Urinary frequency and urgency
(OAB)
According to a new concept proposed by the International Urological Control, the syndrome of frequent, urgent and even urge incontinence is called overactive bladder (OAB), which can occur individually or in any combination. Frequent urination is defined as urination > 8 times in 24h and > 2 times at night, with a volume < 200ml per urination, often after the bladder has been emptied. Urinary urgency refers to the feeling of sudden and urgent urination, which often leads to urgency to go to the toilet. Lu Jianwei, Department of Urology, Shanghai Renji Hospital
Diagnostic steps
The first step is to rule out or diagnose frequent urination caused by abnormal increase in urine volume based on medical history and 24-hour urination card.
Urinary frequency can be divided into physiological and pathological. In physiological cases, the number of urination is related to how much water is drunk, how warm or cold the climate is, and how much sweating there is. Frequent urination due to excessive water intake, nervousness or cold weather is called physiological frequency of urination. Therefore, we should ask the patient’s medical history in detail (daily intake, whether or not to take relevant drugs, etc.); if necessary, we can ask the patient to record the 24-hour urination card, which is very important to record the patient’s fluid intake and urination during the day and night, and can indirectly reflect the patient’s bladder function; certain drugs, such as: taking diuretics or antihypertensive drugs containing diuretic ingredients, or drinking coffee, strong tea Some medications, such as taking diuretics or antihypertensive drugs with diuretic ingredients, or drinking coffee, strong tea, or large amounts of beer, cause excessive urine production in the body, and the symptoms of frequent urination may occur. In addition, if the total volume of urine increases when excessive urine is produced, and the volume of urine increases each time, and there is no history of related medication, it is necessary to further exclude or diagnose whether the frequency of urination is caused by an abnormal increase in urine volume due to diabetes mellitus, uremia, polyuria in acute renal failure or primary aldosteronism.
The second step is to rule out or diagnose neurogenic OAB based on the presence or absence of neurological disease and injury.
Neurogenic OAB is mainly due to hyperreflexia of the supraspinal nervous system (cerebrovascular disease, brain tumor, traumatic brain injury, and Parkinson’s disease, etc.). symptoms. Patients may also be characterized by reduced bladder capacity and small amounts of residual urine.
In 78% of patients with cerebrovascular disease and 40-70% of patients with Parkinson’s disease, urodynamic testing reveals a hyperreflexia of the detrusor muscles (an uninhibited contraction of the bladder on urodynamic testing – an uninhibited contraction of the detrusor muscles is diagnosed as a systolic pressure of more than 15 cmH2O during the bladder storage phase). Most patients have clinical symptoms of urinary frequency and urgency. In addition to routine physical examination and urodynamic examination, the ice water test is also performed: after emptying the bladder with an F16 catheter, 60 ml of 14°C ice water is injected rapidly.
In addition, some patients may also have a dysfunction of the forced urinary muscle-urethral sphincter synergism, i.e., they also have symptoms of difficulty in urination, which can aggravate the damage to the upper urinary tract, cause hydronephrosis and affect kidney function, and should be treated early.
The third step is to rule out or diagnose OAB caused by inflammatory stimulation based on urine/prostate fluid examination.
Urinary frequency and urgency are common symptoms in the case of inflammation of the urethra, bladder or prostate. In addition to the symptoms of urinary frequency and urgency, patients often have symptoms such as pain or burning sensation in the urethra, lumbago, soreness in the lower abdomen or perineum, and fever. Laboratory tests include: (a) routine urine examination, leukocytosis and pus urine; (b) staining of urine sediment smear to find bacteria; (c) urine bacterial culture to find bacteria and urine colony count >105/ml; (d) routine examination of prostate fluid in male patients, leukocytes >10/HP; (e) positive culture of bacteria, mycoplasma or chlamydia in male prostate fluid; (f) routine blood tests. Elevated leukocytes and left shift of neutrophil nuclei.
Prostatitis can be divided into two types: acute and chronic.
The main symptoms of acute prostatitis are perineal distension and discomfort, and vague pain in the abdomen, which can radiate to the lumbosacral region, penis and thighs. If it is caused by a urinary tract infection, the symptoms may include frequent urination, urgent urination, painful urination or hematuria. The onset of the disease is rapid and may be accompanied by fever, chills, anorexia, fatigue and other systemic symptoms. On examination, the peripheral blood white blood cells are increased, and a large number of white blood cells can be seen in the urine. The enlarged prostate can be palpated by rectal palpation, with obvious pressure pain and fluctuating sensation when an abscess is formed. Chronic prostatitis The main symptoms are frequent and incomplete urination as well as burning and itching in the urethra. The pain is often distended and throbbing, radiating to the head of the penis and perineum, and there is suprapubic and lumbosacral discomfort. Patients often have prostatic overflow, which mostly occurs at the end of urination or during bowel straining, with a white discharge from the urethra. The prostate is unevenly soft and hard with mild tenderness on rectal palpation.
Step 4 Exclude or diagnose OAB due to obstruction/foreign body irritation based on ultrasound/anal finger examination.
Bladder outlet obstruction (male prostate enlargement, female bladder neck obstruction, etc.) may cause urinary frequency and urgency (OAB). For the early stage of prostate enlargement, it is caused by prostate congestion and irritation, which is more significant at night and manifests as increased nocturia; as the obstruction worsens, the bladder forced urinary muscle gradually loses its function, and the urine in the bladder cannot be purged at each urination, and residual urine appears, which reduces the effective capacity of the bladder and makes the urination The effective capacity of the bladder is reduced and the interval time between voiding is shortened, and the frequency of urination is gradually increased; in addition, the hypersensitive lesion of the detrusor muscle due to the increased pressure during voiding is also an important factor; if there is a bladder stone or infection, the frequency of urination is more obvious. The differential diagnosis can be made clinically by anal examination, ultrasound and urodynamic examination (maximum urethral pressure, functional urethral length, P-Q diagram analysis, etc.). (See the section on prostatic nodules for details)
Foreign bodies in the bladder (stones, ducts, tumors, etc.) can irritate the bladder mucosa, resulting in secondary symptoms of urinary frequency and urgency (OAB). Most bladder stones present clinically with urinary pain, dysuria, and hematuria in addition to frequency and urgency, often triggered or exacerbated by activity and vigorous exercise, and can be diagnosed by ultrasound, radiographs, and cystoscopy. About 10% of bladder tumors may have starting symptoms as urinary frequency and urgency, which may be extensive carcinoma in situ or invasive carcinoma, especially those growing in the third region of the bladder; the clinically important symptom is painless intermittent carnal hematuria, which can be diagnosed by ultrasound, cystoscopy, and CT examination.
(To be continued)
Author: Jianwei Lu