Underactive bladder – Really a problem or the new disease created by the industry?
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underactive bladder janemeijlink janemeijlink 3 34 Aug 31, 2017 by jennyics jennyics


Editor: Dr Kevin Rademakers
June 2017

Lower urinary tract symptoms (LUTS) can be caused by various conditions. Amongst this heterogeneous group of conditions, detrusor underactivity (DU) is one of the causes for voiding LUTS (4). DU is often hidden behind other clinical phenotypes such as bladder outlet obstruction (BOO) or dysfunctional voiding; it may also coincide with the presence of urinary tract infections (UTIs) or urinary incontinence. Symptomatology includes prolonged voiding time, altered bladder filling sensation, (feeling of) post-void residual urine and/or slow urinary stream. Acute urinary retention (AUR) - as an extreme clinical presentation of DU - has a low incidence in young men with an incidence of 0.2 per 1000 man-years (6). However, the incidence increases with age and the debilitating effect of catheterisation may impact a patient’s quality of life (6-10).
The original definition on detrusor underactivity (DU) was written in the year 2002 (1). In addition to the ICS definition of DU, an ICS working group has proposed in the year 2015 a working definition for a more clinical approach of the topic in order to enable screening of patients based on symptoms and signs rather than pressure-flow measurement. This Underactive Bladder (UAB) working hypothesis includes: ‘A symptom complex suggestive of detrusor underactivity and is usually characterised by prolonged urination time with or without a sensation of incomplete bladder emptying, usually with hesitancy, reduced sensation on filling and a slow stream‘ (18). Theoretically, a partial overlap between UAB, DU and BOO is considered but the purpose of the working hypothesis is to clinically identify patients who are suspicious of having DU (in pressure-flow analysis) (18,19). However, there is a lack of scientific data particularly on the clinical symptom complex and its relation to urodynamically defined DU. The absence of robust data makes it impossible to accept the above mentioned clinical hypothesis already as a definition. A recent study of Gammie et al. exposed that the use of only LUTS in the diagnostic route might not have enough discriminative power to differentiate UAB from other causes of voiding dysfunction (20).
The exact prevalence of the DU/UAB is difficult to define due to the ongoing debate of the definitions. The reader has to keep in mind that the occurrence of the condition(s) is dependent on the definition and the used threshold values as well as on the available assessment tools for identification and differentiation. Therefore, researchers are currently only able to make a rough estimation of the prevalence of DU and UAB.
Patients with PVR due to DU are often difficult to identify because symptoms and signs are often masked behind identical or similar symptoms or signs of voiding dysfunction. To complicate matter, men or women with DU may even be without PVR or LUTS. Based on current literature, the prevalence of DU in men has been estimated to be 9-23% and as high as 48% in men aged <50 years and >65 years, respectively. In women, prevalence of DU is estimated to be between 4% and 45%. However, more recent studies suggested prevalence rates between 10 and 20%

Until now, DU has only been characterised by the presence of PVR in the absence of BOO. Therefore, the previously published studies on the epidemiology of DU have not considered the coexistence of DU and BOO. Though, urologists frequently see men with LUTS and PVR after unsuccessful treatment of BOO (for example after transurethral resection of the prostate, TURP) or female patients with LUTS complaints or PVR after urinary incontinence surgery. DU is known to have an unfavourable influence on the outcome of both TURP (37-39) and mid-urethral slings (40).


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