Prevalence and predictors of overactive bladder in nonpregnant nulliparous women below 65 years of age

Introduction and hypothesis

The aetiology of the overactive bladder (OAB) symptom complex is still poorly understood. In order to obtain further insight, the prevalence and predictors of the symptoms included in OAB, that is urgency, urgency incontinence (UUI), frequency and nocturia, were investigated in a sample of nonpregnant nulliparous women.

Methods

A national, postal and web-based survey of OAB symptoms was conducted in women aged 25–64 years (n = 9,197). Crude prevalence and prevalence adjusted according to body mass index (BMI) were calculated from a logistic regression model to evaluate the prevalence of OAB.

Results

The response rate was 52%. The prevalence of urgency, bothersome urgency, UUI, and nocturia, but not daytime frequency, increased consistently with advancing age and increasing BMI. Urgency was associated with BMI, age ≥45 years, nocturia, and daytime frequency of eight or more micturitions. Daytime urinary micturition frequency was not affected by age either in women with OAB or in women without OAB. Bothersome OAB affected almost half of the woman in the oldest age group and was strongly associated with nocturia of two or more micturitions and OAB with UUI.

Conclusions

There were contrasting changes in the prevalence of the different symptoms included in OAB. With increasing age and BMI, the prevalence of nocturia, urgency and UUI increased, while daytime frequency remained stable. These findings are of importance as the primary endpoint for the evaluation of drug therapies for OAB has often been daytime urinary frequency.

     

Is pretreatment cystometry important in predicting response to mirabegron in women with overactive bladder symptoms?

Introduction and hypothesis

The aim of this study was to evaluate for any association between pretreatment cystometry results and outcome of treatment with mirabegron in women with overactive bladder (OAB) symptoms.

Methods

This was a prospective observational study of women with OAB symptoms that proved refractory to conservative management. All women underwent filling and voiding subtraction cystometry prior to further treatment. Women were treated with mirabegron 50 mg once daily, and outcomes were evaluated after 6 weeks’ treatment. The primary outcome measure was change in symptoms as indicated by response to the Patient Global Impression of Improvement (PGI-I) scale. The presence of detrusor overactivity (DO), the highest detrusor pressure recorded during the filling phase, the presence of urodynamic stress incontinence (USI), cystometric capacity, voided volume, maximum flow rate and detrusor pressure at maximum flow were all compared between responders and nonresponders.

Results

The study population consisted of 169 women; response rate to mirabegron was 69.8 %. There was no association between the presence of DO or maximum detrusor pressure during filling and USI, cystometric capacity, maximum flow rate and detrusor pressure at maximum flow and treatment response. In a subgroup with OAB symptoms refractory to previous treatment with antimuscarinics, there was an association between the presence of DO and a positive treatment response (p?=?0.02).

Conclusions

Overall, there is no association between urodynamic findings and response to treatment with mirabegron. This may reflect the fact that mirabegron’s mode of action mechanisms are not measurable using cystometry. In women with refractory symptoms, however, the presence of DO is associated with a positive response to treatment.

     

Microalbuminuria among HIV-infected antiretroviral therapy-naive children in the Democratic Republic of Congo

Background

To determine the prevalence of microalbuminuria and associated factors among Congolese human immunodeficiency virus (HIV)-infected children.

Methods

This was a cross-sectional study in which 77 HIV-infected antiretroviral therapy-naive children and 89 uninfected controls were enrolled. Microalbuminuria was assessed using the immune-turbidimetry method, and associated factors were studied by logistic regression.

Results/Conclusion

The prevalence of microalbuminuria was 18% in the HIV-infected children and 2% in the HIV-uninfected children. No common determinants of proteinuria were significantly associated with microalbuminuria.

     

Management of Overactive Bladder in Older Women

Purpose of review:

This review will highlight our current understanding of age-related changes in bladder function and propose important clinical considerations in the management of overactive bladder (OAB) specific to older women.

