Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-Committee of the International Continence Society

Appendix B The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-Committee of the International Continence Society

Paul Abrams, Linda Cardozo, Magnus Fall, Derek Griffiths, Peter Rosier, Ulf Ulmsten, Philip van Kerrebroeck, Arne Victor, Alan Wein

This report presents definitions of the symptoms, signs, urodynamic observations and conditions associated with lower urinary tract dysfunction (LUTD) and urodynamic studies (UDS), for use in all patient groups from children to the elderly.

The definitions restate or update those presented in previous International Continence Society Standardisation of Terminology reports (see references) and those shortly to be published on Urethral Function [Lose et al., in press] and Nocturia [van Kerrebroeck et al., 2002]. The published ICS report on the technical aspects of urodynamic equipment [Rowan et al., 1987] will be complemented by the new ICS report on urodynamic practice to be published shortly [Schäfer et al., 2002]. In addition there are four published ICS outcome reports [Fonda et al., 1998; Lose et al., 1998; Mattiasson et al., 1998; Nordling et al., 1998].

New or changed definitions are all indicated, however, recommendations concerning technique are not included in the main text of this report.

The definitions have been written to be compatible with the WHO publication ICIDH-2 [International Classification of Functioning, Disability and Health] published in 2001 and ICD10, the International Classification of Diseases. As far as possible, the definitions are descriptive of observations, without implying underlying assumptions that may later prove to be incorrect or incomplete. By following this principle the International Continence Society (ICS) aims to facilitate comparison of results and enable effective communication by investigators who use urodynamic methods. This report restates the ICS principle that symptoms, signs and conditions are separate categories, and adds a category of urodynamic observations. In addition, terminology related to therapies is included [Andersen et al., 1992].

When a reference is made to the whole anatomical organ the vesica urinaria, the correct term is the bladder. When the smooth muscle structure known as the m.detrusor urinae is being discussed, then the correct term is detrusor.

It is suggested that acknowledgement of these standards in written publications be indicated by a footnote to the section “Methods and Materials” or its equivalent, to read as follows:

“Methods, definitions and units conform to the standards recommended by the International Continence Society, except where specifically noted.”

The report covers the following areas:

LOWER URINARY TRACT SYMPTOMS (LUTS)

Symptoms are the subjective indicator of a disease or change in condition as perceived by the patient, carer or partner and may lead him/her to seek help from health care professionals. (NEW)

Symptoms may either be volunteered or described during the patient interview. They are usually qualitative. In general, Lower Urinary Tract Symptoms cannot be used to make a definitive diagnosis. Lower Urinary Tract Symptoms can also indicate pathologies other than lower urinary tract dysfunction, such as urinary infection.

SIGNS SUGGESTIVE OF LOWER URINARY TRACT DYSFUNCTION (LUTD)

Signs are observed by the physician including simple means, to verify symptoms and quantify them. (NEW)

For example, a classical sign is the observation of leakage on coughing. Observations from frequency volume charts, pad tests and validated symptom and quality of life questionnaires are examples of other instruments that can be used to verify and quantify symptoms.

URODYNAMIC OBSERVATIONS

Urodynamic observations are observations made during urodynamic studies. (NEW)

For example, an involuntary detrusor contraction (detrusor overactivity) is a urodynamic observation. In general, a urodynamic observation may have a number of possible underlying causes and does not represent a definitive diagnosis of a disease or condition and may occur with a variety of symptoms and signs, or in the absence of any symptoms or signs.

CONDITIONS

Conditions are defined by the presence of urodynamic observations associated with characteristic symptoms or signs and/or non-urodynamic evidence of relevant pathological processes. (NEW)

TREATMENT

Treatment for lower urinary tract dysfunction: these definitions are from the 7th ICS report on Lower Urinary Tract Rehabilitation Techniques [Andersen et al., 1992].

1. LOWER URINARY TRACT SYMPTOMS (LUTS)

Lower urinary tract symptoms are defined from the individual’s perspective, who is usually, but not necessarily a patient within the healthcare system. Symptoms are either volunteered by, or elicited from, the individual or may be described by the individual’s caregiver.

