Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults

Bladder dysfunction in adolescents with type 1 diabetes

BACKGROUND

It is increasingly significant that adults with diabetes experience lower urinary tract symptoms, however, there has been limited research in younger individuals with type 1 diabetes.

OBJECTIVE

To investigate bladder function using non-invasive urodynamics as a potential indicator of autonomic neuropathy in adolescents with type 1 diabetes. This involved examining the association between urinary flow disturbances, reported symptoms, and results from other autonomic tests.

STUDY DESIGN

Cross-sectional study enrolling 49 adolescents with type 1 diabetes and 18 control subjects. All participants underwent uroflowmetry and ultrasound scanning, completed the Composite Autonomic Symptom Score (COMPASS)-31 questionnaire, and were instructed to record their morning urine volume and voiding frequencies and report them back. Cardiovascular reflex tests (CARTs) and the quantitative sudomotor axon reflex test (QSART) were performed.

RESULTS

The main results are shown in the Summary figure.

DISCUSSION

In this study, urological abnormalities were not significantly more frequent in adolescents with diabetes, however, urological issues were observed. This is supported by previous findings of Szabo et al. who found that adolescents with type 1 diabetes had reduced flow acceleration and time to maximum flow compared to control subjects. In our study, we observed cases with reduced acceleration and prolonged uroflow curves, possibly indicating detrusor underactivity. People with diabetes had a higher risk of nocturia than healthy controls, which our results supported. Some adolescents reported urination twice per night. Based on these findings, it is considered beneficial to ask about urological symptoms annually to determine if more examinations (frequency-volume charts and uroflowmetry) are necessary and/or if any opportunities for treatment optimization exist. However, uroflowmetry has limitations, as bladder filling and emptying is a complex process involving multiple pathways and neurological centers, making it difficult to standardize and evaluate. Another limitation of this study was that our control group was smaller and consisted of fewer males than females, which could affect the results due to differences in anatomy and physiology in the lower urinary tract system.

CONCLUSION

In conclusion, adolescents with type 1 diabetes, as well as healthy adolescents, frequently experience urological symptoms. Although urological abnormalities were not significantly more frequent in adolescents with diabetes in this study, the focus on nocturia and risk for bladder dysfunction seems relevant, even in adolescents without any other tests indicating autonomic dysfunction.

Correlation Between Apical, Anterior, and Posterior Vaginal Wall Prolapse With Voiding Dysfunction: A Single Center Retrospective Cohort Study

Objective

Voiding Dysfunction (VD) is one of the most common disorders among women, which is characterized by a disorder in urination. Pelvic organ prolapse is one of the factors that can affect VD. In this study, the relationship between prolapse in the anterior, posterior, and apical areas and VD has been evaluated.

Materials and methods

This is a cohort retrospective study. The participants in this study were women with VD, who referred to the pelvic floor disorders clinic of Imam Khomeini Hospital in Tehran in 2018-2020. Clinical information was obtained retrospectively from the hospital's electronic data system, also symptoms (intermittent stream, incomplete voiding, poor flow, post void dribble, straining to void, stage anterior, posterior and apical) and urodynamic parameters (including EMG, PVR100, Qmax12, and pdet20) were evaluated, which included detailed questionnaires (Urinary Distress Inventory 6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7)), pelvic examination, and complete urodynamic evaluation.

Results

There was a direct relationship between the age of the patients and the stage of prolapse (p<0.001). So that, the stage increased with age. In addition, it was found that the severity of urinary symptoms is related to the stage of prolapse in the apical area (p=0.001). Also, the results showed that intermittent stream symptoms and the symptoms of staining to void had a significant relationship with the stage of prolapse (III and IV) in the apical and anterior areas. Also, it was shown that only PVR > 100 had a significant relationship with the stage of prolapse in the apical area (p=0.001).

Conclusion

Intermittent stream and straining to void were related to the stages of prolapse in the apical and anterior regions. It was also concluded that the greater the prolapse, the higher the value of PVR > 100.

The Use of Uroflowmetry as a Diagnostic Test

PURPOSE OF REVIEW

Uroflowmetry is widely used for initial non-invasive evaluation of lower urinary tract disorders. Current clinical use is mostly restricted to a scrutiny of the maximum flow rate and uroflow pattern recorded by a conventional flowmeter in a health care facility. There are several advancements in our understanding and in available technologies that promise to transform clinical utilization of this simple test.

