Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults

Abstract

Dysfunctional voiding (DV) is a voiding disorder characterized by dyssynergic striated sphincteric activity in the absence of a proven neurological etiology. It can present at any age with a spectrum of storage and voiding symptoms that may resemble florid neurogenic bladder. There is a striking lack of clarity regarding what this entity represents, the diagnostic methodology and treatment. The limitations of existing guideline documents are analyzed. Specifically, use of the term “habitual”, the assumption that bladder changes are secondary to the outlet, the emphasis on “staccato” voiding and the implication of striated urethral sphincter are discussed. Literature shows that DV may also present with continuous slow flow or normal flow. Dyssynergia may be at the level of the striated urethral sphincter, the pelvic floor or both, better termed “striated urethral sphincter-pelvic floor complex” (SUS-PFC).A diagnostic algorithm is provided so that patients are evaluated on merit rather than on the basis of different philosophies of individual centers. High-risk markers such as hydronephrosis, vesicoureteral reflux, renal failure or marked voiding difficulty should prompt a formal urodynamics evaluation and imaging for neurological etiology. Patients with predominantly storage symptoms with incidental staccato voiding can be managed initially, on the basis of non-invasive evaluation. Conservative urotherapy including biofeedback is appropriate initial management for patients without high risk factors. Treatment and evaluation should be escalated based on response. Patients with severe DV will need treatment similar to neurogenic bladder including clean intermittent catheterization and measures to control storage pressures.

Voiding Dysfunction

“…As discussed in a previous review, this author has made a case for modifying this defi nition to refl ect the two key components of dysfunctional voiding, namely, dyssynergia of the striated urethral sphincterpelvic fl oor complex and lack of a clear neurological etiology [ 6 ]. In a small but signifi cant proportion of these patients, neurological abnormalities may manifest subsequently [ 20 ].…”

“…In some women, this may help to resolve a "habitual" striated sphincter dyssynergia [ 32 ]. Alphaadrenergic blockers are usually not useful but can be tried in patients with safe voiding pressures [ 6 ]. Patients with very high voiding pressures can potentially damage their upper tracts and such patients should not be offered alpha-adrenergic blockers since it is unlikely to work and a more effective treatment option must be chosen.…”

“…10.5 ). Some women may have slow but non-staccato fl ow or even normal fl ow rates [ 6 ]. Hence, in suspected dysfunctional voiding, urodynamic evaluation is important for diagnosis and management.…”

“…Moreover, applicability of Western nomograms to Indian patients has pitfalls [ 5 ]. There are limitations to the ICS documentation for dysfunctional voiding [ 6 ]. Specifi cally, not all patients with dysfunctional voiding without an underlying neurological problem will show an intermittent fl ow and the terminologies documents need to make allowance for this fi nding.…”

“…Those patients with high-risk markers such as refl ux, hydronephrosis, marked voiding diffi culty, or renal dysfunction should undergo urodynamic evaluation at the outset [ 6 ]. Patients with primarily storage symptoms can undergo initial management based on urofl ow with surface electromyography recording.…”