Relationship of fluid intake to voluntary micturition and urinary incontinence in geriatric patients

Compliance to Individualized Recommendations Based on an Evidence-Based Algorithm for Behavioral Management of Lower Urinary Tract Symptoms

PURPOSE

The aim of this study was to evaluate patient compliance to individualized recommendations for self-management of fluid intake, bladder irritants, and timing of fluid consumption.

DESIGN

Single-group, before-after pilot study.

SUBJECTS AND SETTING

The sample comprised 22 patients (17 male and 5 females, mean age 62 years, age range 27-84 years). The study setting was the uroflow clinic at Southmead Hospital, Bristol, UK, a tertiary level referral hospital for complex evaluation and treatment of urological patients.

METHODS

Patients were given a bladder diary to complete after 2 weeks, which was compared with the bladder diary they had originally brought to clinic, to see whether the advice was followed. The bladder diary used required the patient to document the times and volumes of urination over a period of 3 days, magnitude of urinary urgency felt at the time, along with fluid intake timing, amount, and type of beverage. The study was not designed to measure changes in symptoms, but observed changes recorded in the bladder diaries are reported.

RESULTS

All 6 of the 22 participants who were advised to increase the volume of fluid intake complied, with an increased average intake of a mean of 520 mL (range 100-1450 mL). Similarly, one participant advised to reduce fluid intake decreased their fluid intake by 1800 mL per day. Thirteen out of 16 patients (81%) who were advised to remove caffeine, alcohol, or artificial sweeteners from their diet complied, indicated by no bladder irritant being recorded on their bladder diary. Nine out of 12 patients (75%) advised to reduce fluid intake in the evenings complied, decreased fluid intake after 6 PM by an average of 240 mL (range 100-550 mL less).

CONCLUSIONS

A majority of participants given fluid intake advice that is specific to their symptoms and lifestyle complied with recommendations. Simple guidance could usefully be given to patients before they are referred to specialist urological care or undergo urodynamic testing.

What do we really know about the role of caffeine on urinary tract symptoms? A scoping review on caffeine consumption and lower urinary tract symptoms in adults

AIMS

The purpose of this scoping review was to map out the existing literature on caffeine intake and lower urinary tract symptoms (LUTS) in adults.

METHODS

In this scoping review, we searched for all studies available until June 2019 in MEDLINE, Embase, CINAHL, Cochrane Central Register, PsycINFO, LILACS, LiSSa, Web of Science, and Joanna Briggs Institute electronic databases, in addition to a hand search of the bibliographies of all relevant articles and a gray literature search. Both intervention studies on the effects of caffeine reduction in adults with LUTS and observational studies on the association between caffeine intake and LUTS-related outcomes in adults were included and assessed for methodological quality by two independent reviewers.

RESULTS

Fourteen intervention and 12 observational studies were included. Overall, there was a decrease in urgency episodes (level of evidence 2, grade of recommendation B) and nocturnal enuresis episodes (4, C) with caffeine reduction. Observational studies reported an unclear association between caffeine intake and LUTS-related outcomes. Most importantly, this present review highlighted high heterogeneity in the studied populations, caffeine measures, and reported outcomes. There was also unknown or high risk of bias in most identified studies.

CONCLUSIONS

Caffeine reduction appears to reduce LUTS. Future studies on caffeine reduction interventions should target populations with urgency and urge urinary incontinence, which show the most promising results, and include valid and reliable measures of caffeine intake and LUTS. Finally, future studies should also use reporting guidelines to ensure lower risk of bias.

A systematic approach to the investigation and treatment of nocturia

Level of evidence: 4.

Managing autonomic dysfunction in Parkinson's disease: a review of emerging drugs

Introduction: Autonomic dysfunction is an integral part of Parkinson disease (PD) complex and can be seen both in early and advanced stages. There is a paucity of medicines available to manage autonomic dysfunction in PD and this adds to the considerable morbidity associated with the illness.Areas covered: The pathophysiology and the available therapeutic options of autonomic dysfunction seen in PD are discussed in detail. The potential targets for novel regimens are reviewed and the available literature on the drugs emerging in management of autonomic dysfunction in PD is highlighted.Expert opinion: In the current scenario, there are several drugs that can be tried for constipation viz stool laxatives, prucalopride, prokinetic agents and a high fiber diet. Bladder dysfunction has been treated with β-agonists and with mirabegron, a selective β-3 agonist, the anticholinergic side effects are minimized, and the drug has been found to be effective. Orthostatic hypotension is managed with midodrine while droxidopa is a new drug with promising efficacy. Botulinum toxin works best for management of sialorrhea, but repeated injections are needed.