Recent findings:

Frailty, functional and cognitive impairment, multimorbidity, polypharmacy, estrogen deficiency, and remaining life expectancy are important clinical factors to consider and may impact OAB symptom management in older women. Third-line therapies, particularly PTNS, may be preferable over second-line therapy in some cases.

Summary:

Due to the complexity within this population, the standard treatment algorithms may not be applicable, thus a broader, more holistic focus is recommended when managing OAB in older women.

     

The Use of Predictive Markers for the Development of a Model to Predict Weight Loss Following Vertical Sleeve Gastrectomy

Background

Average percent excess weight loss data is commonly discussed preoperatively to guide patient expectations following surgery. However, there is a wide range and variation in weight loss following vertical sleeve gastrectomy (SG). Unfortunately, most surgeons and even fewer patients have heard of using predictive models to help guide their decisions on procedure choice. We have developed a predictive model for SG to help patient choice prior to this major life-changing decision.

Objective

Predict weight loss results for SG patients at 1 year using preoperative data.

Setting

Private practice.

Methods

Three hundred and seventy-one SG patients met the criteria for our study. These patients underwent surgery between October 2008 and June 2016. Non-linear regressions were performed to interpolate individual patient weights at 1 year. Multivariate analysis was used to find factors that affected weight loss. A model was constructed to predict weight loss performance.

Results

Variables that affect weight loss were found to be preoperative body mass index (BMI), age, hypertension, and diabetes. Diabetes and hypertension together were found to significantly affect weight loss.

Conclusion

Patient weight loss can be accurately predicted by simple preoperative factors. These findings should be used to help patients and surgeons decide if the SG is an appropriate surgery for each patient. Using this model, most patients can avoid failure by choosing an appropriate surgical approach for their personal circumstances.

     

The role of acupuncture in managing overactive bladder; a review of the literature

Introduction and hypothesis

Overactive bladder (OAB) affects a considerable proportion of men and women in the United States and is associated with significant costs and quality of life (QoL) reduction. While medication remains a mainstay of treatment, there is increasing interest in the use of alternative medicine in the form of acupuncture. We reviewed the literature on the role of acupuncture in managing OAB.

Methods

A narrative review was compiled after searching electronic databases (PubMed, MEDLINE, Scopus, and EMBASE) for clinical studies involving acupuncture in treating OAB. Databases were searched from the time of inception through September 2015 by a clinician for articles reporting the results related to the use of acupuncture in OAB. Key search terms were acupuncture, overactive bladder, bladder instability, urgency, urinary incontinence. Articles in English or translated into English were included.

Results

Initial animal studies suggest several biochemical mechanisms of action underlying the effect of acupuncture on OAB suppression. The experience in humans includes two case series and six comparative trials. All studies demonstrated subjective improvement in OAB symptoms, and some reported objective improvement in urodynamic studies. Notably, some comparative trials showed the benefit of acupuncture to be comparable with antimuscarinic treatment.

Conclusion

Despite their limitations, existing studies serve as a promising foundation for suggesting a role for acupuncture as an alternative therapy for OAB. Further well-designed studies are required to investigate optimal technique and their outcomes.

     

Effectiveness of BTX-A and neuromodulation in treating OAB with or without detrusor overactivity: a systematic review

Introduction and hypothesis

Patients with refractory overactive bladder (OAB) pose a therapeutic challenge. Guidelines such as those from the National Institute for Health and Care Excellence recommend invasive treatments such as botulinum toxin-A ((BTX-A), sacral neural stimulation (SNS) etc. only if there is detrusor overactivity (DO) on urodynamics.

Methods

Our aim was to systematically evaluate evidence based on the presence or absence of DO in relation to differences in effectiveness and complications related to invasive treatment in patients with refractory OAB. We carried out a systematic search of Cochrane, MEDLINE, Embase, CINAHL, LILACS, meta-Register of Controlled Trials (mRCT), CENTRAL, and Google Scholar databases from inception until April 2016. Abstracts presented at IUGA, ICS and EAU conferences (until April 2016) were included and journals that were hand searched.

