WO1999020299A1 - Human urinary incontinence and methods of treatment - Google Patents

Human urinary incontinence and methods of treatment Download PDF

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Publication number
WO1999020299A1
WO1999020299A1 PCT/US1998/021919 US9821919W WO9920299A1 WO 1999020299 A1 WO1999020299 A1 WO 1999020299A1 US 9821919 W US9821919 W US 9821919W WO 9920299 A1 WO9920299 A1 WO 9920299A1
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igf
urinary incontinence
receptor
growth factor
patient
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PCT/US1998/021919
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French (fr)
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E. Martin Spencer
Tom Lue
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Spencer E Martin
Tom Lue
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/22—Hormones
    • A61K38/30—Insulin-like growth factors, i.e. somatomedins, e.g. IGF-1, IGF-2

Definitions

  • This invention relates to human urinary incontinence and methods to prevent and treat this condition.
  • Urinary incontinence is one of the most common medical problems in the United States and Western countries.
  • the National Institutes of Health research studies show that the annual cost of urinary incontinence management in the United States is over 10.3 billion dollars.
  • Alpha-adrenergic antagonists Drugs that block the nerve transmission by alpha- adrenergic receptors.
  • Anticholinergic agents Drugs that block impulses from postganglionic cholinergic nerves.
  • Catheterization The insertion of a tube through the urethra into the urinary bladder.
  • Cholinergic agents Drugs that mimic the action of the neurotransmitter acetylcholine.
  • Detrusor A muscle in the wall of the urinary bladder that forces urine from the bladder when it contracts.
  • Ectopic ureter A ureter that is situated in an abnormal position in the urinary bladder.
  • Fascia Sheets of connective tissue made up of interlacing layers of collagen fibers containing fibroblast cells.
  • hypophysectomy The removal of the pituitary gland.
  • IGF-I Insulin-like growth factor-I.
  • ISD Intrinsic sphincter deficiency. Defective muscles that run over the distal urethra and normally maintain it in a closed position preventing the leakage of urine.
  • Kegel exercises A series of muscle exercises designed to reduce incontinence in the female.
  • Somatomedins An older name for insulin-like growth factors.
  • SUI Stress urinary incontinence: Urinary leakage secondary to an increase in abdominal pressure, in the absence of a detrusor contraction or an over-distended bladder.
  • Striated muscle Muscle that possesses a transverse banding structure as in skeletal muscle.
  • Sympathomimetic A drug that produces the responses achieved by stimulating the sympathetic nervous system.
  • Ureter One of two bilateral tubes that conduct urine from the kidney to the urinary bladder.
  • Urethra The channel that conducts urine from the urinary bladder to the exterior.
  • Urethral meatus The external outlet of the urethra.
  • Vesicovaginal fistula An abnormal communications between the urinary bladder and the vagina.
  • Urinary incontinence is the involuntary leakage of urine through the urethral meatus. Urinary incontinence has been traditionally divided into 4 categories: stress, urge, overflow, and total urinary incontinence. Stress urinary incontinence is defined as urinary leakage secondary to an increase in abdominal pressure in the absence of 1) a contraction of the detrusor muscle of the bladder or 2) an over-distended bladder.'The etiology of this type of incontinence will be discussed in the next section. Urge incontinence is the loss of urine associated with a strong desire to urinate and usually occurs secondary to a sensory or motor dysfunction.
  • Total incontinence refers to a continuous loss of urine which can occur with a vesicovaginal fistula (an abnormal communication between the bladder and vagina), ectopic ureter (an abnormal insertion of the ureter in the bladder) or a severe urethral intrinsic sphincter deficiency.
  • SUI stress urinary incontinence
  • ISD urethral intrinsic sphincter deficiency
  • the supporting layer consists of the anterior vaginal wall and fascia.
  • the stability of this suburethral layer depends on intact, lateral connections of the anterior vaginal wall and fascia to: a) the levator and muscles, and b) a strong fascial layer called the arcus tendineus fasciae pelvis. Damage to the pelvic nerves, muscles, and fascia are the most frequently cited causes of SUI after delivery.
  • Contraction of the urethral sphincter compresses the distal urethra.
  • the sphincter consists of two arches of striated muscle. Reflex contraction of the normal sphincter under stress conditions, such as a cough, prevents urine loss.
  • Hyper mobility of the urethra and bladder neck during stress accounts for up to 85% of cases of SUI.
  • Anterior vaginal wall relaxation caused by trauma to the bladder-urethra-pelvic floor during vaginal delivery, is the single most important factor in the development of hyper mobility-related stress incontinence.
  • Foldspang, A. et al. "Parity as a correlate of adult female urinary incontinence prevalence," J. of Epidemiology and Community Health 46, pp 595-600, (1992). The factors next in importance are aging, hormonal changes, and pelvic surgery.
  • Gilpin, S.A. et al. The effect of age on the autonomic innervation of the urinary bladder," Brit. J. Urol..
