Investigation of LUTS July 2005

Symptoms Lower Urinary Tract Symptoms (LUTS) is For four days, the patient records the time Urinary tract endoscopy; they get up and go to bed, their fluid intake a term that covers symptoms that result • Similarly this is not indicated unless and the volume of urine passed each time from conditions and diseases affecting the there is a specific indication such as they go to the toilet. The patient may bladder and the urethra. These are: blood in the urine or a symptom such as also be asked to record every episode of bladder pain. • Storage symptoms which include the incontinence and the use of incontinence symptoms (urgency, pads. It may be necessary to ask patients Urodynamic Studies: urgency incontinence, frequency and to keep a food diary to assess the quantity Many patients are treated with an empirical ) as well as pain and stress of water containing foods eaten each day. diagnosis provided the treatment is safe incontinence. It is possible to add additional requests and/or relatively inexpensive. For example, for information such as urgency episodes, • Voiding symptoms which include slow provision of aids, lifestyle interventions, but care must be taken not to overload the and/or interrupted stream, terminal pelvic floor muscle training for stress patient with demands for information. dribble hesitancy and straining. incontinence and bladder training and Suspicious symptoms such as haematuria The frequency volume chart is particularly antimuscarinic drugs for overactive bladder. (blood in the urine) and dysuria (pain helpful in assessing /excessive Should a patient fail to respond to the above passing urine) may indicate bladder urine production/ and nocturnal polyuria measures, or if treatment is potentially tumour or . /excessive urine production during the night hazardous and expensive, or if the symptoms • Post micturition symptoms which include Clinical Assessment: are adversely affecting the patient’s quality post micturition dribble (or incontinence) of life, then a urodynamic diagnosis is and the sensation of incomplete emptying. Physical Examination desirable. • Simple cardiac and respiratory Assessment Urodynamic studies range in complexity; examination to exclude signs of heart History: failure. • Urine flow measurement and the assessment of bladder emptying (by Assessment begins with taking a history and • Abdominal examination to exclude a ultrasound) is a simple screening test for the following questions will be asked about pelvic mess or palpable bladder. This voiding dysfunction. each of the above symptoms: should include rectal examination. • Filling cystometry is the test of choice • If the above symptoms are present. • Simple neurological examination for storage symptoms such as OAB or • Their frequency and severity. • Pelvic examination in women to assess incontinence of any type. oestrogen status and the presence of • Any variation between night and day. • Pressure flow studies of voiding are able pelvic organ prolapse. • Any precipitating or relieving factors. to confirm whether the patient’s symptoms Urine Analysis: are due to bladder outlet obstruction or an • The coping measures used by the patient underactive detrusor. to improve the symptom. This should be performed on every patient and is done with a diagnostic urine Complex urodynamic tests such as; • The impact of the symptoms on quality of “dipstick” to: life and social functioning. • Video-urodynamics are indicated when • Exclude blood in the urine information on lower urinary tract Increasingly, validated questionnaires are structure combined with information • Exclude the possibility of urinary tract being used to research patients’ LUTS. The on lower urinary tract function is also infection. This may be indicated by a International Consultation on Incontinence required. has developed a modular questionnaire, the positive test for nitrites, protein or white ICIQ (www.iciq.net). The ICIQ has modules cells and would be confirmed by urine • Ambulatory urodynamics are useful if for men and women covering LUTS, effect culture. conventional studies don’t provide the answers. on quality of life and sexual function. • Exclude glucose in the urine. In conclusion, the assessment of LUTS Frequency Volume Chart Urinary tract imaging (ultrasound or X-ray): should be methodical and extensive enough Both the patient and their nurse/doctor • This is not routinely indicated unless to provide the basis for managing the gain great knowledge and insight into the there is a specific indication such as patient’s symptoms. individual’s LUTS if a frequency volume chart blood in the urine. (bladder diary) is completed. Overactive Bladder July 2005

