Further Enhancing Non-Pharmacological Therapy for Incontinence

描述(申请人提供)：急迫性尿失禁(UI)是一种不由自主的尿液渗漏，伴随着突然的排尿欲望。尿失禁普遍、病态和昂贵(2000年每年近200亿美元)，是老年人的主要问题。尽管它通常被归因于膀胱痉挛(也称为逼尿肌过度活动[DO])，但尿失禁的实际原因尚不清楚，治疗仍然不足，在过去50年中几乎没有改善。推荐使用生物反馈的一线治疗行为疗法(BFB)与药物治疗一样成功，也更安全，但很少使用，因为它需要设备、专业知识和时间，而这些并不广泛可用。我们正在进行的研究的目标是确定预测BFB反应的因素，更重要的是确定BFB是如何工作的。这样的理解应该会让医生进一步提高它的疗效，简化它的传递，并促进它更广泛的应用。然而，这项正在进行的研究表明，最重要的因素不是存在于下尿路，而是存在于大脑控制它的方式。虽然对这种大脑控制知之甚少，但我们的初步研究表明，关键区域可以被识别出来，这些区域之间的联系也可以被识别出来，这些中心在仍控制着自己的膀胱的老年人和患有尿失禁的老年人中的运作方式是不同的。为了证明这些中心就是相关的，这些发现必须在一个单独的、更大的老年人群体中得到证实。此外，如果这些数据是正确的，那么患有尿崩症的人的大脑异常应该会随着BFB的临床反应而得到改善。因此，这项建议的具体目的是：(1)在患有和不患有尿崩症的更大一组老年女性(&gt；60岁)中证实这些试点发现；以及(2)确定尿崩症患者的异常脑部发现是否通过BFB改善，以及这种改善是否与临床改善平行。为了达到这些目标，受试者将在8周的BFB课程之前和之后进行研究。评估将包括临床评估，下尿路功能的详细测试，以及使用功能磁共振成像(FMRI)的非侵入性脑成像。BFB后的结果将与治疗前进行比较，临床改善将与大脑异常的变化进行比较。此外，因为这些人中的一些人即使他们的DO持续存在也会变成可控性的，他们的大脑变化将与DO解决的同龄人进行比较。这项研究的知识可以为老年人尿失禁的原因以及成功治疗的机制提供重要的见解。反过来，这些知识应该有助于设计更简单、更有效的治疗方法，使更多的人受益。项目描述学习膀胱控制是儿童发育过程中的一个里程碑，成年后失去膀胱控制可能是一种灾难性的经历，往往会危及独立和积极的生活。这种情况的原因尚不清楚，因此治疗效果不是很好，针对性也很差。由于生物反馈辅助的膀胱训练是最有希望、最安全的现有治疗方法，有关其工作原理的新知识可能会使其变得更加有效，并得到更广泛的应用。

DESCRIPTION (provided by applicant): Urinary urge incontinence (UI) is involuntary leakage of urine that is accompanied by a sudden desire to urinate. Prevalent, morbid, and costly (nearly $20 billion annually in 2000), UI is a major problem for older adults. Although it is generally ascribed to bladder spasms (also known as detrusor overactivity [DO]), the actual causes of UI are unknown, and therapy remains inadequate and little improved over the last 50 years. The recommended first-line treatment behavioral therapy using biofeedback (BFB) is as successful as medications and safer, but it is rarely used because it requires equipment, expertise, and time that are not widely available. The goal of our ongoing study is to determine the factors that predict BFB response and, more importantly, how BFB works. Such understanding should allow physicians to further enhance its efficacy, streamline its delivery, and facilitate its more widespread application. However, this ongoing study is suggesting that the most important factors reside not in the lower urinary tract but rather in the way the brain controls it. While little is known about such brain control, our pilot studies suggest that the key areas can be identified, as can the connections between these areas, and that there are differences between the way these centers function in older people who remain in control of their bladder and in those who develop UI. To prove that these centers are the ones involved, the findings must be confirmed in a separate and larger group of older adults. In addition, if these data are correct, then the brain abnormalities in people who suffer from UI should improve in concert with the clinical response to BFB. Thus, the specific aims of this proposal are: (1) to confirm these pilot findings in a larger group of older women (>60 years old) with and without UI; and (2) to determine whether the abnormal brain findings in those with UI improve with BFB and whether such improvement parallels the clinical improvement. To address these aims, subjects will be studied before and after an 8 week course of BFB. The evaluation will include a clinical evaluation, detailed testing of lower urinary tract function, and non-invasive brain imaging using functional magnetic resonance imaging (fMRI). Findings after BFB will be compared with those before therapy and clinical improvement will be compared with change in the brain abnormalities. In addition, because some of these people will become continent even though their DO persists, their brain changes will be compared with those of their peers in whom the DO resolves. Knowledge from this study could shed important insights into the cause of UI in older adults, as well as the mechanisms that underlie its successful treatment. In turn, such knowledge should facilitate design of therapy that is simpler and more effective so that more people can benefit.Project Narrative The learning of bladder control is a milestone in child development, and the loss of bladder control as an adult can be a disastrous experience and one that often can compromise an independent and active life. The causes of this condition are not clear, and thus therapy is not very effective and is poorly targeted. Because biofeedback-assisted bladder training is the most promising and safest of available treatments, new knowledge of how it works could allow it to become even more effective and more widely available.