  • Intrinsic Sphincter Deficiency 15% of woman with SUI have an anatomically well-supported urethra and bladder neck but still experience stress incontinence. This is due to intrinsic sphincter deficiency (ISD).
  • ISD intrinsic sphincter deficiency
  • the most common causes of ISD include: urethral sphincteric damage after delivery, a prior anti-incontinence surgical procedure, pelvic radiation, trauma, and neurogenic disorders resulting in urethral denervation. Since many women with urethral hyper mobility do not have stress incontinence, some researchers now believe that most patients with stress incontinence have both hyper mobility and ISD.
  • the therapy of urge incontinence consists of oral anticholinergic agents, electrical stimulation, and bladder augmentation surgery in refractory cases. Even acupuncture and biofeedback have been advocated.
  • Treatment of overflow incontinence consists of removing or correcting the underlying causes such as intermittent catheterization, surgical correction of an urethral stricture, cholinergic agents, or alpha-adrenergic antagonists to facilitate voiding.
  • treatments include Kegel exercises, electrical stimulation, sympathomimetics, collagen injections, bladder neck suspension and sling operations.
  • medical and surgical management of incontinence is unsatisfactory. Surgical approaches have additional drawbacks in that they are expensive and often create partial urethral obstruction and bladder irritability. No one has attempted to use insulin-like growth factors for therapy.
  • IGF Insulin-like Growth Factors
  • IGF-I acts favorably on all the major sites, smooth muscle, striated muscle, nervous tissue, and connective tissue, contributing to SUI, and probably the other forms of incontinence. However, no one has considered using IGF-I to treat incontinence.
  • IGF-I insulin-like growth factor binding protein-2 and -4
  • Growth Regulation 5 pp 45-52 (1995).
  • IGF-I also stimulates elastin gene expression in aortic smooth muscle cells. Rich, C. B. et al. "IGF-I regulation of elastogenesis: comparison of aortic and lung cells.” Am. J. Physiol. 263, pp 1,276-1,282
  • IGF-I promotes the proliferation and differentiation of myoblasts. IGF-I stimulates differentiation by inducing synthesis of myogenin, a protein that controls terminal differentiation. Florini, J. R. et al. "Insulin-like growth factor-I stimulates terminal myogenic differentiation by induction of myogenin gene expression.” Mol. Endocrinology 5, pp 718-724 (1991). IGF-I is also a potent anabolic hormone for striated muscle even in states of trauma and catabolism. It acts primarily by decreasing protein breakdown and only weakly stimulates protein synthesis. GH is less anabolic than IGF-I. 3. Nervous tissue
  • IGF receptors are expressed at high levels in the nervous system. Marks, J. L. et al. "Localization of type I insulin-like growth factor receptor messenger RNA in the adult rat brain by in situ hybridization.” Mol. Endocrinology 5, pp II
  • IGFs support the growth and differentiation of fetal neurons in culture and stimulate RNA, DNA and protein synthesis. The result is induction of expression of early genes, cytoskeletal proteins, and neurite outgrowth.
  • Pecio-Pinto, E. et al. "Effects of insulin, insulin-like growth factor II, nerve growth factor on neurite formation and survival in cultured sympathetic and sensory neurons.” J. Neurosci 6, pp 1211-1216 (1991). Hypophysectomy, which dramatically lowers IGF-I levels, impairs nerve regeneration. Conversely IGF-I promotes the survival of injured sensory and motor neurons. Skottner, A. et al.
  • IGFs acting as neurotropic factors may be derived from local muscle tissue.
  • the gene expressions of IGF-I and -II are both increased in denervated muscle.
  • Caroni, P. et al. "Role of muscle insulin-like growth factors in nerve sprouting: suppression of terminal sprouting in paralyzed muscle by IGF-binding protein 4.” J. Cell Biology 125, pp 893-902 (1994). This locally produced IGF can stimulate injured sensory and motor neurons and intramuscular neurite outgrowth.
  • IGF-1 also can block drug-induced peripheral neuropathy in mice. Apfel, S. C. et al. "Neurotrophic factors in the treatment of peripheral neuropathy.” Ciba Foundation Symposium 196, pp 98-108, (1996). There are, however, no published reports of IGFs stimulating the regeneration of non-adrenergic, non- cholinergic (NANC) nerves.
  • NANC non-cholinergic
  • IGF-I stimulates the repair of wounded tissue acting at many sites throughout the healing process including stimulating fibroblasts and collagen synthesis.
  • Spencer, E.M. “Somatomedins: Do they play a pivotal role in wound healing?" Growth Factors and Other Aspects of Wound Healing: Biological and Clinical Implications. Alan R. Liss, pp 103-116 (1988).
  • Addition of IGF-I to wounds hastens repair, especially if it is complexed with IGF binding protein-3.
