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19. Overview of the Evaluation of Lower Urinary Tract Dysfunction (LUTD)
Keywords
BladderLower urinary tract dysfunctionEvaluationSymptomsQuestionnairesIntroduction
The vesicourethral unit comprises the bladder and urethra, working in co-operation to store and void urine. To obtain this physiological balance, a fully functional bladder (detrusor, urothelium), a normal urinary sphincter and a healthy urethra are necessary. A perfect coordination driven by the central and peripheral nervous system is also required.
Lower urinary tract systems
Storage symptoms | Voiding symptoms | Post void symptoms |
|---|---|---|
Frequency | Slow/splitting/intermittent stream | Feeling of incomplete emptying |
Urgency | Hesitancy | Post-micturition dribble |
Incontinence | Straining | |
Increased/reduced/ absent/painful bladder sensation | Terminal dribble | |
Nocturia |
Symptoms related to LUTD, named Lower Urinary Tract Symptoms (LUTS), are spontaneously identified as related to the urinary tract by the patient and can dramatically impact quality of life. A complete clinical evaluation (especially when the patient is seen for the first time or referred for an expert advice) is necessary to (1) correctly identify and label the LUTS, (2) evaluate the symptom intensity, bother and quality of life, (3) suspect the potential aetiology (LUTD), (4) rule out complications, red flags and emergency and finally (5) guide further investigations and propose an approach for LUTD management [4].
The present chapter presents the basic, standard and advanced aspects of practical clinical evaluation of LUTS through patient interview, clinical examination and clinical tests during a urological visit. Underlying clinical concepts, pathophysiology, specialized investigations and therapeutic options are discussed elsewhere.
First, clinical characterisation of each symptom and directly related clinical tests are presented. Then, general items of clinical evaluation (questionnaires, patient history, general tests, biology, imaging and urodynamics) are detailed with their potential roles and indications in LUTS evaluation.
Identification and Specific Evaluation of Storage and Voiding Symptoms
Storage Phase
The bladder is storing urine 99% of the time. During this phase, the bladder is filled with urine brought by the ureters. Urine transport is possible because of antegrade peristaltic waves, pushing the urine is the bladder. Decompensation may occur when bladder pressure exceeds 40 cm of water [5]. Thus, a correct compliance of the bladder wall is necessary for an adequate bladder filling without pressure increase. Compliance is calculated by dividing the volume variation (δV) by the change in detrusor pressure (δPdet). It is expressed in ml/cm H2O.
During filling, sensations through bladder afferences have to be normal (first sensation of filling, first desire to void, strong desire to void), non-painful, progressive and happening for physiological volumes.
Urine is also stored during the night, normally avoiding the symptom of being awaken by the need to pass urine (defining nocturia).
Lastly, the urine has to be kept inside the bladder, without involuntary loss of urine outside micturition (defining urinary incontinence) [6], or during the night (defining nocturnal enuresis).
Evaluation of Storage Symptoms during Patient Interview
Storage symptoms, including nocturia, represent the majority of patient complaints [7]. Those symptoms are also the most bothersome and impacting very much quality of life. They are identified during patient interview.
