Management of the Overactive Bladder: Treatment of Refractory Cases

Educational Objectives

The goal of this program is to improve diagnosis and management of overactive bladder (OAB). After hearing and assimilating this program, the clinician will be better able to:

1. Integrate posterior tibial nerve stimulation into an office practice.

2. Implant a sacral neuromodulation unit.

Summary

Definition: patient refractory if behavioral treatment, PFE, and anticholinergics failed or not tolerated by patient

Algorithm: after history, examination, and diary, treat everyone with behavioral therapy (BT); most achieve partial results; BT easy and inexpensive with no side effects; BT includes fluid modification and timed voiding but not PFE; if BT not effective, treat with PFE, anticholinergics, or both; anticholinergics — if no response in 1 mo, increase dose, try second anticholinergic, or use imipramine (Tofranil, Surmontil) off-label; imipramine has synergistic effect with anticholinergics, but avoid in elderly and patients with arrhythmias; if ineffective, use percutaneous tibial nerve stimulation (PTNS); may consider PTNS as first-line treatment; if ineffective, use sacral neuromodulation or onabotulinumtoxinA (off-label in idiopathic OAB); finally, consider experimental protocol or bladder augmentation; if two anticholinergics fail, response to third unlikely

Neuromodulation: alters physiologic neural pathways; electrode connected to pulse generator inhibits or stimulates neural impulses; precise mechanism of action unknown; electrical stimulation may interfere with abnormal afferent messages from lining of bladder and pelvic floor and allow normal bladder function to return

Tibial neuromodulation: place small needle near tibial nerve; patient should feel stimulation, not pain; tibial nerve branches and has inputs into sacral nerves responsible for bladder function; treat for 30 min weekly for 12 wk or twice weekly for 6 wk; effective within 5 to 6 wk; treat monthly or when symptoms return; in 220-patient study, moderate or marked improvement shown in 55% of PTNS group and 21% of sham group

Sacral neuromodulation: stimulates S3; place lead with fluoroscopy; may place in office for first week with external stimulator, then implant; alternatively, use staged trial; place permanent lead in operating room, and add stimulator 2 to 3 wk later; preoperative urodynamics not required; placement — on lateral film, hump often visible at foramen of S3; place needle and assess S3 responses; should see bellowing of buttocks and quivering of large toe; if patient awake, ask what he or she feels; women feel stimulation in anus, rectum, or vagina, and men in penis, scrotum, or rectum; if needle misplaced at S2, entire leg moves; if needle at S4, only bellowing of buttocks seen; use patient response plus fluoroscopy to locate S3; proper placement optimizes battery life; trials — 70% of patients had good response out to 5 yr; although not approved for treating neurologic disease, several studies support such use; 90% of patients who initially respond do well; disadvantages — effect may diminish with progression of neurologic disease; manufacturer states magnetic resonance imaging (MRI) contraindicated; successful use of MRI reported if unit turned off, but wire could vibrate during MRI and damage nerve

OnabotulinumtoxinA: blocks release of acetylcholine (ACh) from nerve endings; may work on motor pathways by partially paralyzing muscle and also on sensory pathways; in contrast to anticholinergics, which block receptors on detrusor muscle, toxin prevents ACh-containing vesicles from binding with nerve cell membrane and releasing ACh; technique for women — after instillation of intravesical lidocaine, inject small amounts of toxin throughout bladder via cystoscopy in office; patients with neurogenic disease show improved QOL and fewer episodes of UI; median duration of response 9 mo; recent study randomized patients with idiopathic OAB to placebo vs 50, 100, or 150 U of toxin; lower doses used for OAB than for patients with neurogenic disease; success rates similar with 100 and 150 U doses; postvoid residual and incidence of retention higher in patients receiving 150 U than 100 U; patients receiving toxin should understand possibility of temporary need for intermittent catheterization

Bladder augmentation: cut bladder in half and sew ileal patch over top of bladder; prevents abnormal contractions and increases volume of bladder; popularity of operation decreasing with availability of neuromodulation and onabotulinumtoxinA; most patients need intermittent catheterization after augmentation

Readings

Anger JT et al: Outcomes of intravesical botulinum toxin for idiopathic overactive bladder symptoms: a systematic review of the literature. J Urol. 2010;183(6):2258-64; Blaivas JG et al: The urgency perception score: validation and test-retest. J Urol. 2007;177(1):199-202; Blaivas JG et al: Two types of urgency. Neurourol Urodyn. 2009;28(3):188-90; Blaivas JG et al: Validation of the overactive bladder symptom score. J Urol. 2007;178(2):543-7; discussion 547; Blaivas JG et al: The urgency perception score: validation and test-retest. J Urol. 2007;177(1):199-202; Coyne KS et al: Defining urinary urgency: patient descriptions of “gotta go”. Neurourol Urodyn. 2012;31(4):455-9; Duthie JB et al: Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database Syst Rev. 2011;(12):CD005493; Ellsworth P: Treatment of overactive bladder symptoms beyond antimuscarinics: current and future therapies. Postgrad Med. 2012;124(3):16-27; Irwin DE et al: Understanding the elements of overactive bladder: questions raised by the EPIC study. BJU Int. 2008;101(11):1381-7; Irwin DE et al: Prevalence, severity, and symptom bother of lower urinary tract symptoms among men in the EPIC study: impact of overactive bladder. Eur Urol. 2009;56(1):14-20; Leong RK et al: Current information on sacral neuromodulation and botulinum toxin treatment for refractory idiopathic overactive bladder syndrome: a review. Urol Int. 2010;84(3):245-53; Marinkovic CM et al: The management of overactive bladder syndrome. BMJ. 2012;344:e2365; Novara G et al: A systematic review and meta-analysis of randomized controlled trials with antimuscarinic drugs for overactive bladder. Eur Urol. 2008;54(4):740-63; Vasavada SP et al: Neuromodulation techniques: a comparison of available and new therapies. Curr Urol Rep. 2007;8(6):455-60

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this issue, the following has been disclosed: Dr. Goldman is a consultant and advisor to Allergan, American Medical Systems (AMS), Johnson & Johnson, Pfizer, and T-DOC Company, is on the speakers’ bureau for Allergan, Astellas Pharma US, Johnson & Johnson, and Pfizer. The planning committee reported nothing to disclose. In his lecture, Dr. Goldman presents information related to off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Goldman spoke at Female Urology and Urogynecology Symposium, sponsored by OBG Management, TTMed Urology, and The Christ Hospital and held March 22-24, 2012, in Las Vegas, NV. To learn about upcoming urology courses sponsored by OBG Management, go to www.obgmanagement.com. To learn about upcoming urology courses sponsored by TTMed, go to www.ttmed.com/urology. To learn about upcoming courses sponsored by The Christ Hospital, go to thechristhospital.com/cme. The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this issue.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR360304

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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