Glinski Ronald W, Siegel Steven
Center for Continence Care and Female Urology, Metro Urology Specialists, 2550 University Avenue West, Suite 240N, St. Paul, MN 55114.
Indian J Urol. 2007 Apr;23(2):166-73. doi: 10.4103/0970-1591.32069.
In this review, we discuss the treatment of refractory overactive bladder (OAB) that has not adequately responded to medication therapy and we propose an appropriate care pathway to the treatment of OAB. We also attempt to address the cost of OAB treatments.
A selective expert review of the current literature on the subject of refractory OAB using MEDLINE was performed and the data is summarized. We also review our experience in treating refractory OAB. The role and outcomes of various treatment options for refractory OAB are discussed and combined therapy with oral anticholinergics is explored. Emerging remedies including intravesical botulinum toxin injection and pudendal neuromodulation are also reviewed, along with conventional surgical options.
In general behavioral therapy, pelvic floor electrical stimulation, magnetic therapy and posterior tibial nerve stimulation (PTNS), have shown symptom decreases in 50-80% of patients with OAB. Depending on the study, combination therapy with oral anticholinergics seems to improve efficacy of behavioral therapy and PTNS in approximately 10-30%. In multicenter, long-term randomized controlled trials, sacral neuromodulation has been shown to improve symptoms of OAB and OAB incontinence in up to 80% of the patients treated. Studies involving emerging therapies such as pudendal serve stimulation suggest that there may be a 15-20% increase in efficacy over sacral neuromodulation, but long-term studies are not yet available. Another emerging therapy, botulinum toxin, is also showing similar success in reducing OAB symptoms in 80-90% of patients. Surgical approaches, such as bladder augmentation, are a last resort in the treatment of OAB and are rarely used at this point unless upper tract damage is a concern and all other treatment options have been exhausted.
The vast majority of OAB patients can be managed successfully by behavioral options with or without anticholinergic medications. When those fail, neuromodulation or intravesical botulinum toxin therapies are successful alternatives for most of the remaining group. We encourage practitioners responsible for the care of OAB patients to gain experience with these options. More research is needed to assess the cost-effectiveness of various OAB treatments.
在本综述中，我们讨论对药物治疗反应欠佳的难治性膀胱过度活动症（OAB）的治疗方法，并提出OAB治疗的合适护理路径。我们还尝试探讨OAB治疗的成本。
使用MEDLINE对有关难治性OAB主题的当前文献进行了选择性专家综述，并对数据进行了总结。我们还回顾了我们治疗难治性OAB的经验。讨论了难治性OAB各种治疗选择的作用和结果，并探讨了口服抗胆碱能药物的联合治疗。还回顾了包括膀胱内注射肉毒杆菌毒素和阴部神经调节在内的新兴治疗方法以及传统手术选择。
一般而言，行为疗法、盆底电刺激、磁疗和胫后神经刺激（PTNS）已使50 - 80%的OAB患者症状减轻。根据研究，口服抗胆碱能药物联合治疗似乎能使行为疗法和PTNS的疗效提高约10 - 30%。在多中心长期随机对照试验中，骶神经调节已被证明能使高达80%接受治疗的患者的OAB症状和OAB失禁得到改善。涉及阴部神经刺激等新兴疗法的研究表明，其疗效可能比骶神经调节提高15 - 20%，但尚无长期研究。另一种新兴疗法肉毒杆菌毒素在80 - 90%的患者中减轻OAB症状方面也显示出类似的成功。手术方法，如膀胱扩大术，是OAB治疗的最后手段，目前很少使用，除非担心上尿路受损且所有其他治疗选择均已用尽。
绝大多数OAB患者可以通过行为疗法成功治疗，无论是否使用抗胆碱能药物。当这些方法失败时，神经调节或膀胱内注射肉毒杆菌毒素疗法是其余大多数患者的成功替代方案。我们鼓励负责OAB患者护理的从业者积累这些治疗方法的经验。需要更多研究来评估各种OAB治疗的成本效益。
