Abstract Background The clinical diagnosis of detrusor underactivity (DU) is hampered by the need for invasive pressure flow studies (PFS) in combination with a lack of knowledge of the associated ...signs and symptoms. This has contributed to a lack of awareness of DU and underactive bladder, and to the assumption that symptoms are always due to bladder outlet obstruction (BOO). Objective To investigate the signs and symptoms recorded in a large urodynamic database of patients who met the diagnoses of DU, BOO, and normal, to identify the clinical features associated with DU. Design, setting, and participants From the database of 28 282 adult PFS records, 1788 patients were classified into: (1) those with DU without BOO; (2) those with BOO without DU; and (3) those with normal PFS. Results Patients with DU reported a statistically significantly higher occurrence of decreased and/or interrupted urinary stream, hesitancy, feeling of incomplete bladder emptying, palpable bladder, and absent and/or decreased sensation compared with patients with normal PFS. Other differences were found between men with DU and BOO, and between women with DU and normal PFS. Conclusions There are signs and symptoms that can distinguish DU patients from patients with normal PFS and further distinguish between DU and BOO, which is traditionally invasively diagnosed. This is a first step to better understand the clinical presentation of DU patients, is consistent with the recent underactive bladder working definition, and justifies further exploration of the signs and symptoms of DU. Patient summary The clinical diagnosis of detrusor underactivity is hampered by the need for invasive urodynamics in combination with a lack of knowledge of the associated signs and symptoms. This study has shown that there are signs and symptoms that can distinguish men and women patients with DU from patients with either normal urodynamic studies or with BOO.
Study Type – Symptom prevalence (prospective cohort)
Level of Evidence 1b
What’s known on the subject? and What does the study add?
Few prevalence studies used current ICS LUTS symptom definitions ...and to our knowledge no studies exist that estimate total worldwide prevalence of reported LUTS symptoms. One of the primary goals of this analysis was to estimate current and future worldwide prevalence of LUTS among adults. Our estimation model suggests that LUTS are highly prevalent worldwide, with an increasing burden predicted over time.
OBJECTIVE
• To estimate and predict worldwide and regional prevalence of lower urinary tract symptoms (LUTS), overactive bladder (OAB), urinary incontinence (UI) and LUTS suggestive of bladder outlet obstruction (LUTS/BOO) in 2008, 2013 and 2018 based on current International Continence Society symptom definitions in adults aged ≥20 years.
PATIENTS AND METHODS
• Numbers and prevalence of individuals affected by each condition were calculated with an estimation model using gender‐ and age‐stratified prevalence data from the EPIC study along with gender‐ and age‐stratified worldwide and regional population estimates from the US Census Bureau International Data Base.
RESULTS
• An estimated 45.2%, 10.7%, 8.2% and 21.5% of the 2008 worldwide population (4.3 billion) was affected by at least one LUTS, OAB, UI and LUTS/BOO, respectively. By 2018, an estimated 2.3 billion individuals will be affected by at least one LUTS (18.4% increase), 546 million by OAB (20.1%), 423 million by UI (21.6%) and 1.1 billion by LUTS/BOO (18.5%).
• The regional burden of these conditions is estimated to be greatest in Asia, with numbers of affected individuals expected to increase most in the developing regions of Africa (30.1–31.1% increase across conditions, 2008–2018), South America (20.5–24.7%) and Asia (19.7–24.4%).
CONCLUSIONS
• This model suggests that LUTS, OAB, UI and LUTS/BOO are highly prevalent conditions worldwide. Numbers of affected individuals are projected to increase with time, with the greatest increase in burden anticipated in developing regions.
• There are important worldwide public‐health and clinical management implications to be considered over the next decade to effectively prevent and manage these conditions.
Objective
To develop a clear understanding of the relationship between severity of urinary incontinence (UI) and health‐related quality of life (HRQoL) and mental well‐being in a population of women ...of working age with the requisite demands of a busy, active life.
Subjects and Methods
A survey of women with UI, aged between 45 and 60 years, was conducted via the internet in the UK, France, Germany and USA between 1 and 30 September 2013. Validated outcome measures were used to assess symptoms and the impact of UI on activities of daily life, HRQoL, and mental well‐being: The International Consultation on Incontinence Modular Questionnaire Short Form; (ICIQ‐UI Short Form); the ICIQ‐Lower Urinary Tract Symptoms Quality of Life; (ICIQ‐LUTSqol); the Warwick‐Edinburgh Mental Well‐being Scale (WEMWBS). The relationships between UI, HRQoL and mental well‐being were analysed using analyses of variance and regression.
Results
The survey was completed by 1203 women with UI with an average age of 52.7 years. Based upon responses to the ICIQ‐UI Short Form about the amount of urine that leaks, respondents were categorised as having light (n = 1023, 87%), medium (n = 134, 11%), or severe UI (n = 20, 2%). The scores on the ICIQ‐UI Short Form increased with severity mean (sd) scores: light UI 7.9 (3.4), medium UI 13.8 (2.9), and severe UI 18.3 (3.9), as did the impact on HRQoL, assessed using the ICIQ‐LUTSqol mean (sd) scores: light UI 30.6 (7.3), medium UI 41.0 (11.2), and severe UI 56.9 (17.6). Mental well‐being decreased with severity of UI, the mean (se) WEMWBS scores were: light UI 48.3 (10.1), medium UI 44.5 (9.5), and severe UI 39.9 (16.2).