Results

We found five studies (two prospective cohort studies and subgroup analyses of two randomized controlled trials (RCTs) and one cohort study for BTX-A, one multicenter prospective cohort study for percutaneous tibial nerve stimulation (PTNS) and three (one RCT and two cohort studies) for SNS. The outcomes in patients without (n?=?77) or with (n?=?135) DO were similar in the context of urodynamic findings, bladder diaries, quality of life (QoL) questionnaires, etc. when treated with BTX-A [odds ratio (OR) 1.52, 95% confidence interval (CI) 0.40–5.77] or SNS (50 patients without and 81 with DO; OR1.37, CI 0.76–2.48). Outcomes for PTNS (based on a single study) seem to be better in patients without DO.

Conclusion

The limited evidence suggests that urodynamic diagnosis of DO does not alter patient reported outcomes for invasive treatments such as BTX-A and SNS. Noninferiority RCTs powered to evaluate the role of DO in predicting treatment response are required.

     

Is mirabegron equally as effective when used as first- or second-line therapy in women with overactive bladder?

Introduction and hypothesis

No previous studies have investigated the efficacy of mirabegron 50 mg as the first-line therapy in OAB patients. Hence, the primary objective of this study was to evaluate the efficacy of mirabegron in treatment-naive patients in comparison with those who had discontinued antimuscarinic therapy because of insufficient efficacy.

Methods

All consecutive women who had pure OAB symptoms (including urgency with or without urgency incontinence and frequency) for at least 3 months were considered for this study. Women were divided into two groups: women without any previous pharmacological treatment for OAB (group 1) and women with a previous history of failed antimuscarinics therapy (group 2).

Results

At 3-month follow-up, the objective results on the basis of the frequency–volume chart showed a significant improvement in both groups. Furthermore, a significant reduction in the Overactive Bladder Questionnaire Short Form (OABq-SF) score and in the Indevus Urgency Severity Scale (IUSS) questionnaire were reported in both groups. However, the improvement in objective and subjective outcomes was superior in group 1 to that in group 2.

Conclusions

Mirabegron is efficacious in improving OAB symptoms in both naïve patients and those who discontinued primary antimuscarinic therapy; however, its efficacy is superior when prescribed as first-line therapy.

     

Efficacy of pelvic floor muscle training in women with overactive bladder syndrome: a systematic review

Introduction and hypothesis

Our objective was to evaluate the effectiveness of pelvic floor muscle training (PFMT) in reducing overactive bladder (OAB) symptoms in women.

Methods

Searches were performed at MEDLINE, PubMed, Physiotherapy Evidence Database (PEDro), Scielo, and Central Cochrane Library PubMed until January 2017. Controlled trials were researched by two independent reviewers. Eligible studies were restricted to random and controlled clinical trials that investigated the effectiveness of PFMT in decreasing OAB symptoms. Qualitative methodology was evaluated using the PEDro scale. Data was analyzed and interpreted qualitatively.

Results

The final search retrieved eight studies (n =?1161 women with urgency symptoms), which were published between 2002 and 2016. The methodological scores varied between 4 and 7 in the PEDro scale. PFMT, with the objective of controlling urgent micturition, demonstrated improvements in quality of life in women with OAB. Most data in this revision came from small- to moderate-sized trials, with different and inconsistent outcome measures, which could have impacted the end results.

Conclusions

The literature regarding the effectiveness of PFMT in OAB remains heterogeneous and inconclusive.

     

Basal and stress-activated hypothalamic pituitary adrenal axis function in postmenopausal women with overactive bladder

Introduction and hypothesis

The aim of this study was to measure physiologic and psychologic stress reactivity in women with overactive bladder (OAB). There is growing evidence in preclinical models that central nervous system dysregulation, particularly in response to psychological stress, may contribute to lower urinary tract symptoms in women with OAB.

