Marilena Gubbiotti

The efficacy and safety of duloxetine in a multidrug regimen for chronic prostatitis/chronic pelvic pain syndrome.

OBJECTIVE To evaluate the efficacy and safety of duloxetine hydrochloride in the treatment of patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS Thirty-eight CP/CPPS patients completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and International Index of Erectile Function-Erectile Function-5 (IIEF-5) questionnaires, uroflowmetry, and evaluation of psychologic status using Hamilton Anxiety Scale (HAM-A) and Hamilton Depression Scale (HAM-D). Patients were randomly assigned to 2 treatments groups. Treatment in group 1 consisted of a simultaneous oral administration of tamsulosin (0.4 mg/d, 60 mg/d), saw palmetto (320 mg/d), and duloxetine (60 mg/d). Treatment in group 2 consisted of tamsulosin (0.4 mg/d) and saw palmetto (320 mg/d). NIH-CPSI and IIEF-5 questionnaires, uroflowmetry, and evaluation of the psychological status were repeated at 16 weeks of follow-up. RESULTS At 16 weeks, a significant improvement in NIH-CPSI pain subscore, NIH-CPSI quality of life subscore, and NIH-CPSI total score were observed in group 1 patients compared with those in group 2 (P <.01, respectively), together with a significant improvement in HAM-A and HAM-D scores (P <.01, respectively). Patients in group 2 showed a significant improvement in NIH-CPSI total score, in the urinary symptoms subscore, and in the HAM-A total score. No significant differences were observed in IIEF-5 scores in the 2 groups. Maximum flow rate significantly increased in both groups. In group 1, 20% of patients stopped the study due to adverse effects. CONCLUSION The use of duloxetine in a multimodal treatment with an α-blocker medication and a saw palmetto extract allowed better results in controlling clinical symptoms, psychologic status and quality of life patients affected by CP/CPPS.

OnabotulinumtoxinA intravesical treatment in patients affected by overactive bladder syndrome: best practice in real-life management.

Purpose We evaluated intradetrusorial OnabotulinumtoxinA (Onabot/A) treatment protocols in patients with idiopathic overactive bladder (OAB), in order to assess the care of patients before, during and after treatment. Methods In 64 OAB patients injected with Onabot/A, we reviewed the length of the hospital stay, frequency of catheterization, frequency of intraoperative and postoperative complications, and patients’ satisfaction to the proposed treatment protocol (as assessed by VAS). We also compared the results of the 3-day voiding diary, uroflowmetry with postvoid residual urine (PVR) and VAS to score the bother of urinary symptoms on quality of life (QoL) before and after treatment. Results Twenty-one patients were firstly treated in an ‘inpatient’ setting. The mean ± SD duration of hospitalization and catheterization was 39.4 ± 12.6 and 37.8 ± 10.6 h, respectively. The mean ± SD VAS values of treatment satisfaction and of bother of urinary symptoms on QoL were 6.3 ± 1.1 and 8.2 ± 1.3, respectively. The mean ± SD PVR value was 74.3 ± 15.2 ml. Frequency of UTIs was 2.4 ± 1.6. Forty-three patients were treated on an outpatient basis; the mean ± SD duration of catheterization, the ‘outpatient’ stay and the mean ± SD frequency of UTIs were lower than those of patients treated in an inpatient setting. The mean ± SD VAS value to score QoL was high. Conclusions Intradetrusorial Onabot/A injection is a simple and fast procedure that can be easily carried on in an outpatient setting under local anesthesia, with low rates of intraoperative and postoperative complications.

Intradetrusorial Botulinum Toxin in Patients with Multiple Sclerosis: A Neurophysiological Study