Conclusion
In women with UI, aged 45–60 years, UI symptoms directly affect HRQoL, which subsequently impacts negatively on mental well‐being.
From time to time we publish a full review of drugs that are available for the treatment of common conditions. In this issue, the review is written by two of the leading authorities in the world, ...Paul Abrams and Karl‐Erik Andersson, on the topic of overactive bladder and antimuscarinic agents. This in‐depth review covers the entire range of questions that might be asked about this common area of interest.
Overactive bladder (OAB) is a syndrome characterized by urinary urgency, with or without urgency urinary incontinence, usually with frequency and nocturia. OAB symptoms are often associated with detrusor overactivity (DO). Like OAB symptoms, the prevalence of DO increases with age and can have a neurogenic and/or myogenic aetiology. Bladder outlet obstruction can be a contributing factor in DO, possibly through cholinergic denervation of the detrusor and supersensitivity of muscarinic receptors to acetylcholine, although the prevalence of OAB is similar in men and women across age groups. Acetylcholine is the primary contractile neurotransmitter in the human detrusor, and antimuscarinics exert their effects on OAB/DO by inhibiting the binding of acetylcholine at muscarinic receptors M2 and M3 on detrusor smooth muscle cells and other structures within the bladder wall. Worldwide, there are six antimuscarinic drugs currently marketed for the treatment of OAB: oxybutynin, tolterodine, propiverine, trospium, darifenacin, and solifenacin. Each has demonstrated efficacy for the treatment of OAB symptoms, but their pharmacokinetic and adverse event profiles differ somewhat due to structural differences (tertiary vs quaternary amines), muscarinic receptor subtype selectivities, and organ selectivities. Antimuscarinics are generally well tolerated, even in special populations (e.g. men with bladder outlet obstruction, elderly patients, children). The most frequently reported adverse events in clinical studies of antimuscarinics are dry mouth, constipation, headache, and blurred vision; few patients withdraw from clinical trials because of adverse events.
Development of an antimuscarinic with functional selectivity for the bladder would reduce the occurrence of antimuscarinic adverse events. The therapeutic potential of several other agents, such as α3‐adrenoceptor agonists, purinergic receptor antagonists, phosphodiesterase inhibitors, neurokinin‐1 receptor antagonists, opioids, and Rho‐kinase inhibitors, is also under investigation for the treatment of OAB.
In 1998 the first ICI was held in Monaco, sponsored by WHO and organized by the International Continence Society and International Consultation on Urological Diseases. The Scientific Committee ...recognized the need to develop a universally applicable questionnaire for wide application across international populations in clinical practice and research to assess urinary incontinence, facilitating the comparison of findings from different settings and studies, in a manner similar to the International Prostate Symptom Score.
An Advisory Board was formed to steer the development of the ICIQ and a decision was made to extend the concept further, developing the ICIQ Modular Questionnaire.
The first module developed was the ICIQ Short Form Questionnaire for urinary incontinence. ICIQ modules have been developed or adapted for urinary tract symptoms and they are being developed for vaginal and lower bowel symptoms. Additional sexual matters and quality of life modules will become available for each condition area. Modules to assess patient satisfaction are expected to be of particular use for assessing treatment effectiveness. The ICIQ Advisory Board recently proposed the development of the ICIQ website, which is anticipated to be crucial for informing potential users of the phase of development of all ICIQ modules.
The ICIQ can offer a full range of urinary tract symptom questionnaires. The website will aim to attract collaborators committed to the concept of this internationally accepted modular questionnaire who are willing to help with its development.
Estimate the prevalence of urinary incontinence (UI), overactive bladder (OAB), and other lower urinary tract symptoms (LUTS) among men and women in five countries using the 2002 International ...Continence Society (ICS) definitions.
This population-based, cross-sectional survey was conducted between April and December 2005 in Canada, Germany, Italy, Sweden, and the United Kingdom using computer-assisted telephone interviews. A random sample of men and women aged >/= 18 yr residing in the five countries and who were representative of the general populations in these countries was selected. Using 2002 ICS definitions, the prevalence estimates of storage, voiding, and postmicturition LUTS were calculated. Data were stratified by country, age cohort, and gender.
A total of 19,165 individuals agreed to participate; 64.3% reported at least one LUTS. Nocturia was the most prevalent LUTS (men, 48.6%; women, 54.5%). The prevalence of storage LUTS (men, 51.3%; women, 59.2%) was greater than that for voiding (men, 25.7%; women, 19.5%) and postmicturition (men, 16.9%; women, 14.2%) symptoms combined. The overall prevalence of OAB was 11.8%; rates were similar in men and women and increased with age. OAB was more prevalent than all types of UI combined (9.4%).
