International Continence Society 2002 terminology report: have urogynecological conditions (diagnoses) been overlooked?
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- Haylen, B.T. & Chetty, N. Int Urogynecol J (2007) 18: 373. doi:10.1007/s00192-006-0206-7
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A comparison of the 2002 International Continence Society (ICS) Terminology Standardization Report  with its predecessor  reveals obvious discrepancies and ambiguities in the former. Seriously affected is the urogynecology terminology for “conditions” (diagnoses). ICS terminology is currently used as a reference by the International Urogynecological Association, the American Urogynecological Society, the European Urogynecological Association and many other national urogynecological and gynecological groups.
In the earlier document , there are clear definitions for the conditions (some alternatively called dysfunctions, though still representing diagnoses). All of these required urodynamic investigations. They included genuine stress incontinence, detrusor instability and sensory urgency. Genuine stress incontinence and detrusor instability have been denoted in the Report  as having been replaced by the terms urodynamic stress incontinence and detrusor overactivity. These latter terms are called “urodynamic observations.” They are not referred to as a condition (diagnosis) that can be offered clinically to a patient.
In Section 3 of the 2002 Report  entitled “Urodynamic observations and conditions” and Section 4 entitled “Conditions,” there are only two mentions of the word “condition” in the text: (1) the possible connection of detrusoroveractivity to a neurological condition (Section 3.2.2) and (2) dysfunctional voiding in children (Section 3.3.4). The reader is at a loss as to what terminology might specifically qualify as a “condition” (diagnosis).
The authors of the Report  rejected entirely the term sensoryurgency, one with a predominantly urogynecological emphasis. They cited (Footnote 23, “reason” number 1) the frequently used comment in the Report  of a “lack of intuitive meaning.” “Intuitive” means “perceived by immediate insight” . One is less able to interpret such a comment in view of the overall difficulties elsewhere in Sections 3 and 4 of the Report . There is no clearly stated replacement terminology. An expanded critique on the ICS decision regarding sensoryurgency below will describe (1) prevalence figures of up to 13% of urogynecology patients and (2) a substantial academic usage over 25 years .
The other three most common urogynecological conditions (diagnoses; [4, 5]) are voidingdifficulty (based again on urodynamic findings), uterineand/orvaginalprolapse (based on clinical signs) and recurrenturinarytractinfections (based on history). No attempt was made in the Report  to include the terms voidingdifficulty or recurrenturinarytract infections.
The use of the term voiding difficulty dates back to at least 1975 , though it is yet to be formally acknowledged by the ICS. It was defined elsewhere in 1991  as “abnormally slow and/or incomplete micturition.” The criteria for its diagnosis are an abnormally slow urine flow rate and/or an abnormally high residual urine volume. Normal and abnormal figures for both parameters are available [8–10]. A cause of the voiding difficulty should desirably be determined by voiding cystometry. While prevalence rates for voiding difficulty up to 14%  were known at the time of preparation of the Report , a prevalence figure of firstly 24%  then another at 39%  have now been published. This diagnosis should be addressed in terminology.
Studies on recurrent urinary tract infections (UTIs) date back to at least 1966 . The term is poorly defined anywhere though the high prevalence of this condition among urogynecology patients needs acknowledgement. There is the difficulty of balancing the practical clinical definition and the scientific one. With a bias toward the former, a definition might be the presence of a certain number of (medically) documented UTI over a certain time. “Recur” strictly means to “occur again” or “be repeated” . Two or more UTI and three or more UTI (using this definition) in the previous 12 months were shown to occur with a prevalence of 21% and 13%, respectively .
Terminology for prolapse was developed for a separate 1996 terminology report . It was reconfirmed in a “simplified version” in the 2002 Report . Traditional terms such as prolapse, cystocele, rectocoele, enterocele (vaginal vault prolapse), which had a clear meaning to all gynecologists, were replaced by terms of four to eight words. While there is an argument that brevity and history (the term cystocoele  has been in use since at least 1807) are possible casualties of the changes, there have been significant advances in the accurate diagnosis of all types of prolapse.
The situation with male-oriented terminology in the Report  appears no easier. Closest to a “condition” or a “diagnosis” in Section 3 would be in bladder outflow obstruction (Section 3:3:4), where there is the word “diagnosed” mentioned.
How were the urogynecological “conditions” (diagnoses) overlooked?
