Comparison of sensation-related voiding patterns between continent and incontinent women: A study with a 3-day sensation-related bladder diary (SR-BD)

Can we increase the value of data from bladder diaries? International Consultation on Incontinence-Research Society 2023

BACKGROUND

Bladder diaries represent a fundamental component in the assessment of patients presenting with lower urinary tract symptoms. Nevertheless, their importance often remains underappreciated and undervalued within clinical practice. This paper aims to conduct a comprehensive review of the existing literature concerning the utility of bladder diaries, underscore the criticality of their precision, elucidate the factors contributing to noncompliance with bladder diary completion, and investigate potential strategies for enhancing patient compliance.

MATERIALS AND METHODS

A review of the English-language scientific literature available in the domains of Medline, Embase, Emcare, Midirs, and Cinahl was conducted. This was supplemented by discussion at the International Consultation on Incontinence Research Society Proposal session to define knowledge and identify gaps in knowledge surrounding the utility of bladder diaries. The existing evidence and outcome of the relevant discussion held in the meeting are presented.

RESULTS

Bladder diaries (BD) serve to characterize the nature and severity of storage lower urinary tract symptoms (LUTS) and provide an objective record of an individual's urination patterns. They aid in the refinement and customization of treatment strategies based on the clinical responses documented in the diary, optimizing treatment outcomes. Notably, both BD and urodynamic studies (UDS) play complementary yet distinct roles in LUTS evaluation. BD offers a more comprehensive and accessible approach to assessing specific storage LUTS, particularly due to their affordability and widespread availability, especially in resource-limited settings. Nevertheless, the absence of a standardized BD format across global healthcare systems presents a significant challenge. Despite being recognized as reliable, noninvasive, validated, and cost-effective tools for evaluating patients with LUTS, the implementation and completion of BD have proven to be complex. The introduction of automated bladder diaries heralds an era of precise, real-time data collection, potentially enhancing the patient-clinician relationship. Completion of bladder diaries depends on an array of individual, social, and healthcare-specific factors. Compliance with bladder diary completion could be enhanced with clear instructions, patient education, regular follow-ups and positive re-enforcement. This study has identified four critical areas for future research: Addressing healthcare disparities between affluent and developing nations, enhancing the current functionality and effectiveness of bladder diaries, exploring the feasibility of incorporating bladder diaries into the treatment and education process and improving the quality and functionality of existing bladder diaries.

CONCLUSION

Bladder diaries play a pivotal role in the evaluation and management of patients with LUTS, providing a holistic perspective. When their complete potential is harnessed, they have the capacity to revolutionize the paradigm of LUTS management, ushering in a patient-centered era of care.

Lower urinary tract symptoms and toileting behaviors in Turkish adult women

This study aimed to investigate lower urinary tract symptoms (LUTS) in Turkish adult women and to compare toileting behaviors in women with and without LUTS. This cross-sectional study was conducted in 815 women. The International Consultation on Incontinence Modular Questionnaire - Female LUTS and a toileting behaviors form, created by the authors, were used in evaluations. Nearly 50 % of the women had at least one LUTS, 45.8 % had storage symptoms, 7.4 % had voiding symptoms, and 20.2 % had incontinence symptoms. The rates of premature urination, straining during urination, delayed urination, and sitting on the toilet while urinating were higher in women with LUTS than in women without LUTS (p < .05). The rate of squatting on the toilet while urinating was lower in women with LUTS than those without LUTS (p < .05). Various LUTS were common in adult women. Some toileting behaviors such as premature urination, straining during urination, delayed urination, and sitting on the toilet while urinating were higher in women with LUTS compared to women without LUTS. Since the rate of unhealthy toilet behaviors is higher in women with LUTS, it is important to know unhealthy toilet behaviors in the management of LUTS and to organize training programs to prevent these behaviors and LUTS.

Toileting Behaviors and Lower Urinary Tract Symptoms Among Female Physicians and Medical Students

IMPORTANCE

A greater understanding of the relationship between toileting behaviors and lower urinary tract symptoms (LUTS) has the potential to generate awareness and improvement of overall bladder health in specific populations.

OBJECTIVE

The aim of the study was to investigate the prevalence and correlation between maladaptive toileting behaviors and LUTS among female medical trainees and attending physicians.

