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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Raising Expectations in the Management of Overactive Bladder: Focus on Urgency


GOAL
To provide urologists, urogynecologists, and primary care physicians with the latest information on the diagnosis and treatment of overactive bladder.

TARGET AUDIENCE
This activity is designed for urologists, urogynecologists, and primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Identify the neuromuscular and central and peripheral nervous system mechanisms that control normal and overactive bladder (OAB) function.
  • Evaluate basic and advanced diagnostic methods for patients with OAB.
  • Identify and discuss nonpharmacologic and pharmacologic therapies for OAB.
  • Differentiate pharmacologic treatment options on the basis of efficacy measure, adverse events, and treatment duration effect.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award.
Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity:  2 hours.

Release date: November 15, 2004. Expiration date: November 15, 2006.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from GlaxoSmithKline and Yamanouchi Pharma America, Inc.

Although not an official part of the AUGS/SGS Joint Scientific Meeting, the program for this symposium was reviewed and its presentation permitted by both societies.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:


PROGRAM DIRECTOR

Geoffrey W. Cundiff, MD
Associate Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Chair, Department of Obstetrics and Gynecology
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Dr Cundiff reports receiving grants/research support from Cook Ob/Gyn; and serving as a consultant to C.R. Bard, Inc, Darol Inc, and Eli Lilly and Company.

PARTICIPATING FACULTY

David A. Ginsberg, MD
Assistant Professor of Urology
Keck School of Medicine
University of Southern California
Los Angeles, California
Chief of Urology Science
Ranchos Los Amigos National Rehabilitation Center
Downey, California
Dr Ginsberg reports serving as a consultant to Allergan Inc, Inderus Pharmaceuticals, Inc, and Pfizer Inc; receiving honoraria from and serving on the speakers' bureau for Indevus Pharmaceuticals, Inc, Novartis Pharmaceuticals USA, Pfizer Inc, and Yamanouchi Pharma America, Inc.

Vikram Khullar, MD, MRCOG
Senior Lecturer and Consultant Urogynaecologist
St. Mary's Hospital
Imperial College
London, United Kingdom
Dr Khullar reports receiving grants/research support from Pfizer Inc, Schwarz Pharma USA, and Yamanouchi Pharma America, Inc; serving as a consultant to Eli Lilly and Company; and receiving honoraria from Eli Lilly and Company, Pfizer Inc, Schwarz Pharma USA, and Yamanouchi Pharma America, Inc.

Lauri J. Romanzi, MD, FACOG
Clinical Associate Professor
Department of Obstetrics and Gynecology
Joan and Sanford I. Weill Medical College
Cornell University
Clinical Associate Professor
New York - Weill Cornell Medical Center
New York, New York
Dr Romanzi reports receiving grants/research support from Ethicon Inc, serving as a consultant to and receiving honoraria from Novartis Pharmaceuticals USA, Pfizer Inc, Procter & Gamble, and Yamanouchi Pharma America, Inc.

William D. Steers, MD, FACS
Hovey Dabney Professor of Urology
Chair, Department of Urology
University of Virginia Health System
Charlottesville, Virginia
Dr Steers reports receiving grants/research support from Novartis Pharmaceuticals USA and Pfizer Inc; and serving as a consultant to Eli Lilly and Company, Novartis Pharmaceuticals USA, and Yamanouchi Pharma America, Inc.

Notice: In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty member has disclosed that her article has referenced the following unlabeled/unapproved uses of drugs or devices:

Dr Romanzi—darifenacin, solifenacin

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Evaluating Clinical Advances In Overactive Bladder
Geoffrey W. Cundiff, MD*

Overactive bladder (OAB) affects millions of Americans, and the aging of the population ensures that the number of people who suffer from of OAB will continue to increase in the coming decades.

Though not a life-threatening condition, OAB often has an adverse impact on an individual's quality of life. The hallmark symptom of urgency can disrupt virtually every aspect of a person's social and personal life. Urgency often occurs with other bothersome symptoms that include urge incontinence, urinary frequency, and nocturia, each of which exacts a toll on social interaction, self-esteem, and personal well-being. In some cases, the condition severely limits virtually every aspect of social interaction because of the sudden, uncontrollable urge to urinate and concerns surrounding that troublesome symptom and the fear of episodes of incontinence. Many patients have night after night of interrupted sleep due to OAB-related nocturia.

