Editing CUA: Overactive Bladder (2017) (section)

== Diagnosis and Evaluation ==

* '''Recommended (4): H+P, urinalysis, questionnaire, voiding diary (3-7 days)'''
*# '''History and Physical Exam'''
*#* '''History'''
*#** '''Symptoms and signs that characterize OAB'''
*#*** '''Questions about urinary symptoms associated with OAB should be subdivided into (SVPMO):'''
*#**** '''S'''torage problems (frequency, urgency, nocturia, incontinence)
*#**** '''V'''oiding symptoms (hesitancy, straining, poor and intermittent flow)
*#**** '''P'''ost-'''m'''icturition symptoms (sensation of incomplete emptying, post-micturition dribble)
*#**** '''O'''ther symptoms (nocturnal enuresis, dysuria)
*#*** '''Rapidity of onset, duration of symptoms, and baseline symptom levels'''
*#** '''Severity of bladder symptoms and influence on patient’s QOL and day-to-day activities'''
*#*** Severity can be assessed by asking about pad usage, including pad weight, size, number of used pads, and number of urinary incontinence episodes per day'''.'''
*#** '''Fluid intake habits'''
*#*** Patients should be asked about how much fluid they drink each day, what type of fluids they prefer (with a special consideration for caffeine intake as an exacerbating factor for urgency and frequency), and how many times they void over a 24-hour period.
*#**** '''Excessive or inadequate intake can produce or exacerbate some of the OAB symptoms'''.
*#*** '''Assessment of other potential bladder irritants (alcohol, carbonated drinks) is also important''' and provide an opportunity to educate the patients about modifiable habits
*#** '''In women, a thorough obstetric and gynecological history''' may help to understand the underlying cause and identify factors that may influence treatment decisions.
*#** '''Comorbidities'''
*#*** '''May produce or worsen OAB symptoms including neurological diseases''' (i.e., stroke, Parkinson’s disease, multiple sclerosis, spinal cord injury), '''endocrine disorders''' (i.e., complicated and uncontrolled diabetes, diabetes insipidus), '''urological conditions''' (i.e., BPH, urolithiasis, recurrent urogenital infections, bladder/prostate cancer), '''respiratory dysfunctions with chronic cough''' (i.e., chronic obstructive pulmonary disease), '''fecal motility disorders''' (constipation or fecal incontinence), '''chronic pelvic pain, mobility deficits, prior pelvic surgeries, pelvic cancers, and pelvic radiation.'''
*#**** OAB and bladder outlet obstruction (BOO) due to benign prostatic hyperplasia are common comorbid conditions
*#*** '''Psychiatric disorders''' such as depression, dementia and anxiety can contribute to abnormal voiding patterns.
*#*** '''Ensure that there are no contraindications or risk factors for potential complications with the introduction of OAB pharmacotherapy. Conditions to consider include'''
*#**** '''Cardiac history, in particular a prolonged QT interval, functional gastrointestinal pathology, myasthenia gravis, or uncontrolled narrow angle glaucoma, due to concerns with anticholinergics'''
*#**** '''Uncontrolled hypertension due to concerns with beta-3 agonist'''
*#**** '''Renal and liver impairment due to metabolism of anticholinergics and beta-3 agonists.'''
*#** '''Medication use'''
*#*** Both prescribed and over-the-counter may precipitate or worsen OAB symptoms. Diuretics and sympathomimetics can cause urgency, frequency, and urgency incontinence.
*#** Exclude other disorders that could be the cause of the patient’s symptoms
*#* '''Physical exam'''
*#** '''General evaluation of mental status, cognitive impairment, obesity, physical dexterity, and mobility'''
*#** '''Abdominal and pelvic examination'''
*#*** Pelvic examination should assess tissue quality and sensation, urethra, pelvic floor supports/pelvic organ prolapse, and stress incontinence (cough test).
*#** '''Digital examination of the vagina and/or rectum''' '''should be performed'''
*#** '''Neurological examination''' with a special attention to the sacral neuronal pathways from S1 to S4 with the assessment of perineal sensation, bulbocavernosus reflex, rectal sphincter tone, and ability to contract the anal sphincter '''should be performed in the presence of any neurological symptoms'''.
