in Men Kristy M Borawski MD Associate Professor Department of Urology University of North Carolina Overall prevalence of OAB is significant EPIC study 118 with OAB NICE study 1864 yo 3 urinary incontinence ID: 912744
Download Presentation The PPT/PDF document "@ BorawskiKristy Refractory Overactive B..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
@BorawskiKristy
Refractory Overactive Bladder
in Men
Kristy M. Borawski, MDAssociate ProfessorDepartment of UrologyUniversity of North Carolina
Slide2Overall prevalence of OAB is significantEPIC study11.8% with OAB
NICE study18-64 y/o: 3% urinary incontinence
>65: 8.5%28.5% of these with clinically significant urge urinary incontinence
Irwin, et al. Eur Urol 2006; 50:1306-1314. Morant SV, et al. Int J Clin Pract 2008; 62:688-694
Slide3Overall prevalence of OAB is significantStewart, et al. US based study
16% prevalence of OAB in menOAB wet symptoms increase with age with substantial increases after age 64 Lower Urinary Tract Dysfunction Research Network (LURN)
51% of responders reported any urinary incontinence46% urge incontinenceOlder patients with higher odds of nocturia & urgency
Stewart, et al. World J Urol 2003; 20(6):327-336. Cameron, et al. J Urol 2018; 199(4):1023-1031.
Slide4Coyne KS, et al. Urol 2011; 77(5): 1081-1087.
Slide5Economic Impact
$76.2 billion in 2015
Coyne KS, et al. J Manag Care Pharm 2014; 20(2):130-140.
Slide6$0.24/pad, 3 per day
$21.60/month
$259 / year
$0.24/pad, 6 per day$43.20/month$518 / year
Slide7$0.68/brief, 3 per day
$61/month
$734 / year
Avg Social Secutity Monthy Benefit: $1461
4% of monthly income on depends
Slide8Are we ignoring male OAB?Morant
et al25% men diagnosed with OAB6-7% of men with storage LUTS were placed on
anticholinergics36% of men with LUTS/BPH received alpha blocker and/or 5-alpha reductase inhibitor
Morant, et al. Int J Clin Pract 2008; 62:688-694.
Slide9Pathophysiology of OAB in menHormonal changes
Bladder outlet obstructionAgingIschemiaNeurologic conditions
Gomelsky, et al.
Ther Adv Urol 2009; 1(4):209-221.
Slide10Nadir Osman and Christopher Chapple
. Bladder outlet obstruction and the overactive bladder. In Overactive Bladder: Practical Management. 2015.
Slide11Will OAB symptoms improve after treatment of bladder outlet obstruction?
Slide12Will OAB symptoms improve after treatment of BOO?
Symptomatic OAB persists in ~25-30% of patients post TURPUK: 10 year follow-up post TURPIncrease in detrusor overactivity from 40-60% in those who remain unobstructed
Nadir Osman and Christopher
Chapple. Bladder outlet obstruction and the overactive bladder. In Overactive Bladder: Practical Management. 2015.. Thomas AW. J Urol 2005 174: 1887-1891.
Slide13Will OAB symptoms improve after treatment of BOO?
Persistent OAB symptoms associated with:Advanced ageLower maximum cystometric
capacityEarly onset detrusor overactivityHigh amplitude detrusor overactive contraction
Antunes et al. J Urol 2015; 193: 2028-2032. Nadir Osman and Christopher Chapple. Bladder outlet obstruction and the overactive bladder. In Overactive Bladder: Practical Management. 2015.
Slide14Management for male refractory OAB
f
Slide15Weight Modification
Slide168% weight loss resulted in a 70% reduction in all incontinence episodes (both stress and urge incontinence)
NEJM 360, 2009.
Slide17Combination medical therapy
f
Slide18Combination therapySolifenacin + mirabegron
Mueller, et al.
Neurol Urodyn 2019; 38: 779-792.
Slide19Solifenacin 5mg + mirabegron 50mg
Combination group with greater improvement over monotherapyIncontinence episodes / 24 hrMicturitions / 24
hr
Mueller, et al. Neurol Urodyn 2019; 38: 779-792.
Slide20Solifenacin 5mg + mirabegron 50mgSafety
47.2% all patients reported at least one adverse event
Higher incidence in combination groupIncrease in mean pulse rates from baseline of >1bpm were noted in combination & mirabegron group only in younger age groupsBlood pressure: all three groups had minor increase in systolic blood pressureNo clinically significant change in combination group compared to monotherapy groups
Mueller, et al. Neurol Urodyn 2019; 38: 779-792.
Slide21Solifenacin 5mg + mirabegron 50mgSafety
Increased residual urine volumeNo patients in mirabegron group had increased PVR
No patients in solifenacin group had increased PVR3/1206 had increased PVR in combination groupNo data on gender availableAge: 2 were <75 y/o
Mueller, et al. Neurol Urodyn 2019; 38: 779-792.
Slide22Solifenacin 5mg + mirabegron 50mgSafety
Urinary retention Mirabegron: 1 (0.3%) patient >65 y/oSolifenacin: 1 (0.3%) patient <65 y/o
Combination group: 6 (0.5%) patients all <75No data on gender available
Mueller, et al. Neurol Urodyn 2019; 38: 779-792.
