EURURO Vol. 72 No. 3

Platinum Priority – Editorial and Reply from Authors

Referring to the article published on pp. 402–407 of this issue

Towards a Greater Understanding of Underactive Bladder

Mikkel Fode

a , b , * ,

Jens Sønksen

Department of Urology, Zealand University Hospital, Roskilde, Denmark;

Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark

It has traditionally been thought that lower urinary tract

symptoms (LUTS) in men stem from an enlarged prostate,

while problems in women have been attributed to bladder

dysfunction. However, over the last decades our under-

standing of LUTS has increased and the urinary tract is now

viewed as a functional unit with many possible causes of

dysfunction

[1]

. In addition, it has been recognized that

subjective urinary problems are not specific to a defined

pathophysiology. This means that new research has ensued

to identify varying causes of LUTS. In this regard, underac-

tive bladder (UAB) and detrusor underactivity (DU) have

received little attention despite the fact that they are

commonly encountered in the clinic

[2]

. In this issue of

European Urology

, Uren and coworkers

[3]

present a

qualitative exploration of the patient experience among

44men and women with urodynamic signs of DU. The study

is important and groundbreaking in its efforts to explore

subjective experiences in these patients, and it represents a

much-needed research effort. However, the work is clearly

preliminary and seems to leave us with as many questions

as it answers.

The International Continence Society defines DU as ‘‘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’’

[4] .

Meanwhile, there is no consensus on more specific

diagnostic criteria, including concrete urodynamic thresh-

olds for contractile strength and a ‘‘normal’’ urination time

span. In addition, it is well known from research on

overactive bladder that there is not necessarily concordance

between urodynamic findings and patient symptoms

[5] .

Thus, it may not be reasonable that the authors define

UAB as ‘‘the symptom complex of urodynamically diag-

nosed detrusor underactivity

. . .

’’. Rather, it would be

prudent to stick to the full working definition previously

proposed by Chapple et al

[6] ,

which is only partly quoted:

‘‘The underactive bladder is a symptom complex suggestive

of detrusor underactivity and is usually characterized by

prolonged urination time with or without a sensation of

incomplete bladder emptying, usually with hesitancy,

reduced sensation on filling, and a slow stream.’’ The

important distinction is that the symptoms are only

suggestive of a specific urodynamic abnormality, in line

with our current conception of the urinary tract as a

functional unit. Chapple et al

[6]

go on to specify that

‘‘underactive bladder symptom complex is not synonymous

with DU

. . .

’’. Nevertheless, Uren et al specifically included

their participants on the basis of urodynamic findings. The

picture is further complicated by the fact that the

participants were selected via retrospective chart reviews

of patients who had been referred for urodynamic studies.

This means that symptomatic patients were preselected

and that their LUTS could have had causes other than DU.

The issue is highlighted by the fact that more than half of the

participants had other detectable urinary problems in the

form of urinary incontinence, detrusor overactivity, or

bladder outlet obstruction. In this context it is not

surprising that the study identifies a wide range of both

voiding and storage symptoms in the participants. Consid-

ering the purpose of the study, it is somewhat concerning

that the most common symptom was nocturia, while

30%

did not describe a slow urinary stream and

50% reported a

sensation of incomplete bladder emptying. Furthermore,

storage symptoms, traditionally defined as part of the

overactive bladder complex, seem to exert the most

significant bother on quality of life. Although residual urine

can cause storage symptoms, these issues make it unlikely

that all of the participants truly suffered from UAB. Thus,

E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 4 0 8 – 4 1 0

available at

www.scienced irect.com

journal homepage:

www.europeanurology.com

DOI of original article:

http://dx.doi.org/10.1016/j.eururo.2017.03.045

* Corresponding author. Department of Urology, Zealand University Hospital, Sygehusvej 10, DK-4000 Roskilde, Denmark. Tel. +4526213800.

E-mail address:

mikkelfode@gmail.com

(M. Fode).

0302-2838/