title: The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review.
abstract: OBJECTIVE
  To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research.
  
  
  METHODS
  We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: 'detrusor underactivity', 'underactive bladder', 'post voiding residual', 'post micturition residual', 'acontractile bladder', 'detrusor failure', and 'detrusor areflexia'.
  
  
  RESULTS
  DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function.
  
  
  CONCLUSIONS
  Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.
authors.affiliation: Department of Urology, University of California Irvine, CA, USA; Department of Urology, Faculty of Medicine, Aswan University, Egypt.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Department of Urology, University of California Irvine, CA, USA.
authors.forename: Bilal
authors.initials: B
authors.lastname: Farhan
authors.affiliation: Department of Urology, University of California Irvine, CA, USA.
authors.forename: Simone
authors.initials: S
authors.lastname: Vernez
authors.affiliation: Department of Urology, University of California Irvine, CA, USA.
authors.forename: Gamal M
authors.initials: GM
authors.lastname: Ghoniem
keywords: BCI, bladder contractility index; Bladder outlet obstruction; CUR, chronic urinary retention; Chronic urinary retention; DHIC, detrusor hyperactivity with impaired contractility; DO, detrusor overactivity; DU, detrusor underactivity; Detrusor underactivity; ICS, International Continence Society; LinPURR, linear passive urethral resistance relation; OAB, overactive bladder; PVR, post-void residual urine; Pdet@Qmax, detrusor pressure at maximal flow; Qmax, maximum urinary flow rate; UDS, urodynamic study; Underactive bladder; Urodynamic