The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society☆

Article Outline

• Lower urinary tract symptoms (LUTS)
• Signs suggestive of lower urinary tract dysfunction (LUTD)
• Urodynamic observations
• Conditions
• Treatment
• 1. Lower urinary tract symptoms (LUTS)
  • 1.1. Storage symptoms are experienced during the storage phase of the bladder and include daytime frequency and nocturia. (new)
  • 1.2. Voiding symptoms are experienced during the voiding phase. (new)
  • 1.3. Post micturition symptoms are experienced immediately after micturition. (new)
  • 1.4. Symptoms associated with sexual intercourse
  • 1.5. Symptoms associated with pelvic organ prolapse
  • 1.6. Genital and lower urinary tract pain *8 The terms “strangury”, “bladder spasm”, and “dysuria” are difficult to define and of uncertain meaning and should not be used in relation to lower urinary tract dysfunction, unless a precise meaning is stated. Dysuria literally means ‘abnormal urination’ and is used correctly in some European countries. However, it is often used to describe the stinging/burning sensation characteristic of urinary infection. It is suggested that the descriptive words such as stinging and burning should be used in future. *8
  • 1.7. Genito-urinary pain syndromes and symptom syndromes suggestive of LUTD
    • 1.7.1. Genito-urinary pain syndromes are all chronic in their nature. Pain is the major complaint but concomitant complaints are of lower urinary tract, bowel, sexual or gynaecological nature
    • 1.7.2. Symptom syndromes suggestive of lower urinary tract dysfunction
• 2. Signs suggestive of lower urinary tract dysfunction (LUTD)
  • 2.1. Measuring the frequency, severity and impact of lower urinary tract symptoms
  • 2.2. Physical examination is essential in the assessment of all patients with lower urinary tract dysfunction. It should include abdominal, pelvic, perineal and a focussed neurological examination. For patients with possible neurogenic lower urinary tract dysfunction, a more extensive neurological examination is needed
    • 2.2.1. Abdominal: the bladder may be felt by abdominal palpation or by suprapubic percussion. pressure suprapubically or during bimanual vaginal examination may induce a desire to pass urine
      • 2.2.2. Perineal/genital inspection allows the description of the skin, for example the presence of atrophy or excoriation, any abnormal anatomical features and the observation of incontinence
  • 2.2.3. Vaginal examination allows the description of observed and palpable anatomical abnormalities and the assessment of pelvic floor muscle function, as described in the ICS report on pelvic organ prolapse. The definitions given are simplified versions of the definitions in that report4
  • 2.2.4. Pelvic floor muscle function can be qualitatively defined by the tone at rest and the strength of a voluntary or reflex contraction as strong, weak or absent or by a validated grading system (e.g. Oxford 1-5). A pelvic muscle contraction may be assessed by visual inspection, by palpation, electromyography or perineometry. Factors to be assessed include strength, duration, displacement and repeatability. (new)
    • 2.2.5. Rectal examination allows the description of observed and palpable anatomical abnormalities and is the easiest method of assessing pelvic floor muscle function in children and men. In addition, rectal examination is essential in children with urinary incontinence to rule out faecal impaction
  • 2.3. Pad testing may be used to quantify the amount of urine lost during incontinence episodes and methods range from a short provocative test to a 24-hour pad test
    • 3. Urodynamic observations and conditions
      • 3.1. Urodynamic techniques
  • 3.2. Filling cystometry
    • 3.2.1. Bladder sensation during filling cystometry
    • 3.2.2. Detrusor function during filling cystometry
    • 3.2.3. Bladder compliance during filling cystometry
    • 3.2.4. Bladder capacity: during filling cystometry
    • 3.2.5. Urethral function during filling cystometry
    • 3.2.6. Assessment of urethral function during filling cystometry
  • 3.3. Pressure flow studies
    • 3.3.1. Measurement of urine flow
    • 3.3.2. Pressure measurements during pressure flow studies (PFS)
    • 3.3.3. Detrusor function during voiding
    • 3.3.4. Urethral function during voiding
• 4. Conditions
• 5. Treatment
  • 5.1. Lower urinary tract rehabilitation is defined as non-surgical, non-pharmacological treatment for lower urinary tract function and includes
  • 5.2. Electrical stimulation is the application of electrical current to stimulate the pelvic viscera or their nerve supply
  • 5.3. Catheterisation is a technique for bladder emptying employing a catheter to drain the bladder or a urinary reservoir
    • 5.3.1. Intermittent (in/out) catheterisation is defined as drainage or aspiration of the bladder or a urinary reservoir with subsequent removal of the catheter
    • 5.3.2. Indwelling catheterisation: an indwelling catheter remains in the bladder, urinary reservoir or urinary conduit for a period of time longer than one emptying
      • 5.4. Bladder reflex triggering comprises various manoeuvres performed by the patient or the therapist in order to elicit reflex detrusor contraction by exteroceptive stimuli
    • 5.5. Bladder expression comprises various manoeuvres aimed at increasing intravesical pressure in order to facilitate bladder emptying
  • Acknowledgements
  • Addendum
• References
• Copyright

