Lower urinary tract symptoms

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Chapter 17 Lower urinary tract symptoms

Judith Goh

Urinary incontinence is the complaint of involuntary urinary leakage. Lower urinary tract symptoms include complaints regarding urinary storage, voiding or postmicturition symptoms. When a woman presents with urinary symptoms, a detailed history on lower urinary tract symptoms is required.

History

• daytime frequency (normally up to 8 times a day): increased frequency is associated with increased fluid intake, detrusor overactivity, poor bladder compliance or increase in bladder sensation
• nocturia: waking up to pass urine
• urinary urgency: sudden desire to pass urine, which is difficult to defer
• urinary stress incontinence: involuntary leakage on effort or exertion
• urinary urge incontinence: involuntary leakage accompanied by urgency

• may present with frequent losses or large leakage
• commonly associated with ‘triggers’ causing urgency and incontinence (e.g. turning on taps, coming home with ‘key-in-the-door’)

• continuous leakage
• voiding problems

• slow stream
• straining to void: effort required to initiate, maintain or improve urinary flow
• intermittent flow
• hesitancy: difficulty in initiating micturition

• postmicturition

• sensation of incomplete emptying
• postvoid dribble: leaking after voiding (e.g. when standing from the toilet)

• other urinary history

• dysuria, haematuria, previous urinary tract infections
• suprapubic pain
• coital incontinence

• other history

• constipation
• caffeine intake
• symptoms of prolapse: needing to reduce the prolapse to void
• previous gynaecological/urological procedures

Examination

A physical examination is performed to exclude transient causes and to evaluate other disease and functional ability.

• general, weight
• vulva (excoriation or urine dermatitis)
• gynaecological, vaginal prolapse, vaginal atrophy, urine in vagina
• local neurological
• urethra

• urethral diverticulum, scarring around urethra and anterior vaginal wall
• mobility of urethra
• cough test and/or reduce prolapse and ask the woman to cough to assess for urinary stress incontinence

Investigation

This would depend on the history and examination.

• bladder diary

• very useful tool
• over a 2–3 day period, the woman is asked to record the times of micturition and her voided volumes, together with symptoms (e.g. urgency, incontinence)
• fluid intake is also recorded

• urinalysis and culture, cytology
• postvoid residual volume
• blood sugar, renal function
• dye test: if a urinary tract fistula is suspected

Further evaluation

Further evaluation includes urodynamics assessment, cystoscopy and imaging. Criteria for further evaluation include uncertain diagnosis, failure of response to initial therapy, consideration of surgical intervention and suspicion of other pathology.

Urodynamic assessment

The tests are designed to determine the functional status of the urinary bladder and urethra. The main components of urodynamics assessment are uroflowmetry, cystometry and urethral closure pressure/Valsalva leak point pressure.

• Uroflowmetry is a timed measure of voided urine volume.

• a simple and non-invasive tool
• cannot distinguish between obstruction and detrusor weakness as cause of voiding dysfunction without simultaneous measurement of detrusor function

• Cystometry is a test of detrusor function consisting of an observation and/or recording of the pressure/volume relationship during bladder filling.
• Maximal urethral closure pressure is the highest pressure, relative to bladder pressure, generated along the functional length of the urethra.
• Valsalva leak point pressure is the intravesical pressure at which urinary leakage occurs due to an increase in intra-abdominal pressure and in the absence of detrusor contraction.

Common causes of urinary incontinence

• urodynamic stress incontinence
• urge incontinence

• idiopathic detrusor overactivity (detrusor instability)
• neurogenic detrusor overactivity (detrusor hyperreflexia)

• mixed incontinence (combined stress and urge)
• overflow incontinence: atonic detrusor, impaired bladder compliance
• extraurethral incontinence: genito-urinary fistula, urethral diverticulum, congenital abnormality
• functional disorders: cognitive impairment, physical disorder, psychological
• reversible causes (temporary causes)

• conditions affecting lower urinary tract: infection, atrophy, constipation
• drugs, diuretics, caffeine, alcohol
• increased urine production: hyperglycaemia, excessive fluids
• impaired mobility

Treatment of urinary incontinence

Aims are to:

• determine cause of incontinence
• detect and treat related urinary tract pathology
• evaluate the woman and available resources

The extent and interpretation of evaluation must be tailored to the individual. A multidisciplinary team approach optimises outcomes. Not all detected conditions can be cured and simple interventions may be effective even in the absence of a diagnosis. Many women with urinary incontinence develop undesirable bladder habits, which often exacerbate the problem and/or provoke other urinary symptoms (e.g. ‘going just in case’, voiding too often, reducing oral fluids). There is evidence to suggest that in women with mixed incontinence, detrusor overactivity should be treated prior to continence surgery, as this optimises overall outcomes.

In Australia, resources are available to women, including government-funded or subsidised schemes such as home assessments and continence products. The Continence Foundation of Australia provides a 24-hour helpline for men and women with urinary and faecal incontinence.

Overactive bladder

• overactive bladder is a symptom complex: urgency with or without urge incontinence, usually associated with frequency and nocturia
• detrusor overactivity

• a urodynamic diagnosis: involuntary detrusor pressure rise during filling/cystometrogram, which may be spontaneous or provoked
• causes include neurogenic, outflow obstruction, ageing and idiopathic (most common)

• overactive bladder survey in Europe and USA: about 17% of women with symptoms suggestive of overactive bladder; increasing prevalence with increasing age

Overactive bladder and idiopathic detrusor overactivity

The mainstay of treatment is non-surgical.

