Assessment and Management of Urinary Dysfunction in 187 Patients with Parkinson's Disease.

BACKGROUND: Urinary dysfunction is common in Parkinson's disease (PD) patients and management options are limited. OBJECTIVE: This study aimed to explore the management of urinary dysfunction by researching the special needs of PD patients. METHODS: PD patients with urinary dysfunction who underwent urodynamic testing were recruited from a single center from October 2013 to February 2019. The urinary symptoms, International Prostate Symptom Score and Hoehn-Yahr scale were evaluated. Management was made at the urologists' discretion with follow-up after three weeks. Urinary symptoms, urodynamics and the management of urinary dysfunction were analyzed. RESULTS: A total of 187 patients with a median age of 66.2 and Hoehn-Yahr scale soccer of 2 were enrolled. Irritative symptoms were more common than obstructive symptoms, while obstructive symptoms were more common in male than female patients, except for incomplete voiding. There were 51% cases of detrusor overactivity, followed by 33% with bladder outlet obstruction, 13% had normal function, 12% had detrusor underactivity, 9% had stress incontinence, 7% had increased bladder sensation and 4% had an acontractile bladder. Tolterodine and tamsulosin were the most common therapeutic agents, respectively prescribed to 38.5% and 27.3% of the patients. Other treatments included catheterization, botulinum toxin A bladder wall injection, transurethral resection of the prostate and urethral dilatation. Urinary symptoms were improved significantly in 74.5% of the patients (p < 0.001), including 27 patients treated with tamsulosin only and 54 patients with tolterodine only. CONCLUSIONS: Urinary symptoms and urodynamics were highly variable in PD patients, indicating that most patients may benefit from personalized management.

Clinical characteristics of autoimmune GFAP astrocytopathy.

The clinical features of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy remain to be elucidated. We describe here the clinical features of 14 patients with GFAP astrocytopathy confirmed by detection of GFAP-IgG in cerebrospinal fluid (CSF). The novel findings of this study are as follows. First, over half of the patients presented with movement disorders (tremor, myoclonus, and ataxia), autonomic dysfunction (mainly urinary dysfunction), and hyponatremia. Second, most patients showed transient elevation of adenosine deaminase activity levels in CSF. Finally, some patients showed bilateral hyperintensities in the posterior part of the thalamus on brain magnetic resonance imaging.

Estimating the quality-of-life impact and cost-effectiveness of alpha-blocker and anti-muscarinic combination treatment in men with lower urinary tract symptoms related to benign prostatic hyperplasia and overactive bladder.

OBJECTIVE: A 12-week clinical trial (TIMES) demonstrated that therapy with tolterodine extended release (TOL) + tamsulosin (TAM) provides clinical benefits vs TOL or TAM monotherapy or placebo (PBO) in men with lower urinary tract symptoms (LUTS) including overactive bladder (OAB). The present analysis estimated the costs and quality-adjusted life-years (QALYs) associated with these therapies from the perspective of the UK healthcare system. METHODS: TIMES cohorts receiving TOL, TAM, TOL + TAM, or PBO were followed from therapy initiation to 12 weeks. A decision-tree model was used to extrapolate the 12-week results to 1 year (including need for surgery owing to treatment failure at 12 weeks) and to track patients' outcomes (symptoms, utility, and costs). Because TIMES did not include costs and QALYs, data from the EpiLUTS epidemiologic survey (12,796 males) were used to model a mathematical relationship between LUTS (daytime and nocturnal frequency, urgency episodes, urgency urinary incontinence episodes, and International Prostate Symptom Score [IPSS]), quality-of-life, and utility. This was used to convert improvements in TIMES patients' LUTS into utility scores and QALYs. The model included drug and surgery procedure costs and hospital length of stay. RESULTS: Incremental QALYs of TOL + TAM vs PBO, TAM, and TOL were 0.042, 0.021, and 0.013, and corresponding incremental costs were £189, £223, and -£70, respectively, resulting in cost-utility ratios for TOL + TAM of £4508/QALY gained compared with PBO and £10,381/QALY gained compared with TAM. TOL + TAM combination therapy was both more effective and cost-saving compared with TOL. Univariate sensitivity analyses showed that patient utility was most responsive to changes in drug efficacy on IPSS and urgency episodes. Changing the percentage of patients undergoing surgery did not substantially affect model outcomes. The main limitation of the study was that the relation between LUTS and patient utility was based on an indirect association. CONCLUSIONS: TOL + TAM combination therapy appears to be cost-effective compared with TOL or TAM monotherapy or PBO in male patients with LUTS.

