© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
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Rosenberg ET AL.
Understanding symptoms
It is essential to recognize that symptoms consistent
with OAB could be medically or urologically based.
Therefore a good understanding of the function of
the genitourinary organs (bladder and prostate) is
crucial. In order to understand abnormal function of
the urinary tract it is helpful to understand normal.
As mentioned earlier the bladder has the function
urine storage. It must also void this urine when an
adequate amount is attained. The bladder normally
holds 300 mL-500 mL of fluid. It should be able to store
this amount at a comfortable and low pressure. When
300 mL-500 mL is reached emptying should occur with
anadequateandcomfortablebladder contraction leaving
aminimal residual. Abnormal function of the bladder is
seen as voiding frequently of small amounts (frequency),
having an uncontrollable urge (urgency), not having
enough time orwarning to reach the bathroomsuch that
there is some leakage (urgency urinary incontinence),
or incomplete emptying. Therefore, knowing the
voided volume associated with the symptoms offers
key insights into the bladder function and assists in
identifying its role in the patient’s symptoms. The
bladder should also provide adequate outlet resistance.
Decreased resistance results in incontinence.
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The normal function of the prostate is the production
of fluid for seminal emission. As the male ages the
prostate increases in size. By the sixth decade of
life 50% of men will have some degree of prostate
hyperplasia and by the eighth decade this will increase
to 90%.
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If this enlargement compresses the prostatic
urethra then there is the possibility of obstruction
of urinary flow as well as retention. The symptoms
presented may include hesitancy, a weakened stream,
intermittency or straining to void. Symptoms and
bother depend on the degree of this obstruction.
Therefore, knowing flow of urine offers key insights
into the role of the prostate in the patient’s problem.
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Understanding normal bladder or prostate activity
subsequently helps the PCP understand when urinary
function runs afoul. If the patient has any of the
symptoms of urgency, urge incontinence, frequency,
nocturia, hesitancy and/or decreased flow it is essential
to try to elicit if the primary issue at hand is volume or
flow. If it is volume, focus should be on the bladder.
Volume per void can be readily attainedwith a bladder
hat, or urine collection vehicle, that the patient can use
in the privacy of their home. This would be kept in the
formof a voiding diary that will be discussed in further
detail later. If the primary problem is flow, then focus
should be on obstructionwhich is generally the prostate
in men, or maybe a prolapsed bladder in women.
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Defining flowmay seemdifficult without a flowmeter,
but, in fact, adequate flow is exhibitedwith the “arc” of
the void, not mL/sec. Most patients will understand an
“arc” as opposed to a “dribble”. If volume and floware
normal then the focus should be onwhy the patient has
the enhanced fluid productionwhichmay be caused by
a medical condition or a medication.
Basic work up: identifying LUTS
The screening for OAB symptoms requires minimal
time from a PCP as a self-administered screener or
questionnaire canbe used inmost clinical settings. These
tools are not meant to diagnose OAB or incontinence,
rather to identify symptoms that may need treatment
and to help rule out other significant or serious causes
of LUTS.
3,11
Understandably, they may not always be
practical in the office of the busy PCP in which case
being familiar with the questions is helpful. Table 1 lists
examples of questions regarding symptom onset,
duration, severity and bother that may be useful.
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TABLE 1.
Simple screening questions for evaluation of overactive bladder and incontinence
Do you get sudden urges to go to the bathroom that are so strong you can’t ignore them? (OAB)
How often do you go to the bathroom? Is it more than 8 times in a 24-hour period? (OAB)
Do you have uncontrollable urges to urinate that sometimes result in wetting accidents? (urge incontinence)
Do you leak urine on the way to the bathroom?
(urge incontinence)
Do you frequently get up two or more times during the night to go to the bathroom? (OAB)
Do you avoid places you think won’t have a nearby restroom?
(OAB or urge incontinence)
When you’re in an unfamiliar place, do you make sure you knowwhere the restroom is? (OAB or urge incontinence)
Do you leak urine when you laugh, cough or sneeze?
(stress incontinence)
Do you use absorbent pads to keep from wetting your clothes?
(stress incontinence
or urge incontinence)
