Urinary Bladder

Importance: Up to 40% of men older than 50 years have lower urinary tract symptoms, including urinary urgency, nocturia, and weak urinary stream, due to disorders of the bladder and prostate. These symptoms negatively affect quality of life and may be associated with urinary retention, which can cause kidney insufficiency, bladder calculi, hematuria, and urinary tract infections.

Observations: In men, lower urinary tract symptoms can be caused by bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), an overactive bladder detrusor (a syndrome of urinary urgency and frequency), or both. Behavioral therapy, including pelvic floor physical therapy, timed voiding (voiding at specific intervals), and fluid restriction, can improve symptoms. Medications including α-blockers (such as tamsulosin), 5α-reductase inhibitors (such as finasteride), and phosphodiesterase 5 inhibitors (such as tadalafil) improve lower urinary tract symptoms (mean improvement, 3-10 points on the International Prostate Symptom Score [IPSS], which ranges from 0-35, with higher scores indicating greater severity) and can prevent symptom worsening measured by increased IPSS greater than or equal to 4 points or development of secondary sequelae, such as urinary retention. Combination therapies are more effective than monotherapy. For example, α-blockade (eg, tamsulosin) combined with 5α-reductase inhibition (eg, finasteride) lowers progression risk to less than 10% compared with 10% to 15% with monotherapy. Treatment for overactive bladder detrusor, including anticholinergics (eg, trospium) and β3 agonists (eg, mirabegron), reduces voiding frequency by 2 to 4 times per day and reduces episodes of urinary incontinence by 10 to 20 times per week. Surgery (eg, transurethral resection of the prostate, holmium laser enucleation of the prostate) and minimally invasive surgery are highly effective for refractory or complicated cases of BPH, defined as persistent symptoms despite behavioral and pharmacologic therapy, and these therapies can improve IPSS by 10 to 15 points. Minimally invasive procedures, such as water vapor therapy (endoscopic injection of steam into BPH tissue) and prostatic urethral lift (endoscopic insertion of nonabsorbable suture implants that mechanically open the urethra), have lower complication rates of incontinence (0%-8%), erectile dysfunction (0%-3%), and retrograde ejaculation (0%-3%) but are associated with increased need for surgical retreatment (3.4%-21%) compared with transurethral resection of the prostate (5%) and holmium laser enucleation of the prostate (3.3%).

Conclusions and relevance: Lower urinary tract symptoms, defined as urinary urgency, nocturia, or weak stream, are common among men and are usually caused by BPH, overactive bladder detrusor, or both. First-line therapy consists of behavioral intervention, such as pelvic floor physical therapy and timed voiding, as well as pharmacologic therapy, including α-adrenergic blockers (tamsulosin), 5α-reductase inhibitors (finasteride), phosphodiesterase inhibitors (tadalafil), anticholinergics (trospium), and β3 agonists (mirabegron).

Author/s:

John T Wei, Casey A Dauw, Casey N Brodsky

Non-Surgical Management of Urinary Incontinence

Alex Haga — Tue, 25 Feb 2025 17:42:11 +0000

Date Added:

February 25, 2025

Journal/Publication:

The Journal of the American Board of Family Medicine

Publication Date:

September 1, 2024

Issue:

Volume:

Pages:

909-918

URL:

Non-Surgical Management of Urinary Incontinence

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.3122/jabfm.2023.230471R1

Keywords

urinary incontinence

incontinence

stress urinary incontinence

MeSH

urinary tract infections

A review of the non-surgical management of urinary incontinence. James W. Mold, MD, MPH

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Urinary incontinence management varies depending on the type of incontinence and severity of symptoms. Types of incontinence include stress (SUI), urge or overactive bladder (OAB), mixed, neurogenic, and overflow incontinence. First-line treatment for OAB and SUI is nonpharmacologic management. Behavioral therapy is first-line treatment for urge incontinence. Vaginal mechanical devices (cones, pessaries, and urethral plugs), pelvic floor muscle training, and electroacupuncture are recommended as first-line treatment for women with SUI. Biofeedback and electric muscle stimulation can be adjunctive therapy for SUI. Antimuscarinics and β-3 agonists can be used as adjective therapy for those with OAB who do not improve with behavioral therapy. β-3 agonists have less anticholinergic side effects compared with antimuscarinics for OAB. Adverse medication effects can often lead to discontinuation due to poor tolerability. Third-line therapies are for those who fail conservative and pharmacologic therapies and lack high-grade evidence. Neuromodulation, neurotoxin injections, vaginal laser therapy, and acupuncture are third-line in OAB management. Pharmacologic management with α-1-blockers is recommended as first-line treatment for moderate to severe overflow incontinence from BPH. 5-α reductase inhibitors can be used as an adjunct medication in those with refractory overflow incontinence symptoms and a PSA ≥ 1.5 mg/dL. Clean intermittent catheterization is first-line therapy for neurogenic bladder but can increase risk of catheter-associated urinary tract infection. Clinicians should assess type of incontinence, patient goals, side effect profile, and tolerability to determine an individualized treatment plan for each patient.

