Overactive Bladder (Non-Neurogenic) in Adults Flashcards

1
Q

Diagnosis of OAB: Minimum requirements for diagnosis

A

The clinician should engage in a diagnostic process to document symptoms and signs that characterize OAB and exclude other disorders that could be the cause of the patient’s symptoms

The minimum requirements for this process are

  • A careful history
  • Physical exam
  • Urinalysis
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2
Q

OAB Diagnosis: Tests done at the clinician’s discretion

A

In some patients, additional procedures and measures may be necessary to validate an OAB diagnosis, exclude other disorders and fully inform the treatment plan.

At the clinician’s discretion:

  • A urine culture
  • And/or post-void residual assessment
  • Information from bladder diaries and/or symptom questionnaires may be obtained
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3
Q

What should NOT be part of the initial workup of the uncomplicated OAB patient?

A

Urodynamics
Cystoscopy
Diagnostic renal and bladder ultrasound

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4
Q

Is OAB a disease?

A

OAB is not a disease; it is a symptom complex that generally is not a life- threatening condition.

After assessment has been performed to exclude conditions requiring treatment and counseling, no treatment is an acceptable choice made by some patients and caregivers.

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5
Q

Education for OAB Patients

A

Clinicians should provide education to patients regarding normal lower urinary tract function, what is known about OAB, the benefits versus risks/burdens of the available treatment alternatives and the fact that acceptable symptom control may require trials of multiple therapeutic options before it is achieved.

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6
Q

First line treatment for OAB

A

Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) as first line therapy to all patients with OAB.

  • Bladder training
  • Bladder control strategies
  • Pelvic floor muscle training
  • Fluid management

Recommendation: Behavioral therapies may be combined with pharmacologic management.

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7
Q

Second line treatment for OAB

A

Pharmacologic treatment

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8
Q

What second line treatment should be offered to patients with OAB?

A

Clinicians should offer oral anti-muscarinics or oral β3-adrenoceptor agonists as second-line therapy.

  • If an immediate release (IR) and an extended release (ER) formulation are available, then ER formulations should preferentially be prescribed over IR formulations because of lower rates of dry mouth.
  • Transdermal (TDS) oxybutynin (patch or gel) may be offered.

If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti- muscarinic medication, then a dose modification or a different anti-muscarinic medication or a β3-adrenoceptor agonist may be tried.

Clinicians may consider combination therapy with an anti-muscarinic and β3-adrenoceptor agonist for patients refractory to monotherapy with either anti-muscarinics or β3-adrenoceptor agonists.

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9
Q

What are contraindications for anti-muscarinics in patients with OAB?

A

Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless approved by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients with impaired gastric emptying or a history of urinary retention.

    • Narrow angle glaucoma
    • Impaired gastric emptying
    • History of urinary retention

Clinicians must use caution in prescribing anti-muscarinics in patients who are using other medications with anti- cholinergic properties.

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10
Q

If a patient gets constipation or dry mouth from an anti-muscarinic, what is the next step if the patient has OAB?

A

Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic therapy. Management may include bowel management, fluid management, dose modification or alternative anti- muscarinics.

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11
Q

What should you watch out for in a frail OAB patient?

A

Clinicians should use caution in prescribing anti-muscarinics or β3-adrenoceptor agonists in the frail OAB patient.

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12
Q

What happens if an OAB patient is refractory to behavioral and pharmacologic therapy?

A

Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy.

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13
Q

What are third line treatments for OAB?

A

Botox, PTNS and Neuromodulation

Of note, the OAB addendum says about PTNS: “n other words, the lines of therapy, while representing a successive increase in risk or invasiveness, are not intended to represent a strict algorithm. This is specifically relevant with regard to PTNS, as it is the opinion of the Panel that, given the minimally invasive and reversible nature of this therapy, juxtaposed with the potential side effects and cost of medications, PTNS can be considered in drug-naïve patients who opt to forego pharmacotherapy.”

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14
Q

Botox Dosing and Counseling in OAB

A

This is a third line treatment.

Clinicians may offer intradetrusor onabotulinumtoxinA (100U) as third-line treatment in the carefully-selected and thoroughly-counseled patient who has been refractory to first- and second-line OAB treatments. The patient must be able and willing to return for frequent post-void residual evaluation and able and willing to perform self- catheterization if necessary.

100!!!!
Be willing to self-cath (and able)

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15
Q

PTNS in OAB

A

Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected patient population.

THIRD LINE treatment

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16
Q

Sacral neuromodulation in OAB

A

Clinicians may offer sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure.

THIRD LINE treatment

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17
Q

What if something doesn’t work in the third line treatments for OAB?

A

Practitioners and patients should persist with new treatments for an adequate trial in order to determine whether the therapy is efficacious and tolerable. Combination therapeutic approaches should be assembled methodically, with the addition of new therapies occurring only when the relative efficacy of the preceding therapy is known. Therapies that do not demonstrate efficacy after an adequate trial should be ceased.

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18
Q

Fourth line treatment for OAB

A

In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB patients may be considered.

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19
Q

Should OAB patients have indwelling catheters?

A

Indwelling catheters (including transurethral, suprapubic, etc.) are not recommended as a management strategy for OAB because of the adverse risk/benefit balance except as a last resort in selected patients.

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20
Q

Follow-up for OAB

A

The clinician should offer follow up with the patient to assess compliance, efficacy, side effects and possible alternative treatments.

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21
Q

What are the symptoms of OAB?

A

– Urgency, urinary frequency, nocturia, urinary urge incontinence

Urgency is defined by IUGA/ICS as the “complaint of a sudden, compelling desire to pass urine which is difficult to defer.” Urgency is considered the hallmark symptom of OAB, but it has proven difficult to precisely define or to characterize for research or clinical purposes. Therefore, many studies of OAB treatments have relied upon other measures (e.g., number of voids, number of incontinence episodes) to measure treatment response.

Urinary frequency can be reliably measured with a voiding diary. Traditionally, up to seven micturition episodes during waking hours has been considered normal, but this number is highly variable based upon hours of sleep, fluid intake, comorbid medical conditions and other factors.

Nocturia is the complaint of interruption of sleep one or more times because of the need to void. In one study, three or more episodes of nocturia constitutes moderate or major bother. Like daytime frequency, nocturia is a multifactorial symptom which is often due to factors unrelated to OAB (e.g., excessive nighttime urine production, sleep apnea).

Urgency urinary incontinence is defined as the involuntary leakage of urine, associated with a sudden compelling desire to void. Incontinence episodes can be measured reliably with a diary, and the quantity of urine leakage can be measured with pad tests. However, in patients with mixed urinary incontinence (both stress and urgency incontinence), it can be difficult to distinguish between incontinence subtypes. Therefore, it is common for OAB treatment trials to utilize total incontinence episodes as an outcome measure.

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22
Q

What is the definition of nocturnal polyuria?

A

The production of greater than 20 to 33% of total 24 hour urine output during the period of sleep, which is age- dependent with 20% for younger individuals and 33% for elderly individuals.

In nocturnal polyuria, nocturnal voids are frequently normal or large volume as opposed to the small volume voids commonly observed in nocturia associated with OAB.

Sleep disturbances, vascular and/ or cardiac disease and other medical conditions are often associated with nocturnal polyuria. As such, it is often age-dependent, increasing in prevalence with aging and with poorer general health.

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23
Q

What history should you ask about for OAB?

A

Questions should assess bladder storage symptoms associated with OAB (e.g., urgency, urgency incontinence, frequency, nocturia), other bladder storage problems (e.g., stress incontinence episodes) and bladder emptying (e.g., hesitancy, straining to void, prior history of urinary retention, force of stream, intermittency of stream). The symptom of urgency as defined by IUGA/ICS is the “complaint of sudden compelling desire to pass urine which is difficult to defer.”
-The clinician can simply ask if the patient has a problem getting to the bathroom in time, assuming the patient has normal mobility.

