Jessica M. DeLong, MD
Kurt A. McCammon, MD, FACS
BASICS
DESCRIPTION
• Urgency is the complaint of a sudden compelling desire to void that is difficult to defer while frequency is the complaint by a patient that he or she voids too often
• Urgency:
– Urgency is the most common symptom of overactive bladder (OAB).
– Urge incontinence is involuntary leakage of urine preceded by the above symptom (1).
• Frequency:
– There is no minimum number of voids.
– Nocturia is the complaint of waking at night to void one or more times.
• These are classified as storage symptoms.
EPIDEMIOLOGY
Incidence
Not well known; one study showed 9.2%
Prevalence
Estimates vary
RISK FACTORS
• Dependent upon etiology
– Older age
Genetics
N/A
PATHOPHYSIOLOGY
• Inflammation/irritation
– Infection, malignancy, urinary lithiasis, etc.
• Neurogenic
• Myogenic (2)
• Polyuria
• Idiopathic
ASSOCIATED CONDITIONS
• Bladder outlet obstruction
• Diverticulosis
• Dysfunctional voiding
• Interstitial cystitis (IC)/painful bladder syndrome (PBS)
• OAB
• Urinary tract infection (UTI)
• Vaginitis
GENERAL PREVENTION
• Treat any underlying condition (eg, UTI)
• Maintain good voiding habits and regular bowel pattern
DIAGNOSIS
HISTORY
• Use validated questionnaires when possible
– International prostate symptom score (IPSS), IPSS-QOL
– Urgency sensation scale
• Irritative voiding symptoms:
– Urgency, frequency, urge incontinence, nocturia
• Obstructive voiding symptoms:
– Hesitancy, slow stream, post-void dribbling, retention
– Consider causes of bladder outlet obstruction
• Other medical history
– Stone disease
– Malignancy such as bladder cancer
• Symptoms of infection
• Episodes of gross hematuria
• Bowel habits
• Sexual function
• Current medications
– Diuretics, alpha blockers
• Tobacco use
• Family history
• Pregnancy is normally associated with urinary frequency
• Voiding diary, nature, and volume of fluid intake
PHYSICAL EXAM
• In males:
– External genital exam to evaluate for phimosis, evidence for lichen sclerosis (LS), urethral discharge or mass
– Digital rectal exam (DRE) to:
Evaluate prostate size, nodularity
Assess for rectal mass or fecal impaction
Assess perineal sensation, bulbocavernosus reflex, anal sphincter tone
• In females:
– Pelvic exam to:
Assess for mass, pelvic floor support
Detect stress urinary incontinence (SUI by employing Valsalva manuever
Assess urethral lesions or discharge
• General exam for peripheral edema
• Focused neurologic exam
– Mental status exam
– Motor deficits, gait stability
– Sensory deficits, reflexes
• Abdominal exam
– Palpable mass (retention, fibroids, etc.)
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis (UA): Exclude other pathology
– Specific gravity
– Presence of leukocyte esterase (LE), nitrates, and pyuria suggests UTI
– Microhematuria necessitates further work up
Cystoscopy, triphasic CT
– Glucose: Assess for diabetes
– Protein: Assess for medical renal disease
Obtain culture if UA suggestive of infection
– Urinary cytology to rule out urothelial carcinoma
Imaging
• Renal/bladder ultrasound (US):
– If bladder outlet obstruction (BOO) suspected (ie, elevated PVR)
– If renal insufficiency
• Dedicated pelvic US (female):
– If adnexal mass or uterine abnormality noted on pelvic exam
• KUB may be appropriate initial study if stones are suspected
• CT:
– If hematuria, triphasic CT is standard of care
– If stones suspected, non-contrast CT
ALERT
If UA suggests infection or hematuria, appropriate evaluation is key.
