FYI

BERKELEY, CA (Urotoday.com) - Overactive bladder (OAB) is a highly prevalent condition with enormous related costs per year. Several antimuscarinic drugs are on the market, with some drugs such as oxybutynin, tolterodine, propiverine, or trospium available both in immediate-release (IR) and extended-release (ER) formulations. Moreover, oxybutynin is available also as sustained-delivery patch for transdermal administration.

The selection of the most appropriate one for every single patient might be quite a complex task. The choice of the first drug to be used, the selection of the most appropriate dosage, formulations and route of administration, the criteria for selection of a second anticholinergic drug in case of insufficient efficacy or intolerable adverse events, and, finally, costs are some of the most important issues that should be evaluated.

A systematic review of the literature was performed in August 2007 using Medline, Embase, and Web of Science. Efficacy (micturitions/24 Hrs, volume voided per micturition, urgency urinary incontinence episodes/24 hrs, incontinence episodes/24 Hrs.) and safety (mainly, adverse event, and withdrawal rates) end-points were evaluated in the RCTs assessing the role of anticholinergic drugs in non-neurogenic OAB.

The data of our systematic review and meta-analysis showed that tolterodine IR had a more favorable profile of adverse events than oxybutynin IR, while the controlled-release formulations of the 2 drugs had similar efficacy and safety. In all the comparisons among IR and ER formulations, ER formulations showed some kind of advantages, either in terms of efficacy or safety. With regards to solifenacin, a single RCT demonstrated the non-inferiority of solifenacin compared to tolterodine ER, while our meta-analysis showed similar rates of adverse events, with the exception of constipation that was more common in the solifenacin arm. A single trial is currently available on fesoterodine, suggesting that the new drug might be more efficacious than tolterodine ER. With regards to the routes of administration, a transdermal route did not seem to provide any significant advantage compared to oral intake, considering higher rate of localized application side effects and withdrawal due to adverse events.

The overall quality of the randomized controlled trials available in the field of overactive bladder was good. However, almost all the trials evaluated short-term therapy (mostly 12 weeks). Moreover, almost all the studies provided efficacy data derived from bladder diaries. A more suitable evaluation should also include subjective outcomes - such as the so-called patient-reported outcomes - lacking in most of the studies. Besides, virtually all the evidence derived from pharmaceutical company-sponsored trials reflected the needs of the companies for registrational studies - rather than addressing the questions more relevant to the clinical practice.

Considering these limitations, providing clear recommendations for the every-day clinical practice was not easy. With regard to the selection of the first drug to use in naïve patients, the physician might prescribe oxybutynin ER, tolterodine ER 4 mg or solifenacin 5/10 mg. Similarly, darifenacin 15 mg and fesoterodine 4 mg might be considered as valuable options, although further evaluation is needed and RCTs are ongoing. In case of insufficient clinical efficacy, the choice of the second-line drug therapy really cannot be based on solid pieces of evidence due to the lack of randomized trials. Making assumptions from the available data, in case of lack of efficacy of the first-line ER drug, fesoterodine 8 mg and solifenacin 10 mg might be a possible option, although an increased rate of adverse events has to be expected. In case of failure of the first line ER drug due to adverse events such as dry mouth, the transdermal formulation might provide some advantages compared to the oral one. Should the patient experience constipation, shifting from solifenacin to tolterodine ER might be useful. Alternatively, those patients taking IR formulations of anticholinergic drugs, without successful results, might be offered dose titration - providing the patients have not experienced significantly adverse events. Ultimately, ER formulations might be the preferred choice.

Written by:
Giacomo Novara, MD, FEBU, as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc… of their research by referencing the published abstract.

This article was found at 000health.com. It is as relevant today as it was when it was written.

One of the largest-ever studies into urinary incontinence in women has found a very high prevalence - even in young women, and even in those who’ve never had a baby - and that adolescent bedwetting might be an important and neglected factor.

The University of Newcastle in New South Wales has been following the health of 42,000 women, and one of the things they asked about was whether they had any problems holding their water.

The two main problems are stress incontinence, which affects younger women more. This is trouble with leakage when laughing, coughing or taking exercise.

The other problem, especially in older women, is urge incontinence - which is an intense desire to pass water and trouble holding on.

Line up 100 adult women and around 35 of them will have a problem.

The risk factors are: increased weight - every kilo adds more pressure to the bladder; child bearing - the first and fourth children are the ones which cause the problem; and adolescent bedwetting. One of the reasons for high rates among young women is the under-recognised issue of unresolved bedwetting which goes on into adolescence and even early adulthood. It’s hidden and neglected.