The EPIC study is the largest population-based survey to assess prevalence rates of OAB, UI, and other LUTS in five countries. To date, this is the first study to evaluate these symptoms simultaneously using the 2002 ICS definitions. The results indicate that these symptoms are highly prevalent in the countries surveyed.
Abstract Context Nocturia is a common urologic symptom that has been covered in a variety of reported studies in the literature but is not specifically covered in current guidelines. Objective To ...comprehensively review the literature pertaining to the definition, etiologies, and consequences of nocturia and assess the evidence supporting the use of conservative medical and interventional therapy. Evidence acquisition A literature search was conducted using the keyword nocturia , restricted to articles in the English language, after 2000 and before April 2012, in PubMed/Medline, Embase, Scopus, Web of Science, and Cochrane Library databases. Regarding treatment modalities, studies were included only if nocturia was a primary end point and if the studies were designed as randomized controlled trials without limit of date. When suitable, a meta-analysis was conducted. Papers covering treatment options for nocturia specifically related to nonurologic conditions were excluded. Evidence synthesis Nocturia is still defined as the symptom of wakening from sleep once or more often to void. The prevalence is high in both genders and increases with age. Frequency–volume charts, which are the pivotal tool of clinical assessment, detect 24-h polyuria, nocturnal polyuria (NP), or reduced nocturnal bladder capacity and help to target specific nonurologic etiologies. Nocturia is a morbid condition that significantly affects quality of life and increases mortality. Besides behavioral measures, validated treatment options include oral desmopressin, which is superior to placebo in treating NP. While the level of evidence for desmopressin is high, limited data support the use of α1 -blockers and antimuscarinics; however, only rarely has nocturia been a primary end point when studying these drug classes, and studies have not consistently controlled for the effect of NP. Conclusions Our knowledge of nocturia, its etiology, and its management has substantially improved in recent years. The evidence available on the management of nocturia remains limited; contributory factors include (1) the complexity of associated conditions, (2) the underuse of objective evaluation tools, and (3) the lack of specific focus on nocturia in clinical trials.
Introduction
Patients with nocturia have to face many hurdles before being diagnosed and treated properly. The aim of this paper is to: summarize the nocturia patient pathway, explore how nocturia is ...diagnosed and treated in the real world and use the Delphi method to develop a practical algorithm with a focus on what steps need to be taken before prescribing desmopressin.
Methods
Evidence comes from existing guidelines (Google, PubMed), International Consultation on Incontinence‐Research Society (ICI‐RS) 2017, prescribing information and a Delphi panel (3 rounds). The International Continence Society initiated this study, the authors represent the ICI‐RS, European Association of Urology, and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU).
Results
Diagnostic packages: consensus on, history taking for all causalities, intake diary (fluid, food) and bladder diary, not for its duration. Pelvic (women) or rectal (men) examination, prostate‐specific antigen, serum sodium check (SSC), renal function, endocrine screening: when judged necessary. Timing or empty stomach when SSC is not important. Therapeutic packages: the safe candidates for desmopressin can be phenotyped as no polydipsia, heart/kidney failure, severe leg edema or obstructive sleep apnea syndrome. Lifestyle interventions may be useful. Initiating desmopressin: risk management consensus on three clinical pictures.
Follow‐up of desmopressin therapy: there was consensus on SSC day 3 to 7, and at 1 month. Stop therapy if SSC is <130 mmol/L regardless of symptoms. Stop if SSC is 130 to 135 mmol/L with symptoms of hyponatremia.
Conclusion
A summary of the nocturia patient pathway across different medical specialists is useful in the visualization and phenotyping of patients for diagnosis and therapy. By summarizing basic knowledge of desmopressin, we aim to ease its initiation and shorten the patient journey for nocturia.
Aims
Lower urinary tract symptoms (LUTS) can be classified into symptom syndromes based on which symptoms are predominant. Overactive bladder (OAB) syndrome, a storage dysfunction, and underactive ...bladder (UAB) syndrome, a voiding dysfunction, are common syndromes, which urodynamic tests may show to be caused by detrusor overactivity (DO) and detrusor underactivity (DU), but can also be associated with other urethro‐vesical dysfunctions. Sometimes OAB and UAB can coexist in the same patient and, if so, need a specific approach beyond treatment of the single and apparently opposing syndromes.
Methods
During its 2019 meeting in Bristol, the International Consultation on Incontinence Research Society held a literature review and expert consensus discussion focused on the emerging awareness of the coexisting overactive–underactive bladder (COUB).
Results
The consensus considered whether COUB is the combination of OAB and UAB syndromes, or a real unique clinical syndrome in the same patient, possibly with a common etiology. Definitions, pathophysiology, diagnosis, and treatment were discussed, and high‐priority research questions were identified.
Conclusions
COUB (with or without urodynamic evidence of DO and DU) may be considered a real clinical syndrome, because it differs from single OAB and UAB, and may not be the combination of both syndromes. Urodynamic tests may be necessary in unclear cases or in cases not responding to initial treatment of the most troublesome symptoms. It is pivotal to define the evolution of the syndrome and the characteristic population, and to recognize predictive or phenotyping factors to develop a specific approach and adequate outcome measures.