Pharmacotherapy of overactive bladder: epidemiology and pathophysiology of overactive bladder.

INTRODUCTION: Overactive bladder (OAB) describes complex symptoms, comprising of urinary urgency, with or without urinary incontinence, often with increased daytime frequency and nocturia in the absence of infection or other obvious etiology. OAB is highly prevalent and affects physical and mental health, activities of daily life and the quality of life of millions of adults. The pathophysiology of OAB and detrusor overactivity is still not completely known, but is most probably multifactorial. AREAS COVERED: The epidemiology and pathophysiology of OAB is reviewed. A literature search using PubMed from 2000 to 2010 was undertaken for this review with pertinent older papers referenced as needed to gain a clearer understanding of the epidemiology of OAB and related bladder pathophysiology, which it is hoped will lead to more effective and better-tolerated treatments for OAB. EXPERT OPINION: With recent advances in our understanding of the basic science of OAB, it is becoming clear that the control of bladder function is far more complex than previously believed. Recent research has highlighted several potential targets for the treatment of OAB, particularly within the mechanosensory pathways.

Identifying patients with benign prostatic hyperplasia through a diagnosis of, or treatment for, erectile dysfunction.

OBJECTIVE: Erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) associated with benign prostate hyperplasia (BPH) are highly correlated. This study examined rates of screening, diagnosis, and treatment of BPH/LUTS among men seeking care for ED. RESEARCH DESIGN AND METHODS: This was a retrospective US claims data analysis (1999-2004) evaluating men > or = 40 years old with a new diagnosis of or prescription medication for ED. Multivariate analyses were used to examine times to screening, diagnosis, and treatment. RESULTS: 81 659 men with ED were identified (mean age 57 years). The baseline prevalence of recorded BPH was 1.5%. During the follow-up period (mean 2.2 years), 7.6% had documented BPH. Time to screening was shorter among patients seeing urologists (121.1 days) compared with those seeing primary-care physicians (282.2 days). Controlling for demographic and clinical characteristics, patients who saw a urologist were more likely to be screened (OR: 2.4, p < 0.0001), diagnosed with BPH (OR: 1.8, p < 0.0001), and treated (OR: 1.3, p < 0.0001), relative to patients seeing other providers. Men aged 75 and over were 43% less likely to be screened (p < 0.0001), but 5.4 times more likely to be diagnosed with BPH (p < 0.0001) and 5.3 times more likely to be treated (p < 0.0001) compared with men aged 40-49. CONCLUSIONS: Screening for BPH appears less likely for men with ED who do not see a urologist. When screening does occur, it takes much longer with non-specialty providers. Patient age and provider specialty are key factors associated with screening, diagnosis, and treatment of BPH among men with ED.

Overactive bladder: an update.

PURPOSE OF REVIEW: Overactive bladder is an important lower urinary tract syndrome that negatively affects the quality of life of millions of people worldwide. Both sexes and all age groups may be affected; therefore many specialists, including urologists, gynaecologists, geriatricians, paediatricians, physiotherapists and continence advisors, are involved in the management of patients with overactive bladder. RECENT FINDINGS: There is ongoing research, both basic science and clinical trials, to establish the cause of overactive bladder and to determine the best method of managing patients who suffer from this syndrome. New theories and modified definitions of overactive bladder have been proposed, structured evidence-based management guidelines have been established, more prevalence studies have been conducted and new treatment strategies have emerged. SUMMARY: Overactive bladder is now recognized as a chronic debilitating condition that costs millions of dollars. With an ageing population these costs will increase, and it is necessary that health systems around the world recognize this. Further research into the basic science of the condition is required to identify the true cause of overactive bladder, allowing new targeted treatments to be established.

Assessment of the impact of sildenafil citrate on lower urinary tract symptoms in men with erectile dysfunction.