The cost of incontinence is considerable to these women - hundreds of dollars a year, excluding the expense of treatments.

Teaching better bladder control and pelvic floor exercises to young women is thought to be part of the answer, and the Newcastle researchers have had some success with a more time-convenient regimen than is normally used.

Found at Medical News Today

UroToday.com - Any urologist dealing with incontinence in the female patient must deal with pelvic organ prolapse. At a minimum the urologist must evaluate the patient for prolapse and make an appropriate referral to either another urologist or a gynecologist for management. Other degrees of involvement range from evaluation and complete treatment to evaluation and treatment of complications following prolapse surgery.

The role of the evaluation is to diagnose the extent of the problem and to implement management. During the history symptoms pertaining to prolapse should be sought. An assessment of bother should be elicited and a discussion should be had as to the treatment expectations. A variety of condition specific questionnaires are available to aid in quantifying symptoms and to assess quality of life and bother. A pelvic exam is performed to assess the health of the vaginal mucosa and to assess and grade any prolapse. A stress test is performed to assess for stress incontinence. The muscular integrity of the pelvic floor and the external anal sphincter should also be assessed. A post void residual is checked. Further evaluation with imaging and or urodynamics is performed on a case by case basis. Once the diagnosis of prolapse is made then a decision regarding treatment should be made. Conservative treatment with pelvic muscle exercises or a pessary may suffice. If surgical treatment is to performed the approach should be based on the patient’s problems and her expectations for recovery and durability.

The most common complications of prolapse surgery that the urologist will deal with are; persistent or de novo incontinence, new onset of recurrent infections, hematuria, pain and obstruction. Incontinence should be worked up with a history and physical and urodynamics. If there is any concern for foreign material in the bladder or urethra a cystoscopy should be performed. Cystoscopy should also be performed in the case of persistent infections or hematuria. Urodynamics may be helpful to diagnose obstruction but it is reasonable to take down a sling or anterior repair without urodynamic proof of obstruction if there is a clear temporal relationship between the surgery and the onset of obstruction.

Mesh used in prolapse repairs should be removed in the case of pain, infection or misplacement. Mesh in the bladder can be removed endoscopically, laparoscopically or with an open technique. Mesh extrusion can be treated with partial removal and flap closure over the defect. When recurrent incontinence or prolapse occurs following a mesh repair one can consider placing additional mesh but if one procedure has failed it is reasonable to consider a different approach on a second repair. In summary the urologist who deals with incontinence must evaluate the patient for prolapse and treat or refer those patients who need surgical treatment. Urologists will also be asked to evaluate patients with complications following prolapse surgery as many of these patients may require a cystoscopy and or urodynamic testing. Treatment of complications following prolapse surgery will depend on the nature of the complication.

Presented by: E. Ann Gormley, MD, FACS, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.

To access the latest urology news releases from UroToday, go to: www.urotoday.com

Copyright © 2008 - UroToday

Found at WAOW TV9

by Pam Warnke

WESTON (WAOW) – While most Mothers are happy to discuss what’s new and first in their babies lives, something you probably won’t hear them talk much about is urinary incontinence.

For many, the stigma attached with the condition is something they’d rather keep quiet.

“It is a common problem for women,” says Christine Block a physical therapist with Marshfield Clinic.

But it’s not something they have live with, although keeping quiet often puts them in that situation.

Block says, “They need to talk to their OBGYN or talk to their doctor about that because there’s conservative treatments such as phyical therapy.”

As a physical therapist, Block treats patients suffering from U.I.  She’s also a new Mom.

She suggests you see your doctor who can help prescribe treatment for the problem, often times leading patients to physical therapy.

Block says, “We go through an evaluation and we look at their pelvic floor muscle strength.  We also look at the spine and their pelvis to see how things are moving because all of that can be affected by pregnancy as the ligments loosen up and stretch for the baby.”

Those loosened ligaments can lead to the inability to hold urine in the bladder following childbirth.

Strengthening the muscles with isolated exercise can help.

She says, “A lot of people will use their butt muscles or their leg muscles instead of using the pelvic floor muscles, and if you’re doing a kegel exercise correctly, you should be able to stop your urine flow when you go to the bathroom and that’s a good test of being able to do them properly.”

If this conservative option doesn’t work, there are other options.

Talk with your doctor to find out how to get back into a life with out urinary incontinence.

“Women don’t have to live with that, and I think that’s the most important thing people need to know,” says Block.