Inquiry into fluid intake habits should be performed, including asking patients how much fluid and of what type (e.g., with or without caffeine) they drink each day, how many times they void each day and how many times they void at night.

  • Patients who do not appear able to provide accurate intake and voiding information should fill out a fluid diary.
  • Normal frequency consists of voiding every three to four hours with a median of approximately six voids a day.

Current medication use also should be reviewed to ensure that voiding symptoms are not a consequence of a prescribed medication, particularly diuretics.

The degree of bother from bladder symptoms also should be assessed.

Co-morbid conditions should be completely elicited as these conditions may directly impact bladder function. Patients with co-morbid conditions and OAB symptoms would be considered complicated OAB patients.
-These co-morbid conditions include neurologic diseases (i.e., stroke, multiple sclerosis, spinal cord injury), mobility deficits, medically complicated/uncontrolled diabetes, fecal motility disorders (fecal incontinence/ constipation), chronic pelvic pain, history of recurrent urinary tract infections (UTIs), gross hematuria, prior pelvic/vaginal surgeries (incontinence/prolapse surgeries), pelvic cancer (bladder, colon, cervix, uterus, prostate) and pelvic radiation.

The female patient with significant prolapse (i.e., prolapse beyond the introitus) also may be considered a complicated OAB patient. Patients with urgency incontinence, particularly younger patients, or a patient with extremely severe symptoms could represent a complicated OAB patient with an occult neurologic condition. A patient who has failed multiple anti-muscarinics to control OAB symptoms could also be considered a complicated OAB patient.

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24
Q

What physical exam should be performed for OAB?

A

A careful, directed physical exam should be performed.

An abdominal exam should be performed to assess for scars, masses, hernias and areas of tenderness as well as for suprapubic distension that may indicate urinary retention.

Examination of lower extremities for edema should be done to give the clinician an assessment of the potential for fluid shifts during periods of postural changes.

A rectal/ genitourinary exam to rule out pelvic floor disorders (e.g., pelvic floor muscle spasticity, pain, pelvic organ prolapse) in females and prostatic pathology in males should be performed.

In menopausal females, atrophic vaginitis should be assessed as a possible contributing factor to incontinence symptoms.

The examiner should assess for perineal skin for rash or breakdown.

The examiner also should assess perineal sensation, rectal sphincter tone and ability to contract the anal sphincter in order to evaluate pelvic floor tone and potential ability to perform pelvic floor exercises (e.g., the ability to contract the levator ani muscles) as well as to rule out impaction and constipation.

Cognitive impairment is related to symptom severity and has therapeutic implications regarding goals and options. The Mini-Mental State Examination (MMSE)32 is a standardized, quick and useful assessment of cognitive function.

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25
Q

How much does weight loss help OAB symptoms?

A

The most definitive trial reported that a six-month behavioral weight loss intervention resulted in an 8.0% weight loss in obese women, reduced overall incontinence episodes per week by 47% (compared to 28% in the control group) and reduced UUI episodes by 42% (compared to 26% in controls).

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26
Q

History - OAB - Abridged from JU

A

Urgency is the “complaint of a sudden, compelling desire to pass urine which is difficult to defer.” Urgency is the hallmark symptom of OAB, but it has proven difficult to precisely define or to characterize for research or clinical purposes. Therefore, many studies of OAB treatment response have relied upon other measures (eg, number of voids, number of incontinence episodes).

Urinary frequency can be reliably measured with a voiding diary. Traditionally, up to seven micturition episodes during waking hours has been considered normal, but this number is highly variable based upon hours of sleep, fluid intake, comorbid medical conditions and other factors.

Nocturia is the interruption of sleep one or more times because of the need to void and is a multifactorial symptom often due to factors unrelated to OAB, including excessive nighttime urine production and sleep apnea.

Urgency urinary incontinence is the involuntary leakage of urine associated with a sudden compel- ling desire to void. Incontinence episodes can be measured reliably with a diary. However, in patients with mixed urinary incontinence (both stress and urgency incontinence), it can be difficult to distinguish between incontinence subtypes.

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27
Q

OAB Differential Diagnosis from JU

A

The differential of nocturia includes nocturnal polyuria, low nocturnal bladder capacity or both. In nocturnal polyuria, nocturnal voids are frequently normal or large volume as opposed to the small volume voids commonly observed in nocturia associated with OAB. Sleep disturbances, vascular and/or cardiac disease and other medical conditions are often associated with nocturnal polyuria.

Frequency that is the result of polydipsia and resulting polyuria may mimic OAB; the two are distinguished with the use of frequency-volume charts. Polydipsia-related frequency is physiologically self- induced and should be managed with education and consideration of fluid management.

While the clinical presentation of interstitial cystitis/ bladder pain syndrome shares the symptoms of OAB, bladder and/or pelvic pain, including dyspareunia, is a crucial component of its presentation in contradistinction to OAB.

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28
Q

What are complications associate with placement of SNM?

A

electric shock

infection/irritation

lead migration

needs for surgical revision

pain at stimulator or lead site

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29
Q

Options for end stage OAB s/p medical therapy, botox, SNM, PTNS?

A

augmentation cystoplasty

foley

spt

urinary diversion

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30
Q

what is ddx for patient with bladder storage sxs?

A

atrophic vaginitis

bladder cancer

DI

distal ureteral stone

IC/CPP

Nocturnal polyuria

OAB

Polydipsia

Radiation cystitis

vascular and/or cardiac dz

neuro (MS/SCI/CVA)

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31
Q

potential causes of nocturia?

A

nocturnal polyuria (20% in young and 33% in old)

BPH

low nocturnal bladder capacity

sleep disturbance/OSA

mobilization of LE edema

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32
Q

Initial evaluation of patient with OAB sxs should include?

A

assessment of cognitive ability

IPSS and bother

PVR

UA +/- UCx

Voiding diary

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33
Q

A voiding diary should have which info?

A

circumstances and reasons for incontinence episodes

severity of urgency

time of each incontinence episode

time of each void

volume of void

+/- intake and type of fluid

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34
Q

Common a/e and contraindications of anti-muscarinics?

A

a/e: constipation, dry mouth, caution with frail, dementia/confusion

contra: hx of urinary retention, impaired gastric emptying, use of solid KCl tabs, narrow angle glaucoma

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35
Q

What is on differential for a woman with frequency, urgency, nocturia, and leakage?

A

OAB
DM
Polydipsia (frequency/volume chart)
DI (large voids)
IC/BPS
Atrophic vaginitis
UTI
Bladder stones
Bladder cancer

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36
Q

What is best used for workup of suspected OAB patient?

A

UDS not used for uncomplicated patient

Voiding diary (r/o nocturnal polyuria; consider night-time fluid, CHF, renal dz, OSA; ?33% total 24h urine)

Pad weight test

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37
Q

What are first line therapies for OAB?

A

patient education

treatment goals

no treatment acceptable

behavioral (bladder training, bladder control, PFMT, fluid management, caffeine)

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38
Q

What are second line therapies for OAB?

A

Oral anti-muscarinics or b-agonists

XL over IR

Transdermal

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39
Q

What are third line therapies for OAB?

A

Botox (contra: pregnancy, breast feeding, neuromuscular compromise [myasthenia gravis, ALS], active UTI)
PTNS
SNM

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40
Q

How is OAB defined by the International Urogynecological Association (IUGA) and International Continence Society (ICS)?

A

OAB is defined by IUGA and ICS as the presence of “urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence (UUI), in the absence of UTI or other obvious pathology.”

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41
Q

Why is urgency considered the hallmark symptom of OAB?