Diagnostic Procedures/Surgery
• Check post void residual (PVR)
• Cystoscopy:
– If hematuria or persistent problems
May detect bladder pathology (tumor, calculus), BOO
• Urodynamics (UDS):
– If conservative therapy fails
– Can help define treatment options and evaluate for neurogenic component
Pathologic Findings
Dependent upon etiology
DIFFERENTIAL DIAGNOSIS
• Inflammation—UTI, urethritis
• Radiation cystitis
• IC/PBS
• Trauma—local or neurologic
• Foreign body
• Neurologic condition (ie, spina bifida, spinal cord injury, neuropathy)
• Neoplasm—urologic or nonurologic by local extension
– Urothelial carcinoma, especially CIS, often causes urinary frequency
• Urolithiasis
• Polyuria
• Drugs—diuretics, irritants
• Gynecologic-vaginitis, pregnancy
TREATMENT
GENERAL MEASURES
• Based on underlying etiology
– Treat UTI with appropriate antibiotics
– Initiate appropriate workup and management of hematuria
• In general, treatment is divided into:
– Conservative (behavioral)
– Pharmacotherapy
– Surgery
MEDICATION
First Line
• Choice based on etiology
• Antimuscarinics are used to inhibit detrusor contractions by competitively inhibiting muscarinic cholinergic receptors. Common side effects: dry mouth and constipation. Maximal effect after 3 mo
– Oxybutynin
5 mg PO TID; XL 15 mg daily-BID
Transdermal patch 3.9 mg/d: may be good option to avoid cognitive side effects
– Trospium 20 mg PO BID; XR 60 mg PO daily
– Tolterodine 1–2 mg PO BID
– Darifenacin 7.5–15 mg PO daily
– Solifenacin 5–10 mg PO daily
• β-3 adrenergic receptor antagonist: A newer drug; induces detrusor relaxation
– Mirabegron 25–50 mg PO daily
• α-Blockers are used to decrease outflow obstruction due to prostatic hypertrophy. Common side effects: dizziness, retrograde ejaculation
– Tamsulosin 0.4 mg PO qhs
– Alfuzosin 10 mg PO daily
– Terazosin start 1 mg PO qhs, titrate up to 20 mg
– Doxazosin start 1 mg PO daily titrate to 8 mg
– Silodosin 8 mg PO daily
• 5-α-reductase inhibitors are used to lower DHT in men with prostates >40 cc. Are synergistic with α-blockers and take 6–12 mo for maximum effect:
– Finasteride 5 mg PO daily
– Dutasteride 0.5 mg PO daily
Second Line
• PDE5 inhibitors
– Documented efficacy for men with lower urinary tract symptoms (LUTS)/OAB
FDA approved for signs and symptoms of BPH with our without erectile dysfunction
• Imipramine
– No good quality RCTs
• Estrogens (vaginal superior to systemic) may be beneficial for post-menopausal women
– Contraindicated if history of venous thromboembolism (VTE), breast cancer
SURGERY/OTHER PROCEDURES
• Intravesical botulinum toxin A (onabotulinumtoxinA) injection
– If refractory to pharmacologic therapy
– Decreases bladder contraction
– Clean intermittent catheterization (CIC) may be necessary postoperatively
• Sacral neuromodulation: Interstim® implantation
– Stimulation of S3 afferent nerve
– 2-stage procedure; revision rates 7–33%
– Not recommended in neurogenic voiding dysfunction, elderly
• Correction of BOO
– Transurethral resection of prostate (TURP); transurethral incision of prostate (TUIP)
• Correction of pelvic floor prolapse in females
• If fails all other therapy and associated with incontinence can consider bladder augmentation or urinary diversion
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Behavioral therapy is first-line
– Bladder training may include biofeedback and pelvic floor physical therapy
– Timed voiding
– Kegel exercises may be of benefit
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Generally a long-term problem; dependent on etiology
COMPLICATIONS
Common side effects of pharmacotherapy include dry mouth and constipation
FOLLOW-UP
Patient Monitoring
• Depends upon etiology, treatment, response
– Often periodic visit with voiding diary, uroflow, PVR
Patient Resources
MedlinePlus: Frequent or urgent urination. http://www.nlm.nih.gov/medlineplus/ency/article/003140.htm
REFERENCES
1. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: Report from the standardization sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167–178.
2. Michel MC, Chapple CR. Basic mechanisms of urgency; preclinical and clinical evidence. Eur Urol. 2009;56:298–308.
3. Xin Z, Huang Y, Lu J, et al. Addition of antimuscarinics to alpha-blockers for treatment of lower urinary tract symptoms in men: A meta-analysis. Urology. 2013;82:270–277.
ADDITIONAL READING
N/A
See Also (Topic, Algorithm, Media)
• Bladder Outlet Obstruction (BOO)
• Incontinence, Urinary, Adult Female
• Lower Urinary Tract Symptoms (LUTS)
• Neurogenic Bladder
• Overactive Bladder (OAB)
• Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC)
• Prostate, Benign Hyperplasia/Hypertrophy (BPH)
• Prostatitis, General
CODES
ICD9
• 596.51 Hypertonicity of bladder
• 788.41 Urinary frequency
• 788.63 Urgency of urination
ICD10
• N32.81 Overactive bladder
• R35.0 Frequency of micturition
• R39.15 Urgency of urination
CLINICAL/SURGICAL PEARLS
• Hematuria warrants appropriate workup. May be a presentation of genitourinary malignancy.
• Anticholinergics are contraindicated in patients with untreated narrow-angle glaucoma.
• Combination of antimuscarinics plus alpha blockers may be better than either alone for men with LUTS (3).
• Use anticholinergics with caution in elderly patients, as cognitive effects may be pronounced.
• Use of intravaginal estrogen for postmenopausal women may worsen incontinence.