Voiding Dysfunction

Dysfunctional voiding (DV), or voiding dysfunction, is a voiding ailment caused by dyssynergic striated sphincter activity in people who don't have any neurological problems. Bladder outlet obstruction causes voiding difficulties as well as storage problems as the bladder changes as a result of the obstruction. It can strike at any age. Urinary incontinence, nighttime enuresis, or recurrent urinary infection are common in young children, but voiding problems are more common in adults. The condition can show in a variety of ways, and the consequences of a DV diagnosis can range from mild to fatal. The impact on one's quality of life can be significant. The florid disease can show as a kind of neurogenic bladder that is nearly indistinguishable from the typical neurogenic bladder, and individuals with this condition may develop bilateral hydronephrosis and end-stage renal failure.

In both pediatric and adult urology, the diagnosis of DV is prevalent. However, there is a notable lack of certainty and agreement in the literature about what the word DV refers to. Protocols for evaluation are highly different and are more influenced by the philosophy of the treatment unit than by patient circumstances.

Definition and Terminology

In 1915, Beer may have been the first to identify voiding difficulties, recurrent infections, and sphincteric incoordination. Without a neurological diagnosis, a dizzying assortment of words has been used to characterize people with external sphincter dyssynergia during the next century. The names Hinman and Allen became related to a more aggressive variant of the disease. Allen was the first to coin the term dysfunctional voiding in 1977. Several standardized publications have incorporated this phrase since then.

The International Children's Continence Society (ICCS) terminology report defines a child with dysfunctional voiding as someone who habitually contracts the urinary tract sphincter during voiding, adding that the term should only be used if repeated uroflow measured values show a staccato pattern or unless verified by urodynamics.

The ICCS's usage of the term "habitually" implies that a) this is a taught behavior and b) these children's sphincter relaxation is under their conscious control. While there are certainly children who have picked up a bad voiding method, such evidence is lacking in a vast number of children who come with DV. Should the ICCS continue to include a subjective and difficult-to-verify term in the definition? According to the ICCS paper, DV causes bladder alterations and reflux. While this may be accurate in some children, the concept that all bladder alterations are caused by the sphincter lacks scientific support.

The International Continence Society (ICS) describes DV as "intermittent and/or varying flow rate during voiding in neurally normal individuals due to involuntary intermittent contractions of the periurethral striated muscle." The ICS report, on the other hand, makes no mention of a non-fluctuating sluggish flow caused by dyssynergia in a neurally intact person. While the text states that the variable flow is caused by contractions of the periurethral muscle fibers, needle electromyography, which can detect the activity of this muscle, is not widely used in most urodynamics facilities. The activity of the pelvic floor, external anal, and urethral sphincters is seen on the electrodes attached. There is also evidence that DV can be caused by striated sphincter dyssynergia, pelvic floor dyssynergia, or both. As a result, the term "periurethral striated muscle" could be replaced with a striated urethral sphincter-pelvic floor complex.

Voiding Dysfunction Pathogenesis

DV has long been thought to be a habitual disorder, owing to the child's incorrect practice of contracting rather than releasing the striated urethral sphincter-pelvic floor complex during voiding. This might happen as a result of poor toilet training or as a reaction to urgency or pelvic discomfort. Urgency may begin as a result of detrusor overactivity or a urinary infection. Urinary symptoms may be aggravated if constipation is present. DV can be caused by chronic infantile or fetal voiding practices, have familial or hereditary roots, be unwittingly induced by disciplinarian teachers at school, and be linked to behavioral issues. At least some DV patients have underlying neurogenic abnormalities that will become apparent if they are monitored for a long time.

A search for an undiagnosed neurological lesion should be conducted in all patients with unexplained severe DV. DV could be the result of a slight neuronal injury. Current imaging technology may or may not be sensitive enough to detect such lesions. Routine magnetic resonance imaging (MRI) has a poor yield of 7 percent in children with lower urinary tract disorders without overt neurological signs and symptoms, but this could be enhanced by focusing on children with aberrant cutaneous findings. Some patients with mild neurological signs and symptoms may be diagnosed with tethered cord syndrome. Due to a fixed, inelastic anchoring of the conus, people with a tethered cord have their spinal cord stretched.

