James A. Hokanson

Objective: To evaluate the rate, timing, and predictors of additional therapy among women with idiopathic overactive bladder (OAB) following initial minimally invasive therapies (MIT). Study Design: Retrospective single center cohort study of women with idiopathic OAB treated between 2012 and 2021. Using ICD and procedural codes, we identified women who underwent posterior tibial nerve stimulation (PTNS), sacral neuromodulation (SNM), or intradetrusor onabotulinumtoxinA (BTX). The primary outcome was receipt of additional OAB treatments including OAB medication and/or a different MIT after initial clinical response to MIT. Kaplan-Meier analysis estimated time to additional therapies; Cox proportional hazards and random survival forest models identified predictors. Results: 1,007 women were included (PTNS: 459; SNM: 192; BTX: 356). At three years, 68% of PTNS patients, 52% of BTX patients, and 40% of SNM women required additional therapies with most patients receiving a prescription for additional pharmacotherapy rather than receiving a different MIT. Median time to additional treatments was 12 months (PTNS), 30 months (BTX), and 53 months (SNM). Multiple indications for SNM were associated with decreased hazard for AT (HR 0.56 95% CI 0.33-0.95, p=0.03) while recurrent urinary tract infections were associated with needing additional therapies in the BTX cohort (HR 1.8, 95% CI: 1.1-3.2). Conclusions: Following initial MIT for idiopathic OAB, many women required additional treatment within three years, with most receiving a prescription for pharmacotherapy rather than receiving another MIT. Why This Matters: Overactive bladder (OAB) affects over 33% of women in the United States, and current AUA/SUFU guidelines have shifted from traditional stepwise therapy toward shared decision-making and multimodal treatment. While minimally invasive therapies (MIT) are effective options for OAB, real-world data on patient trajectories after MIT initiation, including rates of treatment augmentation, crossover, or return to pharmacotherapy, remain limited. This retrospective cohort of 1,007 women with idiopathic OAB provides novel data on post-MIT OAB therapy, with 40–68% of patients requiring additional therapy within three years. We noted significant differences in baseline characteristics and treatment tractories between the groups of patients stratified by first MIT and could not directly compare rates of AT between MITs. Factors associated with additional therapy included recurrent urinary tract infections after BTX, whereas multiple indications for SNM were associated with decreased use of AT. Most women who required additional treatment received pharmacotherapy rather than crossing over to a different MIT. These findings reinforce that OAB management is a dynamic, ongoing process rather than a one-time intervention, and that additional therapy is common. Clinicians can use these data to set realistic expectations during counseling, framing additional therapy as a common and anticipated part of the treatment trajectory rather than a treatment failure.

Purpose: To investigate sensory and motor function of the bladder and urethra in women with and without urgency urinary incontinence (UUI).Materials and Methods: Treatment‐seeking women with UUI and healthy, asymptomatic, nontreatment seeking controls enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Organ‐Based study (LURN‐Organ) and underwent a single session of physiological testing. Testing included rapid‐fill cystometry before and after lidocaine administration, urethral pressure profiles, pelvic floor contraction (Kegel) testing, and tuning fork sensation testing at the urethral meatus.Results: Data were collected from 31 asymptomatic controls and 56 women with UUI. Women with UUI were more likely to demonstrate detrusor overactivity (DO) (32% vs. 10% in controls, p = 0.019). In addition, women with UUI on average generated 25% lower active urethral closure pressures during maximal contraction (p = 0.0016) and reported sensations at lower volumes during cystometry (34% lower for first desire to void, p = 0.028; 34% lower for strong desire to void, p = 0.0017; and 32% lower for maximum cystometric capacity, p = 0.0047). Women with UUI demonstrated diminished urethral sensation on the tuning fork test (median of 7 vs. 8 in controls) though the difference was not significant (p = 0.054). Considerable overlap in all findings occurred between cases and controls in each parameter. While individual component comparisons revealed some differences, additional multivariable analysis demonstrated prominently the physiological heterogeneity of women with UUI.Conclusions: Women with UUI demonstrated varying amounts of bladder sensory dysfunction, urethral motor dysfunction and bladder motor dysfunction. Considering the function of lower urinary tract components in combination may reveal UUI phenotypes, highlighting the need to study UUI from a multifactorial perspective.Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT04557748.

Little is known about the effects of different bladder filling rates on cystometric results. Various sources have suggested that faster filling is “provocative” to the bladder. However, in this study we varied bladder filling rates in anesthetized rats and observed less detrusor overactivity with faster filling, not more. We explain this discrepancy as a miscommunication about what being provocative means, where faster filling leads to worse bladder compliance (as we observed), not more detrusor overactivity.

Importance: Many women report inadequate symptom control after sacral neuromodulation (SNM), despite 50% reduction in urgency incontinence episodes (UUIE) after test stimulation.Objective: To determine the ideal percent UUIE reduction after test stimulation that predicts 24‐month success.Study Design: Using data from a multicenter SNM trial, we constructed receiver operating characteristic curves to identify an ideal threshold of percent UUIE reduction after test stimulation. We defined 24‐month success as Patient Global Impression of Improvement of “very much better” to “better.” We compared predictive accuracy of two models predicting success: (1) percent UUIE reduction alone and (2) with baseline characteristics.Results: Of 149 women (median [IQR] baseline daily UUIE 4.7 [3.7, 6.0]), the ideal threshold for 24‐month success was 72% (95% confidence interval 64,76%) UUIE reduction with accuracy 0.54 (0.42, 0.66), sensitivity 0.71 (0.56, 0.86) and specificity 0.27 (0.05, 0.55). The accuracy of the 50% reduction threshold was 0.60 (0.49, 0.71), sensitivity 0.95 (0.88, 1.0) and specificity 0.04 (0.0, 0.12). Percent reduction in UUIE was not better than chance in predicting 24‐month success (concordance index [c‐index] 0.47 [0.46, 0.62]); adding age, body mass index, diabetes mellitus and visual or hearing impairment the c‐index was 0.68 (0.61, 0.78).Conclusions: Among women who received an internal pulse generator (IPG) due to ≥50% UUIE reduction after test stimulation, we found no ideal threshold that better predicted 24‐month success. Percent reduction in UUIE after test stimulation poorly predicts 24‐month success with or without clinical factors. Given this, re‐evaluating how we determine who should receive an IPG is needed.

Acute low-amplitude electrical stimulation of sacral nerve (sacral neuromodulation) did not increase bladder capacity in anesthetized CD, obese-prone, or obese-resistant rats. Increasing stimulation amplitude correlated with increases in bladder capacity and pudendal sensory nerve recruitment. It is unclear how the high-amplitude acute stimulation that is commonly used in animal experiments to generate immediate effects compares mechanistically to the chronic low-amplitude stimulation used clinically.