Surgical treatment of post-prostatectomy stress urinary incontinence in adult men: Report from the 6th International Consultation on Incontinence

AIMS

To report the recommendations of the 6th International Consultation on Incontinence (ICI) on post-prostatectomy urinary incontinence.

METHODS

The 6th ICI committee on surgical treatment of urinary incontinence in men assessed and reviewed the outcomes of surgical therapy and updated the prior recommendations published in 2013. Articles from peer-reviewed journals, abstracts from scientific meetings, and literature searches by hand and electronically formed the basis of this review. The resulting guidelines were presented at the 2016 ICI meeting in Tokyo, Japan.

RESULTS

Voiding diary and pad tests are valuable for assessing quantity of leakage. Cystoscopy and/or urodynamics may be useful in guiding therapy depending on the type of incontinence and presumed etiology. Artificial Urinary Sphincter (AUS) is the preferred treatment for men with moderate to severe stress urinary incontinence (SUI) after RP. Male slings are an acceptable approach for men with mild to moderate SUI. Much discussion centers on the definition of moderate SUI. Injectable agents have a poor success rate in men with SUI. Options for recurrent SUI due to urethral atrophy after AUS implantation include changing the pressure balloon, downsizing the cuff and increasing the amount of fluid in the system. Infection and/or erosion demand surgical removal or revision of all or part of the prosthesis.

CONCLUSIONS

Although there are several series reporting the outcomes of different surgical interventions for PPUI, there is still a need for prospective randomized clinical trials. Recommendations for future research include standardized workup and outcome measures, and complete reporting of adverse events at long-term.

Treatment Options for Urogenital Dysfunction in Parkinson's Disease

Urogenital dysfunction is commonly reported in Parkinson’s disease (PD), and history taking and a bladder diary form the cornerstone of evaluation. The assessment of lower urinary tract (LUT) symptoms include urinalysis, ultrasonography, and urodynamic studies and help to evaluate concomitant urological pathologies such as benign prostate enlargement. Antimuscarinic medications are the first line treatment for overactive bladder (OAB) symptoms and solifenacin has been specifically studied in PD. Antimuscarininc drugs may exacerbate PD-related constipation and xerostomia, and caution is advised when using these medications in individuals where cognitive impairment is suspected. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Intradetrusor injections of botulinum toxin have been shown to be effective for detrusor overactivity, however, are associated with the risk of urinary retention. Neuromodulation is a promising, minimally invasive treatment for PD-related OAB symptoms. Erectile dysfunction is commonly reported and first line treatments include phosphodiesterase-5 inhibitors. A patient-tailored approach is required for the optimal management of urogenital dysfunction in PD.

Nocturia in Parkinson's Disease: Why Does It Occur and How to Manage?

BACKGROUND

Nocturia is one of the commonest nonmotor symptoms in Parkinson's disease (PD) and has a significant impact on quality of life both for patients and their carers. There exists a relation between nocturia and poor sleep quality, falls, and institutionalization. Nocturia may manifest as a result of reduced functional bladder capacity or nocturnal polyuria; however, most often the cause is multifactorial. Disorders of circadian rhythm regulation are known to occur with sleep disturbances in PD may also contribute to nocturia.

METHODS AND RESULTS

In this review, an overview of the assessment and management of nocturia in patients with PD is presented. History taking, medication review, and a bladder diary form the cornerstone of the evaluation. Urinalysis, ultrasonography, and urodynamic studies help to assess the cause for lower urinary tract symptoms and exclude concomitant pathologies, such as bladder outlet obstruction. Antimuscarinic medications are the first-line treatment for the overactive bladder; however, caution is needed when using these medications in individuals predisposed to cognitive impairment. Desmopressin is effective for managing nocturnal polyuria.