This report presents definitions of the symptoms, signs, urodynamic observations and conditions associated with lower urinary tract dysfunction (LUTD) and urodynamic studies (UDS), for use in all patient groups from children to the elderly.

The definitions restate or update those presented in previous International Continence Society Standardisation of Terminology reports1, 2, 3, 4, 5, 6, 7 and published on Urethral Function8 and Nocturia.9 The published ICS report on the technical aspects of urodynamic equipment10 is complemented by the new ICS report on urodynamic practice.11 In addition, there are four published ICS outcome reports.12, 13, 14, 15

New or changed definitions are all indicated; however, recommendations concerning technique are not included in the main text of this report.

The definitions have been written to be compatible with the WHO publication ICIDH-2 (International Classification of Functioning, Disability and Health) published in 2001 and ICD10, the International Classification of Diseases.16 As far as possible, the definitions are descriptive of observations, without implying underlying assumptions that may later prove to be incorrect or incomplete. By following this principle, the International Continence Society (ICS) aims to facilitate comparison of results and enable effective communication by investigators who use urodynamic methods. This report restates the ICS principle that symptoms, signs and conditions are separate categories and adds a category of urodynamic observations. In addition, terminology related to therapies is included.3

When a reference is made to the whole anatomical organ the vesica urinaria, the correct term is the bladder. When the smooth muscle structure known as the m. detrusor urinae is being discussed, then the correct term is detrusor.

It is suggested that acknowledgement of these standards in written publications be indicated by a footnote to the section “Methods and Materials” or its equivalent, to read as follows:

“Methods, definitions and units conform to the standards recommended by the International Continence Society, except where specifically noted”.

The report covers the following areas:

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Lower urinary tract symptoms (LUTS) 

Symptoms are the subjective indicator of a disease or change in condition as perceived by the patient, caregiver or partner and may lead him/her to seek help from health care professionals. (NEW)

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. Lower Urinary Tract Symptoms can also indicate pathologies other than lower urinary tract dysfunction, such as urinary infection.

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Signs suggestive of lower urinary tract dysfunction (LUTD) 

Signs are observed by the physician including simple means, to verify symptoms and quantify them. (NEW)

For example, a classical sign is the observation of leakage on coughing. Observations from frequency volume charts, pad tests and validated symptom and quality of life questionnaires are examples of other instruments that can be used to verify and quantify symptoms.

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Urodynamic observations 

Urodynamic observations are observations made during urodynamic studies. (NEW)

For example, an involuntary detrusor contraction (detrusor overactivity) is a urodynamic observation. In general, a urodynamic observation may have a number of possible underlying causes and does not represent a definitive diagnosis of a disease or condition and may occur with a variety of symptoms and signs, or in the absence of any symptoms or signs.

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Conditions 

Conditions are defined by the presence of urodynamic observations associated with characteristic symptoms or signs and/or non-urodynamic evidence of relevant pathological processes. (NEW)

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Treatment 

Treatment for lower urinary tract dysfunction: these definitions are from the 7th ICS report on Lower Urinary Tract Rehabilitation Techniques.3

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1. Lower urinary tract symptoms (LUTS) 

Lower urinary tract symptoms are defined from the individual’s perspective who is usually, but not necessarily, a patient within the healthcare system. Symptoms are either volunteered by, or elicited from, the individual or may be described by the individual’s caregiver.

Lower urinary tract symptoms are divided into three groups: storage, voiding, and post micturition symptoms.

