Fda Approves New Indication For Botox For Urinary Incontinence
On January 18, 2013, the U.S. Food and Drug Administration announced a new approval for Botox, generically known as OnabotulinumtoxinA. Patients diagnosed with urinary incontinence due to an overactive bladder can be prescribed Botox, if they are unable to take or are unresponsive to anticholinergic medications. This new indication is supported by two clinical trials of 1,105 patients with symptoms of overactive bladder, where patients randomly received injections of 100 units of Botox or placebo. After 12 weeks, those treated with Botox experienced urinary incontinence an average of 1.6 to 1.9 times less per day and also needed to urinate on average 1.0 to 1.7 times less per day than the placebo group.1
For overactive bladder, the recommended dose is 100 Units of Botox, which is also the maximum recommended dose. Prophylactic treatment for urinary tract infection is also important. Antibiotics, other than aminoglycosides, should be administered 1 3 days pre-treatment, on the day of treatment, and 1 3 days post-treatment to reduce this risk.5
Mechanisms Of Urinary Continence
In healthy individuals, the urinary bladder senses the volume of urine by means of distention. Distention of the bladder excites afferent A-delta fibers that relay information to the pontine storage center in the brain. The brain, in turn, triggers efferent impulses to enhance urine storage through activation of the sympathetic innervation of the lower urinary tract . These impulses also activate the somatic, pudendal, and sacral nerves.1
The hypogastric nerves release norepinephrine to stimulate beta3-adrenoceptors in the detrusor and alpha1-adrenoceptors in the bladder neck and proximal urethra. The role of beta3-adrenoceptors is to mediate smooth-muscle relaxation and increase bladder compliance, whereas that of alpha1-adrenoceptors is to mediate smooth-muscle contraction and increase bladder outlet resistance.1 The somatic, pudendal, and sacral nerves release acetylcholine to act on nicotinic receptors in the striated muscle in the distal urethra and pelvic floor, which contract to increase bladder outlet resistance.1
Efferent sympathetic outflow and somatic outflow are stopped when afferent signaling to the brain exceeds a certain threshold. At this point, the parasympathetic outflow is activated via pelvic nerves. These nerves release acetylcholine, which then acts on muscarinic receptors in detrusor smooth-muscle cells to cause contraction. A number of transmitters, including dopamine and serotonin, and endorphins are involved in this process.1
Botulinum Toxin Injections For Oab
You might be wondering, “Botox? Like movie stars use on their forehead?” Yes, the same substance that dermatologists use to smooth out wrinkles can also be used to relax an overactive bladder.
To treat incontinence, doctors inject botulinum toxininto the bladder muscle. This is done with a needle that is inserted via a long tube called a cystoscope that goes up into the bladder. “The goal is to reduce the over-activity of the bladder muscle so that the patient has better control, but still allow enough muscle contraction to empty the bladder,” Rames says. The effects generally last for about 9 months. So far there don’t seem to be any major side effects from botulinum toxin, although it’s only recommended if your symptoms aren’t controlled with behavioral therapies, medications, or a combination of both.
Show Sources
Linda Brubaker, MD, professor, department of obstetrics & gynecology and urology, Loyola University Chicago Stritch School of Medicine, Chicago.
Ross Rames, MD, associate professor of urology, Medical University of South Carolina, Charleston.
UpToDate: “Treatment of Urinary Incontinence.”
National Association for Continence: “Overactive Bladder Treatment.”
Duthie JB. Cochrane Summaries, Dec. 7, 2011.
National Association for Continence: “Urgency Urinary Incontinence/Overactive Bladder.”
News release, FDA.
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Overactive Bladder Causes And Symptoms
Overactive bladder is a clinical condition that happens when the muscles of the bladder contract involuntarily. When the bladder muscle contracts too frequently or at the wrong time, the person might have signs of an OAB.
The condition is marked by a sudden need to urinate that is difficult to manage with or without accidental urinary discharge and typically with elevated urinary frequency. Unintentional urinary leakage due to urgency is referred to as UUI. Excessive urination and nocturnal symptoms are some of the other symptoms of OAB.