CONCLUSIONS

An individualized approach is recommended to optimize the management of nocturia in PD.

Impact of Dry Mouth on Fluid Intake and Overactive Bladder Symptoms in Women taking Fesoterodine

PURPOSE

We investigated the long-term relationships between dry mouth, fluid intake and overactive bladder symptoms in women undergoing treatment with fesoterodine. We hypothesized that women who experienced dry mouth would increase their fluid intake and worsen their urinary symptoms.

MATERIALS AND METHODS

We conducted a prospective ancillary study to a 9-month open-label trial of fesoterodine for women with urgency urinary incontinence. Fluid intake was measured and compared according to reported dry mouth. Multivariable analysis was used to study the interaction between dry mouth, fluid intake and urinary symptoms.

RESULTS

During the study 407 women without dry mouth significantly reduced their fluid intake (mean decrease 172.1 ml, median 118.3 ml, p = 0.02), while 91 women with dry mouth did not (mean decrease 95.8 ml, median 118.3 ml, p = 0.54). On univariable analysis a greater proportion of women who experienced dry mouth reported improvement in their urinary symptoms compared to women without dry mouth (60.5% vs 47.2%, p = 0.03). On multivariable analysis black women were less likely to report dry mouth (OR 0.4, 95% CI 0.2-0.9, p = 0.03) and older women were less likely to report improvement in urinary symptoms (OR 0.98, 95% CI 0.96-0.99, p = 0.003). Factors not associated with improvement in urinary symptoms on multiple regression were dry mouth, baseline fluid intake volume, change in fluid intake volume and caffeine intake volume.

CONCLUSIONS

In women with overactive bladder receiving fesoterodine dry mouth may prevent restriction of fluid intake but does not diminish treatment efficacy.

Impact of behaviour and lifestyle on bladder health

Bladder conditions, including UTI, UI, and bladder cancer, are highly prevalent and affect a wide range of populations. There are a variety of modifiable behavioral and lifestyle factors that influence bladder health. Some factors, such as smoking and obesity, increase the risk or severity of bladder conditions, whereas other factors, such as pelvic floor muscle exercise, are protective. Although clinical practice may be assumed to be the most appropriate ground for education on behavioral and lifestyle factors that influence bladder health, it is also crucial to extend these messages into the general population through public health interventions to reach those who have not yet developed bladder conditions and to maximize the prevention impact of these behaviors. Appropriate changes in these factors have the potential for an enormous impact on bladder health if implemented on a population-based level.

A cutoff value based on analysis of a reference population decreases overestimation of the prevalence of nocturnal polyuria

PURPOSE

We sought criteria for nocturnal polyuria in asymptomatic, nonurological adults of all ages by reporting reference values of the ratio of daytime and nighttime urine volumes, and finding nocturia predictors.

MATERIALS AND METHODS

Data from a database of frequency-volume charts from a reference population of 894 nonurological, asymptomatic volunteers of all age groups were analyzed. The nocturnal polyuria index and the nocturia index were calculated and factors influencing these values were determined by multivariate analysis.

RESULTS

The nocturnal polyuria index had wide variation but a normal distribution with a mean ± SD of 30% ± 12%. The 95th percentile of the values was 53%. Above this cutoff a patient had nocturnal polyuria. This value contrasts with the International Continence Society definition of 33% but agrees with several other reports. On multivariate regression analysis with the nocturnal polyuria index as the dependent variable sleeping time, maximum voided volume and age were the covariates. However, the increase in the nocturnal polyuria index by age was small. Excluding polyuria and nocturia from analysis did not alter the results in a relevant way. The nocturnal voiding frequency depended on sleeping time and maximum voided volume but most of all on the nocturia index.

CONCLUSIONS

The prevalence of nocturnal polyuria is overestimated. We suggest a new cutoff value for the nocturnal polyuria index, that is nocturnal polyuria exists when the nocturnal polyuria index exceeds 53%. The nocturia index is the best predictor of nocturia.