Methods

Postmenopausal women with OAB and healthy controls underwent Structured Clinical Interview for DSM-IV Axis I disorders (SCID) to identify those without identifiable psychiatric disease. Eligible participants underwent physiologic measures including basal (cortisol-awakening response; CAR) and stress-activated salivary cortisol levels, heart rate (HR), urinary metanephrines and neurotrophins, as well as validated symptom assessment for stress, anxiety, depression, and bladder dysfunction at baseline and during, and following an acute laboratory stressor, the Trier Social Stress Test (TSST).

Results

Baseline measures of cortisol reactivity measured by CAR showed blunted response among women with OAB (p?=?0.015), while cortisol response to the TSST was greater in the OAB group (p?=?0.019). Among OAB patients, bladder urgency as measured by visual analog scale (VAS) increased from pre- to post-TSST (p?=?0.04). There was a main effect of TSST on HR (p?<?0.001), but no group interaction.

Conclusions

Preliminary findings suggest that women with OAB have greater physiologic and psychologic stress reactivity than healthy controls. Importantly for women with OAB, acute stress appears to exacerbate bladder urgency. Evaluation of the markers of stress response may suggest targets for potential diagnostic and therapeutic interventions.

     

What Is the Role of Additional Pharmacotherapy and Neuromodulation in Patients with Marginal Benefit from Botulinum Toxin Injection?

Purpose of Review

Third-line therapies for patients with overactive bladder (OAB) can improve symptoms for those who have failed conservative therapies. Options include percutaneous tibial nerve stimulation (PTNS), cystoscopic injection of onabotulinumtoxinA (BTX-A), and sacral neuromodulation (SNM). This paper aims to review the current literature on the treatment of patients with idiopathic OAB who have undergone BTX-A injections and have not responded or have undesirable side effects from the therapy.

Recent Findings

There are no randomized control trials examining the role of concurrent medical therapy and BTX-A; rather, there are observational studies in the neurogenic population. Furthermore, there are two observational studies on the role of SNM in BTX-A refractory idiopathic OAB patients demonstrating its safety and efficacy.

Summary

There are many options available to the patient who fails BTX-A. Further research in this specific patient population is necessary to determine why patients have suboptimal responses and to delineate the next step in treatment.

     

Development of a core set of outcome measures for OAB treatment

Introduction and hypothesis

Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).

Methods

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.

Results

The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.

Conclusions

The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

     

Micronutrient and Protein Deficiencies After Gastric Bypass and Sleeve Gastrectomy: a 1-year Follow-up

Background

Roux-en-Y gastric bypass (GBP) and sleeve gastrectomy (SG) have increased dramatically, potentially increasing the prevalence of nutritional deficiencies. The aim of this study was to analyze the effects of food restriction during the first year after bariatric surgery (BS) on nutritional parameters.

Methods

Twenty-two and 30 obese patients undergoing GBP and SG were prospectively followed at baseline and 3, 6, and 12 months after BS (N?=?14 and N?=?19 at T12). We evaluated food intake and nutrient adequacy (T0, T3, T12), as well as serum vitamin and mineral concentration (T0, T3, T6, T12).

Results

At baseline, GBP and SG patients had similar clinical characteristics, food intake, nutrient adequacy, and serum concentration. The drastic energy and food reduction led to very low probabilities of adequacy for nutrients similar in both models (T3, T12). Serum analysis demonstrated a continuous decrease in prealbumin during the follow-up, indicating mild protein depletion in 37 and 38 % of GBP patients and 57 and 52 % of SG patients, respectively, at T3 and T12. Conversely, despite the low probabilities of adequacy observed at T3 and T12, systematic multivitamin and mineral supplementation after GBP and SG prevented most nutritional deficiencies.

