THE STANDARDISATION OF TERMINOLOGY IN LOWER URINARY TRACT FUNCTION

Report from the Standardisation Sub-committee of the International Continence Society

Committee: Paul Abram ! Bristol Urological Institute! Li"#a Car#o$o! Kings College Hospital, London! Ma%"u Fall! Sahlgrensja University Hospital, Gteborg, Dere& Gri''it( ! University o !ittsburgh, Peter Ro ier! "utch Institute or Healthcare I#prove#ent, Utrecht, Ul' Ulm te"! Uppsala University Hospital, P(ili) *a" +errebroe,&! University Hospital $aastricht, Ar"e -i,tor! $edical !roducts %gency, Uppsala, Ala" Wei"! University o !hiladelphia. +e/0or# : Sta"#ar#i atio"! Termi"olo%/! Lo0er Uri"ar/ Tra,t Fu",tio"! I"ter"atio"al Co"ti"e",e So,iet/.

&his report presents de initions o the sy#pto#s, signs, urodyna#ic observations and conditions associated 'ith lo'er urinary tract dys unction (LU&") and urodyna#ic studies (U"S), or use in all patients groups ro# children to the elderly* &he de initions restate or update those presented in previous International Continence Society Standardisation o &er#inology reports (+,-) and published on Urethral .unction (/) and 0octuria (1)* &he published ICS report on the technical aspects o urodyna#ic e2uip#ent (+3) is co#ple#ented by the ne' ICS report on urodyna#ic practice (++) In addition there are our published ICS outco#e reports (+4,+5)* 0e' or changed de initions are all indicated6 ho'ever, reco##endations concerning techni2ue are not included in the #ain te7t o this report* &he de initions have been 'ritten to be co#patible 'ith the 8H9 publication ICI"H,4 (International Classi ication o .unctioning, "isability and Health) published in 433+ and IC"+3, the International Classi ication o "iseases (+:)* %s ar as possible, the de initions are descriptive o observations, 'ithout i#plying underlying assu#ptions that #ay later prove to be incorrect or inco#plete* By ollo'ing this principle, the International Continence Society (ICS) ai#s to acilitate co#parison o results and enable e ective co##unication by investigators 'ho use urodyna#ic #ethods* &his report restates the ICS principle that sy#pto#s, signs and conditions are separate categories and adds a category o urodyna#ic observations* In addition, ter#inology related to therapies is included (;)* 8hen a re erence is #ade to the 'hole anato#ical organ the vesica urinaria, the correct ter# is the bladder* 8hen the s#ooth #uscle structure <no'n as the #*detrusor urinae is being discussed, then the correct ter# is detrusor* It is suggested that ac<no'ledge#ent o these standards in 'ritten publications be indicated by a ootnote to the section =$ethods and $aterials> or its e2uivalent, to read as ollo's?

=$ethods, de initions and units con or# to the standards reco##ended by the International Continence Society, e7cept 'here speci ically noted>* &he report covers the ollo'ing areas? +* Lower Urinary Tract Symptoms (LUTS) Symptoms are the subjective indicator o a disease or change in condition as perceived by the patient, carer or partner and #ay lead hi#@her to see< help ro# health care pro essionals* 1NEW2 Sy#pto#s #ay either be volunteered or described during the patient intervie'* &hey are usually 2ualitative* In general, Lo'er Urinary &ract Sy#pto#s cannot be used to #a<e a de initive diagnosis* Lo'er Urinary &ract Sy#pto#s can also indicate pathologies other than lo'er urinary tract dys unction, such as urinary in ection* 4* Signs suggestive of Lower Urinary Tract Dysfunction (LUTD) Signs are observed by the physician including si#ple #eans, to veri y sy#pto#s and 2uanti y the#* 1NEW2 .or e7a#ple, a classical sign is the observation o lea<age on coughing* 9bservations ro# re2uency volu#e charts, pad tests and validated sy#pto# and 2uality o li e 2uestionnaires are e7a#ples o other instru#ents that can be used to veri y and 2uanti y sy#pto#s* ;* Urodynamic Observations Urodynamic observations are observations #ade during urodyna#ic studies* 1NEW2 .or e7a#ple, an involuntary detrusor contraction (detrusor overactivity) is a urodyna#ic observation* In general, a urodyna#ic observation #ay have a nu#ber o possible underlying causes and does not represent a de initive diagnosis o a disease or condition and #ay occur 'ith a variety o sy#pto#s and signs, or in the absence o any sy#pto#s or signs* A* Conditions Conditions are de ined by the presence o urodyna#ic observations associated 'ith characteristic sy#pto#s or signs and@or non, urodyna#ic evidence o relevant pathological processes* 1NEW2 Treatment Treatment or lo'er urinary tract dys unction? these de initions are ro# the -th ICS report on Lo'er Urinary &ract Behabilitation &echni2ues (;)*

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3.

LOWER URINARY TRACT SYMPTOMS 1LUTS2

Lo'er urinary tract sy#pto#s are de ined ro# the individualCs perspective 'ho is usually, but not necessarily, a patient 'ithin the healthcare syste#* Sy#pto#s are either volunteered by, or elicited ro#, the individual or #ay be described by the individualCs caregiver* Lo'er urinary tract sy#pto#s are divided into three groups? storage, voiding, and post #icturition sy#pto#s* +*+ Storage Symptoms are e7perienced during the storage phase o the bladder and include dayti#e re2uency and nocturia* 1NEW2 Increased daytime frequency is the co#plaint by the patient 'ho considers that he@she voids too o ten by day* 1NEW2 &his ter# is e2uivalent to polla<isuria used in #any countries* Nocturia is the co#plaint that the individual has to 'a<e at night one or #ore ti#es to void* 1NEW2 5 FOOTNOTE 3

FOOTNOTE 1 T!e term nig!t time frequency differs from t!at for nocturia" as it inc#udes voids t!at occur after t!e individua# !as gone to bed" but before !e$s!e !as gone to s#eep" and voids %!ic! occur in t!e ear#y morning %!ic! prevent t!e individua# from getting bac& to s#eep as !e$s!e %is!es' T!ese voids before and after s#eep may need to be considered in researc! studies" for e(amp#e" in nocturna# po#yuria' If t!is definition %ere used t!en an adapted definition of daytime frequency %ou#d need to be used %it! it' 4 4 Urgency is the co#plaint o a sudden co#pelling desire to pass urine 'hich is di icult to de er* 1CHANGED2 Urinary incontinence is the co#plaint o any involuntary lea<age o urine* 1NEW2 5 FOOTNOTE 6

In each speci ic circu#stance, urinary incontinence should be urther described by speci ying relevant actors such as type, re2uency, severity, precipitating actors, social i#pact, e ect on hygiene and 2uality o li e, the #easures used to contain the lea<age and 'hether or not the individual see<s or desires help because o urinary incontinence* 7 FOOTNOTE 8 Urinary lea<age #ay need to be distinguished ro# s'eating or vaginal discharge* FOOTNOTE ) * In infants and sma## c!i#dren t!e definition of Urinary Incontinence is not app#icab#e' In scientific communications t!e definition of incontinence in c!i#dren %ou#d need furt!er e(p#anation' FOOTNOTE + T!e origina# ICS definition of incontinence , Urinary incontinence is t!e invo#untary #oss of urine t!at is a socia# or !ygienic prob#em-" re#ates t!e comp#aint to qua#ity of #ife ./o01 issues' Some /o0 instruments !ave

been and are being deve#oped in order to assess t!e impact of bot! incontinence and ot!er 0UTS on /o0' 4 Stress urinary incontinence is the co#plaint o involuntary lea<age on e ort or e7ertion, or on sneeDing or coughing* 1CHANGED2 7 FOOTNOTE 9

FOOTNOTE 2 T!e committee considers t!e term 3stress incontinence- to be unsatisfactory in t!e Eng#is! #anguage because of its menta# connotations' T!e S%edis!" Frenc! and Ita#ian e(pression 3effort incontinence- is preferab#e' 4o%ever" %ords suc! as 3effort- or 3e(ertion- sti## do not capture some of t!e common precipitating factors for stress incontinence suc! as coug!ing or snee5ing' For t!is reason t!e term is #eft unc!anged' 4 Urge urinary incontinence is the co#plaint o involuntary lea<age acco#panied by or i##ediately preceded by urgency* 1CHANGED2 7 FOOTNOTE :