Lower urinary tract symptom terminology
Storage symptoms | |
|---|---|
Increased daytime frequency | The complaint by the patient who considers that he/she voids too often by day (term is equivalent to pollakiuria used in many countries). |
Nocturia | The complaint that the patient has to wake at night one or more times to void. |
Urgency | A sudden compelling desire to pass urine which is difficult to defer. |
Urinary incontinence (UI) | Any involuntary leakage of urine |
Stress urinary incontinence (SUI) | Involuntary leakage on effort or exertion, or coughing or sneezing |
Urge(ncy) urinary incontinence (UUI) | Involuntary leakage accompanied by or immediately preceded by urgency |
Mixed urinary incontinence (MUI) | Involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing |
Enuresis | Any involuntary loss of urine |
Nocturnal enuresis | Loss of urine occurring during sleep (involuntary symptom as opposed to nocturia which is a voluntary symptom) |
Continuous urinary incontinence | Continuous leakage of urine |
Other types of urinary incontinence | May be situational, for example incontinence during sexual intercourse, or giggle incontinence |
Bladder sensations during storage phase | |
Normal bladder sensation | Aware of bladder filling and increased sensation up to a strong desire to void |
Increased bladder sensation | Aware of an early and persistent desire to void |
Reduced bladder sensation | Aware of bladder filling but does not feel a definite desire to void |
Absent bladder sensation | No awareness of bladder filling or desire to void |
Nonspecific bladder sensation | No specific bladder sensation but may perceive bladder filling as abdominal fullness, or spasticity (most frequently seen in neurological patients) |
Voiding symptoms | |
Slow stream | The perception of reduced urine flow, usually compared to previous performance or in comparison to others |
Splitting or spraying | Description of the urine stream |
Hesitancy | Difficulty in initiating micturition, resulting in a delay in the onset of voiding after the individual is ready to pass urine |
Intermittent stream (intermittency) | Urine flow which stops and starts, on one or more occasions, during micturition |
Straining | The muscular effort used to either initiate, maintain, or improve the urinary stream |
Terminal dribbling | A prolonged final part of micturition, where the flow has slowed to a trickle/dribble |
Post micturition symptoms | |
Felling of incomplete emptying | A feeling experienced by the individual after passing urine |
Post micturition dribble | The involuntary loss of urine immediately after an individual has finished passing urine, usually after leaving the toilet in men or after rising from the toilet in women |
Other symptoms | |
Symptoms associated with sexual intercourse | e.g. dyspareunia, vaginal dryness, and incontinence (should be described as fully as possible—It is helpful to define urine leakage as: During penetration, during intercourse, or at orgasm) |
Symptoms associated with pelvic organ prolapse | e.g. “something coming down,” low backache, vaginal bulging sensation, and dragging sensation (may need to digitally replace the prolapse in order to defecate or micturate) |
Genital and lower urinary tract pain | Pain, discomfort and pressure may be related to bladder filling or voiding or may be felt after micturition, or even be continuous. The terms “strangury,” “bladder spasm,” and “dysuria” are difficult to define and of uncertain meeting and should not be used, unless a precise meaning is stated. Dysuria literally means “abnormal urination.” however, it is often incorrectly used to describe the stinging/ burning sensation characteristic of an urinary infection |
Painful bladder syndrome symptoms | |
Bladder pain syndrome/ painful bladder syndrome/ interstitial cystitis (BPS/PBS/IC) | Suprapubic pain related to bladder filling and associated with other lower urinary tract symptoms, usually increased frequency (but no urgency) (diagnosed only in the absence of UTI or other obvious pathology). This is a specific diagnosis usually confirmed by typical cystoscopic and histological features |
This terminology refers specifically to symptoms elicited in a history; subtly different definitions are in use in other specific scenarios, for example when using frequency/volume charts. More information on all of the terminology is available in “The Standardisation of Terminology in Lower Urinary Tract Function Report.”
Once symptoms have been identified, further clinical assessment is necessary to characterize the clinical picture.
Urgency, as the cornerstone of overactive bladder syndrome, is characterized by a sudden compel to pass urine that is difficult to defer. It has to be differentiated from pain, or normal filling sensation (strong desire to void) when the bladder is full. Many ways have been described to ask the right question to the patient and not be too suggestive to avoid overdiagnosis, and try to quantify the intensity of the symptom [8], including standardized questionnaires (see hereunder). Circumstances of urgency—if any—must be specified by the patient, especially precipitating factors (shower, hands in cold water, approaching home door, cold weather, stand up position, etc.).
Frequency and nocturia can be overestimated by the patient and are at best recorded on a bladder diary.
Incontinence is sorted among different subtypes and further characterized by pad test and clinical examination (as described thereafter). Types of incontinence diagnosed at the time of patient interview include (following ICS general definitions [6]):
Urinary stress incontinence: Urinary stress incontinence is the involuntary leakage of urine on effort or exertion or on sneezing or coughing. It occurs with a rise in intraabdominal pressure in the absence of detrusor overactivity. It is usually due to intrinsic urethral sphincter deficiency and/or hypermobility of the urethra.