Author/s:

Ranna Al-Dossari, Monica Kalra, Julie Adkison, Bich-May Nguyen

What Should I Know About Recurrent UTIs in Older Women?

Alex Haga — Thu, 13 Jun 2024 21:47:57 +0000

Date Added:

June 13, 2024

Journal/Publication:

JAMA Internal Medicine

Publication Date:

June 10, 2024

URL:

What Should I Know About Recurrent UTIs in Older Women?

Type:

Patient Education Materials

Format:

Article

DOI (1):

10.1001/jamainternmed.2024.1854

Keywords

urinary tract infections

female

PMID (1):

38857042

MeSH

female

Urinary Bladder

Urination

urinary tract infections

Vagina

menopause

Information for older women and their caregivers about diagnosis and treatment of suspected urinary tract infections. James W. Mold, MD, MPH

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This JAMA Internal Medicine Patient Page describes urinary tract infections, their causes, and how to treat them and prevent future episodes.

Author/s:

Sonali D Advani, Kimberly C Claeys, Nazema Y Siddiqui

Recurrent Urinary Tract Infection in Older Outpatient Women

Alex Haga — Thu, 13 Jun 2024 21:35:58 +0000

Date Added:

June 13, 2024

Journal/Publication:

JAMA Internal Medicine

Publisher:

JAMA

Publication Date:

June 10, 2024

URL:

Recurrent Urinary Tract Infection in Older Outpatient Women

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2024.1069

Keywords

urinary tract infections

PMID (1):

38856992

MeSH

urinary tract infections

A review of some of the challenges involved in the diagnosis and management of urinary tract infections in older women. James W. Mold, MD, MPH

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This Clinical Insights discusses special considerations in recurrent urinary tract infection diagnosis and management in older women.

Author/s:

Alison J Huang, Deborah Grady, Lona Mody

Uterine Fibroids

Alex Haga — Tue, 23 Apr 2024 17:28:25 +0000

Date Added:

April 23, 2024

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

April 10, 2024

URL:

Uterine Fibroids

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.0447

Keywords

MeSH

A review of current knowledge regarding uterine fibroids and what to do about them. James W. Mold, MPH

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Uterine fibroids are sex–steroid responsive benign tumors primarily composed of smooth muscle cells and extracellular matrix that develop in the wall of the uterus.1 They are one of the most common neoplasms in reproductive-aged women. Lifetime prevalence estimates in premenopausal women range from 40% to 89%, depending on the method of detection, the study population, and the ages of those studied. Fibroids can range in size from less than 1 cm to more than 20 cm. Although not all individuals with fibroids have symptoms, typical symptoms include abnormal uterine bleeding/heavy menstrual bleeding (AUB/HMB), pelvic bulk symptoms (protruding abdomen, pressure on bladder and bowels), pain, and reproductive morbidity (ie, infertility). Due to their high prevalence and associated symptoms, fibroids are the leading cause of hysterectomy in the US and account for up to $34 billion annually in direct and indirect costs.

Author/s:

Marsh, E.E., Wegienka, G., Williams, D.R.

Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction

Aubrey Delammermore — Tue, 25 Oct 2022 05:00:00 +0000

Date Added:

October 25, 2022

Journal/Publication:

New England Journal of Medicine Evidence

Publisher:

Massachusetts Medical Society

Publication Date:

July 7, 2022

Issue:

Volume:

URL:

Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction

Type:

Clinical Research Results

Format:

Article

Keywords

Sacral Neuromodulation

Lower Urinary Tract Dysfunction

referral and consultation

Odds Ratio

Randomized Controlled Trials as Topic

MeSH

Electric Stimulation Therapy

Many patients with various forms of neurogenic bladder (neurogenic lower urinary tract dysfunction) appear to benefit significantly from sacral neuromodulation, a fairly simple, reversible surgical procedure. James W. Mold, MD, MPH

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BACKGROUND
Neurogenic lower urinary tract dysfunction (NLUTD) is a highly prevalent and disabling condition; nevertheless, standard treatments often remain unsatisfactory. Sacral neuromodulation (SNM) is a well-established therapy for non-NLUTD, but there is a lack of randomized controlled trials to show benefit in patients with NLUTD.

METHODS
For this sham-controlled, double-blind, multicenter trial, patients with refractory NLUTD (and intended SNM) were recruited at four Swiss SNM referral centers. After lead placement into the sacral foramina S3 (rarely, S4), all participants underwent SNM testing. If successful (≥50% improvement in key bladder diary variables), the neurostimulator was implanted for permanent stimulation. For 2 months, neuromodulation was optimized using subsensory stimulation with individually adjusted parameters. Thereafter, the neurostimulator remained on or was switched off (1:1 random allocation to group SNM ON or SNM OFF, respectively) for 2 months, followed by a neurourologic reevaluation. The primary outcome was success, as defined above, of SNM compared with baseline.

