Overactive Bladder (Non-Neurogenic) in Adults

Question 1

Diagnosis of OAB: Minimum requirements for diagnosis

Answer 1

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

Question 2

OAB Diagnosis: Tests done at the clinician’s discretion

Answer 2

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

Question 3

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

Answer 3

Urodynamics
Cystoscopy
Diagnostic renal and bladder ultrasound

Question 4

Is OAB a disease?

Answer 4

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.

Question 5

Education for OAB Patients

Answer 5

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.

Question 6

First line treatment for OAB

Answer 6

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.

Question 7

Second line treatment for OAB

Answer 7

Pharmacologic treatment

Question 8

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

Answer 8

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.

Question 9

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

Answer 9

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.

Question 10

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

Answer 10

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.

Question 11

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

Answer 11

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

Question 12

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

Answer 12

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

Question 13

What are third line treatments for OAB?

Answer 13

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.”

Question 14

Botox Dosing and Counseling in OAB

Answer 14

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)

Question 15

PTNS in OAB

Answer 15

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

THIRD LINE treatment

Question 16

Sacral neuromodulation in OAB

Answer 16

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

Question 17

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

Answer 17

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.

Question 18

Fourth line treatment for OAB

Answer 18

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

Question 19

Should OAB patients have indwelling catheters?

Answer 19

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.

Question 20

Follow-up for OAB

Answer 20

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

Question 21

What are the symptoms of OAB?

Answer 21

– 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.

Question 22

What is the definition of nocturnal polyuria?

Answer 22

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.

Question 23

What history should you ask about for OAB?

Answer 23

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.

Question 24

What physical exam should be performed for OAB?

Answer 24

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.

Question 25

How much does weight loss help OAB symptoms?

Answer 25

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).

Question 26

History - OAB - Abridged from JU

Answer 26

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.

Question 27

OAB Differential Diagnosis from JU

Answer 27

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.

Question 28

What are complications associate with placement of SNM?

Answer 28

electric shock

infection/irritation

lead migration

needs for surgical revision

pain at stimulator or lead site

Question 29

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

Answer 29

augmentation cystoplasty

foley

spt

urinary diversion

Question 30

what is ddx for patient with bladder storage sxs?

Answer 30

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)

Question 31

potential causes of nocturia?

Answer 31

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

BPH

low nocturnal bladder capacity

sleep disturbance/OSA

mobilization of LE edema

Question 32

Initial evaluation of patient with OAB sxs should include?

Answer 32

assessment of cognitive ability

IPSS and bother

PVR

UA +/- UCx

Voiding diary

Question 33

A voiding diary should have which info?

Answer 33

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

Question 34

Common a/e and contraindications of anti-muscarinics?

Answer 34

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

Question 35

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

Answer 35

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

Question 36

What is best used for workup of suspected OAB patient?

Answer 36

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

Question 37

What are first line therapies for OAB?

Answer 37

patient education

treatment goals

no treatment acceptable

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

Question 38

What are second line therapies for OAB?

Answer 38

Oral anti-muscarinics or b-agonists

XL over IR

Transdermal

Question 39

What are third line therapies for OAB?

Answer 39

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

Question 40

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

Answer 40

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.”

Question 41

Why is urgency considered the hallmark symptom of OAB?

Answer 41

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

Question 42

How is urinary frequency measured?

Answer 42

Urinary frequency can be reliably measured with a voiding diary.

Question 43

How is urgency urinary incontinence defined?

Answer 43

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

Question 44

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

Answer 44

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

Question 45

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

Answer 45

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

Question 46

Is UUI more common in women or men?

Answer 46

UUI is consistently more common in women than in men.

Question 47

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

Answer 47

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

Question 47

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

Answer 47

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

Question 48

What proportion of OAB cases remit during a given year?

Answer 48

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

Question 49

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

Answer 49

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

Question 50

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

Answer 50

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

Question 51

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

Answer 51

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

Question 52

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

Answer 52

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

Question 53

What are the burdens associated with OAB?

Answer 53

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.

Question 54

How does urinary incontinence affect psychosocial functioning?

Answer 54

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.

Question 55

What age group is most impacted by OAB symptoms?

Answer 55

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.

Question 56

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

Answer 56

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

Question 57

What is the differential diagnosis of nocturia?

Answer 57

Nocturnal polyuria, low nocturnal bladder capacity, or both.

Question 58

How is nocturnal polyuria different from nocturia associated with OAB?

Answer 58

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

Question 59

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

Answer 59

Interstitial cystitis/bladder pain syndrome.

Question 60

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

Answer 60

Menopausal female patients.

Question 61

What is the purpose of the diagnostic process for OAB?

Answer 61

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.

Question 62

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

Answer 62

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.

Question 63

What should be assessed during the physical examination for OAB?

Answer 63

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.

Question 64

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

Answer 64

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.

Question 65

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

Answer 65

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.

Question 66

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

Answer 66

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

Question 67

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

Answer 67

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.

Question 68

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

Answer 68

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

Question 69

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

Answer 69

d) All of the above

Question 70

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

Answer 70

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

Question 71

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

Answer 71

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

Question 72

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

Answer 72

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

Question 73

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

Answer 73

d) As a last resort in selected patients

Question 74

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.

