Assessment of Lower Urinary Tract Symptoms

Introduction

Lower urinary tract symptoms (LUTS) refer to symptoms that result from conditions and diseases affecting the bladder and the urethra. These consist of:

• Urinary incontinence symptoms, including stress urinary incontinence; urgency urinary incontinence; mixed urinary incontinence; nocturnal enuresis; postural incontinence; continuous, insensible and coital incontinence.
• Bladder storage symptoms, which include the overactive bladder symptoms urgency, frequency and nocturia with or without urgency incontinence.
• Voiding symptoms, which include urinary retention, hesitancy, straining to void, slow and/or interrupted stream, splitting or spraying, terminal dribble, position dependent micturition and incomplete emptying.
• Post-micturition symptoms, which include post-micturition leakage.
• Suspicious symptoms and signs such as haematuria (blood in the urine) and dysuria (pain on passing urine) that may indicate other pathology such as bladder tumour, stone disease, or urinary tract infection.

History

Assessment begins with taking a thorough history. The following queries are made to elucidate the patient’s particular constellation of symptoms:

• Which of the above symptoms are present.
• Symptom frequency and severity.
• Variation between night-time and daytime symptoms.
• Precipitating or relieving factors.
• Prior treatments and their success.
• Coping measures used by the patients to improve their symptoms.
• The impact of the symptoms on quality of life and social function.
  Increasingly, validated questionnaires are being used to better characterise patients’ LUTS and to provide an objective means of determining response to therapy. The International Consultation on Incontinence has developed a comprehensive questionnaire, the ICIQ (www.iciq.net). The ICIQ has modules for men and women that assess LUTS as well as associated effects on quality of life and sexual function.

Frequency Volume Chart / Bladder Diary

Both the patient and the treating practitioner gain great knowledge and insight into the individual’s LUTS if a frequency/volume chart (bladder diary) is completed. For three days, the patients record the time they get up and go to bed, their fluid intake, the volume of urine passed each time they void, every episode of incontinence and the use of incontinence pads. Patients may also be asked to keep a food diary to assess the quantity of water-containing foods eaten each day. Some practitioners also add items such as number of urgency episodes, but care must be taken not to overload the patient with demands for information. The frequency/volume chart is particularly helpful in assessing nocturnal polyuria vs. nocturia, excessive urine volumes during the night vs. an excess number of night-time urination episodes.

Physical Examination

• Clinical cardiovascular and respiratory examination to exclude signs of heart failure.
• Abdominal examination to exclude a pelvic mass or palpable bladder.
• Clinical neurological examination.
• Pelvic examination in women to assess oestrogen status and the presence of pelvic organ prolapse or other pelvic or lower genital tract pathology.
• Digital rectal examination in men to assess prostate size and the presence or absence of a nodule.

Urine Analysis

This should be performed on every patient and can be done with a diagnostic urine “dipstick” to exclude:

• Blood in the urine.
• The possibility of urinary tract infection. This may be indicated by a positive test for nitrites or white cells and would be confirmed by urine culture.
• Glucose in the urine.

Urinary tract imaging (ultrasound or CT scan)

This is not routinely performed unless there is a specific indication such as blood in the urine, recurrent urinary tract infections or complicated voiding dysfunction.

Urinary tract endoscopy

Similarly, this is not routinely performed unless there is a specific indication such as blood in the urine or a symptom such as bladder pain.

Urodynamic Studies

Many patients are treated once a diagnosis is made on the basis of the history and clinical examination provided the treatment is safe and cost-effective. Examples of such interventions include lifestyle modifications, pelvic floor muscle training for stress, urgency or mixed incontinence, bladder training and antimuscarinic medications for overactive bladder and alpha-receptor antagonists for outlet obstruction in men and women. Should a patient present with complex voiding dysfunction, fail to respond to the above measures, has had a previous surgical intervention or if treatment is potentially hazardous, then a urodynamic evaluation is desirable.
Urodynamic studies range in complexity:

• Urine flow measurement (uroflowmetry) in conjunction with assessment of bladder emptying, by catheterisation or ultrasound, is a simple non-invasive screening test, which is used to assess voiding patterns and post-void residual volumes and may also be used for objective assessment of response to therapy.
• Filling cystometry is the test of choice for storage symptoms such as OAB or incontinence of any type.
• Pressure flow studies of voiding are able to confirm whether the patient’s symptoms are due to bladder outlet obstruction or an underactive detrusor muscle.
  Complex testing such as video urodynamics is indicated when anatomic detail is required in addition to information on lower urinary tract function.

Conclusion

The assessment of a patient with LUTS ranges from baseline history, clinical examination, urine analysis and frequency volume bladder diaries, to a series of investigations as mandated by the clinical situation including imaging, endoscopy and urodynamic investigations.
It should be staged, methodical and sufficiently extensive to provide a sound anatomic and physiologic basis for establishing a diagnosis, managing the patient’s symptoms and monitoring treatment outcomes.

References

1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Neurourol Urodyn. 2002; 21(2):179-83.
2. Avery K, Donovan J, Peters TJ, et al. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23(4):322-30.
3. Chapple CR, Wein AJ, Abrams P, et al. Lower urinary tract symptoms revisited: a broader clinical perspective. Eur Urol 2008; 54(3):563-9.
4. Rosier PF, Gajewski JB, Sand PK, et al; International Consultation on Incontinence 2008 Committee on Dynamic Testing. Executive summary: The International Consultation on Incontinence 2008—Committee on: “Dynamic Testing” for urinary incontinence and for faecal incontinence. Part I: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients. Neurourol Urodyn 2010:29(1):140-5.
5. Mehdizadeh JL, Leach GE. Role of urodynamic testing in benign prostatic hyperplasia and male lower urinary tract symptoms. Urol Clin North Amer 2009; 36(4):431-41.
6. Bosch JL, Weiss JP. The prevalence and causes of nocturia. J. Urol. 2010; 184(2); 440-6.
7. Haylen BT1, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20.