Slide23Slide24OnabotulinumtoxinA
Slide25OnabotulinumtoxinA
Slide26Slide27Placebo vs OnabotA
100U60% vs 29% positive response
5.4% retention rate350+ = CIC200-350mL based on symptoms88.4% female
Slide28Placebo vs OnabotulinumA
100 USimilar outcomes to EMBARK study6.9% CIC PVR >350mL = CIC
PVR 200-350mL based on symptoms84.5% female
Slide29Placebo vs OnabotA
50U/100U/150U/200U/300U
92% female
Slide30Male subjects >18 years of age with confirmed detrusor overactivity on urodynamics who received
intradetrusor
BoNT-A from 2004 – present65 men received 133 BoNT-A treatments6 had prior BOO procedure9 had prior prostatectomy
100 units most common dose in menUrology 2018; 123: 242-246.
Slide31Faure Walker et al. Urol 2018; 123: 242-246.
Slide32Faure Walker et al. Urol 2018; 123: 242-246.
CIC recommended for PVR >150mL with symptoms
Slide33Faure Walker et al. Urol 2019; 123: 242-246.
Baseline urodynamics in men
Men with good bladder contractility (BCI >150) had lower de novo CIC but did not reach significance
BCI =
PdetQMax
+ (5 x
Qmax
)
Slide3488 male patients with mean follow up of 69 months
Success defined as patient still on treatment at last follow-up or stopped
botox treatment due to cure of symptomsNeurol
Urodyn 2017; 36: 1855 – 1859.
Slide35Slide3675% of patients stopped treatment due to either insufficient results or side effects
Slide37Side effects
5% required de novo CIC PVR >250mL
12.5% UTI
Slide382 center double blinded RCT in patients with OAB secondary to BOO refractory or anticholinergic medication & persistent >3 months after surgical intervention for BOO
Placebo vs 200U onabotulinumtoxinA
Randomized, double-blind, placebo controlled pilot study of
intradetrusor injections of onabotulinumtoxinA for the treatment of refractory overactive bladder persisting following surgical management of benign prostatic hyperplasia.Chughtai B1, Dunphy C, Lee R, Lee D,
Sheth S,
Marks L,
Kaplan SA,
Te AE.
Can J Urol 2014; 2: 7217 – 7221.
Slide39OnabotulinumtoxinA group with improved QOL scores at 180 & 270 days after treatment
Lower ICIQ (incontinence questionnaire) scoresDecreased urinary frequency (11 8/day) although statistical significance not achieved
IPSS, PVR & urgency were unchanged postoperatively in both groups
Randomized, double-blind, placebo controlled pilot study of intradetrusor injections of onabotulinumtoxinA for the treatment of refractory overactive bladder persisting following surgical management of benign prostatic hyperplasia.Chughtai B1, Dunphy C,
Lee R,
Lee D,
Sheth S,
Marks L,
Kaplan SA,
Te AE.
Slide40Electrical Stimulation
Slide41Sacral Nerve Stimulation
Slide42Sacral Nerve StimulationSuccess rates 33-88% at 6 months widely reported for refractory urge incontinence
Slide43Slide44Neurourol Urodyn 2015; 24: 224-230.
Slide45J Urol 2018; 199: 229-236.
Slide46J Urol 2018; 199: 229-236.
Slide47J Urol 2018; 199: 229-236.
Slide48J Urol 2018; 199: 229-236.
Slide49Does Gender Influence Response Rates to Sacral Neuromodulation?
Anger, et al. 2016. Outcomes of SNM in a privately insured population
Laudano et al. 2015. Disparities in the use of SNM among Medicare beneficiariesCameron, et al. 2011. National trends in the usage of sacral nerve test stimulation
Less men undergo placement of impulse generator (IPG) compared to women
Slide50Int Urol Neph
2018; 50: 825-832.
92% women vs. 82% men had initial success & went onto placement of generatorMen
More overall improvement in urge incontinence episodes per dayLess incontinence severityAlthough improvement in incontinence severity only seen in womenSimilar QOL parameters
Slide51Sacral neuromodulation after
botox failure?
Slide5220 patients, 4 men16/20 responded to test phase (70%)11/16 were still improved at 1 year
J Urol 2013; 190: 2148-2152.
Slide5336 patients, 1 male63.9% responded to test phaseLone male was a non responder
At last follow-up, 73.9% of initial responders were still satisfied (29.1 months)
Slide54Adverse Events
Overall surgical intervention 33% due to lack or loss of efficacy19.1% had explantation of device
IneffectiveNeed for MRINo data on gender influence on AEs
J Urol 2018; 199: 229-236.
Slide55Posterior Tibial Nerve Stimulation
Slide5624 men in PTNS arm (21.8%)
J Urol 2010; 183: 1438-1443.
Slide57J Urol 2010; 183: 1438-1443.
Slide58J Urol 2010; 183: 1438-1443.
Slide59J Urol 2013; 189: 2194 – 2201.
~ 1 maintenance treatment per month
Slide60Male OAB is an often untreated condition with significant QOL / financial implications
Paucity of data for refractory OAB / urge incontinence in menCannot assume that outcomes in women = men
Slide61