These terminology issues may have arisen from the attempt to separate the new (additional) term “urodynamic observation” from the term “condition” ending up with no clear “conditions.” Whether this was an attempt to make ICS terminology compatible with the World Health Organization document InternationalClassification of Functioning, Disability and Health (ICIDH-2) and the InternationalClassification of Diseases (ICD-10) is uncertain, though the above separation is confusing and spurious. A “condition” is defined, in its first use, as the “presence of urodynamic observations associated with characteristic (undefined) symptoms or signs.” It is not possible to separate this from “urodynamic observation” defined as “observation made during urodynamic studies.” One would hardly perform urodynamics without some symptoms and/or signs. The former is not necessarily characteristic of the latter. The bladder is known to be an “unreliable witness” .
The second use of “condition” is defined as “non-urodynamic evidence of relevant pathological processes.” There are no further explanations or examples. There is a stated aim to “de-emphasize the necessity for urodynamic testing as other evidence or investigation might be useful in defining conditions.” Again, no further details are offered. One should make no apologies for demanding urodynamic investigations to confirm certain “conditions” (diagnoses). It is not an “egotistical” attitude . The whole scientific and clinical basis of the assessment and investigation of lower urinary tract symptoms to date has been to improve the accuracy of the diagnoses in order to recommend appropriate treatment. While this can happen with an improved understanding of symptoms and signs, giving rise perhaps to a “provisional diagnosis,” urodynamics remains the ultimate key complementary investigation to confirm this.
Is “condition” an appropriate term for medical use?
The term “condition” has been bracketed with “diagnosis” as the former term’s only possible clinical usage. The ICS 2002 Report  persisted with the use of “condition” as a key term, though it appears to actually have nomedical interpretation. Oxford, Black’s and Gould’s medical dictionaries have no definition for “condition”; Medline and Embase have no subject headings for “condition” (Drummond 2006, Biomedical Librarian, University of New South Wales, Sydney personal communication). One medical dictionary, with both terms included , gave no clinical interpretations for “condition,” while “diagnosis” clearly refers to “the determination of the nature of a disease; clinical: made from a study of the signs and symptoms of a disease; laboratory” (multiple options mentioned).
There is a strong argument that the word “condition” is not an appropriate term for medical use. It should be replaced by “diagnosis.”
A brief look at three urodynamically based urogynecological “conditions” (diagnoses) affected by this report will now be made. The old terminology will be listed first and the new terminology second.
Genuine stress incontinence—urodynamic stress incontinence
This is the least complicated and most understandable change. However, there is no indication as to whether urodynamic stress incontinence is a “urodynamic observation” or a “condition,” the latter a possible diagnosis. It is stated as the preferred term to genuine stress incontinence, a definite “condition” (diagnosis).
Detrusor instability (motor urgency)—detrusor overactivity
Detrusor overactivity is stated to be a “urodynamic observation.” To convert it to a “condition” requires, seemingly, the presence of “characteristic symptoms,” though there are none in the text immediately linked to this term. Do the prefacing terms idiopathic or neurogenic create a “condition,” one with no cause or a neurological cause? Three other variations have been introduced, phasic and terminal detrusoroveractivity and detrusor overactivity incontinence; these terms are perhaps more interesting to the urodynamicist than to the clinician.
The main issue of what is the “condition” (diagnosis) the clinician can present to a patient has been overlooked. Despite this, detrusor instability, a previous “condition” and three other terms in Section 3:2:2 “detrusor function during filling cystometry,” were again deemed to have “little intuitive meaning.” It was recommended that their use be abandoned.
Sensory urgency—(?) increased bladder sensation
The 2002 Report’s  dismissal of the term sensory urgency eliminates a previously defined “condition” (increased perceived bladder sensation during filling, an early first desire to void and low bladder capacity in the absence of recorded UTI or bladder overactivity [21, 22]). It has been applicable to between 10% [23, 24] and 13% urogynecology of patients , dating back a generation, since at least 1978 . There are at least 54 papers specifically on or including the diagnosis of sensory urgency . These papers involved 181 individual authors .
It has been demonstrated that sensory urgency and detrusor overactivity, both assumed here to be “conditions” (diagnoses), are part of the same spectrum of bladder dysfunction . The only differences in the clinical and urodynamic profiles of the two conditions are (1) a significantly higher prevalence of the symptom of urge incontinence and (2) by definition, abnormal detrusor contractions in women with detrusor overactivity. Women with sensory urgency are symptomatic, mainly with frequency, nocturia, urgency and some urge incontinence. Their lower urinary tract function is not normal.
