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    急迫性尿失禁是膀胱過(guò)度活動(dòng)癥的表現，或是膀胱肌肉緊張過(guò)度和尿道括約肌的合作不當所引起的尿頻、尿急等癥狀，多發(fā)生在中風(fēng)患者身上，常見(jiàn)的治療為藥物和電擊治療。抗膽堿能藥物和A型肉毒桿菌毒素被用于治療急迫性尿失禁，但目前尚需要直接比較這兩種治療的數據。

    美國北卡羅來(lái)納州達勒姆市杜克大學(xué)醫學(xué)中心的安東尼·G·維斯科等進(jìn)行了一項雙盲、雙安慰劑對照的隨機試驗，試驗納入了患特發(fā)性急迫性尿失禁，每3天發(fā)作急迫性尿失禁≥5次（在日記中記錄）的女性。在6個(gè)月期間，研究者將參與者隨機分配接受每日口服抗膽堿能藥物（索利那新，初始5mg，可能增至10mg，如有需要接下來(lái)改為曲司氯銨XR 60 mg）加逼尿肌內注射（生理）鹽水一次或逼尿肌內注射100 U A型肉毒桿菌毒素一次加每日口服安慰劑。主要轉歸為在6個(gè)月期間每日的急迫性尿失禁平均發(fā)作次數較基線(xiàn)時(shí)的減少值（按每月提交的3天日記中的記錄）。次要轉歸包括急迫性尿失禁完全緩解、生活質(zhì)量、導尿管使用以及不良反應。

    在進(jìn)行隨機分組的249名女性中，247名接受了治療，241名有可用于主要轉歸分析的數據。在6個(gè)月期間，抗膽堿能組每日急迫性尿失禁發(fā)作次數由基線(xiàn)時(shí)的平均每天5.0次平均減少3.4次，A型肉毒桿菌毒素組平均每天減少3.3次（P＝0.81）。分別有13%和27%的女性報告急迫性尿失禁完全緩解（P＝0.003）。兩組生活質(zhì)量均有改善，沒(méi)有顯著(zhù)組間差異。抗膽堿能組口干的發(fā)生率更高（46%對31%，P＝0.02），但2個(gè)月時(shí)的導尿管使用率（0%對5%，P＝0.01）和尿路感染發(fā)生率更低（13%對33%，P＜0.001）。

    口服抗膽堿能治療和注射A型肉毒桿菌毒素與急迫性尿失禁每日發(fā)作頻率降低程度相似有關(guān)。接受A型肉毒桿菌毒素組發(fā)生口干的可能性較小，出現急迫性尿失禁完全緩解的可能性更大，但一過(guò)性尿潴留和尿路感染發(fā)生率更高。

    Anticholinergic Therapy vs. OnabotulinumtoxinA for Urgency Urinary Incontinence

    Anthony G. Visco, M.D., Linda Brubaker, M.D., Holly E. Richter, Ph.D., M.D., Ingrid Nygaard, M.D., Marie Fidela R. Paraiso, M.D., Shawn A. Menefee, M.D., Joseph Schaffer, M.D., Jerry Lowder, M.D., Salil Khandwala, M.D., Larry Sirls, M.D., Cathie Spino, D.Sc., Tracy L. Nolen, Dr.P.H., Dennis Wallace, Ph.D.,  and Susan F. Meikle, M.D., M.S.P.H., for the Pelvic Floor Disorders Network

Background: Anticholinergic medications and onabotulinumtoxinA are used to treat urgency uri-nary incontinence, but data directly comparing the two types of therapy are needed.

Methods: We performed a double-blind, double-placebo–controlled, randomized trial involving women with idiopathic urgency urinary incontinence who had five or more episodes of  urgency  urinary  incontinence  per  3-day  period,  as  recorded  in  a  diary.  For  a 6-month period, participants were randomly assigned to daily oral anticholinergic medication (solifenacin, 5 mg initially, with possible escalation to 10 mg and, if necessary, subsequent switch to trospium XR, 60 mg) plus one intradetrusor injection of saline or one intradetrusor injection of 100 U of onabotulinumtoxinA plus daily oral placebo. The primary outcome was the reduction from baseline in mean episodes of urgency urinary incontinence per day over the 6-month period, as recorded in 3-day diaries submitted monthly. Secondary outcomes included complete resolution of urgency urinary incontinence, quality of life, use of catheters, and adverse events.

Results: Of 249 women who underwent randomization, 247 were treated, and 241 had data available for the primary outcome analyses. The mean reduction in episodes of ur-gency urinary incontinence per day over the course of 6 months, from a baseline average of 5.0 per day, was 3.4 in the anticholinergic group and 3.3 in the onabotu-linumtoxinA group (P  = 0.81). Complete resolution of urgency urinary incontinence was reported by 13% and 27% of the women, respectively (P = 0.003). Quality of life improved in both groups, without significant between-group differences. The anti-cholinergic group had a higher rate of dry mouth (46% vs. 31%, P  = 0.02) but lower rates of catheter use at 2 months (0% vs. 5%, P = 0.01) and urinary tract infections (13% vs. 33%, P<0.001).

Conclusions: Oral anticholinergic therapy and onabotulinumtoxinA by injection were associated with similar reductions in the frequency of daily episodes of urgency urinary incon-tinence. The group receiving onabotulinumtoxinA was less likely to have dry mouth and more likely to have complete resolution of urgency urinary incontinence but had higher rates of transient urinary retention and urinary tract infections.