Urgency urinary incontinence: Urgency incontinence occurs in the same time or just after an urgency. Warning time (evaluation the interval between the onset of urgency and the time of micturition or incontinence) will be assessed.
Postural urinary incontinence: Postural urinary incontinence is the involuntary leakage of urine caused by change of position like getting up or standing up.
Mixed urinary incontinence: There is an association of urge and stress urinary incontinence.
Circumstances of urinary incontinence may be difficult to specify for patients.
When several types of urinary incontinence coexist, the main complaint is alleged.
Nocturnal enuresis: Nocturnal enuresis means any leakage of urine during sleep.
Continuous incontinence Continuous urinary incontinence is the complaint of continuous leakage of urine. A severe intrinsic sphincter deficiency may occur continuous incontinence.
Insensible urinary incontinence Urinary incontinence is the complaint of involuntary leakage of urine without patient being aware of predisposing factors. In this case the patient is conscious about incontinence by being wet rather than feeling a leakage.
Coital incontinence: Patient complaint of involuntary leakage of urine during sexual intercourse. It can occur during sex or especially during orgasm (climaturia).
In case of extra-urethral incontinence, involuntary loss of urine is observed by an another external orifice. Congenital abnormality or fistula between bladder and vagina would be checked at physical examination (see under). A “color test” may be performed by the clinician: the bladder is filled with a coloured solution (methylene blue), and the catheter is left in place to block the urine flow. Any issue of blue fluid, notably through the vagina, can be ascertained.
Overflow incontinence is the involuntary loss of urine associated with overdistension of the bladder secondary to inefficient bladder emptying. The bladder is overfilled and empties only when the volume exceeds the anatomical capacity. Chronic retention is an important condition to consider in any patient with incontinence. A palpable bladder is an important item during the physical examination.
bladder disease (bladder tumour, stone, foreign body, fibrosis, radiation cystisis)
bladder outlet obstruction
abnormal bladder sensitivity (afferent pathway)
detrusor overactivity
neurological dysfunction (spinal cord injury, supra thamalamic dysfunction, peripheric nerve injury)
sphincter deficiency, urethral instability, urethral hypermobility
Nocturia can be due to reduced functional bladder capacity, 24 hr. polyuria, nocturnal polyuria, or sleep disturbances, as assessed by a bladder diary. Further causes are diagnosed by specific investigations (Table 19.2).
Frequency-Volume Chart (Bladder Diary)
To better assess storage symptoms, especially frequency and nocturia, a frequency– volume chart (FVC) is required. If possible, it is ideally obtained at the time of the consultation. Standard evaluation includes hours of voiding, symptoms at the time of voiding, episodes of incontinence (if any), and most importantly, the volume of each micturition. At the moment no standard method exist for ambulatory measurement of micturition volume, but some tools are under development (ultraprecise body mass measurement after and before voiding, connected penile cuffs, etc.). When adding pads weight evaluation, fluid intake, and recording of activities to a FVC, a complete “voiding diary” is obtained.
The FVC is usually recommended for a minimum of 3 days [9]. Seven days FVCs have been proposed through clinical research protocol but are barely used in clinical practice. The duration of the FVC/bladder diary needs to be long enough to avoid sampling errors, but short enough to avoid non-compliance. There is no strict rule for the timing of FVC completion, but it should at best reflect the usual conditions of the patient (working hours, holidays, week-end, etc.).
The primary goal of FVC is to collect objective data about frequency, micturitions during hours of sleep, as well as the amount of urine per micturition (real life functional bladder capacity), and total volume of urine per 24 hours. FVC is the cornerstone of storage symptoms evaluation, and may be also useful during follow-up. Here are reviewed the main abnormalities that can be found on a FVC.
24 Hours Urine Production
A correctly filled FVC results in the opportunity to assess the total urine production during 24 h. Polyuria, defined by more than 40 mL/kg urine output over a 24-hour period [10], might explain a number of storage symptoms because the functional bladder capacity is often reached during night and day. Ruling out a polyuria and adapting fluid intake may thus decrease, at no cost, the intensity of storage symptoms. In case of polyuria, polydipsia may be suspected, potentially related to extra-urological diseases.