Fluid intake and voiding parameters in asymptomatic Turkish women

INTRODUCTION AND HYPOTHESIS

For an accurate evaluation of bladder diaries, we aim to investigate normal urinary habits and determining factors on functional bladder capacity, frequency, and 24-h volume in the bladder diaries of asymptomatic women.

METHODS

One-hundred and fifteen asymptomatic women who recorded a 24-h bladder diary were included in the study. Linear regression analyses were used to explore associations between diary values and patient characteristics.

RESULTS

Total number of voids was related to age, body mass index, total voided volume, total fluid intake, total diuresis rate, and maximum fluid intake in one go. Maximum, average, and minimum volumes per void were found to be related to body mass index, total voided volume, total fluid intake, total diuresis rate, and maximum fluid intake. When we used multiple regression analysis, only maximum fluid intake was found to be related to the total number of voids, maximum, average, and minimum volumes per void.

CONCLUSIONS

Maximum fluid intake rather than total voided volume seems to be an important determinant factor for total number of voids and functional bladder capacity.

Practical management of nocturia in urology

Until last decades, nocturia has been considered as an irritative symptom of benign prostatic hyperplasia (BPH), but the nocturia is unresponsive symptoms to various modalities of BPH treatment. More recently, it has been recognized that the prostate is not so quite important as previously believed, as nocturia is equally common in women. The understanding of nocturia has been much changed in last decade; it is a highly prevalent condition, and symptoms in men and women are really no different either quantitatively or qualitatively. The successful introduction of desmopressin (l-deamino-8-D-arginine vasopressin, DDAVP) to decrease nocturnal urine output in severe nocturia which resistant to conventional BPH treatment and in women demonstrated new perspectives in management of nocturia. We reviewed the definition and etiologies of nocturia, offering the current diagnostic procedures and standards of care.

Fluid intake and risk of stress, urgency, and mixed urinary incontinence

OBJECTIVE

We investigated the relation between total fluid intake and incident urinary incontinence in the Nurses' Health Study cohorts.

STUDY DESIGN

We measured daily fluid intake using food frequency questionnaires among 65,167 women, who were 37-79 years old, without urinary incontinence at study baseline (2000-2001). Women reported incontinence incidence on questionnaires during 4 years of follow-up evaluation. Multivariable-adjusted hazard ratios and 95% confidence intervals were calculated with Cox proportional hazards models.

RESULTS

We found no association between total fluid intake and risk of incident incontinence (hazard ratio, 1.04; 95% confidence interval, 0.98-1.10; comparing top vs bottom quintile of fluid intake). In analyses of incontinence type, total fluid intake was not associated with risks of incident stress, urgency, or mixed incontinence.

CONCLUSION

No significant risk of incident urinary incontinence was found with higher fluid intake in women. These findings suggest that women should not restrict their fluid intake to prevent incontinence development.

Nocturia

Nocturia is a common symptom in women which has profound negative impact on the quality of life. With the increase in aging population, nocturia is becoming an important clinical problem. A proper understanding of cardio-respiratory, metabolic, and neurological patho-physiology of nocturia is imperative for appropriate management of nocturia. When managing a patient with nocturia it is important to evaluate the patient as a whole rather than from urological perspective only. In this article we attempt to discuss the definition, etiology, clinical features and management of nocturia so that a comprehensive approach to management can be adopted when faced with a woman complaining of nocturia.

Medical management of overactive bladder

Overactive bladder (OAB), as defined by the International Continence Society, is characterized by a symptom complex including urinary urgency with or without urge incontinence, usually associated with frequency and nocturia. OAB syndrome has an incidence reported from six European countries ranging between 12-17%, while in the United States; a study conducted by the National Overactive Bladder Evaluation program found the incidence at 17%. In Asia, the prevalence of OAB is reported at 53.1%. In about 75%, OAB symptoms are due to idiopathic detrusor activity; neurological disease, bladder outflow obstruction (BOO) intrinsic bladder pathology and other chronic pelvic floor disorders are implicated in the others. OAB can be diagnosed easily and managed effectively with both non-pharmacological and pharmacological therapies. The first-line treatments are lifestyle interventions, bladder training, pelvic floor muscle exercises and anticholinergic drugs. Antimuscarinics are the drug class of choice for OAB symptoms; with proven efficacy, and adverse event profiles that differ somewhat.

