Dysfunctional Voiding in Women

Educational Objectives

The goal of this program is to improve diagnosis and treatment of dysfunctional voiding in women. After hearing and assimilating this program, the clinician will be better able to:

1. Identify patients with dysfunctional voiding.
2. Perform an appropriate workup for patients with symptoms of dysfunctional voiding.

Summary

Dysfunctional voiding (DV): intermittent and/or fluctuating urinary flow rate due to involuntary contractions in periurethral striated muscles during voiding in neurologically normal patients; muscle dysfunction — failure of pelvic floor muscles to relax during voiding; inadequate contraction of bladder for emptying

Detrusor-sphincter dyssynergia (DSD): seen in patients who have DV with neurologic etiology (eg, spinal cord injury, multiple sclerosis, stroke, spinal surgery); discoordination between detrusor and sphincter during voiding secondary to involuntary activation of sphincter

Dysfunctional voiding vs lower urinary tract symptoms: symptoms overlap; no consensus reached about definition of DV or diagnostic criteria for voiding abnormalities in women; storage and emptying problems can coexist (ie, patients can have atonic or hypotonic bladder plus difficulty relaxing sphincter)

Bladder function in women: normal — compared with men, women have lower resting tone pressure and void at lower voiding pressure; abnormal — detrusor underactivity and/or bladder outlet obstruction

Epidemiology: based on large meta-analysis of data from >15,000 patients ≥40 yr of age, prevalence of DV 6% (may be higher [eg, 30%]; clinicians should ask patients about symptoms)

Common complaints and symptoms: “I dribble a lot”; “When I think I’m done peeing, I stand and still dribble”; sensation of incompletely emptying; weak urine stream; urinary hesitancy, urgency, frequency, or retention; overflow incontinence; symptoms overlap with those of overactive bladder and irritative voiding symptoms; constipation

Risk factors: “pump” problem — age; menopause; diabetes; urinary tract infections (UTIs); drugs; postanesthesia state; neurologic problems; constipation; immobility; outflow problem — history of sling surgery or urethral surgery; physical obstruction of urethra (eg, urethral stricture, diverticulum); pelvic organ prolapse; stones; DSD

Evaluation: detailed patient history; physical examination; pelvic examination; digital rectal examination (check resting tone and for fecal impaction); bulboacavernosus reflex testing to check whether spinal cord segments L5 to S5 intact; postvoid residual (PVR) urine volume (specificity 38%, sensitivity ≈57%); ask patient to keep voiding diary; renal ultrasonography to rule out stones; cystoscopy (check for, eg, urethral obstruction, mesh from prior mesh surgery); perform urodynamics study

Urodynamic study: bladder function testing; checks outflow emptying and coordination of voiding (between bladder contraction and external sphincter relaxation); compliance — filling of bladder at low detrusor pressure; detrusor pressure rises during filling phase in patients with noncompliant bladders; capacity — check bladder capacity; core sensation — patients with diabetes or diabetic cystopathy often do not feel first sensation of needing to void until bladder filled with 300 to 400 mL of fluid; continence — check for leaking with activity (eg, laughing, coughing) during test; involuntary contractions — assess detrusor activity; voiding phase — check pressure flow and flow rate; check for obstruction or stricture; perform electromyography (EMG); obtain PVR urine volume

Case presentation: woman in 30s with sickle cell disease presents with difficulty voiding (reports voiding only 2-3 times/day); urodynamic study — shows noncompliant bladder (ie, detrusor pressure rises with filling of bladder [patients with noncompliant bladder may have unilateral hydronephrosis, or if severely progressive, bilateral hydronephrosis]); woman has

Readings

Espuña-Pons M et al: Overactive bladder symptoms and voiding dysfunction in neurologically normal women. Neurourol Urodyn. 2012 Apr;31(4):422-8; Goldman HB, Appell RA: Voiding dysfunction in women with diabetes mellitus. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(2):130-3; Olujide LO, O’Sullivan SM: Female voiding dysfunction. Best Pract Res Clin Obstet Gynaecol. 2005 Dec;19(6):807-28; Onyishi SE, Twiss CO: Pressure flow studies in men and women. Urol Clin North Am. 2014 Aug;41(3):453-67, ix; Park J et al: Voiding dysfunction in older women with overactive bladder symptoms: A comparison of urodynamic parameters between women with normal and elevated post-void residual urine. Neurourol Urodyn. 2016 Jan;35(1):95-9; Robinson D et al: Defining female voiding dysfunction: ICI-RS 2011. Neurourol Urodyn. 2012 Mar;31(3):313-6; Rosenblum N et al: Voiding dysfunction in young, nulliparous women: symptoms and urodynamic findings. Int Urogynecol J Pelvic Floor Dysfunct. 2004 Nov-Dec;15(6):373-7.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Ojo-Carons presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Ojo-Carons spoke in Virginia Beach, VA, at Urology Updates for the Primary Care Provider, presented April 20-21, 2018, by the Eastern Virginia Medical School, Departments of Continuing Medical Education and Urology. For information about CME offerings from this sponsor, please visit https://www.evms.edu/education/cme/. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP663402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.