Irritative voiding: Time to reconsider common tests?

San Diego-Two large studies have arrived at very different conclusions about the value of routine urine cytology and cystoscopy for evaluating women presenting with irritative voiding symptoms.

One study demonstrated a low incidence of abnormal findings, and investigators concluded that "routine use of urinary cytology and cystoscopy should be reconsidered" in the evaluation of women presenting with irritative voiding symptoms.

And although investigators in the second study found little correlation between microscopic hematuria and bladder cancer, they concluded that bladder cancer deserves consideration in women with unexplained irritative urinary tract symptoms, and that cystoscopy should continue to represent an essential diagnostic tool in the evaluation of such patients.

Low-yield tests?

The larger of the two studies examined 1,783 urine cytologies performed between 2000 and 2003 at a tertiary urogynecology clinic. The study was undertaken because of uncertainty surrounding the role of cytology and cystoscopy in the evaluation of women with irritative voiding symptoms, according to Eric Sokol, MD, a urogynecology and pelvic reconstructive surgery fellow at Brown University, Providence, RI.

"Urinary cytology and cystoscopy are commonly used in the initial evaluation of women with irritative voiding symptoms to aid in the detection of urinary tract malignancies," Dr. Sokol said. "They are standard diagnostic and monitoring tools for superficial bladder cancer. However, they might be low-yield tests in an unscreened population of women presenting with irritative voiding symptoms.

"Traditional teaching has implicitly advocated for the use of cytology and cystoscopy, but clinical recommendations are based largely on studies including men or in patients with gross hematuria. Algorithms to define the optimal approach to women presenting with irritative voiding symptoms are lacking."

Dr. Sokol reported findings from a subanalysis of 564 consecutive patients who had cytology and cystoscopy as part of the workup for irritative voiding symptoms. The analysis was undertaken to permit more efficient evaluation of cystoscopic outcomes.

Similar characteristics Irritative voiding symptoms were defined as urgency, pain or burning with urination, frequency, or nocturia. Overall 1,661 of the 1,783 cytology tests were normal. An additional 112 were atypical; seven (0.4%) were suspicious or malignant; and three were unsatisfactory for evaluation.

In the subanalysis, 516 of 564 cytologies were normal (91.5%), and 48 (8.5%) were atypical. No test yielded suspicious or malignant results.

Dr. Sokol said the subanalysis showed that women with and without abnormal cytology findings had similar demographic and clinical characteristics. The only factor that predicted abnormal results was dysuria (odds ratio: 3.41). Further analysis showed that 548 women (97.2%) had no underlying abnormalities.

The most common abnormality was cystitis, which was seen in 10 patients (1.8%). Three patients had suspicious bladder lesions, which were found to be benign on biopsy, and one each had bladder stones and diverticulum.

Only one patient had a tumor, but the tumor was not associated with atypical cytology. In fact, only two of 48 atypical results were associated with underlying abnormalities-cystitis in both cases.

"We have shown in our population of women with irritative voiding symptoms that high-risk abnormalities on urinary cytologic and cystoscopic testing are rare," Dr. Sokol said. "We believe that urinary cytology and cystoscopy are low-yield tests in the initial evaluation of women with irritative voiding symptoms, and their routine use should be reconsidered."

Cystoscopy indications The second study involved 1,584 women presenting with unexplained irritative voiding symptoms. The most common presenting symptom was nocturia (90.2%). Additionally, 23.7% of women had hematuria, including microscopic hematuria in 21.6%. About half of the women (47.5%) had a history of urologic surgery, and 10% had a history of previous malignancy.

"The underlying risk of cancer in this population of women with irritative voiding symptoms has not been previously defined," said Roger Goldberg, MD, a urogynecologist and pelvic reconstruction surgeon at the Evanston (IL) Continence Center. "Indications for cystoscopy certainly are not uniform."