Symptoms 1. Proven direct effect. 2. Effect correlated with urgency but inconsistent URGENCY The function of the lower urinary tract due to multifactorial etiology of the system. (bladder) is to temporarily store a continuously 1 increasing amount of urine at low pressure Increased Frequency and and expel it under appropriate and socially 2 2 Nocturia Reduced Intervoid Interval Incontinence acceptable circumstances. The reservoir function of the bladder during the filling phase 1 (which represents the majority of its activity cycle) is characterised by a permanently low Reduced Volume Voided per Micturition pressure within it over a wide volume range, with a bladder outlet that remains firmly The symptom of urgency is the most OAB are present and their significance is the closed, even under conditions of abdominal troublesome and drives the other symptoms of most important first step, towards effective straining. Conversely, during voiding the syndrome: Various studies have reported that treatment of the condition. Please refer to bladder should be able to develop a sustained this symptom complex affects 16 -17% of the Factsheet No 1. contraction of sufficient strength with the population worldwide. Incontinence occurs Treatment bladder outlet offering a low resistance to in approximately a third of these individuals. urinary flow to ensure complete emptying of This symptom complex increases in incidence Behavioural therapy and pharmacotherapy the bladder. The Standardisation Committee of with increasing age and affects between are the mainstay of treatment and there is the International Continence Society specifies 70-80% of people by the age of 80. It is the a continuing search for more effective and the international standard definitions for the most common reason why men seek advice selective drugs with minimal side effects. symptoms, signs and conditions associated for ‘ related problems’ and is more About 50% of patients gain satisfactory with lower urinary tract dysfunction. These likely to be associated with incontinence in benefit from pharmacotherapy. Behavioural are detailed in their most recent report (the women than men. It is often not recognized therapy involves altering a patient’s drinking Standardisation of Terminology of Lower but is a treatable’ condition’, and this group pattern by drinking less before bed or before Urinary Tract Function) which is available on of symptoms are the most bothersome to a journey, while retraining the bladder to hold the ICS website (www.icsoffice.org). patients, producing devastating effects on on for a longer time. A fluid/volume chart helps with this. Lifestyle interventions in the form OAB is a symptom syndrome that is defined quality of life. of cutting out of caffeine and alcohol, and as ‘urgency, with or without urgency Whilst OAB is a symptom complex clearly fluid restriction can be helpful. Most people incontinence, usually with frequency distinct from bladder overactivity –which can suffering from this problem can attempt this and nocturia (sleep-disturbing voiding)’ be proven by specialist investigation- the before seeking advice. A number of drugs are – these symptoms are suggestive of bladder majority of people with OAB are thought to available with proven effectiveness including overactivity (urodynamically demonstrable have this underlying diagnosis. As mentioned darifenacin, solifenacin, tolterodine, trospium, involuntary bladder contractions – see below) above, the detrusor pressure normally oxybutynin and propiverine. Recently, the focus but can be due to other forms of voiding or remains low during bladder filling. The has been on minimally invasive therapies such urinary dysfunction – these terms can be used occurrence of involuntary bladder contractions as intravesical injection of botulinum toxin if there is no proven infection or other obvious during the filling phase of an urodynamic or neuro-modulation. Surgery for detrusor pathology. (bladder function) study, spontaneously or overactivity should be reserved only for on provocation, is called ‘detrusor (bladder) At this juncture it is useful to consider the patients for whom all conservative treatment overactivity. Detrusor overactivity may definition of the various terms applied to the modalities have failed, since all surgical have several causes. Idiopathic detrusor symptoms of the OAB syndrome: procedures bring with them potential risks and overactivity (where there is no identifiable complications. • Urgency: The complaint of a sudden, cause) is the most common type. Idiopathic compelling desire to pass urine that is detrusor overactivity may of course be due to Conclusion difficult to defer (for fear of leakage) unrecognised neurogenic (neurological – nerve ‘Overactive bladder’ is the term applied to an related dysfunction) or due to myogenic • Urgency incontinence: The complaint of extremely bothersome and common complex of (muscle related problems); which are thought involuntary leakage of urine accompanied or symptoms often unrecognised as a diagnosis to be the most common recognised causes of immediately preceded by urgency in the population; being associated with bladder overactivity. There is a clear age- underlying bladder overactivity in the majority • Frequency: (Going more than 8 times in 24 related increase in bladder overactivity with is of cases. This condition causes enormous hours) usually accompanies urgency with exacerbated by cognitive impairment. or without urge incontinence and is the disruption of quality of life often leading to complaint by the patient who considers that Assessment social isolation with important psychological and financial consequences and may even lead he/she voids too often by day. Clinical diagnosis is based on a careful to increased mortality in the elderly. • Nocturia: Usually accompanies urgency history supplemented by the use of a bladder with or without urge incontinence and is the diary filled in by the patient documenting complaint that the individual has to wake at how often they void over a 24 hour period. night one or more times to void. Recognizing the possibility that symptoms of Stress July 2005