Lower urinary tract symptoms are divided into three groups, storage, voiding, and post micturition symptoms.

1.1 Storage Symptoms

are experienced during the storage phase of the bladder, and include daytime frequency and nocturia. (NEW)

• Increased daytime frequency is the complaint by the patient who considers that he/she voids too often by day. (NEW) This term is equivalent to pollakisuria used in many countries.

• Nocturia is the complaint that the individual has to wake at night one or more times to void. (NEW)¹

• Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer. (CHANGED)

• Urinary incontinence is the complaint of any involuntary leakage of urine. (NEW)²

In each specific circumstance, urinary incontinence should be further described by specifying relevant factors such as type, frequency, severity, precipitating factors, social impact, effect on hygiene and quality of life, the measures used to contain the leakage, and whether or not the individual seeks or desires help because of urinary incontinence.³

Urinary leakage may need to be distinguished from sweating or vaginal discharge.

• Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. (CHANGED)⁴

• Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency. (CHANGED)⁵

• Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing. (NEW)

• Enuresis means any involuntary loss of urine. (ORIGINAL) If it is used to denote incontinence during sleep, it should always be qualified with the adjective “nocturnal.”

• Nocturnal enuresis is the complaint of loss of urine occurring during sleep. (NEW)

• Continuous urinary incontinence is the complaint of continuous leakage. (NEW)

• Other types of urinary incontinence may be situational, for example the report of incontinence during sexual intercourse, or giggle incontinence.

• Bladder sensation can be defined, during history taking, by five categories.

Normal: the individual is aware of bladder filling and increasing sensation up to a strong desire to void. (NEW)

Increased: the individual feels an early and persistent desire to void. (NEW)

Reduced: the individual is aware of bladder filling but does not feel a definite desire to void. (NEW)

Absent: the individual reports no sensation of bladder filling or desire to void. (NEW)

Non-specific: the individual reports no specific bladder sensation, but may perceive bladder filling as abdominal fullness, vegetative symptoms, or spasticity. (NEW)⁶

1.2 Voiding Symptoms

are experienced during the voiding phase. (NEW)

• Slow stream is reported by the individual as his or her perception of reduced urine flow, usually compared to previous performance or in comparison to others. (NEW)

• Splitting or spraying of the urine stream may be reported. (NEW)

• Intermittent stream (Intermittency) is the term used when the individual describes urine flow, which stops and starts, on one or more occasions, during micturition. (NEW)

• Hesitancy is the term used when an individual describes difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine. (NEW)

• Straining to void describes the muscular effort used to either initiate, maintain, or improve the urinary stream. (NEW)⁷

• Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble. (NEW)

1.3 Post Micturition Symptoms

are experienced immediately after micturition. (NEW)

• Feeling of incomplete emptying is a self-explanatory term for a feeling experienced by the individual after passing urine. (NEW)

• Post micturition dribble is the term used when an individual describes the involuntary loss of urine immediately after he or she has finished passing urine, usually after leaving the toilet in men, or after rising from the toilet in women. (NEW)

1.4 Symptoms Associated with Sexual Intercourse

Dyspareunia, vaginal dryness, and incontinence are amongst the symptoms women may describe during or after intercourse. These symptoms should be described as fully as possible. It is helpful to define urine leakage as: during penetration, during intercourse, or at orgasm.

1.5 Symptoms Associated with Pelvic Organ Prolapse

The feeling of a lump (“something coming down”), low backache, heaviness, dragging sensation, or the need to digitally replace the prolapse in order to defecate or micturate, are amongst the symptoms women may describe who have a prolapse.