Found at UroToday.com

UroToday.com - The incontinent patient is evaluated in order to make a presumptive diagnosis so that treatment can be offered. The evaluation begins with a history and a physical examination. The history focuses on the description of the patient’s incontinence.

Although the history may define the patient’s problem it may be misleading. Urge incontinence may be triggered by activities such as coughing so that by history the patient would seem to have stress incontinence. A patient who only complains of urge may also have stress incontinence. Mixed incontinence is very common with at least 65% of patients with stress incontinence having associated urgency or urge incontinence. It may be impossible to determine by history alone which is the more significant problem. Assessing the patient’s bother and determining their expectations of treatment may further guide how aggressive one needs to be both with the evaluation and the presentation of treatment options.

The important parts of the physical exam are an examination of the abdomen and pelvis including a provocative stress test. If the test is done supine and there is no leakage it should be repeated standing, as this will increase the patient’s abdominal pressure. A urinalysis and a post-void residual (PVR) should be performed in all incontinent patients.

Incontinence questionnaires, voiding diaries, and pad weight tests can provide more objective data than the history alone. Upper tract imaging is indicated in the patient with a history of hematuria and in patients with suspected hydroureteronephrosis. Other imaging may be useful to further evaluate other suspected pelvic pathology. Urodynamics are performed to determine if the incontinence is due to bladder or urethral dysfunction or both, to assess if the patient has a storage or emptying problem and lastly in an effort to identify patients whose upper tracts are at risk due to high bladder storage pressures.

The most common abnormality of bladder function is detrusor over activity that causes urge incontinence. Detrusor over activity is defined as the inability to suppress involuntary detrusor contractions during filling.1 A cystometrogram may fail to demonstrate any detrusor over activity in a patient who has urge incontinence by history. Any patients with symptoms of urge incontinence by history should be presumed to have urge incontinence. The purpose of urodynamics is not to diagnose detrusor over activity but to examine compliance, to diagnose stress incontinence, to rule out obstruction as a cause of either overflow or urge incontinence and to insure that the patient has a reasonable, safe, bladder capacity.

The diagnosis of stress incontinence is best made with measurement of the abdominal pressure required to induce urinary loss, the Valsalva or abdominal leak point pressure and, or fluoroscopy. Stress incontinence is diagnosed if there is urethral loss of urine associated with an elevation of abdominal pressure. Valsalva leak point pressure (VLPP) is used to diagnose stress incontinence since it is abdominal pressure that is the expulsive force in stress incontinence. Measurement of the VLPP allows for quantification of the degree of urethral dysfunction. A normal urethra will not leak at any pressure. A mobile urethra will leak at high abdominal pressures (>120 cm H2O) and a poorly functioning intrinsic sphincter will leak at low pressures (<60 cm H2O).2 The majority of patients with a ALPP of <90 cm H2O have intrinsic sphincter dysfunction.

A pressure flow test is indicated in the patient in whom obstruction is suspected. Such patients would include the patient who has had a prior procedure for stress incontinence, the patient with a large post void residual or the patient with significant prolapse and obstructive or irritative symptoms. No universally accepted definition of bladder outlet obstruction in women exists. Usually bladder outlet obstruction is defined as high pressure-low flow. However since some women normally void with very low detrusor pressures it is difficult to define a high detrusor pressure in women. In patients with emptying problems or suspected neurogenic dysfunction an EMG may be indicated. Cystoscopy is indicated in the work up of some incontinent patients.

The evaluation of the incontinent patient consists of a history, a physical, urinalysis and a postvoid residual. Optional evaluative tests consist of a variety of urodynamic tests, imaging studies and cystoscopy.
References:
1. International Continence Society Committee on Standardization of Terminology of lower urinary tract function. Neurourol. Urodyn., 7; 1988, 403.
2. McGuire, E.J., Fitzpatrick, C.C., Wan, I., Bloom, D., Sanvordenker, J., Ritchey M., and Gormley, E.A., J Urol, Clinical assessment of urethral sphincter function. 150: 1993, 1452.

Presented by: E. Ann Gormley, MD, FACS, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.

To access the latest urology news releases from UroToday, go to: www.urotoday.com

Copyright © 2008 - UroToday

Found at Woman Reproduction Health

Author Paul Rodgers

Incontinence is much more common in women than in men. It is more common among women in younger ages while among men it was more common in those aged 60 years and above. Among men, the sharpest increase occurred at age 60-69 years while among women the increase was more steady.

Women are most likely to develop incontinence during pregnancy, childbirth or after hormonal changes that occur with menopause. Women living with incontinence often find themselves scouting out the nearest restroom for fear of having an accident in public or avoiding social engagements because they feel anxiety about odor or appearance problems, even with a protective under garment.

