Heesakkers2_EU_Genito.qxp 1/8/07 10:11 Page 61
Overactive Bladder
The Complexities of Diagnosing and Treating Overactive Bladder in Men –
New Patients, New Data, New Treatment Options
a report by
Kamiel AJ Kuijpers and John PFA Heesakkers
Research Fellow and Chief Clinician, Department of Urology, Radboud University Medical Center
Voiding and Storage Lower Urinary Tract Symptoms which provides accurate data of normal urinary habits. LUTS
The prevalence of lower urinary tract symptoms (LUTS) in men is high. A questionnaires, such as the International Continence Society (ICS) male
study in five European countries revealed that 62.5% of men in the questionnaire or the International Prostate Symptom Score (IPSS)
general population (n=5,460) reported at least one LUTS.
1
LUTS include questionnaire, estimate the patient’s subjective bother. Further analysis of
storage symptoms (daytime urinary frequency, nocturia, urgency, urinary male LUTS is primarily targeted to the prostate. This is not surprising, as
incontinence) and voiding symptoms (slow stream, splitting or spraying, historically used terms to describe male LUTS were all focused on the
intermittency, hesitancy, straining, terminal dribble).
2
Storage LUTS are prostate as the main perpetrator (e.g. prostatism or clinical BPH). The
reported nearly twice as often (51.4%) as voiding LUTS (25.7%). LUTS urinary flow test, which measures peak urinary flow and residual volume,
can be associated with pathological conditions of the prostate, the is used to evaluate bladder emptying. This uroflowmetry provides
bladder or both,
3
in which benign prostatic hyperplasia (BPH) and the relatively reasonable correlation with BOO, but may be misinterpreted by
overactive bladder (OAB) play a major role. inaccurate detrusor contractility. In these cases, pressure-flow analysis is
used to distinguish BOO from detrusor underactivity during voiding.
Lower Urinary Tract Symptoms Terminology – Overactive
Bladder and Benign Prostatic Enlargement However, many men with LUTS do not have BOO. Therefore, not all male
The OAB is characterised by urgency, frequency and nocturia with or LUTS can be screened in such a straightforward manner as previously
without urge incontinence. In fact, it comprises the same symptoms as described. Laniado et al. reported that urodynamically confirmed BOO
storage LUTS but excludes types of incontinence other than urge occurred in only 48% of referred men with LUTS.
6
Additionally, BOO and
incontinence. It therefore forms a comparable subset of storage LUTS OAB often occur together. Studies reported that nearly 50% of men with
as found being persistent after transurethral resection of the prostate LUTS and urodynamically confirmed BOO had DO.
7,8
This illustrates the
(TURP). OAB is reasonably well correlated with detrusor overactivity core of complexity surrounding the diagnosis and treatment of male
(DO), which is defined as involuntary detrusor contractions during the LUTS. Therefore, the ideal approach for evaluating men with LUTS in
filling phase that the patient cannot inhibit. The term benign prostatic whom presumptive therapy fails is to always use full urodynamic analysis
hyperplasia (BPH) is used and reserved for the typical histological (cystometry for filling and pressure-flow for voiding) to identify possible
pattern that defines the disease. Benign prostatic enlargement (BPE) is underlying bladder pathology, such as DO.
caused by BPH and may cause bladder outlet obstruction (BOO), a
functional diagnosis.
Kamiel Kuijpers is a Research Fellow in the Department of
The Complex Interplay of Overactive Bladder and Benign
Urology at the Radboud University Medical Centre in
Nijmegen, The Netherlands. He received the Astellas
Prostatic Enlargement European Foundation 2006 Prize Fund award and was
As DO may be primary or develop secondary to BOO, as shown in
awarded the prize for second best abstract (non-oncology)
at the 21st Annual European Association of Urology (EAU)
obstructive animal models,
4
a complex interplay of prostatic pathology
Congress in Paris. He also deals with complex incontinence
and bladder dysfunction eventually leads to storage LUTS in men. problems in a supra-regional tertiary referral unit and
However, one must keep in mind that the existence of BOO and DO does
teaches students. He obtained his medical degree at the
Radboud University in 2005 and is finishing his PhD in
not always have a causal relationship.
translational research considering the overactive bladder.
The precise cause of DO in men with BOO has not been identified. It is John Heesakkers is Chief Clinician and a full-time Staff
suggested that BOO may cause DO by cholinergic denervation of the
Urologist in the Department of Urology at the Radboud
University Medical Center in Nijmegen. He heads the unit
detrusor and consequent supersensitivity of muscarinic receptors.
5
BOO
of functional urology and is also Consultant Urologist in
may also result in ischaemia, patchy denervation, altered electrical
the rehabilitation centre, St Maartenskliniek, Nijmegen,
properties of smooth muscle and hypertrophied neurons. These changes
and the MS Centre, Nijmegen. He is the author or
co-author of approximately 50 peer-reviewed publications,
lead to a re-organisation of the spinal micturition reflex, resulting in
200 abstracts and 100 lectures on urology. He is a
increased excitability and thereby triggering the sense of urgency and
reviewer for several journals, including European Urology,
Neurourology and Urodynamics, Journal of Urology and Urology. Dr Heesakkers completed
culminating in an involuntary detrusor contraction. This contraction
his PhD thesis on dynamic graciloplasty and earned his medical degree at Catholic
clinically evokes storage LUTS. University, Nijmegen and his Master of Business Administration from Erasmus University,
Rotterdam. He completed residencies in surgery and urology at Maastricht University
Hospital, also in The Netherlands.
Evaluation of Male Lower Urinary Tract Symptoms
Initial evaluation of men with LUTS starts with completing a voiding diary,
© TOUCH BRIEFINGS 2007 61
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