RECENT FINDINGS

Several aspects of the uroflow test in addition to maximum flow rate and uroflow pattern show potential diagnostic utility. This includes flow acceleration, uroflow indices, uroflow-electromyography including lag time, stop uroflow test, and uroflow-based nomograms. There are initial attempts to use artificial intelligence in analysis. There is also new data with regard to factors influencing variability of uroflow testing that might influence the diagnostic value in as yet uncertain ways including diurnal variability, postural variability, locational variability, and operator variability. There are new technologies for uroflow testing in a home environment allowing for easy repetition. However, there are several challenges owing to a paucity of clinical data and standardization. There are also critical lacunae in terminology that need to be addressed. There are exciting new advancements in the field of uroflowmetry. However, there is need to standardize and validate the newer uroflow tracing analyses and technologies.

The effect of botulinum toxin A in children with non-neurogenic therapy-refractory dysfunctional voiding - A systematic review

INTRODUCTION

Dysfunctional voiding (DV) is a habitual voiding disorder caused by involuntary contraction or non-relaxation of the external urethral sphincter (EUS) during voiding. This contraction causes high post-void residuals (PVR), urinary incontinence and urinary tract infections (UTIs). Various treatments for DV are available, but some children do not respond. Intersphincteric botulinum toxin-A (BTX-A) may be a possible treatment for therapy-refractory children with DV.

OBJECTIVE

The aim of this systematic review is to summarize the effects and safety of intersphincteric BTX-A as a treatment for therapy-refractory DV in children.

METHODS

A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies reporting on the usage of intersphincteric BTX-A as a treatment for DV in children were included. Data on PVR, maximum flow rate (Qmax), repeat injections and complications were extracted.

RESULTS

From a total of 277 articles, five cohort studies were identified, reporting on 78 children with DV of whom 53 were female (68 %) and 25 were male (32 %). Sample sizes ranged from ten to twenty patients. Mean or median age at the time of intervention ranged from 8 to 10.5 years. Meta-analysis could not be performed due to lack of data. The narrative synthesis approach was therefore used to summarize the results. All studies showed significant decrease in PVR after BTX-A injection. Three studies showed a 33-69 % improvement on incontinence after BTX-A injection. Less UTIs were reported after treatment. A temporary increase in incontinence, UTIs and transitory numbness to the gluteus muscle were reported as side-effects.

CONCLUSIONS

BTX-A could be a safe and effective treatment option for therapy-refractory DV in children by reducing PVR, UTIs and incontinence. Hereby, the synergistic effect of BTX-A and urotherapy should be emphasized in future management. Furthermore, this study identified gaps in current knowledge that are of interest for future research.

Defining the "Cutoff" on the Urethral Caliber in Diagnosing a Female Urethral Stricture

Introduction The rarity in detecting female urethral stricture (FUS) backed by the inconsistency regarding the cutoff on the caliber to direct any treatment for its increase poses a challenge to its existence. Therefore, the present study was conducted to determine the caliber of the urethra that clearly identifies a FUS. Materials and method In this prospective observational study conducted between November 2015 and July 2017, women with obstructive lower urinary tract symptoms (LUTS) and a history of relief on at least a single urethral dilatation were included if the American Urological Association (AUA) score was more than seven and the maximum flow rate (Qmax) was less than 20 mL/sec. Of the 71 women recruited, 10 women had recognizable external causes: caruncle (five), mucosal prolapse (three), and meatal stenosis (two). The remaining 61 underwent voiding cystourethrogram (VCUG) and urodynamics followed by urethrocystoscopy, if the findings suggested a stricture. A definitive diagnosis was sought in those without stricture disease. We categorized all patients as either having a "true" stricture or an alternate etiology. Categorical variables were presented in number and percentage (%) and continuous variables as mean ± standard deviation (SD). Results The mean dilatation ranged between one and six; the mean AUA score, ~17.82 ± 3.59; mean Qmax, ~10.21 ± 3.39 mL/sec; and the mean post-void residue (PVR), 106.65 ± 51 mL. A total of 29 patients were diagnosed to have stricture (dense = 17; flimsy = 12). None of the patients in this group had a urethral caliber of more than 14 French (Fr). Other etiologies were dysfunctional voiding (17), underactive bladder (seven), cystocele (four), and primary bladder neck obstruction (PBNO) (four). Conclusion Women with voiding LUTS should be screened for FUS only if the urethral caliber is ≤14 Fr.

The Persistency Index: a novel screening tool for identifying myofascial pelvic floor dysfunction in patients seeking care for lower urinary tract symptoms

BACKGROUND

Patients with myofascial pelvic floor dysfunction often present with lower urinary tract symptoms, such as urinary frequency, urgency, and bladder pressure. Often confused with other lower urinary tract disorders, this constellation of symptoms, recently termed myofascial urinary frequency syndrome, is distinct from other lower urinary tract symptoms and optimally responds to pelvic floor physical therapy. A detailed pelvic floor myofascial examination performed by a skilled provider is currently the only method to identify myofascial urinary frequency syndrome. Despite a high influence on quality of life, low awareness of this condition combined with no objective diagnostic testing leads to the frequent misdiagnosis or underdiagnosis of myofascial urinary frequency syndrome.

OBJECTIVE

This study aimed to develop a screening measure to identify patients with myofascial urinary frequency syndrome (bothersome lower urinary tract symptoms secondary to myofascial pelvic floor dysfunction) from patient-reported symptoms.

STUDY DESIGN

A population of patients with isolated myofascial urinary frequency syndrome was identified by provider diagnosis from a tertiary urology practice and verified by standardized pelvic floor myofascial examination and perineal surface pelvic floor electromyography. Least Angle Shrinkage and Selection Operator was used to identify candidate features from the Overactive Bladder Questionnaire, Female Genitourinary Pain Index, and Pelvic Floor Distress Index predictive of myofascial urinary frequency syndrome in a pooled population also containing subjects with overactive bladder (n=42), interstitial cystitis/bladder pain syndrome (n=51), and asymptomatic controls (n=54) (derivation cohort). A simple, summated score of the most discriminatory questions using the original scaling of the Pelvic Floor Distress Index 5 (0-4) and Genitourinary Pain Index 5 (0-5) and modified scaling of Female Genitourinary Pain Index 2b (0-3) had an area under the curve of 0.75. As myofascial urinary frequency syndrome was more prevalent in younger subjects, the inclusion of an age penalty (3 points added if under the age of 50 years) improved the area under the curve to 0.8. This score was defined as the Persistency Index (possible score of 0-15). The Youden Index was used to identify the optimal cut point Persistency Index score for maximizing sensitivity and specificity.

RESULTS

Using a development cohort of 215 subjects, the severity (Pelvic Floor Distress Index 5) and persistent nature (Female Genitourinary Pain Index 5) of the sensation of incomplete bladder emptying and dyspareunia (Female Genitourinary Pain Index 2b) were the most discriminatory characteristics of the myofascial urinary frequency syndrome group, which were combined with age to create the Persistency Index. The Persistency Index performed well in a validation cohort of 719 patients with various lower urinary tract symptoms, including overactive bladder (n=285), interstitial cystitis/bladder pain syndrome (n=53), myofascial urinary frequency syndrome (n=111), controls (n=209), and unknown diagnoses (n=61), exhibiting an area under the curve of 0.74. A Persistency Index score ≥7 accurately identified patients with myofascial urinary frequency syndrome from an unselected population of individuals with lower urinary tract symptoms with 80% sensitivity and 61% specificity. A combination of the Persistency Index with the previously defined Bladder Pain Composite Index and Urge Incontinence Composite Index separated a population of women seeking care for lower urinary tract symptoms into groups consistent with overactive bladder, interstitial cystitis/bladder pain syndrome, and myofascial urinary frequency syndrome phenotypes with an overall diagnostic accuracy of 82%.

CONCLUSION

Our study recommends a novel screening method for patients presenting with lower urinary tract symptoms to identify patients with myofascial urinary frequency syndrome. As telemedicine becomes more common, this index provides a way of screening for myofascial urinary frequency syndrome and initiating pelvic floor physical therapy even before a confirmatory pelvic examination.

Efficacy of single and repeated transurethral bladder neck incisions for female voiding dysfunction

OBJECTIVE

This study aimed to assess the efficacy of single and repeat transurethral bladder neck incision (TUI-BN) for female voiding dysfunction caused by bladder outlet obstruction (BNO). Further, the predictive factors associated with better treatment outcomes were identified.

METHODS

Women with voiding difficulty due to BNO who underwent TUI-BN were included in this research. All patients underwent videourodynamics study at baseline and after TUI-BN. Successful outcome was defined as a voiding efficiency of ≥ 66.7% and a global response assessment score of ≥ 2 after treatment. Repeat TUI-BN was considered for patients with insufficient improvement. The outcomes of repeat surgery, surgical complications, and predictive factors of successful outcomes were evaluated.

RESULTS

In total 158 cases, the success rates were 61.4% and 45.2% after the first and second TUI-BN, respectively, with an overall cumulative rate of 70.3%. The success rates were comparable between patients with detrusor underactivity (DU) and those without (54.9% vs. 68.4%). The absence of a previous history of suburethral sling and a high baseline corrected maximum flow rate were a significant predictor of favorable outcomes. The cumulative rate of regaining self-voiding function was 95.1%. The incidence rates of vesico-vaginal fistula and de novo stress urinary incontinence requiring surgery were 1.2% and 2.5%, respectively.

CONCLUSIONS

Regardless of the presence of DU, TUI-BN is effective against female voiding dysfunction caused by BNO. Repeat procedures are beneficial and can improve self-voiding function. A high corrected maximum flow rate and the absence of a previous history of suburethral sling can contribute to greater success rates.

From Clinical Scenarios to the Management of Lower Urinary Tract Symptoms in Children: A Focus for the General Pediatrician

Lower urinary tract symptoms (LUTS) are a relevant problem in the pediatric population, having a very high prevalence. Diurnal incontinence and nocturnal enuresis are surely the most frequent symptoms, presenting, respectively, in up to 30% of school-age children and up to 10% of children between 6 and 7 years. Stypsis is the most common comorbidity, and it must be considered in the management of LUTS; indeed, the treatment of constipation is curative in most cases for both incontinence and enuresis. The presence or absence of diurnal symptoms in nocturnal enuresis and urgency in diurnal incontinence helps in the differential diagnosis. Urotherapy is always the first-line treatment, while oxybutynin and desmopressin (where appropriate) may help if the first-line treatment is unsuccessful. It is essential to identify conditions that are potentially dangerous for kidney and urinary tract well-being, for which LUTS can be the first manifestation. Starting from a series of clinical scenarios, we will underline the diagnostic clues behind LUTS in children and we will summarize clinical and surgical approaches for the proper management of these conditions.

Voiding Dysfunction Due to Urethral Sphincter Dysfunction Might Be an Early Neurological Presentation of Central Nervous System Disorders in Aged Patients

PURPOSE

To investigate the incidence of central nervous system (CNS) diseases in adult patients with voiding dysfunction and videourodynamics (VUDS) proven urethral sphincter dysfunction.

METHODS

This retrospective analysis reviewed the medical charts of patients aged > 60 years who underwent VUDS for non-prostatic voiding dysfunction from 2006 to 2021. A chart review was performed to search for the occurrence and treatment of CNS diseases after the VUDS examination up to 2022. The diagnosis of CNS disease, such as cerebrovascular accidents (CVA), Parkinson's disease (PD), and dementia, by neurologists was also retrieved from the charts. Based on the VUDS findings, patients were divided into the following subgroups: dysfunctional voiding (DV), poor relaxation of the external sphincter (PRES), and hypersensitive bladder (HSB) and coordinated sphincter subgroups. The incidence of CVA, PD, and dementia in each subgroup was recorded and compared among them using one-way analysis of variance (ANOVA).

RESULTS

A total of 306 patients were included. VUDS examinations revealed DV in 87 patients, PRES in 108, and HSB in 111. Among them, 36 (11.8%) patients had CNS disease, including CVA in 23 (7.5%), PD in 4 (1.3%), and dementia in 9 (2.9%). Among the three subgroups, the DV group had the highest incidence rate of CNS disease (n = 16, 18.4%), followed by PRES (n = 12, 11.1%) and HSB (n = 8, 7.2%). However, no significant difference was noted in the incidence of CNS disease across the three subgroups. Nevertheless, the incidence of CNS disease was higher in patients with DV and PRES than that in the general population.

CONCLUSIONS

The incidence of CNS diseases was high in patients aged > 60 years with voiding dysfunction due to urethral sphincter dysfunction. Patients with VUDS-confirmed DV had the highest incidence of CNS disease among the three subgroups.

Urine flow acceleration in healthy children: A retrospective cohort study

AIMS

To establish normal reference values of urine flow acceleration (Q_acc ) in healthy children, as there is a lack of nomograms for normative reference values of Q_acc by voided volumes in the pediatric population so far. Q_acc might be an early indicator of autonomic neuropathy in children and adolescents.

METHODS

Data were retrospectively collected from healthy children who underwent uroflowmetry between 1990 and 1992. Exclusion criteria were voided volume less than 20 ml, and postvoid residual more than 15%. Baseline characteristics and uroflowmetry parameters were collected from girls and boys aged between 6 and 18 years. Voided volume, voiding time, time to maximum flow rate, and maximum and average flow rates of urine were measured, and Q_acc was calculated. Postvoid bladder diameter was measured by ultrasonography and converted to volume.

RESULTS

Uroflowmetry parameters of 208 children (≤18 years old, 45.2% girls, mean age 9.68 ± 3.09 years) who performed 404 micturition were analyzed. Median voided volume, voiding time, time to Q_max , Q_ave , Q_max , Q_acc , and postvoid residual volume were 130 [20-460] ml, 10 [3-56] s, 3 [1-14] s, 11.7 [2.5-36.6] ml/s, 20.5 [5-50] ml/s, 6 [0.81-25] ml/s² , and 1.83 [0-38.62] ml, respectively. Q_acc nomograms were given in centile forms for girls and boys separately, which show an inversely proportional correlation between voided volumes.

CONCLUSIONS

These are the first nomograms for normative reference values of Q_acc in the pediatric population (girls and boys separately) by voided volumes in centile forms. These may be useful to interpret abnormal Q_acc values and diagnose lower urinary tract diseases over a wide range of voided volumes.

Prevalence of Lower Urinary Tract Symptoms in Children with Attention-Deficit/Hyperactivity Disorder: Comparison of Hospital and Population-Based Cohorts of 13,000 Patients

Background: This study investigates the prevalence of lower urinary tract symptoms (LUTS) in school-age children with Attention-Deficit/Hyperactivity Disorder (ADHD) based on hospital-based and population-based cohorts. Methods: The hospital-based sample comprised 42 children with ADHD and 65 without ADHD aged 6−12 years. Voiding dysfunction was assessed by the Dysfunctional Voiding Scoring System (DVSS) questionnaire. We compared the baseline data, DVSS score, and uroflowmetry between the two groups. For the population-based cohort in the national insurance database, we included 6526 children aged 6−12 years, whose claims record included the diagnosis of ADHD, and another 6526 control subjects matched by gender and age. We compared the presence of LUTS diagnosis codes between the two groups. Results: Our results showed that, for the hospital-based cohort, the mean total DVSS score and the proportion of significant LUTS in children in the ADHD group were significantly higher than in subjects in the non-ADHD group. The DVSS subscales showed that the item “I cannot wait when I have to pee” item was significantly higher in the ADHD group (1.62 ± 1.17 vs. 0.90 ± 1.09, p = 0.002). For the population-based cohort, children with ADHD had a significantly higher likelihood of storage symptoms (5.53% vs. 2.91%, p < 0.001) and enuresis (3.28% vs. 1.95%, p < 0.001) compared with those of the no ADHD group. Conclusions: Children with ADHD have a higher prevalence of significant LUTS, especially storage symptoms and enuresis, than children without ADHD. The observed correlations between ADHD and LUTS provided the supporting evidence to evaluate the concomitant voiding dysfunction in children with ADHD.

Neurogenic non-neurogenic bladder in childhood: complications and prognostic factors

BACKGROUND

Neurogenic non-neurogenic bladder is a common problem in clinical practice. Untreated, complications can be serious.

AIM

Identify complications of neurogenic non-neurogenic bladder and determine the predictive factors of their occurrence.

METHODS

Prospective, cross-sectional and analytical study (September 2016-September 2017) on a series of cases of children carrying VNNN, followed in the nephrology pediatric department of Charles Nicolle Hospital in Tunis.

RESULTS

Twenty-four patients were included in the study. The predictive criteria for neurogenic non-neurogenic bladder complications that we were able to highlight were: female sex, phasic detrusor bladder overactivity, bladder hypocompliance, and midstream hypercontractility.

CONCLUSION

Neurogenic non-neurogenic bladder is a common pathology in pediatrics, it is important to diagnose and manage appropriately and early to avoid its complications.

Exome sequencing implicates a novel heterozygous missense variant in DSTYK in autosomal dominant lower urinary tract dysfunction and mild hereditary spastic paraparesis

Introduction

DSTYK encodes dual serine/threonine and tyrosine protein kinase. DSTYK has been associated with autosomal-dominant congenital anomalies of the kidney and urinary tract and with autosomal-recessive hereditary spastic paraplegia type 23. Here, we report a father and his two dizygotic twin sons carrying a novel heterozygous missense variant in DSTYK, presenting with early onset lower urinary tract dysfunction due to dysfunctional voiding. Moreover, in the later course of the disease, both sons presented with bilateral spasticity in their lower limbs, brisk reflexes, and absence seizures.

Materials and methods

Exome sequencing in the affected father and his affected sons was performed. The sons presented clinically with urinary hesitancy, dysfunctional voiding, and night incontinence till adolescence, while the father reported difficulty in voiding. In the sons, cystoscopy excluded urethral valves and revealed hypertrophy of the bladder neck and trabeculated bladder. Additionally, both sons were diagnosed with absence epilepsy in early childhood. Filtering of exome data focused on rare (MAF < 0.01%), autosomal-dominant variants, predicted to be deleterious, residing in highly conserved regions of the exome.

Results

Exome analysis identified a novel, heterozygous missense variant (c.271C>A (p.Leu91Met)) in DSTYK segregating with the disease. In silico prediction analyses uniformly rated the variant to be deleterious suggesting the variant to be disease-causing in the family.

Conclusion

To the best of our knowledge, this is the first report of early onset dysfunctional voiding, seizures, and bilateral spasticity of the lower limbs associated with a novel heterozygous dominant missense variant in DSTYK.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40348-021-00122-y.

Therapeutic efficacy of biofeedback pelvic floor muscle exercise in women with dysfunctional voiding

Dysfunctional voiding (DV), a voiding dysfunction due to hyperactivity of the external urethral sphincter or pelvic floor muscles leading involuntary intermittent contractions during voiding, is not uncommon in neurologically normal women with lower urinary tract symptoms (LUTS). We aimed to investigate the therapeutic efficacy of biofeedback pelvic floor muscle training (PFMT) in female patients with DV and to identify the therapeutic efficacy. Thirty-one patients diagnosed with DV. All participates completed the 3-month biofeedback PFMT program, which was conducted by one experienced physiotherapist. At 3 months after treatment, the assessment of treatment outcomes included global response assessment (GRA), and the changes of clinical symptoms, quality of life index, and uroflowmetry parameters. 25 (80.6%) patients had successful outcomes (GRA ≥ 2), and clinical symptoms and quality of life index significantly improved after PFMT. Additionally, uroflowmetry parameters including maximum flow rate, voided volume, voiding efficiency, total bladder capacity, voiding time, and time to maximum flow rate significantly improved after PFMT treatment. Patients with the history of recurrent urinary tract infection in recent 1 year were found to have unsatisfied therapeutic outcomes. In conclusion, biofeedback PFMT is effective in female patients with DV with significant improvements in clinical symptoms, quality of life, and uroflowmetry parameters. The history of urinary tract infection in recent 1 year is a negative predictor of successful outcome.

The risk factors for recurrence of febrile urinary tract infection and renal scarring in children with functional urinary incontinence

OBJECTIVES

Functional urinary incontinence is often associated with recurrent urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scarring. This study aims to evaluate the correlations between urodynamic findings and recurrence of UTI, VUR, and renal scarring in children with functional incontinence.

METHODS

In this retrospective observational study, data on the presence of VUR, urodynamics and 99Tc-dimercaptosuccinic acid scintigraphy findings, and episodes of febrile UTI were obtained from patients' records. The patients had at least 3 years of follow-up.

RESULTS

There were significant associations between recurrence of UTI and decreased bladder capacity (hazard ratio: 1.321, P = .028). The receiver operator characteristic curve analysis showed a cutoff value for compliance of 13.25 mL/cmH₂ O for renal scarring (P = .000). There was a significant association between bladder wall thickening and VUR (odds ratio: 2.311, P = .008). The compliance had a cutoff value of 14.7 mL/cm H₂ O (P = .023) for severe VUR. The frequency of renal scarring was higher in patients with severe VUR and dysfunctional voiding (P = .001 and P = .041, respectively). The independent risk factors for renal scarring were low compliance, severe VUR, and dysfunctional voiding in children with functional incontinence, but recurrence of febrile UTI was not a risk factor for renal scarring. Decreased bladder capacity was a risk factor for recurrence of febrile UTI.

CONCLUSIONS

The present study suggests that low compliance, severe VUR, and dysfunctional voiding, but not the recurrence of febrile UTI, are the independent risk factors for renal scarring in children with functional incontinence, and decreased bladder capacity is the risk factor for the recurrence of febrile UTI.

The Therapeutic Effects and Pathophysiology of Botulinum Toxin A on Voiding Dysfunction Due to Urethral Sphincter Dysfunction

Neurogenic and non-neurogenic urethral sphincter dysfunction are common causes of voiding dysfunction. Injections of botulinum toxin A (BoNT-A) into the urethral sphincter have been used to treat urethral sphincter dysfunction (USD) refractory to conventional treatment. Since its first use for patients with detrusor sphincter dyssynergia in 1988, BoNT-A has been applied to various causes of USD, including dysfunctional voiding, Fowler’s syndrome, and poor relaxation of the external urethral sphincter. BoNT-A is believed to decrease urethral resistance via paralysis of the striated sphincter muscle through inhibition of acetylcholine release in the neuromuscular junction. Recovery of detrusor function in patients with detrusor underactivity combined with a hyperactive sphincter also suggested the potential neuromodulation effect of sphincteric BoNT-A injection. A large proportion of patients with different causes of USD report significant improvement in voiding after sphincteric BoNT-A injections. However, patient satisfaction might not increase with an improvement in the symptoms because of concomitant side effects including exacerbated incontinence, urinary urgency, and over-expectation. Nonetheless, in terms of efficacy and safety, BoNT-A is still a reasonable option for refractory voiding function. To date, studies focusing on urethral sphincter BoNT-A injections have been limited to the heterogeneous etiologies of USD. Further well-designed studies are thus needed.

Medical evaluation and management of male and female voiding dysfunction: a review

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.

Pelvic floor electromyography and urine flow patterns in children with vesicoureteral reflux and lower urinary tract symptoms

OBJECTIVE

To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients.

MATERIALS AND METHODS

We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines.

RESULTS

Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients.

CONCLUSIONS

Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR.

A Prospective Study to Evaluate the Efficacy of Botulinum Toxin-A in the Management of Dysfunctional Voiding in Women

Objectives:

To assess the outcomes of Botulinum Toxin-A (BoNT-A) to the external urethral sphincter (EUS) in dysfunctional voiding (DV) refractory to standard urotherapy and bowel management.

Methods:

Our criteria to diagnose DV in women included neurologically normal individuals with lower urinary tract symptoms, dilated proximal urethra on voiding cystourethrogram, and high detrusor pressure (PdetQmax > 20 cm H₂O) associated with increased electromyography activity during voiding in urodynamic study (UDS). A total of 16 female patients with a median age of 36 years (5-60 years) received BoNT-A from June 2014 to December 2015. Patients below and above 10 years of age received 100 units and 200 units of BoNT-A to EUS, respectively. Patients were followed up till 6 months.

Results:

Mean AUA (American Urological Association) symptom score decreased significantly from 11.75 ± 6.14 to 5.06 ± 5.1 and 4.25 ± 3.4 at day 14 and day 45 after BoNT-A, respectively (P < .0001). There were no significant improvements in maximal flow (Qmax) on uroflowmetry (UFM) and detrusor pressure at maximal flow (PdetQmax) in UDS. Significant reduction in post-void residual (PVR) from 69.31 ± 77.3 to 17.50 ± 22.3 mL at day 14 (P = .007) was observed, although the reduction was not significant at day 45. Although minor adverse effects were reported, none were serious or life-threatening.

Conclusions:

Our study showed that BoNT-A plays a role in improvement of urinary symptoms and reduces PVR at D14 in DV, but showed no improvement in UFM and urodynamic parameters, albeit with limited numbers and limited follow-up.

Is urotherapy alone as effective as a combination of urotherapy and biofeedback in children with dysfunctional voiding?

Objective:

To compare standard urotherapy with a combination of urotherapy and biofeedback sessions and to determine the changes that these therapies promote in children with dysfunctional voiding.

Patients and Methods:

The data of 45 patients who participated in the study from January 2010 to March 2013 were evaluated. All patients underwent urinary system ultrasonography to determine post-void residual urine volumes and urinary system anomalies. All patients were diagnosed using uroflowmetry - electromyography (EMG). The flow pattern, maximum flow rate, and urethral sphincter activity were evaluated in all patients using uroflowmetry - EMG. Each patient underwent standard urotherapy, and the results were recorded. Subsequently, biofeedback sessions were added for all patients, and the changes in the results were recorded and statistically compared.

Results:

A total of forty - five patients were included, of which 34 were female and 11 were male and the average age of the patients was 8.4 ± 2.44 years (range: 5 - 15 years). After the standard urotherapy plus biofeedback sessions, the post-void residual urine volumes, incontinence rates and infection rates of patients were significantly lower than those with the standard urotherapy (p < 0.05). A statistically significant improvement in voiding symptoms was observed after the addition of biofeedback sessions to the standard urotherapy compared with the standard urotherapy alone (p < 0.05).

Conclusions:

Our study showed that a combination of urotherapy and biofeedback was more effective in decreasing urinary incontinence rates, infection rates and post - void residual urine volumes in children with dysfunctional voiding than standard urotherapy alone, and it also showed that this combination therapy corrected voiding patterns significantly and objectively.

Dysfunctional voiding: Challenges of disease transition from childhood to adulthood

N/A

Management of Neurogenic Bladder

This article provides a comprehensive summary of the clinical approach, investigative modalities and management of a child with neurogenic bladder disease due to myelodysplasia. It is aimed at pediatric physicians and surgeons working in developing nations. The methodologies suggested are simple and can be practised even in resource poor regions. The goal of management is avoidance of Chronic kidney disease and for this, meticulous bladder management is the key.

Videourodynamic analysis of the urethral sphincter overactivity and the poor relaxing pelvic floor muscles in women with voiding dysfunction

AIMS

Voiding dysfunction due to dysfunctional voiding (DV) and poor relaxation of the external sphincter (PRES) are commonly found among adult women with lower urinary tract symptoms (LUTS) during videourodynamic study (VUDS). This study analyzed the VUDS characteristics of DV and PRES in female voiding dysfunction.

METHODS

This retrospective study involved 1914 women aged >18 years with refractory LUTS. The medical records and the VUDS parameters were reviewed. Patients diagnosed with DV and PRES participated in the study. The VUDS characteristics and urethral sphincter activities were compared with those of urodynamically normal women.

RESULTS

Of the 1914 women, 325 (17.0%) and 336 (17.6%) were diagnosed with DV and PRES, respectively. Detrusor overactivity (DO) occurred in 60% of the women with DV and in 5.7% of the women with PRES. Patients with DV had significantly increased bladder sensation, lower cystometric bladder capacity (CBC), lower bladder compliance, higher voiding detrusor pressure, smaller voided volume (VV), larger post-void residual volume (PVR), lower voiding efficiency (VE), and higher bladder outlet obstruction index (BOOI) than the women with PRES and the control individuals. Patients with PRES had significantly increased bladder sensation, lower CBC, lower maximum flow rate, smaller VV, larger PVR, and lower VE than the control individuals.

