- Email: [email protected]
Re: Nonantimuscarinic Treatment for Overactive Bladder: A Systematic Review
EURURO-6989; No. of Pages 2 EUROPEAN UROLOGY XXX (2016) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Nonantimuscarinic Treatment for Overactive Bladder: A Systematic Review Olivera CK, Meriwether K, El-Nashar S, et al Am J Obstet Gynecol 2016;215:34–57 Expert’s summary: To determine the efficacy and safety of nonantimuscarinic treatments for women with overactive bladder (OAB), Olivera et al performed a systematic review that included adults (>18 yr of age) with OAB symptoms of urgency, frequency, nocturia, urgency urinary incontinence (UUI), diagnoses of refractory OAB, refractory UUI, and OAB syndrome. They accepted any study (retrospective, prospective, cohort, randomized controlled trials, case series, case control, crosssectional, crossover) in which there were two arms and a number greater than 100 if at least one of the arms was a nonantimuscarinic therapy for OAB. There were 156 articles screened and 99 of these met all criteria for inclusion in the systematic review. The final interventions and comparators were (1) behavioral therapy (including weight loss, fluid management, diet modification, bladder training, and pelvic floor muscle training; (2) alternative medical therapy (most commonly acupuncture); (3) biofeedback; (4) botulinum toxin A formulations; (5) mirabegron; (6) magnetic stimulation; (7) vaginal electrical stimulation; (8) sacral neuromodulation; and (9) posterior tibial nerve therapy. After carefully analyzing the different alternatives, Olivera et al concluded that nonantimuscarinic treatments may be equivalent to or, in some cases, preferable to typical antimuscarinic medications in the treatment of OAB symptoms. Among the nonantimuscarinic treatment alternatives, they suggested the most benefit for OAB patients will probably be from reversible treatments with minimal side effects that are proven to have good efficacy in short time frames, and that this may be best demonstrated by physiotherapy (optimally with biofeedback) and posterior tibial nerve stimulation. Expert’s comments: In the management of OAB, The International Consultation on Incontinence (ICI) recommends supervised bladder training and antimuscarinics as the initial treatment [1]. Currently, b3adrenoceptor agonists (mirabegron) are widely used an alternative to antimuscarinics, with botulinum toxin A reserved for
‘‘refractory’’ OAB. There is now good evidence, as shown by Olivera et al, that other nonantimuscarinic therapies can be effective and may be considered and accepted as initial treatment. Even if current evidence is insufficient to recommend one form of nonantimuscarinic treatment over another, it seems reasonable to consider some of them (besides antimuscarinics and mirabegron) as second-line alternatives (accepting behavioral/physical therapy as first-line treatment). Several randomized trials have demonstrated that posterior tibial nerve stimulation has effects equal to or better than those of antimuscarinics on OAB symptoms, but with minimal side effects [2–4]. Magnetic stimulation and vaginal electrical stimulation may have documented effects, but seem less attractive alternatives. When considering the limitations of antimuscarinics, particularly in an aging OAB population (cognitive disturbances), risks must be carefully weighed against benefits. Optimally, treatment should be individualized after the needs and expectations of the patient have been taken into account. Effective long-term treatment of OAB symptoms remains a problem. It seems that individualized treatment using existing approved second-line alternatives (antimuscarinics, b3-adrenoceptor agonists) and posterior tibial nerve stimulation, and their combinations, may be one way to achieve acceptable patient satisfaction. Conflicts of interest: The author has nothing to disclose.
References [1] Abrams P, Cardozo L, Khoury S, Wein A. editors. Incontinence. ed. 5. International Consultation on Urological Diseases; 2013. www.icud.info/PDFs/INCONTINENCE%202013.pdf. [2] Peters KM, MacDiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol 2009;182:1055–61. [3] Leong FC, McLennan MT, Barr SA, Steele AC. Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: efficacy and time to response. Female Pelvic Med Reconstr Surg 2011;17:74–5. [4] Moossdorff-Steinhauser HF, Berghmans B. Effects of percutaneous tibial nerve stimulation on adult patients with overactive bladder syndrome: a systematic review. Neurourol Urodyn 2013;32: 206–14.
http://dx.doi.org/10.1016/j.eururo.2016.08.034 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
EURURO-6989; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
Karl-Erik Anderssona,b,* a
b
*Corresponding author. Department of Obstetrics and
Institute for Regenerative Medicine, Wake Forest University School of
Gynecology, Institute of Clinical Medicine,
Medicine, Winston Salem, NC, USA
Aarhus University Hospital, Palle Juul-Jensens Boulevard 99,
Department of Obstetrics and Gynecology, Institute of Clinical Medicine,
DK 8200 Aarhus N, Denmark.