1.1. Storage symptoms are experienced during the storage phase of the bladder and include daytime frequency and nocturia. (new) 

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, the measures used to contain the leakage and whether or not the individual seeks or desires help because of urinary incontinence. *3

Urinary leakage may need to be distinguished from sweating or vaginal discharge.

1.2. Voiding symptoms are experienced during the voiding phase. (new) 

1.3. Post micturition symptoms are experienced immediately after micturition. (new) 

1.4. Symptoms associated with sexual intercourse 

Dyspareunia, vaginal dryness and incontinence are amongst the symptoms women may describe during or after intercourse. These symptoms should be described as fully as possible. It is helpful to define urine leakage as: during penetration, during intercourse, or at orgasm.

1.5. Symptoms associated with pelvic organ prolapse 

The feeling of a lump (“something coming down”), low backache, heaviness, dragging sensation, or the need to digitally replace the prolapse in order to defaecate or micturate, are amongst the symptoms women may describe who have a prolapse.

1.6. Genital and lower urinary tract pain *8 

Pain, discomfort and pressure are part of a spectrum of abnormal sensations felt by the individual. Pain produces the greatest impact on the patient and may be related to bladder filling or voiding, may be felt after micturition, or be continuous. Pain should also be characterised by type, frequency, duration, precipitating and relieving factors and by location as defined below:

1.7. Genito-urinary pain syndromes and symptom syndromes suggestive of LUTD 

Syndromes describe constellations, or varying combinations of symptoms, but cannot be used for precise diagnosis. The use of the word ‘syndrome’ can only be justified if there is at least one other symptom in addition to the symptom used to describe the syndrome. In scientific communications the incidence of individual symptoms within the syndrome should be stated, in addition to the number of individuals with the syndrome.

The syndromes described are functional abnormalities for which a precise cause has not been defined. It is presumed that routine assessment (history taking, physical examination, and other appropriate investigations) has excluded obvious local pathologies such as those that are infective, neoplastic, metabolic or hormonal in nature.

In clinical practice, empirical diagnoses are often used as the basis for initial management after assessing the individual’s lower urinary tract symptoms, physical findings and the results of urinalysis and other indicated investigations.

These symptom combinations are suggestive of urodynamically demonstrable detrusor overactivity but can be due to other forms of urethro-vesical dysfunction. These terms can be used if there is no proven infection or other obvious pathology.

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2. Signs suggestive of lower urinary tract dysfunction (LUTD) 

2.1. Measuring the frequency, severity and impact of lower urinary tract symptoms 

Asking the patient to record micturitions and symptoms *13 for a period of days provides invaluable information. The recording of micturition events can be in three main forms:

The following measurements can be abstracted from frequency volume charts and bladder diaries:

This is usually commenced after the first void produced after rising in the morning and is completed by including the first void on rising the following morning.

The maximum, mean and minimum voided volumes over the period of recording may be stated. *17

2.2. Physical examination is essential in the assessment of all patients with lower urinary tract dysfunction. It should include abdominal, pelvic, perineal and a focussed neurological examination. For patients with possible neurogenic lower urinary tract dysfunction, a more extensive neurological examination is needed 

2.2.2. Perineal/genital inspection allows the description of the skin, for example the presence of atrophy or excoriation, any abnormal anatomical features and the observation of incontinence 

Stress leakage is presumed to be due to raised abdominal pressure.

2.2.3. Vaginal examination allows the description of observed and palpable anatomical abnormalities and the assessment of pelvic floor muscle function, as described in the ICS report on pelvic organ prolapse. The definitions given are simplified versions of the definitions in that report4 

Pelvic organ prolapse can occur in association with urinary incontinence and other lower urinary tract dysfunction and may on occasion mask incontinence.

2.2.4. Pelvic floor muscle function can be qualitatively defined by the tone at rest and the strength of a voluntary or reflex contraction as strong, weak or absent or by a validated grading system (e.g. Oxford 1-5). A pelvic muscle contraction may be assessed by visual inspection, by palpation, electromyography or perineometry. Factors to be assessed include strength, duration, displacement and repeatability. (new) 

2.3. Pad testing may be used to quantify the amount of urine lost during incontinence episodes and methods range from a short provocative test to a 24-hour pad test 

3.1. Urodynamic techniques 

There are two principal methods of urodynamic investigation:

Both filling cystometry and pressure flow studies of voiding require the following measurements:

3.2. Filling cystometry 

The word “cystometry” is commonly used to describe the urodynamic investigation of the filling phase of the micturition cycle. To eliminate confusion, the following definitions are proposed:

The filling phase starts when filling commences and ends when the patient and urodynamicist decide that “permission to void” has been given. *20

Bladder and urethral function, during filling, need to be defined separately.