Symptoms Stress urinary incontinence (SUI) is the if the waiting time for surgery is long, the effects on the bladder or by improving the complaint of involuntary leakage of urine on symptoms may be ameliorated by appropriate control of conditions affecting lower urinary effort or exertion, or on sneezing or coughing. conservative interventions. Drug regimens tract function. avoiding diuretics, control of chronic cough It is the most common presenting symptom Traditionally, surgery for stress and constipation, cessation of smoking, for which women seek the advice of a urinary incontinence has relied upon exclusion or treatment of urinary tract clinician. is uncommon in coloposuspension or open sling procedures infection, and weight reduction are desirable. the male population and usually follows prior with comparable results. One must consider surgery. Any incontinence in an elderly male In recent years there has been a wide variety the risks of morbidity and mortality when should always raise the suspicion of chronic of new continence devices developed. counselling regarding surgery, and be aware . The presence of pelvic Although interest continues with clinicians of the risks of de novo detrusor overactivity organ prolapse in women can be associated and patients, many of the devices have and voiding difficulty, failure of the with stress urinary incontinence. The latter never made it on to the market or have procedure, and future recurrence. may be “masked” by the prolapse itself been removed from the market shortly after Over the last 20 years, attention has and is only detected after reposition of the release. Some products are available on the been directed at developing less invasive prolapse or becomes evident after pelvic floor Internet but until they become more widely procedures with reduced morbidity, hospital reconstructive surgery. available, they will continue to be limited to stay and time taken to return to normal life. Urgency urinary incontinence is the complaint specialist units in controlled trials. Of the minimally invasive, mid-urethral of involuntary leakage accompanied by, or The mainstay of treatment for stress supports, tension free vaginal tape (TVT) has immediately preceded by a strong desire to urinary incontinence is physiotherapy, with been the most extensively investigated. In a void. Mixed incontinence is the complaint of recourse to surgery when indicated and trial to compare TVT with colposuspension involuntary leakage associated with urgency desired. Physiotherapy modalities include as a primary treatment for SUI, no significant and also with exertion, effort, sneezing or pelvic floor muscle training, electrical difference was found between the groups coughing. A history of incontinence with stimulation, vaginal cones, and the use of for cure rates. However, surgery with TVT these other symptoms could suggest the biofeedback. Physical therapies represent led to more operative complications than possibility of detrusor overactivity (DO). the least invasive, but effective option for colposuspension, but colposuspension treating stress urinary incontinence. For this Assessment was associated with more postoperative reason they are commonly used as first-line complications and longer recovery. (See Factsheet 1). Based on a history and treatment. Many women’s symptoms are clinical examination of the pelvis, it is cured or improved so that they do not require Coaptation of the urethral mucosa is an possible to reach a presumed diagnosis of surgery, with its potential complications. important part of the continence mechanism. SUI due to sphincteric incompetence, as a If it fails, reduced pressures are needed to A new drug has been marketed, specifically basis for treatment with lifestyle modification overcome the continence mechanism, and for the treatment of stress incontinence. In and physiotherapy. so peri-urethral bulking agents aim to create randomised, double-blind, placebo-controlled artificial cushions at the bladder neck. Urodynamic stress incontinence can only be trials comparing duloxetine 80mg/day and diagnosed after performing urodynamics, placebo. Incontinence was significantly Male stress urinary incontinence is common and is the involuntary leakage of urine reduced in comparison with the placebo arm after radical prostatectomy and the artificial per urethram during periods of raised with comparable improvement in the women urinary sphincter is the most effective intra-abdominal pressure, in the absence most severely affected, with more than 14 treatment of choice to overcome it. of a detrusor contraction. Therefore, incontinence episodes per week. The most Conclusion the International Continence Society common adverse effects are nausea, dry recommends a full clinical and urodynamic mouth, fatigue, insomnia, and constipation. Urinary incontinence remains a common and assessment to objectively assess stress distressing condition, which adversely affects It is appropriate to review the outcome of urinary incontinence, chiefly before surgery. the quality of life of women. The advent of initial treatment, with referral for specialist urodynamic studies has enabled an accurate Treatment management where treatment fails. diagnosis to be made in most cases. A conservative approach is justified ‘Complicated’ incontinence (in the presence if symptoms are only mild, or easily of pain, haematuria, or recurrence after Recent advances in the management of manageable. When a woman’s family is previous corrective surgery) also requires stress urinary incontinence have favoured incomplete, or when symptoms manifest specialist management. a less invasive approach, and whilst initial results are promising, long-term results are during pregnancy, surgery should be avoided. Considering other medical conditions and awaited. Effective management is based on a If surgery is considered unwise because of their treatment may help, by changing multi-disciplinary, multi-modal approach. medical illness, when surgery is refused, or medication to an alternative that has fewer Painful Bladder Syndrome July 2005