In some other cases, reduced urine production may be seen (e.g. less than 1 L per day). This reduced voiding volume per day may be due to a voluntary reduction of fluid intake by the patient to minimize frequency, nocturia or urgency episodes.
Daytime Urinary Frequency and Functional Bladder Capacity
Increase daytime urinary frequency (out of a context of polyuria) occurs when functional bladder capacity is weak. The average voiding volume reflects the functional bladder capacity. The threshold usually admitted for frequency is 8 voids per day, with intervals of more than 2 h between micturitions, but the symptom bother is at least as important.
A reduced functional bladder capacity may be interpreted in line with the symptoms leading to voids (normal sensation or urgency). Increased frequency may be associated or not with nocturia.
Nocturia
24 h polyuria (see above), defined by adding all voided volumes during 24 h.
Nocturnal polyuria, defined by an excess of urine production during night time. The so-called nocturnal polyuria index is the percentage of urine produced during the night, obtained by dividing the amount of urine produced at night (adding all nocturia episodes + first morning void) by the 24 h urine volume. Above a limit of 33%, nocturnal polyuria can be ascertained. This threshold has been largely debated without clear consensus in the literature, because this threshold may vary with age [11]. Identification of nocturnal polyuria is very important because underlying causes (heart failure, renal impairment, obstructive sleep apnea) are often extra urologic and need specific investigations not to be missed [4, 11].
Pad Testing
Pad testing is a simple, non-invasive objective method for detecting and quantifying urine leakage. It is considered as a basic item for evaluation of incontinence. The principle of the test is to wear a pad and have normal activities, approaching the usual daily activities of the patient.
To obtain a reliable pad –test result (especially in subjects with variable or intermittent urinary incontinence), the test should be done over a long period of time. For instance, home pad tests lasting 24–48 h are superior to 1 h test in detecting urinary incontinence. Standard test are thus usually done for 3 days. One hour past test, as formalized by the ICS, can be used in clinical protocols [6]. In this ICS-Pad test, the upper limit of weight increase for the 1-hr test in continent women is 1.4 g.
The normal upper limit in a 24 h test is 2–4 g, accounting for sweating or vaginal discharge especially in women.
Voiding Phase
Voiding phase represent less than 1% of time. Normal voiding occurs on demand, promptly, with normally strong continuous flow and complete emptying without pain.
Impaired bladder contractility
Failure of urethral sphincter relaxation
Bladder outlet obstruction, whatever the cause.
Some recent papers have identified potential clinical signs in favour of underactive detrusor rather than (or associated to) obstruction, with urodynamics being the gold standard. Basic evaluation, described hereunder, is the cornerstone of initial patient work-up before more invasive tests.
Identification of Voiding Symptoms during Patient Interview
Hesitancy is the term used when an individual describes difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine.
Straining to void describes the muscular effort (abdominal or suprapubic pressure, Valsalva manoeuvers) used to either initiate, maintain or improve the urinary stream.
Position dependant micturition is the term used when the individual has to void in abnormal position (bent forward, tilted behind, half sat) to initiate, maintain or improve the micturition.
Dysuria is the term used when the individual describes pain when is voiding.
Slow stream is reported by the individual as his or her perception of reduced urine flow, usually compared to previous performance or in comparison to others.
Splitting or spraying of the urine stream may be reported.
Intermittent stream (Intermittency) is the term used when the individual describes urine flow which stops and starts, on one or more occasions, during micturition.
Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/ dribble.
Urinary retention is the term used when an individual complaints any voluntary micturition.
Feeling of incomplete emptying is a self-explanatory term for a feeling experienced by the individual after passing urine.
Post micturition dribble is the term used when an individual describes the involuntary loss of urine immediately after he or she has finished passing urine, usually after leaving the toilet in men, or after rising from the toilet in women.
Need to immediately re-void: the individual complaints a new desire to void just after voiding
The goal of patient interview is to identify and characterize at best what is the patient complain. However, this will always remain subjective and the systematic next step is the uroflowmetry, which is the reference tool for obtaining an objective evaluation of bladder emptying.
Uroflowmetry
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