Women who change sexual partners or begin having sexual intercourse more frequently may experience bladder or urinary tract infections more often than women in monogamous relationships. Women who perform high-impact exercise are susceptible to urinary leakage, particularly those with a low foot arch, which, on impact, increases the shock to the pelvic area.

In most instances, bladder symptoms can be controlled successfully using strategies that include appropriate medication, management techniques, and self-help. A bladder management program allows you to empty your bladder in an acceptable manner when it it is convenient for you. Only you and you doctor can decide which bladder management program works best for you. If you drink the recommended amounts of fluid and use ICP for your bladder management, you should empty your bladder at least every 3 to 4 hours during the times you are awake. The goals of bladder management are: To preserve normal urinary tract function and prevent potentially dangerous complications.

Cancers confined to the inner lining of the bladder are called “superficial” and comprise 80% of all bladder cancers. Cancers that have spread into the bladder wall are called “deep” bladder cancers and those that have spread to lymph nodes and/or distantly to lungs, liver or other organs are referred to as “metastatic. The grade of the cancer is probably the single most important predictor of prognosis for superficial bladder cancers. While the exact causes of all bladder cancers are unknown, certain exposures are strongly linked to its development–certainly smoking has been found to be a significant risk factor, as well as exposure to asbestos. Unfortunately, most bladder cancers are not diagnosed until they have become very large.

Invasive cancers can spread through the bladder wall into nearby organs such as the prostate gland in men, the vagina in women, the bowel, or lymph nodes. Bladder cancer is more common among men than women and more common among whites than blacks. In women, the cancer may have spread to the womb, ovaries, and other parts of the reproductive system. For example, women who have been treated with radiotherapy for uterine or ovarian cancer have a higher risk of developing bladder cancer than women who just have surgery. In men, because the bladder is located near the prostate, the doctor will insert a finger in the male’s rectum to feel the bladder, while in women, the examination is performed through the vagina because the bladder is located in the womb.

However, bladder cancer is overall considered one of the more surviveable cancers, with more than half of both men and women alive five years after diagnosis.

Found at WebMD

You don’t have to just live with incontinence — simple changes like these 13 tips can help you take control.

Like it or not, urinary incontinence is a fact of life for many people. It can happen as we get older, and for women during pregnancy or after birth, even as the result of a persistent cough. What can you do to take control?

For answers, WebMD went to the American Urological Association and Craig Comiter, MD, associate professor of urology at Stanford University School of Medicine. Here are their tips on how to take matters into your own hands — and make living with urinary incontinence a lot easier.

Which Type of Urinary Incontinence Do You Have?

Urinary incontinence (UI) is the involuntary loss of urine and “it’s a common condition” in men and women of all ages, says the American Urological Association. The two main types of urinary incontinence are:

• Stress incontinence, which can cause leakage when you cough, sneeze, exercise, laugh, or strain to lift something heavy.
• Urge incontinence, which is an unexpected, sudden urge to urinate, one that’s so strong it can be hard to reach the bathroom in time.

No matter which type of urinary incontinence you have, simple behavioral tips can help you deal day to day.

8 Quick Tips for Coping With Urinary Incontinence

1. Do Kegel Exercises. An important urinary incontinence treatment, Kegels are especially effective for women with mild symptoms, says Comiter. “I would advocate Kegel exercises as the most commonly used initial treatment.”

Kegels are simple to do: Simply clench and unclench your pelvic floor muscles. Which muscles are those? Next time you pee, stop the stream of urine midway. Presto! You’ve just found your pelvic floor muscles and done your first Kegel.

But don’t make a habit of stopping your urine when you pee, as it can actually weaken muscles. Do Kegels anywhere and everywhere else, though: while online, on hold, or in the car. Start by clenching your pelvic floor muscles for three seconds, then release for three. Repeat ten times. As you develop strength over time, aim to hold the muscles for ten seconds and release for ten.

2. Stick to a Pee Schedule. Don’t feel like you need to go? Head to the bathroom anyway. Why? Timed urination helps keep the bladder empty, Comiter tells WebMD, and “empty bladders cannot leak.” It might take a little time to discern the schedule that’s best for you, but Comiter recommends starting with a timed urination every one to two hours.

3. Fill the Void. And don’t be in a hurry when you’re in the bathroom. Take your time in there and after you’ve finished urinating, relax a bit and then urinate again — this practice, called double voiding, helps really empty the bladder.