  • Sommer, A. et al. "Molecular genetics and actions of recombinant insulin-like growth factor binding protein-3.” In Modern Concepts of Insulin-like Growth
  • IGF binding proteins The biological actions of the IGFs are also regulated by a class of 6 or more IGF binding proteins which are found in plasma and the extracellular fluid. Chan, K. and Spencer, E.M., "General aspects of insulin-like growth factor binding proteins.” Endocrine in press (1997). The most abundant circulating IGF binding protein is IGF binding protein-3. The biological actions of IGF-I are generally inhibited when it associates with an IGF binding protein. However, under certain experimental conditions, the complexing with IGF binding protein- 3, and other IGF binding proteins except IGF binding protein-4, may potentiate the action of the IGF. Somnier, A.
  • IGF-I insulin receptor insensitivity
  • GH receptor dysfunction Luon dwarfism
  • amyotrophic lateral sclerosis presently under a compassionate use indication.
  • the method comprises administering to the patient after the pelvic trauma or injury a therapeutic amount of a therapeutic composition which includes an agent selected from the group consisting of IGF- I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism.
  • a therapeutic composition which includes an agent selected from the group consisting of IGF- I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism.
  • the therapeutic composition may further include IGF binding proteins or analogs or derivatives of IGF binding proteins.
  • the therapeutic composition may also further include GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism.
  • the method includes administering to the patient after the pelvic trauma or injury a therapeutic amount of a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism. Methods are also provided for treating urinary incontinence in a patient.
  • the method comprises administering to a patient with urinary incontinence a therapeutic amount of a therapeutic composition which includes an agent selected from the group consisting of IGF-I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism.
  • a therapeutic composition which includes an agent selected from the group consisting of IGF-I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism.
  • the therapeutic composition may further include IGF binding proteins or analogs or derivatives of IGF binding proteins.
  • the therapeutic composition may also further include GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism.
  • the method includes administering to the patient with urinary incontinence a therapeutic amount of a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism.
  • a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism.
  • the therapeutic composition may further include a second growth factor.
  • second growth factors which may be used include platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor- alpha or beta, and a neurotropic growth factor.
  • the therapeutic composition may be delivered locally or systemically.
  • the therapeutic amount is delivered systemically for at least about 30 days, optionally for between about 30 and 90 days.
  • IGF-I may be useful therapeutically to treat or prevent urinary incontinence.
  • IGF-I may be particularly useful to treat or prevent urinary incontinence in women secondary to birth trauma and in women and men secondary to radical pelvic surgery.
  • IGF-I may also be useful in both women and men to treat established SUI and other types of incontinence related to aging, obesity and other factors.
  • This application of an IGF, with or without one or more of its potentiating binding proteins would provide a minimally invasive but more physiologic approach to the therapy of urinary incontinence.
  • GH could also be useful in the prevention and therapy of urinary incontinence.
  • a combination of GH plus an IGF, with or without IGF binding proteins, might also be therapeutically beneficial.
  • IGF-I insulin-like growth factor-I
  • GH growth hormone
  • IGF-I plus GH body growth and IGF binding proteins in hypophysectomized rats. Endocrinology 137, pp 1913-1920, (1996).
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of: a) IGF-I or IGF-II, b) modified forms of IGFs, or c) a compound capable of activating the IGF-I receptor or post-receptor mechanism.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of IGF-I or IGF-II or modified forms of these in combination with one the natural or modified IGF binding proteins in an effective molecular ratio.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post- receptor mechanism.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) IGF-I or IGF-II, b) modified forms of IGFs, or c) a compound capable of activating the IGF-I receptor or post-receptor mechanism in combination with an effective amount of GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post-receptor mechanism.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of IGF-I or IGF-II or modified forms of these in combination with one the natural or modified IGF binding proteins in an effective molecular ratio and in combination with a) GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post-receptor mechanism.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) IGF-I or IGF-II, b) modified forms of IGFs, or c) a compound capable of activating the IGF-I receptor or post-receptor mechanism in combination with an effective amount of another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
  • another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of IGF-I or IGF-II or modified forms of these in combination with one the natural or modified IGF binding proteins in an effective molecular ratio and in combination with an effective amount of another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
  • another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
  • a method for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post-receptor mechanism in combination with an effective amount of another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
  • another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
  • the above methods solve the problem of how to prevent urinary incontinence developing as a result of childbirth, surgery of the bladder in men and women, or radical prostatectomy.
  • the invention may also be useful to treat both female and male patients who already have stress, urge and overflow incontinence resulting from a variety of etiologies such as birth trauma, aging, smoking, obesity and radical cancer surgery in the pelvis.
  • IGF-I insulin growth factor-I
  • the effect of IGF-I could have resulted from enhancing the regeneration of the smooth and striated muscle, nerves and connective tissue of the urethra and pelvic floor, and promoting more efficient contraction of proximal and distal urethral sphincter mechanism.
  • the combination of an IGF with an IGF binding protein other than IGF binding protein-4 may prove superior to IGF-I alone for the reason described heretofore.
  • GH alone or combined with either an IGF or a complex of an IGF with an IGF Binding protein may also be efficacious.
