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Description and classification of lower urinary tract dysfunction and pelvic organ prolapse
Introduction
The purposes of any classification system are to facilitate understanding of disease etiology and pathophysiology, to help establish and standardize treatment and research guidelines, and to avoid confusion among those who are concerned with the problem. Classification systems for voiding disorders and pelvic organ prolapse have been based on various symptoms, as well as anatomic, radiographic, and urodynamic findings. This chapter reviews the classification of voiding dysfunction in women, as well as the differential diagnosis of urinary incontinence using up-to-date terminology from the International Continence Society (ICS). Pelvic organ prolapse terminology, quantitative assessment, and staging are also reviewed. Lastly, the ICS classification system of vaginal prostheses and graft complications is presented. It is hoped that the nomenclature used in these classification systems will become more widely understood and used, and that further research will be aimed at defining their clinical applicability.
Classification systems of lower urinary tract dysfunction
International continence society classification
In 1973 the ICS established a committee for the standardization of terminology of lower urinary tract function. Over the subsequent decades, reports from this committee and its subcommittees have been considered the gold standard in establishing terminology related to lower urinary tract function and dysfunction. In 2010, the ICS terminology for lower urinary tract dysfunction was updated and incorporated into a report on terminology for female pelvic floor dysfunction (published jointly by the International Urogynecological Association [IUGA] and the ICS). In 2018, more focused ICS terminology reports were published related to nocturnal lower urinary tract function and underactive bladder. Each report highlights the importance of basing diagnoses for pelvic floor disorders on the correlation between a woman’s symptoms, signs, and relevant diagnostic investigations. The following sections summarize terminology and classifications for female lower urinary tract dysfunction based on the 2010 IUGA/ICS report, as well as the ICS terminology updates from 2018.
The lower urinary tract is composed of the bladder and urethra, which work together as a functional unit to store and excrete urine. Symptoms, signs, urodynamic observations, and conditions are separate categories with unique but overlapping terminologies. Although a complete urodynamic investigation is not necessary for all symptomatic patients, some clinical or urodynamic assessment of the filling and voiding phases is essential for each patient. It is useful to examine bladder and urethral activity separately in each phase. If urodynamic studies are performed, results should clearly reflect the patient’s signs and symptoms.
Filling and storage phase.
The ICS classification of abnormalities of the storage and voiding phases is outlined in Box 8.1 and diagrammed in Fig. 8.1 . Cystometry measures the pressure/volume relationship of the bladder during filling and storage and assesses bladder function in terms of bladder sensation, detrusor activity, bladder capacity, and bladder compliance.
Box 8.1
The International Continence Society Classification of Lower Urinary Tract Dysfunction
I
Storage phase
- A.
Bladder function during storage
- 1.
Detrusor activity
- a.
Normal
- b.
Overactive
- a.
- 2.
Bladder sensation
- a.
Normal
- b.
Increased (oversensitivity)
- c.
Reduced
- d.
Absent
- e.
Nonspecific bladder sensations
- f.
Bladder pain
- g.
Urgency
- a.
- 3.
Bladder capacity
- 4.
Bladder compliance
- 1.
- B.
Urethral function during storage
- 1.
Normal
- 2.
Incompetent
- 3.
Urethral relaxation (instability)
- 1.
II
Voiding phase
- A.
Detrusor function during voiding
- 1.
Normal
- 2.
Abnormal
- a.
Underactive
- b.
Acontractile
- a.
- 1.
- B.
Urethral function during voiding
- 1.
Normal
- 2.
Abnormal
- a.
Bladder outlet obstruction
- b.
Dysfunctional voiding
- c.
Detrusor sphincter dyssynergia
- a.
- 1.
Detrusor activity may be normal or overactive. Overactive detrusor function is characterized by involuntary detrusor contractions during filling. These contractions may be spontaneous or provoked and cannot be suppressed completely. Overactive detrusor function in the absence of a known neurologic abnormality is called idiopathic detrusor overactivity, and overactivity caused by disturbance of the nervous control mechanisms is called neurogenic detrusor overactivity. These conditions are often associated with the symptom of urinary urgency. Urgency, with or without urgency incontinence, usually with frequency and nocturia in the absence of urinary tract infection or obvious pathology, is described as overactive bladder (urgency) syndrome. Terminology used to describe overactive bladder is provided in Box 8.2 .
Box 8.2
International Urogynecological Association/International Continence Society Terminology for Overactive Bladder
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