Recent reports on the occult or minimally tethered cords are more interesting. A pathologically extended conus or a conus that sits below the L2 level has been used to identify classic tethered cord. However, anecdotal evidence suggests that the cord can sometimes be excessively stretched without being in an improper location after surgical separation of the filum in children with apparently normal cord locations. Such minor lesions could also explain why some children present with the condition before toilet training has begun. In such people, surgical division of the filum terminale is debatable, yet it may relieve bladder dysfunction.

The correlation of an unusual facial expression in certain children with DV is another possible observational evidence for an unexplained neurological illness in these patients. The closeness of the bladder and facial expression cortical areas in the brain explains the link between facial expression and bladder function in this urofacial Syndrome. This makes an abnormality connection between the two centers more likely.

It's more difficult to explain DV in adults who are experiencing it for the first time. Without a doubt, some of these people are adults who grew up with an untreated voiding condition. However, many individuals deny having experienced voiding symptoms as a youngster. Is this a behavior that these people picked up later in life? Women with symptoms of the lower urinary tract are more likely to recall having a similar condition as a child. Women who have vesicoureteral reflux as a child are more likely to have aberrant sphincteric activity. As a result, urine patterns in adolescence may be the result of undetected childhood disorders, at least in some women.

It's possible that pelvic pain is to blame for DV in certain cases. Cameron found bladder outlet blockage in 49 percent of the 230 women with painful bladder syndrome who had urodynamic data. This was attributed to DV. Bladder pain, according to the authors, causes a reflex contraction of the pelvic floor during voiding, resulting in DV.

Some researchers have attempted to distinguish between striated urethral sphincter dyssynergia and pelvic floor dyssynergia. Deindl discovered incorrect pelvic floor muscle relaxation and external urethral sphincter stimulation during voiding in 10 of 15 women with DV and retention. Only women with pelvic floor activation responded to biofeedback training, which has prognostic implications.

Voiding Dysfunction Epidemiology

It is unknown what the true estimation of DV in the general population is. The methods used to estimate the population of DV are controversial. Depending on the terminology utilized and the methodology used, a range of 4-46 percent has been reported. These estimates are most likely a huge underestimation of the true prevalence. The highest value in this data comes from a demographic survey of 19,245 children in South Korea. Despite the fact that the authors referred to the condition as DV, it appears that they were looking for any urine symptom in the general population rather than the particular problem of DV.

DV can account for up to 42% of referrals to the Pediatric Urology department in tertiary care facilities. In adult urology centers, DV is frequently seen in 0.5-2.5 percent of patients. Groutz discovered that males and females had the same prevalence, with men having a mean age of 45 years and women having a mean age of 51 years.

Voiding Dysfunction Symptoms

Urinary incontinence is common in children with defective voiding, both during the day and at night. Urinary frequency, urgency, urge incontinence, or nighttime enuresis is all possibilities. Associated detrusor overactivity, urinary infection, or decreased bladder capacity due to big residual urine can cause storage symptoms, which can be exacerbated by constipation or behavioral issues. Some of these patients may have a characteristic facial expression. Adults frequently appear with voiding problems or inexplicable retention. Patients may struggle to empty in public areas, or they may require physical or mental cues to do so, such as the noise of running water or the need to deliberately relax.

Storage symptoms are prevalent, and they may be the only symptoms present. Urge incontinence was discovered in 44% of the time, voiding difficulty was found in 55%, and urine retention was found in 8% of the time. In another study, the average urine frequency was found to be 12 in both men and women, with 4 and 3.5 nocturnal voids in men and women, respectively. Patients with DV have long been thought to be at risk for urinary tract infection, but a new study disproves this idea.

The purpose of the history is to determine the type of bladder symptom, the degree of the discomfort, the health and consistency of the urinary system, and a thorough search for a fundamental neurological reason. An assessment of higher mental functions and their age-appropriateness, a basic neurological assessment, including the back and spine, and a targeted neuro-urological assessment must all be part of the medical examination. The bowel function should be thoroughly examined.

