Current concepts in voiding dysfunction and dysfunctional voiding: A review from a urogynaecologist's perspective.

BACKGROUND: Female voiding dysfunction is a complex disorder, lacks definition, and is poorly understood and difficult to manage. CAUSES OF FEMALE VOIDING DYSFUNCTION: As there is no agreed classification of female voiding dysfunction, it is important to identify the several potential factors that might cause voiding dysfunction, namely anatomic, neurogenic, pharmacologic, endocrine, pharmacological and other causes. PRESENTATION AND CLINICAL EVALUATION: Traditional and novel techniques are available and the importance and diagnostic dilemma related to these conditions need to be understood. We conclude by emphasizing the need to simplify the diagnosis and nomenclature of these conditions from a more clinical point of view as against an investigational perspective.

BACKGROUND AND DEFINITIONS

Female voiding dysfunction (VD) is a complex disorder, lacks definition, and is poorly understood and difficult to manage.[1] This narrative review attempts to address within the constraints of the controversies surrounding this area, what is considered normal voiding function and what can be considered voiding dysfunction in females, its causes and management and new clinical approaches to it. There is consensus that there is no agreed classification for female voiding dysfunction,[1] however, all voiding dysfunctions can be pragmatically classified as either a failure to fill or store urine in the bladder or failure of the bladder to empty. The International Continence Society (ICS) states that: ‘Normal voiding is achieved by a voluntarily initiated continuous detrusor contraction that leads to complete bladder emptying within a normal time span and in the absence of obstruction’.[2]

‘Voiding dysfunction’ (VD) a diagnosis by symptoms and urodynamic investigations is defined by ICS/IUGA as abnormally slow and/or incomplete micturition. Abnormal slow urine flow rates and abnormally high post void residuals, the basis of this diagnosis.[234] This diagnosis should be based on a repeated measurement to confirm abnormality. Stanton et al., (1983) defined these measures as peak flow rates of < 15 ml/second and/or 200 ml or more of residual urine.[234] However, residual volume of urine needs to be considered in conjunction with bladder capacity, patient's symptoms and renal function.[3] Beer first described voiding difficulty, recurrent infections and sphincteric incoordination in 1915.[5] Over the subsequent century a bewildering array of terms has been used to describe individuals with external sphincter dyssynergia in the absence of a neurological diagnosis. The current term “dysfunctional voiding” (DV) was first used by Allen in 1977.[6] This term has subsequently been adopted by several standardization documents. The ICS defines DV as “intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated muscle during voiding in neurologically normal individuals”.[2] However, there is no provision in the ICS document for describing a non-fluctuating slow flow due to dyssynergia in a neurologically intact person. Also, while the document specifies that the fluctuating flow should be due to contractions of the periurethral striated muscle, needle electromyography that can show activity of this muscle is not commonly employed in most urodynamics laboratories. Also, there is literature to show that DV may occur due to either striated sphincter dyssynergia, pelvic floor dyssynergia or both. Hence, it might be preferable to replace the term “periurethral striated muscle” with “striated urethral sphincter-pelvic floor complex (SUS-PFC)”.[1]

It is suggested that the terms “habitual”, “periurethral striated muscle”, “intermittent” and “fluctuating” be dropped. Instead, the definition should reflect two key diagnostic components, dyssynergic SUS-PFC and lack of a clear neurological etiology. This is in line with the urological community's move away from labels with etiological or syndromic connotations such as “automatic bladder” or “obstructive voiding”. Any dyssynergia irrespective of whether the flow is continuous, intermittent or staccato should be included in this definition. It should be clearly recognized that a revised diagnosis of detrusor sphincter dyssynergia would be made in case a neurological problem were to surface subsequently. While some of the female adults with DV represent children who grew up with an unaddressed voiding problem, many patients completely deny the existence of voiding symptoms in their childhood which leads to the speculation that it might be a learnt behavior in adulthood.[7] Also, abnormal sphincteric behavior is commoner in women who had vesicoureteral reflux in childhood. In some women, urinary patterns in adulthood may be the result of unrecognized childhood dysfunction. In some patients it is conceivable that pelvic pain could be responsible for DV.

