Options for the treatment of bladder dysfunction in neurologic disease, "Beyond the Abstract," by Eliza Lamin, MD

BERKELEY, CA (UroToday.com) - There is much information available to the public for patients and prescribers about the different treatment options for overactive and neurogenic bladder. The goal of this paper was to outline the available treatment options, including side effects and cost. While not traditionally considered by doctors or patients, cost has become an important consideration in the treatment of chronic conditions like bladder dysfunction. Cost can have a large impact on the treatment choice a patient makes.

In the category of antimuscarinic drugs for overactive bladder, the least expensive option is oxybutynin IR, but the oral dosage has significant side effects of dry mouth and cognitive dysfunction in the elderly. The ER, patch, and gel formulations were created to address this, with some success. Other antimuscarinic agents have been developed with greater muscarinic receptor selectivity and are thought to better target the bladder and have fewer side effects. These include tolterodine, trospium, solifenacin, darifenacin, and fesoterodine. When bladder symptoms are refractory to antimuscarinincs, or side effects are intolerable, there are other medications that may be beneficial (beta-agonists, phosphodiesterase inhibitors, and tricyclic antidepressants). Desmopressin and baclofen have also been used to treat nocturnal polyuria and detrusor sphincter dyssynergia, respectively. Our review organized these products to better understand mechanism, side effects, and cost, with the goal of proving the reader with a framework to decide which drug to use; we also addressed the pharmacologic options for difficulty or incomplete emptying (alpha adrenergic agents).

Non-pharmacologic options including percutaneous tibial nerve stimulation (PTNS), sacral neuromodulation (InterStim®), and botulinum toxin A injections for refractory idiopathic or neurogenic overactive bladder were addressed. Cost comparison found that PTNS is more expensive in the short term compared to oral options (tolterodine), but in the long run is more cost effective. PTNS was slightly less expensive then Botox injections (over a 2-year period). The InterStim® device, which is approved for treatment of refractory overactive bladder as well as non-obstructive urinary retention, is often used off label for mixed symptom neurogenic bladder dysfunction. While significantly more expensive in upfront cost than the other treatment modalities, long term cost and cost effectiveness data are lacking. A major limitation to its use in the neurogenic population is MRI incompatibility, with the exception of brain MRI, for which it is approved.

There is very little data on patient satisfaction and cost effectiveness of major surgery such as augmentation cystoplasty for refractory idiopathic or neurogenic overactive bladder. As minimally invasive surgical options become more widely available, it will be important to study the cost effectiveness of these modalities. This information will help in the development of treatment paradigms aimed at maximizing patient satisfaction and minimizing cost.

Written by:
Eliza Lamin, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA USA

Urologic agents for treatment of bladder dysfunction in neurologic disease - Abstract

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