Voiding Dysfunction Diagnosis

Most children can keep dry during the day by the age of four. Voiding dysfunction isn't identified until a child is beyond the age of four and hasn't had an accident during the day for at least six months after finishing toilet training. The child will get a physical checkup as a first step to see if there are any anatomical or physiological issues that could be triggering daytime wetting.

If the physical examination reveals no problems, the doctor may conduct the following non-invasive tests:

• Urinalysis: A urinary tract infection, which can promote incontinence and urgency, will be examined in the child's urine.
• Ultrasound of the Kidney and Bladder: This imaging technique can demonstrate how well the child can clear their bladder.
• Uroflow EMG (electromyogram): this test determines how well the bladder receives brain impulses.
• The KUB is a form of X-ray that is used to evaluate if constipation is the cause of urine incontinence.

Physicians may offer these tests if the kid has complex symptoms or symptoms that do not respond to treatment:

• Urodynamic testing involves inserting a catheter into the urethra and filling the bladder with saline (saltwater) to allow doctors to assess the bladder's strength.
• The VCUG (Voiding Cystourethrogram) test determines how effectively the child's bladder functions. Urodynamic evaluation can be used in conjunction with VCUG.
• Magnetic Resonance Imaging of the spine: If doctors suspect the child has a neurogenic bladder, they may recommend an MRI of the spine. Despite the fact that this is a non-invasive technique, most children will need to be sedated.

Voiding Dysfunction Treatment

The goal of DV treatment is to teach patients how to relax the bladder outlet when voiding. Several treatments have been tried, including suggestion or hypnotherapy, bladder reconditioning, bladder drilling, biofeedback for the pelvic floor, anticholinergic drugs to relax the bladder, and alpha-adrenergic blockers to relax the bladder neck, but no single strategy works reliably. For individuals lacking high-risk factors, conservative urotherapy with biofeedback is an appropriate first line of treatment. Those with high-risk signs may need to start clean intermittent self-catheterization as soon as possible.

The therapy of these individuals is identical to that of classical neurogenic bladder patients, including clean intermittent catheterization and storage pressure control methods. Renal replacement therapy, such as dialysis and transplantation, will be required for patients who deteriorate despite treatment or who present with renal dysfunction. The absence of high-quality data makes it difficult to draw treatment conclusions.

Urotherapy

Urotherapy is a term that refers to all non-pharmacological, non-surgical treatments that can improve urinary tract function. Urotherapy has been shown to minimize constipation, urinary infections, and vesicoureteral reflux therapies in pediatric patients. Urotherapys’ many elements are not standardized, and the measures can be used in conjunction with medication. Urotherapy must be a continuous procedure. The initial assessment, training, and management are all part of the first step. Step two involves a series of biofeedback sessions, which include teaching the child how to recognize and contract/relax the pelvic floor muscles while watching a uroflow curve. Step three is continuous bowel care, keeping a voiding diary, and doing pelvic floor exercises. The diagnosis of chronic behavioral and psychological disorders is the final phase. When combined with a progression of treatment based on the response, this management strategy has been shown to have a 95-100 percent success rate in children with DV. It's important to keep in mind that many youngsters have been diagnosed solely on the basis of storage symptoms and a staccato uroflow.

• Bowel care impact

A link between gastrointestinal symptoms and the urinary tract has been proposed by several writers. In a population-based study in South Korea, 46 percent of people had symptoms of DV, 31 percent had abnormal bowel function, and 18 percent had both, indicating a statistically significant correlation. The most prevalent theory has been that the two systems (S2 and S4) share similar innervation and are anatomically close. It's likely that the aberrant pelvic floor function that causes DV could also cause constipation on its own. Others, on the other hand, have not discovered a link. Constipation therapy that is aggressive may have an independent positive effect on urinary tract function, and one-third of children may be able to avoid recurring urinary infections.