Painful Bladder Syndrome Including

Symptoms Painful bladder syndrome (PBS) has a major normal with a number of other disorders Conclusion impact on the patient’s quality of life. The including allergies, irritable bowel PBS/IC is a difficult condition: difficult to frequent and painful need to urinate means syndrome, fibromyalgia, systemic lupus diagnose, difficult to treat and difficult for that the patient is constantly looking for the erythematosus and Sjogren’s syndrome. the patient to cope with. next toilet. This can form a serious obstacle Assessment to work, travel, social life and relationships. Lack of sleep due to pain and frequent Due to the lack of any clinical diagnostic night-time causes fatigue, lack of criteria or any specific test, diagnosis is concentration and irritability, while painful based on symptoms, examination, urinalysis sexual activity may have a dramatic effect and the exclusion of any identifiable causes on a marriage or partnership. such as benign or malignant tumours, bladder or genital bacterial or viral Painful bladder syndrome is a chronic, infection, radiation, chemical or tuberculous painful condition of the bladder of unknown cystitis, bladder or urethral obstruction, origin. Although the symptoms may initially prostate disorders and any other pelvic/ resemble a bladder infection, urinalysis gynaecological disorders. appears normal and a urine culture is negative. Interstitial cystitis (IC) is a A under anaesthesia with subgroup of PBS patients with inflammatory hydrodistension and bladder biopsy may changes in the bladder. Further specification provide information concerning the presence of these changes awaits more research, of glomerulations (pinpoint haemorrhages), but includes cystoscopic and morphological inflammation and an increased number findings. of mast cells in the bladder wall, bladder capacity and Hunner’s ulcer. The findings This distressing and potentially debilitating may provide support for a diagnosis and bladder condition is characterised by bladder form a useful guide for the type of treatment pain, with a frequent and often intense to be followed. “Classic” IC with ulcers may desire to urinate including at night. The lead to a fibrotic, contracted bladder which pain, which in some patients may be very is not seen in non-ulcerative PBS/IC. Many severe, typically increases as the bladder patients may never progress further than fills and is temporarily alleviated when it is a relatively mild form of the disease and emptied. This pain may be suprapubic, in may have a normal bladder capacity under the bladder/urethra, vaginal, in the penis, anaesthesia. scrotum, testicles and perineum and may radiate to the lower back and groin. It may Treatment be burning or stabbing pain or a feeling Since there is as yet no cure for PBS/IC, of pressure or heaviness. Both male and treatment is aimed at alleviating the female patients may experience pain with symptoms and improving the patient’s sexual activity. The course of the disease quality of life. Treatment is highly individual may be characterised by exacerbation and since no therapy exists that is equally remission (“flares”) or the pain may be effective for all patients. It may consist continuous. of diet modification, one or more oral PBS/IC is believed to affect mainly women drugs, bladder installations or injections, (+ 90%) and is found worldwide in all age neuromodulation or surgical interventions. groups, including children. Surgery is considered to be a last resort but may be the only option for severe, refractory PBS/IC is associated more commonly than cases. Pelvic Organ Prolapse July 2005