INTRODUCTION: Sildenafil citrate is an effective and well-tolerated oral erectogenic medication. Through phosphodiesterase type 5 (PDE5) inhibition, it induces relaxation in penile smooth muscle, resulting in erection. Due to its mild affinity for other PDE enzymes, it may cause smooth muscle relaxation in a number of other organs. Recent data suggest an association between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Anecdotally some patients cite improvement in LUTS while using sildenafil. AIM: This study was conducted to assess the impact of Viagra on LUTS, using the International Prostate Symptom Score (IPSS) questionnaire. MAIN OUTCOME MEASURE: International Index of Erectile Function (IIEF) and IPSS inventories. METHODS: Men presenting to a sexual dysfunction clinic who were candidates and opted for treatment with sildenafil completed the IIEF and IPSS. Men with the IPSS scores greater than 10 were enrolled and completed the IPSS and IIEF questionnaires at least 3 months after the commencement of sildenafil. Comparisons were made between pre- and posttreatment scores in the IPSS and erectile function (EF) domain of the IIEF. RESULTS: Forty-eight men were enrolled, with a mean age of 62 +/- 11 years. The mean improvement in the EF domain score was 7 points (P = 0.01). The mean improvement in the IPSS score was 4.6 points (P = 0.013) and in quality of life (QOL) score was 1.4 points (P = 0.025). In total, 60% of men improved their IPSS score, and 35% had at least a 4-point improvement in their score. The mean number of uses of sildenafil per week was 2.0 +/- 0.6. No significant correlation was seen between the degree of the IPSS improvement and baseline IPSS, baseline EF domain score, or magnitude of improvement in EF domain score. CONCLUSIONS: These data indicate a positive impact of Viagra on men with mild to moderate LUTS. It is presumed, although unproven, that the medication's effect is mediated through bladder neck/prostatic smooth muscle relaxation.

Drug treatment of overactive bladder: efficacy, cost and quality-of-life considerations.

Overactive bladder (OAB) syndrome has been recognised by the International Continence Society as an important symptom syndrome that affects millions of people worldwide. Quality of life is affected in most people with OAB; however, the aetiology is unknown. Some researchers suggest that it is because of a damage to central inhibitory pathways or sensitisation of peripheral afferent terminals in the bladder, others suggest that it is a bladder muscle problem; the reality is probably a spectrum encompassing these two main explanations. Therefore, treatment is difficult and is aimed at alleviating symptoms (being those of urgency, with or without urge incontinence, usually with frequency and nocturia) rather than treating the cause. A thorough patient history and physical examination are required to establish a possible diagnosis. Frequency/volume charts form an important aid to the diagnosis. Once a presumptive diagnosis is made, conservative management forms the first line of treatment and includes lifestyle modifications, bladder training and pelvic floor exercises. If this fails, pharmacotherapy, in the form of anticholinergic drugs, is initiated. There are many antimuscarinic drugs, for example oxybutynin, tolterodine and trospium chloride. Each has a different specificity to bladder muscarinic receptors, thus producing different adverse effect profiles (e.g. dry mouth, blurred vision and constipation). Different individuals experience these adverse effects to different extents. New anticholinergic drugs, that have undergone phase III trials and are more specific to the muscarinic M3 human bladder receptor, are being introduced to the market in 2004 (e.g. solifenacin succinate and darifenacin). In addition to adverse effect profile, cost and improvement in quality of life are important factors in choosing treatment. Further research is being conducted on other types of drugs and different administration modalities, for example intravesical botulinum toxin A. Sacral nerve neuromodulation is emerging as a potential treatment, but if all treatments fail then surgery is the last resort.

Economics of lower urinary tract symptoms (LUTS) in older people.

Urinary incontinence is an area of clinical and social importance to older people and providers of care. This article provides an update on the 'symptom' of urinary incontinence and reviews the concept of lower urinary tract symptoms (LUTS). The challenges facing health services researchers working in this field are also discussed in terms of trying to quantify the size and extent of the underlying problem. Economic issues and work undertaken to evaluate the cost of LUTS are appraised and the common nonsurgical treatments for LUTS are described together with associated conditions and their cost implications. The cost to individuals and society of LUTS is generally underestimated and the importance of reducing its severity (if cure is not achievable) makes clinical and economic sense.

Evaluation of suspected urinary tract infection in ambulatory women: a cost-utility analysis of office-based strategies.