FOOTNOTE 6 Urge incontinence can present in different symptomatic forms7 for e(amp#e" as frequent sma## #osses bet%een micturitions or as a catastrop!ic #ea& %it! comp#ete b#adder emptying' 4 8i(ed urinary incontinence is the co#plaint o involuntary lea<age associated 'ith urgency and also 'ith e7ertion, e ort, sneeDing or coughing* 1NEW2 Enuresis #eans any involuntary loss o urine* I it is used to denote incontinence during sleep, it should al'ays be 2uali ied 'ith the adjective EnocturnalC* 1ORIGINAL2 I it is used to denote incontinence during sleep, it should al'ays be 2uali ied 'ith the adjective =nocturnal>* 4 F F Nocturna# enuresis is the co#plaint o loss o urine occurring during sleep* 1NEW2 Continuous urinary incontinence is the co#plaint o continuous lea<age* 1NEW2 Ot!er types of urinary incontinence #ay be situational, or e7a#ple the report o incontinence during se7ual intercourse, or giggle incontinence* 9#adder sensation can be de ined, during history ta<ing, by ive categories* Norma#: the individual is a'are o bladder illing and increasing sensation up to a strong desire to void* 1NEW2

Increased: the individual eels an early and persistent desire to void* 1NEW2 ;educed: the individual is a'are o bladder illing but does not eel a de inite desire to void* 1NEW2 <bsent: the individual reports no sensation o bladder illing or desire to void* 1NEW2 Non*specific: the individual reports no speci ic bladder sensation but #ay perceive bladder illing as abdo#inal ullness, vegetative sy#pto#s, or spasticity* 1NEW2 7 FOOTNOTE ; FOOTNOTE = * T!ese non*specific symptoms are most frequent#y seen in neuro#ogica# patients" particu#ar#y t!ose %it! spina# cord trauma and in c!i#dren and adu#ts %it! ma#formations of t!e spina# cord' +*4 >oiding Symptoms are e7perienced during the voiding phase* 1NEW2 4 S#o% stream is reported by the individual as his or her perception o reduced urine lo', usually co#pared to previous per or#ance or in co#parison to others* 1NEW2 Sp#itting or spraying o the urine strea# #ay be reported* 1NEW2 Intermittent stream .Intermittency1 is the ter# used 'hen the individual describes urine lo' 'hich stops and starts, on one or #ore occasions, during #icturition* 1NEW2 4esitancy is the ter# used 'hen an individual describes di iculty in initiating #icturition resulting in a delay in the onset o voiding a ter the individual is ready to pass urine* 1NEW2 Straining to void describes the #uscular e ort used to either initiate, #aintain or i#prove the urinary strea#* 1NEW2 7 FOOTNOTE <

4 4

FOOTNOTE ? Suprapubic pressure may be used to initiate or maintain urine f#o%' T!e Cred@ manoeuvre is used by some spina# cord inAury patients" and gir#s %it! detrusor underactivity sometimes press suprapubica##y to !e#p empty t!e b#adder' 4 Termina# dribb#e is the ter# used 'hen an individual describes a prolonged inal part o #icturition, 'hen the lo' has slo'ed to a tric<le@dribble* 1NEW2

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Bost 8icturition Symptoms are e7perienced i##ediately a ter #icturition. 1NEW2 4 4 Fee#ing of incomp#ete emptying is a sel ,e7planatory ter# or a eeling e7perienced by the individual a ter passing urine* 1NEW2 Bost micturition dribb#e is the ter# used 'hen an individual describes the involuntary loss o urine i##ediately a ter he or she has inished passing urine, usually a ter leaving the toilet in #en, or a ter rising ro# the toilet in 'o#en* 1NEW2

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Symptoms <ssociated %it! Se(ua# Intercourse "yspareunia, vaginal dryness and incontinence are a#ongst the sy#pto#s 'o#en #ay describe during or a ter intercourse* &hese sy#pto#s should be described as ully as possible* It is help ul to de ine urine lea<age as? during penetration, during intercourse, or at orgas#* Symptoms <ssociated %it! Be#vic Organ Bro#apse &he eeling o a lu#p (=so#ething co#ing do'n>), lo' bac<ache, heaviness, dragging sensation, or the need to digitally replace the prolapse in order to de aecate or #icturate, are a#ongst the sy#pto#s 'o#en #ay describe 'ho have a prolapse* Cenita# and 0o%er Urinary Tract Bain 7 FOOTNOTE = !ain, disco# ort and pressure are part o a spectru# o abnor#al sensations elt by the individual* !ain produces the greatest i#pact on the patient and #ay be related to bladder illing or voiding, #ay be elt a ter #icturition, or be continuous* !ain should also be characterised by type, re2uency, duration, precipitating and relieving actors and by location as de ined belo'?

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FOOTNOTE D T!e terms 3strangury-" 3b#adder spasm-" and 3dysuria- are difficu#t to define and of uncertain meaning and s!ou#d not be used in re#ation to #o%er urinary tract dysfunction" un#ess a precise meaning is stated' Eysuria #itera##y means Fabnorma# urinationG and is used correct#y in some European countries' 4o%ever" it is often used to describe t!e stinging$burning sensation c!aracteristic of urinary infection' It is suggested t!at t!ese descriptive %ords s!ou#d be used in future' 4 4 4 4 4 9#adder pain is elt suprapubically or retropubically, and usually increases 'ith bladder illing, it #ay persist a ter voiding* 1NEW2 Uret!ra# pain is elt in the urethra and the individual indicates the urethra as the site* 1NEW2 >u#va# pain is elt in and around the e7ternal genitalia* 1NEW2 >agina# pain is elt internally, above the introitus* 1NEW2 Scrota# pain #ay or #ay not be localised, or e7a#ple to the testis, epididy#is, cord structures or scrotal s<in* 1NEW2

Berinea# pain is elt? in the e#ale, bet'een the posterior ourchette (posterior lip o the introitus) and the anus, and in the #ale, bet'een the scrotu# and the anus* 1NEW2 Be#vic pain is less 'ell de ined than, or e7a#ple, bladder, urethral or perineal pain and is less clearly related to the #icturition cycle or to bo'el unction and is not localised to any single pelvic organ* 1NEW2

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Cenito*Urinary Bain Syndromes and Symptom Syndromes Suggestive of 0UTE Syndro#es describe constellations, or varying co#binations o sy#pto#s, but cannot be used or precise diagnosis* &he use o the 'ord Esyndro#eC can only be justi ied i there is at least one other sy#pto# in addition to the sy#pto# used to describe the syndro#e* In scienti ic co##unications the incidence o individual sy#pto#s 'ithin the syndro#e should be stated, in addition to the nu#ber o individuals 'ith the syndro#e* &he syndro#es described are unctional abnor#alities or 'hich a precise cause has not been de ined* It is presu#ed that routine assess#ent (history ta<ing, physical e7a#ination, and other appropriate investigations) has e7cluded obvious local pathologies such as those that are in ective, neoplastic, #etabolic or hor#onal in nature* +*-*+ Cenito*Urinary Bain Syndromes are all chronic in their nature* !ain is the #ajor co#plaint but conco#itnat co#plaints are o lo'er urinary tract, bo'el, se7ual or gynaecological nature* 4 Bainfu# b#adder syndrome is the co#plaint o suprapubic pain related to bladder illing, acco#panied by other sy#pto#s such as increased dayti#e and night,ti#e re2uency, in the absence o proven urinary in ection or other obvious pathology* 1NEW2 5 FOOTNOTE >

FOOTNOTE H * T!e ICS be#ieves t!is to be a preferab#e term to 3interstitia# cystitis-' Interstitia# cystitis is a specific diagnosis and requires confirmation by typica# cystoscopic and !isto#ogica# features' In t!e investigation of b#adder pain it may be necessary to e(c#ude conditions suc! as carcinoma in situ and endometriosis' 4 Uret!ra# pain syndrome is the occurrence o recurrent episodic urethral pain usually on voiding, 'ith dayti#e re2uency and nocturia, in the absence o proven in ection or other obvious pathology* 1NEW2 >u#va# pain syndrome is the occurrence o persistent or recurrent episodic vulval pain, 'hich is either related to the #icturition cycle or associated 'ith sy#pto#s suggestive o

urinary tract or se7ual dys unction* &here is no proven in ection or other obvious pathology* 1NEW2 7 FOOTNOTE 3? FOOTNOTE 1I T!e ICS suggests t!at t!e term vu#vodynia .vu#va pain1 s!ou#d not be used" as it #eads to confusion bet%een a sing#e symptom and a syndrome' 4 >agina# pain syndrome is the occurrence o persistent or recurrent episodic vaginal pain 'hich is associated 'ith sy#pto#s suggestive o urinary tract or se7ual dys unction* &here is no proven vaginal in ection or other obvious pathology* Scrota# pain syndrome is the occurrence o persistent or recurrent episodic scrotal pain 'hich is associated 'ith sy#pto#s suggestive o urinary tract or se7ual dys unction* &here is no proven epididi#o,orchitis or other obvious pathology* Berinea# pain syndrome is the occurrence o persistent or recurrent episodic perineal pain 'hich is either related to the #icturition cycle or associated 'ith sy#pto#s suggestive o urinary tract or se7ual dys unction* &here is no proven in ection or other obvious pathology* 1NEW2 7 FOOTNOTE 33

