Highlighting Botox, sacral nerve stimulation as emerging OAB treatments for elderly patients

Two studies participated in the 2022 Annual Meeting of the South Central Division of the AUA highlight botulinum toxin (Botox) and sacral nerve stimulation (SNS) as alternative treatment options for patients over 70 years of age with overactive bladder (OAB).1,2

AUA guidelines recommend behavioral therapies, such as bladder training, fluid administration, and pelvic floor muscle training, as a first-line approach for patients with OAB. Guidelines also suggest that for some patients, combined behavioral therapies with pharmacological management may be an appropriate first-line approach. The second-line treatments recommended by the AUA guidelines are oral anticholinergics and b-3 agonists.

Researchers at Houston Methodist Hospital and Texas A&M College of Medicine were interested in finding alternative treatment approaches, noting that oral anticholinergics have been associated with cognitive impairment and that vitamin B3 agonists have been associated with negative effects on blood pressure. They also emphasized that elderly patients may be more likely to experience these side effects, making new options particularly important for this population.

The aim of the two separate studies was to demonstrate that onabotulinumtoxinA and SNS are robust later options for elderly OAB patients with potential for upgrading in the treatment paradigm.

Onabotulinumtoxin

Researchers in the onabotulinumtoxinA study conducted a retrospective chart review of patients who received intradetrusor onabotulinumtoxinA (BTX-A) injections at urology clinics between May 2015 and September 2021. Overall, the study included 103 patients over the age of 70, 83% of whom were female. .

Before receiving the first injection, 91% of patients emptied spontaneously. The most common symptoms were urinary urgency (98.1%), enuresis (91%), and daytime frequency (83%). Previous pharmacological administration of OAB included anticholinergics in 66% of patients and b-3 agonists in 26.2% of patients. The doses of injected BTX-A were 100 units (88.3%) and 200 units (8.7%).

Overall, 4 patients required temporary de novo intermittent catheterization and 1 patient required fixed catheter placement. At follow-up, 19% of patients (20%) had symptoms of a UTI.

OAB symptom assessment showed significant improvement in urinary incontinence (87% of patients), urinary urgency (73%), daytime urination frequency (65%), and nighttime frequency (57%). More than half of the patients (56.3%) returned to the clinic for repeat injections because they had a good symptomatic response, and 88% did not require OAB medications after follow-up.

“BTX-A is well tolerated in patients over 70 years of age with significant improvement in all areas of OAB symptoms and a significant reduction in their needs for oral OAB medications. This provides an option for patients to reduce oral medications with unwanted side effects of this particular class potentially earlier in the OAB management algorithm,” the authors wrote in the conclusion of their study.

sacral nerve stimulation

The SNS study included a retrospective chart review to identify patients aged 70 years who received SNS from 2018 to 2021 in the researchers’ urology department. The review generated the study population from 36 patients who underwent a phased percutaneous nerve (PNE) or SNS evaluation. Two thirds of patients (66.7%) were female and 94% were spontaneously voiding. Patient symptoms included urinary urgency (94%), urge incontinence (92%), nocturia (86%), and frequency (81%). Previous treatment included b-3 agonists (83%), anticholinergics (69%), and combination therapy (19%).

In all, 22 (61%) of 36 patients chose PNE mode, and 14 patients (39%) chose PNE mode without prior PNE. Eighteen (82%) of 22 patients who underwent PNE testing had improved symptoms and opted to receive a full SNS transplant. Improvement in urinary symptoms was reported in approximately three quarters (71%) of 14 patients who initially underwent the staging procedure. Furthermore, among patients who underwent SNS mode, improvements were reported in daytime frequency (88% of patients), nocturnal urination (74%), urgency (83%), and urge incontinence (83%).

The researchers note that, “There was no significant difference in outcomes between patients with a positive PNE response versus full SNS placement.”

In their closing notes, the study authors wrote that “SNS therapy is a safe and effective treatment option for elderly patients with overactive bladder who may have failed medications or behavioral modifications. Based on this retrospective chart review, first- and second-line treatments are not predictive.” to how patients respond to the nerve stimulation mode. Furthermore, PNE up to full implantation and staged SNS placement have similar symptomatic benefit in the elderly.”

references

1. Hernandez N, Miceli L, Stading R, et al. Results of intraperitoneal retritoxin A (BTX-A) injections in the elderly. Filed at: AUA’s 101st Annual Meeting. 7-10 September 2022; Coronado, California. poster 69.

2. Stading R, Hernandez N, Saleh A, et al. Outcome and safety of sacral nerve stimulation placement in the elderly with overactive bladder. Filed at: AUA’s 101st Annual Meeting. 7-10 September 2022; Coronado, California. poster 70.