Inflammation in Women With Urgency Urinary Incontinence Treated With Anticholinergics
Phase: PHASE4
Conditions: Urinary Incontinence, Urgency Urinary
Sponsor: Brigham and Women's Hospital

10/28/2020 
 
 
 
 
 
 
 
 
 
Inflammation in Women with Urgency Urinary Incontinence Treated with Anticholinergics 
Version Date: 10/28/2020 
ID #: 2018P000980 
 
 
 
 

10/28/2020 
Vatche A. Minassian, MD, MPH 
Jeannine M. Miranne, MD, MS 
Iwona Gabriel, MD, PhD 
    Maura Craig, PA-C 
Lise Ann Caldara, PA-C 
Talar Abdalian, MS 
I. Specific Aims 
 
Specific Aim 1: To assess inflammatory markers in urine and serum before and after a 6-week 
treatment course with anticholinergics. 
Specific Aim 2: To determine the role of urinary microbiome in relation to inflammation before 
and after a 6-week treatment course with anticholinergics. 
 
II. Background & Significance 
 
Urinary incontinence (UI) is a very common condition affecting women of all ages. UI is 
an emotionally, socially, physically and economically burdensome condition (1). It has a significant 
impact on quality of life (QOL), where urinary incontinence has been shown to be associated with 
embarrassment, anxiety, and depression. Total costs of UI (direct and indirect) are about $11 
billion/a year (2).    
The influence of the human microbiota on normal health and disease conditions is 
increasingly appreciated in a variety of medical fields (3). The hypothesis of “sterile” bladder has 
recently been disputed (4), leading to a series of investigations about the role of urinary microbiota 
in urinary incontinence. Stress urinary incontinence does not appear to be associated with urinary 
microbiota (5), while urgency urinary incontinence (UUI) is highly related to microbial status and 
diversity (4,5). The role of inflammation in relation to urinary microbiome is understudied among 
women treated for UUI. An important emerging question is whether the inflammatory milieu and 
urinary microbiota interact and vary over time, and in particular, in response to UI treatment.  
Data from the Anticholinergic Versus Botulinum A Comparison (ABC) Trial showed that 
women with sequence-positive urine samples (DNA positive) responded better to treatment 
(anticholinergics or botulinum toxin A) and had decreased number of UUI episodes (6). 
Furthermore, those women had less urinary tract infections (6). A study solely devoted to 
analyzing the role of urinary microbiome in the treatment of UUI with solifenacin (anticholinergic) 
showed changes in microbial abundance after 12-week treatment (7). Clinically, many women 
with UUI fail pharmacologic treatment options with anticholinergics. 
We hypothesize that an increased inflammatory response due to an altered urinary 
microbiome at baseline predisposes women to a higher rate of failure of UUI treatment with 
anticholinergic medications. The objective of this pilot study is to better understand the urinary 
microbiome and associated inflammatory markers in blood and urine in women with UUI, and 
whether they vary over time secondary to anticholinergic treatment. To address this goal, we plan 
to enroll 20 women with UUI presenting to our Urogynecology Clinic. 
References  

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1. Molinuevo B, Batista-Miranda JE. Under the tip of the iceberg: psychological factors in 
incontinence. Neurourol Urodyn 2012; 31:669-71. 
2. Hu TW, Wagner TH, Bentkover JD et al. Costs of urinary incontinence and overactive 
bladder in the United States: a comparative study. Urology. 2004; 63:461–5. 
3. Cho I, Blaser MJ. The human microbiome at the interface of health and disease. Nat Rev 
Genet 2012; 13: 260-70.  
4. Hilt EE, McKinley K, Pearce M et al. Urine is not sterile: use of enhanced urine culture 
techniques to detect resident bacterial flora in the adult female bladder. J Clin Microbiol 
2014; 52: 871-6. 
5. Thomas-White KJ, Kliethermes S, Rickey L et al. Evaluation of the urinary microbiota of 
women with uncomplicated stress urinary incontinence. Am J Obstet Gynecol 2017; 216: 
55: e1-16.  
6. Pearce M, Zilliox M, Thomas-White KJ et al. The female urinary microbiota in urgency 
urinary incontinence. Am J Obstet Gynecol 2015; 213: 347.e1-e11.  
7. Thomas-White KJ, Hilt EE, Fok C et al. Incontinence medication response relates to the 
female urinary microbiota. Int Urogynecol J 2016; 27: 723-33.   
 