FOOTNOTE 11 T!e ICS suggests t!at in men" t!e term prostatodynia .prostate* pain1 s!ou#d not be used as it #eads to confusion bet%een a sing#e symptom and a syndrome' 4 Be#vic pain syndrome is the occurrence o persistent or recurrent episodic pelvic pain associated 'ith sy#pto#s suggestive o lo'er urinary tract, se7ual, bo'el or gynaecological dys unction* &here is no proven in ection or other obvious pathology* 1NEW2

+*-*4. Symptom Syndromes Suggestive of 0o%er Urinary Tract Eysfunction In clinical practice, e#pirical diagnoses are o ten used as the basis or initial #anage#ent a ter assessing the individualCs lo'er urinary tract sy#pto#s, physical indings and the results o urinalysis and other indicated investigations* F Urgency, 'ith or 'ithout urge incontinence, usually 'ith re2uency and nocturia, can be described as the o*era,ti*e bla##er /"#rome, ur%e /"#rome or ur%e",/7're@ue",/ /"#rome* 1NEW2

&hese sy#pto# co#binations are suggestive o urodyna#ically de#onstrable detrusor overactivity but can be due to other or#s o urethro,vesical dys unction* &hese ter#s can be used i there is no proven in ection or other obvious pathology* 4 0o%er urinary tract symptoms suggestive of b#adder out#et obstruction is a ter# used 'hen a #an co#plains predo#inately o voiding sy#pto#s in the absence o in ection or obvious pathology other than possible causes o outlet obstruction* 1NEW2 5 FOOTNOTE 36

FOOTNOTE 1) in %omen voiding symptoms are usua##y t!oug!t to suggest detrusor underactivity rat!er t!an b#adder out#et obstruction'

6. 4*+

SIGNS SUGGESTI-E OF LOWER URINARY TRACT DYSFUNCTION 1LUTD2 8easuring t!e Frequency" Severity and Impact of 0o%er Urinary Tract Symptoms %s<ing the patient to record #icturitions and sy#pto#s 1FOOTNOTE 382 or a period o days provides invaluable in or#ation* &he recording o #icturition events can be in three #ain or#s?

FOOTNOTE 1+ * >a#idated questionnaires are usefu# for recording symptoms" t!eir frequency" severity and bot!er" and t!e impact of 0UTS on /o0' T!e instrument used s!ou#d be specified' 4 4 8icturition time c!art: this records only the ti#es o #icturitions, day and night, or at least 4A hours* 1NEW2 Frequency vo#ume c!art .F>C1: this records the volu#es voided as 'ell as the ti#e o each #icturition, day and night, or at least 4A hours* 1CHANGED2 9#adder diary: this records the ti#es o #icturitions and voided volu#es, incontinence episodes, pad usage and other in or#ation such as luid inta<e, the degree o urgency and the degree o incontinence* 1NEW2 5 FOOTNOTE 39

FOOTNOTE 12 * It is usefu# to as& t!e individua# to ma&e an estimate of #iquid inta&e' T!is may be done precise#y by measuring t!e vo#ume of eac! drin& or crude#y by as&ing !o% many drin&s are ta&en in a )2 !our period' If t!e individua# eats significant quantities of %ater containing foods .vegetab#es" fruit" sa#ads1 t!en an appreciab#e effect on urine production %i## resu#t' T!e time t!at diuretic t!erapy is ta&en s!ou#d be mar&ed on a c!art or diary'

&he ollo'ing #easure#ents can be abstracted ro# re2uency volu#e charts and bladder diaries? 4 Eaytime frequency is the nu#ber o voids recorded during 'a<ing hours and includes the last void be ore sleep and the irst void a ter 'a<ing and rising in the #orning* 1NEW2 Nocturia is the nu#ber o voids recorded during a nightCs sleep? each void is preceded and ollo'ed by sleep* 1NEW2 )2*!our frequency is the total nu#ber o dayti#e voids and episodes o nocturia during a speci ied 4A hours period* 1NEW2 )2*!our production is #easured by collecting all urine or 4A hours* 1NEW2 &his is usually co##enced a ter the irst void produced a ter rising in the #orning and is co#pleted by including the irst void on rising the ollo'ing #orning* 4 Bo#yuria is de ined as the #easured production o #ore than 4*/ litres o urine in 4A hours in adults* It #ay be use ul to loo< at output over shorter ti#e ra#es (van Kerrebroec< et al*, 4334)* 1NEW2 5 FOOTNOTE 3:

4 4 4

FOOTNOTE 16 * T!e causes of po#yuria are various and revie%ed e#se%!ere but inc#ude !abitua# e(cess f#uid inta&e' T!e figure of )'D is based on a ?I&g person voiding J 2Im#$&g' 4 Nocturna# urine vo#ume is de ined as the total volu#e o urine passed bet'een the ti#e the individual goes to bed 'ith the intention o sleeping and the ti#e o 'a<ing 'ith the intention o rising* 1NEW2 &here ore, it e7cludes the last void be ore going to bed but includes the irst void a ter rising in the #orning* Nocturna# po#yuria is present 'hen an increased proportion o the 4A, hour output occurs at night (nor#ally during the / hours 'hilst the patient is in bed)* 1NEW2 &he night ti#e urine output e7cludes the last void be ore sleep but includes the irst void o the #orning* 7 FOOTNOTE 3;

FOOTNOTE 1= T!e norma# range of nocturna# urine production differs %it! age and t!e norma# ranges remain to be defined' T!erefore" nocturna# po#yuria is present %!en greater t!an )IK .young adu#ts1 to ++K .over =6 years1 is produced at nig!t' 4ence t!e precise definition is dependent on age' 4 8a(imum voided vo#ume is the largest volu#e o urine voided during a single #icturition and is deter#ined either ro# the re2uency@volu#e chart or bladder diary* 1NEW2

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&he #a7i#u#, #ean and #ini#u# voided volu#es over the period o recording #ay be stated* 7 FOOTNOTE 3< FOOTNOTE 1? * T!e term 3functiona# b#adder capacity- is no #onger recommended" as 3voided vo#ume- is a c#earer and #ess confusing term" particu#ar#y if qua#ified e'g' Fma(imum voided vo#umeG' If t!e term 3b#adder capacity- is used" in any situation" it imp#ies t!at t!is !as been measured in some %ay" if on#y by abdomina# u#trasound' In adu#ts" voided vo#umes vary considerab#y' In c!i#dren" t!e 3e(pected vo#ume- may be ca#cu#ated from t!e formu#a .+IL .age in years A +I1 in m#1' <ssuming no residua# urine" t!is %i## be equa# to t!e 3e(pected b#adder capacity-' 4*4 B!ysica# E(amination is essential in the assess#ent o all patients 'ith lo'er urinary tract dys unction* It should include abdo#inal, pelvic, perineal and a ocussed neurological e7a#ination* .or patients 'ith possible neurogenic lo'er urinary tract dys unction, a #ore e7tensive neurological e7a#ination is needed* 4*4*+ <bdomina#? the bladder #ay be elt by abdo#inal palpation or by suprapubic percussion* !ressure suprapubically or during bi#anual vaginal e7a#ination #ay induce a desire to pass urine* Berinea# $ Cenita# Inspection allo's the description o the s<in, or e7a#ple the presence o atrophy or e7coriation, any abnor#al anato#ical eatures and the observation o incontinence* 4 4 Urinary incontinence .t!e sign1 is de ined as urine lea<age seen during e7a#ination? this #ay be urethral or e7traurethral* Stress urinary incontinence is the observation o involuntary lea<age ro# the urethra, synchronous 'ith e7ertion@e ort, or sneeDing or coughing* 1CHANGED2 5 FOOTNOTE 3= Stress Lea<age is presu#ed to be due to raised abdo#inal pressure* FOOTNOTE 1D Coug!ing may induce a detrusor contraction" !ence t!e sign of stress incontinence is on#y a re#iab#e indication of urodynamic stress incontinence %!en #ea&age occurs sync!ronous#y %it! t!e first proper coug! and stops at t!e end of t!at coug!' 4 E(tra*uret!ra# incontinence is de ined as the observation o urine lea<age through channels other than the urethra* 1ORIGINAL2