The rate at which the bladder is filled is divided into:

Bladder storage function should be described according to bladder sensation, detrusor activity, bladder compliance and bladder capacity. *21

In everyday life the individual attempts to inhibit detrusor activity until he or she is in a position to void. Therefore, when the aims of the filling study have been achieved, and when the patient has a desire to void, normally the ‘permission to void’ is given (see Filling Cystometry). That moment is indicated on the urodynamic trace and all detrusor activity before this ‘permission’ is defined as ‘involuntary detrusor activity’.

There are certain patterns of detrusor overactivity:

In a patient with normal sensation, urgency is likely to be experienced just before the leakage episode. *27

Detrusor overactivity may also be qualified, when possible, according to cause, for example:

This term replaces the term “detrusor hyperreflexia”. (NEW)

This term replaces “detrusor instability”. *28

In clinical and research practice, the extent of neurological examination/investigation varies. It is likely that the proportion of neurogenic: idiopathic detrusor overactivity will increase if a more complete neurological assessment is carried out.

Other patterns of detrusor overactivity are seen, for example, the combination of phasic and terminal detrusor overactivity, and the sustained high pressure detrusor contractions seen in spinal cord injury patients when attempted voiding occurs against a dyssynergic sphincter.

Compliance is calculated by dividing the volume change (ΔV) by the change in detrusor pressure (Δpdet) during that change in bladder volume (C = V. Δpdet). It is expressed in ml/cm H₂O.

A variety of means of calculating bladder compliance has been described. The ICS recommends that two standard points should be used for compliance calculations: the investigator may wish to define additional points. The standards points are:

The urethral closure mechanism during storage may be competent or incompetent.

Urodynamic stress incontinence is now the preferred term to “genuine stress incontinence”. *32

3.3. Pressure flow studies 

Voiding is described in terms of detrusor and urethral function and assessed by measuring urine flow rate and voiding pressures.

The voiding phase starts when ‘permission to void’ is given, or when uncontrollable voiding begins, and ends when the patient considers voiding has finished.

Urine flow is defined either as continuous, that is without interruption, or as intermittent, when an individual states that the flow stops and starts during a single visit to the bathroom in order to void. The continuous flow curve is defined as a smooth arc-shaped curve or fluctuating when there are multiple peaks during a period of continuous urine flow. *35

The following measurements are applicable to each of the pressure curves: intravesical, abdominal and detrusor pressure.

This is the initial isovolumetric contraction period of micturition. Flow measurement delay should be taken into account when measuring opening time.

Normal voiding is achieved by a voluntarily initiated continuous detrusor contraction that leads to complete bladder emptying within a normal time span, and in the absence of obstruction. For a given detrusor contraction, the magnitude of the recorded pressure rise will depend on the degree of outlet resistance. (ORIGINAL)

During voiding, urethral function may be:

Normal urethra function is defined as urethra that opens and is continuously relaxed to allow the bladder to be emptied at a normal pressure. (CHANGED)

Abnormal urethra function may be due to either obstruction to urethral overactivity or the urethra cannot open due to anatomic abnormality, such as an enlarged prostate or a urethral stricture.

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4. Conditions 

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5. Treatment 

The following definitions were published in the 7th ICS report on Lower Urinary Tract Rehabilitation Techniques3 and remain in their original form.

5.1. Lower urinary tract rehabilitation is defined as non-surgical, non-pharmacological treatment for lower urinary tract function and includes 

This may be achieved by modification of the behaviour and/or environment of the patient.

5.2. Electrical stimulation is the application of electrical current to stimulate the pelvic viscera or their nerve supply 

The aim of electrical stimulation may be to directly induce a therapeutic response or to modulate lower urinary tract, bowel or sexual dysfunction.

5.3. Catheterisation is a technique for bladder emptying employing a catheter to drain the bladder or a urinary reservoir 

The following types of intermittent catheterisation are defined:

5.4. Bladder reflex triggering comprises various manoeuvres performed by the patient or the therapist in order to elicit reflex detrusor contraction by exteroceptive stimuli 

The most commonly used manoeuvres are suprapubic tapping, thigh scratching and anal/rectal manipulation.

