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Differential Diagnosis of Overactive Bladder in Men

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Differential Diagnosis of Overactive Bladder in Men Differential Diagnosis of Overactive Bladder in Men Jerry G. Blaivas,* Brian K. Marks, Jeffrey P. Weiss,†,‡ Georgia Panagopoulos and Chandra Somaroo From the State University of New York Downstate Medical School (BKM, JPW, Brooklyn and Weill Medical College of Cornell University and Lenox Hill Hospital, New York, New York Abbreviations Purpose: We determined the differential diagnosis of concomitant pathological and Acronyms conditions in men with overactive bladder symptoms. BOO ϭ bladder outlet obstruction Materials and Methods: We performed an observational, descriptive study to elucidate the differential diagnosis in men with overactive bladder symptoms BPE ϭ benign prostatic using a previously validated overactive bladder symptom questionnaire. All enlargement patients provided an extensive history, completed the self-administered question- ϭ OAB overactive bladder naire and a 24-hour voiding diary, and underwent physical examination, 24-hour pad test, uroflowmetry, post-void residual urine measurement, cystoscopy and Submitted for publication April 1, 2009. urodynamics. Selection criteria were developed to assign cases to a category, Supported by The Urocenter of New York. * Financial interest and/or other relationship including idiopathic overactive bladder, benign prostatic enlargement, benign with Bayer, Pfizer, Endegun and HDH. prostatic obstruction, neurogenic bladder, bladder cancer, prostate cancer treat- † Correspondence: Veterans Affairs New York ment complications, urethral stricture, bladder stones and bladder diverticulum. Harbor Healthcare System, 800 Poly Pl., Mail Route Code 112A, Brooklyn, New York 11209 Results: Of 122 men who met selection criteria for overactive bladder detrusor (telephone: 718-836-6600, extension 6885; FAX: overactivity was identified in 99 (79%) on urodynamics. The differential diagnosis 212-838-3213; e-mail: [email protected]). was benign prostatic enlargement in 40 men (32%), benign prostatic obstruction ‡ Financial interest and/or other relationship with Ferring, Pfizer and Watson. in 27 (22%), complications of prostate cancer treatment in 25 (20%), neurogenic Supplementary material for this article can be bladder in 13 (11%), urethral stricture in 7 (6%), idiopathic overactive bladder in obtained at http://www.urologysite.com/. 6 (5%), bladder stone in 2 (2%), bladder cancer in 1 (1%) and bladder diverticulum in 1 (1%). Conclusions: Overactive bladder is a complex diagnosis with many underlying, contributing urological pathologies. It should be considered a symptom complex and not a syndrome. Knowledge of the differential diagnosis in men with over- active bladder symptoms would hopefully provide clinicians with a diagnostic rubric to more specifically treat such patients with improved success. Key Words: urinary bladder, overactive; diagnosis, differential; urinary bladder, neurogenic; prostatic hyperplasia; signs and symptoms APPROXIMATELY 9% to 16% of the gen- prostatic obstruction, neurogenic blad- eral adult population has OAB symp- der, infection, bladder carcinoma, blad- toms.1,2 As defined by the International der stone, sphincteric incontinence and Continence Society, OAB is “urgency, postoperative causes.2,4–8 The etiology with or without urge incontinence, usu- and prevalence of these pathological ally with frequency and nocturia” and conditions in patients with OAB are “in the absence of infection or other less well-defined. proven etiology.” 3 However, often pa- Research has focused on the rela- tients with OAB symptoms have other tionship between the urodynamic find- proven etiologies. These concomitant ing of detrusor overactivity and associ- pathological conditions include BPE, ated urodynamic findings or urological 0022-5347/09/1826-2814/0 Vol. 182, 2814-2818, December 2009 ® 2814 www.jurology.com THE JOURNAL OF UROLOGY Printed in U.S.A. Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2009.08.039 DIFFERENTIAL DIAGNOSIS OF OVERACTIVE BLADDER IN MEN 2815 Table 1. OAB differential diagnoses therapy without other identified bladder or prostate pa- thology. Neurogenic bladder was defined as OAB symp- Differential Diagnosis No. Pts (%) toms in the presence of a known neurological disorder, BPE 40 (32) including cerebrovascular accident, myelopathy, Parkin- Benign prostatic obstruction 27 (22) son’s disease and multiple sclerosis. Idiopathic OAB was Prostate Ca treatment complications 25 (20) defined as urgency in the absence of the mentioned diag- Neurogenic bladder 13 (11) noses. Urethral stricture 7 (6) Idiopathic OAB 6 (5) Bladder stone 2 (2) RESULTS Bladder Ca 1 (1) Bladder diverticulum 1 (1) In 122 men who met OAB selection criteria mean age was 70 years (median 67, range 