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Uncategorised incontinence is the observation o involuntary lea<age that cannot be classi ied into one o the above categories on the basis o signs and sy#pto#s* 1NEW2

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>agina# e(amination allo's the description o observed and palpable anato#ical abnor#alities and the assess#ent o pelvic loor #uscle unction, as described in the ICS report on !elvic 9rgan !rolapse* &he de initions given are si#pli ied versions o the de initions in that report* (Bu#p et al*, +11:) 4 Be#vic organ pro#apse is de ined as the descent o one or #ore o ? the anterior vaginal 'all, the posterior vaginal 'all, and the ape7 o the vagina (cervi7@uterus) or vault (cu ) a ter hysterecto#y* %bsence o prolapse is de ined as stage 3 support6 prolapse can be staged ro# stage I to stage IG* 1NEW2 !elvic organ prolapse can occur in association 'ith urinary incontinence and other lo'er urinary tract dys unction and #ay on occasion #as< incontinence* 4 <nterior vagina# %a## pro#apse is de ined as descent o the anterior vagina so that the urethrovesical junction (a point ;c# pro7i#al to the e7ternal urinary #eatus) or any anterior point pro7i#al to this is less than ;c# above the plane o the hy#en* 1CHANGED2 Bro#apse of t!e apica# segment of t!e vagina is de ined as any descent o the vaginal cu scar (a ter hysterecto#y) or cervi7, belo' a point'hich is 4c# less than the total vaginal length above the plane o the hy#en* 1CHANGED2 Bosterior vagina# %a## pro#apse is de ined as any descent o the posterior vaginal 'all so that a #idline point on the posterior vaginal 'all ;c# above the level o the hy#en or any posterior point pro7i#al to this, less than ;c# above the plane o the hy#en* 1CHANGED2

4*4*A* Be#vic f#oor musc#e function can be 2ualitatively de ined by the tone at rest and the strength o a voluntary or re le7 contraction as strong, 'ea< or absent or by a validated grading syste# (e*g* 97 ord +,5)* % pelvic #uscle contraction #ay be assessed by visual inspection, by palpation, electro#yography or perineo#etry* .actors to be assessed include strength, duration, displace#ent and repeatability* 1NEW2 4*4*5 ;ecta# e(amination allo's the description o observed and palpable anato#ical abnor#alities and is the easiest #ethod o assessing pelvic loor #uscle unction in children and #en* In addition, rectal

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e7a#ination is essential in children 'ith urinary incontinence to rule out aecal inpaction* 4 Be#vic f#oor musc#e function can be 2ualitatively de ined, during rectal e7a#ination, by the tone at rest and the strength o a voluntary contraction, as strong, 'ea< or absent* 1NEW2

4*;

Bad testing #ay be used to 2uanti y the a#ount o urine lost during incontinence episodes and #ethods range ro# a short provocative test to a 4A,hour pad test*

8. ;*+

URODYNAMIC OBSER-ATIONS AND CONDITIONS Urodynamic Tec!niques &here are t'o principal #ethods o urodyna#ic investigation? 4 Conventiona# urodynamic studies nor#ally ta<e place in the urodyna#ic laboratory and usually involve arti icial bladder illing* 1NEW2 7 F <rtificia# b#adder fi##ing is de ined as illing the bladder, via a catheter, 'ith a speci ied li2uid at a speci ied rate 1NEW2

<mbu#atory urodynamic studies are de ined as a unctional test o the lo'er urinary tract, utilising natural illing, and reproducing the subjectCs every day activities* 7 FOOTNOTE 3>

FOOTNOTE 1H T!e term <mbu#atory Urodynamics is used to indicate t!at monitoring usua##y ta&es p#ace outside t!e urodynamic #aboratory" rat!er t!an t!e subAectGs mobi#ity using natura# fi##ing' 7 Natura# fi##ing #eans that the bladder is illed by the production o urine rather than by an arti icial #ediu#*

Both illing cysto#etry and pressure lo' studies o voiding re2uire the ollo'ing #easure#ents? 4 4 Intravesica# pressure is the pressure 'ithin the bladder* 1ORIGINAL2 <bdomina# pressure is ta<en to be the pressure surrounding the bladder* In current practice it is esti#ated ro# rectal, vaginal or, less co##only, ro# e7traperitoneal pressure or a bo'el sto#a* &he si#ultaneous #easure#ent o abdo#inal pressure is essential or the interpretation o the intravesical pressure trace* 1ORIGINAL2

+;

Eetrusor pressure is that co#ponent o intravesical pressure that is created by orces in the bladder 'all (passive and active)* It is esti#ated by subtracting abdo#inal pressure ro# intravesical pressure* 1ORIGINAL2

;*4

Fi##ing Cystometry &he 'ord =cysto#etry> is co##only used to describe the urodyna#ic investigation o the illing phase o the #icturition cycle* &o eli#inate con usion, the ollo'ing de initions are proposed? 4 Fi##ing cystometry is the #ethod by 'hich the pressure@volu#e relationship o the bladder is #easured during bladder illing* 1ORIGINAL2 &he illing phase starts 'hen illing co##ences and ends 'hen the patient and urodyna#icist decide that =per#ission to void> has been given* 5 FOOTNOTE 6? Bladder and urethral unction, during illing, need to be de ined separately* &he rate at 'hich the bladder is illed is divided into? , B!ysio#ogica# fi##ing rate is de ined as a illing rate less than the predicted #a7i#u# , predicted #a7i#u# body 'eight in <g divided by A e7pressed as #l@#in (+-) 1CHANGED2 Non*p!ysio#ogica# fi##ing rate is de ined as a illing rate greater than the predicted #a7i#u# illing rate , predicted #a7i#u# body 'eight in <g divided by A e7pressed as #l@#in (+-) 1CHANGED2

FOOTNOTE )I , T!e ICS no #onger %is!es to divide fi##ing rates into s#o%" medium and fast' In practice a#most a## investigations are performed using medium fi##ing rates %!ic! !ave a %ide range' It may be more important during investigations to consider %!et!er or not t!e fi##ing rate used during conventiona# urodynamic studies can be considered p!ysio#ogica#' Bladder storage unction should be described according to bladder sensation, detrusor activity, bladder co#pliance and bladder capacity* 7 FOOTNOTE 63 FOOTNOTE )1 7 M!i#st b#adder sensation is assessed during fi##ing cystometry t!e assumption t!at it is sensation from t!e b#adder a#one" %it!out uret!ra# or pe#vic components may be fa#se' ;*4*+ 9#adder sensation during fi##ing cystometry Norma# b#adder sensation can be judged by three de ined points noted during illing cysto#etry and evaluated in relation

+A

to the bladder volu#e at that #o#ent and in relation to the patientCs sy#pto#atic co#plaints* First sensation of b#adder fi##ing is the eeling the patient has, during illing cysto#etry, 'hen he@she irst beco#es a'are o the bladder illing* 1NEW2 First desire to void is de ined as the eeling, during illing cysto#etry, that 'ould lead the patient to pass urine at the ne7t convenient #o#ent, but voiding can be delayed i necessary* 1CHANGED2 Strong desire to void this is de ined, during illing cysto#etry, as a persistent desire to void 'ithout the ear o lea<age* 1ORIGINAL2 Increased b#adder sensation is de ined, during illing cysto#etry, as an early irst sensation o bladder illing (or an early desire to void) and@or an early strong desire to void, 'hich occurs at lo' bladder volu#e and 'hich persists* 1NEW2 7 FOOTNOTE 66

