched PubMed for original articles up to December 2006. Abstracts published at international congresses were also considered if they provided substantial new information. Based on this review it appears that a majority of patients with spinal cord injury regains continence after botulinum toxin A injection and that in children with myelomeningocele a significant improvement in continence can also be achieved. A concomitant reduction of intravesical pressure protects the upper urinary tract in these patients. In idiopathic detrusor overactivity, injection of botulinum toxin A also resulted in improvement of continence and reduction of daily micturition frequency. For both indications a high success rate could be achieved with an average duration of the effect of 6 months. Repeated injections into the detrusor seem to have no adverse effects in terms of duration or strength of the effect. Side effects were marginal and systemic side effects were experienced only in individual cases; in some patients with idiopathic detrusor overactivity intermittent self-catheterization was required. Overall intradetrusor injections of botulinum toxin seem to be a new, highly effective, and safe alternative in the treatment of neurogenic and idiopathic detrusor overactivity.     

Epidemiologie und Pathophysiologie der überaktiven Blase

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.     

Therapie der überaktiven Blase mit Propiverin ER

Background

The aim of this non-interventional study was to evaluate the efficacy and tolerability of propiverine ER under real life conditions.

Patients and methods

The treatment of 5,565 patients with urge urinary incontinence, urgency or mixed urinary incontinence was documented over a 12-week period. Incontinence episodes, voiding frequency and voided volume were recorded at 3 visits (admission, after 4 and 12 weeks). Additionally the tolerability was evaluated at visits 2 and 3.

Results

The average incontinence episodes/24 h decreased during therapy from 4.23 to 2.89. The frequency of micturitions/24 h decreased by 5.50. The voided volume improved by 69 ml. Approximately 92 % of investigators and patients assessed the efficacy similarly with ?very good“ and ?good”. Dry mouth was the most frequent adverse drug reaction and decreased from 16.5 % after 4 weeks to 13.6 % after 12 weeks of treatment.

Conclusion

The efficacy and tolerability of propiverine ER were confirmed under real life conditions.     

Second-line-Therapie der idiopathisch überaktiven Blase

The syndrome of idiopathic overactive bladder (I-OAB) impairs quality of life for the affected individuals. Conservative treatment options such as antimuscarinics are not always effective, and resulting side effects can lead the patient to stop treatment. In recently years, minimally invasive and reversible sacral neuromodulation and botulinum toxin A have become available. Currently, the approved treatment option for I-OAB that is recommended by the International Consultation on Incontinence is sacral neuromodulation by InterStim therapy. This article gives an overview of the present clinical evidence on the effectiveness and reliability of these two treatment modalities as well as the current significance of sacral neuromodulation and botulinum toxin A for the second-line treatment of adult I-OAB.     

Intravesikale Therapie der überaktiven Blase

Introduction

Despite recent advances in the field of anticholinergic drugs, lack of efficiency and side effects are still the main reasons for discontinuation of treatment. The introduction of botulinum A toxin was a milestone in the treatment of detrusor overactivity. The treatment, however, is invasive, the duration of the treatment effects is limited, and long-term results are not yet available. The following addresses therapeutic alternatives to local treatment of overactive bladder.

Materials and Methods

A total of 52 patients received intravesical oxybutynin. In 16 patients, capsaicin was instilled in the bladder and 28 patients were treated with EMDA.

Results

Intravesical oxybutynin was successful in 86%; the success rate of capsaicin instillation was 47%. EMDA was successful in 78%. Two transient ischemic attacks following EMDA were observed as significant side effects.

Conclusion

Besides botulinum A toxin, several effective treatment options are available for patients with detrusor overactivity refractory to oral anticholinergic treatment. Therefore, in each individual patient, possible risks and complications of the different treatment options should be considered thoroughly to find the optimal method in each case.     