More than 30 million people in the US suffer from troubling symptoms of OAB, which can significantly hamper the day-to-day activities of the patients.
Fda Approves Gemtesa For Overactive Bladder
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The FDA recently approved a new drug application for Gemtesa, a novel treatment for overactive bladder in adults, its manufacturer announced in a press release.
Gemtesa helps relax the detrusor bladder muscle, enabling the bladder to hold more urine, thereby reducing symptoms of overactive bladder, according to the manufacturer.
Gemtesa is the first beta 3-agonist available as a once-daily pill which does not require dose titration,David Staskin, MD, a clinical trial investigator and a leading urologist at St. Elizabeths Medical Center in Boston, said in a press release.
The FDAs approval of vibegron was based on data from the 12-week, double blind, placebo-controlled, phase 3 EMPOWUR study, which included more than 4,000 patients with overactive bladder. The results showed that vibegron was associated with statistically significant reductions in daily urge urinary incontinence, micturitions and urgency episodes, according to the press release.
The most common adverse events tied to vibegron use were diarrhea, headache, nasopharyngitis, nausea and upper respiratory tract infection, Urovant Sciences said in the release.
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Fda Oks New Treatment For Patients With Overactive Bladder
Vibegron 75 mg tablets are indicated to treat patients with an overactive bladder.
Officials with the FDA have approved vibegron 75 mg tablets for the treatment of patients with an overactive bladder .
According to Sumitovant, vibegron is the first new oral branded OAB medication approved by the FDA since 2012. In OAB, the bladder muscle contracts involuntarily, resulting in symptoms such as urinary urgency, urgency incontinence, frequent urination, and nocturia.
Vibegron is a once-daily, oral beta-3 adrenergic receptor agonist designed to treat symptom such as urge urinary incontinence , urgency, and urinary frequency in adults.
The approval was based on data from a clinical trial program involving more than 4000 patients with OAB, including the 12-week, double-blind, placebo-controlled phase 3 EMPOWUR study with a dose of 75 mg and the double-blind EMPOWUR long-term extension study. The results showed that treatment with vibegron significantly reduced daily UUI, micturitions, and urgency episodes, as well as an increase in the volume voided when compared with placebo.
According to clinical trial investigators, the data showing a reduction in urgency episodes is unique among currently available OAB treatments.
The FDA granted the approval for vibegron to Urovant Sciences, a member of the Sumitovant family of companies. Urovant Sciences plans to launch vibegron in the US in late first quarter of 2021.
Reference:
Pharmacologic Agents That Cause Urinary Incontinence
A variety of drugs have been implicated in urinary incontinence, and attempts have been made to determine the mechanism responsible based upon current understanding of the processes involved in continence and the transmitters that play a role. Each of the processes described previously can be manipulated by pharmacologic agents to cause one or more types of incontinence.
The drugs commonly pinpointed in urinary incontinence include anticholinergics, alpha-adrenergic agonists, alpha-antagonists, diuretics, calcium channel blockers, sedative-hypnotics, ACE inhibitors, and antiparkinsonian medications. Depending upon the mode of action, the effect may be direct or indirect and can lead to any of the types of incontinence. Taking these factors into account, it is important to consider a patients drug therapy as a cause of incontinence, particularly in new-onset incontinence patients and in elderly patients, in whom polypharmacy is common.11,12
On the other hand, a pharmacologic agent or any other factor that results in chronic urinary retention can lead to a rise in intravesical pressure and a resultant trickling loss of urine. In this way, drugs that cause urinary retention can indirectly lead to overflow incontinence.2
It is useful to note that many antidepressants and antipsychotics exhibit considerable alpha1-adrenoceptor antagonist activity.1
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New Treatment Options For Urge Incontinence
Posted August 2014
Update on new treatment options for urge incontinence
- Botulinum toxin bladder wall injection
- Sacral neurostimulation implant
- Mirabegron medication
Botox
In Australia Botox has received regulatory approval for the management of urge incontinence in women who do not respond to oral medications. Botox for the treatment of urge incontinence is now covered by health funds. The treating doctor must be an approved provider . Botox injection into the bladder wall is simple and effective therapy. It can be performed under local anaesthesia as a day procedure. Women who undergo Botox bladder wall injections come into hospital and have a solution of local anaesthetic placed in the bladder. This solution takes approximately 20 minutes to anaesthetise the bladder. A small telescope is passed through the urethra into the bladder. This telescope allows Dr Carey to inject the Botox into the bladder wall under vision. Botox treatments tend to wear off over 6 to 12 months and repeat top-up injections are generally required. The main potential side-effect of Botox injections into the bladder wall is incomplete bladder emptying occurring in about 6 in 100 women.
