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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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Risk factors
Several factors can contribute to the development of UAB, including aging, bladder outlet obstruction, diabetes mellitus, neurologic disorders, and nervous injury to the spinal cord, cauda equine, and peripheral pelvic nerve.
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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 2025) and the European Association of Urology (EAU/EAUN 2025).
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Diagnostic investigations
History and physical examination: as per EAU/EAUN 2025 guidelines, elicit a complete medical history, including symptoms and comorbidities, and perform a focused physical examination in patients with LUTS.
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Post-void residual volume
Urinary tract imaging
Urinalysis
Urinary biomarkers
Therapeutic procedures
Urinary catheterization
As per EAU 2025 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.
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Offer indwelling transurethral catheterization or suprapubic cystostomy in male patients only when other modalities for urinary drainage have failed or are unsuitable.
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