Systematic review of therapy for neurogenic detrusor overactivity

Abstract

While many neurologic diseases predispose patients to neurogenic detrusor overactivity (NDO), the only populations that have been systematically studied are adults with multiple sclerosis (MS), adults with spinal cord injury (SCI) and children and young adults with myelodysplasia. First-line pharmacotherapy for NDO is an antimuscarinic drug. However, the evidence base for these agents in this indication is poor. There is some high-quality evidence for the efficacy of detrusor injections of botulinum toxin A in the treatment of NDO, with significant reduction in urgency incontinence episodes, improved urodynamic parameters, and improved quality of life. While few adverse events have been reported with this therapy, there is a need for intermittent self-catheterization in these groups. N eurogenic detrusor overactivity (NDO) can be seen with various neurological diseases. At present, however, the only such populations that have been systematically studied are adults with multiple sclerosis (MS) and spinal cord injury (SCI) and children and young adults with myelodysplasia. There have yet to be any randomized, controlled studies evaluating therapy for NDO in Parkinson's Disease or dementia. This review will, therefore, focus on the available treatment evidence from the above-mentioned conditions. Antimuscarinic therapy for neurogenic detrusor overactivityThe first-line, mainstay treatment of NDO is the antimuscarinic drugs. This practice is not, however, based on a great deal of high quality research. Indeed, the body of evidence for their efficacy based on randomized controlled trials (RCTs) is surprisingly poor. In total, there are only five Grade-A studies in adults.1-5 These studies, which spanned from 1985 to 2007, examined the effect of oral propiverine, oxybutynin, trospium or propantheline or intravesical atropine. The research in MS has also been reviewed in a systematic fashion in a Cochrane review published in 2009. 6 In children with myelodysplasia, there are two RCTs 7,8 and 11 observational studies. 9-19Looking at all this evidence, propiverine, trospium, oxybutynin, propantheline and tolterodine have all been shown to produce clinical and some evidence of urodynamic improvement in NDO. Although this evidence is sufficient to conclude that "antimuscarinics are effective in NDO," prescribing more recently introduced antimuscarinics is not evidence-based. Rather, there is an assumption that their demonstrated efficacy in non-neurogenic DO is "carried over" to the NDO group. Indeed, everyday clinical experience does seem to bear that assumption out and even suggests that antimuscarinics may in fact be more efficacious in NDO than in idiopathic DO and that their benefits are longer lasting. Other oral therapies for neurogenic detrusor overactivity DesmopressinThe evidence for efficacy of desmopressin in MS for treatment of nocturia and daytime frequency is level 1, based on the results of a meta-analysis published in 2005. 20 However, desmopressin does carry the risk of hyponatremia, particularly ...

Alterations in Nerve-Evoked Bladder Contractions in a Coronavirus-Induced Mouse Model of Multiple Sclerosis

“…Currently, therapeutic options are not specific for neurogenic bladder, lack efficacy, and have poor patient adherence [12] . Antimuscarinic drugs are the first-line of treatment, however there is little evidence to support their efficacy in neurogenic bladder dysfunction [12] , [13] .…”

“…Currently, therapeutic options are not specific for neurogenic bladder, lack efficacy, and have poor patient adherence [12] . Antimuscarinic drugs are the first-line of treatment, however there is little evidence to support their efficacy in neurogenic bladder dysfunction [12] , [13] . A better understanding of the pathological changes in bladder innervation and effects of nerve degeneration on the contractile mechanisms of the detrusor will lead to the development of much-needed treatment options for this subset of patients.…”

Symptomatic management in multiple sclerosis

“…Pelvic floor exercises and behavior therapy has shown to help bladder frequency or urgency. [ 69 70 ] While robust clinical trial evidence is limited,[ 71 ] a number of anticholinergic drugs are used commonly as first-line pharmacotherapy. These include oxybutynin, trospium, tolterodine, propiverine, solifenacin, derifenacin, and mirabegron.…”

Botulinum neurotoxin-A treatment of lower urinary tract symptoms in multiple sclerosis

“…30,31 Alpha-adrenergic antagonists may reduce outlet resistance, and other oral therapies (desmopressin and cannabinoids) may be indicated to improve urinary symptoms in specific situations. 29,32 Intravesical therapy of urgency and incontinence with vanilloid agents (resiniferatoxin, capsaicin) has delivered inconsistent outcomes. 33 Sacral nerve stimulation appears to be more effective than posterior tibial or dorsal penile/clitoral stimulation; however, the implantable stimulator precludes further MRI evaluation.…”