Page 18 - Bladder Dysfunction in the Context of the Bladder-Brain Connection - Ilse Groenendijk.pdf

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Chapter 1
invasive therapies has been proven, patients’ therapy adherence decreases on the long term and causes the effect of these therapies to fade.35, 36 Evidence suggests that pelvic floor muscle training is effective not only in patients with stress UI, but also in patients with urgency UI, mixed UI, pelvic organ prolapse or bowel dysfunction.36
Many different Pharmacological therapies are available in functional urology. Anti- muscarinics have been the cornerstone in pharmacotherapy of OAB. Although various antimuscarinics differ in pharmacological and pharmacokinetic profiles, the use of the majority of these agents is limited because of the suboptimal efficacy or bothersome side effects in particular dry-mouth and constipation.37, 38 In 2013, the first beta3 agonist became clinically available: mirabegron.33 As the working mechanism is different from that of antimuscarinics, beta3 agonists have a different profile of side effects and might therefore be beneficial for some patients. The reported dry rates for tolterodine (anti- muscarinic) and mirabergron were both around 45%, and therapy adherence was also comparable between both drugs.39 For the treatment of LUTS attributable to benign prostatic hyperplasia, alpha-blockers still have the most established role, despite new available drug combinations.40 Pharmacological therapies for other diseases in the field of functional urology, such as UAB and BPS, do not yet have a place within clinical practice. Some large trials are currently investigating pharmacological therapies for UAB and BPS.
Intermittent self-catheterization is a therapy for patients who are unable to void, or have a significant post void residual. The therapy can decrease the risk of renal failure and the amount of urinary tract infections in patients with UAB and is often indicated in neuro-urological patients, to decrease the bladder pressure and to preserve kidney function.18, 20
Invasive therapies range from minimally invasive treatments to invasive surgery like the construction of a urinary diversion.
Different minimally-invasive surgical options exist for stress UI, with good results for both women and men.41, 42 For the treatment of refractory urgency UI, either botulinum toxin A injections or sacral neuromodulation are indicated as minimally-invasive thera- pies.
Injections with botulinum toxin A is an often-used therapy in patients with neuro- urological disorders. Botulinum toxin A is described to achieve a long-lasting but reversible chemical denervation of the bladder. Possible disadvantages are the need of intermittent catheterization, and the occurrence of urinary tract infections.43
Sacral neuromodulation is another option in patients with refractory urgency UI. This implies the placement of an electrode in the sacral foramen alongside a sacral nerve, usually S3. Chronic electrical stimulation of the afferent somatic sacral nerve fibers inhibits the detrusor muscle.44 The long-term success rates in responders are reported to be 67%.45 An accurate screening test is necessary to distinguish responders from