British Journal of Obstetrics and Gynaecology December 1991,Vol. 98,pp. 1287-1289
Sensory urgency: how full is your bladder? SARAH M. CREIGHTON, J. MALCOLM PEARCE, ISABEL ROBSON, KATHRYN WANG, STUART L. STANTON Abstract
Objective-To investigate whether women with sensory urgency have an abnormal perception of bladder fullness. Design-Prospective observational study. Setting-Urodynamic Unit, St George’s Hospital, London. Subjects-15 women with sensory urgency, 15 women with idiopathic detrusor instability and 15 without symptoms of frequency or urgency (control group). Interventions-All the women attended for cystometry. Each was asked to complete a visual analogue score of how full she perceived her bladder to be on a scale from 1 to 10. This was done before filling cystometry and at three times during bladder filling. At each time actual filled volume was noted. Main outcome measures-Maximum bladder capacity and individual perception of bladder fullness. Results-Women with sensory urgency and detrusor instability had similar maximum bladder capacity although values in both groups were significantly lower than in the control group; thus percentage of maximum bladder capacity was used for analysis. Linear regression was performed for each group of patients and a predicted visual analogue score at 25,50 and 75% of capacity calculated. These were compared between groups by rank analysis of variance. There was no significant difference between sensory urgency and detrusor instability. However, at 25, 50 and 75% of capacity, both groups had a significantly higher score than the control group. Conclusions-This abnormal perception would explain symptoms of frequency and urgency in these two groups. These results also confirm the similarity between detrusor instability and sensory urgency.
Sensory urge incontinence has been defined as involuntary loss of urine associated with a strong desire to void which is not due to uninhibited The Urodynamic Unit, Department of Obstetrics and Gynaecdogy, St George’s Hospital, Tooting, London
SW17 S. M. CREIGHTON Clinical Research Fellow J. M. PEARCE Consultant Gynaecologist I. ROBSON Urodynamic Nurse K. WANG Urodynamic Sister S. L. STANTON Consultant Gynaecologist Correspondence: S. M. Creighton, Registrar in Obstetrics and Gynaecology, King’s College Hospital, Denmark Hill. London SE5 9RS.
detrusor contractions and has been called a hypersensitivity dysfunction (International Continence Society 1990). Patients with sensory urgency have a history usually indistinguishable from those with detrusor instability but without the associated pressure rises on filling cystometry. The prevalence of sensory urgency in women attending urodynamic clinics has been estimated at 6% as compared with 31% for detrusor instability (Peattie et al., 1988). Sensory urgency is usually treated with the same drugs as detrusor instability. Its aetiology, like that of detrusor instability, is unknown and drug treatment is often unsuccessful. Behavioural methods such as bladder drill (Jarvis & Miller 1287
1288
S. M . Creighton et al.
1980), biofeedback (Cardozo et af. 1978; Peattie etal. 1988), psychotherapy (Macaulay 1988) and hypnosis (Freeman & Baxby 1982) have all been used. Success rates of over 80% were achieved in all these reports and this might imply an underlying psychological cause. Patients with anorexia nervosa have been shown to have a distorted body image. When asked to indicate their own perception of their body size, they have been shown to consistently over estimate (Slade et al. 1973). This study was designed to determine whether patients with sensory urgency have an analogous abnormal perception of bladder fullness.
All patients had a negative urine culture and frequency was determined with a urinary diary. The visual analogue scores for each patient were regressed against the percentage of maximum bladder capacity. The regression lines were used to predict the visual analogue score for each individual at 25, SO and 75% of maximum bladder capacity. These scores were then compared between groups by two way rank analysis of variance. It is not possible to simply record maximum bladder capacity and then repeat the cystometry asking each patient to record a visual analogue score at 25, 50 and 75% of maximum bladder volume, as the maximum cystometric capacity is believed to improve with repeated bladder filling.
Subjects and methods
All definitions and terms used are in accordance with the terminology developed by the International Continence Society (1990). All the women who attended the urodynamic unit for cystometry were asked to participate in the study. They were requested to attend with a comfortably full bladder and on arrival at the unit indicated their perception o f bladder fullness on a visual analogue scale from 0 to 10, with 0 as empty and 10 as full. They voided and the amount of urine passed (together with any residual urine) was recorded. Subtracted twin channel cystometry was performed with a filling rate of 100ml/min. Provocative measures such as cough and hand washing were used. The visual analogue scale was repeated at the first desire to void, at a random time during filling and at maximum desire to void. At each time the actual bladder volume was recorded as a percentage of maximum capacity. Following interpretation of cystometry, three groups were chosen for analysis. These were consecutive patients falling into one of three clearly defined diagnostic categories; 15 with a diagnosis of sensory urgency based on clinical history of frequency, urgency and urge incontinence and stable cystometry, 15 with frequency, urgency and urge incontinence and detrusor instability on cystometry and 15 with no complaints of frequency, urgency or urge incontinence and stable cystometry. This last group included women who were attending the unit with complaints of only stress incontinence. Symptoms of frequency and urgency were excluded in this group by a careful history and a urinary diary. They form the comparison group.