Symptoms Treatment Pelvic organ prolapse (POP) or genital Urinary incontinence in association with Prevention of genital prolapse is theoretic- prolapse is the herniation of pelvic organs pelvic organ prolapse (POP) can be overt or ally feasible by identifying risk factors and through the urogenital diaphragm into the occult. avoiding child birth induced pelvic floor vagina. Overt incontinence means that the patient damage. Epidemiological data on the prevalence is symptomatic: there is a genital prolapse, Life-style interventions (such as Body Mass of genital prolapse are scanty and mainly the patient complains of stress or mixed Index reduction and stopping smoking) may based on surgical data bases. Given an incontinence and at physical examination be helpful. average life expectancy of 79 years, the the stress test is positive, resulting in Pelvic floor muscle training can be useful in lifetime risk of a woman undergoing at urinary loss at coughing or during Valsalva. both the prevention and in the treatment of least one operation is about 11.1% in this Occult incontinence may also be referred low degree prolapse; it is useless in cases population. Analysis of the component to as masked or latent incontinence: there of high degree prolapse, even though it procedures show that 40.1% of all pelvic is a genital prolapse, the patient does not can have a role before and after surgical floor operations address the anterior vaginal complain of urinary incontinence or she treatment. compartment, 18.0% address all three refers in the past a period of mild stress compartments, and 15.6% address both incontinence which then spontaneously Pessaries can be indicated in the frail elderly the anterior and posterior compartments. disappeared. During physical examination, or in patients refusing surgical treatment. Repeat procedures comprise about 30%, there is no visible stress incontinence In cases of symptomatic genital prolapse, highlighting the risk of recurrence. when the prolapse is out, but after prolapse surgical repair is the standard treatment, Several large surgical data base studies repositioning, the stress test becomes excluding patients not suitable for an confirm an annual age related surgical positive. operation due to age/comorbidity. Genital incidence in the range of 10 to 30 per 10,000 So occult incontinence is defined by a prolapse surgical repair can be performed women. positive stress test only after prolapse vaginally, abdominally, vaginally and abdominally, and laparoscopically. The population prevalence for prolapse repositioning. Stage II or higher is between 2 and 4% but Occult incontinence is related to the Each route has indications, advantages and may be much higher in clinical populations issue of de novo stress incontinence after disadvantages. seeking gynaecological care. surgical prolapse repair which ranges from Conclusions The number of women with POP who never 15 to 80% and is a very unfortunate event Careful decision making is based on the seek medical attention is unknown. both for the patient and the surgeon. It is conceivable that most of patients with de recognition of the following variables: Clinical features of genital prolapse novo stress incontinence had occult stress Precise anatomic defects, aetiology, include a variety of symptoms typical of incontinence before surgery. exacerbating and promoting events, this condition such as the sensation of a patient’s desires and expectations lump, a dragging feeling and/or lumbar Assessment especially related to sexual activity, age and pain together with other associated The ICS Standardisation Committee has performance status, native tissue quality disorders related to urinary, bowel and produced a standardised validated system: and durability, risk factors and life style. sexual functions. Patients could present POP-Q ICS system which enables a numeric with urinary incontinence, faecal and/or and reproducible prolapse classification. It is Risk factors are: familial, body mass flatus incontinence, sensory and emptying critical that the examiner sees and describes index, previous prolapse surgery, defective abnormalities of lower urinary tract, the maximum protrusion noted by the connective tissue, constipation and straining defaecatory dysfunction and constipation, individual during her daily activities. at stool, denervation and myopathy, leading sexual dysfunction and chronic pelvic pain. to a wide levator ani hiatus. For general assessment see Factsheet 1.

Faecal Incontinence July 2005

Symptoms Inability to control the bowels or “faecal loss of independence. Severe constipation enable a diagnosis. Sometimes further tests incontinence” is a socially devastating (“impaction”) may eventually cause to image the anal sphincter muscles (by symptom. leakage from the bowel (“overflow ultrasound or MRI), to inspect the lining of diarrhoea”). the bowel (endoscopy) or to test the nerve Faecal incontinence is surprisingly common, and muscle function of the lower bowel • Many other factors can affect bowel affecting about 5% of all adults, both men (Anorectal testing) are indicated. and women. One adult in every hundred has function, including anxiety, medications a regular problem. There are many possible diet alcohol and caffeine as well as toilet Treatment accessibility for people with disabilities. underlying causes, the most common of Treatment will depend on the cause. which include: Urgency incontinence: the person knows Sometimes a fairly simple adjustment of • Childbirth . The muscles of the anal that a toilet is needed urgently, but just diet and medications is sufficient. Anti- sphincter can be stretched or even torn cannot hold on long enough to make it to diarrhoea medication often helps those during vaginal birth. This is most likely if the toilet in time. This is usually the result with loose stool. Bowel and anal sphincter the birth is difficult or the baby needs the of loose bowel motions and/or weak anal retraining are commonly used (this may be help of instruments to be born. sphincter muscles. with the aid of specialist equipment, termed “biofeedback”). • Anal sphincter damage can also be Passive incontinence: stool leaks, usually caused by other injuries, or inadvertently without any warning or sensation. This is Some causes of faecal incontinence are during surgery (such as an operation for often the result of nerve damage, weak amenable to surgical correction. If the haemorrhoids (piles). muscles or severe constipation. muscles have been damaged, a direct sphincter repair may be indicated. Complex Assessment • Anal conditions such as haemorrhoids or injuries may need complete reconstruction prolapse can cause leakage. The majority of people with faecal or implantation of a neosphincter • Diarrhoea . Anyone with an upset incontinence are too embarrassed to seek or a nerve pacemaker (sacral nerve stomach may have to run for the toilet professional help, or they wrongly assume stimulation). Several new approaches are in if stool is loose. Some people have that nothing can be done. This is a pity as development, but have yet to be proven. the majority can be improved, and many bowel disorders that give them regular Living with long term faecal incontinence cured. diarrhoea: a few cannot reliably make it to limits quality of life. Few products are the toilet in time. The first step is an individual assessment suitable. Skin breakdown and social • Nerve damage. People with neurological to determine the cause. This will include isolation are complications. detailed questions as to the history and conditions may have difficulty with Conclusion sensation, or with making the muscles pattern of the problem, related medical work as they wish, or both. Spinal cord conditions and medications, diet and There is a need for much greater public injury, multiple sclerosis and spina bifida fluid intake, and questions to ensure that awareness and for more professional are among many conditions which can there are no “sinister symptoms” (such as interest and research into the neglected lead to faecal incontinence. bleeding, anaemia or unexplained weight area of faecal incontinence. loss) which might suggest bowel disease • Frail elderly, especially those in Nursing or even colon cancer (the second most Homes, may become very constipated for common cancer in Western countries). The a variety of reasons due to poor health, assessment and a physical examination may medications, diseases, immobility and Neurological Bladder July 2005