Aarhus University, Aarhus, Denmark
E-mail addresses: [email protected], [email protected].
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Nonantimuscarinic Treatment for Overactive Bladder: A Systematic Review Olivera CK, Meriwether K, El-Nashar S, et al Am J Obstet Gynecol 2016;215:34–57 Expert’s summary: To determine the efficacy and safety of nonantimuscarinic treatments for women with overactive bladder (OAB), Olivera et al performed a systematic review that included adults (>18 yr of age) with OAB symptoms of urgency, frequency, nocturia, urgency urinary incontinence (UUI), diagnoses of refractory OAB, refractory UUI, and OAB syndrome. They accepted any study (retrospective, prospective, cohort, randomized controlled trials, case series, case control, crosssectional, crossover) in which there were two arms and a number greater than 100 if at least one of the arms was a nonantimuscarinic therapy for OAB. There were 156 articles screened and 99 of these met all criteria for inclusion in the systematic review. The final interventions and comparators were (1) behavioral therapy (including weight loss, fluid management, diet modification, bladder training, and pelvic floor muscle training; (2) alternative medical therapy (most commonly acupuncture); (3) biofeedback; (4) botulinum toxin A formulations; (5) mirabegron; (6) magnetic stimulation; (7) vaginal electrical stimulation; (8) sacral neuromodulation; and (9) posterior tibial nerve therapy. After carefully analyzing the different alternatives, Olivera et al concluded that nonantimuscarinic treatments may be equivalent to or, in some cases, preferable to typical antimuscarinic medications in the treatment of OAB symptoms. Among the nonantimuscarinic treatment alternatives, they suggested the most benefit for OAB patients will probably be from reversible treatments with minimal side effects that are proven to have good efficacy in short time frames, and that this may be best demonstrated by physiotherapy (optimally with biofeedback) and posterior tibial nerve stimulation. Expert’s comments: In the management of OAB, The International Consultation on Incontinence (ICI) recommends supervised bladder training and antimuscarinics as the initial treatment [1]. Currently, b3adrenoceptor agonists (mirabegron) are widely used an alternative to antimuscarinics, with botulinum toxin A reserved for
‘‘refractory’’ OAB. There is now good evidence, as shown by Olivera et al, that other nonantimuscarinic therapies can be effective and may be considered and accepted as initial treatment. Even if current evidence is insufficient to recommend one form of nonantimuscarinic treatment over another, it seems reasonable to consider some of them (besides antimuscarinics and mirabegron) as second-line alternatives (accepting behavioral/physical therapy as first-line treatment). Several randomized trials have demonstrated that posterior tibial nerve stimulation has effects equal to or better than those of antimuscarinics on OAB symptoms, but with minimal side effects [2–4]. Magnetic stimulation and vaginal electrical stimulation may have documented effects, but seem less attractive alternatives. When considering the limitations of antimuscarinics, particularly in an aging OAB population (cognitive disturbances), risks must be carefully weighed against benefits. Optimally, treatment should be individualized after the needs and expectations of the patient have been taken into account. Effective long-term treatment of OAB symptoms remains a problem. It seems that individualized treatment using existing approved second-line alternatives (antimuscarinics, b3-adrenoceptor agonists) and posterior tibial nerve stimulation, and their combinations, may be one way to achieve acceptable patient satisfaction. Conflicts of interest: The author has nothing to disclose.
References [1] Abrams P, Cardozo L, Khoury S, Wein A. editors. Incontinence. ed. 5. International Consultation on Urological Diseases; 2013. www.icud.info/PDFs/INCONTINENCE%202013.pdf. [2] Peters KM, MacDiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol 2009;182:1055–61. [3] Leong FC, McLennan MT, Barr SA, Steele AC. Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: efficacy and time to response. Female Pelvic Med Reconstr Surg 2011;17:74–5. [4] Moossdorff-Steinhauser HF, Berghmans B. Effects of percutaneous tibial nerve stimulation on adult patients with overactive bladder syndrome: a systematic review. Neurourol Urodyn 2013;32: 206–14.
http://dx.doi.org/10.1016/j.eururo.2016.08.034 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
EURURO-6989; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
Karl-Erik Anderssona,b,* a
b
*Corresponding author. Department of Obstetrics and
Institute for Regenerative Medicine, Wake Forest University School of
Gynecology, Institute of Clinical Medicine,
Medicine, Winston Salem, NC, USA
Aarhus University Hospital, Palle Juul-Jensens Boulevard 99,
Department of Obstetrics and Gynecology, Institute of Clinical Medicine,
DK 8200 Aarhus N, Denmark.
Aarhus University, Aarhus, Denmark
E-mail addresses: [email protected], [email protected].