Anticholinergic drugs represent the mainstay of therapy for OAB. However, currently available therapies are limited by the incidence of side effects and tolerability, which cause many patients to discontinue therapy. New, more effective therapies are needed.

The avenue toward more effective therapy leads to a better understanding of the pathophysiology of over- active bladder and an appreciation of its complexity. The muscarinic receptors have been the focus of ef-forts to understand OAB and to develop new therapies for the condition. However, an evolving understanding of the muscarinic receptor system suggests that the receptor system interacts with multiple other neurotransmitters, receptors, and cells, making OAB far more complex than previously recognized. Moreover, targeting the muscarinic receptors with anticholinergic agents may have effects that go far beyond those previously recognized.

Growing awareness of the complexity of OAB has pointed to a need for better approaches to diagnose and evaluate the condition. Ambulatory urodynamic monitoring represents one possible alternative to current diagnostic approaches for OAB, although certainly not the only potential alternative.

The following continuing education activity reflects input from a distinguished faculty that has a specific interest in the challenges posed by OAB. Each presentation focuses on different challenges and facets of OAB to provide a comprehensive overview of the current status of diagnosis, evaluation, and treatment of the condition.

Dr David A. Ginsberg begins with an overview of recent developments in the terminology of OAB. New terminology focuses on the improved understanding of the symptomatology of OAB. In particular, the terminology takes into account the recognition that only a minority of OAB patients have episodes of incontinence. Moreover, the terminology distinguishes the normal urge to urinate from the desperate sense of urgency that OAB patients often experience. Dr Ginsberg also touches on the comorbid conditions that often accompany OAB, including falls and fractures related to rushing to the toilet, urinary tract infection, sleep disturbance, and depression.

Dr William D. Steers reviews the current and evolving understanding of the concept of urgency and its pathophysiology. The article includes a specific focus on the role of the urothelium and the various neurotransmitters and receptor systems that appear to play a role in the urgency that characterizes OAB. Dr Steers also discusses the role of antimuscarinic agents as the principal therapy for OAB and how understanding about the effects of antimuscarinics has changed. Historically viewed as agents that address the symptoms of frequency and urge incontinence, antimuscarinics also may help increase warning time and reduce urgency.

Current methods for diagnosis of OAB have a number of limitations. Dr Vikram Khullar discusses standard approaches to diagnosis and evaluation and the need for improved methods to diagnose OAB. Ambulatory urodynamic monitoring (AUM) is one alternative diagnostic approach to OAB, and Dr Khullar presents data from a randomized trial that highlights the potential of AUM in the diagnosis and evaluation of OAB. He also touches on the limitations of AUM and notes the need for continued development of new diagnostic strategies for OAB.

Dr Lauri J. Romanzi completes the program with a review of different therapies available for treatment of OAB. Behavioral management can be effective in man aging many patients, but the success of various behavioral approaches is highly dependent on patient motivation, cooperation, and adherence. Not all patients who have episodes of incontinence become dry using behavioral techniques.

Pharmacologic therapy is the other mainstay of treatment for OAB but has notable limitations related to tolerability, which affects compliance. The combination of behavioral and pharmacologic therapy is more effective than either modality alone. Dr Romanzi also provides an overview of clinical data on new and emerging pharmacologic therapies for OAB. Her article includes recent findings related to approved agents such as oxybutynin, tolterodine, and trospium, as well as the investigational agents solifenacin* and darifenacin. The overview should help physicians who treat OAB develop a perspective on the potential role of different therapies.

Upon completing this educational activity, a clinician should have improved understanding about the current status of OAB, its pathophysiology, its diagnosis, and its treatment. The information included in this activity is readily applicable to clinical practice and can provide important guidance in the management of the challenging condition of OAB.

*Associate Professor, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine; Chair, Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.

Address correspondence to: Geoffrey W. Cundiff, MD, Johns Hopkins University School of Medicine, Department of OB/GYN A1C-125, 4940 Eastern Avenue, Baltimore, MD 21224. E-mail: gcundiff@jhmi.edu.





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