STUDY DESIGN

We surveyed female medical students, residents, fellows, and attending physicians at an academic hospital, capturing demographics, voiding behaviors, LUTS, and fluid intake using the Bristol Female Lower Urinary Tract Symptoms Short Form, the Toileting Behavior-Women's Elimination Behaviors, and the Beverage Intake Questionnaire.

RESULTS

A total of 146 medical students and physicians participated in the study. Eighty-three percent reported at least 1 LUTS, most commonly storage symptoms, particularly incontinence (30%, stress urinary incontinence > urgency urinary incontinence). Altered toileting behaviors included "worrying about public toilet cleanliness" (82%), "emptying the bladder before leaving home" (81%), "delaying emptying their bladder when busy" (87%), and "waiting until they could not hold urine any longer" (57%). Total Toileting Behavior-Women's Elimination Behaviors scores were significantly associated with total Bristol Female Lower Urinary Tract Symptoms scores (β = 0.27; 95% CI, 0.12-0.42; P<0.01). This remained true after adjusting for total fluid intake in medical students (β = 0.41, P<0.01) and resident physicians (β = 0.28, P = 0.03) but was not correlated among attending physicians (β = -0.07, P = 0.77).

CONCLUSIONS

Female physicians and medical students experience a high prevalence of LUTS. Many engage in maladaptive toileting behaviors, which highly correlate with LUTS (especially among medical students and residents) and may lead to impaired bladder health.

Bladder sensations in male and female overactive bladder patients compared to healthy volunteers: a sensation-related bladder diary evaluation

Objectives: To investigate the differences in bladder sensations of overactive bladder (OAB) patients compared to healthy volunteers. In addition, to see if bladder sensations are different in men and women.Methods: In a prospective, longitudinal study (METC 09-2-095), 66 volunteers and 68 OAB patients were included. Anticholinergic medication was stopped. Subjects filled out a sensation-related bladder diary (SR-BD), for two periods of 3 days, including a 4-points urgency scale and visual analogue scale for perception of bladder fullness.Results: In total, 6160 voids were assessed. Patients voided more often with higher degrees of urge at a lower mean voided volume (193 vs 270 ml/void; p < 0.001) than healthy volunteers. The mean urinary frequency per litre diuresis was also higher (5.8 vs 4.1/l; p < 0.001) in patients. At the same voided volume: patients perceived a higher mean bladder fullness, independent of the degree of urge, and higher urgency (1.4 vs 0.5/100 ml; p < 0.001) than healthy volunteers. There were no gender differences in the above-mentioned voiding parameters, except for the mean voided volume at urge 3 in volunteers (340 ml in men vs 362 ml in women; p = 0.03) and urge 1 in patients (171 ml in men vs 135 ml in women; p = 0.027).Conclusions: Bladder sensations were significantly increased in everyday life for both male and female OAB patients compared to healthy volunteers. OAB patients experienced a higher mean bladder fullness sensation, independent of the degree of urge, and higher mean urge/urgency at the same voided volume than volunteers. Bladder sensations are crucial in the assessment of treatment response.

Toileting Behaviors of Women-What is Healthy?

PURPOSE

The objective of this study was to assess toileting behaviors in community dwelling women.

MATERIALS AND METHODS

Women 18 years old or older were recruited through a national registry of research volunteers. They were asked to complete validated questionnaires assessing urinary symptoms and toileting behaviors, specifically place preference for voiding, convenience voiding, delayed voiding, straining during voiding and position preference for voiding. The PPBC (patient perception of bladder condition) was administered to assess the participant impression of bladder health. Analyses were done to determine the prevalence of each toileting behavior reported to occur sometimes or more often as well as differences in toileting behaviors in women with vs without self-perceived bladder problems based on the PPBC response.

RESULTS

The 6,695 women who completed the questionnaires were 18 to 89 years old (mean ± SD age 41.4 ± 15). Of the women 79.9% identified as white and 71.0% were college educated. Of the women 6,613 (98.8%) reported a place preference for voiding. The 3,552 women (53.1%) who reported a bladder problem were more likely to report convenience voiding, delayed voiding and strained voiding behaviors. While 6,657 women (99.4%) reported sitting to void at home only 5,108 (76.2%) reported sitting when using public toilets.