FOOTNOTE )) T!e assessment of t!e subAectGs b#adder sensation is subAective and it is not" for e(amp#e" possib#e to quantify 3#o% b#adder vo#ume- in t!e definition of 3increased b#adder sensation-' 4 ;educed b#adder sensation is de ined, during illing cysto#etry, as di#inished sensation throughout bladder illing* 1NEW2 <bsent b#adder sensation #eans that, during illing cysto#etry, the individual has no bladder sensation* 1NEW2 Non*specific b#adder sensations" during illing cysto#etry, #ay #a<e the individual a'are o bladder illing, or e7a#ple, abdo#inal ullness or vegetative sy#pto#s* 1NEW2 9#adder pain" during illing cysto#etry, is a sel e7planatory ter# and is an abnor#al inding* 1NEW2 Urgency" during illing cysto#etry, is a sudden co#pelling desire to void* 1NEW2 7 FOOTNOTE 68

4 4

4 4

FOOTNOTE )+ * T!e ICS no #onger recommends t!e terms 3motor urgency- and 3sensory urgency-' T!ese terms are often misused and !ave #itt#e intuitive meaning' Furt!ermore" it may be simp#istic to re#ate urgency Aust to t!e presence or absence of detrusor overactivity %!en t!ere is usua##y a concomitant fa## in uret!ra# pressure'

+5

T!e vesica#$uret!ra# sensory t!res!o#d is de ined as the least current 'hich consistently produces a sensation perceived by the subject during sti#ulation at the site under investigation* (%ndersen et al*, +114) 7 ORIGINAL

;*4*4

Eetrusor function during fi##ing cystometry In everyday li e the individual atte#pts to inhibit detrusor activity until he or she is in a position to void* &here ore, 'hen the ai#s o the illing study have been achieved, and 'hen the patient has a desire to void, nor#ally the Eper#ission to voidC is given (see .illing Cysto#etry)* &hat #o#ent is indicated on the urodyna#ic trace and all detrusor activity be ore this Eper#issionC is de ined as Einvoluntary detrusor activityC* 7 Norma# detrusor function: allo's bladder illing 'ith little or no change in pressure* 0o involuntary phasic contractions occur despite provocation* 1ORIGINAL2 Eetrusor overactivity is a urodyna#ic observation characterised by involuntary detrusor contractions during the illing phase 'hich #ay be spontaneous or provo<ed* 1CHANGED2 7 FOOTNOTE 69

FOOTNOTE )2 * T!ere is no #o%er #imit for t!e amp#itude of an invo#untary detrusor contraction but confident interpretation of #o% pressure %aves .amp#itude sma##er t!an 6cm of 4)O1 depends on 3!ig! qua#ity- urodynamic tec!nique' T!e p!rase 3%!ic! t!e patient cannot comp#ete#y suppress- !as been de#eted from t!e o#d definition' &here are certain patterns o detrusor overactivity? 7 B!asic detrusor overactivity is de ined by a characteristic 'ave or# and #ay or #ay not lead to urinary incontinence* 1NEW2 7 FOOTNOTE 6:

FOOTNOTE )6 * B!asic detrusor contractions are not a#%ays accompanied by any sensation or may be interpreted as a first sensation of b#adder fi##ing or as a norma# desire to void' * Termina# detrusor overactivity is de ined as a single, involuntary detrusor contraction, occurring at cysto#etric capacity, 'hich cannot be suppressed and results in incontinence usually resulting in bladder e#ptying (voiding)' 1NEW2 7 FOOTNOTE 6;

FOOTNOTE )= 3Termina# detrusor overactivity- is a ne% ICS term: it is typica##y associated %it! reduced b#adder sensation" for e(amp#e" in t!e e#der#y stro&e patient %!en urgency may be fe#t as t!e voiding contraction occurs' 4o%ever" in comp#ete spina# cord inAury patients t!ere may be no sensation %!atsoever'

+:

Eetrusor overactivity incontinence is incontinence due to an involuntary detrusor contraction* 1NEW2 In a patient 'ith nor#al sensation, urgency is li<ely to be e7perienced just be ore the lea<age episode* 7 FOOTNOTE 6<

FOOTNOTE )? ICS recommends t!at t!e terms 3motor urge incontinence- and 3ref#e( incontinence- s!ou#d no #onger be used as t!ey !ave no intuitive meaning and are often misused' Eetrusor Overactivity #ay also be 2uali ied, 'hen possible, according to cause, or e7a#ple? 4 Neurogenic detrusor overactivity 'hen there is a relevant neurological condition* &his ter# replaces the ter# =detrusor hyperre le7ia>* 1NEW2 4 Idiopat!ic detrusor overactivity 'hen there is no de ined cause* 1NEW2 &his ter# replaces =detrusor instability>* 7 FOOTNOTE 6= FOOTNOTE )D * T!e terms 3detrusor instabi#ity- and 3detrusor !yperref#e(ia%ere bot! used as generic terms" in t!e Eng#is! spea&ing %or#d and Scandinavia" prior to t!e first ICS report in 1H?=' <s a compromise t!ey %ere a##ocated to idiopat!ic and neurogenic overactivity respective#y' <s t!ere is no rea# #ogic or intuitive meaning to t!e terms" t!e ICS be#ieves t!ey s!ou#d be abandoned' In c#inica# and researc! practice" t!e e(tent of neuro#ogica# e(amination$investigation varies' It is #i&e#y t!at t!e proportion of neurogenic:idiopat!ic detrusor overactivity %i## increase if a more comp#ete neuro#ogica# assessment is carried out' 9ther patterns o detrusor overactivity are seen, or e7a#ple, the co#bination o phasic and ter#inal detrusor overactivity, and the sustained high pressure detrusor contractions seen in spinal cord injury patients 'hen atte#pted voiding occurs against a dyssynergic sphincter* F Brovocative manoeuvres are de ined as techni2ues used during urodyna#ics in an e ort to provo<e detrusor overactivity, or e7a#ple, rapid illing, use o cooled or acid #ediu#, postural changes and hand 'ashing* 1NEW2

;*4*;* 9#adder comp#iance during fi##ing cystometry

+-

9#adder comp#iance describes the relationship bet'een change in bladder volu#e and change in detrusor pressure* 1CHANGED2 7 FOOTNOTE 6>

FOOTNOTE )H T!e observation of reduced b#adder comp#iance during conventiona# fi##ing cystometry is often re#ated to re#ative#y fast b#adder fi##ing: t!e incidence of reduced comp#iance is mar&ed#y #o%er if t!e b#adder is fi##ed at p!ysio#ogica# rates" as in ambu#atory urodynamics' Comp#iance is ca cu ated by dividing t!e vo ume c!ange("#) by t!e c!ange in detrusor pressure ("pdet) during t!at c!ange in b adder vo ume (C$ #. "pdet). %t is e&pressed in m 'cm ()*. < variety of means of ca#cu#ating b#adder comp#iance !as been described' T!e ICS recommends t!at t%o standard points s!ou#d be used for comp#iance ca#cu#ations: t!e investigator may %is! to define additiona# points' T!e standards points are: 1' t!e detrusor pressure at t!e start of b#adder fi##ing and t!e corresponding b#adder vo#ume .usua##y 5ero1" and )' t!e detrusor pressure .and corresponding b#adder vo#ume1 at cystometric capacity or immediate#y before t!e start of any detrusor contraction t!at causes significant #ea&age .and t!erefore causes t!e b#adder vo#ume to decrease" affecting comp#iance ca#cu#ation1' 9ot! points are measured e(c#uding any detrusor contraction' ;*4*A* 9#adder Capacity: Euring Fi##ing Cystometry 4 Cystometric capacity is the bladder volu#e at the end o the illing cysto#etrogra#, 'hen =per#ission to void> is usually given* &he end point should be speci ied, or e7a#ple, i illing is stopped 'hen the patient has a nor#al desire to void* &he cysto#etric capacity is the volu#e voided together 'ith any residual urine* 1CHANGED2 7 FOOTNOTE 8?