A

Urgency is considered the hallmark symptom of OAB because it is the sudden, compelling desire to pass urine which is difficult to defer.

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42
Q

How is urinary frequency measured?

A

Urinary frequency can be reliably measured with a voiding diary.

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43
Q

How is urgency urinary incontinence defined?

A

Urgency urinary incontinence is defined as the involuntary leakage of urine, associated with a sudden compelling desire to void.

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44
Q

What is a common outcome measure used in OAB treatment trials?

A

Total incontinence episodes are a common outcome measure used in OAB treatment trials.

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45
Q

What is the prevalence range of OAB in men and women according to population-based studies?

A

OAB prevalence rates range from 7% to 27% in men, and 9% to 43% in women.

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46
Q

Is UUI more common in women or men?

A

UUI is consistently more common in women than in men.

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47
Q

Does the prevalence and severity of OAB symptoms tend to increase with age?

A

Yes, OAB symptom prevalence and severity tend to increase with age.

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47
Q

Does the prevalence and severity of OAB symptoms tend to increase with age?

A

Yes, OAB symptom prevalence and severity tend to increase with age.

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48
Q

What proportion of OAB cases remit during a given year?

A

A proportion of OAB cases (37-39%) remit during a given year.

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49
Q

Why is assessment of patient-reported outcomes (PROs) important in OAB management?

A

The degree of bother caused by OAB symptoms directly affects OAB care-seeking, treatment intensity, and satisfaction with treatment.

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50
Q

What is the problem with the lack of standardization in PRO questionnaire instruments developed to assess OAB symptoms?

A

The lack of standardization has often limited the comparability and generalizability of PROs across research studies.

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51
Q

What has the International Consultation on Incontinence developed to address the issue of standardization in PROs?

A

The International Consultation on Incontinence has developed a series of standardized modular questionnaires for pelvic conditions, including OAB.

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52
Q

What is the Panel’s stance on the development of standardized PRO tools for OAB?

A

The Panel encourages the development of such standardized PRO tools which can be used in OAB research and clinical practice.

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53
Q

What are the burdens associated with OAB?

A

The burdens associated with OAB include the time and effort required to manage symptoms during daily life, the resources required to obtain costly treatments, and negative impacts on psychosocial functioning and quality of life.

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54
Q

How does urinary incontinence affect psychosocial functioning?

A

Urinary incontinence may have severe psychological and social consequences, resulting in restricted activities and unwillingness to be exposed to environments where access to a bathroom may be difficult. It can also negatively impact sexual function and marital satisfaction, and has been linked to depressive illness.

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55
Q

What age group is most impacted by OAB symptoms?

A

Older adults (e.g., ≥ 65 years) are most impacted by OAB symptoms, with significant impairments in quality of life, including high rates of anxiety and depression.

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56
Q

What are the symptoms that may lead to a diagnosis of overactive bladder (OAB)?

A

Symptoms of urinary frequency (both daytime and night) and urgency, with or without urgency incontinence.

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57
Q

What is the differential diagnosis of nocturia?

A

Nocturnal polyuria, low nocturnal bladder capacity, or both.

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58
Q

How is nocturnal polyuria different from nocturia associated with OAB?

A

Nocturnal polyuria is associated with normal or large volume voids, while OAB is associated with small volume voids.

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59
Q

What condition shares symptoms of urinary frequency and urgency with OAB, but also includes bladder and/or pelvic pain?

A

Interstitial cystitis/bladder pain syndrome.

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60
Q

In what type of patient can atrophic vaginitis be a contributing factor to incontinence symptoms?

A

Menopausal female patients.

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61
Q

What is the purpose of the diagnostic process for OAB?

A

The purpose of the diagnostic process is to document symptoms and signs that characterize OAB and exclude other disorders that could be the cause of the patient’s symptoms.

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62
Q

What questions should be asked during the history taking for OAB?

A

Questions should assess bladder storage symptoms associated with OAB (e.g., urgency, urgency incontinence, frequency, nocturia), other bladder storage problems (e.g., stress incontinence episodes), bladder emptying (e.g., hesitancy, straining to void, prior history of urinary retention, force of stream, intermittency of stream), and the degree of bother from bladder symptoms.

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63
Q

What should be assessed during the physical examination for OAB?

A

The examiner should perform an abdominal exam, examination of lower extremities for edema, a rectal/genitourinary exam, and assess for perineal skin for rash or breakdown. They should also assess perineal sensation, rectal sphincter tone, and ability to contract the anal sphincter to evaluate pelvic floor tone and potential ability to perform pelvic floor exercises.

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64
Q

When is a urinalysis necessary during the diagnostic process for OAB?

A

A urinalysis is necessary to rule out UTI and hematuria. A urine culture is not necessary unless an indication of infection is found, and if evidence of hematuria not associated with infection is found, then the patient should be referred for urologic evaluation.

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65
Q

When should patients with OAB be referred to a specialist for further evaluation and treatment?

A

Patients with co-morbid conditions and OAB symptoms, patients who have failed multiple anti-muscarinics to control OAB symptoms, or those with urgency incontinence, particularly younger patients, or a patient with extremely severe symptoms could represent a complicated OAB patient with an occult neurologic condition. If the history elicits any of these co-morbid conditions and/or special situations, then the clinician should consider referring these patients to a specialist for further evaluation and treatment.

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66
Q

What is the minimum requirement for the diagnostic process for OAB?

A

The minimum requirements for the diagnostic process for OAB are a careful history, physical exam, and urinalysis.

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67
Q

What are the potential uses of bladder diaries for patients with OAB symptoms?

A

Bladder diaries are useful in some patients, particularly the patient who cannot describe or who is not familiar with intake and voiding patterns. They also document baseline symptom levels so that treatment efficacy may be assessed, and provide information that can help the clinician plan appropriate components of intervention, particularly behavioral intervention.

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68
Q

Are urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound recommended in the initial diagnostic workup of the uncomplicated OAB patient?

A

No, urodynamics, cystoscopy, and diagnostic renal and bladder ultrasound are not recommended in the initial diagnostic workup of the uncomplicated OAB patient.

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69
Q

What should the clinician consider when developing an individualized treatment plan for OAB?
a) The severity of adverse events
b) The reversibility of adverse events
c) The potential benefit to the patient
d) All of the above

A

d) All of the above

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70
Q

Why were behavioral therapies selected as first-line therapies for OAB?
a) They are the most effective treatment for OAB
b) They have the least amount of adverse events
c) They require an investment of time and effort by the patient to achieve maximum benefits
d) They are the most cost-effective treatment for OAB

A

c) They require an investment of time and effort by the patient to achieve maximum benefits

71
Q

What is clinical effectiveness?
a) The balance between benefits and risks/burdens of a treatment
b) The ability of a treatment to cure a condition
c) The invasiveness of a treatment
d) The duration of potential adverse events

A

a) The balance between benefits and risks/burdens of a treatment

72
Q

When is surgical intervention recommended for OAB?
a) As a first-line treatment
b) As a second-line treatment
c) As a third-line treatment
d) Only for the rare non-neurogenic patient who has failed all other therapeutic options and whose symptoms are intolerable

A

d) Only for the rare non-neurogenic patient who has failed all other therapeutic options and whose symptoms are intolerable

73
Q

When should the use of indwelling catheters be considered for OAB?
a) As a first-line treatment
b) As a second-line treatment
c) As a third-line treatment
d) As a last resort in selected patients

A

d) As a last resort in selected patients

74
Q

Which of the following statements is true regarding the treatment of OAB?

A) All patients should proceed through each line of therapy in order.
B) Patients with cognitive deficits and severely reduced mobility may not be good candidates for pharmacological or invasive treatments.
C) Surgical intervention is the first line of treatment for non-neurogenic patients with OAB.
D) PTNS should only be considered after a patient has failed all other therapeutic options.