PROBLEM STATEMENT

The true estimate of DV in the general population is not known. Reported population estimates of DV are based on questionable methodology. A wide variation from 4.2-46.4% has been reported depending on the definition used and the methodology adopted[234] and the result of lack of definition for diagnosis of female voiding dysfunction.[911] This underlines the need for more reviews and research in this area. The highest figure in this data was derived from a population survey with indistinct definitions in South Korea of 19,240 children.[8] Groutz found an equal prevalence in men and women with a mean age was 44.9 years in men and 51.5 years in women.[9] Prevalence of bladder or urethral obstruction is unknown,[911] but several authors[9111213] have reported higher incidences of detrusor underactivity than bladder outlet obstruction among neurologically healthy women who experience voiding problems. More recently, Nitti et al.,[14] reported that 23% of females in their study were classified as having bladder outflow obstruction, leading to dysfunctional voiding. In a review of video urodynamic studies, Groutz et al., (2000) observed the incidence of voiding dysfunction as 2% with half of these females having genital prolapse repair and previous surgery for continence-related problems.[910] In a more recent study, Carlson et al., (2001) reported a 12% incidence of female voiding dysfunction.[15]

CAUSES OF FEMALE VOIDING DYSFUNCTION

The ICS has suggested that voiding dysfunction may have either bladder or urethral causes.[2]

Primarily bladder causes

Underactivity or arreflexia of the detrusor muscle results in the build up of residual volumes of urine. Sensation in the bladder may or may not be present. Frequency is a common symptom if sensation is present, as only a small proportion of the bladder volume is used. Weakness of the detrusor muscle can be linked to damage of the peripheral nerves of the bladder as in diabetic neuropathy or damage caused to the lower spinal cord. There is some evidence that the detrusor muscle degenerates with age,[19] which may affect the detrusor's ability to maintain a sustained contraction to complete bladder emptying. Bladder over-distension can lead to impaired detrusor contractility through ischemic and neuropathic damage to the bladder wall,[91118] thus resulting in voiding dysfunction. Acute urinary retention in females can lead to over-distension of the bladder, especially if it remains untreated. Causes of urinary retention in females may be attributed to chronic constipation, childbirth (including labor and delivery), spinal anesthesia, neurological disease, uterine fibroids, ovarian cysts or anticholinergic and/or psychotropic medication.

Urethral causes

Olujide and O'Sullivan[1] describe intrinsic and extrinsic causes of urethral blockage that can cause voiding difficulties in females. Urethral stenosis can arise as a result of scar tissue that has been caused by urethral catheterization or instrumentation, such as cystoscopy or urethral dilation, inflammation, infection or urethral injury. Urethral diverticulae are an important cause of voiding dysfunction as they cause urethral compression, which can lead to urinary retention. However, urethral diverticulae are difficult to diagnose, relying on thorough digital vaginal examination and possible further investigation such as cystoscopy. Urethral narrowing caused by atrophy of urogenital tissue in the older female and urethral caruncles (benign lesions) may lead to voiding dysfunction.

Neurogenic causes

Patients with neurological disorders, such as multiple sclerosis (MS) or spinal cord problems, can present with voiding dysfunction. More than 80% of patients with MS have urinary dysfunction and this increases to 96% when the duration of the disease is more than 10 years.[25] Many of these females have chronic voiding problems leading to urinary retention. Loss of inhibitory function can lead to hyperreflexia and loss of voluntary control, which can result in loss of co-ordination of the detrusor and voiding pattern. Detrusor sphincter dyssynergia is common in this group of females.