Behaviour modification and benign prostatic hyperplasia: replacement for medications

PURPOSE OF REVIEW

Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) is a highly prevalent chronic disease. The cost impact of treatment is high. The field of behavioural treatments which could be suitable in the majority of uncomplicated patients has rarely been assessed. We summarize the recent knowledge and data from behavioural interventions chiefly the randomized controlled trial (RCT) of a self-management programme for BPH.

RECENT FINDINGS

The self-management RCT has revealed that a rigorously structured behavioural programme can significantly reduce lower urinary tract symptoms severity and decrease objective symptoms like nocturia, urgency and frequency compared with standard care alone. The elements of the programme and their behavioural framework are carefully defined. The basis of the programme's effectiveness is yet unknown, but may involve changes in bladder capacity rather than simple fluid management. The sphere of behavioural interventions for BPH is lacking and requires more research.

SUMMARY

Elements of the self-management programme are already being used in watchful waiting. Improving quality of life of patients with BPH through self-management will help patients and may reduce the financial burden on healthcare systems. The promotion of multidisciplinary team is a key step in implementing self-management strategies. With larger scale trials, the limitations raised and questions posed by the RCT can be further addressed.

Self-management for men with lower urinary tract symptoms

Treatment for men with lower urinary tract symptoms (LUTS) has developed into a "cascade" that escalates from watchful waiting through medical treatment to surgery. Self-management can help men to adopt lifestyle and behavioral modifications that will avoid or delay an escalation in treatment and reduce symptoms. Although many of these interventions are advised to men with LUTS, it is usually in a nonstandardized and unsystematic way. Recent work in this area has defined a self-management program for men with uncomplicated LUTS using formal methods and assessed its effectiveness in a randomized controlled trial. Self-management significantly reduced the frequency of escalation through the treatment cascade and reduced urinary symptoms (as effective as medication), suggesting that self-management could be considered as first-line treatment for men with LUTS.

Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence

Behavioural interventions are effective treatments for overactive bladder (OAB) and urgency urinary incontinence (UUI). They are in part aimed at improving symptoms with patient education on healthy bladder habits and lifestyle modifications, including the establishment of normal voiding intervals, elimination of bladder irritants from the diet, management of fluid intake, weight control, management of bowel regularity and smoking cessation. Behavioural interventions also include specific training techniques aimed at re-establishing normal voiding intervals and continence. Training techniques include bladder training, which includes a progressive voiding schedule together with relaxation and distraction for urgency suppression, and multicomponent behavioural training, which, in conjunction with pelvic floor muscle (PFM) exercises, includes PFM contraction to control urgency and increase the interval between voids. Guidelines for the conservative treatment of OAB and UUI have been published by several organisations and the physiological basis and evidence for the effectiveness of behavioural interventions, including lifestyle modifications, in the treatment of OAB and UUI have been described. However, many primary care clinicians may have a limited awareness of the evidence supporting the often straight-forward treatment recommendations and guidance for incorporating behavioural interventions into busy primary care practices, because most of this information has appeared in the specialty literature. The purpose of this review is to provide an overview of behavioural interventions for OAB and UUI that can be incorporated with minimal time and effort into the treatment armamentarium of all clinicians that care for patients with bladder problems. Practical supporting materials that will facilitate the use of these interventions in the clinic are included; these can be used to help patients understand lifestyle choices and voiding behaviours that may improve function in patients experiencing OAB symptoms and/or UUI as well as promote healthy bladder behaviours and perhaps even prevent future bladder problems. Interventions for stress urinary incontinence are beyond the scope of this review.

Bladder diary measurements in asymptomatic males: frequency, volume per void, and 24-hr volume

AIMS

To collect bladder diary frequency and volume measurements from asymptomatic males and to use these data to develop clinical reference values.