CONCLUSIONS

Certain toileting behaviors, of which some may be considered unhealthy, were common in this sample of women and most were associated with a perception of bladder problems. Voiding positions other than sitting were frequently used when away from home. These data have important implications for defining bladder health and implementing behavior based interventions for women with lower urinary tract symptoms.

Methods of assessing and recording bladder sensation: a review of the literature

Introduction and hypothesis

The objective was to review different methods that have been used to assess bladder sensation and to provide an overview of the accuracy and objectivity of the measurement of the subjective perception of the bladder.

Methods

The MEDLINE and PubMed databases were searched to identify articles. References from those articles were also searched. Terms used for the search were: urinary bladder, sensation, cystometry, urodynamics, urinary incontinence and focus group. Eight hundred and fifty abstracts were identified from databases, and 12 from other sources. Twenty-two duplicate articles were removed. Irrelevant articles were excluded after reading their titles. Fifty-four articles were eligible, but 17 were excluded after reading the full text, leaving 37 articles where assessment of bladder sensation was the main aim.

Results

Six different methods of measuring bladder sensation have been described in the literature. Although the most frequently used was cystometry, this is an invasive tool and does not reproduce bladder behaviour during daily life because it records bladder sensation as episodic events. The visual analogue scale using a forced diuresis protocol seemed to be an excellent tool. It was non-invasive and evaluated bladder sensation continuously, from an empty to a full bladder.

Conclusions

In some of the studies, the samples were too small to draw any significant conclusions. There were also conflicting data on which tool was the most accurate, especially as each method of evaluating bladder sensation may influence the way it is described by participants.

Validation of a water-load protocol to define the pattern of bladder sensation

Introduction and hypothesis

The aim of this study was to confirm reliability of a water-load diuresis protocol and to assess the utility of bladder sensation curves.

Methods

For confirmation of fixed diuresis rate (phase 1), 12 volunteers consumed 250–300 ml of water every 15 min and recorded bladder sensation on a visual analogue scale (VAS) every 5 min to maximum sensation over two filling cycles: voids 1 and 2 (V1 and V2). The test was performed twice. For test–retest validation (phase 2), 24 participants underwent the same protocol drinking 300 ml of water every 15 min. Diuresis rates and voided volumes were compared between cycles and across tests.

Results

In phase 1, there was no difference in median void volume (V1 735 ml, V2 678 ml p = 0.433) or median diuresis rates (V2 12.1 ml/min, V3 14.4 ml/min p = 0.136) between cycles. When comparing those who drank 250–300 ml/15 min, there was less variability in those drinking 300-ml aliquots, so this was standardised for later experiments; 95% upper confidence limit of variability of the diuresis rate was calculated as 4.5 ml/min. Any test with a greater difference was rejected as invalid. In phase 2, only 16 participants were analysed. There was no difference in median void volumes between tests [V1 763 ml and 820 ml (p = 0.109) and V2 788 ml and 796 ml (p = 0.266)] or in diuresis rates between test 1 (12.33 ml/min) and 2 (14.40 ml/min) (p = 0.056). Median area under the curve was similar between test 1 404.96 and test 2 418.63.

Conclusions

This refined protocol reliably produced stable diuresis with a water load of 300 ml/15 min, excluding those with a difference in diuresis rate > 4.5 ml/min.

Effects of an education program on toileting behaviors and bladder symptoms in overactive bladder patients with type 2 diabetes: A randomized clinical trial

BACKGROUND

Overactive bladder is more common in patients with type 2 diabetes than in those without diabetes. Many patients with diabetes adopt unhealthy toileting behaviors to empty their bladder that may contribute to the onset or worsening of overactive bladder.

OBJECTIVE

To investigate whether an education program targeting toileting behaviors is effective for helping overactive bladder patients with type 2 diabetes in terms of adopting healthy toileting behaviors, improving bladder symptoms, and enhancing quality of life.

DESIGN

The study was a parallel, pragmatic, open-label randomized trial.

SETTINGS

The trial was conducted in a hospital-based endocrinology outpatient department in Jinan, China.

PARTICIPANTS

A total of 104 patients were randomly assigned to a 6-week education program or a control group.

