For referred elderly men with LUT dysfunction persisting with or after initial management, diagnosis should not only confirm or exclude BOO. Urodynamic testing also gives the possibility to quantify detrusor voiding contraction strength as well as detrusor volume adaptation and relaxation. Detrusor overactivity is very prevalent in elderly men and is undeniably intermingling in the male LUT dysfunction syndrome.
Elderly men without high-grade BOO and with detrusor overactivity would profit from specific medical management. Men with high-grade BOO and detrusor overactivity may deserve a less expectative management than men with a moderate grade of BOO without detrusor overactivity.
Physiological demonstration of the mechanism of action and of effect size should be the basis of the introduction of every new management option surgical, instrumental, or medical for LUT dysfunction. Contemporary diagnosis of LUT dysfunction, especially of UI or too frequent voiding in women over 40 years of age or both , and of symptoms of dysfunction in men over 45 years of age begins with a LUT syndrome diagnosis on the basis of clinical epidemiology and reported symptoms and signs, including fluid balance.
Initial non-invasive management can safely be based on this. However, I plead that, if initial management fails, both categories of patients deserve objective assessment of their LUT function as the basis for further specific and individualized management. Objective testing is inescapable and invaluable in secondary health care on the basis of good practice, and urodynamic testing is the undisputed gold standard for this objective assessment and the only way to stage and grade the dysfunction.
Individualized management on the basis of objective diagnosis is the paradigm of modern health care. Functional urology should not lag behind. F Faculty Reviews are written by members of the prestigious F Faculty. They are commissioned and are peer reviewed before publication to ensure that the final, published version is comprehensive and accessible.
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FPrime FWorkspace item :. Home Browse Contemporary diagnosis of lower urinary tract dysfunction. ALL Metrics. Get PDF. Get XML. How to cite this article. NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details. Contemporary diagnosis of lower urinary tract dysfunction.
Introduction: Diagnosis of lower urinary tract LUT dysfunction starts with categorization in clinical syndromes, and initial management is based on the assumptions about pathophysiology that these syndromes contain. Statements and suggestions to improve reflect personal opinion. For two groups of patients with LUT dysfunction, the strategy of initial diagnosis is summarized and desirable principles of secondary care diagnosis are discussed.
More specifically, a structure for the contemporary care of women with signs and symptoms of urinary incontinence is described and for that of the group of men older than 45 years with symptoms of LUT dysfunction. Conclusions: Urodynamic testing is the undisputed gold standard for objective assessment and is the only way to stage and grade the dysfunction. Clinical practice guidelines and clinical specialists are too modest about the use and applicability of objective or urodynamic testing for referred persons with LUT dysfunction that is resistant to initial pragmatic management.
Objective assessment and diagnosis are mainstays in secondary care, and the indication to perform objective assessments in patients with LUT dysfunction should be advised much more specifically in guidelines and practice recommendations. Corresponding Author s. Peter Rosier p. Grant information: The author s declared that no grants were involved in supporting this work.
Introduction The normal lower urinary tract LUT stores urine and is able to evacuate this at suitable moments. Women with symptoms of urinary incontinence The initial workup of a woman who presents with UI includes history and clinical exam to be completed with a drinking voiding diary, reporting at least 24 hours, as is recommended in every practice guideline. Conclusions Contemporary diagnosis of LUT dysfunction, especially of UI or too frequent voiding in women over 40 years of age or both , and of symptoms of dysfunction in men over 45 years of age begins with a LUT syndrome diagnosis on the basis of clinical epidemiology and reported symptoms and signs, including fluid balance.
Bladder Dysfunction in the Adult - The Basis for Clinical Management | Alan J. Wein | Springer
Grant information The author s declared that no grants were involved in supporting this work. F recommended References 1. F Med Rep. J Urol. Neurourol Urodyn. Paris, France; Reference Source 6. Reference Source 8. PubMed Abstract Urol Int. Obstet Gynecol. PLoS One. Turk J Urol. Br J Obstet Gynaecol. Three methods have been used to diagnose POUR: history and physical examination, the need for bladder catheterization, and, more recently, ultrasonographic assessment table 2.
Table 2. Pain and discomfort in the lower part of the abdomen have been used as conventional indicators of POUR. However, these symptoms may be masked by regional anesthesia, comorbidities including patients with spinal cord injury or stroke or sedated patients who are unable to effectively communicate their symptoms. Clinical assessment by palpation and percussion in the suprapubic area is another commonly used method for diagnosis of POUR.
Contemporary diagnosis of lower urinary tract dysfunction.
