Introduction: Challenges in the Detection and Diagnosis of Bladder Dysfunction

INTRODUCTION Challenges in the Detection and Diagnosis of Bladder Dysfunction: Optimal Strategies for the Primary Care Physician Herbert Lepor, MD Department of Urology, New York University School of Medicine, New York, NY [Rev Urol. 2004;6(suppl 1):S1-S2] © 2004 MedReviews, LLC ladder dysfunction is a common condition that affects millions of persons and is particularly common in the elderly. It has been estimated that 15% to 30% of all older persons living in the community and at least one half of those being managed in long-term care facilities have urinary incontinence.1 Urinary incontinence has a significant negative impact on quality of life and may result in serious complications, including urinary tract infections, cellulitis, pressure ulcers, loss of sleep, depression, sexual impairment, and falls and fractures.1-3 Although the pathophysiology of bladder dysfunction remains incompletely understood, there have been important advances in both the evaluation and management of patients with this condition. The 6 articles comprising this supplement summarize the age-related changes in the bladder that may lead to lower urinary tract symptoms (LUTS), challenges involved in detection and diagnosis of bladder dysfunction, new approaches to differential diagnosis, and treatment options for patients with this condition. M. B. Siroky, MD, reviews age-related changes in the structure and function of the bladder and how these changes may lead to dysfunction and LUTS, including urinary incontinence. He notes that key mechanisms underlying voiding dysfunction in older persons include diminished detrusor muscle function, fibrosis of the bladder wall, and increased sensitivity to autonomic nervous system neurotransmitters, particularly norepinephrine. These changes may result in reduced bladder capacity, an increase in uninhibited detrusor contractions, decreased urinary flow rate, diminished urethral pressure profile, and increased postvoid residual urine volume (PVR). Herbert Lepor, MD, focuses on the evaluation of patients with benign prostatic hyperplasia (BPH), a condition that has been estimated to affect 50% of men aged 51 to 60 years and 90% of men older than 80 years in the United States.4 Dr Lepor notes that the first aim when evaluating men with LUTS is to exclude other conditions that may mimic BPH. Patient assessment should include determination of the American Urological Association (AUA) symptom score, detailed medical history taking, digital rectal examination, urinalysis, and measurement of serum prostate-specific antigen (PSA). Dr Lepor also emphasizes that prostate cancer and BPH may coexist in many patients and that the presence of prostate cancer B VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY S1 Introduction continued substantially alters patient management. Assessment of baseline symptom severity is important in men with BPH for making the decision of whether to initiate therapy and for future evaluation of effects of therapy. Evaluation of baseline symptom severity should include determination of the AUA symptom score and measurement of PVR, which can be readily accomplished using a small, portable ultrasonography device. Richard S. Pelman, MD, reviews challenges in the detection and diagnosis of bladder dysfunction, with particular emphasis on the primary care setting. Primary care physicians must become familiar with the current definitions of specific conditions associated with bladder dysfunction, as well as with new diagnostic tools. Dr Pelman pays particular attention to overactive bladder (OAB), a condition defined as urinary urgency with or without urge incontinence, usually with frequency and nocturia, in the absence of a pathologic or metabolic condition that might explain these symptoms. This disorder affects approximately 16% of men and women in the United States and has an associated annual cost exceeding $12 billion.5,6 Dr Pelman also emphasizes the importance of careful history taking, physical examination, laboratory testing, use of voiding diaries, and measurement of PVR using ultrasound in the diagnosis of OAB. Naoki Yoshimura, MD, PhD, and Michael B. Chancellor, MD, follow with an overview of the evaluation and treatment of impaired bladder emptying. They note that incomplete bladder emptying can result from many conditions, including urethral obstruction, shy bladder syndrome, and detrusor areflexia, and that it is often associated with an injury or disease (eg, spinal cord injury, disc herniation, acquired immunodeficien- S2 VOL. 6 SUPPL. 1 2004 cy syndrome, Lyme disease, herpes zoster, neurosyphilis) that affects the normal neural control of the bladder. Treatment options for patients with urinary retention include biofeedback to teach muscle relaxation, drug therapy with bethanechol chloride, and sacral nerve neuromodulation. Recent studies have also shown that injection of botulinum toxin to suppress pelvic floor spasticity may be effective in patients who are refractory to first-line therapies. Christopher E. Kelly, MD, reviews different approaches to the evaluation of voiding dysfunction and bladder volume in patients with LUTS. He notes that uroflowmetry, which measures urine voided per unit time, is effective for the identification of patients who need further urodynamic studies but cannot definitively diagnose bladder outlet obstruction, as it does not distinguish true obstruction from poor contractility. Measurement of PVR is particularly useful in assessing voiding dysfunction and identifying patients who may have bladder outlet obstruction. PVR can now be measured accurately, conveniently, and noninvasively with portable ultrasound bladder scanners.7,8 These devices have several important advantages over catheterization for measurement of PVR, including improved cost-effectiveness and no risk of urethral trauma or urinary tract infection. Bladder ultrasound may also be used to determine bladder wall thickness and mass, both of which have been associated with outflow obstruction. Khaled A. Imam, MD, CMD, summarizes the role of the primary care physician in managing patients with bladder dysfunction. He notes that primary care practitioners are ideally positioned to screen for and manage bladder dysfunction but that many clinicians fail to assess their elderly patients for this condition.9 Dr Imam REVIEWS IN UROLOGY provides a concise diagnosis and treatment algorithm designed to streamline the evaluation and management of patients with bladder dysfunction. Key features of this algorithm are an emphasis on PVR determination as an essential component of the evaluation of persons with incontinence and the recommendation that management should be tailored to the individual patient. In summary, this supplement provides primary care physicians and other practitioners with essential upto-date information about the etiology of bladder dysfunction; new safe and convenient tools, such as portable ultrasound bladder scanners, that can improve diagnosis; and treatment options for patients with this condition. We hope that these targeted reviews will help clinicians improve the diagnosis and effective management of this common, but undertreated, condition. References 1. 2. 3. 4. 5. 6. 7. 8. 9. Fantl JA, Newman DK, Colling J. Cinical Practice Guideline Number 2 Update: Urinary Incontinence in Adults: Acute and Chronic Management. Rockville, Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services; 1996. Publication AHCPR 96-0682. Tromp AM, Smith JH, Deeg DJH, et al. Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J Bone Miner Res. 1981; 13:1932-1939. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? J Am Geriatr Soc. 2000; 48:721-725. McConnell JD. Epidemiology, etiology, pathophysiology, and diagnosis of benign prostatic hyperplasia. In: Walsh PC, Retic AB, Vaughan ED Jr, Wein AJ, eds. Campbell's Urology. Vol 2. 7th ed. Philadelphia: WB Saunders Co; 1998:14291452. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20:327-336. Hu TW, Wagner TH, Bentkover JD, et al. Estimated economic costs of overactive bladder in the United States. Urology. 2003;61:1123-1128. Frederickson M, Neitzel JJ, Miller EH, et al. The implementation of bedside bladder ultrasound technology: effects on patient and cost postoperative outcomes in tertiary care. Orthop Nurs. 2000;19:79-87. Marks LS, Dorey FJ, Macairan ML, et al. Threedimensional ultrasound device for rapid determination of bladder volume. Urology. 1997; 50:341-348. Bland DR, Dugan E, Cohen SJ, et al. The effects of implementation of the Agency for Health Care Policy and Research urinary incontinence guidelines in primary care practice. J Am Geriatr Soc. 2003;51:979-984.