Answer 74

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

Question 75

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

Answer 75

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.

Question 76

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

Answer 76

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.

Question 77

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

Answer 77

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

Question 78

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

Answer 78

b. Grade B

Question 79

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

Answer 79

d. All of the above

Question 80

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

Answer 80

b. A six-month behavioral weight loss intervention

Question 81

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%

Answer 81

c. 47%

Question 82

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

Answer 82

b. Reduced voiding frequency

Question 83

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

Answer 83

b. No

Question 84

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

Answer 84

d. All three approaches had similar effects

Question 85

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

Answer 85

b. Grade B

Question 86

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.

Answer 86

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

Question 87

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.

Answer 87

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

Question 88

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.

Answer 88

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

Question 89

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

Answer 89

C) Both A and B

Question 90

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.

Answer 90

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

Question 91

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

Answer 91

B) Dry mouth

Question 92

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.

Answer 92

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

Question 93

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

Answer 93

c) Mirabegron has similar efficacy to antimuscarinics

Question 94

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

Answer 94

b) Extended release (ER) formulations

Question 95

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%

Answer 95

a) 18.0%

Question 96

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

Answer 96

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.

Question 97

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

Answer 97

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

Question 98

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

Answer 98

c) Erythema or pruritus.

Question 99

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.

Answer 99

c

Question 100

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

Answer 100

a) Solifenacin 5 mg plus mirabegron 50 mg

Question 101

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)

Answer 101

a) Ellington et al. (2016)

Question 102

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

Answer 102

d) β3-adrenoceptor agonists

Question 103

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

Answer 103

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

Question 104

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

Answer 104

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

Question 105

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

Answer 105

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

Question 106

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)

Answer 106

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

Question 107

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

Answer 107

a) Glaucoma

Question 108

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.

Answer 108

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

Question 109

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.

Answer 109

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

Question 110

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

Answer 110

c) Dry mouth

Question 111

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

Answer 111

a) Possible effects of medication on bowel function

Question 112

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

Answer 112

c) Modify the patient’s diet

Question 113

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

Answer 113

b) Reduce the dose

Question 114

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

Answer 114

b) Starting with a minimal dose

Question 115

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.

Answer 115

c) Potentiation of side effects of antimuscarinics.

Question 116

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.

Answer 116

b) Antipsychotic medications.

Question 117

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

Answer 117

c) Frail elderly patients

Question 118

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

Answer 118

b) Cognitive deficits and impaired thermoregulation

Question 119

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

Answer 119

c) Behavioral strategies such as prompted voiding

Question 120

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.

Answer 120

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.

Question 121

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

Answer 121

b) 100U

Question 122

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.

Answer 122

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

Question 123

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

Answer 123

c) Urinary tract infection (UTI)

Question 124

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

Answer 124

a) 1 week to 12 weeks

Question 125

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

Answer 125

c) Urinary incontinence episodes

Question 126

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

Answer 126

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

Question 127

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%

Answer 127

d) 61%

Question 128

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%

Answer 128

d) 60.4%

Question 129

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

Answer 129

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

Question 130

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%

Answer 130

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

Question 131

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

Answer 131

c) Median 3.5 months

Question 132

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

Answer 132

c) Younger patients

Question 133

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%

Answer 133

d. 80%

Question 134

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

Answer 134

c. 11 months

Question 135

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

Answer 135

c. 22%

Question 136

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

Answer 136

c) Tolerability issues

Question 137

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%

Answer 137

b) 17%

Question 138

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

Answer 138

b) Poor efficacy and UTIs

Question 139

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

Answer 139

b) 19.2 months

Question 140

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%

Answer 140

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

Question 141

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

Answer 141

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

Question 142

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

Answer 142

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

Question 143

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

Answer 143

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

Question 144

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%

Answer 144

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%).

Question 145

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.

Answer 145

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.

Question 146

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

Answer 146

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.

Question 147

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

Answer 147

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).

Question 148

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

Answer 148

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).

Question 149

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

Answer 149

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.

Question 150

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

Answer 150

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.

Question 151

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

Answer 151

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.

Question 152

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

Answer 152

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.

Question 153

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.

Answer 153

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.

Question 154

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.

Answer 154

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.

Question 155

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

Answer 155

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.

Question 156

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

Answer 156

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.

Question 157

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

Answer 157

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.

Question 158

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

Answer 158

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.

Question 159

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

Answer 159

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.

Question 160

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

Answer 160

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.

Question 161

What is the FSFI?

Answer 161

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.

Question 162

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

Answer 162

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.

Question 163

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.

Answer 163

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.

Question 164

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

Answer 164

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.

Question 165

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

Answer 165

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.

Question 166

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

Answer 166

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.

Question 167

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

Answer 167

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.

Question 168

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

Answer 168

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.

Question 169

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

Answer 169

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.

Question 170

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

Answer 170

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.

Question 171

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

Answer 171

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.

Question 172

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

Answer 172

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.

Question 173

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

Answer 173

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.

Question 174

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

Answer 174

D) All of the above.

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

Question 175

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

Answer 175

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.

Question 176

What are potential complications of PTNS?

Answer 176

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