Editing AUA: Overactive Bladder (2019) (section)

== Diagnosis and Evaluation ==

* '''<span style="color:#ff0000">Clinical diagnosis</span>'''
**'''<span style="color:#ff0000">OAB symptoms consist of 4 components:</span>'''
**#'''<span style="color:#ff0000">Frequency</span>'''
**#'''<span style="color:#ff0000">Urgency</span>'''
**#'''<span style="color:#ff0000">Urgency incontinence</span>'''
**#'''<span style="color:#ff0000">Nocturia</span>'''
**#*'''OAB symptoms (frequency, urgency and urgency incontinence) may occur only at night, causing a single symptom of nocturia.'''
**'''<span style="color:#ff0000">When urinary frequency (both daytime and night) and urgency, with or without urgency incontinence, in the absence of UTI or other obvious pathology are self-reported as bothersome, the patient may be diagnosed with OAB</span>'''

=== Recommended Investigations ===

==== Mandatory (2) ====
# '''<span style="color:#ff0000">History and Physical Exam</span>'''
# '''<span style="color:#ff0000">Urinalysis</span>'''

==== Optional (4) ====
# '''<span style="color:#ff0000">Urine culture</span>'''
# '''<span style="color:#ff0000">Post void residual</span>'''
# '''<span style="color:#ff0000">Bladder diary</span>'''
# '''<span style="color:#ff0000">Symptom questionnaire</span>'''

=== Not recommended in the initial workup of the uncomplicated patient ===
#'''Urodynamics'''
#'''Cystoscopy'''
#'''Diagnostic renal and bladder ultrasound'''
*'''For complicated or refractory patients, the choice of additional diagnostic tests depends on patient history, QoL and clinician judgment. Neurogenic OAB requires specific evaluation.'''
**
=== Mandatory ===
==== History and Physical Exam ====
===== History =====
* '''<span style="color:#ff0000">Characterize lower urinary tract symptoms (storage and voiding/emptying), including duration of symptoms and baseline symptoms</span>'''
**Assess bladder storage symptoms associated with OAB (e.g., urgency, urgency incontinence, frequency, nocturia) and other bladder storage problems (e.g., stress incontinence episodes) 
***Urinary frequency
****Varies across individuals. 
*****In community-dwelling healthy adults, normal frequency consists of voiding every 3-4 hours with a median of approximately 6 voids a day.
*****Traditionally, up to 7 micturition episodes during waking hours has been considered normal, but this number is highly variable based upon hours of sleep, fluid intake, comorbid medical conditions and other factors.
****Can be reliably measured with a bladder diary.
***Incontinence
****Can be measured reliably with a bladder diary and the quantity of urine leakage can be measured with pad tests.
**Assess bladder emptying (e.g., hesitancy, straining to void, prior history of urinary retention, force of stream, intermittency of stream). 
* '''<span style="color:#ff0000">Amount and type of fluid intake (e.g., with or without caffeine).</span>''' 
**Excessive fluid intake can produce voiding patterns that mimic OAB symptoms.
**'''Patients who do not appear able to provide accurate intake and voiding information should fill out a fluid diary.''' 
* '''<span style="color:#ff0000">Current medications</span>''' 
**Should be reviewed to ensure that symptoms are not related to medications. 
* '''<span style="color:#ff0000">Co-morbid conditions</span>''' 
**'''Neurologic diseases and other genitourinary conditions''' should be considered as they directly impact bladder function.
**'''Criteria for Complicated OAB'''
***'''Female patient with significant prolapse (i.e., prolapse beyond the introitus)''' 
***'''Failed multiple anti-muscarinics to control OAB symptoms''' 
***'''Patients with OAB symptoms and co-morbid conditions including''' 
***#'''Neurologic diseases (i.e., stroke, multiple sclerosis, spinal cord injury)'''
***#'''Mobility deficits'''
***#'''Medically complicated/uncontrolled diabetes'''
***#'''Fecal motility disorders (fecal incontinence/constipation)'''
***#'''Chronic pelvic pain'''
***#'''History of recurrent urinary tract infections (UTIs)'''
***#'''Gross hematuria'''
***#'''Prior pelvic/vaginal surgeries (incontinence/prolapse surgeries)'''
***#'''Pelvic cancer (bladder, colon, cervix, uterus, prostate)'''
***#'''Pelvic radiation''' 
*'''<span style="color:#ff0000">Degree of bother</span>'''
** If patient is not significantly bothered by his/her bladder symptoms, then there is a less compelling reason to treat the symptoms.