Results
A total of 4.5women were studied and their ages and parity are shown in Table 1. Although the patients were not matched, their clinical features are similar. The mean maximum bladder capacity of patients with sensory urgency and detrusor instability was similar at 376ml (SD 129ml) compared with 376 ml (SD 140 ml) (P = 0.98). The comparison group had significantly larger mean maximum bladder capacity than either of these groups at 475 ml (SD 83 ml) ( P ~ 0 . 0 1 )and so percentage of maximum bladder capacity was used for regression analysis. Linear regression adequately described the data for each woman; quadratic terms being insignificant at the 5”/0 level. There was no statistically significant difference in the mean visual analogue score at 25, 50 and 75% of maximum bladder capacity between the women with sensory urgency and those with detrusor instability (Fig. 1). Figure 1 demonstrates the predicted visual analogue score from all patients. There was no significant difference between those patients with sensory urgency and those with detrusor instability. However, at 25, SO and 75% Table 1. Agc and parity in the threc groups of women
investigated ~
Scnsory urgency
(n
= 15)
~~~
Detrusor Comparison group instability (n = 15) (n = 15)
Age (years) 48.4 (21-72) 51 (34-85) 46.2 (19-66) Parity 2.1 (0-4) 2-1 (W) 2.3 (0-7) Results arc mean (range) values.
Sensory urgency and bladder fullness 102! 9 8al 7 65-
*I
.
5 :
s
4-
5 3-
2
5
210-
CSUDI
CSUDI
I
I
CSUDI I
25%
50%
75%
Percentage of bladder capacity Fig. 1. Box and whisker plots of the predictcd visual analogue scorcs at 25, 50 and 75% of maximum cystometric capacity for women without complaints of urgcncy or frequency (C), those with sensory urgcncy (SU) and those with detrusor instability (Dl). Rank analysis of variance shows that womcn in group C had significantly lower perccption of bladdcr fullness (**P
Sensory urgency: how full is your bladder? SARAH M. CREIGHTON, J. MALCOLM PEARCE, ISABEL ROBSON, KATHRYN WANG, STUART L. STANTON Abstract
Objective-To investigate whether women with sensory urgency have an abnormal perception of bladder fullness. Design-Prospective observational study. Setting-Urodynamic Unit, St George’s Hospital, London. Subjects-15 women with sensory urgency, 15 women with idiopathic detrusor instability and 15 without symptoms of frequency or urgency (control group). Interventions-All the women attended for cystometry. Each was asked to complete a visual analogue score of how full she perceived her bladder to be on a scale from 1 to 10. This was done before filling cystometry and at three times during bladder filling. At each time actual filled volume was noted. Main outcome measures-Maximum bladder capacity and individual perception of bladder fullness. Results-Women with sensory urgency and detrusor instability had similar maximum bladder capacity although values in both groups were significantly lower than in the control group; thus percentage of maximum bladder capacity was used for analysis. Linear regression was performed for each group of patients and a predicted visual analogue score at 25,50 and 75% of capacity calculated. These were compared between groups by rank analysis of variance. There was no significant difference between sensory urgency and detrusor instability. However, at 25, 50 and 75% of capacity, both groups had a significantly higher score than the control group. Conclusions-This abnormal perception would explain symptoms of frequency and urgency in these two groups. These results also confirm the similarity between detrusor instability and sensory urgency.
Sensory urge incontinence has been defined as involuntary loss of urine associated with a strong desire to void which is not due to uninhibited The Urodynamic Unit, Department of Obstetrics and Gynaecdogy, St George’s Hospital, Tooting, London
SW17 S. M. CREIGHTON Clinical Research Fellow J. M. PEARCE Consultant Gynaecologist I. ROBSON Urodynamic Nurse K. WANG Urodynamic Sister S. L. STANTON Consultant Gynaecologist Correspondence: S. M. Creighton, Registrar in Obstetrics and Gynaecology, King’s College Hospital, Denmark Hill. London SE5 9RS.
