P.E.V. Van Kerrebroeck

Treatment of overactive bladder: long-term tolerability and efficacy of tolterodine.

Abstract Previously available antimuscarinic therapies for overactive bladder are poorly tolerated due to a high incidence of adverse events, notably dry mouth. Tolterodine is a bladder-selective, antimuscarinic agent for the treatment of frequency, urgency, and urge incontinence that characterize overactive bladder. In a 9-month open-label study, the safety, tolerability, and clinical efficacy of tolterodine 2u2009mg twice daily was evaluated in 854 patients with overactive bladder symptoms who had completed one of four 12u2009week randomized, controlled trials of tolterodine. Safety and tolerability were assessed in terms of adverse events and clinical/laboratory variables. Efficacy was assessed using micturition diaries and patient perception of their bladder condition. In all, 70% of patients remained on treatment for 9 months. Dry mouth was the most frequently reported adverse event, occurring in 28% of patients (intensity: 19% mild, 7% moderate, 2% severe). A total of 9% of patients withdrew due to adverse events. Dosage reduction occurred in 13% of patients. Significant improvements (Pu2009<u20090.0001) in micturitions per 24u2009h (−22%), urge incontinence episodes per 24u2009h (−76%) and volume voided per micturition (+22%) were observed after 9 months of treatment, with 65% of patients reporting an improvement in perception of their bladder problems. The incidence of adverse events and improvements in micturition diary variables during open-label treatment were comparable with those observed during a 12u2009week randomized treatment. It was concluded that tolterodine is well tolerated and maintains its clinical efficacy during 9u2009months of treatment. The high proportion of patients remaining on treatment indicates that tolterodine is an effective long-term treatment for overactive bladder.

Sacral Neuromodulation as a Treatment for Chronic Pelvic Pain

PURPOSEnChronic pelvic pain syndrome is a debilitating disease which often has a major impact on quality of life. A significant number of patients do not respond to conservative treatment and often no good alternative can be offered except radical surgery. Sacral neuromodulation is a well established therapy for patients with lower urinary tract dysfunction. This therapy has also been suggested to be useful in the treatment of chronic pelvic pain. Although currently no Food and Drug Administration approval exists for this indication, several studies have demonstrated promising results. We provide an overview of the published literature on sacral neuromodulation as a treatment for chronic pelvic pain.nnnMATERIALS AND METHODSnA PubMed® search was performed to identify articles in English from 1990 to February 2010 reporting treatment of pelvic pain with sacral neuromodulation. In addition, the current definitions of pelvic pain syndromes and the mechanisms of action are discussed.nnnRESULTSnA total of 12 relevant articles were identified. Of these articles 10 mainly addressed the efficacy of sacral neuromodulation in patients with interstitial cystitis/bladder pain. The percentage of patients who responded to test stimulation was reported between 51% and 77%. Of the 10 articles 7 reported treatment outcome after implantation. The duration of followup ranged between 5 and 87 months. The mean reduction in pain scores was reported between 40% and 72%. The reoperation rate ranged between 27% and 50% after long-term followup. Two articles included patients with miscellaneous urogenital pain syndromes. The success rates after implantation ranged from 60% to 77% with followup ranging between 19 and 36 months.nnnCONCLUSIONSnCurrently there is insufficient evidence to determine the role of sacral neuromodulation in the treatment of chronic pelvic pain. Larger prospective trials with long-term evaluation are required to determine the ultimate efficacy of this treatment.

Selective detrusor activation by sacral ventral nerve-root stimulation: results of intraoperative testing in humans during implantation of a Finetech-Brindley system

Abstract Electrical sacral nerve-root stimulation can be used to induce bladder contraction. However, bladder emptying is hampered by simultaneous contraction of the external urethral sphincter. Voiding may improve when using a stimulation method that allows selective detrusor activation. Both theoretical and animal studies have demonstrated that it is possible to obtain selective detrusor activation by sacral root stimulation using an selective anodal block. The objective of this paper is to demonstrate the feasibility of this stimulation method in humans. For investigation of the stimulation method, intraurethral and intravesical pressure responses to sacral root stimulation were measured in acute experiments on 12 patients. The results show that selective detrusor activation is possible in patients. Future perspectives are discussed.

A Computer model of the neural control of the lower urinary tract

Better understanding of the underlying working mechanism of the neural control of the lower urinary tract will facilitate the treatment of dysfunction with a neurogenic cause. We developed a computer model to study the effect of a neural control system on lower urinary tract behavior. To model the mechanical properties and neural control, assumptions had to be made. These assumptions were based, as much as possible, on knowledge and hypotheses taken from the literature. With valid assumptions, it should be possible to simulate normal as well as pathological behavior.

What Treatment Should We Use If Drugs Fail for OAB; and, What Really Works After Drugs?

To determine (using structured brain storm sessions), which treatments should be used if drugs fail for OAB and to determine priority research questions in relation to this issue.

Sacrale neuromodulatie voor nietobstructieve urineretentie met een voorgeschiedenis van blaasoverdistensie groter dan 1500 cc

Resultaten Twintig patiënten met de natte vorm van iOAB, die eerder BoNTA-behandelingen hadden ondergaan, werden geïncludeerd: 17 (85%) patiënten hadden onvoldoende baat van de eerste of daaropvolgende BoNTA-behandelingen bemerkt. De overige 3 patiënten waren succesvol behandeld met BoNTA, maar waren ontevreden over het herhaaldelijk moeten ondergaan van de behandeling en wilden graag gescreend worden voor behandeling met SNM. Het gemiddelde interval tussen de laatste BoNTA-behandeling en de start van de SNM-teststimulatie bedroeg 23 maanden (range: 7-53). Bij 14 patiënten (70%) was de teststimulatie succesvol (tabel 5.1). Uit de mictiedagboeken bleek dat de episoden van urineverlies, de mate van urineverlies, de frequentie en de urgentie met > 50% waren afgenomen, in vergelijking met de dagboeken van voor de teststimulatie. Bij 5 patiënten was er zelfs sprake van > 90% afname van de episoden van urineverlies. Alle 14 patiënten ondergingen een definitieve implantatie van een neuromodulator. Een jaar na implantatie waren 11 patiënten (79%) tevreden met de SNM-behandeling.

A model of the neural control of the lower urinary tract

The lower urinary tract is controlled by a complex neural system. A neurogenic cause of a lower urinary tract dysfunction is often difficult to specify because the underlying mechanism of the neural control is not clear. In order to investigate which feedback loops are theoretically important, the behaviour of the lower urinary tract was simulated with a model. If, in this model, the efferent signals to the bladder and to the sphincters were based on four afferent signals normal bladder behaviour was simulated. Pathologic behaviour was simulated by varying the influence of the afferent signals on the efferent signals. According to this model these four afferent signals are sufficient to control the bladder.