Botulinumtoxin A bei der Behandlung der infantilen Zerebralparese

Botulinum toxin A represents a significant development in the management of children and adolescents with spastic cerebral palsy. Prerequisites for an adequate result are a correct indication, an exact injection technique and an intensive post-treatment programme. Spastic muscle overactivity and the constant tendency of the involved muscles to shorten with growth cannot be treated by only one method. Therefore a multilevel approach and an integrated treatment schedule including plaster of Paris, orthoses and physiotherapy are currently the best ways to modify the disease process. The inclusion of objective clinical documentation techniques combined with 3-D instrumented gait analysis allows the determination of the indications more exactly and for monitoring the post-treatment results. If started early and correctly, this integrated management approach has the potential to modify the natural history of the disorder, and to reduce the frequency of later surgery.     

Therapie der überaktiven Blase (OAB)

Die Urologie - Der Symptomenkomplex der überaktiven Blase („overactive bladder“, OAB) mit oder ohne Inkontinenz („wet/dry“) hat mit etwa 17% in der europäischen...     

Therapie der ��beraktiven Blase

Background

Epidemiological data demonstrate an increasing prevalence of symptoms of overactive bladder (OAB) with age not only in women, but especially in men. Despite a comparable prevalence, however, men are still highly underrepresented in most large randomized studies on the effect of antimuscarinic drugs.

Question

In this subgroup analysis of the CAP Study the efficacy and tolerability of solifenacin was examined in 111 men with symptoms of OAB. The study was performed in a network between general practitioners and urologists under routine conditions over a period of 12 months.

Results

Treatment with solifenacin reduced all symptoms of OAB significantly, and the use of pads decreased by more than half. The tolerability of therapy was judged as ??excellent?? or ??good?? by over 95% of doctors and patients.

Conclusion

This subgroup analysis of the CAP Study confirms the good efficacy and tolerability of solifenacin in male OAB in daily practice over a treatment period of 1?year.     

Ergebnisse der sakralen Neuromodulation bei Therapie der überaktiven Blase

Currently, sacral nerve modulation (SNM) is an effective treatment for overactive bladder symptoms which are refractory to anticholinergic or muscarinergic treatment. However, SNM requires the implantation of stimulation electrodes at the sacral nerves and a subcutaneous impulse generator. The SNM procedure can be divided into three phases: the acute phase comprising the implantation of the test stimulation electrodes, the subchronic stimulation phase over a period of 7-14 days during which neurostimulation takes place by means of an external impulse generator, and finally chronic SNM after implantation of the final impulse generator.In 1981 the SNM technique for treatment of bladder dysfunctions was first developed by Tanagho and Schmidt and has since been refined, while the range of indications has been extended continuously. It has been shown that patients with neurogenic bladder dysfunctions are able to gain the greatest benefit from SNM. The long-term results of SNM are very encouraging so far. In addition, a highly innovative and promising technique is the implantation of a miniaturized impulse generator with integrated stimulation electrode at the n. pudendus. However, the outcome of these trials has not fully been capable of living up to the expectations so far.     

Wertigkeit des ?nerve growth factor“ beim Syndrom der überaktiven Blase

Objectives

Several studies discussing the pathology of overactive bladder suggested changes in urinary proteins. The neurotrophin “nerve growth factor” (NGF) seems to be an important marker in overactive bladder syndrome (OAB). In this prospectively designed study we evaluated NGF blood levels (sNGF) initially and after injection of botulinum toxin type A (BTX-A) in the detrusor muscle in patients suffering from idiopathic OAB.

Materials and methods

Blood samples were obtained from 26 patients (66.5 years, 28–83) with idiopathic OAB. sNGF levels were measured before and 4 weeks after BTX-A treatment by enzyme-linked immunosorbent assay (ELISA). A group of 32 healthy persons with normal bladder function served as controls (41 years, 19–60). sNGF was evaluated in relation to clinical data and the severity of OAB (wet/dry).

Results

Significantly higher sNGF levels were detected in patients with OAB compared to the control group (58.8 vs 2.0 pg/ml, p<0.005). Further, sNGF levels were elevated in patients with wet OAB compared to patients with dry OAB (85.0 vs 0.73 pg/ml, p<0.005). Patients > 60 years showed significantly higher sNGF levels (77.2 vs 8.9 pg/ml, p<0.05) compared to younger OAB patients. After BTX-A therapy sNGF levels decreased significantly compared to baseline (p<0.005).