A

B) Patients with cognitive deficits and severely reduced mobility may not be good candidates for pharmacological or invasive treatments.

75
Q

Which of the following is not included in the education that clinicians should provide to patients before initiating treatment for OAB?

A) Normal and abnormal bladder function
B) Available treatment options
C) Risks and benefits of treatment alternatives
D) Patients should expect to achieve complete elimination of OAB symptoms with a single treatment option

A

D) Patients should expect to achieve complete elimination of OAB symptoms with a single treatment option. The guideline recommends that clinicians should provide education to patients regarding normal and abnormal bladder function, available treatment options, risks and benefits of treatment alternatives, and the fact that acceptable symptom control may require trials of multiple therapeutic options before it is achieved.

76
Q

What are the two fundamental approaches to behavioral treatment for OAB?

A

The two fundamental approaches to behavioral treatment for OAB are modifying bladder function by changing voiding habits (such as with bladder training and delayed voiding) and behavioral training, which focuses on the bladder outlet and includes pelvic floor muscle training (PFMT) to improve strength and control and techniques for urge suppression.

77
Q

What is the focus of most literature on overactive bladder, and which gender is most commonly studied in this literature?

A

Most literature on overactive bladder focuses on the treatment of urinary incontinence, and most studies have been performed with women.

78
Q

What is the evidence strength grade for offering behavioral therapies as first-line therapy to all patients with OAB?
a. Grade A
b. Grade B
c. Grade C
d. Grade D

A

b. Grade B

79
Q

Why are behavioral therapies designated as first-line treatments for OAB?
a. They are more effective than anti-muscarinic medications
b. They are less invasive than anti-muscarinic medications
c. They can be tailored to address individual patient needs
d. All of the above

A

d. All of the above

80
Q

What is the most definitive trial that evaluated the effects of weight loss on incontinence specifically?
a. A four-month behavioral weight loss intervention
b. A six-month behavioral weight loss intervention
c. An eight-month behavioral weight loss intervention
d. A ten-month behavioral weight loss intervention

A

b. A six-month behavioral weight loss intervention

81
Q

How much reduction in incontinence episodes per week was reported in the most definitive trial that evaluated the effects of weight loss on incontinence specifically?
a. 28%
b. 37%
c. 47%
d. 57%

A

c. 47%

82
Q

What is the effect of reducing caffeine intake on voiding frequency according to a study of bladder training?
a. No effect
b. Reduced voiding frequency
c. Increased voiding frequency
d. Cannot be determined

A

b. Reduced voiding frequency

83
Q

Is there evidence to suggest that a single component of behavioral therapy is essential to efficacy or that a single type of behavioral therapy is superior in efficacy?
a. Yes
b. No
c. Unclear

A

b. No

84
Q

What did a study comparing behavioral training administered with biofeedback, verbal feedback, or self-administered using a pamphlet find?
a. Biofeedback was the most effective
b. Verbal feedback was the most effective
c. Self-administered using a pamphlet was the most effective
d. All three approaches had similar effects

A

d. All three approaches had similar effects

85
Q

What is the evidence strength grade for the effectiveness of behavioral therapies in reducing incontinence episodes, improving voiding parameters, and improving QOL compared to medications?
a. Grade A
b. Grade B
c. Grade C
d. Grade D

A

b. Grade B

86
Q

What is Guideline Statement 7 recommending?
a) Behavioral therapies should be used as the only treatment for OAB.
b) Pharmacologic management should be used as the only treatment for OAB.
c) Behavioral and pharmacologic management should be used in combination for OAB.
d) Combining behavioral and pharmacologic management is contraindicated for OAB.

A

c) Behavioral and pharmacologic management should be used in combination for OAB.

87
Q

Is there any evidence to support combining behavioral and drug therapies for OAB?
a) Yes, the evidence is strong and consistent.
b) No, there is no evidence to support combining these therapies.
c) Yes, there is limited evidence to support combining these therapies.
d) Yes, the evidence shows that combining these therapies can be harmful.

A

c) Yes, there is limited evidence to support combining these therapies.

88
Q

What does the Panel recommend for patients who are not adequately improved on behavioral or drug therapy alone?
a) Discontinue therapy and try alternative treatments.
b) Only continue drug therapy and discontinue behavioral therapy.
c) Only continue behavioral therapy and discontinue drug therapy.
d) Continue the initial therapy and add the alternate therapy using a stepped approach.

A

d) Continue the initial therapy and add the alternate therapy using a stepped approach.

89
Q

What are the recommended second-line therapies for OAB?
A) Oral β3-adrenoceptor agonists
B) Oral antimuscarinics
C) Both A and B
D) None of the above

A

C) Both A and B

90
Q

Is there evidence for differential efficacy across different oral antimuscarinic medications?
A) Yes, some medications are more effective than others.
B) No, there is no compelling evidence for differential efficacy across medications.
C) The evidence is inconclusive.
D) The evidence suggests that only newer medications are effective.

A

B) No, there is no compelling evidence for differential efficacy across medications.

91
Q

What is the most common non-life-threatening side effect associated with oral antimuscarinics?
A) UTI
B) Dry mouth
C) Arrhythmias
D) Constipation

A

B) Dry mouth

92
Q

Is there a relationship between baseline symptom levels and symptom reduction with oral antimuscarinic medications?
A) Yes, patients with more severe symptoms experience greater symptom reductions.
B) No, there is no relationship between baseline symptom levels and symptom reduction.
C) The relationship varies depending on the medication used.
D) The relationship is not clear.

A

A) Yes, patients with more severe symptoms experience greater symptom reductions.

93
Q

How does mirabegron compare to antimuscarinics in terms of efficacy?
a) Mirabegron is more effective than antimuscarinics
b) Mirabegron is less effective than antimuscarinics
c) Mirabegron has similar efficacy to antimuscarinics
d) There is not enough information to compare the efficacy of mirabegron and antimuscarinics

A

c) Mirabegron has similar efficacy to antimuscarinics

94
Q

According to Guideline Statement 9, which formulation of oxybutynin and tolterodine should be preferred?
a) Immediate release (IR) formulations
b) Extended release (ER) formulations
c) Both IR and ER formulations are equally preferred

A

b) Extended release (ER) formulations

95
Q

According to the meta-analysis of adverse events, what is the dry mouth rate for ER tolterodine?
a) 18.0%
b) 28.8%
c) 41.4%

A

a) 18.0%

96
Q

What is the recommended use of transdermal oxybutynin in patients with dry mouth?
a) It should not be used in patients with dry mouth
b) It can be used as an alternative to oral anti-muscarinics
c) It should only be used in patients with severe dry mouth

A

b) It can be used as an alternative to oral anti-muscarinics in patients who are at risk of or who have experienced dry mouth with oral agents.

97
Q

What is the dry mouth rate for the transdermal oxybutynin patch compared to the oral oxybutynin ER formulation?
a) Transdermal oxybutynin has a higher rate of dry mouth
b) Both formulations have the same rate of dry mouth
c) Transdermal oxybutynin has a lower rate of dry mouth

A

c) Transdermal oxybutynin has a lower rate of dry mouth.

98
Q

Which of the following adverse events is most commonly reported in patients using the oxybutynin gel?
a) Dry mouth
b) Constipation
c) Erythema or pruritus

A

c) Erythema or pruritus.

99
Q

What is the main idea of Guideline Statement 11?
a) Patients who experience inadequate symptom control with one anti-muscarinic medication should be prescribed a β3-adrenoceptor agonist.
b) Clinicians should abandon anti-muscarinic therapy if trial of one medication appears to fail.
c) Patients who experience inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication may experience better symptom control and/or a more acceptable adverse drug event profile with another anti-muscarinic.
d) Dose modification is not recommended for patients who experience inadequate symptom control with one anti-muscarinic medication.