MATERIALS AND METHODS

Computer processed three-day bladder diaries were collected from 92 males (median age: 46.2 years; range: 20.6-84.6 years) defined as "asymptomatic" by questionnaire. Minimum (V(min)), maximum (V(max)), and average (V(avg)) volume per void (Vol/Void), 24-hr frequency (F(24)), and 24-hr volume (V(24)) were studied. Relationships of Vol/Void and F(24) to age and V(24) and of V(24) to age were investigated by regression analysis.

RESULTS

V(max) and V(avg) increased as V(24) increased and decreased with increasing age (P < 0.0005). We found no significant relationship between V(min) and age, but V(min) increased with increasing V(24) (P < 0.0005). F(24) increased with increasing V(24) and increasing age (P < 0.0005). We found a concave downward, curvilinear relationship between age and V(24), which, while it did not reach statistical significance, was very similar in shape to age versus V(24) relationships found by other studies of larger datasets.

CONCLUSIONS

Our results suggest that reference values of F(24) and Vol/Void should be adjusted for their relationships to the patient's age and V(24). Regression equations expressing these relationships can be used to make these adjustments. From frequency histograms of residuals the difference between the patient's actual and expected reference measurement can be ranked within the reference population as a percentile. We illustrate this method by using our results to calculate age- and V(24)-adjusted 5% "normal limit" tables of F(24), V(avg), and V(max).

Surgery Insight: surgical management of postprostatectomy incontinence--the artificial urinary sphincter and male sling

Stress urinary incontinence in men is usually a result of intrinsic sphincter deficiency following prostate cancer surgery. Active conservative management with fluid restriction, medication management and pelvic floor exercises is indicated for the first 12 months. If bothersome incontinence persists, urodynamic evaluation is indicated in order to assess detrusor storage function, contractility and sphincteric integrity. Standard surgical options include urethral bulking agents, artificial urinary sphincter (AUS) and male sling. Periurethral injection of bulking agents is satisfactory in only a minority of patients, leaving AUS and male sling as the most common surgical treatments. In patients with severe urinary incontinence, AUS seems to have a higher rate of success than the male sling. Furthermore, AUS is indicated in men with detrusor hypocontractility as adequate detrusor contractility is needed to overcome the fixed resistance of the sling. In patients with milder levels of stress incontinence, the two techniques have approximately equal efficacy in the short-to-intermediate term. While current reports of the male sling are generally limited to 1-4 years' follow-up, the infection, erosion, and revision rate for the male sling seem somewhat lower than that for the AUS in appropriately chosen patients.

Randomized clinical trial of efficacy of self-monitoring techniques to treat urinary incontinence in women

AIM

To assess the efficacy of self-monitoring techniques to reduce urine loss and increase quality of life for women with urinary incontinence.

METHODS

The design was a two arm, randomized, clinical trial with a wait list control group and 3-week intervention. Participants were 224 community-dwelling women 18 and older with UI. Self-monitoring was individualized counseling about fluid and caffeine intake, quick pelvic floor muscle contraction, voiding frequency, and management of constipation. The primary outcome measure was grams of urine loss. Secondary outcomes included episodes of urine loss, quality of life, and caffeine and fluid consumption.

RESULTS

The main effect of self-monitoring on grams of urine loss was significant. After adjusting for baseline urine loss, time in the intervention or in wait list group, age, hormone status, and race the self- monitoring group lost an average of 13.3 g less urine and had improved 26.1 points in quality of life compared to the wait list group. The effect of self-monitoring on episodes of urine loss was not significant in the total sample but was more effective for women who had 9 or more episodes of urine loss, were 65 years or older, and were premenopausal or taking hormone replacement therapy. Participants in the self-monitoring group reduced their caffeine intake, but did not increase their fluid intake compared to the wait list control group.

CONCLUSIONS

Since self-monitoring techniques are simple, safe, inexpensive, and within the scope of practice for most health professionals, they should be considered as first steps to treat women with UI.

Bladder diary measurements in asymptomatic females: functional bladder capacity, frequency, and 24-hr volume

AIMS

To study the effects of age and 24-h volume (V(24)) on bladder diary measurements of voiding frequency (F(24)) and functional bladder capacity (FBC) from an asymptomatic female population. Also, to use these data to develop clinical reference values. (We use FBC as a generic term for bladder diary volume-per-void measurements.)

