AUA 2018: Underactive Bladder: Evaluation and Management

San Francisco, CA (UroToday.com) The SUFU session at the 113th Annual Scientific Meeting of the American Urological Association (AUA) focused on practical topics for the office urologist, of which one of the most challenging is treating patients with underactive bladder (UAB). Hadley Wood, MD presented a discussion of underactive bladder (UAB) diagnosis, management, and future directions for research. Several classification systems of UAB have been reported, which are inconsistent, but generally stratify patients with regards to the etiology of the problem (eg, myogenic versus neuropathic). Despite the development of new definitions and classifications, the treatment of UAB has not changed for many years.

Wood presented urodynamic findings from several cases that demonstrate the broad variety of patients with UAB, but with very different etiologies. 1) A 21 year old female with Lupus who showed phasic detrusor overacitivity (DO) but no volitional contraction, 2) A 61 year-old male with history of TURP, now status post APR for rectal cancer and 3) a 56 year-old female with CP who showed a bladder capacity of 2L, but was unsuccessful with voiding using a strong valsalva. These three patients share a unifying diagnosis of UAB, but require very different treatment strategies, and illustrate the challenge of treating these patients.

In the treatment of UAB, Wood reported little success with acetylcholine agonists. Patients who need a reduction in outlet resistance benefit from alpha blockers or prostate resection. She did discuss the development of stem cell therapies for UAB, which have shown promise in in vitro and in animal studies, but to date have limited human data.

Sacral neuromodulation is a mainstay of therapy for UAB, and is FDA approved for non-obstructive urinary retention. It has shown the most promise in women with idiopathic UAB, and been less successful in male patients. Transcutaneous electrical stimulation (TENS) has been studied with some success in pediatric patients with UAB. 

Wood also discussed less commonly used mechanical therapies for UAB. A triboelectric nanogenerator sensor with actuator, an implantable device that can empty the bladder is in development. A latissumus wrap has also been performed to provide mechanical bladder evacuation but is associated with high complication rates.

Wood then presented her practical approach to management of UAB using an algorithm. The first step is to determine if an obstruction is present and if so, to address this first. When there is no obstruction the treatment will depend on the type of UAB. Idiopathic UAB can benefit from pelvic floor physical therapy and neuromodulation. In patients with secondary OAB, the primary etiology should be addressed. Sacral neuromodulation should be used only in carefully selected patients. There are certain circumstances in which intermittent self-catheterization should always be done: evidence of DSD, hydroureter or hydronephrosis, secondary vesicoureteral reflux, recurrent UTI/urosepsis, CKD, and skin breakdown/decubitus ulcers due to incontinence. There is no established PVR cutoff at which to start self-catheterization, similar to the AUA White Paper on chronic urinary retention.1

Overall this was a very interesting session that discussed the wide range of demographichs and pathophysiology in UAB, with a small number of available treatments. Future studies will hopefully identify new treatment strategies that are specific to the patient’s clinical picture.


Presented by: Hadley Wood, MD; Glickman Urological and Kidney Institute

Reference: 
1. Stoffel JT, Peterson AC, Sandhu JS, Suskind AM, Wei JT, Lightner DJ. AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points. J Urol. 2017;198(1):153-160. doi:10.1016/j.juro.2017.01.075

Written by: Dena Moskowitz, MD; Fellow, Female Pelvic Medicine and Reconstructive Surgery, Virginia Mason Medical Center; @demoskowitz at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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