對於膀胱過動症男性患者 行為治療可和藥物治療匹敵
作者：Jill Stein
出處：WebMD醫學新聞
June 3, 2010 (加州舊金山) — 研究者在美國泌尿科協會(AUA)2010年科學會議中宣稱，對於沒有明顯膀胱出口阻塞的膀胱過動症(overactive bladder，OAB)男性患者，綜合行為治療計畫和抗毒蕈鹼藥物一樣有效。
阿拉巴馬大學醫學教授Kathryn L. Burgio博士向Medscape Urology指出，雖然有些照護者建議對男性和女性的OAB使用行為治療，多數醫師並未在其臨床實務中提供這類療法，例如骨盆底肌肉訓練以及衝動壓抑技術(urge-suppression techniques)。
研究者將143名男性OAB患者隨機分派接受一項為期8週的行為治療或藥物治療。
OAB定義為急尿和頻尿(每天排尿大於8次)，合併或未合併失禁，且無明顯阻塞(單純尿流量測量小於10 mL/s或排尿後殘餘尿液量大於150 mL )。
在一個為期4週的磨合期中，所有研究對象在α阻斷劑治療後都還有持續的OAB症狀。
行為治療為一個綜合訓練計畫，包括骨盆底肌肉運動、延遲排尿、自我監測之膀胱日記、衝動壓抑技術來抑制逼尿肌收縮和減少急尿、頻尿和失禁 。
指派到藥物治療組的病患接受標準的抗毒蕈鹼藥物治療，起始劑量為10 mg緩釋型oxybutynin，依據個人狀況調整到每天5-30 mg。逐步增加劑量的目標是，幫助病患達到他們可以達成且無無法耐受之副作用的最有效劑量。
研究對象在隨機分組前7天以及最後療程後7天進行膀胱日記，以計算24小時排尿頻率、以及夜尿和失禁的改變。
完成行為治療的64名病患，每天平均排尿次數減少，從開始時的11.3次減少到治療後的9.1次(P< .001)，接受藥物治療的60名病患，則是從開始時的11.4次減少到治療後的9.5次(P< .001)。統計分析顯示，兩組在治療後的排尿頻率效果相當(P< .001)。
治療8週之後，隨機分組接受行為治療的病患有36%、藥物治療的病患有30% 每天排尿小於等於8次(P= .48)。夜尿方面，行為治療組平均每晚減少0.72次，藥物治療組減少0.32次(P= .04)。
整體察覺改善方面，在治療結束評估時，行為治療組有38%表示他們「好很多」，藥物治療組則是有29% (P= .34)。在病患滿意方面，行為治療組有56%患者表示「完全滿意」，藥物治療組則是有43%(P= .17)。
Burgio博士表示，試驗結果顯示，骨盆底肌肉訓練、延遲排尿、衝動壓抑技術等行為治療，可有效減少OAB男性的排尿頻率，獲得至少和藥物治療一樣好的結果。
她表示，行為治療因為副作用少，可以適用為無阻塞之OAB男性的第一線治療，而且，因為沒有結果預測因子，對任何想嘗試的非失智病患，我們仍無臨床理由否定行為治療。
新墨西哥大學泌尿科主任、教授、AUA公共媒體委員會主席Anthony Y. Smith醫師向Medscape Urology表示，雖然這是小型研究，其研究發現很有趣，藥物和行為治療之間沒有大差異，表示行為治療有其利益。
他表示，雖然行為治療看似有效，這方式仍是憂喜參半。顯然地，行為治療不會有一些OAB藥物的副作用，但是，其缺點在於為病患設定一個治療模式時的複雜度，因為你需要有人來教各種技術，然後你需要有人確保病患正確地執行這些技術，所以，行為治療相當需要人力。
退伍軍人事務部、退伍軍人健康管理局、復健研究與發展服務等機構資助該研究。Burgio博士報告與其研究團隊和Pfizer、Asellas、Ferring, Alza與Johnson Johnson有各種財務關係，Smith醫師宣告沒有相關資金上的往來。
美國泌尿科協會(AUA)2010年科學會議：摘要1516。發表於2010年6月1日。
Behavioral Therapy Rivals Drug Treatment for Men With Overactive Bladder
By Jill Stein
Medscape Medical News
June 3, 2010 (San Francisco, California) — A comprehensive behavioral therapy program is as effective as antimuscarinic drug therapy for treating overactive bladder (OAB) in men without significant bladder outlet obstruction, investigators announced here at the American Urological Association (AUA) 2010 Annual Scientific Meeting.
