Ⅵ Prostatic Diseases Lower Urinary Tract Symptoms (LUTS) in Middle-Aged and Elderly Men JMAJ 47(12): 543–548, 2004 Tomonori YAMANISHI Associate Professor, Department of Urology, Dokkyo University School of Medicine Abstract: Lower urinary tract symptoms (LUTS) include storage symptoms (previously termed as irritative symptoms), voiding symptoms (previously termed as obstructive symptoms) and post-micturition symptoms. The International Continence Society (ICS) published a new standardization of terminology of lower urinary tract function in 2002. Storage symptoms include increased daytime frequency, nocturia, urgency and incontinence. Of incontinence, stress, urge and mixed incontinence are the major symptoms, and ICS has also defined enuresis, continuous incontinence and giggle incontinence as other types of incontinence. Urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as overactive bladder (OAB) syndrome, urge syndrome, or urgency/frequency syndrome. These syndromes suggest urodynamically demon- strable detrusor overactivity, but may be due to other forms of urethro-vesical dysfunction. Overactive bladder is an empirical diagnosis used as the basis for initial management after assessing lower urinary tract symptoms, physical findings urinalysis, and other indicated evaluation. Voiding symptoms include slow stream, splitting or spraying, intermittency, hesitancy, straining and terminal dribble. Post micturition symptoms include a feeling of incomplete emptying and post micturition dribble. The “feeling of incomplete emptying” symptom was formerly categorized as either a storage symptom or a voiding symptom, but has been categorized among the post micturition symptoms in the new ICS terminology. “Post micturition dribble” is the term used when an individual describes the involuntary loss of urine immediately after he/she has finished passing urine, usually in men after leaving the toilet. Thus this symptom is not incontinence, and is categorized among the post micturition symptoms. Key words: Lower urinary tract symptoms; Men; Overactive bladder; Incontinence; International Continence Society This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol. 130, No. 2, 2003, pages 230–234). The Japanese text is a transcript of a lecture originally aired on April 22, 2003, by the Nihon Shortwave Broadcasting Co., Ltd., in its regular program “Special Course in Medicine”. JMAJ, December 2004—Vol. 47, No. 12 543 T. YAMANISHI Introduction Table 1 Lower Urinary Tract Symptoms: LUTS I. Storage symptoms In middle-aged and elderly men, various 1. Increased daytime frequency, pollakiuria urination disorders are caused by urinary tract 2. Nocturia obstruction due to prostatic hyperplasia and 3. Urgency other diseases, as well as neurogenic bladder 4. Incontinence (1) Stress incontinence due to neurological diseases such as cerebral (2) Urge incontinence infarction. (3) Mixed incontinence Urination symptoms caused by these uri- (4) Enuresis, nocturnal enuresis (5) Continuous incontinence nation disorders are generally referred to as (6) Other types of incontinence [coital incontinence, lower urinary tract symptoms (LUTS). As giggle incontinence] urination disorders are classified into storage 5. Bladder sensation [normal, increased, reduced, absence, non-specific] disorders and voiding disorders, LUTS are II. Voiding symptoms accordingly classified into storage symptoms Slow stream and voiding symptoms. Splitting or spraying The terms related to lower urinary tract Intermittency function, including LUTS, are defined by the Hesitancy Straining to void International Continence Society (ICS), and Terminal dribble the standard terminology was redefined in III. Post micturition symptoms 1) 2002. The new definition includes a new Feeling of incomplete emptying category of post micturition symptoms, in Post micturition dribble addition to conventional storage and voiding symptoms. This article explains LUTS accord- ing to the new terminology. Storage Symptoms OAB wet OAB dry Stress Mixed Urge frequency, Storage symptoms are symptoms occurring incontinence incontinence incontinence urgency in the storage phase, such as increased daytime frequency, nocturia, urgency, and incontinence Overactive bladder (OAB) (Fig. 1). These symptoms were previously called irritative symptoms because they appeared as if resulting from irritation of the bladder. Fig. 1 Storage symptoms and incontinence However, the term “storage symptoms” is now preferred because they actually are not related to irritation.2) urine volume). This may result either from 1. Increased daytime frequency or pollakiuria decreased maximum bladder capacity as a This refers to an abnormal increase in the result of overactive bladder (see below) or frequency of urination. The normal frequency from the decrease in single voided volume of urination in adults is considered to be 4 to 6 reflecting the increase in residual urine.2) times a day. Hence, a frequency of 8 times or When an abnormal increase in urine volume more a day is regarded to constitute increased (diabetes insipidus) increases the frequency of daytime frequency. The cause of this symptom urination, this condition is called polyuria. is the decrease in functional bladder capacity Polyuria is defined by a daily urine volume of (maximum bladder capacity minus residual 2,800 ml or more.3) 544 JMAJ, December 2004—Vol. 47, No. 12 LOWER URINARY TRACT SYMPTOMS IN MEN 2. Nocturia aged in radical prostatectomy. Nocturia is defined as waking at night to (2) Urge urinary incontinence urinate. The ICS standard defines it as rising This refers to incontinence accompanying from sleep to void once or more at night. urgency. The cause is overactive contraction of However, because voiding once at night is not the detrusor muscle. While detrusor over- rare in persons aged 50 or more, nocturia is activity is usually seen in the supranuclear often considered as voiding more than once at neurogenic bladder due to cerebral infarction night. Nocturnal polyuria needs to be differen- or cervical spondylosis, it also arises from lower tiated from nocturia. Nocturnal polyuria is a urinary tract obstruction due to prostatic condition in which nighttime (from 23: 00 to hyperplasia and from unknown causes.4) 7:00) urine volume is 33% or more (20% or Although the former was called detrusor more for young adults) of daily urine volume.3) hypersensitivity and the latter was called unstable bladder in the past, it is difficult to 3. Urgency strictly differentiate these 2 conditions. The Urgency is a sudden compelling desire to new definition, therefore, classifies into neuro- void with a feeling that micturition is imminent. genic and idiopathic detrusor overactivity The former definition classified urgency into (DO). Urge incontinence is the most com- motor urgency associated with overactive con- monly observed type of incontinence among traction of the detrusor muscle and sensory middle-aged and elderly men. urgency caused by hypersensitivity of the [Overactive bladder (OAB)] bladder and the urethra in the absence of While detrusor overactivity is considered the overactive contraction. However, because the cause of increased daytime frequency, urgency, distinction between motor urgency and sensory and urge incontinence, the diagnosis of detru- urgency cannot be shown clearly even by the sor overactivity requires urodynamic testing to use of advanced urodynamic tests, the revised evaluate urination functions. terminology does not divide urgency into these Diagnosis based on a urodynamic obser- types. vation may vary depending on whether it is conventional cystometry or a new method such 4. Urinary incontinence as ambulatory urodynamics (the measurement (1) Stress urinary incontinence of intravesical pressure in essentially the same This refers to the leaking of urine that manner as Holter ECG), as well as whether the occurs during effort or exertion causing sudden test is performed by a specialist in urination, a increases in abdominal pressure, such as cough- general physician, a technician, or a nurse. In ing, straining, laughing, standing up from a addition, we cannot diagnose OAB with 100% sitting position, and lifting heavy objects. A reliability even when advanced urodynamic cause of stress urinary incontinence is ana- studies are performed. tomical abnormalities involving weakening of Therefore, we need to be able to define supporting tissues around the bladder neck and conditions considered to arise from overactive the proximal urethra. Other causes include detrusor based on symptoms in daily practice. hypermobility of the fundus of bladder (Types For this reason, the ICS has defined such I and II) and neurogenic conditions (intrinsic conditions as overactive bladder (syndrome). sphincter deficiency; ISD, Type III).4) OAB is characterized by urinary urgency and Stress urinary incontinence usually occurs in typically accompanies increased daytime fre- women. It is seen in middle-aged and elderly quency and nocturia. There are 2 types of men after prostate surgery, in particular when OAB: one with urge incontinence (OAB wet) the urethral sphincter muscle has been dam- and one without (OAB dry). The ICS considers JMAJ, December 2004—Vol. 47, No. 12 545 T. YAMANISHI OAB to be synonymous with urge syndrome condition with reflex contraction was previ- and urgency/frequency syndrome. ously called reflex bladder, it was unified in the These terms are considered to lack