• initial management (multidisciplinary approach)

• exclude other causes (e.g. infection, voiding dysfunction, neurological)
• bladder diary
• bladder training, pelvic floor rehabilitation
• treat constipation, weight loss, reduce/avoid caffeine

• pharmacological

• major portion of neurohumoral stimulus for physiological bladder contraction is acetylcholine-induced stimulation of postganglionic parasympathetic cholinergic receptor sites on bladder smooth muscle
• anticholinergic drugs: contraindicated in closed-angle glaucoma (availability limited in Australia)

— oxybutynin: oral or patch
— solifenacin, darifenacin, tolterodine

• tricyclic antidepressants (have anticholinergic effects): imipramine, amitriptyline
• oestrogen: topical

• others

• peripheral nerve stimulation

• surgical

• intravesical botox injection
• sacral nerve stimulator implant
• augmentation cystoplasty, diversion

Urodynamic stress incontinence

Conservative management

• multidisciplinary approach
• treat overactive bladder symptoms
• pelvic floor rehabilitation
• vaginal/urethral devices for urinary incontinence

Surgery

There are over 100 described surgical procedures for the management of urodynamic stress incontinence. Common complications of these procedures include voiding difficulty, injury to lower urinary tract, infection, denovo overactive bladder symptoms and failure to treat the stress incontinence. Better results have been documented for the slings and colposuspension, with an approximately 85% success rate. Commonly performed procedures today are: slings (mid-urethral, pubo-vaginal); retropubic urethropexy (Burch colposuspension, Marshall-Marshetti-Krantz (MMK)); and urethral bulking agent.

Slings

• Traditional slings are placed at the urethro-vesical junction.
• In the mid-1990s the mid-urethral sling was described, which allowed minimally invasive surgery, reduced hospital stays and a quicker return to daily activities, without a reduction in success rates.
• Slings are made of fascia (autologous, human donor or xenographs) or synthetic mesh (e.g. polypropylene). When synthetic mesh is to be used, current evidence recommends a macroporous, monofilamentous mesh. This reduces the risk of mesh extrusion/erosion and infection.
• Mid-urethral slings may be placed in the retropubic space (first generation) or through the obturator foramen (second generation). The third-generation slings are ‘exit-less’.

Retropubic urethropexy

• The Burch colposuspension ‘hitches’ the paravaginal tissue to the iliopectineal ligament, whereas the MMK sutures are placed into the periosteum of the posterior part of the pubic symphysis.
• Colposuspension may be performed laparoscopically or via a laparotomy.

Urethral bulking agent

• This involves periurethral or transurethral injection of a bulking agent, under endoscopic control, imaging or using an introducer.
• Materials used as a bulking agent include bovine collagen, silicone microparticles, Teflon and autologous material (e.g. fat).
• As a primary procedure, the success rates are lower (about 50%).
• Advantages include minimal anaesthesia/analgesia, ability to redo or ‘top-up’.

Further reading and resources

Abrams P., Cardozo L., Fall M., et al. Standardisation of terminology of lower urinary tract function. Neurourology Urodynamics. 2002;21:167-178.

Continence Foundation of Australia Helpline: 1800 330 066

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Chapter 17 Lower urinary tract symptoms

Judith Goh

Urinary incontinence is the complaint of involuntary urinary leakage. Lower urinary tract symptoms include complaints regarding urinary storage, voiding or postmicturition symptoms. When a woman presents with urinary symptoms, a detailed history on lower urinary tract symptoms is required.

History

• daytime frequency (normally up to 8 times a day): increased frequency is associated with increased fluid intake, detrusor overactivity, poor bladder compliance or increase in bladder sensation
• nocturia: waking up to pass urine
• urinary urgency: sudden desire to pass urine, which is difficult to defer
• urinary stress incontinence: involuntary leakage on effort or exertion
• urinary urge incontinence: involuntary leakage accompanied by urgency

• may present with frequent losses or large leakage
• commonly associated with ‘triggers’ causing urgency and incontinence (e.g. turning on taps, coming home with ‘key-in-the-door’)

• continuous leakage
• voiding problems

• slow stream
• straining to void: effort required to initiate, maintain or improve urinary flow
• intermittent flow
• hesitancy: difficulty in initiating micturition

• postmicturition

• sensation of incomplete emptying
• postvoid dribble: leaking after voiding (e.g. when standing from the toilet)

• other urinary history

• dysuria, haematuria, previous urinary tract infections
• suprapubic pain
• coital incontinence

• other history

• constipation
• caffeine intake
• symptoms of prolapse: needing to reduce the prolapse to void
• previous gynaecological/urological procedures

Examination

A physical examination is performed to exclude transient causes and to evaluate other disease and functional ability.

• general, weight
• vulva (excoriation or urine dermatitis)
• gynaecological, vaginal prolapse, vaginal atrophy, urine in vagina
• local neurological
• urethra

• urethral diverticulum, scarring around urethra and anterior vaginal wall
• mobility of urethra
• cough test and/or reduce prolapse and ask the woman to cough to assess for urinary stress incontinence

Investigation

This would depend on the history and examination.

• bladder diary

• very useful tool
• over a 2–3 day period, the woman is asked to record the times of micturition and her voided volumes, together with symptoms (e.g. urgency, incontinence)
• fluid intake is also recorded

• urinalysis and culture, cytology
• postvoid residual volume
• blood sugar, renal function
• dye test: if a urinary tract fistula is suspected

Further evaluation

Further evaluation includes urodynamics assessment, cystoscopy and imaging. Criteria for further evaluation include uncertain diagnosis, failure of response to initial therapy, consideration of surgical intervention and suspicion of other pathology.

Urodynamic assessment

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