Autori ed affiliazione:
Giana Michele1,Caccia Stefano2,Ponili Alberto3
1,2,3 Clinica Ginecologica e Ostetrica Centro di Chirurgia ginecologica oncologica avanzato
Università degli Studi del Piemonte Orientale “A. Avogadro” - A.O.U. “Maggiore della Carità”– Novara
Topic: Overactive bladder management
Scopo. Overview of overactive bladder management e treatment.
Materiali e metodi. Review of literature concerning management and treatment.
Risultati. The International Continence Society defines overactive bladder as “urgency, with or without urge incontinence, usually with frequency (voiding eight or more times in a 24-hour period) and nicturia (awakening two or more times at night to void)”. Of these, urgency is the cardinal symptom (in absence of pathologic or metabolic conditions that might explain these symptoms). Treatment options for OAB include: lifestyle modification, behavioural therapy, bladder retraining programs, pharmacological, surgical interventions and neuromodulation. Antimuscarinics (anticholinergics) are the mainstay of oral pharmacotherapy for OAB. Although newer preparations of these medications have sought to improve tolerability and efficacy through alternative routes of delivery and once-daily dosing, improved adherence to treatment and treatment persistence continue to be an ongoing challenge. Antimuscarins have been somewhat limited by the high incidence of side effects and lack of selectivity; MRAs can have serious side effects, such as confusion and cognitive deficits, particularly in older people. Other central nervous system effects include dizziness, somnolence, insomnia, sedation, blurred vision or dry eyes. Assessing the success of first line treatment: improvement is measured by reduction in the number of 24 hour voids and in the number of episodes of frequency, urgency, and urge incontinence; Measurable improvement may take as long as 12 weeks, although it is sometimes seen as early as a week after starting treatment. It is reasonable to allow a four week window for assessing treatment response. After this time, if symptoms have not improved adequately and side effects have not been problematic, the drug can be titrated to a higher dose. We find that patients can see little improvement with one drug. β3 Adrenoceptor is the most abundant of the AR subtypes in human detrusor muscle, suggesting that this subtype mediates detrusor relaxation; the mechanism by which b-AR agonists induce relaxation of smooth muscles is not fully understood, but it is believed that an intracellular pathway for smooth muscle relaxation is activated by cAMP. Botulinum toxin A reduced urgency, frequency, and urge incontinence by 35-50%, significantly improved urodynamic parameters, including increased maximum cystometric capacity (ability to hold urine), increased volume before first involuntary detrusor contraction and the effects of this treatment begin to diminish at six to nine months and repeat treatments are necessary. The most common reasons for discontinuation were insufficient efficacy (13%) and temporary urinary retention (11%).
Conclusioni. Whilst conservative measures are generally used as first line treatment medical drug therapy remains integral in the management of women with OAB. Antimuscarinic agents are the most commonly used drugs although may be associated with troublesome side effects and also lack of efficacy. An improved understanding of the factors involved in persistence of medical OAB therapy is imperative in efforts to optimize therapeutic benefits in this chronic condition. The B3-adrenoceptor agonists represent the first new class of drugs for the treatment of OAB for over 30 years. Newer drugs that target different physiological pathways may soon replace conventional treatments or improve it, but it is too early to comment on their future usefulness.