Objective differences between overactive bladder patients with and without urodynamically proven detrusor overactivity

Introduction and hypothesis  

This paper aims to determine if there are differences between female overactive bladder (OAB) patients with and without urodynamic detrusor overactivity (DO).     

How many uncomplicated male and female overactive bladder patients reveal detrusor overactivity during urodynamic study?

OBJECTIVE: We retrospectively evaluated the incidence of detrusor overactivity (DO) in uncomplicated overactive bladder syndrome (OAB) patients. METHODS: From December 1993 to October 2003, 139 adult patients were referred to an urodynamic clinic for urodynamic evaluation of frequency and/or urinary incontinence. Of these, 50 patients (12 males and 38 females) with urgency, without any overt pathological conditions, were retrospectively evaluated in regard to patient age, storage symptoms, urodynamic parameters, and the presence or absence of DO (DO patients or no DO patients, respectively). RESULTS: The overall incidence of DO was 75% (nine of 12 patients) and 36.8% (14 of 38 patients) in male and female patients, respectively. Two of nine male DO patients and five of 14 female DO patients revealed DO after provocative maneuvers. In male patients, all DO patients were OAB wet. In female patients, 13 of 14 DO patients were OAB wet (92.9%), whereas 17 of 24 no DO patients were also OAB wet (70.8%). Compared with no DO patients, female DO patients revealed statistically significant lower maximum cystometric capacity (P = 0.0139) and lower vesical compliance (P = 0.0002). Although aged 60 years or more was associated with DO in univariate analysis in female patients, any symptoms, even incontinence, were not associated with DO in both sexes. CONCLUSION: It is supposed that, in contrast to male OAB, DO might not be a major underlying cause of uncomplicated female OAB.     

Response to fesoterodine in patients with an overactive bladder and urgency urinary incontinence is independent of the urodynamic finding of detrusor overactivity

Study Type – Therapy (RCT)
Level of Evidence 1b

OBJECTIVE

To determine whether the presence of detrusor overactivity (DO) in patients with overactive bladder (OAB) and urgency urinary incontinence (UUI) is a predictor of the response to treatment with fesoterodine.

PATIENTS AND METHODS

This phase 2 randomized, multicentre, placebo‐controlled trial consisted of a 1‐week placebo run‐in phase followed by an 8‐week double‐blind period. Eligible for the study were men and women aged 18–78 years with symptoms or signs of OAB with UUI; they were stratified into two balanced strata depending on the outcome of a baseline urodynamic assessment. By using this particular study design it was possible to investigate whether there were differences between the strata. The primary endpoint was the change from baseline to week 8 in mean voids/24 h. Secondary endpoints were the changes in UUI episodes/week, and for those patients with DO at baseline, the mean changes in volume at first involuntary contraction associated with a feeling of urgency, first desire to void, and strong desire to void, and change in maximum cystometric capacity. Because there were few patients the secondary analyses were considered exploratory.

RESULTS

Overall, there were linear dose‐response relationships for placebo and the fesoterodine groups for the reduction in the number of voids/24 h and UUI episodes/week. Compared with the placebo group, the least squares mean changes from baseline to week 8 in both variables were significantly improved in patients receiving fesoterodine 4 mg (P = 0.045 and 0.040, respectively), 8 mg (P < 0.001 for both), and 12 mg (P < 0.001 for both). There were no significant differences in treatment responses, as measured by both variables between patients with and without DO. For patients with DO, the mean volume at the first desire to void improved in all fesoterodine treatment groups and worsened in the placebo group.

CONCLUSIONS

Regardless of the presence of DO, the response to fesoterodine treatment was dose‐proportional and associated with significant improvements in OAB symptoms, indicating that the response to OAB pharmacotherapy in patients with UUI was independent of the urodynamic diagnosis of DO.     

Botulinum toxin treatment for overactive bladder and detrusor overactivity in adults

Objectives

To review the evidence in support of botulinum toxin (BoNT-A) for overactive bladder and detrusor overactivity in adults.

Methods

A search of Medline and Pubmed was undertaken using the search terms ‘botulinum toxin’ with ‘overactive bladder’, ‘detrusor overactivity’, ‘randomised trial’ and ‘trial’. A narrative review was undertaken based on the papers identified.

Results

Only four randomised trials reporting the effects of botulinum toxin in this group of patients exist, alongside three systematic reviews and numerous uncontrolled series. Overall, BoNT-A appears an effective treatment modality, with significant and clinically meaningful reductions in urinary symptoms. Urgency and urgency incontinence episodes appear more responsive than absolute frequency. The side effect profile can be predicted from the mode of action of BoNT-A and includes voiding difficulty and urinary tract infection. Few data exist comparing the efficacy and safety of different doses, nor directly comparing the two common preparations, onabotulintum toxin A with apobotulinum toxin A. The cost-effectiveness of BoNT-A remains to be fully evaluated.