Symptoms Since the innervation of the lower urinary emphasis on videourodynamic investigation. External appliances are particularly useful tract (LUT) is both complicated and subtle it In addition to regular assessment ; more for controlling urinary incontinence in is of no surprise that LUT dysfunction occurs refined tests, including nerve conduction neurological patients. Drugs which relax the in most neurological conditions to a variable studies, evoked potential studies and bladder can be helpful. When these simple degree. imaging of the nervous system are often measures fail and before proceeding to helpful. more invasive treatment options, minimally The symptoms are related to the disease, invasive procedures, such as bladder and/or This combination of factors allow a detailed dysfunction or injury type and degree sphincter botulinum toxin injections should definition of the type of neurological (central versus peripheral and complete always be considered. Electrical stimulation dysfunction with particular reference to versus incomplete). In most neurological of the third sacral nerve route is also the various factors which are involved diseases there is a certain degree of filling/ recommended and there is an increasing relating both to the detrusor, bladder neck, voiding function impairment. Examples of interest in the use of intervesical electrical urethral sphincter mechanism and the inter- such diseases could be: stroke, Alzheimer stimulation. disease, dementia, Parkinson’s disease, relationship between these. More complex surgical procedures include multiple sclerosis, spinal cord injury, Treatment neuropathy. the use of sacral anterior nerve root One of the main goals of treatment is to stimulation which can to some extent Both storage and voiding symptoms could be produce a low pressure continent urinary restore a degree of bladder function and present and a mixture of them is frequently reservoir and to allow the appropriate can also be useful with regards to erectile observed. regular emptying of urine at a socially function. If the bladder outlet is constricted In cases with storage symptoms the most convenient time at low pressure to avoid due to spasm of the sphincter then cutting frequent is neurogenic detrusor overactivity upper urinary tract complications and this can be helpful. If the bladder is overtly (a term used instead of idiopathic detrusor prevent urinary infection. Conservative overactive then the pressure in the bladder overactivity in cases of neurogenic bladder). treatment may consist of behavioural can be decreased and its capacity can be Stress incontinence occurs as a result of therapy, catheterisation (intermittent increased by using a segment of bowel injury to the sphincteric muscle itself or its catheterization), the use of drugs which (enterocystoplasty). This is a well tried and innervation. promote both storage () and trusted technique which has been used emptying (alpha adrenergic antagonists) and for many years although it is not without Voiding symptoms include incomplete (or electrical stimulation. complications and any of these patients lack of) bladder emptying as a result of require careful supervision and follow-up. poor bladder contraction (hypocontractility) Triggered voiding is to be used only in or lack of contraction (acontractility). The patients whose situation has proven to be An artificial sphincter on the other hand can outflow bladder obstruction also results in urodynamically safe and stable and who be used to provide control of the bladder impaired bladder emptying and is caused by can manage reflex incontinence. Bladder outlet in patients with incontinence and lack of synchronization between sphincteric expression is basically dangerous and its occasionally sling procedures are of some relaxation and bladder contraction (detrusor/ indications are limited. use. sphincter dyssynergia). Timed voiding, habit retraining and If all treatment modalities fail, then a Assessment prompted voiding can be used as part diversion of urine preferably using a of each individual rehabilitation. Clean continent technique can be very helpful but The diagnosis of neurogenic bladder intermittent catheterisation (CIC) is safe should only be carried out in specialised dysfunction is made based on a detailed and effective both in the short and in the units. assessment of information gathered long-term and CIC is recommended as Conclusions from a full clinical assessment including first choice of treatment for those with history, with particular reference to clinical inability to empty their bladder adequately There is a great deal of ongoing research symptoms and signs, a physical examination and safely, but proper education and looking at all of these different aspects. with neurological testing and evaluation of teaching is necessary. Indwelling catheters Proper dysfunction oriented management the urine. For details see Factsheet 1. particularly when placed transurethrally of patients with neurological diseases To provide a clear functional diagnosis can not be recommended for long term affecting the bladder will substantially urodynamic investigation using a graduated use in neurological patients, when all increase both quality of life and survival. series of tests is needed with special other measures are inappropriate then a suprapubic catheter is to be preferred. Frail Elderly July 2005