Pharmacological causes

Several types of medication are known to contribute to or cause voiding dysfunction.[1] These include:

Antipsychotics, for example, chlorpromazine.

Anticholinergics, for example, oxybutynin.

Antidepressants, for example, amitriptyline.

Anti-parkinsonian drugs, for example, selegiline hydrochloride.

Opiates, for example, morphine.

Antihistamines, for example, promethazine, trimeprazine.

Decongestants, for example, pseudoephedrine.

Anticholinergics interfere with the release and action of acetylcholine in the bladder neuromuscular junctions, while adrenergic agonists increase urethral resistance and can lead to either incomplete bladder emptying or urinary retention.

Endocrine causes

Diabetes mellitus is the most common endocrine disorder that affects bladder or voiding function. Diabetes is known to cause peripheral neuropathy, which affects bladder contractility leading to urinary retention or incomplete bladder emptying. Hypothyroidism can affect the bladder in a similar way.[26]

Psychological causes

Psychological problems have been known to affect voiding function. A number of factors have been identified and include[27] :

Depression.

Stress.

Marital problems.

Bullying in childhood.

Physical and/or psychological abuse.

Schizophrenia.

Idiopathic causes

Poor bladder training during childhood can result in the development of poor voiding habits, as can learned behavior from parents or peers. Bellina et al.,[28] have suggested that individuals who work long hours and do not void regularly during this time are more likely to have voiding dysfunction. Females who have dementia, as in Alzheimer's disease, may experience voiding dysfunction. Frontal lobe changes in the brain can impair decision making, which can change behavior and lead to inappropriate voiding or lack of recognition of the need to void, resulting in urinary retention. Temporal lobe changes impair memory — the patient may not recognize a toilet or what it is used for and may not remember how to initiate voiding. The patient therefore cannot learn new skills to promote voiding.

Other urogynaecological conditions and procedures as causes

Genital organ prolapse may cause urethral kinking, leading to bladder outlet obstruction. While it has been reported in the literature that voiding dysfunction secondary to prolapse occurs,[22] it does not mean that all females presenting with genital organ prolapse will have voiding dysfunction. Surgery for prolapse repair and/or incontinence can lead to voiding dysfunction. While botulinum toxins (Botox®) A and B have been used successfully in the management of females with voiding dysfunction,[23] one of the side effects of this procedure can be continued voiding dysfunction, especially urinary retention. Wang et al., (2002) identified several risk factors that contribute to post-operative voiding dysfunction. Risk factors for post-operative voiding dysfunction[24] :

Age over 65 years.

Additional surgical procedures.

Type of surgical procedure.

Post-operative cystitis.

Pre-operative acontractile bladder.

Excessive elevation of the bladder neck.

Menopausal status.

Abnormal pre-operative voiding studies.

Pre-operative enterocoele or vault prolapse.

Any anti-incontinence procedure can result in edema, urinary infection, kinking or compression of the urethra. This may lead to acute short-term or long-term VD. The latter is usually the result of detrusor hypotonia secondary to a distension injury, or rarely fibrosis and stricture of the urethra resulting in outflow obstruction. With the tension free vaginal tape (TVT) and comparable mid-urethral retropubic or transobturator slings, VD may also result from misplacement or over-tensioning of the device.[24] The incidence of VD varies between procedures ranging from 1.2-24%. The average reported rate is 12.5% (range 3%-32%) following colposuspension. In contrast, the reported rate following TVT ranges from 3%-15%.[24] Anterior compartment surgery can also lead to VD, particularly where there has been excessive elevation of the bladder neck, edema, or hematoma of the bladder base. The risk of VD is also increased with postoperative UTI following prolapse or incontinence surgery. Other factors include age and menopausal status, additional surgical procedures and abnormal preoperative voiding parameters. Pelvic surgery may result in VD secondary to neurogenic injury of the bladder or to severe postoperative pain.[24]