The most commonly used manoeuvres are abdominal straining, Valsalva’s manoeuvre and Credé manoeuvre.

Acknowledgements 

The authors of this report are very grateful to Vicky Rees, Administrator of the ICS, for her typing and editing of numerous drafts of this document.

Addendum 

Formation of the ICS Terminology Committee

The terminology committee was announced at the ICS meeting in Denver 1999 and expressions of interest were invited from those who wished to be active members of the committee. They were asked to comment in detail on the preliminary draft (the discussion paper published in Neurourology and Urodynamics). The nine authors replied with a detailed critique by 1st April 2000 and constitute the committee: Paul Abrams, Linda Cardozo, Magnus Fall, Derek Griffiths, Peter Rosier, Ulf Ulmsten, Philip van Kerrebroeck, Arne Victor, and Alan Wein.

We thank other individuals who later offered their written comments: Jens Thorup Andersen, Walter Artibani, Jerry Blaivas, Linda Brubaker, Rick Bump, Emmanuel Chartier-Kastler, Grace Dorey, Clare Fowler, Kelm Hjalmas, Gordon Hosker, Vik Khullar, Guus Kramer, Gunnar Lose, Joseph Macaluso, Anders Mattiasson, Richard Millard, Rien Nijman, Arwin Ridder, Werner Schäfer, David Vodusek, and Jean Jacques Wyndaele.

A 1/2 day workshop was held at the ICS Annual Meeting in Tampere (August 2000) and a two-day meeting in London, January 2001, which produced draft 5 of the report which was then placed on the ICS website (http://www.icsoffice.org). Discussions on draft 6 took place at the ICS meeting in Korea September 2001; draft 7 then remained on the ICS website until final submission to journals in November 2001.

