Reprinted with permission from Abrams p, Cardozo l, Fall M, Griffiths D, Rozier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The standardization of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Neurobiol Urodynam 2002;21:167-178.
Correspondence to: International Continence Society Office, Southmead Hospital, Bristol, BSIO 5NB, United Kingdom. Email: Vicky@icsoffice.org
Am J Gynecol 2002;187:116-126.
© 2002 Wiley-Liss, Inc. This material is used by permission of Wiley-Liss, Inc., a susbidiary of John Wiley & Sons, Inc.
6/6/125704
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 Standardization of Terminology reports (see references ) and those shortly to be published on urethral function (Lose et al., in press) and nocturia ( ). The published International Continence Society (ICS) report on the technical aspects of urodynamic equipment ( ) will be complemented by the new ICS report on urodynamic practice to be published shortly ( ). In addition, there are four published ICS outcome reports ( ).
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 World Health Organization publication International Classification of Functioning, Disability and Health-2 published in 2001 and the International Classification of Diseases 10. 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 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 ( ).
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 acknowledgment 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:
Lower Urinary Tract Symptoms
Symptoms are the subjective indicator of a disease or change in condition as perceived by the patient, carer, 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 (LUTS) cannot be used to make a definitive diagnosis. LUTS can also indicate pathologies other than lower urinary tract dysfunction, such as urinary infection.
Signs Suggestive of 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.
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.
Lower Urinary Tract Symptoms
LUTS are defined from the individual’s perspective, who is usually, but not necessarily a patient within the health care system. Symptoms are either volunteered by, or elicited from, the individual or may be described by the individual’s caregiver.
LUTS are divided into three groups: storage, voiding, and postmicturition symptoms.
Storage Symptoms
Storage symptoms are experienced during the storage phase of the bladder, and include daytime frequency and nocturia. (NEW)
- •
Increased daytime frequency is the complaint by the patient who considers that he or she voids too often by day. (NEW) This term is equivalent to pollakisuria used in many countries.
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Nocturia is the complaint that the individual has to wake at night one or more times to void. (NEW) 1
1 The term “nighttime frequency” differs from that for nocturia, because it includes voids that occur after the individual has gone to bed, but before he or she has gone to sleep; and voids that occur in the early morning that prevent the individual from getting back to sleep as he or 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.
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Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer. (CHANGED)
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Urinary incontinence is the complaint of any involuntary leakage of urine. (NEW) 2
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.
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
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 to assess the impact of both incontinence and other LUTS on QoL.
Urinary leakage may need to be distinguished from sweating or vaginal discharge.
- •
Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. (CHANGED) 4
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.
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Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency. (CHANGED) 5
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.
- •
Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing. (NEW)
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Enuresis means any involuntary loss of urine. (ORIGINAL) If it is used to denote incontinence during sleep, it should always be qualified with the adjective “nocturnal.”
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Nocturnal enuresis is the complaint of loss of urine occurring during sleep. (NEW)
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Continuous urinary incontinence is the complaint of continuous leakage. (NEW)
- •
Other types of urinary incontinence may be situational, for example the report of incontinence during sexual intercourse, or giggle incontinence.
- •
Bladder sensation can be defined, during history-taking, by five categories.
Normal: the individual is aware of bladder filling and increasing sensation up to a strong desire to void. (NEW)
Increased: the individual feels an early and persistent desire to void. (NEW)
Reduced: the individual is aware of bladder filling but does not feel a definite desire to void. (NEW)
Absent: the individual reports no sensation of bladder filling or desire to void. (NEW)
Nonspecific: the individual reports no specific bladder sensation, but may perceive bladder filling as abdominal fullness, vegetative symptoms, or spasticity. (NEW) 6
6 These nonspecific 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.
Voiding Symptoms
Voiding symptoms are experienced during the voiding phase. (NEW)
- •
Slow stream is reported by the individual as his or her perception of reduced urine flow, usually compared with previous performance or in comparison with others. (NEW)
- •
Splitting or spraying of the urine stream may be reported. (NEW)
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Intermittent stream ( Intermittency ) is the term used when the individual describes urine flow, which stops and starts, on one or more occasions, during micturition. (NEW)
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Hesitancy is the term used when an individual describes difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine. (NEW)
- •
Straining to void describes the muscular effort used to either initiate, maintain, or improve the urinary stream. (NEW) 7
7 Suprapubic pressure may be used to initiate or maintain urine flow. The Credé maneuver is used by some spinal cord injury patients, and girls with detrusor underactivity sometimes press suprapubically to help empty the bladder.