4. Keep the Path Clear. Having accidents before you make it to the bathroom? It’s time to clear your path of obstacles so you can get there faster. And then help yourself once you’re there by wearing easy-to-release clothes — think elastic waistbands and Velcro closures.

5. Cool It on the Caffeine. As much as you may love your java, or crave a cola come 3 p.m., you’re doing yourself no favor by drinking caffeine-rich beverages like coffee, tea, and carbonated drinks. To help control urinary incontinence, eliminate these diuretics — or at least cut back.

6. Drink Up — But Not Too Much. Your body needs fluids, so be sure to drink enough to stay well hydrated. Drink about two quarts (eight cups) to keep your bladder and kidneys healthy.

7. Watch for Medication Side Effects. Talk with your physician to make sure you’re not taking any prescription or over-the-counter drugs that could be making your urinary incontinence worse. If you are — and need those medicines — Comiter suggests you “stay close to home (near a bathroom) for a few hours after taking a diuretic” drug.

8. The Tampon Tip. Women can try wearing a tampon to help control leaks when they jog, run, dance or do other energetic activities. The tampon puts a bit of pressure on your urethra, helping to prevent leakage.

5 Long-Term Tips for Coping With Urinary Incontinence

Managing urinary incontinence is a long-term issue for most people. Be sure you’re doing all you can to make things easier. Some long-term tips include:

1. Talk to Your Doctor. Don’t be shy! Get your physician or urologist on your side. Your doctor can help you find the best treatment for your urinary incontinence.

2. Change Your Diet. A cup of coffee and juice in the morning, a soda with lunch, a few beers or glasses of wine with dinner — it can really add up. Fluid management can be critical in controlling urinary incontinence long term. But you’re body does need fluids. Before making big changes, talk to your doctor.

3. Lose Weight. Weight loss hasn’t definitively been shown to help UI, Comiter tells WebMD, just as being overweight hasn’t been shown to cause incontinence. “However, obesity can lead to diabetes, which can lead to urinary incontinence.”

4. Quit Smoking. While obviously a health hazard, smoking isn’t a strong risk factor for urinary incontinence, Comiter says. But if smoking is causing you to cough, this could be exacerbating your leakage. Chalk this one up as another reason to quit.

5. Medication and Surgery. Both stress incontinence and urge incontinence can be treated with medication, though behavioral therapies like the tips above are often more effective. Surgery is mainly an option for stress incontinence though — as with medication — it may not be the most effective initial treatment for UI. Talk with your doctor to learn more about these options.

All of these tips can help you cope with urinary incontinence, though for day-to-day management Comiter says two of the best tips are also the simplest: Kegel exercises and time urination.

“They are inexpensive, risk free, and if they work in the short term, [they] should work in the long term — especially in patients with mild symptoms.”

Found at A Place for Mom’s Family

Urinary incontinence can be an inconvenient and embarrassing problem that may lead to social isolation and loss of independence. And, while it is common among older adults, urinary incontinence is not a natural part of aging. Surgical and non-surgical treatments as well as behavioral techniques are available to treat urinary incontinence.

Dr. Felicia Lane, urogynecologist with UC Irvine Medical Center and Assistant Professor in the UC Irvine Healthcare Division of Urogynecology will discuss urinary incontinence, and answer questions about the causes, prevention and treatment of urinary incontinence.

When: Friday, August 22, 1:00 p.m. Where: Oasis Senior Center 800 Marguerite Ave. Corona del Mar No reservations are required. For information about other free community health education lectures for seniors, please visit our Website at www.ucihealth.com and click on the Community Events link located in the middle of the page or call Barbara at 714.456.5933.

While urge incontinence, or “overactive bladder,” is commonly treated with pharmacotherapy and behavior modification, most patients do not achieve complete continence with either therapy alone.

In a trial, 307 women with urge incontinence were randomly assigned to 10 weeks drug therapy plus behavioral training or drug therapy alone.

Six months later, 41 percent of women in both groups reported a 70 percent or greater reduction in the frequency of incontinence episodes without additional treatment.

However, more women in the combination therapy group reported that they were completely satisfied with their progress than did women in the drug therapy-alone group.

According to the authors, the study results suggested that patient satisfaction may be influenced by other features such as volume of urine loss, frequency of voiding, or intensity of the urge sensation.

Annals of Internal Medicine is one of the five most widely cited peer-reviewed medical journals in the world. The journal has been published for 81 years and accepts only 7 percent of the original research studies submitted for publication. Annals of Internal Medicine is published by the American College of Physicians (ACP), the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 126,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection, and treatment of illness in adults.