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References 

1. Abrams P, Blaivas JG, Stanton S, Andersen JT. ICS Standardisation of Terminology of Lower Urinary Tract Function 1988. Scand J Urol Nephrol Suppl. 1988;114:5–19
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4. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The Standardisation of Terminology of Female Pelvic Organ Prolapse and Pelvic Floor Dysfunction. Am J Obstet Gynecol. 1996;175:10–11
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• *1 The term night time frequency differs from that for nocturia, as it includes voids that occur after the individual has gone to bed, but before he/she has gone to sleep, and voids which occur in the early morning which prevent the individual from getting back to sleep as he/she wishes. These voids before and after sleep may need to be considered in research studies, for example, in nocturnal polyuria. If this definition were used then an adapted definition of daytime frequency would need to be used with it.
• *2 In infants and small children the definition of Urinary Incontinence is not applicable. In scientific communications the definition of incontinence in children would need further explanation.
• *3 The original ICS definition of incontinence “Urinary incontinence is the involuntary loss of urine that is a social or hygienic problem”, relates the complaint to quality of life (QoL) issues. Some QoL instruments have been and are being developed in order to assess the impact of both incontinence and other LUTS on QoL.
• *4 The committee considers the term “stress incontinence” to be unsatisfactory in the English language because of its mental connotations. The Swedish, French and Italian expression “effort incontinence” is preferable. However, words such as “effort” or “exertion” still do not capture some of the common precipitating factors for stress incontinence such as coughing or sneezing. For this reason the term is left unchanged.
• *5 Urge incontinence can present in different symptomatic forms; for example, as frequent small losses between micturitions or as a catastrophic leak with complete bladder emptying.
• *6 These non-specific symptoms are most frequently seen in neurological patients, particularly those with spinal cord trauma and in children and adults with malformations of the spinal cord.
• *7 Suprapubic pressure may be used to initiate or maintain urine flow. The Credé manoeuvre is used by some spinal cord injury patients, and girls with detrusor underactivity sometimes press suprapubically to help empty the bladder.
• *8 The terms “strangury”, “bladder spasm”, and “dysuria” are difficult to define and of uncertain meaning and should not be used in relation to lower urinary tract dysfunction, unless a precise meaning is stated. Dysuria literally means ‘abnormal urination’ and is used correctly in some European countries. However, it is often used to describe the stinging/burning sensation characteristic of urinary infection. It is suggested that the descriptive words such as stinging and burning should be used in future.
• *9 The ICS believes this to be a preferable term to “interstitial cystitis”. Interstitial cystitis is a specific diagnosis and requires confirmation by typical cystoscopic and histological features. In the investigation of bladder pain it may be necessary to exclude conditions such as carcinoma in situ and endometriosis.
• *10 The ICS suggests that the term vulvodynia (vulva-pain) should not be used, as it leads to confusion between a single symptom and a syndrome.
• *11 The ICS suggests that in men, the term prostatodynia (prostate-pain) should not be used as it leads to confusion between a single symptom and a syndrome.
• *12 In women voiding symptoms are usually thought to suggest detrusor underactivity rather than bladder outlet obstruction.
• *13 Validated questionnaires are useful for recording symptoms, their frequency, severity and bother, and the impact of LUTS on QoL. The instrument used should be specified.
• *14 It is useful to ask the individual to make an estimate of liquid intake. This may be done precisely by measuring the volume of each drink or crudely by asking how many drinks are taken in a 24-hour period. If the individual eats significant quantities of water containing foods (vegetables, fruit, salads) then an appreciable effect on urine production will result. The time that diuretic therapy is taken should be marked on a chart or diary.
• *15 The causes of polyuria are various and reviewed elsewhere but include habitual excess fluid intake. The figure of 2.8 is based on a 70 kg person voiding > 40 ml/kg.
• *16 The normal range of nocturnal urine production differs with age and the normal ranges remain to be defined. Therefore, nocturnal polyuria is present when greater than 20% (young adults) to 33% (over 65 years) is produced at night. Hence the precise definition is dependent on age.
• *17 The term “functional bladder capacity” is no longer recommended, as “voided volume” is a clearer and less confusing term, particularly if qualified e.g. ‘maximum voided volume’. If the term “bladder capacity” is used, in any situation, it implies that this has been measured in some way, if only by abdominal ultrasound. In adults, voided volumes vary considerably. In children, the “expected volume” may be calculated from the formula (30 + (age in years × 30) in ml). Assuming no residual urine, this will be equal to the “expected bladder capacity”.
• *18 Coughing may induce a detrusor contraction, hence the sign of stress incontinence is only a reliable indication of urodynamic stress incontinence when leakage occurs synchronously with the first proper cough and stops at the end of that cough.
• *19 The term Ambulatory Urodynamics is used to indicate that monitoring usually takes place outside the urodynamic laboratory, rather than the subject’s mobility using natural filling.
• *20 The ICS no longer wishes to divide filling rates into slow, medium and fast. In practice almost all investigations are performed using medium filling rates which have a wide range. It may be more important during investigations to consider whether or not the filling rate used during conventional urodynamic studies can be considered physiological.
• *21 Whilst bladder sensation is assessed during filling cystometry the assumption that it is sensation from the bladder alone, without urethral or pelvic components may be false.
• *22 The assessment of the subject’s bladder sensation is subjective and it is not, for example, possible to quantify “low bladder volume” in the definition of “increased bladder sensation”.