  • Combinations including other growth factors, neurotrophic factors, hormones, or cytokines to the IGF and GH preparations just discussed may also improve the therapeutic response.
  • a therapeutic concentration of an IGF systemically a) daily for 30 to 90 days or b) for an effective course to be determined.
  • a local injection of a therapeutic concentration of an IGF intraurethrally and/or in the bladder neck for one or more injections by an effective course to be determined.

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Abstract

A method is provided for treating human urinary incontinence using therapeutic amounts of human insulin-like growth factor-I (IGF-I) administered systemically, intraurethrally, or periurethrally. Alteration of the muscles, nerves and fascia of the bladder, urethra and pelvic floor are the most important factors in the development of urinary incontinence. These alternations may occur in women subsequent to vaginal delivery and may be caused in both sexes by trauma and degeneration. IGF-I significantly decreases the incidence of urinary incontinence in experimental models by its favorable actions on muscle tissues, nervous tissues, and pelvic fascia, in combination or individually. Administering a complex of an IGF with one of the IGF binding proteins may provide a better response than IGF-I alone. Growth hormone may also be effective by virtue of its stimulatory actions on IGF-I and IGF binding protein-3, and possibly by an independent action on tissue repair.

Description

HUMAN URINARY INCONTINENCE AND METHODS OF
TREATMENT
Field of the Invention
This invention relates to human urinary incontinence and methods to prevent and treat this condition.
Background
Urinary incontinence is one of the most common medical problems in the United States and Western countries. The National Institutes of Health research studies show that the annual cost of urinary incontinence management in the United States is over 10.3 billion dollars. Female urinary incontinence, with a prevalence of 10% to 25%, afflicts approximately 20 million American woman.
Twenty-six percent of women 30 to 59 years old report having experienced urinary incontinence during adult life, and 14% consider urinary incontinence an embarrassing social or hygienic problem. Moreover, more than 50% of admissions to nursing homes are prompted by problems related to urinary incontinence. Furthermore, the presence of incontinence makes it more difficult for patients who are in need of nursing home care to be accepted by these units.
A. Glossary
In this application, the following terms are employed: Alpha-adrenergic antagonists: Drugs that block the nerve transmission by alpha- adrenergic receptors.
Anticholinergic agents: Drugs that block impulses from postganglionic cholinergic nerves.
Catheterization: The insertion of a tube through the urethra into the urinary bladder.
Cholinergic agents: Drugs that mimic the action of the neurotransmitter acetylcholine. Detrusor: A muscle in the wall of the urinary bladder that forces urine from the bladder when it contracts.
Ectopic ureter: A ureter that is situated in an abnormal position in the urinary bladder. Fascia: Sheets of connective tissue made up of interlacing layers of collagen fibers containing fibroblast cells.
Hypophysectomy: The removal of the pituitary gland.
IGF-I: Insulin-like growth factor-I.
ISD: Intrinsic sphincter deficiency. Defective muscles that run over the distal urethra and normally maintain it in a closed position preventing the leakage of urine.
Kegel exercises: A series of muscle exercises designed to reduce incontinence in the female.
Somatomedins: An older name for insulin-like growth factors. SUI: Stress urinary incontinence: Urinary leakage secondary to an increase in abdominal pressure, in the absence of a detrusor contraction or an over-distended bladder.
Striated muscle: Muscle that possesses a transverse banding structure as in skeletal muscle. Sympathomimetic: A drug that produces the responses achieved by stimulating the sympathetic nervous system.
Ureter: One of two bilateral tubes that conduct urine from the kidney to the urinary bladder.
Urethra: The channel that conducts urine from the urinary bladder to the exterior.
Urethral meatus: The external outlet of the urethra.
Vesicovaginal fistula: An abnormal communications between the urinary bladder and the vagina. B. The Etiology Of Urinary Incontinence
Urinary incontinence is the involuntary leakage of urine through the urethral meatus. Urinary incontinence has been traditionally divided into 4 categories: stress, urge, overflow, and total urinary incontinence. Stress urinary incontinence is defined as urinary leakage secondary to an increase in abdominal pressure in the absence of 1) a contraction of the detrusor muscle of the bladder or 2) an over-distended bladder.'The etiology of this type of incontinence will be discussed in the next section. Urge incontinence is the loss of urine associated with a strong desire to urinate and usually occurs secondary to a sensory or motor dysfunction. Overflow incontinence occurs when the bladder is at its maximal capacity and its pressure exceeds the restraining pressure in the urethra. Total incontinence refers to a continuous loss of urine which can occur with a vesicovaginal fistula (an abnormal communication between the bladder and vagina), ectopic ureter (an abnormal insertion of the ureter in the bladder) or a severe urethral intrinsic sphincter deficiency.
