Contemporary diagnosis of lower urinary tract dysfunction.

Peter Rosier

doi:10.12688/f1000research.16120.1

Abstract

Introduction: Diagnosis of lower urinary tract (LUT) dysfunction starts with categorization in clinical syndromes, and initial management is based on the assumptions about pathophysiology that these syndromes contain. However, clinical practice guidelines are ambiguous in clinical specialists’ diagnosis of dysfunction after failure of initial management. This is a narrative and critical review of the existing evidence, and the aim is to suggest practice improvements in the process of clinical specialists’ diagnosis for patients resistant to initial management. Methods and Results: Evidence is collated on the basis of the author’s personal preference in combination with good clinical practice general principles. Statements and suggestions to improve reflect personal opinion. For two groups of patients with LUT dysfunction, the strategy of initial diagnosis is summarized and desirable principles of secondary care diagnosis are discussed. More specifically, a structure for the contemporary care of women with signs and symptoms of urinary incontinence is described and for that of the group of men older than 45 years with symptoms of LUT dysfunction. Conclusions: Urodynamic testing is the undisputed gold standard for objective assessment and is the only way to stage and grade the dysfunction. Clinical practice guidelines and clinical specialists are too modest about the use and applicability of objective or urodynamic testing for referred persons with LUT dysfunction that is resistant to initial pragmatic management. Objective assessment and diagnosis are mainstays in secondary care, and the indication to perform objective assessments in patients with LUT dysfunction should be advised much more specifically in guidelines and practice recommendations.

Highlights

Diagnosis of lower urinary tract (LUT) dysfunction starts with categorization in clinical syndromes, and initial management is based on the assumptions about pathophysiology that these syndromes contain
These two groups are very prevalent and the recommendations in the guidelines for secondary care management are especially ambiguous about the relevance of adequate objective diagnosis for these: adult women with symptoms of urinary incontinence (UI) or too frequent voiding and adult men older than 45 years of age with symptoms of LUT dysfunction
I present a narrative, personal, and critical review of the evidence and of general contemporary good medical principles regarding the diagnostic process for patients with LUT dysfunction and the ultimate aims are to improve care and outcome and to reduce harm for these patients

Summary

Introduction

The normal lower urinary tract (LUT) stores urine and is able to evacuate this at suitable moments. Staging and grading of dysfunction and disease are mainstays in secondary care, and the patients with failure after initial management for their UI deserve objective assessment because they worry about the origin of their symptoms[23] and expect information about cause and about the specific and individualized management of their dysfunction[28]. Men with high-grade BOO and detrusor overactivity may deserve a less expectative management than men with a moderate grade of BOO without detrusor overactivity This stratification of disease, as was already introduced in 197930, has been overwhelmed with the (enthusiastic) introduction of minimally invasive and medical management options for elderly men with symptoms and for these options: “one size fits all” –management strategies do not exist in health care, especially not when initiated on the basis of symptoms only. Individualization of management on the basis of objectively assessed pathophysiology should be the gold standard in every clinical specialist’s practice

Conclusions

Findings

PubMed Abstract