This is the first study that attempts to define different forms of cough associated detrusor overactivity (CADO) with implications for the treatment of urinary incontinence (UI) in adult women. Historically, both surgery and medical management have been used to treat women with CADO without clarity in literature regarding when these are indicated [1,2].

This is a retrospective review of all adult women who underwent urodynamics for UI over a 7-year period (May 2011- February 2018) at a tertiary hospital. Demographic, clinical and urodynamic findings were retrieved for all patients demonstrating CADO. The cough spike immediately preceding detrusor overactivity was defined as the index cough and was assumed to be the cough that triggered the phasic contraction. Patients were stratified into four types (Figure 1) depending on the presence or absence of urinary incontinence during different phases of CADO. Measurements were made from CADO with the lowest height of the index cough which resulted in a leak when more than one CADO was noted. ALPP was the minimum pressure at which leak was observed during the study (not necessarily the index cough).  

As per departmental policy, urodynamics was offered to all women planning surgery for stress UI or mixed UI. Women with urgency UI or mixed UI received an initial trial of conservative treatment including bladder training and oral medication with urodynamics reserved for women who were refractory. 

Statistical analysis was performed using R statistical program (version 3.1.3).

Out of 7009 studies, 1338 were for women with urinary incontinence including urgency UI (174), stress UI (290) and mixed UI (874). CADO was noted in 29 (2.2%) women including 6 with clinical urgency UI, 2 with stress UI and 21 with mixed UI (p=0.102, n.s.). 11 of these women had associated spontaneous phasic detrusor overactivity during filling. Table 1 shows the characteristics of different forms of CADO. Type I was the commonest but type III was most bothersome as measured by the Patient Perception of Bladder Condition (PPBC) scale despite similar scores on the Urogenital Distress Inventory short form (UDI 6) scale. There were differences recorded in the urodynamic pattern with a shorter latency of onset as well as shorter duration of CADO contraction in patients with type II.

The phenomenon of CADO has long been recognized but remains poorly described. The most recent ICS standardization document includes this finding for the first time but fails to give any details regarding its characteristics [3]. Careful examination of urodynamic traces clearly shows that CADO is not a single condition but a heterogeneous group with different categories of patients having findings with very different implications for management. Some patients with type II and III CADO may benefit from surgery for stress UI but such surgery is inappropriate in patients with type I and IV CADO.

Defining the type of cough associated detrusor overactivity (CADO) has important implications for treatment and may help improve our understanding of this condition.

Duecy EE, Buchsbaum GM, Flynn M. Presenting symptoms and management of cough-induced detrusor contractions. https://www.ics.org/Abstracts/Publish/44/000198.pdf. Accessed April 1, 2018.
Serels SR, Rackley RR, Appell RA. Surgical Treatment For Stress Urinary Incontinence Associated With Valsalva Induced Detrusor Instability. The Journal of Urology. 2000;163(3):884-887. doi:10.1016/s0022-5347(05)67827-5.
Rosier PF, Schaefer W, Lose G, et al. International Continence Society Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study. Neurourology and Urodynamics. 2016;36(5):1243-1260. doi:10.1002/nau.23124.