METHODS

Primary outcomes included toileting behaviors and bladder symptoms, including dry/wet overactive bladder and severity of urgency. Secondary outcomes were overactive bladder-specific and general quality of life. The patients were reassessed on the outcome variables at the end of the intervention and at 3 months and 6 months following the intervention. The analysis followed the intent-to-treat principle. To account for the longitudinal data with repeated measures, group comparisons for continuous outcomes were evaluated using linear mixed models. Group differences in binary outcomes were examined using mixed-effects logit models.

RESULTS

Compared with the control group, the education program group showed significant changes in three unhealthy toileting behaviors: premature voiding (-0.7, p < 0.001), place preference for voiding (-0.5, p = 0.007), and delayed voiding (-0.2, p = 0.011). The program significantly relieved the bladder symptoms (-2.2, p < 0.001) and decreased the probability of having wet overactive bladder (-0.3, p < 0.001) and the severity of urgency (-0.4, p < 0.001). It also significantly improved the overactive bladder-specific quality of life by 10.8 points (p = 0.001). Regarding patients' general quality of life, the physical aspect was enhanced by 3.0 points (p = 0.049); however, no effect on the mental well-being aspect was observed.

CONCLUSIONS

Among overactive bladder patients with type 2 diabetes, the 6-week education program targeting toileting behaviors resulted in the adoption of healthy toileting behaviors, relief of bladder symptoms and improvement in quality of life in the 6 months following the intervention compared with routine care alone. The education program was highly successful and may represent an effective, acceptable, feasible, and safe intervention for improving bladder health and quality of life during diabetes care, given that the toileting behavioral changes were maintained during the 6-month follow-up period.

Toileting behaviors and overactive bladder in patients with type 2 diabetes: a cross-sectional study in China

Background

Overactive bladder is more prevalent in patients with type 2 diabetes than in those without diabetes. Unhealthy toileting behaviors may be associated with the development and worsening of overactive bladder symptoms. However, little is known about the relationships between toileting behaviors and overactive bladder in patients with diabetes. This study aimed to identify unhealthy toileting behaviors that patients with type 2 diabetes adopted to empty their bladders and investigate the relationships between toileting behaviors and overactive bladder.

Methods

Patients with type 2 diabetes from the endocrinology outpatient department of a hospital in China were recruited. The Toileting Behaviors-Women’s Elimination Behavior and Overactive Bladder Symptom Score questionnaires were used to assess the patients’ toileting behaviors and overactive bladder symptoms. A multivariate logistic regression model was used to explore the relationships between toileting behaviors and overactive bladder.

Results

Almost 14% of patients with diabetes had overactive bladder. The unhealthiest toileting behavior was premature voiding. In the multivariate logistic regression analysis, premature voiding (OR = 1.286, p = 0.016) and straining to void (OR = 1.243, p = 0.026) were associated with overactive bladder. There was a greater likelihood of having overactive bladder when patients engaged in unhealthy toileting behaviors (premature voiding and straining to void).

Conclusions

Overactive bladder in patients with type 2 diabetes was more than twofold higher than that in the general population. Thus, overactive bladder is not just an inconsequential condition for patients with diabetes. Unhealthy toileting behaviors, e.g., premature voiding and straining to void, may contribute to the onset or worsening of overactive bladder in patients with diabetes. Identification and awareness of these modifiable behavioral factors during diabetes care is an essential component of primary prevention, alleviation, and management of overactive bladder symptoms.

The management of neurogenic lower urinary tract dysfunction after spinal cord injury

The management of patients with neurogenic bladder has changed substantially over the past decades. Obtaining balanced lower urinary tract function has become possible in most patients, although, urological complications remain among the most serious complications these patients are likely to have and, even today, these can have a negative effect on quality of life. To this extent, patients with spinal cord injury (SCI) are likely to develop neurogenic bladder, and data are available on most aspects of neurogenic bladder in these patients. Data on physiology and pathophysiology form the basis of our understanding of patients' symptoms, and also provide a basis for the management of these patients. The use of conservative, and/or more invasive treatment measures, their complications and measures to prevent these complications, are all important clinical aspects that merit discussion. Considerable progress has been made in the urological management of patients with SCI over the past decades, but opportunities remain to make diagnosis more accurate and therapy more successful.

