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OAB research in focus

US research finds that female patients on psychiatric medication report more severe OAB symptoms

Women with psychiatric disorders who are on antidepressants and anxiolytics report stronger overactive (OAB) symptoms, yet have less detrusor overactivity (DO), according to new research presented at the American Urological Association’s 2016 Annual Meeting earlier this year. 

US investigators compared OAB symptom severity between 218 women with and without psychiatric conditions. The women were clinically diagnosed with OAB and/or urge urinary incontinence, but none were receiving OAB treatment. 

The women evaluated their OAB symptom severity using several disease-specific questionnaires: the Urogenital Distress Inventory (UDI-6) short form, urinary Pelvic Floor Impact Questionnaire (PFIQ), and Incontinence Severity Index (ISI). During urodynamic evaluation (UDE), healthcare workers recorded the number, amplitude, and length of detrusor contractions and urinary leakage. 

Overall, 140 patients (69 per cent) also reported a previous diagnosis of a psychiatric condition. Depression (107 patients) and/or anxiety (104) were the most common mental health disorders. Other conditions included panic attacks, post-traumatic stress disorder, ADHD, bipolar disorder, and obsessive-compulsive disorder. Patients’ current psychiatric medications were documented.

The investigators found no difference in OAB symptom severity between patients with a previous diagnosed psychiatric disorder and those with no mental disorders.

Among patients with a history of a psychiatric condition, higher UDI-6 scores reflecting more severe OAB were observed for women taking antidepressants and anxiolytics versus no psychiatric medications. ISI scores also were higher in patients on anxiolytics as well as those taking another class of medication, anti-psychotics.

However, patients on antidepressants or anxiolytics experienced a significantly lower rate of DO per hour and shorter contractions compared to patients with no psychiatric history or medications.

“Asking about psychiatric conditions can help provide insight into symptom severity for clinicians caring for women with overactive bladder,” research co-author Dr Jonathan Shaw, told Renal & Urology News. 

“The pathophysiological relationship between psychiatric conditions and overactive bladder remains poorly understood and most of our therapies target the bladder or lower neurological pathways. Such a gap in our understanding presents opportunities for both basic science and clinical research.”

The researchers suggest future studies should investigate how the duration of psychiatric treatment can affect OAB symptoms and possibly develop a psychiatric therapeutic for OAB.

Consultants more likely to prescribe newer OAB drugs initially – US study

Urologists and gynaecologists are more likely to prescribe second-generation agents as initial treatment for OAB, than primary care doctors, according to a study presented at the American Urological Association’s 2016 Annual Meeting.

Urologists and gynaecologists were 49 per cent and 30 per cent more likely than primary care doctors to prescribe second-generation OAB drugs, researchers led by Dr Charles D Scales, Jr, of Duke University Medical Centre in Durham, North Carolina, reported. 

African Americans were 9 per cent less likely than caucasions to be prescribed second-generation OAB drugs.

Compared with US physicians in 2007, US physicians in 2013 were 27 per cent more likely to prescribe second-generation drugs as initial OAB treatment.

Patients with dementia were 13 per cent more likely to be prescribed a second-generation OAB drug than those without dementia, a finding that Dr Scales said is encouraging because limited evidence suggests that certain newer agents may be less likely to worsen dementia.

“The main finding of our study was that specialists were more likely to prescribe newer, more expensive drugs, as the first medication to treat overactive bladder symptoms,” Dr Scales told Renal & Urology News. 

“This finding is important because current guidelines suggest that older and newer extended-release agents are equally effective in treating patient symptoms. Doctors and patients should remember that newer is not automatically better, so when starting medication for overactive bladder symptoms, the benefits, side effects, and costs should be carefully considered.”

Mechanisms in association between OAB and pelvic organ prolapse uncovered

Symptoms of outlet obstruction and urethral sphincter incompetence are associated with OAB in women with pelvic organ prolapse (POP), new research, presented at the American Urological Association’s 2016 Annual Meeting earlier this year, has found.

Epidemiologic studies have demonstrated a high incidence of OAB in women, suggesting that POP may cause OAB. Though it appears that a causal relationship exists, the mechanism by which POP may cause OAB is unclear. Three potential mechanisms are obstruction, activation of bladder stretch receptors from poor anterior vaginal wall support, and coinciding urethral sphincter incompetence. The objective of this study was to investigate pathophysiological risk factors for OAB in women with POP. 