III. Research Design and Methods 
 
Study design, population, and inclusion/exclusion criteria 
 
 
This study is designed as a prospective pilot research of women presenting to our 
Urogynecology Clinic in our Boston or Foxborough locations with UUI symptoms. The inclusion 
criteria are women who have a diagnosis of UUI and are willing to participate in the study and 
provide their blood and urine for research purposes. The exclusion criteria are: lack of consent, 
neurological disease such as Parkinson’s or Multiple Sclerosis, known immunological 
deficiencies, history of UTI in the last 3 months, history of taking anticholinergics within the last 
month, history of antibiotics use in the last month, history of sexually transmitted diseases.  
 
We plan to enroll 20 women who are offered treatment with a standard of care 
anticholinergic medication for 6 weeks. The patient’s provider will explain the study to eligible 
patients and consent will be obtained by the research assistant. Once consent is obtained, a 
catheterized urine sample will be collected from the patient as well as a blood draw by the 
phlebotomist at the Center of Clinical Investigation at Brigham and Women’s Hospital or at the 
phlebotomy lab at The Brigham Health and Brigham and Women’s/Mass General Health Care 
Centers in Foxborough. Participants will be asked to fill the UDI-6 questionnaire and they will be 
given a two-day diary to complete at home before they start the anticholinergic medication. They 
will be then asked to follow up 6 weeks later. Prior to the 6-week follow-up visit, participants will 
fill another 2-day voiding diary and complete the UDI-6 questionnaire. At the 6-week visit, a repeat 
catheterized urine sample will be taken for microbiome and inflammatory markers analysis but no 
blood draw. The urine will be assessed by enhanced urine cultures and DNA sequencing for 
urinary microbiome at baseline and again at 6 weeks. Inflammatory mediators will also be tested 
in urine and blood. The microbiome analysis and bioinformatic analysis will be performed by two 
experienced Harvard Research Core Labs. Inflammatory mediators will be tested by a third 
Research Core Lab at Boston University. Baseline urinary symptoms at enrollment and variation 
of symptoms after 6 weeks of anticholinergic treatment will be assessed using a two-day bladder 
diary and a validated UI questionnaire (UDI-6).  
 
IV. Study procedures 

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a. Visit of enrollment: Participants presenting with UUI diagnosis will complete the informed 
consent document and a baseline UDI-6 questionnaire. (Appendix A). This survey consists 
of 6 questions to assess the nature and severity of urinary incontinence symptoms at 
baseline. In addition, participants will be asked to provide urine sample for microbiome 
and immune markers and blood samples solely for immune markers. Participants will be 
given 2-day bladder diaries to fill out at home and before starting anticholinergic treatment.  
 
b. Randomization/treatment allocation: Randomization will not be performed. All patients 
will receive treatment with anticholinergics for a duration of 6 weeks. 
 
c. Follow up visit after 6 weeks: Participants will complete another 2-day voiding diary 
prior to their visit and they will be asked to bring the diaries to their visit. They will also 
complete the UDI-6 questionnaire to assess changes in urinary symptoms after 6-weeks 
of anticholinergic treatment. Patients will be evaluated for drug effectiveness by the 
treating urogynecologist. Urine will be taken for repeated analysis of microbiome and 
immune markers.   
 
V. Outcome measures  
 
a. Primary outcome: To assess if the urinary microbiome is associated with inflammatory and 
immune changes in women with UUI.  
 
b. Secondary outcomes: To assess the effectiveness of anticholinergic treatment in relation to 
the urinary microbiome and immune status over a 6-week course, and to investigate if the 
interaction of urinary microbiome with host through immunologic markers may alter 
responsiveness to standard of care treatment with anticholinergics.  
 
 
VI: Statistical Considerations 
 
Descriptive statistics will be employed to describe and compare data using parametric statistical 
tests for normally distributed data and non-parametric tests for non-normally distributed data.  We 
will then specifically evaluate the role of microbiome on UUI in our subgroups. Wilcoxon test and 
Mann Whitney test will be applied to estimate the possible differences. The correlation between 
microbiome and inflammatory markers before and after treatment will be assessed by the 
Spearman’s rank correlation. Harvard Catalyst Statisticians will be consulted for statistical 
analysis.   
 