Conclusions

GBP and SG have comparable effects in terms of energy and food restriction and subsequent risk of micronutrient and protein deficiencies in the first year post BS. Such results advocate for a cautious monitoring of protein intake after GPB and SG and a systematic multivitamin and mineral supplementation in the first year after SG.

     

Urinary retention in female OAB after intravesical Botox injection: who is really at risk?

Introduction and hypothesis

Intravesical onabotulinumtoxinA (Botox) injections are effective for the treatment of idiopathic overactive bladder (OAB) symptoms. The aim of our study was to assess the predisposing factors for urinary retention in women with OAB after intravesical Botox injection.

Methods

All participants were women of European descent with idiopathic OAB. OnabotulinumtoxinA (100 U) was administered in 20 intra-detrusor injections. Analysis was performed based on the results of safety assessments made during follow-up (FU) visits on weeks 2, 4 and 12, in 208 women who were treated with Botox injections for refractory OAB and who completed all FU visits.

Results

Women who required clean intermittent self-catheterisation (CISC) and those with post-void residual (PVR) greater than 200 ml were older in comparison with patients with PVR between 50 and 200 ml. Patients who required CISC were also characterised by higher parity and particularly by a higher number of vaginal deliveries. Other factors such as body mass index or comorbidities did not significantly influence PVR and the risk of CISC.

Conclusions

Elderly and/or multiparous women are at increased risk of urinary retention after intravesical 100-U Botox injections. The risk of new onset urine retention in our study has completely disappeared 2 weeks after Botox injections. Based on our results of the way in which the PVRs have changed over time, we can conclude that OAB patients should be optimally assessed during the first 2 weeks after Botox injections.

     

Outcome of coexistent overactive bladder symptoms in women with urodynamic urinary incontinence following anti-incontinence surgery

Introduction and hypothesis

The objective was to investigate the outcome of stress urinary incontinence (SUI) and overactive bladder (OAB) symptoms in women with urodynamic stress incontinence (USI) after transobturator sling procedures (TOTs).

Methods

We evaluated 109 consecutive patients with USI, who had undergone TOT in a tertiary hospital between 2012 and 2014. All patients received evaluations, including structured urogynecological questionnaires and pelvic organ prolapse quantification examination before, and 3 and 12 months after surgery. One-hour pad test and urodynamic testing were performed before and 3–6 months postoperatively. Patient demographics, lower urinary tract symptoms, and urodynamic results were analyzed between pure USI and USI with OAB symptoms.

Results

Persistent SUI occurred in 8 patients at 3 months (7.3 %) and 7 patients at 12 months (6.4 %) postoperatively. The most common OAB symptom was frequency (54.1 %), followed by urgency urinary incontinence (52.3 %), urinary urgency (42.2 %), and nocturia (33 %). Most of these OAB symptoms were resolved at the 3-month and 12-month follow-ups both in patients treated with TOT only and in those treated with TOT combined with other pelvic surgeries. There was no significant difference in the preoperative urodynamic changes between patients with pure USI and USI without OAB groups. However, postoperative urodynamic results showed a significant decrease in the maximal urethral closure pressure in the group of patients with USI and OAB symptoms, but no significant urodynamic changes in the group with pure USI.

Conclusions

Coexistent OAB symptoms are common in women who were diagnosed with USI and most of these symptoms may resolve 3 and 12 months after TOT.

     

Surgery for non-small cell lung cancer in patients with a history of cardiovascular surgery

Purpose

To clarify if previous cardiovascular surgery (CVS) affects the postoperative outcome of surgery for non-small cell lung cancer (NSCLC).

Methods

We reviewed, retrospectively, the medical records of 36 patients with a history of CVS, who underwent lung cancer surgery at a single institution (study group; SG) and compared their characteristics and postoperative outcomes with those of patients without a history of CVS history (control group; CG), and also with those of patients with coexisting cardiovascular diseases in the CG (specified control group; SCG). Finally, we used a thoracic revised cardiac risk index (ThRCRI) to evaluate the risk of perioperative cardiovascular events.

