EURURO-5646; No. of Pages 2 EUROPEAN UROLOGY XXX (2014) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Is a Voiding Diary Really Necessary in 2014? Christopher R. Chapple * Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Review of the functional urology literature demonstrates that it is not possible to effectively evaluate both male and female patients presenting with lower urinary tract symptoms (LUTS) without the use of a urinary diary. The paper by Bright et al. in this edition of the Platinum Journal documents the validation of such a bladder diary [1]. The important clinical information obtained from a bladder diary includes the volume of urine per void and its timing, coupled with other symptoms such as the frequency of episodes of urgency and incontinence. Other supporting evidence is important, such as pad usage; however, this measure can be difficult to interpret because the degree of incontinence is very subjective. Some people will change a pad when it is only slightly damp, whereas others tolerate greater fluid leakage. Assessment of fluid intake will document the type of fluid ingested and will provide information relevant to the volume voided, but it needs to be interpreted during discussion with the patient, particularly if he or she is consuming a high-fluid-content diet. ‘‘The bladder often proves to be an unreliable witness’’ is a phrase coined >30 yr ago in a comprehensive monograph that set the scene for modern functional urologic practice [2]. Review of the literature reveals early references to the use of a urinary diary [3,4]. Although the importance of the bladder diary was clearly recognised many years ago, it was not until the term prostatism was replaced by LUTS [5] that diary use was more widely accepted as important in the clinical management of both male and female patients. Since then, it has been accepted that the term LUTS should be a generic term applied to both men and women. This is supported by epidemiologic studies showing that the different categories of LUTS, namely, storage, voiding, and postmicturition, occur with similar prevalence in both men and women [6], despite very different anatomic and pathophysiologic conditions.
The European Association of Urology guidelines recommend that the accurate assessment of patients’ symptoms requires not only subjective interpretation but also objective quantification of LUTS using a urinary diary, optimally, for at least a 3-d period [1,7,8]. The importance of the psychometric validation approach used in the paper by Bright et al. is that it is the first clear evidence that a bladder diary is a valid and reliable measurement technique [1]. Given current consensus that it is not possible to effectively evaluate both male and female patients with LUTS and institute appropriate treatment without the use of a urinary diary, it is perhaps surprising that a diary has never been adequately validated prior to this publication. It may appear self-evident that the urinary diary is important for providing an accurate representation of the clinical symptoms, and one can cite other examples of ‘‘common sense’’ such as jumping out of an airplane without a parachute is dangerous and examining a patient is useful [8]. Symptom scores will not be accepted as accurate unless they have been validated, and even then, they are not diagnostic. LUTS are nonspecific and, even with a careful history, are dependent on patients’ interpretations of their experiences, their responses to questions, and the clinician’s own bias in interpreting the answers. In contrast, the urinary diary provides clear objective documentation of easily measurable events. A urinary diary is important for both male and female patients because storage symptoms are often the reason for presentation, even in male patients with LUTS thought to be related to benign prostatic hyperplasia causing bladder outlet obstruction. It is essential for the accurate assessment of the storage symptom complex of overactive bladder. Furthermore, bladder diary use will help determine the aetiology of nocturia (sleep-disturbing voiding) by
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2014.02.057. * Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield S10 2JF, UK. Tel./Fax: +44 1142797841. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2014.05.001 0302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Chapple CR. Is a Voiding Diary Really Necessary in 2014? Eur Urol (2014), http://dx.doi.org/ 10.1016/j.eururo.2014.05.001
EURURO-5646; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2014) XXX–XXX
documenting the volumes voided and hence the proportion of urine production at night after the patient has retired to bed. As emphasised in the International Continence Society standardisation of terminology [9], abnormally increased nocturnal polyuria is age dependent, with >20% of the 24-h production in younger patients and >33% in older patients, although age ranges are not specified. Increased nocturnal polyuria often is not due to lower urinary tract dysfunction, and clearly, it is not possible to identify this from a clinical history alone. A bladder diary is also required to evaluate the significance of postvoiding residual. Although there is no international consensus, a widely accepted threshold for a clinically significant residual is one that exceeds >40% of the functional capacity (functional capacity equals the voided volume plus residual). It is evident from this discussion that without measuring voided volumes and determining how representative these are over a 24-h cycle, it is not possible to accurately assess LUTS and response to therapy. The bladder diary also helps guide behavioural modification by providing biofeedback and identifying when the patient is drinking an excessive amount of fluid. Admittedly, it has proven difficult to demonstrate the therapeutic value of a bladder diary in facilitating bladder training and biofeedback in clinical trials, no doubt due to the significant ‘‘bladder training’’ inherent in the design and conduct of these studies. Although the voiding diary is recognised by major guidelines for its utility and effectiveness, it is regrettable that it is only a minority of patients, both male and female, who present with LUTS are routinely investigated with a urinary diary. Failure to use such a simple tool, as suggested by Bright et al. (Appendix 1) [1], may lead to costly, suboptimally evaluated diagnosis and treatment. A paperbased urinary diary has limitations; it may be difficult and time-consuming to interpret if the patient has not filled it out correctly or has used it in an idiosyncratic fashion. Future developments may improve the format and interpretation of
the urinary diary using electronic data capture, analysis, and interpretation [10]. Conflicts of interest: Dr. Chapple is a consultant for AMS, Lilly, and ONO and a consultant, researcher, and speaker and participates in trials for Allergan, Astellas, Pfizer, and Recordati.