 
VII. Data Collection and Transmission  
 
Additional data to be abstracted from the medical records include: age, race, BMI, parity, smoking 
status, menopausal status, comorbidities, present medications (including hormone replacement), 
use of contraceptive medications, use of vaginal estrogen, previous hysterectomy surgery, 
previous removal of ovary(ies), last menstrual period date and the use of tampons, previous 
surgeries for urinary incontinence, duration and type of UI symptoms, presence of prolapse. 
 
All study procedures will be conducted in a manner respectful to maintaining patient 
confidentiality.  All patient data will be kept confidential and appropriate procedures will be 
implemented to assure that patient confidentiality is maintained, including the following: files will 

10/28/2020 
be maintained on password protected computers.  The data will be accessible only to the study 
personnel.  Any publication, presentations, or reports from this research study will maintain the 
anonymity of study subjects. 
 
 
VIII. Human Subject Research and Ethical Concerns 
 
Signed consent in English will be obtained from each participant at the time of enrollment. In the 
event that a non English-speaking patient meets inclusion criteria and is willing to participate, a 
short form consent document will be administered in the presence of a medical interpreter 
obtained through Interpreter Services as per Partners IRB guidelines.  The objectives of the 
study and the data collection procedures will be explained to every prospective participant 
before enrollment.  An IRB-approved consent document will be used. Consent for participants 
will include the following rights: 
 
• 
To either withdraw or refuse participation without prejudice at any time during the study; 
• 
To voluntarily participate in the research; 
• 
To receive new information about the study as it becomes available; 
• 
To understand the procedures, risks, and benefits; 
• 
To maintain confidentiality of personal medical information. 
 
Protection Against Risk: The foreseeable risks include those related to the study procedures 
which include blood taking that may be related to pain, discomfort and bruising, however these 
are short-lasting and transient. Obtaining a urine sample using a catheter may lead to minimal 
pain or discomfort.   
Confidentiality:  Our research staff will take every precaution to protect the confidentiality of 
the collected data.  All personnel who will have access to collected data have completed the 
Program for Ethics Education in Research training with the appropriate HIPAA certification. After 
obtaining initial informed consent, a numerical code will be assigned to each participant. This 
number will correspond to the participant's name in a separate file called a "key." The key will be 
kept in a locked filing cabinet in the principal investigator's office. Only the study investigators 
and research coordinator will have access to this cabinet. Completed data forms and paper 
questionnaires will be placed in a separate locked file cabinet, and only authorized staff 
members will have access to the data. Only de-identified data will be entered into a 
computerized database that is stored on computers which are safeguarded by passwords 
known only to authorized personnel. The data that are collected will be used strictly for the 
purposes of the research in question. Any printout information will be destroyed once the project 
is completed and the manuscript is published. 
 
 
IX. Timing of Study and Recruitment:   
 
This is a pilot study that we expect will be completed within 6-9 months. Approval of IRB 
application is anticipated to occur within 6 weeks. We expect to enroll 20 patients within 3 months 
of study initiation. This will be followed by another 6 weeks for patient follow-up, data collection 
and entry. All urinary and blood microbiome and inflammatory analysis, including the bio-
informatics, will be promptly performed by the three Research Core Labs. Final analysis, 
submission of findings to national meetings, and preparation of manuscript will be completed in 
another 3 months. 

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X. Appendices 
 
 

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Appendix A: UDI-6 questionnaire 
The following symptoms have been described by women who experience accidental 
urine loss.  Please indicate which symptoms you are now experiencing and how 
bothersome they are for you.  Be sure to answer all items. 
A. Do you experience frequent urination? 
 Yes 
 No (skip to B) 
 
↓ 
If ‘yes’, how much does it bother you? 
 
Not at all 
slightly 
moderately 
greatly 
 
 
 
 
 
B. Do you experience urine leakage related to a feeling of urgency? 
 Yes 
 No (skip to C) 
 
↓ 
If ‘yes’, how much does it bother you? 
 
Not at all 
slightly 
moderately 
greatly 
 
 
 
 
 
C. Do you experience urine leakage related to physical activity, coughing or 
sneezing? 
 Yes 
 No (skip to D) 
 
↓ 
If ‘yes’, how much does it bother you? 
 
Not at all 
slightly 
moderately 
greatly 
 
 
 
 
 
D. Do you experience small amounts of urine leakage (that is, drops)? 
 Yes 
 No (skip to E) 
 
↓ 
If ‘yes’, how much does it bother you? 
 
