Reduced/absent bladder sensation
Editor: Kevin Rademakers, date of last amendment 04.06.2015

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Current definitions and explanatory notes: At present, reduced bladder sensation is defined when the individual is aware of bladder filling but does not feel a definite desire to void (1). In addition, Haylen et al. defined diminished bladder sensation as the definite desire to void that occurs later to that previously experienced despite an awareness that the bladder is filling (2). Absent bladder sensation has been defined as no sensation of bladder filling and/or desire to void (1, 2). Both definitions reduced/diminished bladder sensation are only defined by the means of what we have determined as ‘normal bladder filling sensation’. So what is normal bladder sensation? According to the latest terminology document it is called normal sensation when the individual is aware of bladder filling and increased sensation up to a strong desire to void (1). Reduced and/or absent bladder sensation may be of upmost importance in specific voiding dysfunctions. A recent editorial paper of Chapple and colleagues included reduced bladder sensation in the proposed Underactive Bladder working hypothesis (3).

Mechanisms: Work from Smith and colleagues suggests reduced sensation is related to impaired contractility (4). Unpublished data from Rademakers et al. show that the presence of bladder filling sensation in patients who are having a urinary retention is predictive for contractions on ambulatory-UDS in these patients (correlation coefficient (ρ) of -0.723).These results suggest that by the use of additional sensory information during conventional-UDS solely, true bladder acontractility can be confirmed in a more accurate way. Particularly in the subgroup of patients with a complete urinary retention this information will help to predict true acontractility, without the need of performing an ambulatory urodynamic study. In case bladder sensation is present in this patient group an ambulatory-UDS may not be necessary. However, in patients with a urinary retention, without any bladder sensation during conventional-UDS, clinicians have strong arguments to perform an ambulatory-UDS. Both of the abovementioned studies implicate the need of adequate sensory information as one of the requirements for appropriate contractility. Diminished or absent bladder sensation can either be caused by altered afferent firing or central processing of the signals in the periaquaductal gray (PAG) an pontine micturition centre (PMC). The latter might be influenced by signal suppression caused by neocortical activation.


Evaluation of filling/bladder sensation: Which tools are useful to determine bladder sensation; can we use urodynamics or only the sensation-related bladder diary (SRBD)? Ideally, non-invasive sensation related bladder diaries (SRBD) should be used (5). However, the disadvantage of an SRBD would be the absence of the urodynamic traces (6). The in-hospital, non-physiological situation and dependence on the urodynamic staff to annotate the different kind of sensations are clear limitations of urodynamic sensory function assessment (7). This could limit the value of using the exact volumes at which different filling sensations are present. Despite the existing limitations, several recent studies confirmed the tolerability, reliability and reproducibility of urodynamic filling sensation (8-10).

Perspectives and controversies: Studies with regard to bladder sensation has mainly been focused on increased sensation. In contrast, reduced or absent bladder filling sensation is a rather unexplored topic. Therefore, several basic question still remain unanswered, such as:

- ‘What is the clinical importance of absent bladder sensation? And is it related to any potential clinical phenotype?’

- ‘Can we more strictly define diminished bladder sensation? And if so, do we need additional diagnostic tools to further optimise diagnostic work-up to define patients with a diminished bladder sensation.’

- ‘Is diminished/absent bladder sensation a process we still can reverse? Can we influence bladder sensation and herewith improve voiding function in patients with diminished/absent sensation and deteriorated voiding function?

These rather basic question will become important with the increasing amount of research in the field of voiding dysfunction. Specifically as there are currently early stage developments in therapeutic compounds for improvement of voiding function (11, 12). With these developments pre- and post-treatment bladder sensation evaluation might also be considered and of equal importance besides the objective improvement in voiding function.


REFERENCES
1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-78. PubMed PMID: 11857671. Epub 2002/02/22. eng.
2. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20. PubMed PMID: 19941278. Epub 2009/11/27. eng.
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11. Matsuya H, Otsuki T, Kida J, Wakamatsu D, Okada H, Sekido N. PD7-01 ONO-8055, A noverland ptent prostanoid EP2 and EP3 receptor dual agonist, improves voiding dysfunction in a monkey underactive bladder model. The Journal of Urology. 2015;193(4):e184-e5.
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