*# '''Urinalysis'''
*#* '''If evidence of infection is detected, a urine culture should be performed and the infection treated appropriately.'''
*#** After recovering from infection, patient evaluation should be again performed.
*#* '''Low count bacteriuria (103–105 CFU/ml) might be associated with a wide range of LUTS and thus should be treated in patients with OAB symptoms.'''
*#** '''Asymptomatic bacteriuria (>105 CFU/ml), highly prevalent in older persons, diabetic and catheterized patients, or in those with neurogenic lower urinary tract dysfunction, should not be routinely treated except in pregnant women and before urological procedures within the urinary tract'''
*# '''Questionnaires'''
*#* Options include:
*#** Overactive Bladder Questionnaire (OAB-q)
*#** Overactive Bladder Satisfaction Questionnaire (OABS)
*#** Overactive Bladder Symptom Scores Questionnaire (OABSS)
*#** Incontinence Impact Questionnaire (II-Q)
*#** Urogenital Distress Inventory (UDI)
*#** Each questionnaire can be used to improve assessment or monitoring of treatment outcomes. There is no evidence to indicate whether use of QOL or condition-specific questionnaires have an impact on outcomes from treatment
*# '''Voiding diary'''
*#* Semi-objective method of quantifying fluid intake and urological symptoms, such as frequency and possible episodes of urinary incontinence
*#* '''Should document the time, type, and volume of fluid intake, urine volume voided, urgency episodes, and incontinence episodes'''
*#** Can help the physician to differentiate between real small volume frequency (pollakiuria) and polyuria
*#* '''A voiding diary observation with 3‒7 days duration is recommended'''
* '''Not recommended (4): PVR, cystoscopy, imaging, urodynamics'''
*# '''PVR'''
*#* Elevated PVR has a multifactorial etiology, but is usually caused by BOO or detrusor underactivity
*#* '''Measurement of PVR is not mandatory for uncomplicated OAB patients with no risk factors or history of urinary retention.'''
*#* '''PVR should be evaluated in patients with (3):'''
*#*# '''Obstructive symptoms'''
*#*# '''Neurological diagnoses'''
*#*# '''History of either prostatic or incontinence surgery'''
*#** '''In these patients, PVR should be measured prior to starting antimuscarinic treatment.'''
*#*** '''PVR >250‒300 ml warrants special attention if antimuscarinic treatment is intended and consideration should be made as to the existence of other possible pathologies.'''
*# '''Cystoscopy'''
*#* '''May be used to exclude other causes for the symptoms associated with OAB''' (bladder tumour, carcinoma in-situ, ulcers, bladder stones, foreign bodies, cystitis)
*#* '''Recommended in patients with:'''
*#*# '''Recurrent UTI'''
*#*# '''Persistent pyuria'''
*#*# '''Hematuria'''
*#*# '''Bladder pain'''
*#*# '''History of stress incontinence or pelvic surgery'''
*#*# '''Suspected fistula'''
*#*# '''Urethral diverticulum'''
*#*# '''Urinary tract malformation'''
*#* '''Considered in patients with:'''
*#** '''Possible obstructive pathology'''
*# '''Imaging'''
*#* Neurological evaluation with spine imaging (CT, MRI) may be considered for patients with associated neurological symptoms.
*# '''Urodynamics'''
*#* OAB cannot be precisely and directly measured by UDS and is not recommended in the initial patient assessment
*#* '''UDS is indicated when:'''
*#*# '''Diagnosis remains uncertain after history and physical examination'''
*#*# '''Symptoms do not correlate with physical findings'''
*#*# '''Failed previous treatment'''
*#* '''UDS should be taken into consideration in initial diagnosis of patients with:'''
*#*# '''History of radical pelvic surgery and pelvic radiation'''
*#*# '''Neurogenic voiding dysfunction'''
*#*# '''Risk of upper urinary tract deterioration'''
*#* '''The role of videourodynamics in OAB has not been determined and this technique is not currently recommended'''
*#* '''The primary urodynamic abnormality underlying OAB is detrusor overactivity (DO)'''