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.

Keywords: Dysfunctional voiding; International Children's Continence Society; International Continence Society; guidelines; staccato voiding; terminology; urodynamics; uroflow.

Figure 1

(a) Characteristic uroflow in dysfunctional voiding. A 10-year-old boy with daytime urinary incontinence, staccato voiding, elevated residual urine (60 ml) and no hydronephrosis, (b) Dysfunctional voiding in a 58-year-old woman with continuous slow flow and 140 ml residual urine without any underlying neurological etiology. The current guidelines make no provision for categorizing such patients

Figure 2

Triage for patients with dysfunctional voiding. *In patients with refractory non-neurogenic DV, two-thirds of patients will show abnormality on formal urodynamics[77]