• *23 The ICS no longer recommends the terms “motor urgency” and “sensory urgency”. These terms are often misused and have little intuitive meaning. Furthermore, it may be simplistic to relate urgency just to the presence or absence of detrusor overactivity when there is usually a concomitant fall in urethral pressure.
• *24 There is no lower limit for the amplitude of an involuntary detrusor contraction but confident interpretation of low pressure waves (amplitude smaller than 5 cm of H₂O) depends on “high quality” urodynamic technique. The phrase “which the patient cannot completely suppress” has been deleted from the old definition.
• *25 Phasic detrusor contractions are not always accompanied by any sensation or may be interpreted as a first sensation of bladder filling or as a normal desire to void.
• *26 “Terminal detrusor overactivity” is a new ICS term: it is typically associated with reduced bladder sensation, for example, in the elderly stroke patient when urgency may be felt as the voiding contraction occurs. However, in complete spinal cord injury patients there may be no sensation whatsoever.
• *27 ICS recommends that the terms “motor urge incontinence” and “reflex incontinence” should no longer be used as they have no intuitive meaning and are often misused.
• *28 The terms “detrusor instability” and “detrusor hyperreflexia” were both used as generic terms, in the English speaking world and Scandinavia, prior to the first ICS report in 1976. As a compromise they were allocated to idiopathic and neurogenic overactivity respectively. As there is no real logic or intuitive meaning to the terms, the ICS believes they should be abandoned.
• *29 The observation of reduced bladder compliance during conventional filling cystometry is often related to relatively fast bladder filling: the incidence of reduced compliance is markedly lower if the bladder is filled at physiological rates, as in ambulatory urodynamics.
• *30 In certain types of dysfunction, the cystometric capacity cannot be defined in the same terms. In the absence of sensation the cystometric capacity is the volume at which the clinician decides to terminate filling. The reason(s) for terminating filling should be defined, e.g. high detrusor filling pressure, large infused volume or pain. If there is uncontrollable voiding, it is the volume at which this begins. In the presence of sphincter incompetence the cystometric capacity may be significantly increased by occlusion of the urethra e.g. by Foley catheter.
• *31 Fluctuations in urethral pressure have been defined as the “unstable urethra”. However, the significance of the fluctuations and the term itself lack clarity and the term is not recommended by the ICS. If symptoms are seen in association with a decrease in urethral pressure a full description should be given.
• *32 In patients with stress incontinence, there is a spectrum of urethral characteristics ranging from a highly mobile urethra with good intrinsic function to an immobile urethra with poor intrinsic function. Any delineation into categories such as “urethral hypermobility” and “intrinsic sphincter deficiency” may be simplistic and arbitrary, and requires further research.
• *33 The leak pressure point should be qualified according to the site of pressure measurement (rectal, vaginal or intravesical) and the method by which pressure is generated (cough or valsalva). Leak point pressures may be calculated in three ways from the three different baseline values which are in common use: zero (the true zero of intravesical pressure), the value of p_ves measured at zero bladder volume, or the value of p_ves immediately before the cough or valsalva (usually at 200 or 300 ml bladder capacity). The baseline used, and the baseline pressure, should be specified.
• *34 Detrusor leak point pressure has been used most frequently to predict upper tract problems in neurological patients with reduced bladder compliance. ICS has defined it “in the absence of a detrusor contraction” although others will measure DLPP during involuntary detrusor contractions.
• *35 The precise shape of the flow curve is decided by detrusor contractility, the presence of any abdominal straining and by the bladder outlet.11
• *36 A normal detrusor contraction will be recorded as: high pressure if there is high outlet resistance, normal pressure if there is normal outlet resistance: or low pressure if urethral resistance is low.
• *37 If after repeated free flowmetry no residual urine is demonstrated, then the finding of a residual urine during urodynamic studies should be considered an artifact, due to the circumstances of the test.
• *38 Bladder outlet obstruction has been defined for men but, as yet, not adequately in women and children.
• *39 Although dysfunctional voiding is not a very specific term, it is preferred to terms such as “non-neurogenic neurogenic bladder”. Other terms such as “idiopathic detrusor sphincter dyssynergia”, or “sphincter overactivity voiding dysfunction”, may be preferable. However, the term dysfunctional voiding is very well established. The condition occurs most frequently in children. Whilst it is felt that pelvic floor contractions are responsible, it is possible that the intra-urethral striated muscle may be important.
• *40 Detrusor sphincter dyssynergia typically occurs in patients with a supra-sacral lesion, for example after high spinal cord injury, and is uncommon in lesions of the lower cord. Although the intraurethral and periurethral striated muscles are usually held responsible, the smooth muscle of the bladder neck or urethra may also be responsible.
• *41 Non-relaxing sphincter obstruction is found in sacral and infra-sacral lesions, such as meningomyelocoele, and after radical pelvic surgery. In addition, there is often urodynamic stress incontinence during bladder filling. This term replaces “isolated distal sphincter obstruction”.
• *42 Although acute retention is usually thought of as painful, in certain circumstances pain may not be a presenting feature, for example when due to prolapsed intervertebral disc, post partum, or after regional anaesthesia such as an epidural anaesthetic. The retention volume should be significantly greater than the expected normal bladder capacity. In patients after surgery, due to bandaging of the lower abdomen or abdominal wall pain, it may be difficult to detect a painful, palpable or percussible bladder.
• *43 The ICS no longer recommends the term “overflow incontinence”. This term is considered confusing and lacking a convincing definition. If used, a precise definition and any associated pathophysiology, such as reduced urethral function, or detrusor overactivity/low bladder compliance, should be stated. The term chronic retention excludes transient voiding difficulty, for example after surgery for stress incontinence, and implies a significant residual urine; a minimum figure of 300 ml has been previously mentioned.