This method however lacks the sensitivity to provide an accurate measure of the residual urinary volume. Dullness of the bladder to the level of the umbilicus provides a rough estimate of at least ml of urine, but it can vary as much as 1, ml with dullness extending above the umbilicus. In addition, clinical evaluation has been shown to overestimate the bladder volume compared to ultrasound. Pavlin et al. Bladder catheterization is used both as a diagnostic tool and as treatment for POUR. The inability to void in the postoperative period could be multifactorial, including inadequate perioperative fluids.
It is imperative to evaluate and treat the underlying cause before making the diagnosis of POUR and proceeding with catheterization. Catheterization is an invasive procedure with the potential to cause complications, including catheter-related infections, urethral trauma, prostatitis, and patient discomfort. Although ultrasound has been used as an imaging modality to evaluate bladder function, its use in the perioperative period as a diagnostic tool for POUR has gained popularity only in the past decade.
By identifying these patients at risk of having an overdistended bladder, intravenous fluids can be monitored, and inappropriate early discharge can be avoided. POUR has been shown to increase with age, with the risk increasing by 2. A higher incidence of POUR has been reported in men 4. The incidence of POUR varies according to the type of surgery. Although the incidence of POUR in general surgical population is around 3.
Concurrent neurologic diseases such as stroke, poliomyelitis, cerebral palsy, multiple sclerosis, spinal lesions, and diabetic and alcoholic neuropathy are predisposing factors to the development of urinary retention. Administration of muscarinic agonists such as carbachol and bethanecol in animals and humans causes an increase in intravescical pressure, leading to hyperactive detrusor contractions.
The amount of intravenous fluids may influence the development of POUR. In patients undergoing hernia repair and anorectal surgery, intravenous administration of more than ml of fluids during the perioperative period increased the risk of POUR by 2. Prolonged duration of surgery can cause POUR. In fact, Pavlin et al. In this section, we have examined the evidence from published data with regard to the effects of anesthetic and analgesic techniques on the development of POUR.
POUR was defined on the basis of the three methods used in clinical practice, such as clinical examination, the need for bladder catheterization, and ultrasound assessment table 2. Most of the studies did not specify the criteria to define POUR, reporting only whether it was present or not.
The search was amplified to include relevant articles identified by cross-referencing fig. We included, as selection criteria, clinical trials relating to POUR after cardiothoracic, abdominal, obstetric, gynecologic, and orthopedic surgeries. We excluded articles related to pediatric and urology surgeries, reviews, editorial letters, and case reports. Studies that reported incidence of POUR and those from which it was possible to calculate incidence of POUR were grouped by method of anesthesia and by method of analgesia.
The mean percentage reporting the overall incidence of POUR was determined by the method of weighted mean with weighting by the number of subjects in the group. There was considerable variability in the criteria used to define POUR. Variability was minimized by subgrouping the incidence of POUR by the diagnostic method used to define it. Search strategy. A total of studies were identified as suitable for analysis.
There were 86 randomized controlled trials, 21 prospective studies, 23 retrospective studies, 57 clinical and experimental trials, 2 meta-analyses, and 1 review. POUR was the primary outcome in 50 studies and secondary outcome in When patients were grouped by method of anesthesia or analgesia, some studies contributed subjects to more than one group.
In 26 studies, 5, patients received general anesthesia table 3 , whereas 5, patients received intraoperative conduction blockade spinal, epidural and combined spinal-epidural anesthesia in 34 studies table 4. In 9 studies, patients received peripheral nerve blocks, table 7 and 2, patients received infiltrations of local anesthetics in 10 studies table 8.
The overall incidence of POUR after general anesthesia was found to be significantly lower in comparison with conduction blockade, whereas the overall incidence of POUR after epidural analgesia was found to be not significantly different in comparison with systemic analgesia table 9.
Similar incidence was found when the criteria to diagnose POUR were unspecified or based on the need for catheterization table Such discrepancy can be explained by the fact that most of the studies analyzed were retrospective in nature, with the data obtained from the clinical charts.
Furthermore, the clinical criteria used to define POUR differed widely and were often subjective table 2. Due to the relative paucity of studies using ultrasound assessment, it was not possible to make meaningful comparisons. Table 3. Table 4. Table 5. Table 6. Table 7. Table 8. Table 9. Table General anesthetic agents cause bladder atony by interfering with the autonomic nervous system.
Studies in rats and dogs have shown that sedative-hypnotic agents and volatile anesthetics suppress micturition reflex. Halothane also increases bladder capacity. Intrathecal local anesthetics act on the neurons of the sacral spinal cord segments S2—S4 by blocking the transmission of the afferent and efferent action potentials on the nervous fibers from and to the bladder.
Bladder analgesia is due to the block of the transmission of the afferent nerve fibers from the bladder to the micturition center in the brain. The detrusor contraction detrusor block is completely abolished 2—5 min after the injection of spinal anesthesia, and its recovery depends on the duration of sensory block above the S2 and S3 sacral segments. Time for sensory block to regress to S3 is 7—8 h after spinal injection of isobaric bupivacaine 20 mg , hyperbaric bupivacaine Fifteen minutes after the level of analgesia regressed to L5 or lower S2—S3 , the strength of detrusor starts to return to normal values, allowing the patient to void.