Conclusion

NGF appears to play a decisive role in OAB. Its use as a biomarker in both the diagnostics and follow-up after therapy seems promising. To what extent sNGF can be useful as a biomarker or in therapy monitoring needs to be examined prospectively in a larger population.     

Bindenzügelgipsverband in der Behandlung von Frakturen und Pseudarthrosen

Ohne Zusammenfassung Mit 2 Abbildungen.     

Geschlechtsunterschiede in der operativen und endovaskulären Behandlung von Karotisstenosen

Background

About 20% of all ischaemic strokes develop against the backdrop of extracranial macroangiopathy. Men are more frequently affected than women and are an average of 5–10 years younger. Morbidity and mortality are higher in women, however. This paper deals with the question of sex specificity in the surgical and endovascular treatment of extracranial carotid stenoses.

Materials and methods

After a Medline search all prospective randomized studies (CEA vs conservative treatment, CEA vs CAS), meta-analyses, and systematic reviews were perused to look for sex-specific complication rates and long-term results of carotid endarterectomy (CEA) and carotid stenting (CAS).

Results

In the available literature, women are underrepresented, accounting for only 20–30% of all study patients. Overall, compared with men, women have a higher perioperative rate of stroke, albeit without higher mortality. Women have a lower stroke rate in the natural course of symptom-free or symptomatic carotid stenoses. The stroke-protective value for CEA is greater in men, women benefiting only when a very low complication rate is retained. For CAS only isolated sex-specific evaluations are available so far. While in single register studies no sex difference was demonstrable, the 30-day complication rate in the prospective randomized SPACE study was 6.5% for men (OR 1.01, 95%CI 0.58–1.74), while women did not enjoy any significant benefit of CEA (6% vs 7.7%, OR 1.31, 95%CI 0.51–3.44). Sex-specific long-term results after CAS are not available at present.

Conclusions

Gender has an influence on complication rates and long-term results and should be given more attention in future studies.     

Neues über Wesen und operative Behandlung der Ischias

Ohne Zusammenfassung Aus der orthop?disch-chirurgischen Privatklinik Professor Dr. H. Gocht.     

Tierexperimentelle Untersuchungen über den Abtransport von radioaktivem Phosphor aus der Blase

Zusammenfassung Es wird die Blasenwand von Kaninchen mit radioaktivem Eisenphosphat³²P in kolloidaler Lösung infiltriert und die Ausbreitung in die umgebende Blasenwand, in die ableitenden Lymphknoten, in Milz, Leber, Lungen und Nieren autoradiographisch nachgewiesen. Dabei konnte festgestellt werden, daß der Abtransport sowohl auf dem Lymphwege wie auch hämatogen in sehr reichlichem Ausmaße erfolgt.Die erhobenen Befunde lassen die berechtigte Hoffnung auf eine lokale Tumorhemmwirkung zu. Die Speicherung in den regionären und auch fernab liegenden Lymphknoten bewirkt möglicherweise auch eine gewisse Abschirmung der Peripherie gegenüber einer Tumorzellausschwemmung bei operativen Eingriffen an Blasentumoren.Bei den verabreichten Mengen von³²P kam es örtlich und weiter ab zu keinen nennenswerten degenerativen Schädigungen der Gewebe, es ließen sich lediglich an der Injektionsstichstelle eine wechselnd ausgeprägte Hyperämie, Ödem und vereinzelt leuko- und lymphocytäre Infiltrate nachweisen.Mit 7 Textabbildungen     

Qualitätsstandards in der Behandlung und Rehabilitation von Schädel-Hirn-Verletzungen

The quality standards of the “Deutsche gesetzliche Unfallversicherung” (DGUV) on the treatment of traumatic brain injuries were first published in 2015. They describe the optimal conditions and requirements of acute treatment and in all phases of rehabilitation and aftercare, according to the current state of knowledge. The aim is to enable a life worth living in family, school, occupation and society for as many injuries as possible. The quality standards, as systematic orientation and decision-making aids, should promote the future development of the treatment and rehabilitation of traumatic brain injuries of all grades of severity and guarantee a uniformly high quality of treatment. A special and comprehensive rehabilitative alignment as well as a close networking of medical and occupation-promoting services will be of particular importance for the institutions participating in the rehabilitation of patients with traumatic brain injuries.