detrusor contractions and has been called a hypersensitivity dysfunction (International Continence Society 1990). Patients with sensory urgency have a history usually indistinguishable from those with detrusor instability but without the associated pressure rises on filling cystometry. The prevalence of sensory urgency in women attending urodynamic clinics has been estimated at 6% as compared with 31% for detrusor instability (Peattie et al., 1988). Sensory urgency is usually treated with the same drugs as detrusor instability. Its aetiology, like that of detrusor instability, is unknown and drug treatment is often unsuccessful. Behavioural methods such as bladder drill (Jarvis & Miller 1287
1288
S. M . Creighton et al.
1980), biofeedback (Cardozo et af. 1978; Peattie etal. 1988), psychotherapy (Macaulay 1988) and hypnosis (Freeman & Baxby 1982) have all been used. Success rates of over 80% were achieved in all these reports and this might imply an underlying psychological cause. Patients with anorexia nervosa have been shown to have a distorted body image. When asked to indicate their own perception of their body size, they have been shown to consistently over estimate (Slade et al. 1973). This study was designed to determine whether patients with sensory urgency have an analogous abnormal perception of bladder fullness.
All patients had a negative urine culture and frequency was determined with a urinary diary. The visual analogue scores for each patient were regressed against the percentage of maximum bladder capacity. The regression lines were used to predict the visual analogue score for each individual at 25, SO and 75% of maximum bladder capacity. These scores were then compared between groups by two way rank analysis of variance. It is not possible to simply record maximum bladder capacity and then repeat the cystometry asking each patient to record a visual analogue score at 25, 50 and 75% of maximum bladder volume, as the maximum cystometric capacity is believed to improve with repeated bladder filling.
Subjects and methods
All definitions and terms used are in accordance with the terminology developed by the International Continence Society (1990). All the women who attended the urodynamic unit for cystometry were asked to participate in the study. They were requested to attend with a comfortably full bladder and on arrival at the unit indicated their perception o f bladder fullness on a visual analogue scale from 0 to 10, with 0 as empty and 10 as full. They voided and the amount of urine passed (together with any residual urine) was recorded. Subtracted twin channel cystometry was performed with a filling rate of 100ml/min. Provocative measures such as cough and hand washing were used. The visual analogue scale was repeated at the first desire to void, at a random time during filling and at maximum desire to void. At each time the actual bladder volume was recorded as a percentage of maximum capacity. Following interpretation of cystometry, three groups were chosen for analysis. These were consecutive patients falling into one of three clearly defined diagnostic categories; 15 with a diagnosis of sensory urgency based on clinical history of frequency, urgency and urge incontinence and stable cystometry, 15 with frequency, urgency and urge incontinence and detrusor instability on cystometry and 15 with no complaints of frequency, urgency or urge incontinence and stable cystometry. This last group included women who were attending the unit with complaints of only stress incontinence. Symptoms of frequency and urgency were excluded in this group by a careful history and a urinary diary. They form the comparison group.
Results
A total of 4.5women were studied and their ages and parity are shown in Table 1. Although the patients were not matched, their clinical features are similar. The mean maximum bladder capacity of patients with sensory urgency and detrusor instability was similar at 376ml (SD 129ml) compared with 376 ml (SD 140 ml) (P = 0.98). The comparison group had significantly larger mean maximum bladder capacity than either of these groups at 475 ml (SD 83 ml) ( P ~ 0 . 0 1 )and so percentage of maximum bladder capacity was used for regression analysis. Linear regression adequately described the data for each woman; quadratic terms being insignificant at the 5”/0 level. There was no statistically significant difference in the mean visual analogue score at 25, 50 and 75% of maximum bladder capacity between the women with sensory urgency and those with detrusor instability (Fig. 1). Figure 1 demonstrates the predicted visual analogue score from all patients. There was no significant difference between those patients with sensory urgency and those with detrusor instability. However, at 25, SO and 75% Table 1. Agc and parity in the threc groups of women
investigated ~
Scnsory urgency
(n
= 15)
~~~
Detrusor Comparison group instability (n = 15) (n = 15)
Age (years) 48.4 (21-72) 51 (34-85) 46.2 (19-66) Parity 2.1 (0-4) 2-1 (W) 2.3 (0-7) Results arc mean (range) values.
Sensory urgency and bladder fullness 102! 9 8al 7 65-
*I
.
5 :
s
4-
5 3-
2
5
210-
CSUDI
CSUDI
I
I
CSUDI I
25%
50%
75%
Percentage of bladder capacity Fig. 1. Box and whisker plots of the predictcd visual analogue scorcs at 25, 50 and 75% of maximum cystometric capacity for women without complaints of urgcncy or frequency (C), those with sensory urgcncy (SU) and those with detrusor instability (Dl). Rank analysis of variance shows that womcn in group C had significantly lower perccption of bladdcr fullness (**P
