This action might not be possible to undo. Are you sure you want to continue?
A simple method for teaching about voiding disorders
WILLIAM D. STEERS and MIKEL GRAY*
Department of Urology and *School of Nursing, University of Virginia Charlottesville, VA, USA
Accepted for publication 28 July 2005
KEYWORDS lower urinary tract symptoms, classiﬁcation schema, urinary incontinence
INTRODUCTION Several terms have been used to describe functional disorders of the LUT, including urinary incontinence, neurogenic bladder, overactive bladder dysfunction, BPH, interstitial cystitis, and chronic prostatitis (male pelvic pain syndrome). Patients with LUT disorders seek care from a wide range of healthcare providers, including nurses, geriatricians, gynaecologists, urologists, rehabilitation medicine specialists, family physicians and internists, and the collective annual cost of managing them exceeds US$36 billion [1–3]. However, efforts to educate clinicians and students about these disorders have been hindered by variability in the nomenclature used to deﬁne these conditions; overlap among diagnoses; a lack of distinctive classiﬁcations allowing the clinician to readily classify LUT disorders; and the myriad of available treatments. Moreover, patient symptoms and associated bother do not directly correlate with objective signs (pad testing, bladder diaries) or the underlying pathophysiological mechanisms as measured by urodynamic testing. For example, there is a poor correlation between subjective symptoms associated with involuntary urine loss (urge vs stress) and the cause of incontinence . Several didactic classiﬁcation schemes have attempted to characterize LUT disorders but none has proved entirely adequate. For example, a urodynamic-based scheme divides LUT dysfunction into four readily understood classiﬁcations: (i) failure to store urine because of the bladder; (ii) failure to store urine because of the outlet; (iii) failure to empty urine because of the bladder; or (iv) or failure to failure to empty urine because of the outlet. However, clinical application is limited because it requires complex urodynamic testing to accurately classify individual patients. Many classiﬁcation 238
schemes based on the vague term ‘neurogenic bladder’ have been promulgated, but they are difﬁcult to apply in practice because they fail to adequately account for differences in LUT function despite a common neurological diagnosis, and they fail to describe patients with more than one pathology. In addition, they do not uniformly inform therapeutic decisions, particularly in patients with functional limitations that restrict treatment options . A more recent scheme based on urodynamic ﬁndings and symptoms originated within a nomenclature committee composed of experts of the ICS. This scheme is based on a description of LUTS, which are typically divided into storage and voiding symptoms . While this type of taxonomy is useful in describing the various symptoms associated with LUT disorders, it fails to differentiate the underlying causes of the disorder or elucidate appropriate treatment, and it is difﬁcult to comprehend by generalists unfamiliar with urodynamic testing. An objective classiﬁcation scheme based on a prognosis, similar to cancer staging or cardiovascular risks, would be extremely useful in this ﬁeld. Unfortunately, the natural history of many disorders of the LUT is unknown and evidence-based therapies derived from prospective randomized trials are often lacking. Therefore, a simple and reliable scheme for teaching students and generalists is needed, as these professionals are likely to encounter voiding disorders in their clinical practice.
highlighting functional goals, this grid method provides an easy way to visualize combined therapies for complex disorders. Figure 1 provides the conceptual framework for this classiﬁcation scheme; a two-by-two grid with column headings for two functional units is used to characterize LUT dysfunction regardless of the underlying disease. The heading ‘Bladder’ indicates the detrusor muscle and visco-elastic properties of the bladder wall. The heading ‘Outlet’ indicates the bladder neck, urethra and urethral sphincter mechanism. The pelvic ﬂoor musculature and ligamentous support inﬂuence the outlet and could be added to this scheme. Under the ‘Bladder’ heading two pathological possibilities exist, i.e. overactive or underactive. LUTS associated with overactive dysfunction include frequent urination (more than eight episodes/24 h), nocturia (three or more episodes per night), urgency (a sudden and strong desire to urinate that is not easily deferred) and urge urinary incontinence (urine loss associated with urgency). These symptoms have been referred to as ‘irritative’ but more recently they were termed the ‘overactive bladder’ . LUTS associated with an underactive bladder include a diminished or poor force of urinary stream, intermittency of stream, hesitancy, feelings of incomplete bladder emptying, and terminal dribble. Two pathological possibilities are placed beneath the ‘Outlet’ heading, i.e. increased resistance or reduced resistance. Increased resistance indicates BOO and produces LUTS similar to those seen with an underactive detrusor. They include poor force of urinary stream, intermittency or hesitancy, feelings of incomplete bladder emptying and terminal dribble. Further diagnostic testing is needed to clearly differentiate these headings. Reduced urethral resistance is associated with the symptom of stress urinary incontinence, deﬁned as urine loss associated with physical activity, coughing or sneezing. There are 12 known combinations that explain all described voiding disorders. Table 1 lists these classical possibilities with