1.6 Genital and Lower Urinary Tract Pain ⁸

Pain, discomfort and pressure are part of a spectrum of abnormal sensations felt by the individual. Pain produces the greatest impact on the patient and may be related to bladder filling or voiding, may be f elt after micturition, or be continuous. Pain should also be characterised by type, frequency, duration, precipitating and relieving factors and by location as defined below:

• Bladder pain is felt suprapubically or retropubically, usually increases with bladder filling, and may persist after voiding. (NEW)

• Urethral pain is felt in the urethra and the individual indicates the urethra as the site. (NEW)

• Vulval pain is felt in and around the external genitalia. (NEW)

• Vaginal pain is felt internally, above the introitus. (NEW)

• Scrotal pain may or may not be localised, for example to the testis, epididymis, cord structures or scrotal skin. (NEW)

• Perineal pain is felt: in the female, between the posterior fourchette (posterior lip of the introitus) and the anus, and in the male, between the scrotum and the anus. (NEW)

• Pelvic pain is less well defined than, for example, bladder, urethral or perineal pain and is less clearly related to the micturition cycle or to bowel function and is not localised to any single pelvic organ. (NEW)

1.7 Genito-Urinary Pain Syndromes and Symptom Syndromes Suggestive of LUTD

Syndromes describe constellations, or varying combinations of symptoms, but cannot be used for precise diagnosis. The use of the word syndrome can only be justified if there is at least one other symptom in addition to the symptom used to describe the syndrome. In scientific communications the incidence of individual symptoms within the syndrome should be stated, in addition to the number of individuals with the syndrome. The syndromes described are functional abnormalities for which a precise cause has not been defined. It is presumed that routine assessment (history taking, physical examination, and other appropriate investigations) has excluded obvious local pathologies, such as those that are infective, neoplastic, metabolic or hormonal in nature.

1.7.1 Genito-urinary pain syndromes

are all chronic in their nature. Pain is the major complaint but concomitant complaints are of lower urinary tract, bowel, sexual or gynaecological nature.

• Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and nighttime frequency, in the absence of proven urinary infection or other obvious pathology. (NEW)⁹

• Urethral pain syndrome is the occurrence of recurrent episodic urethral pain usually on voiding, with daytime frequency and nocturia, in the absence of proven infection or other obvious pathology. (NEW)

• Vulval pain syndrome is the occurrence of persistent or recurrent episodic vulval pain, which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious pathology. (NEW)¹⁰

• Vaginal pain syndrome is the occurrence of persistent or recurrent episodic vaginal pain which is associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven vaginal infection or other obvious pathology.

• Scrotal pain syndrome is the occurrence of persistent or recurrent episodic scrotal pain which is associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven epididimo-orchitis or other obvious pathology.

• Perineal pain syndrome is the occurrence of persistent or recurrent episodic perineal pain, which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious pathology. (NEW)¹¹

• Pelvic pain syndrome is the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. There is no proven infection or other obvious pathology. (NEW)

1.7.2 Symptom syndromes suggestive of lower urinary tract dysfunction

In clinical practice, empirical diagnoses are often used as the basis for initial management after assessing the individual’s lower urinary tract symptoms, physical findings and the results of urinalysis and other indicated investigations.

• Urgency, with or without urge incontinence, usually with frequency and nocturia, can be describe as the overactive bladder syndrome, urge syndrome or urgency-frequency syndrome. (NEW)

These symptom combinations are suggestive of urodynamically demonstrable detrusor overactivity, but can be due to other forms of urethro-vesical dysfunction. These terms can be used if there is no proven infection or other obvious pathology.

• Lower urinary tract symptoms suggestive of bladder outlet obstruction is a term used when a man complains predominately of voiding symptoms in the absence of infection or obvious pathology other than possible causes of outlet obstruction. (NEW)¹²

2. SIGNS SUGGESTIVE OF LOWER URINARY TRACT DYSFUNCTION (LUTD)

2.1 Measuring the Frequency, Severity and Impact of Lower Urinary Tract Symptoms

Asking the patient to record micturitions and symptoms ¹³ for a period of days provides invaluable information. The recording of micturition events can be in three main forms:

• Micturition time chart: this records only the times of micturitions, day and night, for at least 24 hours. (NEW)

