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Dysfunctional Voiding

Editor: Tom Marcelissen, MD, PhD, Maastricht University Medical Centre

Current definition
The current term “dysfunctional voiding” was first used by Allen in 1977 [1]. This term has subsequently been adopted by the IUGA/ICS Joint Report on the Terminology for Female Pelvic Floor Dysfunction. The definition that exist now is here cited from the report: 'Dysfunctional voiding: This is characterized by an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated or levator muscles during voiding in neurologically normal women. This type of voiding may also be the result of an acontractile detrusor (abdominal voiding) with electromyography (EMG) or video-urodynamics required to distinguish between the two entities' [2].

Old definitions
In the previous century, a wide variety of terms have been used to describe individuals with detrusor-sphincter dyssynergia without in the absence of neurological disease. Table 1 gives an overview of some of the proposed terms.

Table 1. Previously used terms to describe dysfunctional voiding
Non-neurogenic neurogenic bladder
Hinman syndrome
Dysfunctional bladder
Idiopathic detrusor sphincter dyssynergia
Learned voiding dysfunction
Occult neuropathic bladder
Anxious bladder


Perspectives

In the literature, there appears to be a distinction between dysfunctional voiding in children and adults. In children, dysfunctional voiding is often associated with urinary incontinence, representing the main cause of incontinence in approximately 30% of individuals [4]. Nocturnal enuresis and urinary tract infections due to high post-void residual are also common manifestations. Furthermore, bowel dysfunction (constipation or fecal incontinence) is also strongly associated with dysfunctional voiding in children [5]. According to the International Childrens’ Continence Society (ICCS) dysfunctional voiding in a child is characterized by a habitual contraction of the urethral sphincter during voiding and should be confirmed by uroflowmetry (staccato voiding pattern) or urodynamics [5].

Adults typically present with voiding difficulty. Frequently, the diagnosis is done at a late stage mainly due to non-specific symptoms and lack of awareness. The objectives of treatment are to normalize micturition patterns and prevent complications such as renal failure and recurrent infections. Treatment should be started as early as possible and a multidisciplinary approach is beneficial. Table 2 provides an overview of urinary symptoms commonly associated with dysfunctional voiding. Table 3 shows the clinical signs of dysfunctional voiding during diagnostic evaluation.


Table 2. Urinary symptoms associated with dysfunctional voiding
Urgency ± increased frequency
Infrequent or poor bladder emptying
Incontinence during the day
Nighttime voiding dysfunction
Micturition that coincides with rises in abdominal activity



Table 3. Signs of dysfunctional voiding
Small bladder capacity
Increased detrusor thickness
Low detrusor contractility
Impaired relaxation of the external urinary sphincter during voiding
Weak or interrupted urinary stream
Large post-void residual volumes of urine
Faecal soiling
Secondary vesicoureteric reflux, constipation or obstipation

Controversies

There is a lack of clarity and consensus in the literature regarding what condition the term dysfunctional voiding represents. The term dysfunctional voiding implies that there is an impairment of normal voiding physiology. Yet, other causes of this impairment also include reduced bladder contractility. The current definition does not distinguish between these causes. Thus, strictly speaking, the disturbed voiding pattern is caused by dyssynergia of the striated muscles of the pelvic floor and/or urinary sphincter. Therefore, a more accurate definition would be: ‘impaired voiding due to pelvic floor dyssynergia’. Furthermore, there is no provision in the ICS document for describing a non-fluctuating slow flow due to pelvic floor dyssynergia in a neurologically intact individual. Perhaps the components “intermittent” and “fluctuating” should be removed from the ICS definition.

The exact pathogenesis of dysfunctional voiding remains unclear. As postulated by Sinha et al. [7], urinary patterns in adulthood may be the result of unrecognized childhood dysfunction. Also, in some patients it is conceivable that pelvic pain could be responsible for dysfunctional voiding. In these patients bladder pain might trigger a reflex contraction of the pelvic floor during voiding. Furthermore, in patients with Fowler syndrome, the increased urethral sphincter tone might be hormonally triggered. Hence, It is probable that the entity of ‘dysfunctional voiding’ is not homogenous and that there are several distinct etiologies that can lead to it [7]. The end result is one of a dyssynergic sphincteric activity in the absence of a clearly defined neurological reason.


References:

[1] Allen TD. Non-neurogenic neurogenic bladder. J Urol. 1977;177:232–8

[2] Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN; International Urogynecological Association; International Continence Society. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20. Review.

[3 ]'Dysfunctional voiding'; The (new) IUGA-ICS definition, is that a diagnosis and do we have a treatment? W17B, 29 August 2011

[4] Chiozza ML. Dysfunctional voiding. Ped Med Chir 2002; 24(2):137-40

[5] Nijman RJM, Bower W, Elsworth P, Tegkul S, Von Gontard A. diagnosis and management of urinary incontinence and encopresis in childhood. In : Abrams P, Cardozo L, Khoury s, Wein A, Eds. Incontinence. 3rd Edition. Plymouth: health Publication Ltd. 2005
[6] Chase J, Austin P, Hoebeke P, McKenna P. International Children's Continence Society. The management of dysfunctional voiding in children: A report from the Standardisation Committee of the International Children's Continence Society. J Urol. 2010;183:1296–302

[7] Sinha S. Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults. Indian J Urol. 2011 Oct-Dec; 27(4): 437–447.