Results

There was a significant difference in the ThRCRI classifications between the SG and the SCG (p < 0.0001). There were no significant differences in the incidence of intraoperative and postoperative complications between the SG and CG, or between the SG and SCG. The 5-year survival rates of the SG, CG, and SCG were 69.3, 73.9, and 65.4 % in all stages, and 83.5, 82.2, and 70.4 % in stage I, respectively.

Conclusions

Previous CVS did not increase the number of perioperative cardiovascular events in this study and had no significant influence on the prognosis of patients undergoing resection of NSCLC.

     

Pharmacological methods for the preclinical assessment of therapeutics for OAB: an up-to-date review

Introduction

Licenced oral pharmacotherapies for overactive bladder (OAB) act on muscarinic receptors or β₃-adrenoceptors. The search for new drugs to treat OAB that have novel mechanisms of action is very active, with the aim of discovering more effective and/or better tolerated agents.

Methods

A literature review of the most frequently used pharmacological methods for the preclinical assessment of new agents aimed at treating OAB, such as isolated organ technique, electrophysiological techniques, radioligand binding assay, and animal models, was carried out. Novel potential developments based on recent knowledge of urothelial and neural mechanisms are also discussed.

Results

The isolated organ technique, electrophysiological techniques, and the radioligand binding assay are very effective methods for the demonstration that a novel pharmacological target with a specific and high affinity binding site for a new drug is present in the bladder and its modulation regulates functions critical for the pathophysiology of OAB. Afterward, the new drug should be shown to be effective in animal models of OAB, although the translational value of these models is limited by a poor pathophysiological relationship with human OAB. Exciting novel perspectives focusing in particular on the theory of the mucosal–bladder network have recently opened new paths in the discovery and assessment of new therapeutics in this field.

Conclusions

Available experimental models still play a central role in the appraisal of OAB therapeutics; however, their shortcomings and the paucity of very effective drugs indicate the need for new models that better reproduce the pathophysiological features of OAB. Some emerging lines of research show promise. A change of perspective in the future evaluation of putative drugs is required, especially in the light of the latest knowledge on the key role of the mucosal–bladder network and the brain–bladder neural pathways.

     

Effectiveness of botulinum toxin injection in the treatment of de novo OAB symptoms following midurethral sling surgery

Introduction and hypothesis

Intravesical onabotulinumtoxinA (Botox®) is effective for idiopathic overactive bladder (OAB) symptoms. Our primary objective was to compare the efficacy of onabotulinumtoxinA for women with de novo OAB after midurethral sling (MUS) surgery and women with idiopathic OAB.

Methods

Women enrolled in this prospective study had idiopathic (n?=?53) or de novo (n?=?49) OAB symptoms after MUS, with at least one episode of urgency urine incontinence per day. OnabotulinumtoxinA (100 U) was administered in 20 intradetrusor injections. Postvoid residual volumes were checked at 2, 4 and 12 weeks. Participants completed a 3-day bladder diary and the King’s Health Questionnaire (KHQ) before and 12 weeks after treatment.

Results

After 12 weeks, 22 patients (41.5 %) in the idiopathic OAB and 19 patients (38.8 %) in the de novo OAB groups were completely dry. OnabotulinumtoxinA injections had a significant benefit within both groups (p <0.001) to decrease both the daily numbers of voids (?2.39 and ?2.0) and incontinence episodes (?1.38 and ?1.44), with no significant difference between groups. We observed an increase of mean voided volume of >90 ml in both groups. Urinary retention was observed in four patients.

Conclusions

We observed similar improvement in OAB symptoms after intravesical onabotulinumtoxinA injections within both groups. The rates of retention and requirement for catheterization even for women with a prior MUS were acceptable. These observational data provide evidence that onabotulinumtoxinA can effectively treat patients with OAB following stress urinary incontinence surgery.