C. Stress Urinary Incontinence
In females, stress urinary incontinence (SUI) is a major problem that has not been adequately addressed. A significant part of the inability to devise effective therapy has been the absence of an animal model to investigate. Several classifications for SUI in women have been proposed. From a practical standpoint, SUI can be divided into urethral hyper mobility and urethral intrinsic sphincter deficiency (ISD). To better understand the causes of SUI the mechanisms for maintaining continence of urine will be summarized.
1. The urinary continence mechanisms in women
There are two principal components to this mechanism. 1) Pressure from above compresses the urethra against a hammock-like supportive layer closing its lumen. The supporting layer consists of the anterior vaginal wall and fascia. The stability of this suburethral layer depends on intact, lateral connections of the anterior vaginal wall and fascia to: a) the levator and muscles, and b) a strong fascial layer called the arcus tendineus fasciae pelvis. Damage to the pelvic nerves, muscles, and fascia are the most frequently cited causes of SUI after delivery. 2) Contraction of the urethral sphincter compresses the distal urethra. The sphincter consists of two arches of striated muscle. Reflex contraction of the normal sphincter under stress conditions, such as a cough, prevents urine loss.
2. Urethral Hyper Mobility
Hyper mobility of the urethra and bladder neck during stress accounts for up to 85% of cases of SUI. Anterior vaginal wall relaxation, caused by trauma to the bladder-urethra-pelvic floor during vaginal delivery, is the single most important factor in the development of hyper mobility-related stress incontinence. Foldspang, A. et al., "Parity as a correlate of adult female urinary incontinence prevalence," J. of Epidemiology and Community Health 46, pp 595-600, (1992). The factors next in importance are aging, hormonal changes, and pelvic surgery. Gilpin, S.A. et al. "The effect of age on the autonomic innervation of the urinary bladder," Brit. J. Urol.. 58, pp 378-381 (1986). Countouris, N. "The mucosal zones of the female urethra." Urologe Ausgabe 31. pp 81-84 (1992). Miodrag, A. et al. "Sex hormones and the female urinary tract," Drugs 36, pp 491-504, (1988). Other risk factors include obesity, cigarette smoking, chronic constipation, cough, race and connective tissue disease.
3. Intrinsic Sphincter Deficiency (ISD) 15% of woman with SUI have an anatomically well-supported urethra and bladder neck but still experience stress incontinence. This is due to intrinsic sphincter deficiency (ISD). The most common causes of ISD include: urethral sphincteric damage after delivery, a prior anti-incontinence surgical procedure, pelvic radiation, trauma, and neurogenic disorders resulting in urethral denervation. Since many women with urethral hyper mobility do not have stress incontinence, some researchers now believe that most patients with stress incontinence have both hyper mobility and ISD.
D. Treatments For Incontinence The therapy of urge incontinence consists of oral anticholinergic agents, electrical stimulation, and bladder augmentation surgery in refractory cases. Even acupuncture and biofeedback have been advocated. Treatment of overflow incontinence consists of removing or correcting the underlying causes such as intermittent catheterization, surgical correction of an urethral stricture, cholinergic agents, or alpha-adrenergic antagonists to facilitate voiding. For stress incontinence in women, treatments include Kegel exercises, electrical stimulation, sympathomimetics, collagen injections, bladder neck suspension and sling operations. In spite of the multiple treatments, medical and surgical management of incontinence is unsatisfactory. Surgical approaches have additional drawbacks in that they are expensive and often create partial urethral obstruction and bladder irritability. No one has attempted to use insulin-like growth factors for therapy.
E. Insulin-like Growth Factors (IGF The two insulin-like growth factors (IGFs), IGF-I and IGF-II, their receptors, the IGF binding proteins, and the IGF binding protein proteases constitute a system of cellular modulators that play essential roles in the regulation of growth and development. Spencer, E. M. "Modem Concepts of Insulin-like Growth Factors," Elsevier Publishing Co., New York (1991). Classically, IGF-I is known for mediating most of the growth-promoting effects of growth hormone (GH). Schlechter, N. L. et al. "Evidence suggesting that the direct growth-promoting effect of growth hormone on cartilage in vivo is mediated by local production of somatomedin." Proc. Nat. Acad. Sci. 81, pp 7932-7934 (1986). Growth hormone stimulates the production of IGF-I and is the principal regulator of IGF-I production. Nutrition, insulin, and glucocorticoids are some of the other regulators. There are other unknown regulators at the cellular level. IGF-I acts favorably on all the major sites, smooth muscle, striated muscle, nervous tissue, and connective tissue, contributing to SUI, and probably the other forms of incontinence. However, no one has considered using IGF-I to treat incontinence.
1. Smooth muscle
In vitro studies have shown that smooth muscle cells from different sources proliferate in response to IGF-I stimulation. Other growth factors have been reported to synergize with IGF-I. Banskota, N. K. et al. "Insulin, insulin- like growth factor I and platelet-derived growth factor interact additively in the induction of the protooncogene c-myc and cellular proliferation in cultured bovine aortic smooth muscle cells." Mol. Endocrinolog 3, pp 1183-1190 (1989). Hypertrophy of smooth muscle in the urinary bladder of rats induced by urethral ligation was associated in these cells with up-regulation of the expression of the genes for IGF-I and those of the IGF binding proteins-2 and -4. Chen, Y. et al.