Miscellaneous

While neurological or spinal diseases and/or trauma are known to cause voiding dysfunction, Carlson et al.,[15] have suggested that voiding dysfunction in neurologically healthy individuals ‘is an abnormality of bladder emptying where there is failure of the external sphincter to relax during voiding’ more like a learned behavior, in response to an adverse event or condition and is different to detrusor sphincter dyssynergia, which is the result of neurological injury or disease. Some investigators have tried differentiating between pelvic floor dyssynergia and striated urethral sphincter dyssynergia.[1516171819] In a study of 15 women with DV and retention (mean age 38.2 years) Deindl found inappropriate pelvic floor muscle relaxation in 11 and external urethral sphincter activation during voiding in four.[20] Biofeedback training was effective only in women with pelvic floor (pubococcygeus) activation thus having prognostic implications. Young women presenting with urinary retention have been described to have increased urethral sphincter tone which might be hormonally triggered. Such women may have polycystic ovarian disease. They are typically between the age of 15-30 years and have increased sphincter volume and concentric needle EMG demonstration of abnormal decelerating bursts and complex repetitive discharges. This has been labeled the Fowler Syndrome.

Fowler's syndrome has been described as: ‘A primary disorder of the external urethral sphincter with hypertrophy of the muscle fibres, which fail to relax during micturition, resulting in voiding difficulties’.[1] Females with Fowler's syndrome are typically between 15-30 years of age and present with the following[21] :

No urgency.

Residual volume of greater than 1,000 ml.

No evidence of urological or neurological disease.

Polycystic ovaries.

Hirsute with associated acne.

Menstrual irregularities.

Straining to void, which does not assist with bladder emptying.

Events such as childbirth, gynecological procedures, other surgical procedures or acute medical conditions may precede an episode of retention if the other signs and symptoms are present.

Investigations to confirm Fowler's syndrome include:

Raised urethral pressure profile

Increased sphincter volume on ultrasound

Electromyography recordings with a needle electrode inserted into the striated muscle fiber of the urethra, which show abnormal transmission of the electrical discharges resulting in ‘whale noises’

Fowler's syndrome is difficult to treat, although there is good evidence to suggest that sacral neuromodulation is an effective treatment.[21] Hinman syndrome is a functional, non-neurogenic neurogenic bladder outletdisorder, which Groutz et al.,[91118] described as: ‘Voluntary contraction of the external urethral sphincter during micturition leading to voiding dysfunction’. They found this syndrome in 2% of females referred for video urodynamic evaluation of lower urinary tract symptoms. They refer to this voiding problem as ‘acquired voiding dysfunction’. Hinman (1986) suggests that this voiding disorder is caused by learned behavior, which can be reversed with re-educational therapy.[91118] Groutz et al., report that there are some clinic al and urodynamic diagnostic criteria which may be used to establish a diagnosis.[91118]

Clinical evidence may include:

Clinical history of lower urinary tract symptoms, difficulty voiding in public places, having to relax, concentrate, touch genitals during voiding or listen to running water.

Intermittent normal voiding pattern.

Exclusion of neurological disorders or anatomical causes of bladder outlet obstruction.

A definitive diagnosis can be made with either fluoroscopic visualization of the urethra during voiding using radio opaque contrast or with needle electromyography demonstrating external urethral sphincter contractions during micturition. The typical picture presented shows a dilated urethra to the level of the external sphincter with the bladder neck open. This distinguishes dysfunctional voiding from primary bladder neck obstruction.[91118] A higher than expected association of idiopathic hypercalciuria, ranging from 21-30%, has been noted in children with DV syndromes. However, almost all responded to behavioral therapy, dietary modifications and anticholinergics and treatment specifically directed at hypercalciuria was needed in only 2%. The reason for an association between hypercalciuria and DV remains unclear. The authors postulated that calcium microcrystallization may cause injury to the urothelium and this could trigger a variety of urinary symptoms including DV. It is probable that the entity DV is not homogenous and that there are several distinct etiologies that can lead to it. The end result is one of a dyssynergic sphincteric activity in the absence of a clearly defined neurological reason.