Conclusions

BoNT-A is an emerging treatment for overactive bladder and detrusor overactivity. The data available to date are of moderate quality with few large randomised trials. However, the drug appears to be effective and safe, although further work is required to identify the most cost-effective dose and treatment interval for maximum benefit.     

Intravesical botulinum toxin for overactive bladder syndrome without detrusor overactivity

ObjectiveTo report our experience of intravesical botulinum toxin for idiopathic overactive bladder syndrome (OAB) without detrusor overactivity (DOA) on urodynamic assessment.Patients and methodsData regarding presentation, diagnosis, urodynamic findings, date and dose of treatment, and outcomes were recorded prospectively for 94 patients undergoing intravesical botulinum toxin injection for idiopathic overactive bladder syndrome at our institution. The cohort included 19 patients without DOA on urodynamics. A positive response to treatment was defined as patient-reported improvement without the need for further treatment. ICIQ-OAB and UI scores, and bladder diary parameters were also recorded. Rates of urinary retention requiring intermittent or indwelling catheterisation were noted.ResultsThe overall response rate to treatment was 82% (n = 94). Patients without DOA (n = 19) had a response rate of 89%, which compared favourably with a response rate of 81% in patients with DOA (n = 75).Overall, 29% of patients who were voiding normally prior to treatment required intermittent self-catheterisation after the procedure. The requirement for self-catheterisation did not appear to be influenced by urodynamic findings.ConclusionThese preliminary, non-randomised data suggest that intravesical botulinum toxin injection may be efficacious in patients with OAB symptoms without DOA. Further evaluation by means of a randomised, controlled trial is suggested.     

Effect of prolapse repair on voiding and the relationship to overactive bladder and detrusor overactivity

Introduction and hypothesis  The aim of this study was to assess whether prolapse repair affects voiding and whether this results in the resolution of overactive bladder syndrome (OAB). Methods  Forty women with OAB and detrusor overactivity together with anterior wall prolapse who underwent a repair between 2003 and 2007 were studied. Each woman was assessed pre-operatively and post-operatively with a clinical assessment and cystometry. Patients were divided into those who experienced resolution of their OAB symptoms and those with persistent OAB symptoms. Wilcoxon matched pairs signed rank test was used to assess any change in flow rates between these groups. Results  Resolution of OAB was associated with a significant increase (p = 0.049) in the maximum flow rate. Conclusion  Improvement in voiding function may be important in symptom resolution in women with OAB and prolapse. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

The long‐term natural history of overactive bladder symptoms due to idiopathic detrusor overactivity in women

OBJECTIVES

To assess the long‐term natural history of overactive bladder (OAB) symptoms due to idiopathic detrusor overactivity (IDO) in women.

PATIENTS AND METHODS

Original urodynamic traces were reviewed and women who were referred with OAB symptoms and found to have IDO on investigation in our urodynamic unit ≥10 years previously were invited for a repeat urodynamic and symptomatic assessment.

RESULTS

In all, 174 women were identified and invited to participate; 53 had repeat urodynamics, another 32 attended the unit for symptom assessment and a further 23 completed postal questionnaires. There were no significant symptomatic or urodynamic differences between these groups at baseline. Of the 53 who had repeat urodynamics, 46 (88%) had persistent symptomatic IDO.

CONCLUSIONS

OAB symptoms have a significant effect on the quality of life of those affected. OAB symptoms due to IDO in women are persistent, lasting for ≥10 years in 88% of this study population. This information might affect the treatment choices made by patients and their doctors in the management of this condition.     

Participation of the pudendal innervation in the detrusor overactivity of the detrusor and in the overactive bladder syndrome

ObjectivesThe functional symptoms of the filling phase and detrusor overactivity are two inter-related dysfunctions of the lower urinary tract. We have aimed to study the participation of the lesion of the pudendal nerve in both urinary dysfunctions.Material and methodsA cross-sectional cutoff study in a series of 108 women was carried out. The study consisted in the questioning on the presence of functional symptoms of the lower urinary tract, cystomanometry and determination of peripheral pudendal nerve latency time, selective electromyography of the external anal sphincter and determination of the sacral reflex latency time.ResultsA tendency was observed towards significance between the presence of pollakiuria amplitude of motor unit potentials (greater in presence of pollakiuria) and the presence of urgency-incontinence and time of sacral latency (greater in the presence of urge incontinence) and a significant relation between the score on the King's Health Questionnaire and peripheral pudendal nerve latency time. Regarding detrusor hyperactivity, greater sacral latency time was observed in patients with overactivity with tendency towards significance.ConclusionsThere is a relation between pudendal innervation alterations and presence of symptoms in the filling phase and detrusor overactivity. This relation would explain the therapeutic action of the perineal rehabilitation on these dysfunctions.     