"Development of smooth muscle hypertrophy is closely associated with increased gene expression of insulin-like growth factor binding protein-2 and -4," Growth Regulation 5, pp 45-52 (1995). IGF-I also stimulates elastin gene expression in aortic smooth muscle cells. Rich, C. B. et al. "IGF-I regulation of elastogenesis: comparison of aortic and lung cells." Am. J. Physiol. 263, pp 1,276-1,282
(1992).
2. Striated muscle
IGF-I promotes the proliferation and differentiation of myoblasts. IGF-I stimulates differentiation by inducing synthesis of myogenin, a protein that controls terminal differentiation. Florini, J. R. et al. "Insulin-like growth factor-I stimulates terminal myogenic differentiation by induction of myogenin gene expression." Mol. Endocrinology 5, pp 718-724 (1991). IGF-I is also a potent anabolic hormone for striated muscle even in states of trauma and catabolism. It acts primarily by decreasing protein breakdown and only weakly stimulates protein synthesis. GH is less anabolic than IGF-I. 3. Nervous tissue
IGF receptors are expressed at high levels in the nervous system. Marks, J. L. et al. "Localization of type I insulin-like growth factor receptor messenger RNA in the adult rat brain by in situ hybridization." Mol. Endocrinology 5, pp II
58-1168 (1991). IGFs support the growth and differentiation of fetal neurons in culture and stimulate RNA, DNA and protein synthesis. The result is induction of expression of early genes, cytoskeletal proteins, and neurite outgrowth. Pecio-Pinto, E. et al. "Effects of insulin, insulin-like growth factor II, nerve growth factor on neurite formation and survival in cultured sympathetic and sensory neurons." J. Neurosci 6, pp 1211-1216 (1991). Hypophysectomy, which dramatically lowers IGF-I levels, impairs nerve regeneration. Conversely IGF-I promotes the survival of injured sensory and motor neurons. Skottner, A. et al. "Anabolic and tissue repair functions of recombinant insulin-like growth factor V Acta Paediatr. Scand. -. Suppl . 367. pp 63-66 H 990,. The IGFs acting as neurotropic factors may be derived from local muscle tissue. The gene expressions of IGF-I and -II are both increased in denervated muscle. Caroni, P. et al. "Role of muscle insulin-like growth factors in nerve sprouting: suppression of terminal sprouting in paralyzed muscle by IGF-binding protein 4." J. Cell Biology 125, pp 893-902 (1994). This locally produced IGF can stimulate injured sensory and motor neurons and intramuscular neurite outgrowth. IGF-1 also can block drug-induced peripheral neuropathy in mice. Apfel, S. C. et al. "Neurotrophic factors in the treatment of peripheral neuropathy." Ciba Foundation Symposium 196, pp 98-108, (1996). There are, however, no published reports of IGFs stimulating the regeneration of non-adrenergic, non- cholinergic (NANC) nerves.
4. Tissue repair
IGF-I stimulates the repair of wounded tissue acting at many sites throughout the healing process including stimulating fibroblasts and collagen synthesis. Spencer, E.M. "Somatomedins: Do they play a pivotal role in wound healing?" Growth Factors and Other Aspects of Wound Healing: Biological and Clinical Implications. Alan R. Liss, pp 103-116 (1988). Addition of IGF-I to wounds hastens repair, especially if it is complexed with IGF binding protein-3. Sommer, A. et al. "Molecular genetics and actions of recombinant insulin-like growth factor binding protein-3." In Modern Concepts of Insulin-like Growth
Factors, ed. E. M. Spencer, Elsevier Publishing Co., New York, pp 715-728 (1991).
5. IGF binding proteins The biological actions of the IGFs are also regulated by a class of 6 or more IGF binding proteins which are found in plasma and the extracellular fluid. Chan, K. and Spencer, E.M., "General aspects of insulin-like growth factor binding proteins." Endocrine in press (1997). The most abundant circulating IGF binding protein is IGF binding protein-3. The biological actions of IGF-I are generally inhibited when it associates with an IGF binding protein. However, under certain experimental conditions, the complexing with IGF binding protein- 3, and other IGF binding proteins except IGF binding protein-4, may potentiate the action of the IGF. Somnier, A. et al., "Molecular Genetics And Actions of Recombinant Insulin-like Growth Factor Binding Protein-3" Modern Concepts Of Insulin-like Growth Factors, ed. Spencer, E.M., Elsevier Publishing Co., New
York, pp 715-728 (1991). Both IGF-I and GH have been claimed to stimulate the synthesis of IGF binding protein-3.
