cmE case prESENTaTION For more information see below. case 1: classification of Lower Urinary Tract Symptoms (LUTS) and Urinary Incontinence (UI) David R. Staskin, MD LEarNINg ObjEcTIves: Associate Professor of Urology 1. Discuss screening and identification of LUTS; Director, Female Urology and Male Voiding Dysfunction St. Elizabeth’s Medical Center 2. identify different causes of LUTS; Tufts University School of Medicine, Boston, MA 3. demonstrate an awareness of what can be Disclosure record for David R. Staskin, M.D. accomplished in the PCP office in regards Last reviewed/edited this information on January 10, 2011. to evaluation; Uroplasty: Consultant or Advisor; American Medical Systems: Consultant or Advisor; Astellas: Consultant or Advisor; Pfizer: 4. specify treatment options for OAB and BPH; and Consultant or Advisor; Glaxo: Consultant or Advisor; Allergan: Consultant or Advisor 5. examine when to refer for specialist evaluation case/patient #1a: case/patient #1b: case/patient #1c: case/patient #1D: A 62 y/o G4P4 obese A 42 y/o G2P2 female A 79 y/o community dwelling female A 67 y/o male female complains of “weekend athlete” in has recently been discharged from complains of nocturia urgency, frequency, and otherwise excellent health the hospital following THR secondary and recent onset of urgency incontinence. complains of urinary loss to a fall, during which time she had urgency incontinence. She voids 10 times/ with “effort”. She reports an indwelling foley catheter. She On further questioning day and 2 times/night, bothersome urinary leakage complained of minimal voiding he admits to an accompanied by urgency “drops to squirt” with symptoms prior to admission. Most impaired flow and (compelling need to minimal sensation during bothersome is urinary frequency and decreased emptying. void) 50% of the time a cough, laugh, sneeze, or urinary incontinence with minimal He has been taking an and one or two episodes during physical exertion. sensation especially at night on the over-the-counter cold of urgency incontinence She reports no associated way to the bathroom (bedside medication for the per day. urinary urgency, frequency, commode). She also complains of the past week. or nocturia. sensation of incomplete emptying. phySIcIaN accrEDITaTION STaTEmENT pyI h S cIaN crEDIT STaTEmENT The University of North Texas Health Science Center at Fort Worth Office of The University of North Texas Health Science Center has requested that Professional and Continuing Education is accredited by the American the AOA Council on Continuing Medical Education approve this program Osteopathic Association to award continuing medical education to physicians. for 1 hour of AOA Category 2B CME credits. Approval is currently pending. The University of North Texas Health Science Center at Fort Worth The University of North Texas Health Science Center at Fort Worth designates Office of Professional and Continuing Education is accredited by the this enduring material for a maximum of 1 AMA PRA Category 1 Credit(s)™. American Council for Continuing Medical Education (ACCME) to provide Physicians should claim only the credit commensurate with the extent of continuing medical education for physicians. their participation in the activity. QUESTION 1: The assessment of urinary incontinence in every Urinary incontinence should be categorized by symptoms into urgency patient should include: incontinence, stress incontinence, or overflow incontinence – or mixed A. Establish a presumptive or condition specific diagnosis, and (combined) incontinence. Conservative (non-invasive) therapies may exclude underlying organ-specific related or unrelated conditions then be started based on this classification to treat the most troublesome that would require intervention. component, or either component of the incontinence. More sophisticated B. Assess the level of bother and desire for intervention from testing (eg. urodynamics studies) is not required prior to the institution information obtained from the patient or caregiver. of conservative therapy. C. Institute empiric or disease specific primary therapy based on A bladder diary is helpful in order to document and communicate the the risk and benefit of the untreated condition, the nature of the frequency of voids and incontinence episodes experienced by the patient. intervention and the alternative therapies. The AUA symptom score is useful in male patients with LUTS although it D. Prompt the recommendation of additional more complex testing does not include a specific question about urinary leakage. Additional or specialist referral. information as appropriate may include volume of intake, voided volume, E. All of the above and/or symptoms such as urgency or discomfort. DIScUSSION Of QUESTION