28 to 90). Uro- Total 122 (100) dynamics revealed detrusor overactivity in 99 men (79%). Table 1 lists differential diagnoses. Diagnosis in 13 patients with neurogenic bladder 9–11 disorders. Limited information is available on the was cerebrovascular accident in 6, myelopathy in 4, prevalence of associated urological diagnoses in pa- Parkinson’s disease in 1 and multiple sclerosis in 2. tients with OAB syndrome. We used a previously val- Cerebrovascular accident included traumatic hemi- 12 idated questionnaire to identify patients with OAB paresis, transient ischemic attack and stroke. My- and report the prevalence of concomitant urological elopathy was due to viral myelopathy, spinal steno- pathologies in this group. sis and surgical trauma. Based on modified Roehrborn criteria BPE was identified in 56 patients (table 2), of whom 15 had a MATERIALS AND METHODS diagnosis of BOO and 40 had symptomatic BPE We performed an institutional review board approved, without another diagnosis. OAB developed in 25 observational descriptive study to elucidate the differen- men after treatment for prostate cancer. Radical tial diagnosis in men with OAB symptoms. A previously prostatectomy was done in 21 men and all had validated OAB symptom questionnaire12 was adminis- tered in consecutive male patients who presented to 2 sphincteric incontinence and OAB. Four men had independent outpatient urology centers for evaluation of undergone radiation, including brachytherapy in 2, lower urinary tract symptoms during 1 year. Study inclu- and brachytherapy and external beam radiotherapy sion criteria were based on previously validated results.12 in 2. Two of the latter patients also had urethral The questionnaire consisted of 7 questions, each scored on obstruction. a 5-point scale of 0 to 4.12 Patients were included in the OAB cohort if their response was scored as 3 or 4 to the question, “How often do you get a sudden urge or desire to Table 2. Prostate size in all patients urinate that makes you want to stop what you are doing and rush to the bathroom?” Prostate Size No. Pts (%) All patients provided an extensive history, completed 0 15 (15) the self-administered questionnaire and a 24-hour voiding 1ϩ 25 (25) diary, and underwent physical examination, 24-hour pad 2ϩ 44 (44) test (in those with incontinence), uroflowmetry, post-void 3ϩ 8 (8) residual urine measurement, cystoscopy and urodynam- 4ϩ 4 (5) ics. Study selection criteria were developed to assign pa- Unknown 3 (3) tients to a category, including idiopathic OAB, BPE, be- Total 99* nign prostatic obstruction, neurogenic bladder, bladder Benign prostatic obstruction: cancer, complications of prostate cancer treatment, ure- 0 3 (13) thral stricture, bladder stones and bladder diverticulum. 1ϩ 4 (17) ϩ All questionnaires and completed assessments were 2 13 (57) 3ϩ 3 (13) reviewed by an independent research associate. Patients 4ϩ 0 were included in the study based on questionnaire results and placed in the appropriate category based on selection Total 23 criteria. BPE was characterized by prostate size and esti- No benign prostatic obstruction: 0 12 (16) mated by digital rectal examination, as modified from the ϩ 13 1 21 (28) study of Roehrborn et al. Prostate size was graded on a ϩ ϩ 2 31 (40) system of 0 to 4 with the modification 0 representing 3ϩ 5 (7) ϩ less than normal prostate size. Prostate size 2 or greater 4ϩ 4 (5) 13 was categorized as BPE. Prostatic obstruction was diag- Unknown 3 (4) nosed by a Schafer obstruction grade greater than 2. Com- Total 76 plications of prostate cancer treatment were defined as OAB symptoms after radical prostatectomy or radiation * Omitting men with prostate cancer. 2816 DIFFERENTIAL DIAGNOSIS OF OVERACTIVE BLADDER IN MEN DISCUSSION struction were completely alleviated after transure- 18 As defined by the International Continence Society, thral prostate resection. In another small series OAB indicates a symptom complex comprising “ur- detrusor overactivity resolved on urodynamics in gency, with or without urge incontinence, usually 75% of patients after transurethral prostate resec- 19 with frequency and nocturia. in the absence of tion. Thus, treating BOO may provide more bene- infection or other proven etiology.”3 This definition fit since improvement on anticholinergics depends fails to address the well-known differential diagno- on patients continuing the medication indefinitely sis of OAB and the pathological conditions associ- but most discontinue it within a few months because of dissatisfaction with the level of improvement ated with these lower urinary tract symptoms. We 20 noted the prevalence of concomitant urological pa- and/or side effects. thologies in these men identified with OAB using a In our series 56 men had BPE, of whom 16 also validated questionnaire.12 Our study suggests that had BOO. The remaining
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