6. Therapeutic uses of IGF-I IGF-I is used therapeutically in patients with certain types of insulin receptor insensitivity, GH receptor dysfunction (Laron dwarfism), and amyotrophic lateral sclerosis (presently under a compassionate use indication.). Summary of the Invention
Methods are provided for preventing urinary incontinence from occurring in a patient subsequent to a pelvic trauma or injury. Examples of pelvic traumas include but are not limited to pelvic surgery and pelvic births. In one embodiment, the method comprises administering to the patient after the pelvic trauma or injury a therapeutic amount of a therapeutic composition which includes an agent selected from the group consisting of IGF- I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism. Optionally, the therapeutic composition may further include IGF binding proteins or analogs or derivatives of IGF binding proteins. Optionally, the therapeutic composition may also further include GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism. In another embodiment, the method includes administering to the patient after the pelvic trauma or injury a therapeutic amount of a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism. Methods are also provided for treating urinary incontinence in a patient.
In one embodiment, the method comprises administering to a patient with urinary incontinence a therapeutic amount of a therapeutic composition which includes an agent selected from the group consisting of IGF-I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism. Optionally, the therapeutic composition may further include IGF binding proteins or analogs or derivatives of IGF binding proteins. Optionally, the therapeutic composition may also further include GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism. In another embodiment, the method includes administering to the patient with urinary incontinence a therapeutic amount of a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, or a compound capable of activating the GH receptor or post-receptor mechanism.
In each of the above embodiments, the therapeutic composition may further include a second growth factor. Examples of second growth factors which may be used include platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor- alpha or beta, and a neurotropic growth factor.
In each of the above embodiments, the therapeutic composition may be delivered locally or systemically. In one variation, the therapeutic amount is delivered systemically for at least about 30 days, optionally for between about 30 and 90 days.
Detailed Description of the Invention
IGF-I may be useful therapeutically to treat or prevent urinary incontinence. IGF-I may be particularly useful to treat or prevent urinary incontinence in women secondary to birth trauma and in women and men secondary to radical pelvic surgery. IGF-I may also be useful in both women and men to treat established SUI and other types of incontinence related to aging, obesity and other factors. This application of an IGF, with or without one or more of its potentiating binding proteins would provide a minimally invasive but more physiologic approach to the therapy of urinary incontinence. GH could also be useful in the prevention and therapy of urinary incontinence. A combination of GH plus an IGF, with or without IGF binding proteins, might also be therapeutically beneficial. The administration of IGF-I in addition to GH has been shown to produce an additive stimulatory effect on body growth in hypophysectomized rats. Fielder, P. J. et al. "Differential long- term effects of insulin-like growth factor-I (IGF-1), growth hormone (GH), and IGF-I plus GH on body growth and IGF binding proteins in hypophysectomized rats." Endocrinology 137, pp 1913-1920, (1996).
In one embodiment, a method is provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of: a) IGF-I or IGF-II, b) modified forms of IGFs, or c) a compound capable of activating the IGF-I receptor or post-receptor mechanism. In another embodiment, a method is provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of IGF-I or IGF-II or modified forms of these in combination with one the natural or modified IGF binding proteins in an effective molecular ratio.
In yet another embodiment, a method is provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post- receptor mechanism. In yet another embodiment, a method is provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) IGF-I or IGF-II, b) modified forms of IGFs, or c) a compound capable of activating the IGF-I receptor or post-receptor mechanism in combination with an effective amount of GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post-receptor mechanism.
A method is also provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of IGF-I or IGF-II or modified forms of these in combination with one the natural or modified IGF binding proteins in an effective molecular ratio and in combination with a) GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post-receptor mechanism.
A method is also provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) IGF-I or IGF-II, b) modified forms of IGFs, or c) a compound capable of activating the IGF-I receptor or post-receptor mechanism in combination with an effective amount of another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
A method is also provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of IGF-I or IGF-II or modified forms of these in combination with one the natural or modified IGF binding proteins in an effective molecular ratio and in combination with an effective amount of another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor.
A method is also provided for preventing or reversing stress, urge, overflow or complete urinary incontinence that occurs as a result of birth trauma, radical pelvic surgery, aging, obesity, pelvic injury, chronic constipation, or other factors comprising administering systemically or locally in the affected urinary area an effective amount of a) GH, b) a synthetically modified GH, c) peptides capable of stimulating endogenous GH secretion, or d) compounds capable of activating the GH receptor or post-receptor mechanism in combination with an effective amount of another growth factor such as platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, or a neurotropic growth factor. The above methods solve the problem of how to prevent urinary incontinence developing as a result of childbirth, surgery of the bladder in men and women, or radical prostatectomy. The invention may also be useful to treat both female and male patients who already have stress, urge and overflow incontinence resulting from a variety of etiologies such as birth trauma, aging, smoking, obesity and radical cancer surgery in the pelvis.
In experimental studies urinary incontinence was produced in female rats by simulated birth trauma and the effect of systemic 1 GF-I administration on the rate of incontinence was investigated.