• Frequency volume chart (FVC): this records the volumes voided as well as the time of each micturition, day and night, for at least 24 hours. (CHANGED)

• Bladder diary: this records the times of micturitions and voided volumes, incontinence episodes, pad usage and other information such as fluid intake, the degree of urgency and the degree of incontinence. (NEW)¹⁴

The following measurements can be abstracted from frequency volume charts and bladder diaries:

• Daytime frequency is the number of voids recorded during waking hours and includes the last void before sleep and the first void after waking and rising in the morning. (NEW)

• Nocturia is the number of voids recorded during a night’s sleep: each void is preceded and followed by sleep. (NEW)

• 24-hour frequency is the total number of daytime voids and episodes of nocturia during a specified 24-hour period. (NEW)

• 24-hour production is measured by collecting all urine for 24-hours. (NEW)

This is usually commenced after the first void produced after rising in the morning, and is completed by including the first void on rising the following morning.

• Polyuria is defined as the measured production of more than 2.8 litres of urine in 24 hours in adults. It may be useful to look at output over shorter time frames [van Kerrebroeck et al., 2002]. (NEW)¹⁵

• Nocturnal urine volume is defined as the total volume of urine passed between the time the individual goes to bed with the intention of sleeping and the time of waking with the intention of rising. (NEW) Therefore, it excludes the last void before going to bed but includes the first void after rising in the morning.

• Nocturnal polyuria is present when an increased proportion of the 24-hour output occurs at night (normally during the 8 hours whilst the patient is in bed). (NEW) The night time urine output excludes the last void before sleep but includes the first void of the morning.¹⁶

• Maximum voided volume is the largest volume of urine voided during a single micturition and is determined either from the frequency/volume chart or bladder diary. (NEW)

The maximum, mean and minimum voided volumes over the period of recording may be stated.¹⁷

2.2 Physical Examination

is essential in the assessment of all patients with lower urinary tract dysfunction. It should include abdominal, pelvic, perineal and a focussed neurological examination. For patients with possible neurogenic lower urinary tract dysfunction, a more extensive neurological examination is needed.

2.2.1 Abdominal:

the bladder may be felt by abdominal palpation or by suprapubic percussion. Pressure suprapubically or during bimanual vaginal examination may induce a desire to pass urine.

2.2.2 Perineal/genital inspection

allows the description of the skin, for example the presence of atrophy or excoriation, any abnormal anatomical features and the observation of incontinence.

• Urinary incontinence (the sign) is defined as urine leakage seen during examination: this may be urethral or extraurethral.

• Stress urinary incontinence is the observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing or coughing. (CHANGED)¹⁸

Stress Leakage is presumed to be due to raised abdominal pressure.

• Extra-urethral incontinence is defined as observation of urine leakage through channels other than the urethra. (ORIGINAL)

• Uncategorized incontinence is the observation of involuntary leakage that cannot be classified into one of the above categories on the basis of signs and symptoms. (NEW)

2.2.3 Vaginal examination

allows the description of observed and palpable anatomical abnormalities and the assessment of pelvic floor muscle function, as described in the ICS report on Pelvic Organ Prolapse. The definitions given are simplified versions of the definitions in the report. [Bump et al., 1996]

• Pelvic organ prolapse is defined as the descent of one or more of: the anterior vaginal wall, the posterior vaginal wall, and the apex of the vagina (cervix/uterus) or vault (cuff) after hysterectomy. Absence of prolapse is defined as stage 0 support; prolapse can be staged from stage I to stage IV. (NEW)

Pelvic organ prolapse can occur in association with urinary incontinence and other lower urinary tract dysfunction and may on occasion mask incontinence.

• Anterior vaginal wall prolapse is defined as descent of the anterior vagina so that the urethrovesical junction (a point 3cm proximal to the external urinary meatus) or any anterior point proximal to this is less than 3cm above the plane of the hymen. (CHANGED)

• Prolapse of the apical segment of the vagina

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