A

c

100
Q

In the BESIDE trial, what combination therapy was evaluated?
a) Solifenacin 5 mg plus mirabegron 50 mg
b) Solifenacin 10 mg plus mirabegron 25 mg
c) Oxybutynin 5 mg plus fesoterodine 10 mg
d) Tolterodine 2 mg plus darifenacin 7.5 mg

A

a) Solifenacin 5 mg plus mirabegron 50 mg

101
Q

Which study evaluated combination tolterodine and intravaginal estradiol cream?
a) Ellington et al. (2016)
b) Kosilov et al. (2018)
c) Rovner et al. (2018)
d) Gratzke et al. (2018)

A

a) Ellington et al. (2016)

102
Q

Which drug class is recommended as a combination therapy with anti-muscarinics for patients refractory to monotherapy with either anti-muscarinics or β3-adrenoceptor agonists?
a) NSAIDs
b) Beta blockers
c) Opioids
d) β3-adrenoceptor agonists

A

d) β3-adrenoceptor agonists

103
Q

What is the strongest evidence for combination therapy for the treatment of OAB?
A. SYNERGY I/II and BESIDE trials
B. Kosilov et al. studies
C. Ellington et al. study
D. Rovner et al. study

A

A. SYNERGY I/II and BESIDE trials are the studies that provided the strongest evidence for combination therapy for the treatment of OAB.

104
Q

Which drugs are typically used for pharmacotherapy options for the management of OAB?
A. β3-adrenoceptor agonists only
B. Anti-muscarinics only
C. Combination of anti-muscarinics and β3-adrenoceptor agonists
D. None of the above

A

C. Combination of anti-muscarinics and β3-adrenoceptor agonists are typically used for pharmacotherapy options for the management of OAB.

105
Q

What are the most commonly reported treatment-emergent adverse events in combination therapy groups for the treatment of OAB?
A. Dry mouth, constipation, and dyspepsia
B. Headache, nausea, and fatigue
C. Dizziness, blurred vision, and dry eyes
D. All of the above

A

A. Dry mouth, constipation, and dyspepsia are the most commonly reported treatment-emergent adverse events in combination therapy groups for the treatment of OAB.

106
Q

Which of the following studies evaluated combination therapy with solifenacin and trospium in women with OAB?
A. Herschorn et al. (2017)
B. Gratzke et al. (2018)
C. Kosilov et al. (2018)
D. Ellington et al. (2016)

A

C. Kosilov et al. (2018) evaluated combination therapy with solifenacin and trospium in women with OAB.

107
Q

In which condition should anti-muscarinics not be used unless approved by the treating ophthalmologist?
a) Glaucoma
b) Asthma
c) Hypertension
d) Diabetes

A

a) Glaucoma

108
Q

What is the recommended course of action for patients at risk of or with a history of impaired gastric emptying?
a) They should be seen by or receive clearance from a gastroenterologist.
b) They should immediately start taking antimuscarinics.
c) They should undergo surgery.
d) They should consult an endocrinologist.

A

a) They should be seen by or receive clearance from a gastroenterologist.

109
Q

Why are anti-muscarinics contraindicated in patients using solid oral forms of potassium chloride?
a) Because the reduced gastric emptying caused by the anti-muscarinics may increase the potassium absorption of these agents.
b) Because anti-muscarinics increase the gastric emptying.
c) Because anti-muscarinics decrease the absorption of potassium chloride.
d) Because potassium chloride and anti-muscarinics interact in an unpredictable manner.

A

a) Because the reduced gastric emptying caused by the anti-muscarinics may increase the potassium absorption of these agents.

110
Q

What is one of the main reasons cited for discontinuation of anti-muscarinic therapy?
a) Drowsiness
b) Dizziness
c) Dry mouth
d) Headache

A

c) Dry mouth

111
Q

What should patients be educated about before initiating anti-muscarinic therapy?
a) Possible effects of medication on bowel function
b) Possible effects of medication on heart rate
c) Possible effects of medication on vision
d) Possible effects of medication on appetite

A

a) Possible effects of medication on bowel function

112
Q

What is one way to manage constipation and dry mouth in patients on anti-muscarinic therapy?
a) Discontinue the medication
b) Increase the dose of the medication
c) Modify the patient’s diet
d) Recommend regular exercise

A

c) Modify the patient’s diet

113
Q

When dosing options are available for anti-muscarinic therapy, what can be done to provide relief from side-effects?
a) Increase the dose
b) Reduce the dose
c) Switch to a different medication class
d) Add a second medication

A

b) Reduce the dose

114
Q

What should be considered when prescribing anti-muscarinic therapy for older patients?
a) Starting with a high dose
b) Starting with a minimal dose
c) Starting with the maximum recommended dose
d) Starting with a mid-range dose

A

b) Starting with a minimal dose

115
Q

What is the main concern when prescribing antimuscarinics in patients using other medications with anticholinergic properties?
a) Possible drug interactions that may decrease the efficacy of the medication.
b) Increased risk of gastrointestinal bleeding.
c) Potentiation of side effects of antimuscarinics.
d) Possible increase in allergic reactions to the medication.

A

c) Potentiation of side effects of antimuscarinics.

116
Q

Which medications should be used with caution when prescribed with antimuscarinics?
a) Antihypertensive medications.
b) Antipsychotic medications.
c) Anti-inflammatory medications.
d) Anti-seizure medications.

A

b) Antipsychotic medications.

117
Q

In which group of patients should clinicians use caution in prescribing OAB medications?
a) Patients with normal mobility
b) Patients with comorbidities
c) Frail elderly patients
d) Patients with impaired vision

A

c) Frail elderly patients

118
Q

What are the potential adverse events in frail elderly patients who take OAB medications?
a) Dry mouth and constipation
b) Cognitive deficits and impaired thermoregulation
c) Hypertension and tachycardia
d) Rash and hive

A

b) Cognitive deficits and impaired thermoregulation

119
Q

Which of the following strategies may be helpful for patients who cannot tolerate antimuscarinics?
a) Bowel management
b) Fluid management
c) Behavioral strategies such as prompted voiding
d) Dose reduction

A

c) Behavioral strategies such as prompted voiding

120
Q

What is the definition of a refractory patient?
A. The patient who has never tried any treatment
B. The patient who has failed a trial of symptom-appropriate behavioral therapy of sufficient length to evaluate potential efficacy and who has failed a trial of at least one anti-muscarinic medication administered for 1-2 weeks.
C. The patient who has failed a trial of symptom-appropriate behavioral therapy of sufficient length to evaluate potential efficacy and who has failed a trial of at least one anti-muscarinic medication administered for 4 to 8 weeks.
D. The patient who has not responded to other medications for other conditions.

A

C. The patient who has failed a trial of symptom-appropriate behavioral therapy of sufficient length to evaluate potential efficacy and who has failed a trial of at least one anti-muscarinic medication administered for 4 to 8 weeks.

121
Q

What is the FDA-approved dose of intradetrusor onabotulinumtoxinA for treating OAB symptoms?
a) 50U
b) 100U
c) 150U
d) 200U

A

b) 100U

122
Q

Which of the following is true about the studies on onabotulinumtoxinA injections into the detrusor?
a) All studies evaluated abobotulinumtoxinA.
b) All studies used the same dose of onabotulinumtoxinA.
c) Most studies reported significant reductions in incontinence episodes and urgency.
d) All studies reported no adverse events.

A

c) Most studies reported significant reductions in incontinence episodes and urgency.