===== Physical exam (4) =====
# '''<span style="color:#ff0000">Abdominal exam</span>''' 
#*Assess for scars, masses, hernias and areas of tenderness as well as for suprapubic distension that may indicate urinary retention
# '''<span style="color:#ff0000">Rectal/genitourinary exam</span>''' 
#*'''To rule out''' 
#**'''Pelvic floor disorders (e.g., pelvic floor muscle spasticity, pain, pelvic organ prolapse) in females''' 
#**'''Prostatic pathology in males''' 
#*'''In menopausal females, atrophic vaginitis should be assessed''' as a possible contributing factor to incontinence symptoms. 
#*'''Assess for perineal skin for rash or breakdown.'''
#*'''Assess perineal sensation, rectal sphincter tone and ability to contract the anal sphincter''' to
#**Evaluate pelvic floor tone and potential ability to perform pelvic floor exercises (e.g., the ability to contract the levator ani muscles)
#**Rule out impaction and constipation.
# '''<span style="color:#ff0000">Assessment of lower extremities for edema</span>''' 
#*To assess for the potential for fluid shifts during periods of postural changes
#'''<span style="color:#ff0000">Patient’s attire and ability to dress independently</span>''' (as a surrogate for cognitive function)
#*The ability of the patient to dress independently is informative of sufficient motor skills related to toileting habits. This can provide information on the cognitive function of the patient, which is important to evaluate when considering anticholinergics.
#*A Mini-Mental State Examination (MMSE) should be conducted on all patients who may be at risk for cognitive impairment to determine whether symptoms are aggravated by cognitive problems, to ensure that they will be able to follow directions for behavioral therapy and/or to determine the degree of risk for cognitive decline with anti-muscarinic therapy.

==== Urinalysis ====
* '''To rule out UTI and and evaluate for presence of hematuria'''
*If evidence of infection is detected, then a culture should be performed, the infection treated appropriately and symptoms should be reassessed once the infection has cleared.

=== Optional ===
==== Urine culture ====
* Usually not necessary unless indication of infection (i.e., nitrites/leukocyte esterase on dipstick, pyuria/bacteriuria on microscopic exam) is found
*'''In some patients with irritative voiding symptoms but without overt signs of infection, a urine culture may be appropriate to completely exclude the presence of clinically significant bacteriuria'''
**Urinalysis is unreliable for identification of bacterial counts <100,000CFU/mL. 

==== Post-void Residual ====
* Measured with an ultrasound bladder scanner immediately after the patient voids.  
**If an ultrasound scanner is not available, then urethral catheterization may be used to assess PVR.
*'''<span style="color:#ff0000">Not necessary for patients who are receiving first-line behavioral interventions or for uncomplicated patients (i.e., patients without a history of or risk factors for urinary retention) receiving antimuscarinic medications.</span>'''
* '''<span style="color:#ff0000">Indications to assess PVR (4)</span>'''
*#'''<span style="color:#ff0000">Neurologic diagnoses</span>'''
*#'''<span style="color:#ff0000">History of incontinence surgery or prostatic surgery</span>'''
*#'''<span style="color:#ff0000">Presence of voiding/obstructive symptoms</span>'''
*#*As there is considerable overlap between storage and emptying voiding symptoms, baseline PVRs should be performed for males with symptoms prior to initiation of anti-muscarinic therapy.
*#'''<span style="color:#ff0000">Clinician discretion</span>'''
*'''<span style="color:#ff0000">Anti-muscarinics should be used with caution in patients with PVR 250–300 mL.</span>'''
*For any patient on anti-muscarinic therapy, the clinician should be prepared to monitor PVR during the course of treatment should obstructive voiding symptoms appear.

==== Bladder Diary ====
* '''See [https://www.urologyhealth.org/documents/Product-Store/English/Overactive-Bladder-OAB-Bladder-Diary.pdf Urology Care Foundation Link]'''
*'''<span style="color:#ff0000">Documents (2)'''
*#'''<span style="color:#ff0000">Intake AND'''
*#'''<span style="color:#ff0000">Voiding behavior'''
*##'''At a minimum, the patient documents (2):'''
*###'''Time of each void'''   
*###'''Incontinence episode and the circumstances or reasons for the incontinence episode.'''
*##'''Other useful measures'''
*##*'''Voided volumes'''
*##**Provide a practical estimate of the patient's functional bladder capacity in daily life and estimate the amount of overall fluid intake.
*##**Useful to differentiate between polyuria (characterized by normal or large volume voids) from OAB (characterized by frequent small voids).
*##*Rating the degree of urgency associated with each void and incontinence episode
*'''May be useful, particularly for patient education and to document baseline symptoms and treatment efficacy'''              
**'''Self-monitoring with a bladder diary for 3-7 days is a useful first step in initiating behavioral treatments for OAB.''' 
***Usually completed for only 24 to 48 hours due to burden of monitoring

==== Symptoms questionnaire ====
* '''Useful in the quantification of bladder symptoms and bother changes with OAB treatment'''
*Options (4)
*#Urogenital Distress Inventory (UDI)
*#UDI-6 Short Form
*#Incontinence Impact Questionnaire (II-Q)
*#Overactive Bladder Questionnaire (OAB-q)