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Voiding dysfunction due to detrusor underactivity: an overview

Nature Reviews Urology volume 11, pages 454–464 (2014)Cite this article

Subjects

Key Points

  • By default, the lower urinary tract is maintained in storage mode; voiding involves a sequence of behavioural and physiological steps, which permit passage of urine when safe and socially appropriate

  • Detrusor underactivity (DUA) represents a contraction of reduced strength and/or duration during voiding, resulting in prolonged bladder emptying and/or failure to completely empty the bladder within a normal timespan

  • Aetiological factors relevant to DUA include ageing, bladder outlet obstruction, denervation, and neurological disease

  • Urodynamic diagnostic approaches assess bladder pressures and urinary flow, or detrusor pressure changes upon interruption of voiding; generally, fluctuating, poorly sustained detrusor contraction and a low flow rate characterize DUA

  • Therapy is based on the presenting symptoms, with catheterization (usually intermittent) representing the mainstay treatment in symptomatic patients; pharmacological therapies are limited by low efficacy, adverse effects, and marginal quality-of-life improvements

  • Potential therapeutic strategies include attempts to increase detrusor contractility or modulate afferent nerve activity, but the development of new therapeutic options for DUA faces substantial challenges

Abstract

Detrusor underactivity (DUA) is defined as a voiding contraction of reduced strength and/or duration, which prolongs urination and/or prevents complete emptying of the bladder within a 'normal' period of time. This issue is associated with voiding and postmicturition urinary symptoms, and can predispose to urinary infections and acute urinary retention. The aetiology of DUA is influenced by multiple factors, including ageing, bladder outlet obstruction, neurological disease, and autonomic denervation. The true prevalence of this condition remains unknown, as most data come from referral populations. Urodynamic testing is used to diagnose the condition, either by assessing the relationship between bladder pressures and urinary flow, or by interrupting voiding to measure detrusor pressure change under isovolumetric conditions. Current treatments for DUA have poor efficacy and tolerability, and often fail to improve quality of life; muscarinic receptor agonists, in particular, have limited efficacy and frequent adverse effects. Bladder emptying might be achieved through Valsalva straining, and intermittent or indwelling catheterization, although sacral nerve stimulation can reduce dependency on catheterization. Novel stem-cell-based therapies have been attempted; however, new drugs that increase contractility are currently largely conceptual, and the complex pathophysiology of DUA, difficulty achieving organ specificity of treatment, the limited availability of animal models, and the subjective nature of current outcome measures must be addressed to facilitate the development of such agents.

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Figure 1: Results of an invasive urodynamic assessment in a patient with DUA.

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  1. Urology Department, University of Bristol and Bristol Urological Institute, Southmead Hospital, Bristol, BS10 5NB, Avon, UK

    Marcus J. Drake, Jonathan Williams & Dominika A. Bijos

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M.J.D. declares that he is advisory board member for Apogepha. M.J.D. is an advisory board member and has received speaker bureau and research support from Allergan, Astellas, Ferring, and Pfizer. J.W. and D.A.B. declare no competing interests.

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Drake, M., Williams, J. & Bijos, D. Voiding dysfunction due to detrusor underactivity: an overview. Nat Rev Urol 11, 454–464 (2014). https://doi.org/10.1038/nrurol.2014.156

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