Sacral neurostimulation implant
Mirabegron medication
What Is Urinary Incontinence
Many people experience involuntary leakage of urine from the bladder. This condition is called urinary incontinence. It affects nearly a quarter to a third of men and women in the United States. That is millions of Americans.
Urinary incontinence is the leaking of urine from the bladder that you cant control. There are different kinds of urinary incontinence, and not all types are permanent. An experienced doctor can help you find the best treatment for your urinary incontinence.
Stress urinary incontinence is when the muscles arent strong enough to hold urine in the body. SUI shows itself through physical symptoms, including involuntary leaking of urine through the bladder when active.
Overactive bladder is a strong sudden urge to urinate, which may or may not cause urine to leak from the bladder.
In some cases, people experience a combination of both SUI and OAB. This shows itself through physical symptoms. If this is the case for you, you will find involuntary leaking of urine through the bladder and strong sudden urges to urinate that you cant control.
Overflow incontinence is when the bladder isnt able to empty itself completely. Overflow incontinence shows itself through physical symptoms, including constant dribbling of small amounts of urine when the bladder is full.
These symptoms are not just physical. Urinary incontinence has emotional and psychological effects, too.
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Basic Evaluation Of Stress Urinary Incontinence
When women are evaluated for SUI, counseling about treatment should begin with conservative options. The minimum evaluation before primary midurethral sling surgery in women with symptoms of SUI includes the following six steps: 1) history, 2) urinalysis, 3) physical examination, 4) demonstration of stress incontinence, 5) assessment of urethral mobility, and 6) measurement of postvoid residual urine volume.
Who Can And Cannot Take Mirabegron
Mirabegron can be taken by adults .
It is not suitable for everyone. To make sure it’s safe for you, tell your doctor or pharmacist before starting mirabegron if you:
- have had an allergic reaction to mirabegron or any other medicines in the past
- have liver or kidney problems
- have high blood pressure
- are not able to pee or empty your bladder completely
- have a blockage in your bladder
- have a heart problem called QT prolongation
- are pregnant, trying to get pregnant or breastfeeding
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Transvaginal Needle Suspension Procedures
Transvaginal needle suspension techniques evolved as a minimally invasive alternative to the retropubic procedures for SUI due to urethral hypermobility. The original transvaginal needle suspension was first described by Armand Pereyra, MD, in 1959. Since then, however, many modifications of this procedure have been reported. The common feature of each of these modifications is that the anterior abdominal wall fascia is not incised and the suspending sutures are passed through the retropubic space from the vagina to the anterior abdominal wall with a specialized long ligature passer.
Advantages to the transvaginal approach include the avoidance of a large, transfascial abdominal incision shorter operative times less postoperative discomfort shorter hospital stay and the ability to repair coexisting vaginal pathology through the same or slightly extended incision. Disadvantages include a potentially lower long-term cure rate poor intraoperative visualization risk of injury to the bladder and urethra during blind passage of the needles through the retropubic space risk of significant bleeding in the retropubic space with poor operative access from the vaginal incisions and, lastly, infection or erosion of a foreign body if suture buttresses are utilized .
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How To Do Them
Stand, sit or lie down with your knees slightly apart. Relax.
Find your pelvic muscle. Imagine that you are trying to hold back urine or a bowel movement. Squeeze the muscles you would use to do that. DO NOT tighten your stomach or buttocks.
Women: to make sure youve got the right muscle, insert your finger into your vagina while you do the exercise. You should feel a tightening around your finger.