Toileting behaviours and lower urinary tract symptoms among female nurses: A cross-sectional questionnaire survey

BACKGROUND

Unhealthy toileting behaviours exist among women, and lower urinary tract symptoms have a high prevalence and significant effects on quality of life. However, the relationship between toileting behaviours and lower urinary tract symptoms is unclear.

OBJECTIVES

This study aimed to investigate the prevalence of lower urinary tract symptoms among female nurses, and the association between toileting behaviours and lower urinary tract symptoms.

DESIGN

A cross-sectional stratified cluster sampling study.

PARTICIPANTS

A total of 636 female clinical nurses from tertiary hospitals in Jinan (the capital city of Shandong Province, China).

METHODS

The Toileting Behaviour-Women's Elimination Behaviours and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms scales were used to assess the participants' toileting behaviours and lower urinary tract symptoms, respectively. Multiple linear regression analysis was used to evaluate the association between toileting behaviours and lower urinary tract symptoms.

RESULTS

Unhealthy toileting behaviours were common among the female nurses, with delayed voiding being the unhealthiest toileting behaviour, which was followed by place and position preference for voiding. Nearly 68% of the female nurses had at least one lower urinary tract symptom, nearly 50% had incontinence symptoms, 40% had filling symptoms, and 18% had voiding symptoms. Unhealthy toileting behaviours (premature voiding, delayed voiding, and straining to void) were positively associated with lower urinary tract symptoms. However, lower urinary tract symptoms were not significantly associated with voiding place or position preference. Among the control variables, being married or having a history of a urinary tract infection was associated with lower urinary tract symptoms. Having a higher income and regular menstrual period were negatively associated with lower urinary tract symptoms. Compared with vaginal delivery, caesarean delivery had a protective association with lower urinary tract symptoms.

CONCLUSION

Lower urinary tract symptoms among female nurses should not be overlooked, because their prevalence among female clinical nurses exceeded that among the general population of women. These findings highlight the importance of avoiding unhealthy toileting behaviours (especially premature voiding, delayed voiding, and straining to void), as these unhealthy toileting behaviours were significantly associated with susceptibility to lower urinary tract symptoms.

[Clinical and paraclinical evaluations of bladder sensitivity. Review of the literature]

INTRODUCTION

The aim of this work was to carry out a review of the literature on the clinical and paraclinical evaluation of bladder sensory (BS) to better understand BS disorders in nonneurological patients.

METHODS

Thirty-three articles were selected from the Medline(®) Database between 1992 and 2012 using the following key words: "sensory/sensitivity bladder evaluation", "sensory/sensitivity bladder scale", "sensory/sensitivity bladder questionnaire", "urodynamic bladder sensory", "urgency questionnaire" and "Overactive Bladder (OAB) questionnaire".

RESULTS

Evaluation of BS by asking questions during cystometry is validated (LE 2). The sensation of the desire to void progresses linearly with bladder filling (LE 2). Many symptoms and quality of life questionnaires related to BS anomalies have been proposed. Bladder diaries, frequency/volume curves (LE 2) and clinical algorithms (LE 3) could be an alternative to evaluate BS.

CONCLUSION

Current evaluation only provides a partial view of BS. A multidimensional approach should lead to better understanding of BS disorders.

Efficacy of fesoterodine compared with extended-release tolterodine in men and women with overactive bladder

OBJECTIVE

To assess the efficacy of fesoterodine 8 mg vs extended-release (ER) tolterodine 4 mg for overactive bladder (OAB) symptoms in terms of patient-reported outcomes in women and in men.

SUBJECTS AND METHODS

Pooled data from two 12-week, randomized, double-blind, double-dummy studies were analysed. Participants eligible for the studies were ≥18 years old, had self-reported OAB symptoms for ≥3 months in 3-day baseline diaries and had ≥8 micturitions and ≥1 urgency urinary incontinence (UUI) episode per 24 h. Individuals were randomized to fesoterodine (4 mg for 1 week then 8 mg for 11 weeks), ER tolterodine (4 mg), or placebo. Changes from baseline in 3-day bladder diary variables and scores from the Patient Perception of Bladder Condition (PPBC), Urgency Perception Scale (UPS), and Overactive Bladder Questionnaire (OAB-q), were assessed, as was the 'diary-dry' rate (the proportion of subjects with >0 UUI episodes according to baseline diary and no UUI episodes according to post-baseline diary). The primary endpoint was the change from baseline to week 12 in UUI episodes.