123
Q

Which of the following adverse events is most commonly associated with onabotulinumtoxinA injections?
a) Gross hematuria
b) Dry mouth
c) Urinary tract infection (UTI)
d) Impaired vision

A

c) Urinary tract infection (UTI)

124
Q

What is the typical range of follow-up durations for studies evaluating the effects of onabotulinumtoxinA injections in patients with non-neurogenic OAB?
a) 1 week to 12 weeks
b) 12 weeks to 24 weeks
c) 24 weeks to 36 weeks
d) 36 weeks to 48 weeks

A

a) 1 week to 12 weeks

125
Q

What is the primary endpoint measured in the randomized trials evaluating the effects of onabotulinumtoxinA injections in patients with non-neurogenic OAB?
a) Urodynamics parameters
b) Quality of life outcomes
c) Urinary incontinence episodes
d) Adverse events

A

c) Urinary incontinence episodes

126
Q

What was the aim of Wang’s study?
a) To compare the incidence of diabetes mellitus in older and younger patients
b) To compare the incidence of overactive bladder in diabetic and non-diabetic patients
c) To investigate the effectiveness of BTX-A in reducing overactive bladder symptoms in diabetic and non-diabetic patients
d) To compare the levels of large post-void residual volumes in diabetic and non-diabetic patients

A

c) To investigate the effectiveness of BTX-A in reducing overactive bladder symptoms in diabetic and non-diabetic patients

127
Q

What was the success rate for both diabetic and non-diabetic patients in Wang’s study?
a) 56%
b) 47.8%
c) 60.4%
d) 61%

A

d) 61%

128
Q

What proportion of diabetic patients had large post-void residual volumes after six months?
a) 10.4%
b) 33.3%
c) 47.8%
d) 60.4%

A

d) 60.4%

129
Q

What is the definition of frailty in the Liao & Kuo (2013) study?
a) Age >75 years and two or more of the following: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity
b) Age >65 years and three or more of the following: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity
c) Age >70 years and three or more of the following: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity
d) Age >60 years and two or more of the following: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity

A

b) Age >65 years and three or more of the following: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity

130
Q

What was the success rate at six months for all three groups in the Liao & Kuo (2013) study?
a) Frail elderly – 83.4%; Elderly – 91.2%; Younger – 88.9%
b) Frail elderly – 44.9%; Elderly – 52.1%; Younger – 49.4%
c) Frail elderly – 6.82%; Elderly – 22.3%; Younger – 23.1%
d) Frail elderly – 60.7%; Elderly – 39.7%; Younger – 35.7%

A

b) Frail elderly – 44.9%; Elderly – 52.1%; Younger – 49.4%

131
Q

What was the recovery period to spontaneous voiding for frail elderly patients in the Liao & Kuo (2013) study?
a) Median 0.5 months
b) Median 1 month
c) Median 3.5 months
d) There was no difference in the recovery period to spontaneous voiding between the groups

A

c) Median 3.5 months

132
Q

What was the highest rate of UTI occurrence among the patient groups in the Liao & Kuo (2013) study?
a) Frail elderly
b) Elderly
c) Younger patients
d) There was no difference in UTI rates between the groups

A

c) Younger patients

133
Q

What were the success rates for males and females who received 100U BTX-A at three months?
a. 70%
b. 75%
c. 79%
d. 80%

A

d. 80%

134
Q

What was the median time to failure in the Okamura (2013) study?
a. 7.2 months
b. 8 months
c. 11 months
d. 12 months

A

c. 11 months

135
Q

What percentage of patients required CISC two months post-injection in the Granese (2012) study?
a. 1%
b. 3%
c. 22%
d. 25%

A

c. 22%

136
Q

What is the most common reason for discontinuing BTX-A injections, according to Mohee (2012)?
a) Primary failure
b) Secondary failure
c) Tolerability issues
d) Incontinence at baseline

A

c) Tolerability issues

137
Q

In Veeratterapillay’s (2014) study, what percentage of patients did not respond to repeated injections and opted for other treatments?
a) 10%
b) 17%
c) 26%
d) 35%

A

b) 17%

138
Q

What were the most common adverse events reported by Dowson (2012) in patients who received BTX-A injections?
a) AUR and indwelling catheterization
b) Poor efficacy and UTIs
c) Flu-like symptoms and arm paresthesia
d) Bladder pain and leg weakness

A

b) Poor efficacy and UTIs

139
Q

What was the mean interval between the second and third injections in Abeywickrama’s (2013) study?
a) 15.2 months
b) 19.2 months
c) 20.2 months
d) 25.2 months

A

b) 19.2 months

140
Q

What was the success rate of patients who received 200U of BTX-A in the detrusor in Jackson’s study?
a. 70%
b. 81%
c. 89%
d. 94%

A

b. 81%. In Jackson’s study, the success rate for patients who received 200U of BTX-A injected into the detrusor was 81%.

141
Q

In Kanagarajah’s study, which group had a significant improvement in frequency?
a. OAB-dry patients
b. OAB-wet patients
c. Patients without idiopathic DO
d. Patients with idiopathic DO

A

a. OAB-dry patients. In Kanagarajah’s study, patients with OAB-dry who received BTX-A had a significant improvement in frequency.

142
Q

What was the purpose of Manecksha’s (2012) study?
a) To evaluate the effectiveness of BTX-A injection in the treatment of DO
b) To evaluate the effectiveness of different doses of BTX-A in the treatment of DO
c) To evaluate the effectiveness of different injection locations of BTX-A in the treatment of DO
d) To evaluate the safety of BTX-A injection in the treatment of DO

A

c) To evaluate the effectiveness of different injection locations of BTX-A in the treatment of DO

143
Q

What was the main finding of Manecksha’s (2012) study?
a) Both injection locations had similar improvement in OAB symptoms
b) The trigone-sparing injection had greater improvement in OAB symptoms
c) The trigone-including injection had greater improvement in OAB symptoms
d) Both injection locations had no effect on OAB symptoms

A

c) The trigone-including injection had greater improvement in OAB symptoms

144
Q

In Brubaker (2012), what percentage of patients in the BTX-A groups attained their primary OAB treatment goal?
a) 23.7%
b) 34.5% to 65.3%
c) 75%
d) 50%

A

b) 34.5% to 65.3%. Brubaker (2012) reported that greater proportions of patients in the BTX-A groups attained their primary OAB treatment goal (34.5% to 65.3%) compared to those in the placebo group (23.7%).

145
Q

What did Hegele (2011) study?
a. The effectiveness of BTX-A injections in treating OAB.
b. The presence of antibodies in patients who received BTX-A injections.
c. The frequency of CISC required post BTX-A injection.
d. The patient satisfaction rate following BTX-A injection.

A

b. The study conducted by Hegele (2011) was focused on the presence of antibodies post BTX-A injection in patients.

Explanation: The study conducted by Hegele (2011) evaluated the presence of antibodies in patients who received BTX-A injections. The study found that BTX-A antibodies were detectable in 16% of patients, and one patient had a strongly positive titer and experienced complete failure of the treatment. The authors speculated that the presence of antibodies is involved in poor treatment responses.

146
Q

What was the proportion of patients who had detectable BTX-A antibodies in Hegele’s study?
a. 5%
b. 11%
c. 16%
d. 31%

A

c. 16% of patients in Hegele’s study had detectable BTX-A antibodies.

Explanation: Hegele’s study found that BTX-A antibodies were detectable in 16% of patients. One of these patients had a strongly positive titer and experienced complete failure of the treatment, and the other four had slightly positive titers.

147
Q

What is the mean difference in incontinence episodes between BTX-treated patients and placebo patients in the systematic review conducted by Cui (2013)?
a) -3.85
b) 2.47
c) -5.13
d) 5.25

A

a) -3.85.
The mean difference in incontinence episodes between BTX-treated patients (any dose) and placebo patients is -3.85 (95% CI -4.79 to -2.90) according to the meta-analysis performed by Cui (2013).