"Although some providers recommend behavioral treatments for OAB in men and women, most clinicians do not offer such therapies, which can include pelvic floor muscle training and urge-suppression techniques, in their clinical practices," Kathryn L. Burgio, PhD, professor of medicine at the University of Alabama at Birmingham, told Medscape Urology.
The researchers randomized 143 men with OAB to an 8-week course of behavioral or drug therapy.
OAB was defined as urgency and frequent urination (>8 voids per day), with or without incontinence, and without significant obstruction (<10?mL/s on simple uroflowmetry or >150?mL postvoid residual urine).
All participants in the trial had persistent OAB symptoms after alpha-blocker therapy during a 4-week run-in period.
Behavioral therapy consisted of a comprehensive training program, which included pelvic floor muscle exercises, delayed voiding, self-monitoring with bladder diaries, and urge-suppression techniques to inhibit detrusor contraction and reduce urgency, frequency, and incontinence.
Patients assigned to drug therapy received standard antimuscarinic therapy consisting of individually titrated, extended-release oxybutynin, 5 to 30?mg daily, initiated at 10?mg. The goal of dose escalation was to help the patient reach the most effective dose they could achieve without intolerable adverse effects.
Seven-day bladder diaries completed by subjects prior to randomization and after the last treatment session were used to calculate changes in 24-hour frequency of urination, as well as nocturia and incontinence.
The 64 patients who completed behavioral treatment demonstrated a reduction in the mean number of voids per day, from 11.3 at baseline to 9.1 after treatment (P?< .001). The 60 patients who received drug therapy showed a reduction from 11.4 at baseline to 9.5 after treatment (P?< .001). Statistical analysis indicated that the posttreatment voiding frequencies were equivalent (P?< .001).
After 8 weeks of treatment, 36% of patients randomized to behavioral treatment and 30% assigned to drug therapy had 8 or fewer voids per day (P?= .48). Nocturia was reduced by a mean of 0.72 episodes per night in the behavior group and 0.32 episodes in the drug group (P?= .04).
On the global perception of improvement, assessed at the end of treatment, 38% of patients receiving behavioral therapy reported that they were "much better," compared with 29% of those receiving drug therapy (P?= .34). On the patient satisfaction question, 56% receiving behavioral therapy reported being "completely satisfied," compared with 43% receiving drug therapy (P?= .17).
The results of this trial demonstrate that behavioral treatment with pelvic floor muscle training, delayed voiding, and urge-suppression techniques are effective for reducing frequency of voiding in men with OAB, and yield outcomes at least as good as drug therapy, Dr. Burgio said.
"Given its lower side-effect profile, behavioral therapy is an appropriate first-line treatment for OAB in men without obstruction," she said. "Also, because no consistent predictors of outcome have been identified, we maintain that there is no clinical reason to deny behavioral treatment to any nondemented patient who wishes to try it."
"While the study was small, the findings are interesting, and the lack of a large difference between the medical and behavioral therapy groups suggests that there is some benefit with the behavioral therapy," Anthony Y. Smith, MD, chair of the AUA public media committee and professor and chief of the Division of Urology at the University of New Mexico in Albuquerque, told Medscape Urology.
Although behavioral therapy seems to be effective, the intervention is a mixed bag, he cautioned. "Obviously, behavioral therapy won't have the well-described side effects of some of the OAB medications, but the downside is the complexity of setting up a model to treat patients, because you need someone to teach the various techniques and then you need someone to make sure that the patients are performing the techniques correctly. So behavioral therapy can be very labor-intensive."
The study was funded by the Department of Veterans Affairs, Veterans Health Administration, Rehabilitation Research and Development Service. Dr. Burgio reports relevant financial relationships collectively for the research team with Pfizer, Asellas, Ferring, Alza, and Johnson Johnson. Dr. Smith has disclosed no relevant financial relationships.
American Urological Association (AUA) 2010 Annual Scientific Meeting: Abstract?1516. Presented June?1, 2010.