THE TWO-BY-TWO GRID METHOD Based on teaching medical students, residents and non-urologists for over a decade, a binomial-type system was developed that provides a simple conceptualization of pathophysiology and treatment strategies for disorders of the LUT. A proposed advantage of such as system is its ability to summarize pathophysiology, diagnostic methods and treatments on three to ﬁve ﬁgures in a format that can be readily updated when new knowledge becomes available. While
2 0 0 5 B J U I N T E R N A T I O N A L | 9 7 , 2 3 8 – 2 4 2 | doi:10.1111/j.1464-410X.2006.05884.x
antimuscarinic agents are the drugs of choice for an overactive bladder. ﬁxed urethra that fails to respond to increases in intravesical pressure can be placed in the quadrant labelled ‘reduced resistance’ as it can lead to urinary incontinence. Parkinson’s disease and multiple sclerosis. can also be caused by myogenic changes that arise from obstruction. and cause urinary frequency and urge incontinence. 3). Changes in the bladder smooth muscle. Although identifying her dysfunction as reduced resistance seems reasonable it is inaccurate. However. termed the detrusor. rigid urethra corresponding LUTS. Categorization of disorders of the LUT by bladder and outlet (bladder neck. The pathogenesis of overactive (including reduced bladder compliance) and underactive bladder disorders. Underactive + reduced resistance corresponds to failure to store. For didactic purposes these more detailed causes could be placed in the two bladder quadrants for a more advanced audience. Overactive Neurogenic (Afferents. or cough-induced involuntary bladder contractions (overactive bladder). A condition such as a noncompliant. The differential diagnosis of anatomical vs functional causes of ‘increased resistance’ requires urodynamic testing. These conditions can be placed in the ‘overactive’ quadrant. the complaint of stress incontinence in a 45-yearold woman could be due to an underactive bladder with high residual urine and overﬂow. Urodynamics is required to determine an abdominal or Valsalva leak-point pressure to diagnose intrinsic sphincter deﬁciency. radiographic imaging studies of the LUT or cystoscopy. Examples of neurogenic disorders include spinal cord injury. 3.TEACHING ABOUT VOIDING DISORDERS FIG. In addition to categorizing patients by clinical presentation. Allowances need to be made for connective tissue abnormalities of the bladder that cause reduced compliance (distensibility) thereby creating a potentially high intravesical pressures or the urodynamic ﬁnding of a high detrusor leak pressure. Some patients present with obstruction and a ﬁbrotic urethra at the level of the intrinsic sphincter mechanism. In another example. THERAPEUTIC DECISION MAKING To classify patients into any given quadrant based solely on symptoms is difﬁcult because they are not reliable in identifying the underlying pathophysiology. a history. But for generalists such distinctions are irrelevant because diagnostic tests and therapies have yet to be developed relying on these mechanisms. For example. myelodysplasia. Reduced resistance can be due to urethral hypermobility or intrinsic sphincter insufﬁciency (Fig. urodynamic ﬁndings and common clinical diagnoses. CNS) Myogenic Urothelial Connective tissue Underactive Neurogenic (Afferents. it is also possible that the symptoms derive from an underactive bladder. Despite the usefulness of 239 © 2005 BJU INTERNATIONAL . physical examination and urodynamics are usually required. or to urinary incontinence FIG. efferents. and that cell-cell interactions occur. interstitial cells and connective tissue also inﬂuence bladder activity. videourodynamic testing or an imaging study of the pelvic ﬂoor such as MRI. These neurological disorders may give rise to an overactive bladder. Increased resistance Anatomic Functional Cystoscopy imaging Reduced resistance Hypermobility Intrinsic sphincter deficiency • Urodynamics Underactive Reduced resistance** *Includes poor bladder compliance and high detrusor leak pressures **Includes pipestem. a Q-tip test. increased resistance can be due to anatomical abnormalities or functional disorders. Certain disorders such as diabetes mellitus trigger changes in nerves and muscle that can lead to both an overactive and underactive bladder. a 60-yearold man complaining of a slow urinary stream with a residual urine of 300 mL may be categorized as having increased resistance due to BPH (anatomical + functional). To distinguish myogenic from neurogenic causes for overactive or underactive bladder. Overactive + increased resistance corresponds to failure to empty or retain. i. external urethral sphincter). Pathophysiology of increased and reduced (ﬁxed) outlet resistance. urethra. A more accurate categorization requires the combination of measuring residual urine and urodynamics. Figure 2 outlines the two major causes of an overactive or underactive bladder.e. ischaemia or injury. each of the four quadrants can be used to list underlying pathophysiological mechanisms and treatment options. For example. Anatomical conditions include urethral strictures. regardless of cause. myogenic or neurogenic dysfunction. Differentiation of reduced urethral resistance caused by urethral hypermobility or intrinsic sphincter deﬁciency is typically based on physical examination. With regard to the outlet. The functional disorders of detrusor sphincter dyssynergia due to spinal pathology and BPH can fall under both rubrics. accounting for the paradoxical combination of increased plus reduced urethral resistance. categorizing LUT disorders solely based on myogenic or neurogenic causes fails to incorporate recent concepts which recognize that urothelium. Urodynamic testing would determine whether there is detrusor hypocontractility or obstruction. Reduced compliance can be functionally envisioned as an overactive bladder because it can contribute to upper tract deterioration and/or urinary incontinence. 