Anticholinergic drugs for adult neurogenic detrusor overactivity: a systematic review and meta-analysis.

CONTEXT: There is a lack of evidence about the efficacy and safety of anticholinergic drugs and about the optimal anticholinergic drug, if any, for the treatment of adult neurogenic detrusor overactivity (NDO). OBJECTIVE: Review the current evidence on the efficacy, safety, and tolerability of anticholinergic drugs in the treatment of adult NDO. EVIDENCE ACQUISITION: A literature search was conducted from 1966 to May 2011. Meta-analysis of all published randomised controlled trials (RCTs) comparing anticholinergic drugs with placebo and comparing different types, doses, and routes of administration of anticholinergic drugs, in adults with NDO, was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. The primary outcome was patient-reported cure/improvement of overactive bladder symptoms. Secondary outcomes were quality of life (QoL) changes, bladder diary events, urodynamic outcomes, adverse events, and costs to health services. EVIDENCE SYNTHESIS: A total of 960 patients from 16 RCTs with mean follow-up of 3.8 wk were included. Anticholinergic drugs were associated with statistically significantly better patient-reported cure/improvement (risk ratio: 2.80; 95% confidence interval [CI], 1.64 to 4.77), higher maximum cystometric capacity (weighted mean difference [WMD]: 49.49; 95% CI, 15.38 to 84.20), higher volume at first contraction (WMD: 49.92; 95% CI, 20.06 to 79.78), and lower maximum detrusor pressure (WMD: -38.30; 95% CI, -53.17 to -23.43) when compared with placebo. The dry-mouth rates were statistically significantly higher with anticholinergics, with no difference in withdrawals because of adverse events. There was no statistically significant difference in any of the outcomes between oxybutynin and other anticholinergics or among different doses and preparations of anticholinergic drugs. No study reported QoL changes or costs to health services. CONCLUSIONS: Compared with placebo, anticholinergic treatment in patients with NDO is associated with better patient-reported cure/improvement and significant reduction of maximum detrusor pressure; however, there is a higher incidence of adverse events. None of the anticholinergic drugs or different dosages assessed in this review was superior to another.

Correlation of three validated questionnaires for assessment of outcomes following surgical treatment of stress urinary incontinence in women.

OBJECTIVES: To assess the correlation between women's responses to the "Patient Global Impression of Improvement" questionnaire (PGI-I) and changes in women's quality of life and sexual function following surgical treatment of stress urinary incontinence (SUI). STUDY DESIGN: Ancillary analysis of data from a prospective randomised surgical trial: 299 women underwent transobturator tape insertion as a sole procedure and completed the King's Health Questionnaire (KHQ) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at baseline and at 12-month follow-up in addition to PGI-I at 12 months. Spearman's correlation coefficient was used to evaluate the degree of association between PGI-I responses and the changes in total KHQ and PISQ-12 scores. Kruskal-Wallis tests were performed to compare the 7-point scale PGI-I responses in terms of changes in KHQ and PISQ-12 scores. RESULTS: There was a significant positive correlation between PGI-I responses and changes in the total KHQ scores (r=0.48, p<0.001). The changes in the total KHQ score became larger (i.e., more positive) as the PGI-I responses became more positive. There were statistically significant differences across the PGI-I groups with respect to the changes in total KHQ scores (p<0.001). "Very much improved/Much improved" responses on PGI-I were associated with median (IQR) improvement in KHQ scores of 46 (32, 60) and 35 (18, 49) points respectively. An 18-point improvement in total KHQ score was required to clearly indicate a "better" response on PGI-I. There was a statistically significant, but weak, positive correlation between PGI-I responses and the changes in the total PISQ-12 score (r=0.17, p=0.019). CONCLUSION: The Patient Global Impression of Improvement Questionnaire strongly correlates with changes in Kings Health Questionnaire scores following surgery for SUI and can reliably predict improvement and deterioration in women's quality of life. CONDENSATION: The Patient Global Impression of Improvement Questionnaire strongly correlates with, and can predict changes in, Kings Health Questionnaire scores following surgery for stress urinary incontinence.

Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup?

Tubal assessment is an integral part of female fertility evaluation. While diagnostic laparoscopy is gold standard, it is not suitable to be used as a screening test. Hysterosalpingogram (HSG) has been advocated as first-line investigation historically. With advances in diagnostics, more tests are available, such as hysterosalpingo contrast sonography (HyCoSy) and Chlamydia antibody titre (CAT) are available. The CAT test is much cheaper, less invasive and can be performed at any time during the cycle. The CAT test can also be used as a means of identifying which patients need further evaluation. HyCoSy has same diagnostic accuracy as HSG, without exposing women to radiation. We argue that HSG is out of date and has no place in a modern infertility evaluation. We also suggest a pathway (based on history, clinical and ultrasound evaluation) for investigations to screen for and diagnose tubal pathology.