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Overactive Bladder and Incontinence
State of the Art in the Second-line Management of
Idiopathic Overactive Bladder – InterStim Therapy in Perspective
Dirk De Ridder
Head of Clinic, Department of Urology, University Hospital Leuven
Abstract
Idiopathic overactive bladder (I-OAB) is a prevalent and bothersome condition that requires appropriate therapeutic management. When
conservative approaches, such as lifestyle management or antimuscarinics, lead to unsatisfactory results after three months at the most, it
is advisable to progress to specialised management. This review sheds light on the state of the art in minimally invasive second-line therapies
with respect to current clinical evidence of (long-term) efficacy and tolerability/safety. While intradetrusor injection of botulinum toxin-A
therapy remains unlicensed and exploratory for I-OAB to date, sacral neuromodulation (SNM) by InterStim therapy is an approved and well-
established treatment modality for this disorder, in particular when combined with other pelvic floor morbidities. As second-line treatment
options for I-OAB, international urological guidelines endorse SNM with a level A/B recommendation; however, botulinum toxin-A (and
invasive bladder augmentation) received a grade C in women only. Therefore, SNM offers a valuable and worthwhile alternative in the
armamentarium of functional urologists.
Keywords
Botulinum toxin type A, muscarinic antagonists, practice guidelines, sacral neuromodulation, therapeutics, urinary bladder, overactive
Disclosure: Dirk De Ridder is a consultant for Astellas, Pfizer and American Medical Systems (AMS) and an investigator for Allergan, Ipsen, Astellas, Pfizer and AMS.
Acknowledgement: The author is grateful to Ismar Healthcare NV for writing assistance. This was funded by Medtronic International Trading Sarl.
Received: 16 November 2009 Accepted: 10 December 2009
Correspondence: Dirk De Ridder, Head of Clinic, Department of Urology, University Hospital Leuven (Gasthuisberg campus), Herestraat 49, 3000 Leuven, Belgium.
dirk.deridder@uzleuven.be
Overactive Bladder Syndrome are fairly similar and subdivided into initial (i.e. first-line) and specialised
Overactive bladder (OAB) syndrome is a chronic condition (i.e. second-line) treatment for different target sub-groups.
1,4
characterised by a combination of urinary storage symptoms, i.e.
urgency with or without urinary urgency incontinence (UUI), usually First-line Management
with frequency and nocturia.
1
In many cases, OAB is idiopathic With regard to first-line management of I-OAB, it is recommended
(i.e. existing without a discernable pathology) and can be associated that clinicans start by providing appropriate lifestyle advice, physical
with idiopathic detrusor overactivity. The typical symptoms are and behavioural therapies (bladder re-training with scheduled
bothersome for patients and substantially decrease the quality of life voiding times, pelvic floor muscle training, biofeedback, etc.) and/or
of millions of people worldwide, given the overall prevalence rate of pharmacotherapy with antimuscarinic agents.
OAB of about 12%, as reported in a population-based survey in four
European countries and Canada.
2
In fact, as the population ages, the Antimuscarinics are an approved and established treatment
prevalence of OAB will invariably increase,
1
leading to even greater option for patients with I-OAB;
5
they were more effective than
hardship. However, high prevalence rates do not necessarily reflect placebo in a meta-analysis of a high number of randomised
the need for treatment, since discomfort caused by these symptoms controlled trials.
6
However, since most studies ran for less than 12
may depend on other factors. Often, OAB symptoms co-exist with weeks, long-term proof of efficacy is limited.
6,7
In addition, almost
other lower urinary tract symptoms. Apart from its social burden on all agents were found to increase the risk of (systemic) adverse
patients, OAB also places an enormous pressure on society and events compared with placebo. The most common event reported
healthcare systems, which highlights the need for effective forms of was dry mouth (30 versus 8%), followed by pruritus (15 versus 5%)
appropriate management.
3
and constipation (8 versus 4%).
6
While the efficacy–tolerability
balance of individual agents differs,
6
the occurrence of side effects
Current State of the Art in the Management of and the daily therapy burden may explain the low adherence and
Idiopathic Overactive Bladder continuation rate with antimuscarinics in clinical practice. Repeat
Guidance for appropriate management of idiopathic OAB (I-OAB) is prescription data from the UK showed a median duration of
provided by leading urological organisations, i.e. the International antimuscarinic drug use of only three months.
7
Moreover, nearly
Consultation on Incontinence (ICI) and the European Association of half (42%) of patients with OAB have discontinued their medication
Urology. Their most recent treatment algorithms for patients with UUI four months after prescription.
8
40 © TOUCH BRIEFINGS 2009
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