2. However. CNS) Myogenic • History • Examination • Urodynamics Bladder Outlet Overactive* Increased resistance FIG. 1.
voiding frequency. hesitancy. hesitancy. terminal dribble Urodynamic: prolonged or intermittent ﬂow pattern with elevated detrusor contraction pressures (increased urethral resistance) ± increased urinary residual volume Clinical: Bladder neck dyssynergia or contracture. intrinsic sphincter deﬁciency LUTS: urgency. urge incontinence with poor force of stream. hesitancy. intermittency. urethral stricture LUTS: stress incontinence (urine loss with physical exertion. poor duration). intermittency. increased urinary residual volume Clinical: sacral agenesis with residual urine and stress incontinence LUTS: poor force of urinary stream.STEERS and GRAY TABLE 1 Categories of bladder/outlet disorders with associated LUTS. urgency ± urge incontinence. hesitancy. hesitancy. feelings of incomplete bladder emptying. intermittency Urodynamic: Detrusor overactivity with poor contraction strength and elevated urinary residual volumes Clinical: Detrusor hyperactivity with insufﬁcient contractility LUTS: stress UI combined with poor force of stream. stress incontinence. poor force of urinary stream. prostate enlargement. feelings of incomplete bladder emptying. coughing and sneezing) Urodynamic: urine loss with increased abdominal pressure Clinical: stress urinary incontinence. urgency ± urge incontinence Urodynamic: detrusor overactivity Clinical: Overactive bladder. terminal dribble Urodynamic: prolonged or intermittent ﬂow pattern with poor detrusor contraction strength (low amplitude. feelings of incomplete bladder emptying. terminal dribble Urodynamic: Detrusor overactivity. intermittency. terminal dribble Urodynamic: detrusor overactivity. feelings of incomplete bladder emptying. urodynamic ﬁndings or clinical diagnoses Pathophysiology Overactive LUTS/urodynamic ﬁndings/clinical diagnoses or examples LUTS: urgency. poor duration). intermittency. atony of bladder LUTS: poor force of urinary stream. feelings of incomplete bladder emptying. detrusor sphincter dyssynergia causing functional obstruction. voiding frequency. urethral hypermobility. feelings of incomplete bladder emptying. intermittency. hesitancy. urine loss with increased abdominal pressures. increased urinary residual volume Clinical: Acontractile detrusor. intermittency Urodynamic: urine loss with increased abdominal pressure. increased urethral resistance ± increased urinary residual volume Clinical: urethral stricture or prostate enlargement with decompensation of detrusor muscle LUTS: dribbling stress incontinence with poor force of urinary stream. poor duration) and evidence of bladder outlet obstruction and increased urinary residual volume Clinical: Chronic bladder neck contracture after prostatectomy with stress incontinence and residual urine LUTS: urgency. low amplitude detrusor contraction with increased urethral resistance Clinical: Mixed incontinence after retropubic sling with chronic obstruction and hypocontractile bladder Underactive Increased resistance Reduced resistance Overactive + increased resistance + reduced resistance Overactive + underactive Increased resistance + reduced resistance Underactive: + reduced resistance + increased resistance + increased resistance and reduced resistance Overactive + reduced resistance + increased resistance + underactive 240 © 2005 BJU INTERNATIONAL . stress incontinence Urodynamic: urine loss with detrusor overactivity and with increased abdominal pressures Clinical: Mixed urinary incontinence LUTS: urgency (ﬁrst urge may occur after onset of urge incontinence) voiding frequency. intermittency. intermittency. terminaldribble Urodynamic: prolonged or intermittent ﬂow pattern with poor detrusor contraction strength (low amplitude. urge incontinence LUTS: poor force of urinary stream. hesitancy. voiding frequency. urgency ± urge incontinence with poor force of urinary stream. feelings of incomplete bladder emptying. prolonged or intermittent ﬂow pattern with increased urethral resistance ± increased urinary residual volume Clinical: Post-prostatectomy stricture and stress incontinence LUTS: stress incontinence with poor force of urinary stream. poor duration). terminal dribble Urodynamic: urine loss with increased abdominal pressure and prolonged or intermittent ﬂow pattern with poor detrusor contraction strength (low amplitude. urgency ± urge incontinence. voiding frequency. prolonged or intermittent ﬂow pattern with increased urethral resistance ± increased urinary residual volume Clinical: BPH with overactive bladder LUTS: urgency. terminal dribble Urodynamic: prolonged or intermittent ﬂow pattern with poor detrusor contraction strength (low amplitude.