RESULTS

At week 12, women showed significantly greater improvement with fesoterodine 8 mg (n = 1374) than with ER tolterodine 4 mg (n = 1382) and placebo (n = 679) in UUI episodes (primary endpoint), micturition frequency, urgency episodes, and all other diary endpoints (except nocturnal micturitions versus ER tolterodine), and also in scores on the PPBC, UPS, and all OAB-q scales and domains (all P < 0.005). Diary-dry rates in women were significantly greater with fesoterodine (63%) than with tolterodine (57%; P = 0.002) or placebo (48%; P < 0.0001). In men, there were no significant differences in improvement in UUI episodes between any treatment groups at week 12. Improvements in men were significantly greater with fesoterodine 8 mg (n = 265) than with ER tolterodine (n = 275) for severe urgency and the OAB-q Symptom Bother domain and were also significantly greater with fesoterodine than with placebo (n = 133) for micturition frequency, urgency episodes, severe urgency episodes, PPBC responses and scores on all OAB-q scales and domains at week 12 (all P < 0.04). The most frequently reported treatment-emergent adverse events in both genders were dry mouth (women: fesoterodine, 29%; ER tolterodine, 15%; placebo, 6%; men: fesoterodine, 21%; ER tolterodine, 13%; placebo, 5%) and constipation (women: fesoterodine, 5%; ER tolterodine, 4%; placebo, 2%; men: fesoterodine, 5%; ER tolterodine, 3%; placebo, 1%). Urinary retention rates were low in women (fesoterodine, <1%; ER tolterodine, <1%; placebo, 0%) and men (fesoterodine, 2%; ER tolterodine <1%; placebo, 2%).

CONCLUSION

This analysis supports the superiority of fesoterodine 8 mg over ER tolterodine 4 mg on diary endpoints, including UUI, symptom bother and health-related quality of life in women. In men, fesoterodine 8 mg was superior to ER tolterodine 4 mg for improving severe urgency and symptom bother.

Overactive bladder, differential diagnosis, and clinical utility of fesoterodine

Overactive bladder is a symptom syndrome with urgency, frequency and, in many cases, nocturia. Urge incontinence is not present in all. There is no direct correlation with detrusor overactivity, an objective finding during urodynamic testing where involuntary contractions can be noticed. In the pathophysiology, much more attention has been given to the afferent/sensory arm of the micturition reflex in the last decade. Anatomical and infectious causes have to be diagnosed or ruled out. Diagnosis of overactive bladder is made mostly by history-taking, but other tests can be necessary in specific patients. Treatment consists of behavioral measures, a good explanation of the condition, training, and pelvic floor physiotherapy. Drugs are often used. Until recently, antimuscarinic drugs have been the mainstay of pharmacological therapy. Fesoterodine is a newer antimuscarinic agent which is more pharmacodynamically stable then tolterodine. Fesoterodine has been extensively researched using different dosages and compared with placebo and tolterodine, in different age groups, and under different conditions. Fesoterodine is superior to placebo and to tolterodine in the short term and long term. Its safety is very acceptable.

Degree of urge, perception of bladder fullness and bladder volume--how are they related?

PURPOSE

We evaluated the reliability of the degree of urge and perception of bladder fullness scales, the relationship between the scales and bladder volume, and possible differences between bladder sensations experienced in a controlled or an uncontrolled setting.

MATERIALS AND METHODS

Volunteers and patients with overactive bladder symptoms participated in the protocols. They were asked to grade bladder sensation on a 4-point urge scale of no sensation to need to void now and assess the perception of fullness on a visual analog scale of empty to full bladder. This was assessed in a 3-day bladder diary and during controlled, noninvasive bladder filling.

RESULTS

Each scale was reliable and significantly related to bladder volume (p <0.001). Agreement between the scales and voided volume was poor. Patients and volunteers grade bladder fullness and degree of urge higher in an uncontrolled than in a controlled setting.