ONE Referral to a specialist is recommended for hematuria (visible or The answer is E. microscopic), urinary tract infection (persistent or recurrent), prolapse Lower Urinary Tract Symptoms (LUTS) cannot be used to make a (symptomatic or below the introitus), obstruction or retention (symptoms definitive diagnosis since they may also indicate pathologies other than or findings of palpable bladder, hydronephrosis or obstructive renal Lower Urinary Tract Disease (LUTD). LUTS may include Overactive insufficiency), suspected neurological disease, mass (urethral, bladder or Bladder (OAB) a syndrome which may be associated with urgency pelvic - benign or malignant), fistula (urinary or bowel), a history of prior incontinence (OAB-wet) or without incontinence (OAB-dry) and should pelvic surgery or radiation (incontinence, oncologic). prompt consideration and as appropriate, an evaluation for other similar Specific tests (urinalysis, urine culture, post voiding residual urine): symptom based pathology. It is considered standard to perform a urinalysis either by using a Urinary incontinence can be described by symptoms or storage and dipstick test or examining the spun sediment. If a dipstick test is used, emptying function. Incontinence can be qualified by frequency, severity, it is recommended that a “multiproperty” strip that includes fields for precipitating factors, social impact, effect on hygiene and quality of life, hematuria, glucose, leukocyte esterase and nitrite tests be chosen. the measures used to contain the leakage and whether or not the Dipstick is not as accurate as urine culture, being specific for infection individual seeks or desires help. INITIaL maNagEmENT Of UrINary INcONTINENcE in Men Incontinence on Urgency/frequency, Post- Incontinence “Complicated” incontinence physical activity with or without Histoy r micturition with mixed • Recurrent of “total” (usually post- urgency dribble symptoms incontinence prostatectomy) incontinence • Incontinence associated with: – Pain – hematuria • general assessment (see relevant chapter) – recurrent infection • Urinary Symptom Assessment and symptom score (including – Prostate Irradiation frequency-volume chart and questionnaire – radical pelvic surgery c aLINIc L • Assess quality of life and desire for treatment aSSESSmENT • Physical examination: abdominal, rectal, sacral, neurological • Urinalysis ± urine culture -> if infected, treat and reassess • Assessment of pelvic floor muscle function Any other abnormality • Assess post-void residual urine detected e.g. significant post void residual Str ESS mD IxE UrgEnCy pr D ESUmE InCOntInEnCE InCOntInEnCE InCOntInEnCE DIagNOSIS presumed due to (treat most bothersome presumed due to sphincteric incompetence symptom first) detrusor overactivity • Urethral D ISCUSS trEAtmEnt optIOnS wIth thE patIEnt milking • lifestyle interventions mgaNa EmENT • Pelvic floor • Pelvic floor muscle training ± feedback muscle • Scheduled voiding (bladder training) contraction • Incontinence products • A ntimuscarinics (OAB ±urgency incontinence) and a-adrenergic antagonists (if also bladder outlet obstruction) Failure SI pEcIaL zED maNagEmENT but not sensitive. Additional tests available on urine dipstick strips, of decreased bladder emptying, and no anatomical, neurological, organ- such a protein, bilirubin, ketones and pH, may be helpful in the broader specific, or co-morbid risk factors for retention may be assessed for medical management of patients. However, they are not essential in the bladder emptying by history and physical examination alone, depending context of evaluation of the patient with urinary incontinence or lower on the potential morbidity of the failure to diagnose and the nature urinary symptoms. of the intended therapy. A palpable bladder on physical exam is an indication for referral to a specialist. Residual urine determination The PVR is the volume of urine remaining in the bladder following a by bladder scan is preferable to catheterization due to the increased representative void. PVR measurement can be accomplished within a few morbidity associated with instrumentation. Due to the increased minutes of voiding either by catheterization or by calculation of bladder possibility of bladder outlet obstruction due to prostatic obstruction is volume using a portable ultrasound scanner. An increased PVR alone is increased in the male patient, the threshold for investigating residual not necessarily problem, but if combined with high pressures it can lead urine in the male is significantly lower. A PVR should be performed in to upper tract problems. If related to UTI’s, PVR may need to be treated patients where decreased bladder emptying is suspected, especially if since UTI’s may not be eradicated in the presence of