FOOTNOTE +I In certain types of dysfunction" t!e cystometric capacity cannot be defined in t!e same terms' In t!e absence of sensation t!e cystometric capacity is t!e vo#ume at %!ic! t!e c#inician decides to terminate fi##ing' T!e reason .s1 for terminating fi##ing s!ou#d be defined" e'g' !ig! detrusor fi##ing pressure" #arge infused vo#ume or pain' If t!ere is uncontro##ab#e voiding" it is t!e vo#ume at %!ic! t!is begins' In t!e presence of sp!incter incompetence t!e cystometric capacity may be significant#y increased by occ#usion of t!e uret!ra e'g' by Fo#ey cat!eter' 4 8a(imum cystometric capacity" in patients 'ith nor#al sensation, is the volu#e at 'hich the patient eels he@she can no longer delay #icturition (has a strong desire to void)* 1ORIGINAL2 8a(imum anaest!etic b#adder capacity is the volu#e to 'hich the bladder can be illed under deep general or spinal

+/

anaesthetic and should be 2uali ied according to the type o anaesthesia used and the speed, the length o ti#e, and the pressure at 'hich the bladder is illed* 1CHANGED2 ;*4*5 Uret!ra# Function Euring Fi##ing Cystometry &he urethral closure #echanis# during storage #ay be co#petent or inco#petent* 4 Norma# uret!ra# c#osure mec!anism #aintains a positive urethral closure pressure during bladder illing even in the presence o increased abdo#inal pressure, although it #ay be overco#e by detrusor overactivity* 1CHANGED2 Incompetent uret!ra# c#osure mec!anism is de ined as one 'hich allo's lea&a%e o' uri"e i" t(e ab e",e o' a #etru or ,o"tra,tio"* 1ORIGINAL2 Uret!ra# re#a(ation incontinence is de ined as lea<age due to urethral rela7ation in the absence o raised abdo#inal pressure or detrusor overactivity* 1NEW2 , FOOTNOTE 83

FOOTNOTE +1 * F#uctuations in uret!ra# pressure !ave been defined as t!e 3unstab#e uret!ra-' 4o%ever" t!e significance of t!e f#uctuations and t!e term itse#f #ac& c#arity and t!e term is not recommended by t!e ICS' If symptoms are seen in association %it! a decrease in uret!ra# pressure a fu## description s!ou#d be given' 4 Urodynamic stress incontinence is noted during illing cysto#etry and is de ined as the involuntary lea<age o urine during increased abdo#inal pressure, in the absence o a detrusor contraction* 1CHANGED2

Urodyna#ic stress incontinence is no' the pre erred ter# to =genuine stress incontinence>* FOOTNOTE 86 FOOTNOTE +) In patients %it! stress incontinence" t!ere is a spectrum of uret!ra# c!aracteristics ranging from a !ig!#y mobi#e uret!ra %it! good intrinsic function to an immobi#e uret!ra %it! poor intrinsic function' <ny de#ineation into categories suc! as 3uret!ra# !ypermobi#ity- and 3intrinsic sp!incter deficiencymay be simp#istic and arbitrary" and requires furt!er researc!. ;*4*:* <ssessment of Uret!ra# Function Euring Fi##ing Cystometry F Uret!ra# pressure measurement * Uret!ra# pressure is de ined as the luid pressure needed to just open a closed urethra* 1ORIGINAL2

+1

T!e Uret!ra# pressure profi#e is a graph indicating the intralu#inal pressure along the length o the urethra* 1ORIGINAL2 T!e Uret!ra# c#osure pressure profi#e is given by the subtraction o intravesical pressure ro# urethral pressure* 1ORIGINAL2 8a(imum uret!ra# pressure is the #a7i#u# pressure o the #easured pro ile* 1ORIGINAL2 8a(imum uret!ra# c#osure pressure .8UCB1 is the #a7i#u# di erence bet'een the urethral pressure and the intravesical pressure* 1ORIGINAL2 Functiona# profi#e #engt! is the length o the urethra along 'hich the urethral pressure e7ceeds intravesical pressure in 'o#en* Bressure 3transmission- ratio is the incre#ent in urethral pressure on stress as a percentage o the si#ultaneously recorded incre#ent in intravesical pressure*

7 7

<bdomina# #ea& point pressure is the intravesical pressure at 'hich urine lea<age occurs due to increased abdo#inal pressure in the absence o a detrusor contraction* 1NEW2 7 FOOTNOTE 88

FOOTNOTE ++ * T!e 0ea& Bressure Boint s!ou#d be qua#ified according to t!e site of pressure measurement .recta#" vagina# or intravesica#1 and t!e met!od by %!ic! pressure is generated .coug! or va#sa#va1' 0ea& point pressures may be ca#cu#ated in t!ree %ays from t!e t!ree different base#ine va#ues %!ic! are in common use: 5ero .t!e true 5ero of intravesica# pressure1" t!e va#ue of pves measured at 5ero b#adder vo#ume" or t!e va#ue of pves immediate#y before t!e coug! or va#sa#va .usua##y at )II or +IIm# b#adder capacity1' T!e base#ine used" and t!e base#ine pressure" s!ou#d be specified' 4 Eetrusor #ea& point pressure is de ined as the lo'est detrusor pressure at 'hich urine lea<age occurs in the absence o either a detrusor contraction or increased abdo#inal pressure* 1NEW2 7 FOOTNOTE 89

FOOTNOTE +2 * Eetrusor #ea& point pressure !as been used most frequent#y to predict upper tract prob#ems in neuro#ogica# patients %it! reduced b#adder comp#iance' ICS !as defined it 3in t!e absence of a detrusor contraction- a#t!oug! ot!ers %i## measure E0BB during invo#untary detrusor contractions'

43

;*;

Bressure F#o% Studies Goiding is described in ter#s o detrusor and urethral unction and assessed by #easuring urine lo' rate and voiding pressures* Bressure f#o% studies o voiding are the #ethod by 'hich the relationship bet'een pressure in the bladder and urine lo' rate is #easured during bladder e#ptying* (ORIGINAL)

&he voiding phase starts 'hen Eper#ission to voidC is given, or 'hen uncontrollable voiding begins, and ends 'hen the patient considers voiding has inished* ;*;*+ 8easurement of Urine F#o% Urine f#o% is de ined either as ,o"ti"uou , that is 'ithout interruption, or as i"termitte"t, 'hen an individual states that the lo' stops and starts during a single visit to the bathroo# in order to void* &he continuous lo' curve is de ined as a s#ooth arc,shaped curve or luctuating 'hen there are #ultiple pea<s during a period o continuous urine lo'* 7 FOOTNOTE 8:

FOOTNOTE +6 T!e precise s!ape of t!e f#o% curve is decided by detrusor contracti#ity" t!e presence of any abdomina# straining and by t!e b#adder out#et' .111 7 7 7 7 F#o% rate is de ined as the volu#e o luid e7pelled via the urethra per unit ti#e* It is e7pressed in #l@s* 1ORIGINAL2 >oided vo#ume is the total volu#e e7pelled via the urethra* 1ORIGINAL2 8a(imum f#o% rate is the #a7i#u# #easured value o the lo' rate a ter correction or arte acts* 1CHANGED2 >oiding time is total duration o #icturition, i*e* includes interruptions* 8hen voiding is co#pleted 'ithout interruption, voiding ti#e is e2ual to lo' ti#e* 1ORIGINAL2 F#o% time is the ti#e over 'hich #easurable lo' actually occurs* 1ORIGINAL2 <verage f#o% rate is voided volu#e divided by lo' ti#e* &he average lo' should be interpreted 'ith caution i lo' is interrupted or there is a ter#inal dribble* 1CHANGED2 Time to ma(imum f#o% is the elapsed ti#e ro# onset o lo' to #a7i#u# lo'* 1ORIGINAL2

7 7

;*;*4* Bressure 8easurements Euring Bressure F#o% Studies .BFS1 4+

&he ollo'ing #easure#ents are applicable to each o the pressure curves? intravesical, abdo#inal and detrusor pressure* 7 7 * Bremicturition pressure is the pressure recorded i##ediately be ore the initial isovolu#etric contraction* 1ORIGINAL2 Opening pressure is the pressure recorded at the onset o urine lo' (consider ti#e delay)* 1ORIGINAL2 Opening time is the elapsed ti#e ro# initial rise in detrusor pressure to onset o lo'* 1ORIGINAL2 &his is the initial isovolu#etric contraction period o #icturition* .lo' #easure#ent delay should be ta<en into account 'hen #easuring opening ti#e* 7 7 7 7 8a(imum pressure is the #a7i#u# value o the #easured pressure* 1ORIGINAL2 Bressure at ma(imum f#o% is the lo'est pressure recorded at #a7i#u# #easured lo' rate* 1ORIGINAL2 C#osing pressure is the pressure #easured at the end o #easured lo'* 1ORIGINAL2 8inimum voiding pressure is the #ini#u# pressure during #easurable lo' but is not necessarily e2ual to either the opening or closing pressures* F#o% de#ay is the ti#e delay bet'een a change in bladder pressure and the corresponding change in #easured lo' rate*