148
Q

What is the relative risk ratio for UTI in BTX-treated patients compared to placebo-treated patients in the systematic review conducted by Cui (2013)?
a) 2.47
b) 5.25
c) 2.36
d) 3.53

A

c) 2.36.
The relative risk ratio for UTI (using data from Brubaker 2008, Denys 2012, Flynn 2009, Fowler 2012, Tincello 2012) in BTX-treated patients compared to placebo-treated patients was 2.36 (95% CI 1.58 to 3.53) according to the meta-analysis performed by Cui (2013).

149
Q

What is the FDA-approved dose for onabotulinumtoxinA injections?
a) 50U
b) 75U
c) 100U
d) 150U

A

c) 100U.
The Panel judged that the benefits of BTX-A at the 100U dose in the carefully counseled patient outweigh its risks/burdens and designated it a Standard.

150
Q

What is peripheral tibial nerve stimulation (PTNS)?
a) A treatment for overactive bladder that involves the injection of botulinum toxin into the bladder wall
b) A surgical procedure to remove the bladder
c) A non-invasive treatment for overactive bladder that involves stimulating the nerves in the ankle
d) A medication for overactive bladder that is taken orally

A

c) A non-invasive treatment for overactive bladder that involves stimulating the nerves in the ankle. PTNS is a form of neuromodulation that involves the insertion of a needle near the ankle to stimulate the tibial nerve, which then sends signals to the sacral nerve plexus that controls bladder function.

151
Q

What is the evidence strength for the use of PTNS in treating overactive bladder, according to the guideline statement?
a) Grade A
b) Grade B
c) Grade C
d) Grade D

A

c) Grade C. The evidence for the efficacy of PTNS in treating overactive bladder is based on observational studies and a small randomized controlled trial, which is considered to be of moderate quality.

152
Q

What is the most common protocol for PTNS treatment?
a) One session per week for 12 weeks
b) Two sessions per week for 8 weeks
c) Three sessions per week for 4 weeks
d) One session per month for 6 months

A

a) One session per week for 12 weeks. The majority of studies on PTNS have used this protocol, which involves 30 minutes of stimulation per session. For continued benefit, weekly stimulation would have to continue.

153
Q

What is the main conclusion of the studies that focused on documenting the duration of treatment effects of PTNS once treatment ceased?
a. Treatment benefits were retained for up to 12 months once treatment ceased.
b. Treatment benefits were retained for four to six months once treatment ceased.
c. Treatment benefits were retained for up to 24 months once treatment ceased.
d. Treatment benefits were not retained once treatment ceased.

A

b. Treatment benefits were retained for four to six months once treatment ceased, according to several studies that used protocols ranging from 12 weekly sessions to tapering session frequency over five to six months.

154
Q

What did Peters (2013a, 2013b) report about the long-term outcomes of PTNS responders in the SUmiT trial who were willing to continue with therapy?
a. Patients did not report any significant improvements in frequency, nocturia, urgency episodes, and UUI.
b. Patients received a median of 2.0 treatments per month.
c. Scores on the OAB-q and HRQOL as well as symptom severity scores remained significantly improved.
d. Only 4% of patients received 1.0 to <2.0 treatments/month.

A

c. Scores on the OAB-q and HRQOL as well as symptom severity scores remained significantly improved, and patients received a median of 1.0 treatments per month (IQR 0.9 to 1.2), according to Peters (2013a, 2013b) who reported long-term outcomes for PTNS responders identified during the SUmiT trial who were willing to continue with therapy.

155
Q

What is the main conclusion of the systematic reviews and meta-analyses that assessed PTNS?
a) PTNS is not effective in comparison to placebo or anti-muscarinics
b) PTNS is significantly more effective than anti-muscarinics
c) PTNS significantly improves OAB symptoms and has a better adverse event profile than anti-muscarinics
d) PTNS is not recommended as a treatment for OAB

A

c) PTNS significantly improves OAB symptoms and has a better adverse event profile than anti-muscarinics. The systematic reviews and meta-analyses have concluded that there is convincing evidence for the efficacy of PTNS in comparison to placebo or sham conditions, that from 37% to 100% of patients are reported to meet criteria for success, and that adverse events are minimal. PTNS has been found to be similar in magnitude to anti-muscarinics, but with a better adverse event profile.

156
Q

What is the primary weakness of the studies assessing PTNS?
a) Lack of long-term follow-up in a randomized design
b) Lack of control groups in the studies
c) High incidence of adverse events
d) Inability to improve incontinence episodes

A

a) Lack of long-term follow-up in a randomized design. The studies assessing PTNS have been criticized for having predominantly observational designs, varying patient inclusion criteria, small sample sizes, and short follow-up durations for most studies. One of the primary weaknesses identified by these studies is the lack of long-term follow-up in a randomized design.

157
Q

What is the primary outcome measure for the InSite trial evaluating SNS?
a. Change in voids per day
b. Change in incontinence episodes per day
c. OAB therapeutic success defined as ≥50% improvement in average incontinence episodes/day or voids/day or a return to normal voiding frequency of <8 voids/day
d. Change in pad use per day

A

c. OAB therapeutic success defined as ≥50% improvement in average incontinence episodes/day or voids/day or a return to normal voiding frequency of <8 voids/day. The InSite trial evaluated SNS compared to standard medical therapy (SMT) for overactive bladder. The primary outcome measure was OAB therapeutic success defined as ≥50% improvement in average incontinence episodes/day or voids/day or a return to normal voiding frequency of <8 voids/day.

158
Q

The impact of obesity on stage I success rates in SNS patients
b. The effects of SNS on periurethral sensation and urethral sphincter activity
c. Success rates during the testing phase in patients who presented for SNS
d. The impact of the number of incontinence episodes per day on SNS success rates

A

c. Success rates during the testing phase in patients who presented for SNS.

Explanation: Davis (2013) and Yazdany (2011) both reported success rates during the testing phase of SNS in patients who presented for SNS due to lack of medication efficacy or intolerable medication side effects. Davis (2013) reported a 70% success rate during the testing phase, while Yazdany (2011) noted that patients with more than 10 incontinence episodes per day were more likely to have a successful stage I trial compared to those with less than 5 episodes per day.

159
Q

What did Cardarelli (2012) report in their study of SNS?
a) Significant increases in UUI episodes, frequency, nocturia, and pad use
b) Significant decreases in voided volumes at 48 weeks post-implant
c) Significant decreases in UUI episodes, frequency, nocturia, and pad use
d) None of the above

A

c) Significant decreases in UUI episodes, frequency, nocturia, and pad use

Explanation: Cardarelli (2012) reported significant decreases in UUI episodes, frequency, nocturia, and pad use as well as significant increases in voided volumes at 48 weeks post-implant.

160
Q

What did Yih (2013) report in their study of SNS in women?
a) No improvement in sexual functioning after SNS implant
b) FSFI scores improved significantly from mean 15.9 at baseline to mean 13.5
c) ICSI-PI composite score improvements were greater among women with baseline FSFI scores of < 26 compared to ≥ 26
d) FSFI scores improved significantly from mean 13.5 at baseline to mean 15.9, and ICSI-PI composite score improvements were similar among women with baseline FSFI scores of < 26 compared to ≥ 26

A

d) FSFI scores improved significantly from mean 13.5 at baseline to mean 15.9, and ICSI-PI composite score improvements were similar among women with baseline FSFI scores of < 26 compared to ≥ 26

Explanation: Yih (2013) reported on changes in sexual functioning in women after SNS implant. At 12 months post-implant, FSFI scores improved significantly from mean 13.5 at baseline to mean 15.9 and ICSI-PI composite score improvements were similar among women with baseline FSFI scores of < 26 compared to ≥ 26.

161
Q

What is the FSFI?