Patients who already have the diagnosis of sensory urgency are at a significant disadvantage from the ICS Report . Macaulay et al.  suggest that they are more likely to have heightened anxiety and lower self-esteem. It is difficult to tell them that they really did not have the condition in the first place and/or that they now have no diagnosis. It is unlikely that they returned to “normal” in 2002. Academically, it could not be suggested that the 181 authors were writing about an imaginary diagnosis or one with “little intuitive meaning.”
Footnote 23 (“reason” number 2) of the Report  states further on sensory urgency that “it may be simplistic to relate urgency just to the presence or absence of detrusor overactivity when there is usually a concomitant fall in urethral pressure.” It is difficult to gain “immediate insight” into this explanation. No supportive details, evidence or references are provided.
The changed definition of urgency, “complaint of a sudden compelling desire to pass urine which is difficult to defer”
The new symptom of increasedbladder sensation, “the individual feels an early and persistent desire to void”
The newurgency–frequency syndrome, urge syndrome, or overactive bladder syndrome—“symptom combinations (urgency, with or without urge incontinence, usually with frequency and nocturia) suggestive of urodynamically demonstrable detrusor overactivity but can be due to other forms of urethrovesical dysfunction. These terms can be used if there is no proven infection or other obvious pathology.”
A newincreased bladder sensation (during filling cystometry)—“an early first sensation of bladder filling (or an early desire to void) and/or an early strong desire to void, which occurs at low bladder volume and which persists.”
It is suggested in footnote 22 that it is not possible to quantify “low bladder volume” in the definition of “increased bladder sensation.”
Sensory urgency is an important diagnosis for the practicing urogynecologist. Its summary dismissal disenfranchises a whole group of past, present and future women from having an additional workable urogynecological diagnosis and the treatment that might then ensue. It implies, by its action, that the past work of academics in this area is of no ongoing value. There is a need to refine the clarity of its definition for the advantage of those wishing to do research and those needing to treat the women with the diagnosis.
Terminology has scientific (presentations and publications), clinical and educational uses. It would appear that the use of ICS 2002  urogynecological terminology for presentations at its own forum has reached an impasse. ICS has chosen over recent years to strictly police anything other than the above terminology when used in a scientific abstract for its Annual Meeting. Such a policy under the current Report  is unsustainable when the new equivalents for the “conditions” (diagnoses) of genuine stress incontinence, detrusor instability and sensory urgency were recently unable to be provided by ICS officials.
In terms of scientific publications, one is unsure exactly what terminology to use, where one is reminded by ICS to qualify journal articles with the quote that “Methods, definitions and units conform to the standards recommended by the ICS, except where specifically noted.”
In everyday practice, the evidence above confirms that, with the exception of prolapse, clinicians in urogynecology have not been given a clear set of definitions for the most common “conditions” (diagnoses) they encounter, namely, urodynamic stress incontinence, detrusor overactivity, sensory urgency, voiding difficulty and recurrent urinary tract infections. In one way or another, they have been “overlooked.” The first two have ambiguous definitions as “urodynamic observations,” while the last three are either excluded or just not included in the Report .
The educational “fallout” from unclear terminology is significant. ICS has taken on the mantle of guiding world thinking in this area. It should be ever cognizant of its assumed mandate. Despite it being a serious scientific document, it should be possible for the presentation of lower urinary tract terminology to be more user-friendly. One should be able to interpret all sections without being an experienced urodynamic debater. Those at all levels of the healthcare chain will tend to “give up” on trying to learn urogynecological terminology if (1) “conditions” (diagnoses) are changed or eliminated without adequate justification and (2) clarity and brevity cannot be ensured. There should be a definite indication that a term is a “diagnosis” with the inappropriate term “condition” dropped.
The task of monitoring, maintaining and updating ICS terminology falls to the ICS Standardization Committee, the current composition of which (according to the ICS Web site) is seven urologists and one biomedical engineer. While one would not doubt the qualifications of any of these eminent academics to be on the Committee, there is a clear underrepresentation of clinical urogynecologists. It would be unfair to expect the committee of the latter subspecialty to make an informed judgement on terminology for bladder outflow obstruction in men. The Report’s  revision would demand involvement by clinicians who daily diagnose and treat all urogynecological “conditions” (diagnoses).
The different Urogynecological Associations and Societies might, however, need to take a view at some stage as to whether the Report  is actually “working” for them or if the time has been reached when they should coordinate to create their own Terminology Report for Urogynecology.