- •
Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble. (NEW)
Postmicturition Symptoms
Postmicturition symptoms are experienced immediately after micturition. (NEW)
- •
Feeling of incomplete emptying is a self-explanatory term for a feeling experienced by the individual after passing urine. (NEW)
- •
Postmicturition dribble is the term used when an individual describes the involuntary loss of urine immediately after he or she has finished passing urine, usually after leaving the toilet in men, or after rising from the toilet in women. (NEW)
Symptoms Associated with Sexual Intercourse
Dyspareunia, vaginal dryness, and incontinence are among 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.
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 defecate or micturate, are among the symptoms women may describe who have a prolapse.
Genital and Lower Urinary Tract Pain 8
8 The terms “strangury,” “bladder spasm,” and “dysuria” are difficult to define and of uncertain meaning and should not be used in relation to LUTD, 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 these descriptive words should not be used in future.
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 characterized by type, frequency, duration, precipitating, and relieving factors and by location as defined as:
- •
Bladder pain is felt suprapubically or retropubically, usually increases with bladder filling, and may persist after voiding. (NEW)
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Urethral pain is felt in the urethra and the individual indicates the urethra as the site. (NEW)
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Vulval pain is felt in and around the external genitalia. (NEW)
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Vaginal pain is felt internally, above the introitus. (NEW)
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Scrotal pain may or may not be localized, for example to the testis, epididymis, cord structures, or scrotal skin. (NEW)
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Perineal pain is felt: in the female, between the posterior fourchette (posterior lip of the introitus) and the anus, and in the male, between the scrotum and the anus. (NEW)
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Pelvic pain is less well defined than, for example, bladder, urethral or perineal pain and is less clearly related to the micturition cycle or to bowel function and is not localized to any single pelvic organ. (NEW)
Genitourinary 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.
Genitourinary Pain Syndromes
Genitourinary pain syndromes are all chronic in their nature. Pain is the major complaint, but concomitant complaints are of lower urinary tract, bowel, sexual, or gynecological nature
- •
Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and nighttime frequency, in the absence of proven urinary infection or other obvious pathology. (NEW) 9
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 histologic features. In the investigation of bladder pain, it may be necessary to exclude conditions such as carcinoma in situ and endometriosis.
- •
Urethral pain syndrome is the occurrence of recurrent episodic urethral pain usually on voiding, with daytime frequency and nocturia, in the absence of proven infection or other obvious pathology. (NEW)
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Vulval pain syndrome is the occurrence of persistent or recurrent episodic vulval pain, which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious pathology. (NEW) 10
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.
- •
Vaginal pain syndrome is the occurrence of persistent or recurrent episodic vaginal pain that is associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven vaginal infection or other obvious pathology.
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Scrotal pain syndrome is the occurrence of persistent or recurrent episodic scrotal pain that is associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven epididymoorchitis or other obvious pathology.
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Perineal pain syndrome is the occurrence of persistent or recurrent episodic perineal pain, which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious pathology. (NEW) 11
11 The ICS suggests that in men, the term prostatodynia (prostate pain) should not be used because it leads to confusion between a single symptom and a syndrome.
- •
Pelvic pain syndrome is the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel, or gynecological dysfunction. There is no proven infection or other obvious pathology. (NEW)
Symptom Syndromes Suggestive of Lower Urinary Tract Dysfunction
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.
Urgency, with or without urge incontinence, usually with frequency and nocturia, can be describe as the overactive bladder syndrome, urge syndrome, or urgency-frequency syndrome. (NEW)
These symptom combinations are suggestive of urodynamically demonstrable detrusor overactivity, but can be due to other forms of urethrovesical dysfunction. These terms can be used if there is no proven infection or other obvious pathology.
LUTS suggestive of bladder outlet obstruction is a term used when a man complains predominately of voiding symptoms in the absence of infection or obvious pathology other than possible causes of outlet obstruction. (NEW) 12
12 In women, voiding symptoms are usually thought to suggest detrusor underactivity rather than bladder outlet obstruction.