Men: when you tighten the pelvic floor muscle, your penis will twitch and contract in towards your body.
- Tighten the muscles for 5 to 10 seconds. Make sure you keep breathing normally
- Now relax the muscles for about 10 seconds
- Repeat 1220 times, three to five times a day
Stick to it! You should begin to see results after a few weeks. Like any other muscle in your body, your pelvic muscles will only stay strong as long as you exercise them regularly.
If youre having a hard time doing Kegel exercises, your healthcare professional can teach you how to do them correctly. He/she may even suggest a tool or device to help make sure youre using the right muscles .
Your doctor may also suggest biofeedback, a training technique thats used to monitor the contraction of the pelvic floor muscles as you do your Kegel exercises. Biofeedback uses a machine that records the contractions of your muscles and translates the movement into a visual signal that you can watch on a monitor. Some people find this helpful in learning how to do Kegel exercises correctly.
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Treating And Managing Urinary Incontinence
Today, there are more treatments and ways to manage urinary incontinence than ever before. The choice of treatment depends on the type of bladder control problem you have, how serious it is, and what best fits your lifestyle. As a general rule, the simplest and safest treatments should be tried first.
A combination of treatments may help you get better control of your bladder. Your doctor may suggest you try the following:
What If I Miss A Dose
If you miss a dose of Gemtesa, take it as soon as you remember. However, if its almost time for your next dose, you may need to skip the missed dose and take your next dose at the scheduled time.
If you have any questions about when to take your next dose of Gemtesa after you miss a dose, talk with your doctor or pharmacist.
To help make sure that you dont miss a dose, try using a medication reminder. This can include setting an alarm or timer on your phone or downloading a reminder app. A kitchen timer can work, too.
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Fda Approves New Overactive Bladder Drug
Myrbetriq Treats OAB in a New Way
Myrbetriq is an extended-release pill taken once a day. Overactive bladder is a condition in which the bladder muscle cannot be controlled, so it contracts at inappropriate times. Symptoms of overactive bladder include:
- the need to urinate too often
- inability to put off urination
- involuntary urine leakage
In a news release, the FDA says Myrbetriq’s safety and effectiveness were demonstrated in three studies that compared the drug to a placebo. The studies involved more than 4,000 patients.
“An estimated 33 million Americans suffer from overactive bladder, which is uncomfortable, disrupting, and potentially serious,” Victoria Kusiak, MD, of the FDA’s Center for Drug Evaluation and Research, says in the news release. “Today’s approval provides a new treatment option for patients with this debilitating condition.”
Control Your Urge To Urinate
You may be able to control, or suppress, the strong urge to urinate, which is called urge or urgency suppression. With this type of bladder training, you can worry less about finding a bathroom in a hurry. Some people distract themselves to take their minds off needing to urinate. Other people find that long, relaxing breaths or holding still can help. Doing pelvic floor exercises to strengthen your pelvic floor also can help control the urge to urinate. Quick, strong squeezes of the pelvic floor muscles can help suppress urgency when it occurs, which may help you get to the toilet before you leak.
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Urinary Incontinence Treatment & Management
- Author: Sandip P Vasavada, MD Chief Editor: Edward David Kim, MD, FACS
Treatment is keyed to the type of incontinence. The usual approaches are as follows:
- Stress incontinence – Surgery, pelvic floor physiotherapy, anti-incontinence devices, and medication
- Urge incontinence – Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention
- Mixed incontinence – Anticholinergic drugs and surgery
- Overflow incontinence – Catheterization regimen or diversion
- Functional incontinence – Treatment of the underlying cause
Some experts recommend a trial of medical therapy before considering surgical treatment. Others believe that if the incontinence is severe and correctable by surgical means, a trial of medical therapy is not mandatory and need not be performed if the informed patient chooses to proceed directly to surgery.
Treatment of comorbid disease may minimize incontinence episodes. Measures such as smoking cessation, control of asthma, and relief of chronic constipation may be beneficial.
A network meta-analysis of 84 randomized trials of urinary incontinence concluded that behavioral therapies are generally more effective than pharmacologic interventions for stress or urge urinary incontinence, Findings included the following: