Dysfunctional Voiding in Women

Abstract

Dysfunctional voiding (DV) is a type of voiding dysfunction resulting from non-relaxation of pelvic floor and/or external urethral sphincter (EUS) during voiding. It is not limited to any age group or sex. The aetiology is poorly understood and pathogenesis is multi-factorial; it is considered to be an acquired learned behaviour of inappropriately contracting/failing to relax EUS/pelvic floor during voiding. The presentation can be masked by often predominant storage symptoms of urgency, frequency and persistent desire to urinate; therefore, a high index of suspicion is warranted. Initial evaluation includes a comprehensive history and clinical examination, including focused neurological assessment for S2–4 neural segments. In addition, neurological consult may be sought to rule out overt or occult neurological pathology. First-line investigations include urine microscopic and routine examination, uroflowmetry and kidney-ureter-bladder ultrasound with post-void residual urine. Addition of perineal electromyography to uroflowmetry aids in diagnosis by showing failure to relax or increased electromyography activity during voiding. Further invasive diagnostic evaluation incorporates video-urodynamics or urodynamics followed by micturating cystourethrography as per availability. Urodynamic nuances such as plateau detrusor pattern and dynamic micturitional urethral pressure profilometry have been reported to further assist in diagnosis. A multipronged approach to treatment is imperative taking into consideration not only management of lower urinary tract symptoms but also the psychological status and co-complaints, particularly constipation and pelvic pain. Patient education on physiology of function of lower urinary tract, pathophysiology of pelvic floor dysfunction, and chronicity of the disease process is the initial first step; it would help the patient to understand pelvic floor rehabilitation as well as draw realistic goals. Initial urological management entails supervised pelvic floor relaxation exercises and pharmacotherapy, e.g. alpha blockers, skeletal muscle relaxants and bladder sedatives as needed. Next-line treatment options include onabotulinum toxin infiltration into external urethral sphincter (with or without detrusor depending upon coexisting detrusor overactivity) and sacral neuromodulation. Irreversible surgical options, e.g. external sphincterotomy and augmentation cystoplasty, are reserved as last resort in special circumstances. In conclusion, DV is an elusive diagnosis and difficult-to-treat chronic condition, which has significant impact on quality of life. A multidisciplinary team approach with active participation of the patient is imperative for optimizing treatment outcome.