Bladder Dysfunction In The Frail Elderly

Symptoms The elderly experience the same symptoms history including ease of access to toileting indicated in those who fail on conservative of bladder dysfunction as adults of all facilities and ability to perform self care measures and who are medically fit. should be recorded. It is helpful to perform ages with the addition of worsening Aggressive management of concomitant a formal test of cognitive function with confusion in the case of urinary infection medical conditions should be undertaken. the Abbreviated Mental Test score or Mini and the background influence of multiple Constipation should be treated Mental State. A Barthel score to assess medications, metabolic, cerebrovascular and appropriately. age related cerebral dysfunction .However, functioning in the activities of daily living in the frail elderly who may require can also be helpful. Drug therapy should be rationalised and any unnecessary drugs discontinued. assistance with toileting and hygiene, the A bladder diary (see Factsheet 1) is very impact on the quality of life of the carer as helpful, but if this is difficult for the patient Behavioural modification including well as the patient needs to be considered. to carry out, a useful amount of information prompted voiding can be very helpful Urinary incontinence and nocturia are major can be obtained from recording timing of even in moderately confused patients. sources of carer stress and a high risk factor voids, incontinent episodes and timing of Antimuscarinic drugs are helpful, although for admission to institutional care. We drinks alone. drugs which cross the blood brain barrier also need to consider locomotor factors may increase confusion. which may influence continence. Even if the A general physical examination should be mechanisms for maintaining continence are undertaken to exclude cardiac failure and Rehabilitation where necessary should intact, difficulty in reaching the toilet due to neurological disease. The history should be be offered. The provision of aids such as severe arthritis, inability to climb stairs or able to ascertain whether the presence of raised toilet seats and urinals with one way Parkinson’s disease will render the patient an enlarged prostate or genital atrophy is valves can significantly help patients whose incontinent. the main cause of the patient’s symptoms continence is in part due to locomotor or a secondary finding. Faecal impaction difficulties. The concept of social continence The impact of chronic medical conditions is common in the frail elderly and should should be considered. Often the patient such as cardiac failure and chronic cough on be excluded. An assessment of ability to and carers goal may be to keep the patient symptoms of bladder dysfunction means a stand from sitting, gait pattern and ability to dry in certain social situations or at night. thorough medical assessment is essential. coordinate lower body undressing in order to Reaching these goals may prevent the need Polypharmacy is a common problem in void is useful. for long-term care. the elderly population. Many drugs in Detailed urodynamic investigation is not Conclusion common usage can worsen symptoms by routinely necessary or desirable in a frail Bladder dysfunction and urinary causing incomplete bladder emptying or patient but a frequency volume chart incontinence can be personally and constipation. Urinary frequency around the should be used wherever possible with an socially devastating to an elderly patient. timing of diuretic therapy can be a problem ultrasound for post void residual. and correlating symptoms with the timing of They should not be denied access to any drug therapy can be helpful. Treatment appropriate treatments and a full medical and social assessment is essential. This is The elderly should not be denied any Assessment a very important issue which will have far appropriate therapy on the grounds of reaching social and economic implications in The history should include an assessment of age alone. Investigations into suspicious view of the increasing age of the population the patient’s quality of life and the impact on symptoms such as haematuria (blood in the and the greater age related prevalence of the patient’s main carer. A detailed social urine) should be undertaken. Surgery may be these problems. Children’s Incontinence July 2005