a 35-year-old woman with multiple sclerosis and urge incontinence may also have recurrent UTIs. Another example would be an 80-year-old woman with mixed stress and urge incontinence. Thus taxonomy can be used to guide clinicians in staged decision-making. Empirical therapy is often the most cost-effective initial approach. 6. She would be categorized as overactive + increased resistance. or higher the risk. LUTS associated with more poorly understood conditions can also be characterized in this taxonomy. Fig. early guidelines for urinary incontinence did not recommend urodynamic evaluation for initial evaluation or management of BPH [7. leading to reduced urinary stream or difﬁculty urinating. Bladder Outlet Increased resistance Overactive • • • • Behavioural Drug Neuromodulation Surgery • Behavioural • Drug • Minimal invasive/? neuromodulation • Surgery a specialist for further evaluation.8]. The optimum choice of therapy is dictated by bothersome symptoms. Invasive or surgical treatments of bladder and outlet disorders. Indeed. and would be classiﬁed as overactive with or without increased resistance of the outlet. 5. Pelvic ﬂoor muscle training may be instituted to increase urethral resistance and alleviate overactive bladder symptoms. Bladder Overactive • Anticholinergics • Smooth muscle relaxants • Tricyclics • Investigational Outlet Increased resistance • Alpha antagonists • 5 alpha reductase inhibitors • Botulinum toxin Underactive • Bethanechol Reduced resistance • • • • Alpha agonist Estrogen Tricyclic Duloxetine FIG. combined therapy. 5 shows that a rational pharmacological therapy for these two conditions could be the combination of an antimuscarinic and an α-adrenergic blocker. the more invasive the treatment. Underactive • CIC • Surgery Reduced resistance • Bulking • Surgery FIG. For example. Failure to respond to medical therapy would trigger a referral to THERAPIES The conceptual framework we propose for classifying LUT disorders can be expanded to 241 © 2005 BJU INTERNATIONAL . could be tried. In general. more invasive therapy such as a suburethral sling procedure may be warranted. consisting of an antimuscarinic and periurethral bulking agent. the more experts recommend a urodynamic evaluation. if close surveillance is maintained. Therapies can be combined in boxes of two or more disorders. Pharmacological treatments of bladder and outlet disorders. Categories of treatment of bladder and outlet disorders. clean intermittent catheterization. Bladder Overactive • Neurolysis • Augmentation cysto • Divert Outlet Increased resistance • Minimally invasive • Urethrolysis/VIU/ sphincterotomy • TURP/SP prost Underactive • • • • Chimney Mitrofanoff Divert Myoplasty Reduced resistance • Bulking agent • AUS • Retropubic susp/slings • Closure of bladder neck urodynamics to determine the pathophysiology and explain the aetiology of symptoms. CIC. this invasive testing is not mandatory for managing patients. irreversible the therapy. If urodynamic testing revealed detrusor overactivity and intrinsic sphincter deﬁciency. 4. 5 and 6 outline some therapeutic methods that can be used to treat patients.10]. but if this strategy fails further diagnostic testing such as urodynamics can be used. risk/beneﬁt or prognosis. Figures 4. The man with presumed BPH can be tried on an α-adrenergic antagonist without urodynamic testing. or botulinum toxin injection into the external urethral sphincter. Both may be associated with high-tone pelvic ﬂoor muscle dysfunction or increased urethral resistance. If these conservative measures fail. In the ﬁrst case a short course of treatment using pelvic muscle exercises could be initiated in the incontinent patient. An advantage of this simple scheme is the ease of visualizing combined therapies for patients with two types of pathology. Evaluation reveals a residual urine of 250 mL from detrusor sphincter dyssynergia and neurogenic detrusor overactivity. interstitial cystitis and male pelvic pain syndromes are debilitating conditions characterized by urinary frequency and pain [9.TEACHING ABOUT VOIDING DISORDERS FIG. For example.