CONCLUSIONS

DV and PRES were highly prevalent among the adult women with voiding dysfunction. Patients with DV had VUDS characteristics of BOO and urodynamic DO. The clinical symptoms of PRES were similar to those of DV, but the patients had low detrusor contractility and low DO rates.

Botulinum Toxin A and Lower Urinary Tract Dysfunction: Pathophysiology and Mechanisms of Action

The use of onabotulinumtoxinA (BoNT-A) for the treatment of lower urinary tract diseases (LUTD) has increased markedly in recent years. The indications for BoNT-A treatment of LUTD now include neurogenic or idiopathic detrusor overactivity, interstitial cystitis/bladder pain syndrome and voiding dysfunction. The mechanisms of BoNT-A action on LUTDs affect many different aspects. Traditionally, the effects of BoNT-A were believed to be attributable to inhibition of acetylcholine release from the presynaptic efferent nerves at the neuromuscular junctions in the detrusor or urethral sphincter. BoNT-A injection in the bladder also regulated sensory nerve function by blocking neurotransmitter release and reducing receptor expression in the urothelium. In addition, recent studies revealed an anti-inflammatory effect for BoNT-A. Substance P and nerve growth factor in the urine and bladder tissue decreased after BoNT-A injection. Mast cell activation in the bladder also decreased. BoNT-A-induced improvement of urothelium function plays an important mitigating role in bladder dysfunction. Vascular endothelial growth factor expression in urothelium decreased after BoNT-A injection, as did apoptosis. Studies also revealed increased apoptosis in the prostate after BoNT-A injection. Although BoNT-A injection has been widely used to treat different LUTDs refractory to conventional treatment, currently, onabotulinumtoxinA has been proven effective only on urinary incontinence due to IDO and NDO in several large-scale clinical trials. The effects of onabotulinumtoxinA on other LUTDs such as interstitial cystitis, benign prostatic hyperplasia, dysfunctional voiding or detrusor sphincter dyssynergia have not been well demonstrated.

Pelvic floor spasm as a cause of voiding dysfunction

PURPOSE OF REVIEW

Pelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction.

RECENT FINDINGS

To distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms.

SUMMARY

Pelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patient's requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained physical therapist/nurse clinician is essential in the management of these patients.

Dysfunctional voiding

PURPOSE OF REVIEW

Female dysfunctional voiding (FDV) is an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the periurethral striated or levator muscles during voiding in neurologically normal women. Despite its codified definition, because of variable causes, there is a lack of established diagnostic criteria and management. The aim of this study is to give a comprehensive, brief review of the most recent progress in the diagnosis and management of FDV.

RECENT FINDINGS

Currently, there is the need to shed light on several issues in FDV, such as the use of standardized definitions, diagnostic criteria, and treatment modalities. The evaluation of the progress on these matters within 2013 helped to define some key advances in the field of female functional voiding dysfunction and urinary retention.

SUMMARY

In 2013, many diagnostic and therapeutic questions in female voiding dysfunction remain unsolved. However, some data began to emerge. Patients with FDV did not demonstrate a difference in effortful control (effortful control is the ability to regulate one's responses to external stimuli), but did demonstrate a higher rate of surgency (surgency is a trait aspect of emotional reactivity in which a person tends towards high levels of positive affect). Toilet training method in childhood does not seem to have any long-term correlation with FDV. Training with pelvic floor physiotherapy and biofeedback still represents the first-line treatment for FDV. In the management of other causes of female voiding dysfunction, sacral neuromodulation demonstrated a satisfying long-term efficacy in the treatment of nonobstructive urinary retention.

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.

Urinary retention

Urinary retention, defined as the inability to void, is a common medical problem. If unidentified and/or untreated, it may become a serious condition that can lead to kidney damage or urosepsis, compromising the patient's life.
Acute urinary retention (AUR) is usually easy to identify and to treat as patients usually complain of hypogastric pain and anuria. Proper bladder drainage with urethral or suprapubic catheter is the first line of treatment, with posterior studies to determine the cause of retention.
Chronic urinary retention (CUR) is often much more difficult to identify. It is invariably linked to increased post-void residual urine (PVR), but its asymptomatic nature makes it often a hidden condition.
There is a wide range of intrinsic and extrinsic, obstructive and non-obstructive causes affecting the lower urinary tract, which can lead to urinary retention. Due to the differences in urinary physiology and in order to simplify diagnosis and management, these are usually studied separately in men and in women. Management consists of a variety of options depending on the cause of retention, including conservative treatment, drug therapy and several forms of surgery. 
In this review, we make an overview of the main causes of acute and chronic urinary retention in men and women, focusing on the main aspects of diagnosis and management.