MATERIALS AND METHODS

Computer-processed 3-day bladder diaries were collected from 161 females (median age: 46.6 years; range = 19.6-81.8 years) claiming no urological symptoms, previous pelvic surgery and diseases and medications effecting urologic function. Regression analysis was used to investigate relationships among age, FBC and V(24).

RESULTS

Both FBC and F(24) increase as V(24) increases (P < 0.0005). With aging, F(24) increases (P = 0.026) and FBC may decrease slightly (P = 0.02-0.08). There is a concave downward, curvilinear relationship between age and V(24). We used multiple regression to generate tables of FBC and F(24) "normal limits" adjusted for these simultaneous influences of V(24) and age. Removing their relationships to age reduces the variability of FBC and F(24) reference values by 50% and 20%, respectively.

CONCLUSIONS

Our finding, supported by others, that, with increasing V(24), FBC increases more than F(24) suggests an adaptive mechanism that adjusts FBC to urine production to minimize changes in voiding frequency. We illustrate adjustment of reference values for age and V(24) by calculating traditional clinical "normal limits." However, the probable large overlap between "normal" and "abnormal" suggests that it may be more useful to report bladder diary measurements as reference population percentiles rather than to designate them "normal" or "abnormal".

Self-management in lower urinary tract symptoms: the next major therapeutic revolution

The standard treatments for men with lower urinary tract symptoms (LUTS) range from watchful waiting to medical and finally surgical intervention. However, the role of self-management interventions such as education and reassurance, lifestyle modification and behavioural changes has not been formally investigated, although they are widely advocated and utilised for LUTS. Self-management interventions are well established in other chronic diseases such as diabetes, arthritis and asthma. These interventions, if successfully organised within a structured program for LUTS, could improve patient outcomes as well as reduce the economic burden of LUTS treatment, by replacing or augmenting other treatments. Recent studies showing that long-term urodynamic and symptomatic deterioration of LUTS is minimal suggest that this is a safe and valid treatment option. This is supported by a recent pilot study of a LUTS self-management program which showed significant improvements in I-PSS and frequency-volume parameters. The results of a recently completed randomised controlled trial are awaited.

FACTORS THAT DISTINGUISH CONTINENT FROM INCONTINENT OLDER ADULTS WITH DETRUSOR OVERACTIVITY

PURPOSE

In older adults detrusor overactivity (DO) is almost as common in continent individuals as in those with urge incontinence (UUI). Thus, UUI likely reflects the contribution of additional factors. We postulated that of functionally independent individuals in whom transient causes were excluded those in whom DO was accompanied by UUI would be more likely to have smaller functional bladder capacity, less warning and less ability to avert urine loss in the face of DO.

MATERIALS AND METHODS

While blinded to continence status, we reviewed the records of all 52 cognitively intact and nonobstructed volunteers older than 65 years who had DO associated with urgency during urodynamic testing and had been asked to try to prevent leakage for 2 minutes. Of these individuals 31 were continent at home.

RESULTS

In patients with UI mean functional bladder capacity +/- SD was smaller (313 +/- 153 vs 390 +/- 178 ml, p = 0.06) and warning was briefer (87 +/- 81 vs 120 +/- 116 ml), although the association with warning was less impressive (p = 0.14). The ability to forestall leakage for at least 2 minutes correlated strongly with being continent at home (p < 0.002). For continence detrusor suppression at the onset of DO was more important than sphincter contraction.

CONCLUSIONS

Urge incontinence in older adults involves more than simply the presence of DO. Physical function, cognitive function and medications are already known to be important for continence. Our data suggest that functional bladder capacity and the ability to suppress involuntary contraction (and possibly warning) are also potentially important covariates. These factors may represent additional potential targets for behavioral and pharmacological therapy.