A

The FSFI is the Female Sexual Function Index, a questionnaire used to assess sexual function in women. It consists of 19 questions that assess different aspects of sexual function, such as desire, arousal, lubrication, orgasm, satisfaction, and pain. The total FSFI score ranges from 2 to 36, with higher scores indicating better sexual function.

162
Q

What did Peters Killinger’s study evaluate?

A) Success rates during the testing phase of SNS
B) Changes in urodynamics parameters after SNS
C) Differences in outcomes between male and female patients after SNS
D) Differences in outcomes between patients aged 40 to 64 years and patients older than age 64 after SNS

A

D

Explanation: Peters Killinger’s study compared outcomes between patients aged 40 to 64 years with patients older than age 64 after SNS. The study evaluated patients with OAB, IC, or urinary retention, and found that incontinence episodes, frequency, urgency, nocturia, OAB-q scores, and ICSI-PI scores all improved significantly at 26 weeks in both groups.

163
Q

Which of the following is true about patients with concomitant urinary and fecal incontinence treated with sacral neuromodulation?

A) Patients experienced no significant improvement in urinary or fecal incontinence episodes.
B) Patients experienced significant improvement in urinary incontinence episodes, but no significant improvement in fecal incontinence episodes.
C) Patients experienced significant improvement in both urinary and fecal incontinence episodes.
D) Patients experienced significant improvement in fecal incontinence episodes, but no significant improvement in urinary incontinence episodes.

A

C) Patients experienced significant improvement in both urinary and fecal incontinence episodes.

Explanation: Faucheron (2012) evaluated patients with both urinary and fecal incontinence and found that at more than 5 years post-implant, UUI episodes (and fecal incontinence episodes) were significantly reduced. Approximately 74% of patients were satisfied with their improvements in both forms of incontinence, and all QOL measures also exhibited significant improvement.

164
Q

What is the primary outcome in the study by Smits (2013) on patients who discontinued BTX-A therapy and received SNS implant?
A. Improvement in frequency
B. Improvement in urgency
C. Improvement in leakage
D. Improvement in patient satisfaction

A

C. Improvement in leakage, defined as greater than 50% improvement in leakage episodes and severity of leakage measured on a 1 to 4 scale, was the primary outcome in the study by Smits (2013) on patients who discontinued BTX-A therapy and received SNS implant.

165
Q

What adverse events were commonly reported in SNS studies?
A. Pain at the stimulator site
B. Pain at the lead site
C. Lead migration
D. All of the above

A

D. Pain at the stimulator site, pain at the lead site, lead migration, infection/irritation, electric shock, and need for surgical revision were commonly reported adverse events in SNS studies.

166
Q

What is the recommended treatment protocol for SNS therapy?
A. Periodic replacement in a planned surgical procedure
B. Monthly adjustment of the device settings
C. No maintenance required after implantation
D. Daily replacement of the device battery

A

A. The recommended treatment protocol for SNS therapy is periodic replacement in a planned surgical procedure. Patients must also comply with the treatment protocol, which typically involves using a remote control to optimize device function.

167
Q

According to Guideline Statement 21, how long should a patient persist with a new medication before determining its efficacy and adverse events?
a. 1 to 2 weeks
b. 2 to 4 weeks
c. 4 to 8 weeks
d. 8 to 12 weeks

A

c. 4 to 8 weeks. Guideline Statement 21 recommends that practitioners and patients persist with new treatments for a sufficient duration to achieve clarity regarding efficacy and adverse events for a particular therapy before abandoning the therapy prematurely or before adding a second therapy. For medications, this duration is 4 to 8 weeks.

168
Q

According to the expert opinion in the given material, what is the importance of a comprehensive evaluation and trial of behavioral therapy before second-line or third-line treatments for overactive bladder?
a. It reduces the cost of treatment
b. It reduces the need for medications
c. It ensures the OAB diagnosis is correct
d. It reduces the duration of treatment

A

c. It ensures the OAB diagnosis is correct. The expert opinion notes that practitioners regularly encounter patients who present for second-line or third-line treatments who have never undergone a comprehensive evaluation or who have never had a trial of behavioral therapy. Completing a voiding diary to ensure the OAB diagnosis is correct and conducting an adequate trial of behavioral therapy is important before proceeding to more invasive or costly treatments.

169
Q

When should augmentation cystoplasty or urinary diversion be considered for OAB patients?

A

According to Guideline Statement 22, augmentation cystoplasty or urinary diversion for severe, refractory, complicated OAB patients may be considered in rare cases. However, in general, surgery is not recommended for OAB patients except in extremely rare cases, particularly because there are substantial risks to these procedures, including the likely need for long-term intermittent self-catheterization and the risk of malignancy.

170
Q

What is the Panel’s stance on the use of indwelling catheters as a management strategy for OAB?

A

The Panel does not recommend the use of indwelling catheters as a management strategy for OAB except as a last resort in selected patients, due to the adverse risk/benefit balance associated with this approach. The use of diapering and absorbent garments is always preferred to indwelling catheterization. Intermittent catheterization may be an option when concomitant incomplete bladder emptying is present, and indwelling catheterization may be considered as a last resort when urinary incontinence has resulted in the development and progression of decubiti, during the management of those decubiti, or rarely, where urinary incontinence is the predominant disability affecting activities of daily living and therefore may result in institutionalization.

171
Q

What is the purpose of follow-up in OAB treatment?
A) To evaluate patient satisfaction with treatment
B) To assess compliance with treatment protocols, query patients regarding symptom improvements and any adverse events and present information about possible alternative treatments
C) To determine the cause of treatment failure
D) To adjust treatment dosages based on symptom severity

A

B) To assess compliance with treatment protocols, query patients regarding symptom improvements and any adverse events and present information about possible alternative treatments.

Explanation: The purpose of follow-up in OAB treatment is to assess compliance with treatment protocols, query patients regarding symptom improvements and any adverse events, and present information about possible alternative treatments to patients who have insufficient symptom improvement and/or intolerable adverse events.

172
Q

What are some ways to measure symptom changes in OAB treatment?
A) Blood tests
B) MRI scans
C) Patient-rated global response scales and voiding diaries with or without frequency-volume charts
D) Urine tests

A

C) Patient-rated global response scales and voiding diaries with or without frequency-volume charts.

Explanation: Patient-rated global response scales for urgency, urgency incontinence, incontinence, frequency, and nocturia, as well as voiding diaries with or without frequency-volume charts, are some ways to measure symptom changes in OAB treatment.

173
Q

Which OAB treatment options require careful consideration of treatment compliance and adverse events?
A) Behavioral therapies
B) Neuromodulation
C) Anti-muscarinics
D) All of the above

A

D) All of the above.

Explanation: Behavioral therapies, neuromodulation, and anti-muscarinics are OAB treatment options that require careful consideration of treatment compliance and adverse events.

174
Q

What adverse events should be evaluated in patients treated with anti-muscarinics?
A) Dry mouth
B) Constipation
C) CNS effects
D) All of the above

A

D) All of the above.

Explanation: Patients treated with anti-muscarinics should be evaluated for dry mouth, constipation, and CNS effects.

175
Q

How should non-responders to anti-muscarinics be managed?
A) They should be referred for surgery
B) They should be given a higher dose of anti-muscarinics
C) They should be tried on at least one other anti-muscarinic or mirabegron and/or dose modification attempted
D) They should be switched to sacral neuromodulation

A

C) They should be tried on at least one other anti-muscarinic or mirabegron and/or dose modification attempted.

Explanation: Non-responders to anti-muscarinics should be tried on at least one other anti-muscarinic or mirabegron and/or dose modification attempted to determine if a better balance between efficacy and adverse events occurs.

176
Q

What are potential complications of PTNS?

A

Numbness in distribution of posterior tibial nerve. Infection of puncture site. Skin inflammation. Minor pain at puncture site. Bleeding at puncture site.