MD: American Urologic Association. Neurosurg Psychiatry 2003. Hu TW. Am J Obstet Gynecol 2002. Ruggieri MR. Reduced resistance show where tools for symptom or quality-oflife (QoL) assessment ﬁt in the management of patients (Figs 7. Pontari MA et al. ‘overactive’ or a combination of these quadrants. Bentkover JD. allowing binomial combinations. McNaughton Collins M. Barry MJ. simpliﬁes therapeutic planning and conceptualization of LUT disorders for the generalist. Peruggia M. resulting in stress urinary incontinence . The importance of standardisation and validation of symptom scores and quality of life: the urologist’s point of view. 74 (Suppl. IIQ-7 UDI. Michigan Epidemiological Survey Assessment (or Overactive Bladder Screening Questionnaire) can be used to identify LUTS associated with ‘reduced resistance’. AHCPR Publication no. Arch Intern Med 2004. 164: 1231–6 242 © 2005 BJU INTERNATIONAL . UDI-6 King’s Health Quest DI score MESA Bristol female LUT Quest OAN V8 Underactive Outlet Increased resistance FIG. 1994 8 Roehrborn CG. Cardozo L. Bus Health 1997. McConnell JD. McClain R. recognizing that tools are also designed to detect LUTS associated with overactive bladder function . Department of Urology. 4): iv27–iv31 6 Abrams P. 7. 50: 116–22 5 Fowler CJ. 94–0582. Urology 2004. 63: 461–5 3 Smith MD. Chronic Prostatitis Collaborative Research Network. the IPSS or Danish Prostate Symptom Score. Interstitial cystitis: how should we diagnose it and treat it in 2004? Curr Opin Urol 2004. The advantages of this conceptual framework are its simplicity. Steers WD. VA 22908. Leblanc K. CONFLICT OF INTEREST None declared. 2003 9 Nordling J. 172: 839–45 11 O’Leary M. Steers. The economic impact of chronic prostatitis. clarity. Barrie MJ et al. McGhan WF. could be listed under ‘increased resistance’. Hunt T. MD: Department of Health & Human Services. Fall M et al. Symptom scoring and QoL instruments for urinary incontinence that may arise from overactive bladder or reduced outlet resistance. Guideline on the management of benign prostatic hyperplasia. e. 32 (Suppl. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-committee of the International Continence Society. The prostate’s economic squeeze. 187: 116–26 7 McConnell JD. Overactive* AUA-7/ IPSS DAN-PSS ICSmale Underactive Reduced resistance Bladder IIQ. The taxonomy we propose characterizes LUT disorders into only four basic categories. 21: 473–81 Correspondence: William D. Eur Urol 1997. Box 800422. Mechanisms in prostatitis/chronic pelvic pain syndrome. quality of life. University of Virginia.STEERS and GRAY Bladder Outlet FIG. Urogenital Distress Inventory. Neurourol Urodynam 2002. Nurs Res 2001.g. 8. O’Malley KJ. USA. Investigation and management of neurogenic bladder dysfunction. 42 4 Gray M. Dmochowski RR. J Neurol. including the Incontinence Impact Questionnaires. Clinical Practice Guideline: Benign Prostatic Hyperplasia. 15: 40. Charlottesville. King’s Health Questionnaire. 2): 48–9 12 Graham CW. Validated questionnaires for BPH. e-mail: wds6t@virginia. 8). Wagner TH.edu Abbreviations: QoL. Symptom scoring and QoL instruments used for voiding disorders attributed to LUTS from BPH causing increased outlet resistance. 2 REFERENCES 1 Calhoun EA. 14: 323–7 10 Pontari MA. Zhou SZ. Various additional instruments. Baltimore. Rockville. Patrie J. Bruskewitz RC et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. expandability and thoroughness in explaining many common voiding disorders. Questionnaires for women with urinary symptoms. J Urol 2004. A model for predicting motor urge urinary incontinence.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.