CONCLUSIONS

The perception of bladder fullness and the degree of urge have a significant relation to bladder volume in controlled and uncontrolled settings. Due to poor agreement between the scales and actual voided volume these scales cannot replace measuring voided volume. The perception of bladder sensation depends on the setting. Bladder sensation at the hospital might underestimate the bother of symptoms experienced by a patient in daily life.

On the nature of bladder sensation: the concept of sensory modulation

AIMS

Going to the toilet is an essential everyday event. Normally, we do not give much thought to the sensations and factors that trigger voiding behavior: we just go. For many people, this apparently simple task is complicated and dominates their life. They have strong sensations and sudden desires to void, often resulting in incontinence. It is therefore important that we understand the origins for this functional change and identify means to alleviate it.

METHODS

Literature survey.

RESULTS

A considerable body of work has focused on this problem and ideas and concepts on the nature of bladder sensations are embedded in the literature. In this paper we argue the necessity to return to first principles and a re-examination of the problem. We explore the use of focus groups to identify relevant bladder sensation and what triggers 'bladder' behavior. We argue that there are differences in what can be described as 'introspective bladder sensations' and the sensations reported immediately before a void, 'void sensations'. Finally, we propose an alternative model describing how peripheral information generating 'introspective sensations' and 'void sensations' might be different but interrelated sensations. By exploring such ideas and identifying such complexity it is our intention to stimulate debate and generate further research in the field in order to understand better the physiology of bladder sensation and the pathology of increased urge, frequency and incontinence.

CONCLUSIONS

Review of the literature on bladder sensation and the established ideas suggests that we might be missing something and the problem of normal and increased sensation and of urgency may be much more complex.

Reliability and normal ranges for the Patient's Perception of Intensity of Urgency Scale in asymptomatic women

STUDY TYPE

Symptom prevalence (prospective cohort).

LEVEL OF EVIDENCE

1b.

OBJECTIVE

To measure the test-retest reliability of a 7-day bladder diary incorporating the Patient's Perception of Intensity of Urgency Scale (PPIUS), and to establish the normal values of the scale in a population of asymptomatic women.

SUBJECTS AND METHODS

Women volunteers, aged > or =18 years, were screened with the International Consultation on Incontinence Modular Questionnaire - Female Lower Urinary Tract Symptoms Long Form, to exclude those with bothersome lower urinary tract symptoms. Participants completed two separate 7-day bladder diaries with a 1-week interval between. Reliability was assessed using intraclass correlation, Spearman's correlation, and Student's t-test.

RESULTS

Forty volunteers were recruited. Most (67.5%) reported no urgency episodes. Convenience voids accounted for 26.8% of all voids. There was a significant positive effect of age (r = 0.34, P = 0.034) on urgency episodes, but no effect on mean urge scores (r = -0.03, P = 0.843). The reliability of assessment of frequency (0.86), nocturia (0.84), and the mean urge scores (0.85), were better than the reliability of assessment of urgency episodes (0.56), which occurred infrequently. The 95th centile for daily urinary frequency was 7.27 and for weekly urgency episodes was 2.00.

CONCLUSION

The PPIUS is a reliable tool for assessing urinary urge sensation in women. Inclusion of this measure in bladder diaries does not compromise the recording of other variables.

Current management of overactive bladder

PURPOSE OF REVIEW

The concept of overactive bladder has helped us address the problem of urgency and urge incontinence from a symptomatic perspective. In this review, we provide a critical summary of clinically relevant recent publications, focusing in particular on advances in our understanding of assessment methods and therapeutic interventions for overactive bladder in women.

RECENT FINDINGS

According to current definitions, the prevalence of overactive bladder in western nations is now estimated as 13.0%. Although the prevalence increases with age, the symptoms of overactive bladder may follow a relapsing and remitting course. There has been a proliferation of validated symptom and quality of life measures and increasing sophistication in the analysis of bladder diaries. The role of urodynamics in the evaluation of urgency remains uncertain, with many trials showing limited benefit as a preoperative investigation. Fluid restriction and bladder retraining remain important first-line interventions. Many new anticholinergic medications have been licensed, with limited benefits compared with existing preparations. Intravesical botulinum toxin has become a popular alternative for patients who fail oral therapies.

SUMMARY

Although there have been few important therapeutic innovations, recent publications have led to greater sophistication in assessment methods and a clearer understanding of the role of existing interventions.