;*;*;* Eetrusor Function Euring >oiding 7 Norma# detrusor function 0or#al voiding is achieved by a voluntarily initiated continuous detrusor contraction that leads to co#plete bladder e#ptying 'ithin a nor#al ti#e span, and in the absence o obstruction* .or a given detrusor contraction, the #agnitude o the recorded pressure rise 'ill depend on the degree o outlet resistance* 1ORIGINAL2 <bnorma# detrusor activity can be subdivided? 4 Eetrusor underactivity is de ined as a contraction o reduced strength and@or duration, resulting in prolonged bladder e#ptying and@or a ailure to achieve co#plete

44

bladder e#ptying 'ithin a nor#al ti#e span* 1ORIGINAL2 4 <contracti#e detrusor is one that cannot be de#onstrated to contract during urodyna#ic studies* 1ORIGINAL2 7 FOOTNOTE 8;

FOOTNOTE += * < norma# detrusor contraction %i## be recorded as: !ig! pressure if t!ere is !ig! out#et resistance" norma# pressure if t!ere is norma# out#et resistance: or #o% pressure if uret!ra# resistance is #o%' 7 Bost void residua# .B>;1 is de ined as the volu#e o urine le t in the bladder at the end o #icturition* 1ORIGINAL2 7 FOOTNOTE 8<

FOOTNOTE +? * If after repeated free f#o%metry no residua# urine is demonstrated" t!en t!e finding of a residua# urine during urodynamic studies s!ou#d be considered an artifact" due to t!e circumstances of t!e test' ;*;*A* Uret!ra# Function Euring >oiding "uring voiding? Norma# uret!ra function is de ined as urethra that opens and is continuously rela7ed to allo' the bladder to be e#ptied at a nor#al pressure* 1CHANGED2 <bnorma# uret!ra function #ay be due to either obstruction to urethral overactivity or the urethra cannot open due to anato#ic abnor#ality, such as an enlarged prostate or a urethral stricture* 4 9#adder out#et obstruction is the generic ter# or obstruction during voiding and is characterised by increased detrusor pressure and reduced urine lo' rate* It is usually diagnosed by studying the synchronous values o lo'rate and detrusor pressure* 1CHANGED2 7 FOOTNOTE 8=

FOOTNOTE +D 9#adder Out#et Obstruction !as been defined for men but" as yet" not adequate#y in %omen and c!i#dren' 4 Eysfunctiona# voiding is characterised by an inter#ittent and@or luctuating lo' rate due to involuntary inter#ittent contractions o the peri,urethral striated #uscle during voiding in neurologically nor#al individuals* 1CHANGED2 7 FOOTNOTE 8>

FOOTNOTE +H * <#t!oug! dysfunctiona# voiding is not a very specific term" it is preferred to terms suc! as 3non*neurogenic neurogenic b#adder-' Ot!er terms

4;

suc! as 3 idiopat!ic detrusor sp!incter dyssyergia-" or 3 sp!incter overactivity voiding dysfunction-" may be preferab#e' 4o%ever" t!e term dysfunctiona# voiding is very %e## estab#is!ed' T!e condition occurs most frequent#y in c!i#dren' M!i#st it is fe#t t!at pe#vic f#oor contractions are responsib#e" it is possib#e t!at t!e intra* uret!ra# striated musc#e may be important' 4 Eetrusor sp!incter dyssynergia is de ined as a detrusor contraction concurrent 'ith an involuntary contraction o the urethral and@or periurethral striated #uscle* 9ccasionally, lo' #ay be prevented altogether* 1ORIGINAL2 7 FOOTNOTE 9?

FOOTNOTE 2I * Eetrusor sp!incter dyssynergia typica##y occurs in patients %it! a supra*sacra# #esion" for e(amp#e after !ig! spina# cord inAury" and is uncommon in #esions of t!e #o%er cord' <#t!oug! t!e intrauret!ra# and periuret!ra# striated musc#es are usua##y !e#d responsib#e" t!e smoot! musc#e of t!e b#adder nec& or uret!ra may a#so be responsib#e' 4 Non*re#a(ing uret!ra# sp!incter obstruction usually occurs in individuals 'ith a neurological lesion and is characterised by a non rela7ing, obstructing urethra resulting in reduced urine lo'* 1NEW2 7 FOOTNOTE 93

FOOTNOTE 21 * Non*re#a(ing sp!incter obstruction is found in sacra# and infra* sacra# #esions" suc! as meningomye#ocoe#e" and after radica# pe#vic surgery' In addition" t!ere is often urodynamic stress incontinence during b#adder fi##ing' T!is term rep#aces 3iso#ated dista# sp!incter obstruction-'

9.

CONDITIONS 4 <cute retention of urine is de ined as a pain ul, palpable or percussable bladder, 'hen the patient is unable to pass any urine* 1NEW2 7 FOOTNOTE 96

FOOTNOTE 2) * <#t!oug! acute retention is usua##y t!oug!t of as painfu#" in certain circumstances pain may not be a presenting feature" for e(amp#e %!en due to pro#apsed intervertebra# disc" post partum" or after regiona# anaest!esia suc! as an epidura# anaest!etic' T!e retention vo#ume s!ou#d be significant#y greater t!an t!e e(pected norma# b#adder capacity' In patients after surgery" due to bandaging of t!e #o%er abdomen or abdomina# %a## pain" it may be difficu#t to detect a painfu#" pa#pab#e or percussab#e b#adder' 4 C!ronic retention of urine is de ined as a non,pain ul bladder, 'hich re#ains palpable or percussable a ter the patient has passed urine* Such patients #ay be incontinent* 1NEW2 7 FOOTNOTE 98

FOOTNOTE 2+ * T!e ICS no #onger recommends t!e term 3overf#o% incontinence-' T!is term is considered confusing and #ac&ing a convincing definition' If used" a precise definition and any associated pat!op!ysio#ogy" suc!

4A

as reduced uret!ra# function" or detrusor overactivity$#o% b#adder comp#iance" s!ou#d be stated' T!e term c!ronic retention e(c#udes transient voiding difficu#ty" for e(amp#e after surgery for stress incontinence" and imp#ies a significant residua# urine7 a minimum figure of +IIm#s !as been previous#y mentioned' 4 9enign prostatic obstruction is a or# o b adder out et obstruction and #ay be diagnosed 'hen the cause o outlet obstruction is <no'n to be benign prostatic enlarge#ent, due to histologic benign prostatic hyperplasia* 1NEW2 9enign prostatic !yperp#asia is a ter# used (and reserved or) the typical histological pattern 'hich de ines the disease* 1NEW2 9enign prostatic en#argement is de ined as prostatic enlarge#ent due to histologic benign prostatic hyperplasia* &he ter# =prostatic enlarge#ent> should be used in the absence o prostatic histology* 1NEW2

4 4

:.

TREATMENT &he ollo'ing de initions 'ere published in the -th ICS report on Lo'er Urinary &ract Behabilitation &echni2ues H%ndersen et alI and re#ain in their original or#*

5*+

0o%er Urinary Tract ;e!abi#itation is de ined as non,surgical, non, phar#acological treat#ent or lo'er urinary tract unction and includes6 4 4 Be#vic f#oor training, de ined as repetitive selective voluntary contraction and rela7ation o speci ic pelvic loor #uscles* 9iofeedbac&, the techni2ue by 'hich in or#ation about a nor#ally unconscious physiological process is presented to the patient and@or the therapist as a visual, auditory or tactile signal* 9e!avioura# modification, de ined as the analysis and alteration o the relationship bet'een the patientCs sy#pto#s and his or her environ#ent or the treat#ent o #aladaptive voiding patterns* &his #ay be achieved by #odi ication o the behaviour and@or environ#ent o the patient*

5*4

E#ectrica# Stimu#ation is the application o electrical current to sti#ulate the pelvic viscera or their nerve supply* &he ai# o electrical sti#ulation #ay be to directly induce a therapeutic response or to #odulate lo'er urinary tract, bo'el or se7ual dys unction*

5*;

Cat!eteri5ation is a techni2ue or bladder e#ptying e#ploying a catheter to drain the bladder or a urinary reservoir*

45

5*;*+

Intermittent .in$out1 Cat!eterisation is de ined as drainage or aspiration o the bladder or a urinary reservoir 'ith subse2uent re#oval o the catheter* &he ollo'ing types o inter#ittent catheteriDation are de ined?

