Clinical history

Abstract

Medical training places great emphasis on the diagnostic value of careful symptom assessment. Such an evaluation forms a major part of any clinical consultation. However, on the whole, most contemporary reports claim few and weak relations between the presence of lower urinary tract symptoms (LUTS) and clinical measures such as urodynamics. Multiple studies have shown that bladder is an unreliable witness; urinary symptoms alone inaccurately reflect the cause of urinary tract dysfunction (1-4). For example, Jarvis et al. (4) compared the results of clinical and urodynamic diagnosis for 100 women presenting with LUTS. There was agreement between subjective and objective data in 68% of the cases of genuine stress incontinence, but only in 51% of cases of detrusor instability. Patients whose symptoms suggest pure stress incontinence will, on the urodynamic study, demonstrate detrusor instability 11-16% of the time (5,6), whereas up to 22% of women with filling symptoms will actually have pure genuine stress incontinence (4). We analyzed the relation between clinical symptoms and urodynamic data in a group of 267 women presenting in a urological clinic with LUTS. Of these 267 patients, 62 (23%) had pure genuine stress incontinence, and 45 had (17%) symptoms of urgency or of urge incontinence on a questionnaire, without a history of stress urinary incontinence (SUI). On subsequent multichannel urodynamic evaluation, among the 62 patients with genuine stress incontinence, 47 (76%) had stable bladders, and 15 (24%) had unstable bladder contractions during the filling phase of the study. In the group of 45 patients with symptoms suggesting bladder instability, but no SUI, only 29 (64%) had urodynamically proved unstable detrusor, and 16 (36%) showed stable bladder (Table 1). In spite of a “typical” history of detrusor instability, in one-third of the patients, no uninhibited contractions could be demonstrated.