The use of long-acting local anesthetics is related to a higher incidence of POUR. According to the distribution of local anesthetics in the cerebrospinal fluid, the concentration of the hyperbaric local anesthetics in the sacral segments S2—S3 is greater than that caused by an isobaric solution, suggesting that isobaric solutions a similar dose of a hyperbaric drug. In patients undergoing lumbar spine surgery, the incidence of POUR is lower when intrathecal local anesthetics are administered without opioids.
Several studies on animals and on humans have consistently shown that spinal opioids influence bladder functions and cause urinary retention. Reappearance of the micturition reflex corresponds with the return of the nociceptive response. Morphine decreased the urge to void to a lesser degree than sufentanil. These effects were dose-dependent, and the recovery time of the functions of the bladder was shorter with sufentanil than with morphine.
In a study conducted in subjects with spinal lesions up to the sacral region, intrathecal morphine reversed the urodynamic effects that the spinal lesion caused on bladder function. Intrathecal morphine has been shown to enhance bladder capacity by increasing detrusor contractions and decrease vesicosomatic reactions. Similar to intrathecal local anesthetic, epidural local anesthetics act on the sacral and lumbar nerve fibers, blocking the transmission of afferent and efferent nervous impulses from and to the bladder.
The onset and the duration of the block would depend on the pharmacokinetic properties of the local anesthetic used.
The incidence of POUR with epidural local anesthetics for inguinal herniorrhaphy has been shown to be lower than with spinal anesthesia. The urodynamic effects of epidural opioids have been studied extensively. The incidence of POUR after epidural opioids may also be related to the level at which opioids are injected. Administration of opioids in the lumbar epidural space is associated with higher rate of urinary retention compared to thoracic.
Detrusor strength starts to decrease within 5—15 min after 4 mg of epidural morphine, its maximum effect reached between 30 and min and lasting 10—15 h. The urodynamic effects are not dose-dependent as shown for intrathecal opioids. Different epidural opioids have different urodynamic effects depending on their pharmacokinetic properties and receptor selectivity. For similar reasons, the incidence of POUR was also found to be less with epidural buprenorphine as compared with epidural morphine.
Although it has been suggested that the dose of epidural opioid may influence the incidence of POUR, this has yet been not confirmed or corroborated in the literature.
Rucci et al. Micturition abnormalities were observed in all the groups, without significant differences, but the patients that received fentanyl needed catheterization. It is important to discuss potential side effects and subsequent management strategies with patients to avoid the discontinuation of an effective agent.
Patients should be given additional product-specific counseling information: Extended-release formulations should not be crushed or chewed. Transdermal formulations should be applied to clean, dry, intact skin in the appropriate location, as per product labeling.
The site of patch placement among applications should be rotated at least weekly. Gel formulations contain alcohol. The application of sunscreen should be avoided for 30 minutes before or after gel application, and showering should be avoided for 1 hour after use. Pharmacologic treatment for overflow incontinence aims to manage the underlying condition, which is usually BPH.
Agents such as tamsulosin may be appropriate in these cases, with or without other pharmacologic agents. Nonpharmacologic measures e. Mixed incontinence may require a combination of pharmacologic treatments, depending on the etiology e. Certain medications for other concomitant disease states can aggravate UI symptoms. If possible, the offending agent should be discontinued and an alternative agent selected. Regardless of the type of UI diagnosed, nonpharmacologic measures remain the first-line treatment.
Contemporary diagnosis of lower urinary tract dysfunction.
UI is a condition that can affect anyone, especially older women. There are many opportunities for pharmacists to improve the care of patients with UI. Pharmacists can play an important role in patient education on nonpharmacologic measures, which are recommended as first-line treatment for UI. If pharmacologic measures are warranted, the pharmacist should counsel the patient regarding the appropriate use of medications and potential side effects. Additionally, the pharmacist can make recommendations to help manage minor adverse effects in order to improve patient adherence to UI medications.
Urinary incontinence. Pharmacotherapy: A Pathophysiologic Approach.
Agency for Healthcare Research and Quality. Nonsurgical treatments for urinary incontinence in adult women: diagnosis and comparative effectiveness. Accessed June 9, Nitti VW. The prevalence of urinary incontinence. Rev Urol. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Pharmacotherapy in Primary Care. Lexi-Drugs Online.
Accessed May 17, Combination treatment with mirabegron and solifenacin in patients with overactive bladder: efficacy and safety results from a randomised, double-blind, dose-ranging, phase 2 study Symphony. Eur Urol.
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