Case-Based Review

Diagnosis and Management of Complex Pelvic Floor Disorders in Women

Journal of Clinical Outcomes Management. 2015 June;22(6)

References

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Treatment in This Patient

The patient underwent successful robotic sacrocolpopexy with mesh and a transobturator sling. There were no complications during the procedure and she reports no bulge or SUI symptoms. She has not been straining to void and has been emptying her bladder well since the Foley catheter was removed the day after surgery. However, she continues to complain of bothersome urgency, frequency, and urge incontinence. She is wearing 1 to 3 pads daily for leakage. At her 6-week postoperative visit, the exam showed excellent vaginal support, no SUI, low PVR, and her urine culture was negative.

What are the clinical implications of these findings?

At this point it is reasonable to continue treatment of OAB. The patient may continue to see improvement as she gets further out from surgery but especially in a patient that had preoperative OAB symptoms, treatment is indicated and may consist of reminding her of behavioral modifications, returning to pelvic floor physical therapy, or starting her on a medication.

What medications are used to treat OAB?

Anticholinergic Drugs

Anticholinergics are second-line therapy for OAB; these medications prevent the binding of acetylcholine to the M3 muscarinic receptor in the detrusor muscle and inhibit uncontrolled bladder contraction. There are numerous medications and delivery methods (pills, patches, gels) but efficacy is similar among the different drugs and all are limited by side effects such as dry mouth, constipation, and central nervous system side effects. Mirabegron, approved by the FDA in June 2012 and released in October 2012, is an agonist of the β3-adrenoceptor receptor in the detrusor muscle promoting bladder storage. A phase III trial found that mirabegron significantly decreased incontinence episodes and micturition frequency compared to placebo [40]. Dry mouth, common with anticholinergics, was 3 times less likely compared to tolterodine [41]. The most common side effects (headache, urinary tract infection, hypertension, and nasopharyngitis) were similar between treatment and placebo groups.

Long-term compliance, side effects, and decreased efficacy limit the benefits of medication therapy [42]. In one survey, 25% of patients taking OAB medications discontinued them within 12 months with 89% reporting unmet treatment expectations and/or tolerability [43].

6 Months Later

The patient continues to complain of persistent OAB symptoms despite anticholinergic and beta-3 agonist therapy. She reported significant constipation and dry mouth with an anticholinergic and symptoms did not improve with mirebegron. Despite having OAB symptoms prior to her prolapse repair, it is important to evaluate for any other cause of her persistent symptoms. Her surgical repair remains intact and urodynamics and cystoscopy were performed showing no evidence of bladder outlet obstruction and no mesh or suture material in the bladder. There was no leakage with valsalva, though she had some early sensation of fullness (sensory urge). With a negative evaluation, refractory OAB is diagnosed and the patient is a candidate for third-line OAB treatment.

What are third-line OAB treatments?

OnabotulinumtoxinA

OnabotulinumtoxinA (Botox) was approved in 2013 for patients intolerant or unresponsive to behavioral therapy and oral medications. OnabotulinumtoxinA is a chemical neuromodulator that cleaves the SNARE protein SNAP-25, inhibits the fusion of the cytoplasmic vesical to the nerve terminal, and prevents the release of acetylcholine. This causes detrusor muscle relaxation and may also inhibit sensory afferent pathways [44].