References [1] Bright E, Cotterill N, Drake M, Abrams P. Developing and validating the International Consultation on Incontinence Questionnaire bladder diary. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo. 2014.02.057 [2] Turner Warwick RT. Clinical urodynamics: the beginning. Urol Clin North Am 1979;6:8–9. [3] Randolph MF, Greenfield M. Lower urinary tract obstruction in normal male children. Early detection by urinary diary. Am J Dis Child 1965;110:523–30. [4] Turner Warwick RT, Milroy E. Clinical urodynamics: a reappraisal of the value of routine urological procedures in the assessment of urodynamic function. Urol Clin North Am 1979;6:63–70. [5] Abrams P. New words for old: lower urinary tract symptoms for ‘‘prostatism’’. BMJ 1994;308:929–30. [6] Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006;50:1306–15. [7] Lucas MG, Bosch RJ, Burkhard FC, et al. EAU guidelines on surgical treatment of urinary incontinence. Eur Urol 2012;62:1118–29. [8] Abrams P, Cardozo L, Fall M, et al., Standardisation Sub-committee of the International Continence Society. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167–78. [9] Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003;327:1459–61. [10] Mangera A, Marzo A, Heron N, et al. Development of two electronic bladder diaries: a patient and healthcare professionals pilot study. Neurourol Urodyn. In press. http://dx.doi.org/10.1002/nau.22469
Please cite this article in press as: Chapple CR. Is a Voiding Diary Really Necessary in 2014? Eur Urol (2014), http://dx.doi.org/ 10.1016/j.eururo.2014.05.001
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Is a Voiding Diary Really Necessary in 2014? Christopher R. Chapple * Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Review of the functional urology literature demonstrates that it is not possible to effectively evaluate both male and female patients presenting with lower urinary tract symptoms (LUTS) without the use of a urinary diary. The paper by Bright et al. in this edition of the Platinum Journal documents the validation of such a bladder diary [1]. The important clinical information obtained from a bladder diary includes the volume of urine per void and its timing, coupled with other symptoms such as the frequency of episodes of urgency and incontinence. Other supporting evidence is important, such as pad usage; however, this measure can be difficult to interpret because the degree of incontinence is very subjective. Some people will change a pad when it is only slightly damp, whereas others tolerate greater fluid leakage. Assessment of fluid intake will document the type of fluid ingested and will provide information relevant to the volume voided, but it needs to be interpreted during discussion with the patient, particularly if he or she is consuming a high-fluid-content diet. ‘‘The bladder often proves to be an unreliable witness’’ is a phrase coined >30 yr ago in a comprehensive monograph that set the scene for modern functional urologic practice [2]. Review of the literature reveals early references to the use of a urinary diary [3,4]. Although the importance of the bladder diary was clearly recognised many years ago, it was not until the term prostatism was replaced by LUTS [5] that diary use was more widely accepted as important in the clinical management of both male and female patients. Since then, it has been accepted that the term LUTS should be a generic term applied to both men and women. This is supported by epidemiologic studies showing that the different categories of LUTS, namely, storage, voiding, and postmicturition, occur with similar prevalence in both men and women [6], despite very different anatomic and pathophysiologic conditions.