Patients with multiple sclerosis (MS) often complain of urinary disturbances characterized by overactive bladder syndrome and difficulties in bladder emptying. The aim of the study was to investigate the pathophysiology of bladder dysfunction and the neurophysiological effects of intradetrusorial incobotulinum toxin A (BoNT/A) in patients with MS having both brain and spinal MS-related lesions. Twenty-five MS patients with neurogenic detrusor overactivity (NDO) underwent clinical evaluation and soleus Hoffmann reflex (H reflex) study during urodynamics. Of the 25 patients, 14 underwent a further session one month after intradetrusorial BoNT/A injection. Eighteen healthy subjects acted as the control. In healthy subjects, the H reflex size significantly decreased at maximum cystometric capacity (MCC), whereas in MS patients with NDO, the H reflex remained unchanged. In the patients who received intradetrusorial BoNT/A, clinical and urodynamic investigations showed that NDO improved significantly. Volumes at the first, normal and strong desire to void and MCC increased significantly. Despite its efficacy in improving bladder symptoms and in increasing volumes for first desire, normal and strong desire to void, BoNT/A left the H reflex modulation during bladder filling unchanged. In the MS patients we studied having both brain and spinal MS-related lesions, the H reflex size remained unchanged at maximum bladder filling. Since this neurophysiological pattern has been previously found in patients with spinal cord injury, we suggest that bladder dysfunction arises from the MS-related spinal lesions. BoNT/A improves bladder dysfunction by changing bladder afferent input, as shown by urodynamic findings on bladder filling sensations, but its effects on H reflex modulation remain undetectable.

Pharmacologic Goals in Interstitial Cystitis/Bladder Pain Syndrome

During the last 30 years, a number of treatments and management algorithms have been developed and applied in the treatment of patients with Interstitial Cystitis/Bladder Painful Syndrome (IC/BPS), and many behavioral, dietary, interventional, pharmacologic and surgical therapies have been developed in the attempt to control the disease and to offer substantial benefits to the affected patients. Nevertheless, the complexity of the disease in terms of aetiology and pathogenesis still has made it difficult to induce significant and long-lasting benefits for any kind of these treatments. In addition, few well designed, randomised controlled trials have been conducted until now on different treatment modalities, and this still precludes the development of evidence-based management strategies. Indeed, the majority of pharmacological agents used to treat patients with IC/BPS are still off label. In this respect, the Interstitial Cystitis Data Base study noted >180 treatment modalities for IC/BPS, with poor results in the majority of cases [1]. To date, there is general agreement on the use of some agents, orally or intravesically administered, as indicated by the EAU guidelines on chronic pelvic pain [2] and the AUA Guidelines for the Diagnosis and Treatment of Interstitial Cystitis/ Bladder Pain Syndrome [3].

Effects of Onabotulinum Toxin A Intradetrusor Injections on Urinary Symptoms and Sexual Life in Women Affected by Multiple Sclerosis: A Prospective Controlled Study

Background: Voiding and sexual dysfunction in Multiple Sclerosis represent the most devastating dimensions of the disease. Pharmacological treatment of voiding dysfunction could improve sexual life in patients affected by the disease. We investigated the effects of Onabotulinum toxin A intradetrusor injections on urinary symptoms and sexual dysfunction, and on the psychological status of women affected by Multiple Sclerosis with refractory overactive bladder. Methods: 41 patients underwent neurologic and urologic clinical evaluations and were administered the Female Sexual Function Index, the Incontinence-Quality of Life questionnaire, the Hamilton Anxiety Rating Scale and the Hamilton Depression Rating Scale, before and six months after Onabotulinum toxin A intradetrusor injection; 21 continent females affected by the disease acted as controls. Results: At baseline, all patients were incontinent and 35/41 was sexually active, with low Female Sexual Function Index scores. Mild depression and anxiety were detected in all cases with a reduced quality of life. Six months after treatment, overactive bladder symptoms improved significantly in all patients. Arousal, lubrication, orgasm-related problems and desire alterations markedly improved, together with an improvement in anxiety, depression and quality of life. Scores of Female Sexual Function Index, Incontinence-Quality of Life questionnaire, Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale remained unchanged in controls. Conclusion: Onabotulinum toxin A intradetrusor injections not only control overactive bladder symptoms in women affected by multiple sclerosis, but also significantly improve sexual life.

The use of mirabegron in the treatment of overactive bladder in patients affected by Parkinson’s disease

Introduction: Overactive bladder (OAB) is one of the most common autonomic disorders in patients affected by Parkinson’s disease (PD). OAB has a higher prevalence (3080%) also due to patients’ old age and the impact of urinary symptoms may be more pronounced due to the increased burden of concomitant chronic comorbidities. Mirabegron is a specific agonist of β3-adrenoceptors, mediating detrusor smooth muscle relaxation resulting in increase bladder storage capacity and prolonged micturition intervals. Aim of the study was to evaluate the efficacy and tolerability of Mirabegron in PD patients with OAB and different comorbidities, who stopped antimuscarinic medications for intolerable adverse effects.