BACKGROUND: The purpose of this study was to determine the most cost-effective strategy for managing suspected urinary tract infections in otherwise healthy adult women presenting to their primary care physician with dysuria and no symptoms or signs of pyelonephritis. Several office-based management strategies are considered: empiric therapy, use of dipstick analysis, use of complete urinalysis, and several strategies using office or laboratory cultures. METHODS: We constructed a decision tree using model probabilities obtained from the literature. Where published probabilities were unavailable, we used extensive sensitivity analyses. Utilities were obtained from the Index of Well-Being. We obtained costs by surveying hospitals, physicians, and pharmacies. RESULTS: The most cost-effective strategy is to treat empirically ($71.52 per quality-adjusted life month, QALM). When the cost of antibiotics exceeds $74.50 or if the prior probability of having a UTI is under 0.30, then treatment guided by the results of a complete urinalysis is preferred. While it was the preferred strategy, other strategies (complete urinalysis, culture and treat, and dipstick testing only) were associated with greater utility. The marginal cost-effectiveness of these strategies compared with empiric therapy ranged from $2964 to $48,460 per additional QALM. CONCLUSIONS: The preferred strategy of empiric therapy is robust over a wide range of sensitivity analyses. While empiric therapy is associated with the best cost-utility ratio, doing a culture yields the greatest utility at greater incremental cost per QALM. Many primary care physicians already treat UTIs empirically with antibiotics. This study confirms that empiric therapy, while frowned upon by some, is a cost-effective strategy. Other strategies may be considered, but at greater marginal cost. Ultimately these findings need to be confirmed in clinical trials.

[Assessment of the use of oxybutynin hydrochloride (Pollakisu tablets) in the elderly].

Oxybutynin hydrochloride (Pollakisu tablets) was administered at a daily dose of 6 or 9 mg to 75 elderly patients with urinary tract disorders, including neurogenic bladder and unstable bladder, with chief complaints of pollakisuria, urgency on urination and urinary incontinence. A post-marketing follow-up survey (phase IV study) was then performed to evaluate the efficacy safety and usefulness of Pollakisu tablets in these patients. The administration of Pollakisu tablets produced good results in the comprehensive assessment of overall improvement, being rated as "improved" or better in 57.5% of the patients and "slightly improved" or better in 89.0%. The assessment of general safety revealed that the drug caused almost no problems, with "no problem in safety" accounting for 97.3% of the responses. The assessment of the usefulness indicated that Pollakisu tablets are highly useful, being rated as "useful" or better in 58.9% and as "slightly useful" or better in 82.2%. Evaluation of the results according to daily dose indicated that a dose of 6 mg per day was appropriate for elderly patients from the viewpoint of drug efficacy and safety. With respect to adverse reactions, thirst was found in 5 and dysuria in 3 of the 73 patients. The overall incidence of adverse reactions was 11.0%. The above results indicate the efficacy, safety and usefulness of Pollakisu tablets in treating elderly patients with pollakisuria, urgency on urination and urinary incontinence.

Urinary tract infection and dysuria. Cost-conscious evaluation and antibiotic therapy.

Recent research into the pathogenesis and treatment of urinary tract infection (UTI) clearly indicates that our traditional approach has overestimated the need for extensive evaluation and prolonged antibiotic therapy. The great majority of UTIs can be managed adequately with urinalysis and single-dose or three-day antibiotic regimens; only complicated UTIs or those occurring in unusual hosts require cultures and longer courses of treatment.

Assessment of the antihypercholesterolemic drug, Probucol, in benign prostatic hyperplasia.

Seventy patients were administered either Probucol, an anti-cholesterol agent or a placebo in a double blind manner for a period of 1 year in an effort to assess the effectiveness of this agent in treating benign prostatic hyperplasia. Sensation of incomplete voiding and peak and mean voiding flow rates showed a trend which indicated a therapeutic effect, however, this effect was comparable for both placebo and the drug group. This is interpreted as indicating the effectiveness of standard urologic therapy, and double blind trials are therefore needed in assessing different agents for the medical management of benign prostatic hyperplasia.

Medical treatment of prostatic obstruction. An objective assessment.

Thirteen men suffering from prostatic obstruction were treated with an 8-week course of intramuscular injections of prostatic extract. Nine of these men had preliminary and subsequent evaluations of detrusor function and outflow obstruction by means of pressure/flow studies. Improvement in symptoms and measurements were only minimal and occurred in less than one-half of the cases. The greatest increase in flow rate recorded prostatectomy and no significant changes resulting from the injections could be seen on the histologic sections of their glands. These results did not confirm previous reports recommending this form of treatment for prostatic obstruction.