PRESENTATION AND CLINICAL EVALUATION

Patients present with a history of voiding difficulty or unexplained retention. Patients might have difficulty in initiating a void in public places, or might need physical or mental cues to void, such as the sound of running water or the need to ‘deliberately’ relax themselves. Storage symptoms are common and may be the only presenting symptom. Frequency and urgency was found in 94%, urge incontinence in 43%, voiding difficulty in 54% and urinary retention in 9%. Patients with DV have been considered to be at risk for urinary tract infection (UTI), although a recent study has disputed this premise.[9111829] The history is directed towards an assessment of the type of urinary symptom, the severity of bother, the health and integrity of the urinary tract. All medical history should be elicited. Medication history should be noted. Bowel habits and fluid intake and type should be interrogated. An assessment of desire for treatment alternatives should be considered clinical examination must include an assessment of higher mental functions and their age-appropriateness, basic neurological evaluation including back and spine and a focused neuro-urological examination over and above the routine physical examination which includes abdomen, genitalia, perineum to identify prolapse, digital vaginal assessment and digital rectal examination (if indicated) to exclude fecal impaction. Observation of patient's gait, mobility and dexterity is important.

Ancillary clinical tools

Frequency and volume charts (bladder diary) can be used to record objective data regarding fluid intake, frequency of voiding, volumes of urine voided and incontinence episodes. Keeping this diary for three days is recommended, including work and leisure time. It is important to be aware that in cases of chronic urinary retention, the diary may demonstrate normal functional bladder capacity, despite the presence of voiding difficulty symptoms as discussed above. Urinary tract infection (UTI) has been associated with voiding dysfunction and Carlson et al., (2001) report a prevalence of 42% in females with a history of UTI.[1529] Urinalysis using the dipstick method should be used in the first instance, with a midstream urine specimen sent for microscopy, sensitivity and culture if dipstick is positive in the presence of symptoms. A portable bladder scanner to measure residual volume should be used routinely as part of the initial assessment.

Invasive Evaluation

Urodynamics testing

In females with voiding difficulties the voiding pattern will appear interrupted; there is no peak as in the normal ‘bell shape’. However, measurement of flow rate alone cannot distinguish between poor detrusor function and outlet obstruction and further investigation using pressure flow studies may be warranted. When combined with EMG or fluoroscopy, increased SUS-PFC activity can be noted. There is sporadic increase-decrease in the EMG activity. Such observations have classically been made on needle EMG and may be more difficult to identify on surface EMG. Pressure: Flow studies on voiding cystometry are indicated to evaluate the cause of any voiding dysfunction including detrusor underactivity and acontractile detrusor; Urethral function can be assessed during Voiding Cystometry to diagnose bladder outflow obstruction. Kuo differentiated between pelvic floor obstruction and dyssynergic urethral sphincter on video urodynamics and found dyssynergic sphincter in one-fourth and dysyynergic pelvic floor in half of their patients. Both were grouped as DV.[30] The data on video urodynamics suffers from marked recruitment bias and remains poorly standardized. There is little data on what degree of dilatation should serve as a cut-off for abnormality. While video can help in making the diagnosis in individual patients, we need to wait for better quality data before it can be included in the diagnostic algorithm. Glassberg has made a case for using uroflow with EMG as a middle path between the “impressionist” approach of doing minimal tests and a uroflow and the “purist” approach of doing detailed evaluation including a urodynamics evaluation for all patients which is considered the traditional gold standard.[31]

Perineal Ultrasonography can also be used to evaluate paradoxical pelvic floor movement similar to seen in children with VD.

Cystoscopy

No cystoscopic finding is diagnostic of DV. In patients with suspicion of anatomical abnormalities of the lower urinary tract, a diagnostic cystoscopy may be performed and routine diagnostic cystoscopy is not recommended.