RESULTS
Of 124 patients undergoing SNM testing, 65 (52%) had successfully improved lower urinary tract function. Of these, 60 patients (median age, 49.5 years; 43 women) were randomly assigned to the intervention. After 2 months of intervention, the SNM ON group demonstrated a success rate of 76%. In the SNM OFF group, 42% of patients showed sustained SNM effects despite their neurostimulator being switched off during the last 2 months (odds ratio, 4.35; 95% confidence interval, 1.43 to 13.21; P=0.009). During the entire study period, there were 11 adverse events (6 dropouts; no dropouts during the intervention phase).

CONCLUSIONS
SNM effectively corrected refractory NLUTD in the short term in well-selected neurologic patients. (Funded by the Swiss National Science Foundation, Vontobel–Stiftung, Gottfried und Julia Bangerter–Rhyner Stiftung, Dr. Urs Mühlebach, and the Swiss Continence Foundation; ClinicalTrials.gov number, NCT02165774.)

Author/s:

Liechti, M. D., van der Lely, S., Knüpfer, S. C., Abt, D., Kiss, B., Lietner, L., Mordasini, L., Tornic, J., Wöllner, J., Mehnert, U., Bachmann, L. M., Burkhard, F. C., Engeler, D. S., Pannek, J., Kessler, T. M.

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study

Brian Desmarais — Thu, 27 Jun 2019 13:04:17 +0000

Date Added:

June 27, 2019

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

June 24, 2019

URL:

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2019.0677.

Keywords

MeSH

Muscarinic Antagonists

antipsychotic agents

Middle Aged

Anticonvulsants

Confounding Factors (Epidemiology)

Urinary Bladder

cholinergic antagonists

antidepressive agents

I am only posting this article because your patients may ask about it. The research design isn’t very strong, and the association strengths aren’t terribly impressive. The dementia diagnoses weren’t confirmed, and I can’t tell whether patients were still taking the meds, which we know can cause acute cognitive impairment.. James W. Mold, MD, MPH

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IMPORTANCE:

Anticholinergic medicines have short-term cognitive adverse effects, but it is uncertain whether long-term use of these drugs is associated with an increased risk of dementia.

OBJECTIVE:

To assess associations between anticholinergic drug treatments and risk of dementia in persons 55 years or older.

DESIGN, SETTING, AND PARTICIPANTS:

This nested case-control study took place in general practices in England that contributed to the QResearch primary care database. The study evaluated whether exposure to anticholinergic drugs was associated with dementia risk in 58 769 patients with a diagnosis of dementia and 225 574 controls 55 years or older matched by age, sex, general practice, and calendar time. Information on prescriptions for 56 drugs with strong anticholinergic properties was used to calculate measures of cumulative anticholinergic drug exposure. Data were analyzed from May 2016 to June 2018.

EXPOSURES:

The primary exposure was the total standardized daily doses (TSDDs) of anticholinergic drugs prescribed in the 1 to 11 years prior to the date of diagnosis of dementia or equivalent date in matched controls (index date).

MAIN OUTCOMES AND MEASURES:

Odds ratios (ORs) for dementia associated with cumulative exposure to anticholinergic drugs, adjusted for confounding variables.

RESULTS:

Of the entire study population (284 343 case patients and matched controls), 179 365 (63.1%) were women, and the mean (SD) age of the entire population was 82.2 (6.8) years. The adjusted OR for dementia increased from 1.06 (95% CI, 1.03-1.09) in the lowest overall anticholinergic exposure category (total exposure of 1-90 TSDDs) to 1.49 (95% CI, 1.44-1.54) in the highest category (>1095 TSDDs), compared with no anticholinergic drug prescriptions in the 1 to 11 years before the index date. There were significant increases in dementiarisk for the anticholinergic antidepressants (adjusted OR [AOR], 1.29; 95% CI, 1.24-1.34), antiparkinson drugs (AOR, 1.52; 95% CI, 1.16-2.00), antipsychotics (AOR, 1.70; 95% CI, 1.53-1.90), bladder antimuscarinic drugs (AOR, 1.65; 95% CI, 1.56-1.75), and antiepileptic drugs (AOR, 1.39; 95% CI, 1.22-1.57) all for more than 1095 TSDDs. Results were similar when exposures were restricted to exposure windows of 3 to 13 years (AOR, 1.46; 95% CI, 1.41-1.52) and 5 to 20 years (AOR, 1.44; 95% CI, 1.32-1.57) before the index date for more than 1095 TSDDs. Associations were stronger in cases diagnosed before the age of 80 years. The population-attributable fraction associated with total anticholinergic drug exposure during the 1 to 11 years before diagnosis was 10.3%.

CONCLUSIONS AND RELEVANCE:

Exposure to several types of strong anticholinergic drugs is associated with an increased risk ofdementia. These findings highlight the importance of reducing exposure to anticholinergic drugs in middle-aged and older people.

Author/s:

Coupland, C.A.C., Hill, T., Dening, T., Morriss, R., Moore M., Hippisley-Cox J.