2.1: Definitions of Symptoms

Lower urinary tract symptoms, (LUTS) are equally bothersome to men and women, and greatly affect the quality of life (QOL).
The term “Lower urinary tract symptoms” is used to describe a patient’s urinary complaints without implying a cause. Lower urinary tract symptoms were defined by the standardization sub – committee of the International Continence Society.
LUTS are the subjective indicators of a disease or change in conditions as perceived by the patients, carer or partners and may lead her to seek help from health care professionals. Symptoms may either be volunteered or described during the patient interview. They are usually qualitative.
In general, lower urinary tract symptoms cannot be used to make a definitive diagnosis. However LUTS can also indicate pathologies other than lower urinary tract dysfunction, such as urinary infection. The clinician will make his/her best efforts to exclude other causes of LUTS.
Lower urinary tract symptoms are categorized as storage, voiding and post micturition symptoms. (Table 1)

Table \(\PageIndex{2.1.1}\): LUTS

FILLING / STORAGE	EMPTYING / VOIDING	POST VOIDING SYMPTOMS
Frequency	Hesitancy	Post – micturition dribbling
Urgency	Straining to void	Feeling of incomplete emptying
Nocturia	Poor stream
Urgency Incontinence	Intermittency
Stress Incontinence	Dysuria
Nocturnal Incontinence	Terminal dribbling
Bladder / Urethral Pain
Absent or Impaired Sensation

Storage Symptoms are experienced during the storage phase of the bladder, and include daytime frequency and nocturia.

Increased daytime frequency is the complaint by the patient who considers that he/she voids too often by day. The average person voids 6 times a day.

Nocturia is the complaint that the individual has to wake at night one or more times to void.

Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer.

Urinary incontinence is the complaint of any involuntary leakage of urine. In each specific circumstance, urinary incontinence should be further described by specifying relevant factors such as type, frequency, severity, precipitating factors, social impact, effect on hygiene and quality of life, measures used to contain the leakage, and whether or not the individual seeks or desires help because of urinary incontinence.

Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.

Urgency urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency.

Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.

Enuresis means any involuntary loss of urine. If it is used to denote incontinence during sleep, it should always be qualified with the adjective “nocturnal”.

Nocturnal enuresis is the complaint of loss of urine occurring during sleep.

Continuous urinary incontinence is the complaint of continuous leakage and may denote urinary fistula.

Bladder sensation can be defined, during history taking, into four categories.
Normal: the individual is aware of bladder filling and increasing sensation up to a strong desire to void.
Increased: the individual feels an early first sensation of filling and then a persistent desire to void.
Reduced: the individual is aware of bladder filling but does not feel a definite desire to void.
Absent: the individual reports no sensation of bladder filling or desire to void.

Voiding symptoms are experienced during the voiding phase.

Slow stream is reported by the individual as the perception of reduced urine flow, usually compared to previous performance or in comparison to others.

Intermittent stream or Double voiding (Intermittency) is the term used when the individual describes urine flow which stops and starts, on one or more occasions, during micturition.

Hesitancy is the term used when an individual describes difficulty in initiating micturition resulting in delay in the onset of voiding after the individual is ready to pass urine.

Straining to void describes the muscular effort used to initiate, maintain or improve the urinary stream.

Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when flow has slowed to a trickle or dribble.

Post micturition symptoms are experienced immediately after micturition.

Feeling of incomplete emptying is a self – explanatory term for a feeling experienced by the individual after passing urine.

Post micturition dribble is the term used when an individual describes the involuntary loss of urine immediately after passing urine, usually after leaving the toilet.

Frequency – Volume Chart (Bladder Diary)

Frequency – volume charts (FVC) have become an important part of the evaluation of LUTS. Most experts would agree that these charts provide invaluable information about a number of symptoms including urinary frequency, urgency, incontinence episodes, and voided volume. In fact some symptoms, like nocturia, cannot be properly evaluated without a chart. Frequency – volume charts are critical for the distinction between nocturnal overactive bladder and nocturnal polyuria, two common causes of nocturia. Despite this the structure, content and duration of chart keeping for evaluation has not been standardised. There are a number of parameters that can be assessed by the FVC, including: total number of voids per 24 hours, total number of daytime (awake) voids, total number of night time voids, total fluid intake, total voided volume, maximum, minimum and mean voided volume, number of urgency episodes, and number of incontinence episodes.
FVC’s have been shown to be reproducible and more accurate when compared with the patient’s recall. The optimal length of a diary varies according to the parameter assessed and precision and sensitivity required. In addition, if one is trying to assess change, the baseline parameter (e.g number of voids, incontinence episodes) will affect the length of the diary needed to detect a certain change. A 7 day diary is a reasonable option for most patients with incontinence. If record keeping for 7 days increases a patient’s burden the number of days required to evaluate voiding symptoms should be reduced.
The majority of information collected on FVC’s or bladder diaries has been used to establish baselines or to study patients with OAB or incontinence.

Physical examination

A general physical examination of the patient is mandatory, since many co–morbid conditions are likely to impact on the symptoms of LUTS. (Table 2)

Table \(\PageIndex{2.1.2}\): Comorbid conditions causing LUTS

• Medical disorders › Hypertension / heart failure › Mulitple sclerosis › Diabetes Mellitus

• Reduced mobility

• Alzheimers

• Medical therapy, i.e diuretics

• Neurological disorders

A detailed gynaecological assessment is important, with particular attention to pelvic floor disorders, and prolapse. A full neurological examination is also required. Digital rectal examination is useful to evaluate the possibility of co – existent anal / faecal incontinence.