Why is the clinical entity of VD important

Voiding dysfunction can lead to decompensation of proximal urinary tract and vesico-ureteral reflux and apart from that is a major cause of bother and reason for poor quality of life scores after successful pelvic floor surgery. In our population, we needed to detect voiding difficulties because among SUI women both these causes of voiding disorders can promote obstructive complications after surgery. Park and Hong et al., showed that the best predictive factor for obstructive complications after pelvic floor surgery was the maximum flow rate, with which it was shown to be directly correlated.[33] It is thus important to screen women suffering from SUI for emptying symptoms before such surgery. The historical concerns regarding causality of VD in UTI seems disputed, however the two are associated. Failure to identify a chronically filled bladder may lead to bladder injuries during abdominal, pelvic floor or laparoscopic surgeries.

The diagnostic dilemma

Thus we see that we do know about the epidemiological associations of voiding dysfunction; but even the most reliable of all tests for its diagnosis that is urodynamics, lacks standard patterns and reproducibility. Bladder diaries are often omitted due to patient and physician burden and more than one-third of physicians fail to utilize bladder diaries in their evaluation of urinary incontinence. Similarly, patient compliance for recording voided volumes in clinical practice is also low and “diary fatigue” can result in incomplete and inaccurate data. The Questionnaire-Based Voiding Diary (QVD) is a self-administered instrument that can be completed at the initial office visit in 5-7 min and is designed to obtain information that is typically collected through a 48-hr voiding diary.[32] The instrument collects data in four subscales, fluid intake, output, fluid intake behavior, and urinary output. The instrument has excellent reproducibility and construct validity for measuring the type and volume of total fluid intake and different beverages as compared to the bladder diary. The correlation between obstructive symptoms and objective urodynamic findings is known to be poor, but has never been studied in this specific population of SUI women, for which all cases with a POP-Q > Stage 1, previous surgery for SUI, or neurological disorders, were excluded.[34] Wyndaele et al., recently confirmed the poor correlation between symptoms and urodynamic data, and a high prevalence of VD in women, whether it be considered to have a pathological origin or not.[35] The absence of voiding symptoms is not a guarantee of normal micturition, and almost one-third of the women not complaining of any voiding difficulty were actually shown to have an abnormal uroflowmetry. Previous studies have clearly demonstrated the lack of correlation between symptoms and urodynamic diagnoses, especially for obstructive symptoms.

A NEWER AND SIMPLER APPROACH FROM WHAT WE ALREADY KNOW ABOUT VD

The functional classification system proposed and popularized by Wein is simple and practical and allows detection and formulation of treatment options according to classification.[36] In simple terms, voiding dysfunction can be divided into three categories:

Failure to store urine.

Failure to empty urine.

Failure to store and empty.

For example, the symptom of urinary frequency or incontinence is usually associated with dysfunction of the storage phase of micturition, whereas decreased force of stream or elevated post void residual are associated with dysfunction of the emptying phase. In addition, we can view voiding dysfunction in simple anatomical terms:

Bladder dysfunction (overactive, underactive).

Bladder outlet dysfunction (overactive, underactive).

Combined bladder and outlet dysfunction.

These two concepts can be combined so that one can imagine that a patient could present with urinary incontinence (failure to store) secondary to bladder overactivity or bladder outlet underactivity. Similarly a patient with urinary retention (failure to empty) might have an underactive — or hypocontractile bladder or an overactive — or obstructing outlet. Failure to empty and failure to store as well as bladder and outlet dysfunction are not mutually exclusive conditions and can exist in multiple combinations. These very simple concepts can be applied to predict and identify all types of voiding dysfunction. Therefore when evaluating voiding dysfunction, from history and physical examination to simple and comprehensive testing, keeping these concepts in mind can greatly facilitate the process.