The European Association of Urology guidelines recommend that the accurate assessment of patients’ symptoms requires not only subjective interpretation but also objective quantification of LUTS using a urinary diary, optimally, for at least a 3-d period [1,7,8]. The importance of the psychometric validation approach used in the paper by Bright et al. is that it is the first clear evidence that a bladder diary is a valid and reliable measurement technique [1]. Given current consensus that it is not possible to effectively evaluate both male and female patients with LUTS and institute appropriate treatment without the use of a urinary diary, it is perhaps surprising that a diary has never been adequately validated prior to this publication. It may appear self-evident that the urinary diary is important for providing an accurate representation of the clinical symptoms, and one can cite other examples of ‘‘common sense’’ such as jumping out of an airplane without a parachute is dangerous and examining a patient is useful [8]. Symptom scores will not be accepted as accurate unless they have been validated, and even then, they are not diagnostic. LUTS are nonspecific and, even with a careful history, are dependent on patients’ interpretations of their experiences, their responses to questions, and the clinician’s own bias in interpreting the answers. In contrast, the urinary diary provides clear objective documentation of easily measurable events. A urinary diary is important for both male and female patients because storage symptoms are often the reason for presentation, even in male patients with LUTS thought to be related to benign prostatic hyperplasia causing bladder outlet obstruction. It is essential for the accurate assessment of the storage symptom complex of overactive bladder. Furthermore, bladder diary use will help determine the aetiology of nocturia (sleep-disturbing voiding) by
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2014.02.057. * Department of Urology, The Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield S10 2JF, UK. Tel./Fax: +44 1142797841. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2014.05.001 0302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Chapple CR. Is a Voiding Diary Really Necessary in 2014? Eur Urol (2014), http://dx.doi.org/ 10.1016/j.eururo.2014.05.001
EURURO-5646; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2014) XXX–XXX
documenting the volumes voided and hence the proportion of urine production at night after the patient has retired to bed. As emphasised in the International Continence Society standardisation of terminology [9], abnormally increased nocturnal polyuria is age dependent, with >20% of the 24-h production in younger patients and >33% in older patients, although age ranges are not specified. Increased nocturnal polyuria often is not due to lower urinary tract dysfunction, and clearly, it is not possible to identify this from a clinical history alone. A bladder diary is also required to evaluate the significance of postvoiding residual. Although there is no international consensus, a widely accepted threshold for a clinically significant residual is one that exceeds >40% of the functional capacity (functional capacity equals the voided volume plus residual). It is evident from this discussion that without measuring voided volumes and determining how representative these are over a 24-h cycle, it is not possible to accurately assess LUTS and response to therapy. The bladder diary also helps guide behavioural modification by providing biofeedback and identifying when the patient is drinking an excessive amount of fluid. Admittedly, it has proven difficult to demonstrate the therapeutic value of a bladder diary in facilitating bladder training and biofeedback in clinical trials, no doubt due to the significant ‘‘bladder training’’ inherent in the design and conduct of these studies. Although the voiding diary is recognised by major guidelines for its utility and effectiveness, it is regrettable that it is only a minority of patients, both male and female, who present with LUTS are routinely investigated with a urinary diary. Failure to use such a simple tool, as suggested by Bright et al. (Appendix 1) [1], may lead to costly, suboptimally evaluated diagnosis and treatment. A paperbased urinary diary has limitations; it may be difficult and time-consuming to interpret if the patient has not filled it out correctly or has used it in an idiosyncratic fashion. Future developments may improve the format and interpretation of
the urinary diary using electronic data capture, analysis, and interpretation [10]. Conflicts of interest: Dr. Chapple is a consultant for AMS, Lilly, and ONO and a consultant, researcher, and speaker and participates in trials for Allergan, Astellas, Pfizer, and Recordati.
References [1] Bright E, Cotterill N, Drake M, Abrams P. Developing and validating the International Consultation on Incontinence Questionnaire bladder diary. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo. 2014.02.057 [2] Turner Warwick RT. Clinical urodynamics: the beginning. Urol Clin North Am 1979;6:8–9. [3] Randolph MF, Greenfield M. Lower urinary tract obstruction in normal male children. Early detection by urinary diary. Am J Dis Child 1965;110:523–30. [4] Turner Warwick RT, Milroy E. Clinical urodynamics: a reappraisal of the value of routine urological procedures in the assessment of urodynamic function. Urol Clin North Am 1979;6:63–70. [5] Abrams P. New words for old: lower urinary tract symptoms for ‘‘prostatism’’. BMJ 1994;308:929–30. [6] Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006;50:1306–15. [7] Lucas MG, Bosch RJ, Burkhard FC, et al. EAU guidelines on surgical treatment of urinary incontinence. Eur Urol 2012;62:1118–29. [8] Abrams P, Cardozo L, Fall M, et al., Standardisation Sub-committee of the International Continence Society. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167–78. [9] Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003;327:1459–61. [10] Mangera A, Marzo A, Heron N, et al. Development of two electronic bladder diaries: a patient and healthcare professionals pilot study. Neurourol Urodyn. In press. http://dx.doi.org/10.1002/nau.22469
Please cite this article in press as: Chapple CR. Is a Voiding Diary Really Necessary in 2014? Eur Urol (2014), http://dx.doi.org/ 10.1016/j.eururo.2014.05.001