终末型逼尿肌过度活跃患者的尿动力学表现

目的探讨终末型逼尿肌过度活跃患者的尿动力学表现。方法回顾性分析73例尿动力学检查证实为逼尿肌过度活跃患者的尿动力学检查结果,男57例,女16例,平均(51±29)岁,包括梗阻性期相型组(OPDO)18例、神经性期相型(NPDO)组17例、梗阻性终末型(OTDO)组23例和神经性终末型(NTDO)组15例。10例因上尿路疾病需要手术治疗而下尿路功能正常患者[男7例,女3例,平均(45±18)岁]为对照组。结果逼尿肌过度活跃各组最大膀胱压测定容量均显著低于对照组(480±120)ml,OTDO组(214±105)ml,显著低于OPDO组(354±146)ml,NTDO组(191±89)ml,显著低于NPDO组(328±155)ml。逼尿肌过度活跃各组膀胱顺应性显著低于对照组(35±19)ml/cmH2O,NTDO组(19±10.8)ml/cmH2O,显著高于NPDO组(12±6.7)ml/cmH2O。排尿前最大逼尿肌压力OTDO组(13±9)cmH2O,显著低于OPDO组(32±19)cmH2O,NTDO组(12±8)cmH2O,显著低于NPDO组(38±19)cmH2O。NTDO组上尿路扩张发生率(1/15)显著低于NPDO(7/17)组。梗阻性和神经性终末型逼尿肌过度活跃患者最大逼尿肌排尿压,最大尿流率时逼尿肌压力与对照组差异无统计学意义,但膀胱多不能完全排空,OTDO组排空效率在70%左右,显著低于NTDO组。结论终末型逼尿肌过度活跃患者膀胱多高度敏感,其无抑制逼尿肌收缩力接近于正常     

A review of detrusor overactivity and the overactive bladder after radical prostate cancer treatment

There are various forms of treatment for prostate cancer. In addition to oncologic outcomes, physicians, and increasingly patients, are focusing on functional and adverse outcomes. Symptoms of overactive bladder (OAB), including urinary frequency, urgency and incontinence, can occur regardless of treatment modality. This article examines the prevalence, pathophysiology and options for treating OAB after radical prostate cancer treatment. OAB seems to be more common and severe after radiation therapy than after surgical therapy and even persisted longer with complications, suggesting an advantage for surgery over radiotherapy. Because OAB that occurs after radical prostate surgery or radiotherapy can be difficult to treat, it is important that patients are made aware of the potential development of OAB during counselling before decisions regarding treatment choice are made. To ensure a successful outcome of both treatments, it is imperative that clinicians and non‐specialists enquire about and document pretreatment urinary symptoms and carefully evaluate post‐treatment symptoms.     

Insight into new potential targets for the treatment of overactive bladder and detrusor overactivity

Although overactive bladder (OAB) and detrusor overactivity (DO) are not synonyms, they share therapeutic options and partially underlying physiopathological mechanisms. The aim of this overview is to give insight into new potential targets for the treatment of OAB and DO. A narrative review was done in order to reach this goal. Ageing, pelvic floor disorders, hypersensitivity disorders, morphologic bladder changes, neurological diseases, local inflammations, infections, tumors and bladder outlet obstruction may alter the normal voluntary control of micturition, leading to OAB and DO. The main aim of pharmacotherapy is to restore normal control of micturition, inhibiting the emerging pathological involuntary reflex mechanism. Therapeutic targets can be found at the levels of the urothelium, detrusor muscles, autonomic and afferent pathways, spinal cord and brain. Increased expression and/or sensitivity of urothelial-sensory molecules that lead to afferent sensitization have been documented as a possible pathogenesis of OAB. Targeting afferent pathways and/or bladder smooth muscles by modulating activity of ligand receptors and ion channels could be effective to suppress OAB.     

Role of botulinum toxin-A in refractory idiopathic overactive bladder patients without detrusor overactivity

Background  

To evaluate the efficacy of intradetrusor botulinum toxin-A (BTX-A) in idiopathic overactive bladder patients (OAB) refractory to anti-muscarinic therapy, without detrusor overactivity (DOA) on urodynamics.     

Transabdominal ultrasonography of detrusor wall thickness in women with overactive bladder

Study Type – Diagnostic (case series)
Level of Evidence 4

OBJECTIVE

To determine the clinical usefulness of measuring detrusor wall thickness (DWT) as a noninvasive test in women with overactive bladder (OAB).