The researchers conducted a prospective cross sectional study of women with POPQ stage 2 or more POP-evaluated in the outpatient setting. Women with prior incontinence surgery, using a pessary, or taking OAB pharmacotherapy were excluded. Women were administered the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6). 

Based upon the International Continence Society definition, women with OAB were then defined by reporting urgency (sometimes or more) with either frequency (nine or more daily voids) or nocturia (one episode or more). The presence of each obstructive symptom (straining, delayed stream, intermittency) was defined by experiencing that symptom sometimes or more. The need to reduce prolapse to void (ie, splint) was measured by a positive response to question six on the POPDI-6. 

Stress urinary incontinence (SUI) was defined by reporting leakage with physical activity sometimes or more. The degree to which the bladder is stretched by the loss of anterior wall support was defined by the Ba point on the POPQ exam (treated as continuous variable). Logistic regression was used to study the relationship between each risk factor and OAB. 

The study included 74 women (mean age 62.3) and 50 per cent had OAB. Splinting to void and SUI were associated with OAB, while severity of anterior POP was not. 

Symptoms of outlet obstruction and urethral sphincter incompetence were associated with OAB in women with POP. 

Further research is needed to investigate whether unobstructing the bladder and correcting sphincteric incompetence can result in a resolution of OAB after prolapse repair, the research concluded.

UK researchers identify bacterial infection as a possible cause of OAB

A team led by researchers at the University of Kent, UK, has identified bacterial infection as a possible cause of OAB.

The researchers, including the Kent team from the Medway School of Pharmacy, found that some OAB patients had a low-grade inflammation, which was missed by conventional NHS tests. This low-grade inflammation may ultimately result in increased sensory nerve excitation and the symptoms of OAB.

The study found that in these patients the low-grade inflammation is associated with bacteria living inside the bladder wall. 

This was an observational study, which means that no conclusions can be drawn about cause and effect. However, the findings may prompt the clinical re-classification of OAB and inform future therapeutic strategies. These might include protracted treatment with antibiotics to alleviate the symptoms of OAB in some individuals.

The research, entitled ‘Altered Urothelial ATP Signalling in Major Subset of Human Overactive Bladder Patients with Pyuria’ was published during the summer in the journal American Journal of Physiology.

Long-term catheterisation causes increased urinary issues and other health risks

Complications from long-term catheterisation and attendant problems were examined in the plenary session, which focused on ageing and the lower urinary tract, during the 31st Annual European Association of Urology (EAU) Congress held in Munich, Germany, earlier this year.

Prof Florian Wagenlehner, Germany, spoke on long-term catheterisation and he underscored the problem of hospital-related urology infections, which have risen in recent years. Around 15 to 25 per cent of hospitalised patients had long-term catheters and 5 to 10 per cent of nursing home residents also received long-term catheters.

“These are often placed for inappropriate indications and physicians are frequently unaware that catheters were used. In a recent survey of US hospitals, it was shown that around 50 per cent of doctors did not monitor which patients were catheterised and around 75 per cent of them also did not monitor the duration and/or discontinuation.

He said there are complications that are already known, such as catheter-associated urinary tract infections (UTIs), catheter blockade, and inflammation of organs. Many other complications include intravesical knotting (rare), catheter fracture and malignancy, fistulae, erosion, abscess, urosepsis, haematuria, urethral stenosis and stricture, severe mechanical trauma, calculi, encrustation, and asymptomatic bacterial stenosis, among many others.

Five of the most frequent complications are directly related to catheter use. “With regards mortality, we see that urosepsis and urinary tract infections are the only ones that lead to mortality. However, catheter-associated urosepsis has a 60 per cent mortality, a rather high mortality,” according to Prof Wagenlehner. “Catheters should be removed as soon as they are no longer required and institutions should consider nurse-based or electronic physician reminder systems to reduce inappropriate urinary catheterisation,” he noted. 

“Upper urinary tract complications are not adequately addressed. We have to reduce catheter duration,” said Prof Wagenlehner in his concluding remarks.

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