Enuresis & Children’s Incontinence

Symptoms Assessment Bladder dysfunction is the most common A careful history focusing on bowel and For incontinent children, the next step after chronic disease in children. A major impact voiding habits should be checked to get behavioural modification is the use of a drug in quality of life and especially on self- information about dysfunctional voiding The which reduces overactivity in the bladder. esteem is well established. Therefore it main diagnostic tool is the use of a The primary therapy for neurogenic children is recommended that assessment and is an anti-muscarinic treatment. Neurogenic bladder diary (refer to factsheet 1) including treatment should occur in children after children are diagnosed and treated as registration of nocturnal diuretic volume their fifth birthday. Factsheet 5. (pad weight+1st micturition) for nocturnal (bed wetting) is defined as a normal polyuria and definition of the individual Conclusion micturition at the wrong time (night) in the functional bladder capacity (highest voided Enuresis and incontinence in children both wrong place (bed) without any daytime volume in daytime) combined with an have a great negative impact on quality symptoms. We speak about primary enuresis ultrasound assessed post voiding residual of life, with enormous effects on both the when a child was not yet continent in night- urine. child’s normal development and that of time for at least six months. Secondary An age-adjusted functional bladder capacity the family. The several treatment options enuresis means a symptom free interval of can be calculated. An adequate bodyweight outlined above are readily available and are at least six months. adjusted fluid intake should be provided. effective and safe. There are several causes of enuresis: All other investigations are as for adult -night-time polyuria, - night-time bladder procedures with the footnote that invasive storage problems and a combination of procedures in children are recommended both. A lack of the child awakening prior to only for treatment failure patients and voiding is also discussed. It is very important neurogenic or very complicated patients. to differentiate this from children’s Treatment incontinence where children are suffering from daytime symptoms with frequency Behavioural modification should first be (>7/day) and urgency, their bladder capacity utilized with timed drinking and voiding is decreased in an age related fashion and and consumption of 75% of fluid until 5pm they lose smaller amounts of urine in night- using a body weight of just volume of intake time but sometimes wet several times the and a restriction of “sweet” fluids. There same night. should be instruction of how to sit on a toilet (supported with feet at right angles and By coping mechanisms such as restricted arms on the legs) drinking and micturition fluid intake, an increased voiding frequency should be regulated every two - two and a and typical manoeuvres designed to half hours. teach them to hold on - children might be misdiagnosed as enuretics because this is When a child has emptying problems, the symptom which bothers the family most. double voiding especially before bedtime should be performed. Biofeedback training A subgroup of children suffering from lower is an option for persistent dysfunctional urinary tract symptoms are those with an voiding. emptying dysfunction of bladder and bowel which may lead to recurrent urinary tract For enuresis use of an alarm to wake infections, urinary incontinence, reflux of the child up as a form of treatment is an urine to the kidneys, faecal soiling and/or established option. Medical treatment with constipation. an agent to reduce production of fluids by the kidneys has been proven to be both effective and safe. About the ICS July 2005

The International Continence Society was Our Annual Meeting is hosted by a different • The ICS members’ book and certificate founded in 1971 by Eric Glen under the member each year, selected by members • Two bi-annual ICS newsletters name of the “Continent Club” and held its ballot four years in advance. first annual meeting the same year in Exeter • Access to other members worldwide • 2005 Montreal, Canada where 60 participants attended. In 2005, we Chair, Jacques Corcos • Information and education via our have over 2,000 members from 70 different website, office, courses and meetings. countries with over 3,000 delegates • 2006 Christchurch, New Zealand attending ICS 2004 in Paris. Chair, Ted Arnold Today, the society employs three full- time staff at its head office in Bristol, UK The ICS aims to provide education and • 2007 Rotterdam, The Netherlands and has an Executive Board comprising advancement of sciences concerned with Chair, Ruud Bosch four voluntary directors. There is also an urinary tract and pelvic dysfunction including • 2008 Cairo, Egypt Advisory Group and many committees , neurourology, gynaecology and Chair, Sherif Mourad dedicated to various tasks ensuring urodynamics. The Society also promotes the Society’s charitable objectives are research into the causes, remedies and Our membership subscription remains at £50 maintained (see chart below). relief of incontinence and provides access per annum and includes: to the results of that research via website, • Six bi-monthly copies of the Journal email, post, telephone, paper publication, Neurourology and Urodynamics newsletters and presentations, annual congresses and courses. • 40% reduction in registration to our Annual Meeting

ADVISORY GROUP

ICS ICS ICS ICS Meetings & ICS ICS ICS ICS Continence ICS ICS/CUD Ethics Neuro-Urology Scientific Nominations Children’s Standardisation Education Promotion Publications Committee Committee Committee Committee Committee Committee Committee Committee Committee Committee

Imaging Pelvic Floor Urodynamics Terminology Clinical Trials Editorial Board of Neurology ICS Publications Subcommittee Subcommittee Subcommittee Subcommittee Subcommittee and Urodynamics Journal Consultation Group

Resident Education Continuing Medical Guidelines & Standardisation Medical Student Workshops & Approved Nurses’ Education Physiotherapist Subcommittee Education Subcommittee Education Subcommittee Education Subcommittee Courses Subcommittee Subcommittee Education Subcommittee