Twelve normal rats underwent intravaginal balloon inflation with balloons containing 3 ml of fluid for 4 hours. Beginning on the day of injury, six rats received IGF-I at a dose of 2.5 mg/kg/day while the remaining six were used as controls. These injections were given subcutaneously three times a day for three weeks. One week after the last injection, the rats were tested for incontinence by filling their bladder with diluted methylene blue solution and inducing sneezing by tickling a whisker. The urethral meatus was observed for leakage of blue urine. Incontinence was noted in 5 of the 6 controls but only 2 of the 6 IGF- 1 treated rats. The effect of IGF-I could have resulted from enhancing the regeneration of the smooth and striated muscle, nerves and connective tissue of the urethra and pelvic floor, and promoting more efficient contraction of proximal and distal urethral sphincter mechanism. The combination of an IGF with an IGF binding protein other than IGF binding protein-4 may prove superior to IGF-I alone for the reason described heretofore. GH alone or combined with either an IGF or a complex of an IGF with an IGF Binding protein (except IGF binding protein-4) may also be efficacious. Combinations including other growth factors, neurotrophic factors, hormones, or cytokines to the IGF and GH preparations just discussed may also improve the therapeutic response.
EXAMPLES
1. Method For Preventing Incontinence Immediately after pelvic delivery or radical pelvic surgery administer a therapeutic concentration of an IGF systemically a) daily for 30 to 90 days or b) for an effective course to be determined. Alternately, immediately after pelvic delivery or radical pelvic surgery administer a local injection of a therapeutic concentration of an IGF intraurethrally and/or in the bladder neck for one or more in injections by an effective course to be determined.
2. Method for treating established incontinence
After the diagnosis of incontinence has been made administer a therapeutic concentration of an IGF systemically a) daily for 30 to 90 days or b) for an effective course to be determined. Alternately administer a local injection of a therapeutic concentration of an IGF intraurethrally and/or in the bladder neck for one or more injections by an effective course to be determined.
While the present invention is disclosed by reference to the preferred embodiments and examples detailed above, it is to be understood that these examples are intended in an illustrative rather than limiting sense, as it is contemplated that modifications will readily occur to those skilled in the art, which modifications will be within the spirit of the invention and the scope of the appended claims.

Claims

What is claimed is:
1. A method for preventing urinary incontinence from occurring in a patient subsequent to a pelvic trauma or injury comprising: administering to the patient after the pelvic trauma or injury a therapeutic amount of a therapeutic composition which includes an agent selected from the group consisting of IGF-I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post- receptor mechanism.
2. The method according to claim 1 wherein the therapeutic composition further includes IGF binding proteins or analogs or derivatives of IGF binding proteins.
3. The method according to claims 1 or 2 wherein the therapeutic composition further includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, and a compound capable of activating the GH receptor or post-receptor mechanism.
4. A method for preventing urinary incontinence from occurring in a patient subsequent to a pelvic trauma or injury comprising: administering to the patient after the pelvic trauma or injury a therapeutic amount of a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, and a compound capable of activating the GH receptor or post-receptor mechanism.
5. A method according to any one of claims 1-4 wherein the pelvic trauma or injury is a birth, the step of administering including administering the therapeutic composition to the patient after the birth.
6. A method according to any one of claims 1 -4 wherein the pelvic trauma or injury is a pelvic surgery, the step of administering including administering the therapeutic composition to the patient after the pelvic surgery.
7. A method for treating urinary incontinence in a patient comprising administering to the patient with urinary incontinence a therapeutic amount of a therapeutic composition which includes an agent selected from the group consisting of IGF-I, IGF-II, an analog or derivative of IGF-I, an analog or derivative of IGF-II, and a compound capable of activating the IGF-I receptor or post-receptor mechanism.
8. The method according to claim 7 wherein the therapeutic composition further includes IGF binding proteins or analogs or derivatives of IGF binding proteins.
9. The method according to claims 7 or 8 wherein the therapeutic composition further includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, and a compound capable of activating the GH receptor or post-receptor mechanism.
10. A method for treating urinary incontinence in a patient comprising: administering to the patient with urinary incontinence a therapeutic amount of a therapeutic composition which includes GH, an analog or derivative of GH, a peptide capable of stimulating endogenous GH secretion, and a compound capable of activating the GH receptor or post-receptor mechanism.
11. The method according to any one of claims 1-10 wherein the therapeutic composition further includes a second growth factor.
12. The method according to claim 11 wherein the second growth factor is selected from the group consisting of platelet-derived growth factor, acidic or basic fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha or beta, and a neurotropic growth factor.
13. The method according to any one of claim 1-12 wherein the therapeutic amount is delivered systemically.
14. The method according to any one of claim 1-12 wherein the therapeutic amount is delivered systemically for at least about 30 days.
15. The method according to any one of claim 1-12 wherein the therapeutic amount is delivered systemically for between about 30 and 90 days.
16. The method according to any one of claim 1-12 wherein the therapeutic amount is administered by a local injection intraurethrally and/or in the bladder neck.
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