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Underactive bladder

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Updated 2024 EAU guidelines for the management of underactive bladder.

Background

Overview

Definition
UAB, also known as detrusor underactivity, is characterized by reduced strength and/or duration of bladder contractions, leading to incomplete bladder emptying or prolonged urination.
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Pathophysiology
The pathophysiology of UAB is complex and involves both myogenic and neurogenic mechanisms. Myogenic failure refers to a dysfunction in the detrusor muscle, which is responsible for bladder contractions. Neurogenic mechanisms involve dysfunctions in the efferent and/or afferent nerves that control bladder function, as well as potential CNS dysfunction.
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Epidemiology
The prevalence of detrusor underactivity in elderly patients with bothersome LUTS is reported to be 25-48% in men and 12-24% in women.
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Disease course
Clinically, UAB is characterized by a slow urinary stream, hesitancy, and straining to void, leading to prolonged urination time with or without a feeling of incomplete bladder emptying. Storage LUTS, such as nocturia, are also common.
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Prognosis and risk of recurrence
The prognosis of UAB can vary widely, but it is generally a chronic and progressive condition. Complications such as urinary retention and UTIs can further impact the prognosis.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of underactive bladder are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024) and the European Association of Urology (EAU/EAUN 2024). ...
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Diagnostic investigations

History and physical examination: as per EAU/EAUN 2024 guidelines, elicit a complete medical history, including symptoms and comorbidities, and perform a focused physical examination in patients with LUTS.
A
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More topics in this section

  • Post-void residual volume

  • Urinary tract imaging

  • Urinalysis

  • Urinary biomarkers

Medical management

Alpha-blockers: as per EAU 2024 guidelines, offer α-blockers before more invasive techniques.
B

More topics in this section

  • Parasympathomimetics

Therapeutic procedures

Urinary catheterization
As per EAU 2024 guidelines:
Offer clean intermittent self-catheterization in male patients if there is risk of upper tract damage or post-void residual volume is > 300 mL.
B
Offer indwelling transurethral catheterization or suprapubic cystostomy in male patients only when other modalities for urinary drainage have failed or are unsuitable.
B

More topics in this section

  • Intravesical prostaglandins

  • Intravesical electrical stimulation

  • Botulinum toxin injections

  • Sacral neuromodulation

Surgical interventions

Detrusor myoplasty: as per EAU/EAUN 2024 guidelines, do not offer detrusor myoplasty routinely for the treatment of detrusor underactivity in female patients.
D

Patient education

General counseling
As per EAU/EAUN 2024 guidelines:
Encourage double voiding in patients unable to completely empty their bladder.
B
Counsel female patients with UAB using abdominal straining to improve emptying regarding the risk of pelvic organ prolapse.
B