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Moderator: Dr. Pawan Vasudeva, India
Panellists: Dr. Amitabh Sinha, India & Dr. Ranga Wickramarachchi, Sri Lanka
Key Highlights
Case 1: Wet OAB with Nocturnal Polyuria in a Postmenopausal Woman
The panel discussed a patient diagnosed with overactive bladder (OAB) and nocturnal polyuria. The patient's symptoms included a daytime frequency of 8 times and nighttime frequency of 2 times. The maximum voided volume was 300 mL, with most voids being under 200 mL, and the NPI index was 40%. Investigations revealed normal urine analysis, ultrasound, and post-void residual volume (PVRU), though urodynamic function reserve (UFR) was not assessed. Key risk factors included postmenopausal status, obesity, and constipation.
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Management Plan
The initial management focused on lifestyle modifications, such as reducing fluid intake before sleep and addressing weight and constipation issues. Patient education on lower urinary tract function was emphasized. Some panel members preferred starting treatment with both lifestyle changes and medications, while others suggested beginning with lifestyle modifications alone.
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Drug Therapy Considerations
The discussion included the choice of medications, particularly antimuscarinics versus mirabegron. Concerns were raised about the cognitive side effects of antimuscarinics, especially oxybutynin, which has been linked to an increased risk of dementia with long-term use. Vaginal estrogens were also recommended for patients experiencing vaginal atrophy, which can complicate OAB symptoms.
Refractory Cases and Urodynamics:
In refractory cases where initial conservative and pharmacological treatments fail after 12 weeks, the panel discussed the potential need for urodynamics and cystoscopy to guide further treatment.
Botox Therapy:
The discussion included potential dosing for Botox, with considerations for the patient's age and risk of complications. There was a consensus that the decision to use Botox could proceed without urodynamic confirmation of detrusor overactivity, based on clinical history and response to prior treatments.
Case 2: OAB with Parkinsonism
A 79-year-old male with parkinsonism presents with wet overactive bladder (OAB) symptoms and moderate obstructive urinary symptoms. His functional status is stable. Investigations reveal a prostate volume of 40 g and a poor urinary flow rate (PUV) of 37. Urodynamics indicate a bladder capacity of 158 mL during the filling phase with normal compliance, while the voiding phase shows the patient is obstructed but can void completely.
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Management Decision
The panel debated whether to perform urodynamics or initiate medical therapy with anticholinergics for OAB. Given the patient's low-risk profile, it was decided that initial management could proceed without invasive urodynamics.
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Neurology Consultation
The panel emphasised the necessity of consulting a neurologist before any surgical intervention to confirm that the patient has idiopathic Parkinson's Disease (IPD) rather than multiple system atrophy (MSA), as treatment outcomes may differ significantly. If confirmed as IPD, there is a 70% chance the patient will improve following TRP.
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Predicting OAB Improvement Post-TRP
The discussion included key factors that could predict improvement of OAB symptoms after TRP, such as severe urinary symptoms at presentation, low bladder capacity, high amplitude or low volume of detrusor contractions, and the presence of unequivocal obstruction. Patients meeting these criteria are less likely to experience resolution of OAB symptoms post-surgery.
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Red Flags for MSA
Potential red flags indicating MSA instead of PD were discussed, including early onset of urinary symptoms or sexual dysfunction, high post-void residual volumes atypical for PD, and open bladder neck observed in imaging studies. In such cases, a neurology referral is strongly advised.
Société Internationale d'Urologie Congress, 23-26 October 2024, New Delhi, India.