• Biofeedback

The assumption behind behavioral therapy is that the condition is learned and thus theoretically changeable. Children as young as four years old have benefited from biofeedback. Up to 81% of children will recover, with less incontinence and recurrent urine infections. Multiple sittings are required, as well as occasional reinforcement. Improvements in flow rates and residual urine aren't always linked to better results. At three years, the treatment appears to be effective, and it even appears to help children who have failed urotherapy. Incorporating biofeedback into urotherapy is more probable to result in a reduction in residual urine.

Visual feedback of the uroflow curve and educating perineal muscle identification with EMG electrodes are two main approaches to biofeedback. The former is frequently the faster option. It's possible to employ cyclical uroflow sessions with audio feedback, charts, or animation. Biofeedback may also help children with DV who have paradoxical pelvic floor movement. However, the clinical implications of this observation, which occurs in 32% of healthy youngsters, are unknown.

Alpha Blockers

In a formal sense, an alpha-blocker would not be expected to assist voiding in patients with DV, which targets the striated sphincter rather than the bladder neck. Alpha-blockers have been demonstrated to increase symptomatic relief in modest studies. Because objective improvement may not be seen, urodynamic verification of response is recommended in individuals with severe DV. Both adults and children tolerate the treatment well.

Botulinum Toxin

Injections of botulinum toxin into the sphincter have been shown to be beneficial in small case studies. The injection of 500 units of Dysport (Botulinum toxin A) into the external urethral sphincter of nine girls with refractory DV resulted in a considerable rise in voided volume and a decrease in post-void residual, but no change in uroflow rates. Seven girls were able to get rid of their voiding issues. At a six-month follow-up, four of the six girls who had incontinence before the injection had their incontinence cured. In another study, after botulinum toxin, six of eight adult patients with DV voided. The injection is commonly delivered periurethral in women, while it is injected cystoscopically into the sphincter in men. Botulinum toxin takes one to two weeks to take action. In the meanwhile, patients may be provided an indwelling catheter or intermittent self-catheterization.

Neuromodulation

Intractable lower urinary tract dysfunction has been treated with sacral neuromodulation. Neuromodulation's efficiency and efficacy have been thoroughly established. In around three-quarters of youngsters, storage symptoms go away. Children with Down syndrome were featured in two series. The response of DV to the Interstim neuromodulation device was minimal. One of four children in one trial had their retention alleviated, while three of six children on clean intermittent catheterization were able to quit catheterizing in the other. Approximately 62% of children with voiding difficulties benefited from this trial. Despite the fact that both studies conducted pre-treatment urodynamics, neither study reported the results. Neuromodulation also has the added benefit of possibly reducing constipation and irritable bowel symptoms. Patients with DV have been proven to benefit from percutaneous tibial nerve stimulation administered for 35 minutes on a weekly basis for 12 weeks. When compared to patients with overactive bladder, those with DV were considerably more likely to benefit. When compared to residual urine and flow rates, however, storage symptoms were more likely to show an objective advantage.

Long-term outcomes in women with Fowler's syndrome, a kind of DV, are now known, and demonstrate that 79 percent of women continue to empty spontaneously after ten years. Neuromodulation necessitates close monitoring and is not without danger. In 27 percent of patients, the procedure will fail, and 35-50 percent will require revision.

Conclusion

Voiding dysfunction is a prevalent problem among young males. Uroflowmetry is indicated as an important screening tool for individuals with suspected voiding dysfunction, despite the fact that the risk factors for this disorder are yet unknown. In cases of poor urine flow, a video urodynamic study is recommended to provide an accurate diagnosis. The two most common causes of voiding dysfunction in young males are primary bladder neck obstruction and dysfunctional voiding. Medical treatment with a -blocker, surgical treatment with TUIBN, and urotherapy and/or baclofen for DV were all recommended as treatment possibilities. The effect of BoNT-A injections on voiding dysfunction in these patients has been documented in several studies. These studies, on the other hand, tended to have small patient populations and lacked randomization and a control group. More well-designed trials are needed to give more evidence of effective management approaches for young men with voiding dysfunction.