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Underactive bladder: Tackling pitfalls in management

The optimal management of underactive bladder remains elusive and the wide variety of approaches taken by physicians were discussed yesterday in Thematic Session 1 which emphasized that the lack of a specific pathology has often led to under-diagnosis and ineffective treatments.

Chaired by Profs. Jean Nicolas Cornu (FR) and Salvador Arlandis (ES), issues such as defining underactive bladder (UAB) and the pathophysiological mechanisms were examined by speakers Mr. Nadir Osman (GB) and Dr. Tiago Antunes-Lopes (PT), respectively. Following the overview lectures, two cases were presented to look into the issue from various perspectives with Prof. Gommert Van Koeveringe (BE) presenting the case of a man with Benign Prostatic Obstruction (BPO), and Prof. Andrea Tubaro that of a young woman with dysfunctional voiding problems.

Osman underscored the importance of properly defining UAB as he cited the ICS 2018 definition which says that UAB is “…characterized by a slow urinary stream hesitancy and straining to void, with or without a feeling of incomplete bladder emptying, sometimes with storage symptoms.”

He also addressed the issue of whether UAB could be to detrusor underactivity (DUA) as overactive bladder (OAB) is to detrusor overactivity (DOA), as he noted that doing so would facilitate epidemiological studies, make the condition more understandable to patients, and prompt interest in research and drug development, among others. “But UAB symptom complex is desirable only if the diagnosis is sufficiently robust,” he said.

In his closing remarks, Osman said DUA is a common problem in patients with LUTS seen in secondary care. He added that there is little published clinical or scientific research, and that defining a symptom complex of UAB is “…difficult due to the overlap in symptoms of DUA with other LUT dysfunctions.”

Saying that UAB is of “multifactorial aetiopathogenesis,” Osman said there is a lack of “any simple and effective treatments.

Antunes-Lopes, on the other hand, said there is a lack of original studies on the causes and mechanisms of UAB/DUA, as he underscored that the condition is aging-related and multifactorial. “Aging, bladder outlet obstruction (BOO) and ischemia are putative causes of UAB/DUA. Contemporary views emphasize the importance of bladder afferent system,” he said.

During the case discussion, the role of transurethral resection of the prostate (TURP) was examined in men with detrusor underactivity with the panelists observing that patients with pure DUA (no BOO) or with an acontractile detrusor may not be candidates for a TURP.

“There is questionable and no long-term effect of TURP in detrusor underactivity,” said panelist Prof. Stephan Madersbacher (AT). “Thorough pre-operative assessment, use of urodynamics, patient information, and wait-and-see is part of an initial advice.”

In the second case provided by Tubaro, the use of sacral nerve stimulation (SNS) was discussed by Prof. Hann-Chorng Kuo (TW) and Prof. David Castro-Diaz (ES), with the former taking the affirmative position on SNS against Castro-Diaz’s arguments for a more conservative management.

“We know that UAB is a clinical entity which requires more studies. For female patients it is essential to have a multidisciplinary treatment, and for men, TURP may not work and certainly proper assessment is necessary. In all cases, tailored treatment is recommended and exhaustive conservative management should first be considered ahead of new therapies,” said Cornu.

Article By Joel Vega