Nocturia in relation to sleep, health, and medical treatment in the elderly

Nocturia is a common condition in the elderly that profoundly influences general health and quality of life. It appears to predict a higher risk of death. One consequence of nocturia is sleep deterioration, with increased daytime sleepiness and loss of energy and activity. Accidents, e.g. falls, are increased both at night and during the day in elderly persons with nocturia. Nocturia is caused by nocturnal polyuria, reduced voided volumes, or a combination of the two. Nocturnal polyuria can be caused by numerous diseases, e.g. diabetes insipidus, diabetes mellitus, congestive heart failure, and sleep apnoea. A disorder of the vasopressin system, with very low or undetectable vasopressin levels at night, is manifested as an increased nocturnal urine output, which in the most extreme cases reaches 85% of the 24-h diuresis: the prevalence of low or undetectable vasopressin levels at night has been estimated to be 3-4% in those aged >or= 65 years. Treatment of nocturia may include avoiding excessive fluid intake and use of diuretic medication in the afternoon rather than the morning, oral desmopressin at bedtime in cases of nocturnal polyuria, and antimuscarinic agents in the case of overactive bladder or impaired storage capacity of the bladder.

The effect of fluid intake on urinary symptoms in women

PURPOSE

We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity.

MATERIALS AND METHODS

This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life.

RESULTS

A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms.

CONCLUSIONS

Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.

Urinary urge incontinence: causes and management strategies

Bladder control is a skill most people learn in childhood, so if control is lost in adult life the impact can be very significant, particularly on the quality of life of the person affected. There are many causes of loss of bladder control, ranging from neurological conditions to menopause, as well as certain medications. This article discusses urinary urgency and urge incontinence, examines its causes and diagnosis, and provides an overview of the nursing interventions available to treat the problem.

Could self-management challenge pharmacotherapy as a long-term treatment for uncomplicated lower urinary tract symptoms?

PURPOSE OF REVIEW

This review highlights the lifestyle and behavioural management strategies (self-management) available to men with lower urinary tract symptoms.

RECENT FINDINGS

Pharmacotherapy has evolved considerably over the last decade and now most men with lower urinary tract symptoms are treated at some point with either single or combined therapy. However, recent studies reporting the longer term usage of pharmacotherapy have shown significantly high rates of discontinuation due to patient compliance, treatment ineffectiveness, side effects and patient choice. Not all these men will require or desire surgery. For those with bothersome symptoms self-management may be an effective strategy. Self-management interventions include education, reassurance, fluid management, caffeine avoidance, rescheduling concurrent medications and bladder retraining. As in other chronic disease areas such as diabetes and arthritis for which self-management is well established, lifestyle and behavioural interventions for men with lower urinary tract symptoms aim to allow the patient some day-to-day control over their symptoms. These interventions have been shown to be in wide use in the UK without good quality supporting evidence, suggesting that they are thought to be safe and effective.

SUMMARY

Self-management (lifestyle and behavioural) interventions provide men with some control over their symptoms, their role as either a primary treatment strategy or to augment pharmacotherapy has yet to be defined.

Nocturia in adults: etiology and classification

Nocturia is one of the most bothersome of all urologic symptoms, yet even a rudimentary classification does not exist. We herein propose a classification system of nocturia based on a retrospective study. The records of 200 consecutive patients with nocturia were reviewed. Evaluation included history, micturition diary (including day, night, and 24-hr voided volume), postvoid residual urine (PVR), and videourodynamic study (VUDS). Functional bladder capacity (FBC) was determined to be the largest voided volume in a 24-hr period. The etiology of nocturia was thus classified into one of three groups: nocturnal polyuria ([NP] in which voided urine volume during the hours of sleep exceeds 35% of the 24-hr output), nocturnal detrusor overactivity ([NDO] defined as nocturia attributable to diminished bladder capacity during the hours of sleep), and mixed (NP+NDO); polyuria (24-hr urine output >2,500 cc) was classified separately. There were 129 women and 65 men ranging in age from 17 to 94 years (x=59). Overall 13 (7%) had NP, 111 (57%) NDO, and 70 (36%) had a mixed etiology of their nocturia (both NP and NDO). Forty-five (23%) also had polyuria. These data confirm that the etiology of nocturia is multifactorial and in many instances unrelated to the underlying urologic condition. Nocturnal overproduction of urine is a significant component of nocturia in 43% of patients, most of whom will also have NDO. We believe that treatment should be directed at both conditions.