BETHESDA, MD USA (UroToday.com) - The CURE UAB 2-day meeting focused on the neglected condition of underactive bladder (UAB). The meeting brought together federal agencies, basic science researchers, clinicians, and clinical researchers to discuss the current state of this condition and with the aim to move NIH research agendas. The meeting was chaired by Drs. Ananias Diokno and Michael Chancellor, both urologists from Beaumont Hospital in Royal Oak, Michigan. Sponsors included Beaumont Urology CURE Institute, National Institute on Aging, Beaumont CURE Urology, and the Underactive Bladder Foundation.
The presentations were informative and brought to the forefront what is known and/or lacking in this area of urology. Following are some of the meeting highlights.
Dr. Ananias Diokno provided a review of the Symptoms and Evaluation of UAB Through 3 Decades of Geriatric Urology Research. He noted that the basic premise for establishing UAB was the failure to achieve complete bladder emptying and an absence of obstruction. History is essential, as patients usually present with either a long-standing history of bladder emptying symptoms or are asymptomatic, but are found to have high post-voide residuals (PVRs). Some manage their bladders with either an indwelling urinary catheter (IUC) or intermittent catheterization. Confirmation of UAB is usually with pressure flow urodynamic tests that indicate low pressure, poorly sustained or wave-like contractions with an associated poor flow rate.
Dr. Roger Dmochowski, a urologist at Vanderbilt University, reviewed the Epidemiology of UAB by reviewing the ICS definition: “a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span.” Historically, the term “detrusor underactivity (DU)” has been used to describe this condition with prevalence estimates from 4% to 48% of patients with LUTS undergoing UDS. UAB causes can be neurogenic, myogenic (BPH), and idiopathic. Several different Venn diagrams were shown depicting the overlapping of UAB and OAB symptoms, as Dr. Dmochowski felt that UAB was a component of LUTS. But true prevalence has yet to be determined. The message here was that UAB epidemiology needed to be established, the different patient populations needed to be studied, and treatment options are needed.
Geriatricians, Drs. Catherine DuBeau, University of Massachusetts Medical School and George Kuchel of the University of Connecticut presented issues of UAB in the Geriatric Patient. A main message at this meeting was that UAB increases with aging. Dr. DuBeau contrasted OAB with UAB in this patient group. An important point made was that both conditions can occur together with symptoms overlapping. She suggested that UAB in the older adult should follow a syndromic model that would take into account all risk factors (age-related changes, comorbidity, functional and cognitive factors). Treatments are needed, but drug therapies for LUTS (antimuscarinics, alpha blockers) should be used with caution in this age group and may be contraindicated per Beers criteria. It was noted that DHIC has been identified in older patients and these patients have both OAB and UAB symptoms. Dr. Kuchel presented the keynote lecture ("Where we are today with the aging UAB?") noting that there has been a disconnect between clinical practice and the literature with respect to UAB. One of the symptoms of UAB may be an elevated PVR but older adult patients who are found to have elevated PVRs may or may not have symptoms. UAB may be seen in detrusor underactivity (DU) but DU is a urodynamic diagnosis. Dr. Kuchel recommended avoidance of the term UAB other than to define the epidemiology of DU with longitudinal studies. Dr. Kuchel felt that aging causes of DU are multifactorial. Both Drs. DuBeau and Kuchel reviewed the research on DHIC noting that DU and DHIC are more prevalent in older adults, especially frail nursing home residents. Like detrusor overactivity, detrusor underactivity is found in patients without symptoms (normal). Several speakers presented various Venn diagrams to illustrate the overlapping of symptoms. The one presented here shows the relationship between DU and DO (see illustration).
Dr. Chet de Groat presented the Pathophysiology of Underactive Bladder. He provided a detailed review of the underlying mechanisms of UAB: neural, non-neural, or aging. Pathophysiology may include central or peripheral afferent and efferent neural mechanisms, and intrinsic muscle contractile mechanisms.
Drs. Naoki Yoshimura and Lori Birder of the University of Pittsburgh presented the basic science research on UAB, noting animal rat models of aging UAB/DU often exhibit OAB/DO resembling DHIC. These models can be used for development of future treatments. Dr. Birder presented aging and the urothelium and she postulated that the urothelium may play a role in aging and its relationship with instability and impaired contractility.
Dr. Ken Peters, chief of urology at Beaumont Hospital, Royal Oak, MI presented Neuromodulation for the Treatment of Urinary Retention. He provided a review of the causes of neurogenic and non-neurogenic urinary retention (UR). He expanded on the idiopathic cause, Fowler’s syndrome, seen in women who have EMG findings of impaired urethral relaxation that is seen more often in women with polycystic ovaries. Dr. Peters presented his experience with implantable sacral neuromodulation (SNM) and pudendal neuromodulation in patients with UR. His personal experience is that pudendal stimulation resolves UR better than SNM.
Dr. Pradeep Tyagi from the University of Pittsburgh presented on Development of Drug Therapy for UAB. The goals of UAB drug treatment would be to reduce PVR (if elevated), reduce outlet resistance, increase bladder contractility, and reduce recurrent UTIs. Current drugs that can impact UAB have very poor efficacy. What is needed are drugs that target afferent mucosal signaling, target efferent myocyte signaling, or that target supra-spinal and spinal signaling.
Dr. Mary Wilde from the University of Rochester, School of Nursing presented her ongoing research on Indwelling Urinary Catheters. She has developed a theoretical model for self-management of urine floor intervention that includes self-efficacy. She has also developed a urinary diary for patients with IUCs to monitor their symptoms and to be aware of their patterns of urine flow in relation to daily activities.
Diary parameters include:
- Type of fluid and amount
- Urine output in the drainage bag
- Urine color/presence of sediment, mucous, blood clots
As part of her research, Dr. Wilde also tested a catheter journal that allows the patient to record if there on any changes with the catheter and if anything was done about it. The patient was taught to recognize specific symptoms:
- Urine changes (color, odor, sediment)
- Temperature
- Pain or pressure in bladder area or back
- Early, mild symptoms of autonomic dysreflexia (chills, headaches, sweats( seen mainly in patients with a spinal cord injury
- General symptoms (weakness, spasticity, change in the level of alertness
Dr. Wilde is now studying self-management theory in intermittent catheter users. She is testing the feasibility of an online intervention.
The consensus of the meeting was that a paper outlining the current state of UAB with recommendations for future research would be developed. The slides from the meeting will be available online in the near future.
References:
Osman NI, Chapple CR, Abrams P, Dmochowski R, Haab F, Nitti V, Koelbl H, van Kerrebroeck P, Wein AJ. Detrusor underactivity and the underactive bladder: a new clinical entity? A review of current terminology, definitions, epidemiology, aetiology, and diagnosis. Eur Urol. 2014 Feb;65(2):389-98.
Taylor JA 3rd, Kuchel GA. Detrusor underactivity: Clinical features and pathogenesis of an underdiagnosed geriatric condition. J Am Geriatr Soc. 2006 Dec;54(12):1920-32
Wilde MH, Fader M, Ostaszkiewicz J, Prieto J, Moore K. Urinary bag decontamination for long-term use: a systematic review. J Wound Ostomy Continence Nurs. 2013 May-Jun;40(3):299-308
Highlights from the CURE-UAB: 1st International Congress of Urologic Research and Education on Aging Underactive Bladder - February 20 - 21, 2014 - Bethesda North Marriott Hotel & Conference Center - Bethesda, MD USA
Reported by Diane K. Newman, DNP, ANP-BC, FAAN
