Longitudinal Fluctuations in Treatment Response After OnabotulinumToxinA and Sacral Neuromodulation for Refractory Urgency Incontinence

• Published in: The Journal of urology Vol. 211; no. 1; pp. 134 - 143
• Main Authors: Hendrickson, Whitney K, Zhang, Chong, Jelovsek, J Eric, Nygaard, Ingrid E, Presson, Angela P
• Format: Journal Article
• Language: English
• Published: United States 01-01-2024
• Subjects: Botulinum Toxins, Type A - therapeutic use; Female; Humans; Probability; Randomized Controlled Trials as Topic; Sacrum; Transcutaneous Electric Nerve Stimulation; Treatment Outcome; Urinary Bladder, Overactive - therapy; Urinary Incontinence, Urge - therapy; Markov process; patient-reported outcome; overactive bladder
• ISSN: 0022-5347; 1527-3792; 1527-3792
• DOI: 10.1097/JU.0000000000003746

We compared fluctuations in treatment response after onabotulinumtoxinA and sacral neuromodulation for urgency incontinence using Markov models.
We fit data from a randomized trial to Markov models to compare transitions of success/failure over 6 months between 200 U onabotulinumtoxinA and sacral neuromodulation. Objective failure was <50% reduction in urgency incontinence episodes from baseline; subjective failure "strongly disagree" to "neutral" to the Patient Global Symptom Control questionnaire.
Of the 357 participants (median baseline daily urgency incontinence episodes 4.7 [IQR 3.7-6.0]) 61% vs 51% and 3.2% vs 6.1% reported persistent states of objective success and failure over 6 months after onabotulinumtoxinA vs sacral neuromodulation. Participants receiving onabotulinumtoxinA vs sacral neuromodulation had lower 30-day transition probabilities from objective and subjective success to failure (10% vs 14%, ratio 0.75 [95% CI 0.55-0.95]; 14% vs 21%, ratio 0.70 [95% CI 0.51-0.89]). The 30-day transition probability from objective and subjective failure to success did not differ between onabotulinumtoxinA and sacral neuromodulation (40% vs 36%, ratio 1.11 [95% CI 0.73-1.50]; 18% vs 17%, ratio 1.14 [95% CI 0.65-1.64]).
Over 6 months after treatment, 2 in 5 women's symptoms fluctuate. Within these initial 6 months, women receiving onabotulinumtoxinA transitioned from success to failure over 30 days less often than sacral neuromodulation. For both treatments, there was an almost 20%-40% probability over 30 days that women returned to subjective and objective success after failure. Markov models add important information to longitudinal models on how symptoms fluctuate after urgency incontinence treatment.