PATIENTS, SUBJECTS AND METHODS

We prospectively enrolled 122 women with dry OAB, wet OAB, and women with no OAB symptoms (control group). A 3‐day voiding diary was used to differentiate between wet and dry OAB. Transabdominal ultrasonography (TAUS) measurements of DWT were taken at bladder volumes of 250–300 mL and the maximal bladder capacity by both catheter‐ and natural‐filling. Video‐urodynamic studies (VUDS) were used to classify bladder dysfunction in 88 of the women.

RESULTS

The mean (range) age of the women was 58 (20–94) years. There were 39 ‘normal’ controls, 44 women had dry OAB, and 39 had wet OAB. Of the 88 women who had VUDS, 28 had a ‘normal’ test, 30 had increased bladder sensation (IBS), and 30 had detrusor overactivity (DO). The mean DWT at 250–300 mL among three symptomatic subgroups or urodynamic subgroups showed no significant difference by either catheter‐ or natural‐filling methods. The women with wet OAB had significantly greater DWTs than the controls at maximal bladder volume. The maximal bladder capacity was significantly greater in ‘normal’ women than in those with OAB. If we corrected maximal bladder volume to 250 mL, DWT at corrected 250 mL showed no significant difference among three symptomatic subgroups.

CONCLUSIONS

DWT measured by TAUS in women with OAB and without OAB was not different and did not differ with urodynamic status. Thus, TAUS measurement of DWT is not recommended as a useful diagnostic test for DO in women with OAB.     

The natural history of the overactive bladder and detrusor overactivity. A review of the evidence regarding the long-term outcome of the overactive bladder

PURPOSE: The overactive bladder is a widespread medical condition with significant impact on quality of life. We review the existing evidence about the prevalence, impact and long-term followup of the overactive bladder. We also summarize the new International Continence Society terminology associated with the overactive bladder. MATERIALS AND METHODS: A MEDLINE search of all available literature regarding the epidemiology and long-term followup or outcome of the overactive bladder was performed. All articles and relevant resources cited in those articles were reviewed. RESULTS: The new International Continence Society terminology and definitions will allow greater consistency in future research. Two large, recently published surveys of the prevalence of overactive bladder give new insight into the widespread nature of the problem and its significant impact on quality of life. There is little good quality evidence currently available on the long-term outcome of overactive bladder. CONCLUSIONS: There is little published evidence regarding the natural history of overactive bladder. While recent studies have improved understanding the prevalence of the condition, we still know little about long-term outcome. The few published studies suggest that it is a chronic condition that persists urodynamically and symptomatically.     

OnabotulinumtoxinA improves urodynamic outcomes in patients with neurogenic detrusor overactivity

Aims

To evaluate the effect of onabotulinumtoxinA on urodynamic outcomes in patients with urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO).

Methods

Results from two pivotal Phase III trials (n = 691) were pooled. MS or SCI patients with NDO, received intradetrusor onabotulinumtoxinA 200 U (n = 227), 300 U (n = 223), or placebo (n = 241). Change from baseline in UI episodes/week (Week 6), maximum cystometric capacity (MCC), maximum detrusor pressure at first involuntary detrusor contraction (IDC) (P_detmaxIDC), volume at first IDC (V_pmaxIDC), and detrusor compliance (DC) were measured.

Results

OnabotulinumtoxinA significantly increased MCC overall (+153.6 ml with 200 U vs. +11.9 ml with placebo). Over 60% of onabotulinumtoxinA‐treated patients had no IDC at Week 6; in patients with an IDC at Week 6, V_pmaxIDC improved (+183.4 ml with 200 U vs. +17.5 ml with placebo), and P_detmaxIDC decreased (?32.4 cmH₂O with 200 U vs. +1.1 cmH₂O with placebo). OnabotulinumtoxinA‐treated patients had a significant increase in DC (+59.8 ml/cmH₂O with 200 U vs. ?5.2 with placebo). Urodynamic improvements were comparable in patients regardless of baseline DC and corresponded with significant reductions in UI episodes/week for both onabotulinumtoxinA doses versus placebo, with no clinically relevant differences between 200 and 300 U groups. Most common adverse event was urinary tract infection (UTI); complicated UTIs were low across all treatment groups. In patients not catheterizing at baseline, a dose‐dependent increase in post‐void residual urine was observed at Week 2 following onabotulinumtoxinA treatment.

Conclusions

OnabotulinumtoxinA significantly improved urodynamic outcomes in NDO patients, even in those with low baseline DC, and corresponded with improvements in UI episodes. Both doses of onabotulinumtoxinA were well tolerated. Neurourol. Urodynam. 32:1109–1115, 2013. © 2013 Wiley Periodicals, Inc.