Not at all 
slightly 
moderately 
greatly 
 
 
 
 
 
E. Do you experience difficulty emptying your bladder? 
 Yes 
 No (skip to F) 
 
↓ 
If ‘yes’, how much does it bother you? 
 
Not at all 
slightly 
moderately 
greatly 
 
 
 
 
 
F. Do you experience pain or discomfort in the lower abdominal or genital area? 
 Yes 
 No 
 
↓ 
If ‘yes’, how much does it bother you? 
 
Not at all 
slightly 
moderately 
greatly 
 
 
 
 
 

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Appendix B: 
DAILY VOIDING DIARY 
NAME___________________________ Birth Date__________________    Date_______________ 
Time of 
Day 
Type & Amount of 
Fluid Intake 
Amount 
Voided 
(Ounces or cc) 
Amount of 
Leakage 
(small, medium, 
or large) 
Was Urge 
Present? 
Activity 
With 
Leakage   
12:00a 
 
 
 
 
 
1:00 
 
 
 
 
 
2:00 
 
 
 
 
 
3:00 
 
 
 
 
 
4:00 
 
 
 
 
 
5:00 
 
 
 
 
 
6:00 
 
 
 
 
 
7:00 
 
 
 
 
 
8:00 
 
 
 
 
 
9:00 
 
 
 
 
 
10:00 
 
 
 
 
 
11:00 
 
 
 
 
 
12:00p 
 
 
 
 
 
1:00 
 
 
 
 
 
2:00 
 
 
 
 
 
3:00 
 
 
 
 
 
4:00 
 
 
 
 
 
5:00 
 
 
 
 
 
6:00 
 
 
 
 
 
7:00 
 
 
 
 
 
8:00 
 
 
 
 
 
9:00 
 
 
 
 
 
10:00 
 
 
 
 
 
11:00 
 
 
 
 
 
 
Comment: _________________________________ 
Number of pads used in 24 hours: _____________ 
 

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HOW TO KEEP YOUR BLADDER DIARY? 
The main purpose of a bladder diary is to document how your bladder works. A diary can give us an 
excellent picture of your bladder functions, habits and patterns. The diary is used as an evaluation tool. 
Please complete the bladder diary for 3 days and bring it with you to your appointment. 
In the beginning, continue to go about your daily life as normal. You are making a written record of your 
normal bladder patterns so please avoid making any changes in your bladder routines. Your diary will be 
much more accurate if you fill it out as you go through the day. It can be very difficult to remember at 
the end of the day exactly what happened in the morning. The diary plays an important part in your 
health care provider’s ability to understand your problem and should not be taken lightly. 
Also, if possible, remember to change your pad or clothing whenever you feel yourself leaking or notice 
that you are damp. A dry pad or pair of underwear will increase your awareness of problems and 
improve the accuracy of your record. 
INSTRUCTIONS  
Column 1 - Type & Amount of Fluid Intake & Food Intake:  
Record the type and amount of fluid you drank, and food you ate. 
Note the hour you went to sleep and when you woke up for the day. 
Column 2 - Amount Voided (Urinated): 
Place the measured amount of urine in the box with the appropriate time interval each time you urinate 
during the day. You need to fill in ounces or cc (ml) (30 ml / cc equals about one ounce). Use a urine 
collection “hat” or measuring cup for accurate amounts. Urine is sterile so using a baking measuring cup 
may seem gross but it is OK – other ways to measure include counting 1 Mississippi, 2 Mississippi, 3 
Mississippi. If the stream is steady, for each “Mississippi” you have urinated 1 ounce. Don’t count fast. 
Column 3 - Amount of Leakage: 
SMALL = drop or two of urine in your underwear or pad 
MEDIUM = wet pad but not outside 
LARGE = wet pad and outerwear or leaking down the legs or onto the floor 
 
Column 4 - Activity with Leakage & Was Urge Present: 
Describe the activity associated with the leakage i.e. coughing, sneezing, bending, lifting, running, 
jumping, hearing running water, going outside, having a strong urge. 
Describe the urge sensation you had to go as: 
 
MILD= first sensation or desire to go. 
MODERATE = stronger sensation or desire to go. 
STRONG = a very strong sensation or desire to go or get to toilet, move aside!