Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment

Abstract

In Dysfunctional voiding, failure of the external sphincter-pelvic floor complex to relax during micturition results in bladder outflow obstruction with a spectrum of presentation from more benign lower urinary tract dysfunction including recurrent urinary tract infections, to significant upper tract pathology and end-stage renal failure. There is no underlying neurological or anatomical cause and the condition is postulated to be a largely learnt behavior. Diagnosis relies on non-invasive urodynamics and in particular uroflowmetry, plus or minus EMG, which is also used in biofeedback, the mainstay of treatment. The etiology, presentation, diagnosis, and treatment with particular emphasis on non-invasive urodynamics are covered.

Keywords: Dysfunctional voiding; Lower urinary tract dysfunction; Pelvic floor; Urinary tract infection; Uroflowmetry EMG.

Fig. 1

Normal co-ordinated voiding (left) with relaxation of external urethral sphincter and lower voiding detrusor pressure compared with dysfunctional voiding (right) with external sphincter contraction during voiding, dilatation of the proximal urethra (spinning top), detrusor hypertrophy and raised voiding detrusor pressure. Image courtesy of Mr. Massimo Garriboli

Fig. 2

Fluoroscopy showing spinning top urethra, trabeculation, and vesicoureteric reflux in dysfunctional voiding

Fig. 3

Uroflow curve patterns. a Bell-shaped (normal). b Tower-shaped (suggestive of overactive bladder). c Staccato-shaped (suggests dysfunctional voiding). d Interrupted-shaped (suggests underactive detrusor with abdominal straining). e Plateau-shaped (suggestive of static bladder outlet obstruction either anatomical or functional). Courtesy of ICCS (used with permission)

Fig. 4

Ten-year-old boy presenting with daytime urinary incontinence with production of four different uroflow curves in single morning demonstrating need for careful interpretation: a “I missed the funnel and then squeezed some out at the end”. b “It just jetted out” c “The nurse told me to do it all level “ d “Just normal”

Fig. 5

a Uroflow (Q ura) showing staccato-shaped curve caused by pelvic floor activity shown in EMG (pelvic): 9-year-old girl presenting with urinary incontinence and UTI. b Uroflow (Q ura) showing interrupted-shaped curve with minimal pelvic floor activity on EMG, classic of underactive voiding with abdominal straining: 13-year-old girl presenting with difficulties in voiding. c Uroflow (Q ura) showing plateau-shaped curve with significant pelvic floor activity and additional abdominal straining: 10-year-old boy with urinary retention. d Uroflow (Q ura) showing bell-shaped curve with accompanying pelvic floor activity and initial abdominal activity that then reduces: 11-year-old girl with difficulties in initiating and maintaining urinary stream

Fig. 6

Suggested treatment escalation for dysfunctional voiding in childhood (CIC, clean intermittent catheterization)

Fig. 7

a Correct toileting position. b Breathing in. c Breathing out with abdominal relaxation

Fig. 8

Improved uroflowmetry following simple correct toileting instructions given in outpatient appointment: a Fractionated/staccato initial void. b Tower/bell-shaped