I"termitte"t el'7,at(eteri atio" is per or#ed by the patient hi#sel @hersel I"termitte"t ,at(eteri atio" is per or#ed by an attendant (e*g* doctor, nurse or relative) Clea" i"termitte"t ,at(eteri atio": use o a clean techni2ue* &his i#plies ordinary 'ashing techni2ues and use o disposable or cleansed reusable catheters* A e)ti, i"termitte"t ,at(eteri atio": use o a sterile techni2ue* &his i#plies genital disin ection and the use o sterile catheters and instru#ents@gloves* I"#0elli"% ,at(eteri atio": an ind'elling catheter re#ains in the bladder, urinary reservoir or urinary conduit or a period o ti#e longer than one e#ptying*

5*;*4

5*A

9#adder ;ef#e( Triggering co#prises various #anoeuvres per or#ed by the patient or the therapist in order to elicit re le7 detrusor contraction by e7teroceptive sti#uli* &he #ost co##only used #anoeuvres are6 suprapubic tapping, thigh scratching and anal@rectal #anipulation*

5*5

9#adder E(pression co#prises various #anoeuvres ai#ed at increasing intravesical pressure in order to acilitate bladder e#ptying* &he #ost co##only used #anoeuvres are abdo#inal straining, GalsalvaCs #anoeuvre and CredJ #anoeuvre*

%CK098LK"GK$K0&S? &he authors o this report are very grate ul to Gic<y Bees, %d#inistrator o the ICS, or her typing and editing o nu#erous dra ts o this docu#ent* %""K0"U$? Formation of t!e ICS Termino#ogy Committee

4:

&he ter#inology co##ittee 'as announced at the ICS #eeting in "enver +111 and e7pressions o interest 'ere invited ro# those 'ho 'ished to be active #e#bers o the co##ittee* &hey 'ere as<ed to co##ent in detail on the preli#inary dra t (the discussion paper published in ,eurouro ogy and Urodynamics)* &he nine authors replied 'ith a detailed criti2ue by +st %pril 4333 and constitute the co##ittee? Paul Abram ! Li"#a Car#o$o! Ma%"u Fall! Dere& Gri''it( ! Peter Ro ier! Ul' Ulm te"! P(ili) *a" +errebroe,&! Ar"e -i,tor a"# Ala" Wei". 8e than< other individuals 'ho later o ered their 'ritten co##ents? Ce" T(oru) A"#er e"! Walter Artiba"i! Cerr/ Blai*a ! Li"#a Bruba&er! Ri,& Bum)! Emma"uel C(artier7+a tler! Gra,e Dore/! Clare Fo0ler! +elm HDalma ! Gor#o" Ho &er! -i& +(ullar! Guu +ramer! Gu""ar Lo e! Co e)( Ma,alu o! A"#er Mattia o"! Ri,(ar# Millar#! Rie" NiDma"! Ar0i" Ri##er! Wer"er S,(E'er! Da*i# -o#u e&! Cea" Ca,@ue W/"#aele. % L day 'or<shop 'as held at the ICS %nnual $eeting in &a#pere (%ugust 4333) and a t'o,day #eeting in London, Manuary 433+* &his produced dra t 5 o the report 'hich 'as then placed on the ICS 'ebsite ('''*icso ice*org)* "iscussions on dra t : too< place at the ICS #eeting in Korea Septe#ber 433+6 dra t - then re#ained on the ICS 'ebsite until inal sub#ission to journals in 0ove#ber 433+*

Re'ere",e +* %bra#s ! (Chair), Blaivas M G, Stanton S, %ndersen M &N ICS Standardisation o &er#inology o Lo'er Urinary &ract .unction +1// N Scand M Urol 0ephrol, Supp ++A, +1// pages 5 N +1 %bra#s !, Blaivas M G, Stanton S L, %ndersen M (Chair) , ICS :th Beport on the Standardisation o &er#inology o Lo'er Urinary &ract .unction N 0eurourol* Urodyn* ++?51;,:3; (+114) %ndersen M*& (Chair), Blaivas M G, CardoDo L, &huro M N ICS -th Beport on the Standardisation o &er#inology o Lo'er Urinary &ract .unction ,Lo'er Urinary &ract Behabilitation &echni2ues , 0eurourol* Urodyn* ++?51;,:3; (+114) Bu#p B C, $attiasson %, Bo K, Bruba<er L !, "eLancey M 9 L, Klars<ov !, Shull B L, S#ith % B B N &he Standardisation o &er#inology o .e#ale !elvic 9rgan !rolapse and !elvic .loor "ys unction , %# M 9bstet Gynecol* +11:?+-5?+3,+* Gri iths ", Ho ner K, van $astrigt B, Bolle#a H M, Spangberg %, Gleason " N ICS Beport on the Standardisation o &er#inology o Lo'er Urinary &ract .unction? !ressure,.lo' Studies o Goiding, Urethral Besistance and Urethral 9bstruction N 0eurourol* Urodyn* +:?+,+/ (+11-)

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Stohrer $, Goepel $, Kondo %, Kra#er G, $adersbacher H, $illard B, Bossier % 8yndaele M M N ICS Beport on the Standardisation o &er#inology in 0eurogenic Lo'er Urinary &ract "ys unction N 0eurourol* Urodyn* +/?+;1,+5/ (+111) van 8aal'ij< van "oorn K, %nders K, Khullar G, Kulseng,Hansen S, !esce ., Bobertson %, Bosario ", SchO er 8* Standardisation o %#bulatory Urodyna#ic $onitoring? Beport o the Standardisation Sub, co##ittee o the International Continence Soceity or %#bulatory Urodyna#ic Studies N 0eurourol* Urodyn* +1?++;,+45 (4333) Lose G, Gri iths ", Hos<er G, Kulseng,Hanssen S, !erucchini ", SchO er 8, &hind ! and Gersi K , Standardisation o Urethral !ressure $easure#ent? Beport ro# the Standardisation Sub,co##ittee o the International Continence Society N 0eurourol* Urodyn* 4+?45/,4:3 (4334) van Kerrebroec< !, %bra#s !, Chai<in ", "onovan M, .onda ", Mac<son S, Mennu# !, Mohnson &, Lose G, $attiasson %, Bobertson G and 8eiss M , ICS Standardisation Beport on 0octuria? report ro# the standardisation sub,co##ittee o the International Continence Society N 0eurourol* Urodyn* 4+?+1;,11 (4334) Bo'an " (Chair), Ma#es K ", Kra#er % K M L, Sterling % $, Suhel ! . , ICS Beport on Urodyna#ic K2uip#ent? &echnical %spects N M $ed Kng P &ch* Gol ++, 0o 4, !ages 5-,:A ($ar@%pr +1/-) SchO er 8, Sterling % $, Liao L, Spangberg %, !esce ., Qinner 0 B, van Kerrebroec< !, %bra#s ! and $attiasson % N Good Urodyna#ic !ractice? Beport ro# the Standardisation Sub,co##ittee o the International Continence Society N 0eurourol* Urodyn* 4+? 4:+,4-A (4334) $attiasson %, "jurhuus M C, .onda ", Lose G, 0ordling M and Sthrer $ N Standardisation o 9utco#e Studies in !atients 'ith Lo'er Urinary "ys unction? % Beport on General !rinciples ro# the Standardisation Co##ittee o the International Continence Society N 0eurourol* Urodyn* +-?4A1,45; (+11/) 0ordling M, %bra#s !, %#eda K, %ndersen M &, "onovan M, Gri iths ", Kobayashi S, Koyanagi &, SchO er 8, Ralla S and $attiasson % N 9utco#e $easures or Besearch in &reat#ent o %dult $ales 'ith Sy#pto#s o Lo'er Urinary &ract "ys unction N 0eurourol* Urodyn* +-?4:;,4-+ (+11/) .onda ", Besnic< 0 $, Colling M, Burgio K, 9uslander M G, 0orton C, K<elund !, Gersi K and $attiasson % N 9utco#e $easures or Besearch o Lo'er Urinary &ract "ys unction in .rail and 9lder !eople N 0eurourol* Urodyn* +-?4-;,4/+ (+11/) Lose G, .anti M %, Gictor %, 8alter S, 8ells & L, 8y#an M and $attiasson % N 9utco#e $easures or Besearch in %dult 8o#en 'ith

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Sy#pto#s o Lo'er Urinary &ract "ys unction N 0eurourol* Urodyn* +-?455,4:4 (+11/) +:* +-* International Classi ication o .unctioning, "isability and Health N ICI"H,4 'ebsite http?@@'''*'ho*int@icidh Klev#ar< B N 0atural !ressure,Golu#e Curves and Conventional Cysto#etry N Scand M Urol 0ephrol Suppl 43+?+,A (+111)

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