Signs Suggestive of LUTD
Measuring the Frequency, Severity, and Impact of Lower Urinary Tract Symptoms
Asking the patient to record micturitions and symptoms 13
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.
for a period of days provides invaluable information. The recording of micturition events can be in three main forms:- •
Micturition time chart : this records only the times of micturitions, day and night, for at least 24 h. (NEW)
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Frequency volume chart : this records the volumes voided as well as the time of each micturition, day and night, for at least 24 h. (CHANGED)
- •
Bladder diary : this records the times of micturitions and voided volumes, incontinence episodes, pad usage, and other information such as fluid intake, the degree of urgency, and the degree of incontinence. (NEW) 14
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-h period. If the individual eats significant quantities of water-containing foods (vegetables, fruits, 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.
The following measurements can be abstracted from frequency volume charts and bladder diaries:
- •
Daytime frequency is the number of voids recorded during waking hours and includes the last void before sleep and the first void after waking and rising in the morning. (NEW)
- •
Nocturia is the number of voids recorded during a night’s sleep: each void is preceded and followed by sleep. (NEW)
- •
24-h frequency is the total number of daytime voids and episodes of nocturia during a specified 24-h period. (NEW)
- •
24-h production is measured by collecting all urine for 24-h. (NEW)
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.
- •
Polyuria is defined as the measured production of more than 2.8 L of urine in 24 h in adults. It may be useful to look at output over shorter time frames ( ). (NEW) 15
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.
- •
Nocturnal urine volume is defined as the total volume of urine passed between the time the individual goes to bed with the intention of sleeping and the time of waking with the intention of rising. (NEW) Therefore, it excludes the last void before going to bed but includes the first void after rising in the morning.
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Nocturnal polyuria is present when an increased proportion of the 24-h output occurs at night (normally during the 8 h while the patient is in bed). (NEW) The nighttime urine output excludes the last void before sleep but includes the first void of the morning. 16
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% (>65 years) is produced at night. Hence the precise definition is dependent on age.
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Maximum voided volume is the largest volume of urine voided during a single micturition and is determined either from the frequency/volume chart or bladder diary. (NEW)
The maximum, mean, and minimum voided volumes over the period of recording may be stated. 17
17 The term “functional bladder capacity” is no longer recommended because “voided volume” is a clearer and less confusing term, particular 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.”
Physical Examination
Physical examination is essential in the assessment of all patients with LUTD. It should include abdominal, pelvic, perineal, and a focused neurological examination. For patients with possible neurogenic lower urinary tract dysfunction, a more extensive neurological examination is needed.
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
Perineal/Genital Inspection
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
- •
Urinary incontinence ( the sign ) is defined as urine leakage seen during examination: this may be urethral or extraurethral.
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Stress urinary incontinence is the observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing, or coughing. (CHANGED) 18
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.
Stress Leakage is presumed to be due to raised abdominal pressure.
- •
Extraurethral incontinence is defined as observation of urine leakage through channels other than the urethra. (ORIGINAL)
- •
Uncategorized incontinence is the observation of involuntary leakage that cannot be classified into one of the above categories on the basis of signs and symptoms. (NEW)
Vaginal Examination
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 the report ( ).
- •
Pelvic organ prolapse is defined as the descent of one or more of: the anterior vaginal wall, the posterior vaginal wall, and the apex of the vagina (cervix/uterus) or vault (cuff) after hysterectomy. Absence of prolapse is defined as stage 0 support; prolapse can be staged from stage I to stage IV. (NEW)
Pelvic organ prolapse can occur in association with urinary incontinence and other LUTD and may on occasion mask incontinence.
- •
Anterior vaginal wall prolapse is defined as descent of the anterior vagina so that the urethrovesical junction (a point 3 cm proximal to the external urinary meatus) or any anterior point proximal to this is less than 3 cm above the plane of the hymen. (CHANGED)
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Prolapse of the apical segment of the vagina is defined as any descent of the vaginal cuff scar (after hysterectomy) or cervix, below a point which is 2 cm less than the total vaginal length above the plane of the hymen. (CHANGED)
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Posterior vaginal wall prolapse is defined as any descent of the posterior vaginal wall so that a midline point on the posterior vaginal wall 3 cm above the level of the hymen or any posterior point proximal to this, is less than 3 cm above the plane of the hymen. (CHANGED)
Pelvic Floor Muscle Function
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
Rectal Examination
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 fecal impaction.
- •
Pelvic floor muscle function can be qualitatively defined, during rectal examination, by the tone at rest and the strength of a voluntary contraction, as strong, weak, or absent. (NEW)
Pad Testing
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-h pad test.
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