REVIEW URRENT C OPINION
Dysfunctional voiding Walter Artibani and Maria A. Cerruto
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. Keywords dysfunctional voiding, female urinary retention, female urology, Fowler’s syndrome, lower urinary tract dysfunction
INTRODUCTION The field of female urology covers a broad spectrum of pelvic and lower urinary tract disorders prevalent in women, including female voiding dysfunction and urinary retention. Normal voiding in women is achieved by an initial (voluntary) reduction in intraurethral pressure (urethral relaxation) [1,2]. This is generally followed by a continuous detrusor contraction that leads to complete bladder emptying within a normal time span. Many women will void successfully [normal flow rate and no postvoid residual (PVR) urine volume] by urethral relaxation alone, without a rise in detrusor pressure [1,2]. Failure of any of these synergic mechanisms leads to voiding dysfunction and consequently urinary retention. This pathological condition – female dysfunctional voiding (FDV) – may be initiated as a learned response to bladder outlet obstruction (BOO) or detrusor underactivity or acontractility. BOO is the generic term for obstruction during www.co-urology.com
voiding [1,2]. It is a reduced urine flow rate and/or presence of a raised PVR and an increased detrusor pressure. It is usually diagnosed by studying the synchronous values of urine flow rate and detrusor pressure. Female BOO may be due to either anatomical [vaginal prolapse, anti-incontinence surgery, urethral stricture, urethral diverticulum, urethral tumours, primary bladder neck obstruction (PBNO)] or functional (detrusor-sphincter dyssinergia, or dysfunctional voiding) causes. FDV is considered a learned behaviour and is defined as an intermittent and/or fluctuating flow due to involuntary intermittent contractions of the periurethral Urology Clinic, University Hospital of Verona, Verona, Italy Correspondence to Walter Artibani, MD, EAU Adjunct Secretary General & Executive Member Science, Professor and Chair of Urology, University Hospital of Verona, Verona, Italy. e-mail: [email protected] Curr Opin Urol 2014, 24:330–335 DOI:10.1097/MOU.0000000000000074 Volume 24 Number 4 July 2014
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Dysfunctional voiding Artibani and Cerruto
KEY POINTS FDV is the most common described disorder of a nonneurogenic, nonstructural cause leading to voiding difficulty in women. FDV is part of a ‘female voiding dysfunction complex’, whose diagnostic work-up and treatment are problematic. Females with dysfunctional voiding did not demonstrate a difference in effortful control, but did demonstrate a higher rate of surgency. Sacral neuromodulation demonstrated a satisfying longterm efficacy in the treatment of Fowler’s syndrome.
striated or levator muscles during voiding in neurologically normal women [1,2]. This type of voiding may also result from abdominal straining to compensate for an acontractile detrusor (abdominal voiding). Electromyography (EMG) or video-urodynamics is required to distinguish between the two entities [1,2]. FDV should replace the plethora of terms that are used to describe dyssynergic voiding without an apparent neurological cause in women [3]. It should be clearly recognized that the diagnosis would be made by exclusion of a neurological cause and/or EMG pattern of a guarding after initiation of the detrusor contraction. In some women with FDV, a revised diagnosis of detrusor sphincter dyssynergia may be established in case a neurological problem was to surface subsequently [3]. This is particularly possible in patients with multiple sclerosis. Otherwise, such disturbances are best called ‘voiding dysfunction’, a term that does not specify any particular cause [3]. Within the spectrum of female voiding dysfunction and urinary retention different entities and syndromes can be considered [4 ,5 ]. The aim of this study is to give a brief comprehensive review of the most recent progresses in female voiding dysfunction, outlining possible key advances in this field. &
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FEMALE DYSFUNCTIONAL VOIDING Female dysfunctional voiding is probably one of the most common disorders of a non-neurogenic, nonstructural cause leading to voiding difficulty in women [6]. Its true estimate in the general population is not well known and its reported estimates are based on questionable methodology, and its wide variability depends on different definition used and methodology adopted. It occurs in up to 2% of adults referred for urodynamic assessment [7].
Choi et al. [8] performed a prospective, multicentre study at nine hospitals to investigate the characteristics and prevalence of female voiding dysfunction. A total of 1415 women visited urology clinics in nine hospitals from September to December 2005. Among them, 792 patients presented with lower urinary tract symptoms (LUTS). The authors analysed these urinary symptoms with an International Prostate Symptom Score (IPSS) and obtained objective data using uroflowmetry, PVR urine volume, and urinalysis. The authors hereby defined voiding dysfunction as maximum flow rate (Qmax) of 15 ml/s or less, which may be due to either BOO or bladder dysfunction caused by detrusor underactivity. BOO was defined as Qmax less than 15 ml/s with detrusor pressure greater than 20 cmH2O at Qmax, and detrusor underactivity was defined as Qmax less than 15 ml/s with detrusor pressure greater than 20 cmH2O at Qmax on pressure flow studies. One hundred and two patients (12.8%) from a total of 792 LUTS patients complained of voiding difficulty. Among the IPSS categories, incomplete emptying was the most common symptom followed by weak stream. Eighty-nine patients (87.2%) from a total of 102 voiding dysfunction patients showed BOO, whereas 13 patients (12.8%) showed detrusor underactivity. Concomitant diseases observed with voiding dysfunction were overactive bladder (OAB) (32 patients), stress urinary incontinence (SUI) (25), detrusor underactivity (13), previous SUI surgery (12), pelvic organ prolapse (4), and anatomical obstruction (3 patients). The authors concluded that the prevalence of voiding difficulty in female urology patients who visit urologic office clinic was 7.2 of all patients and 12.8 of those with LUTS. Moreover, voiding symptoms were more common than storage symptoms, whereas functional BOO was more prevalent than detrusor underactivity in FDV patients [8]. Adult women with FDV often present with a history of voiding difficulty or unexplained retention. It is thought to represent a learned behaviour in response to an adverse event or condition such as inflammation, infection, trauma or irritation in childhood or adult life [1,7,9]. 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 [7]. 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, and the careful search for a primary neurological cause. Clinical examination must include an assessment of higher mental functions and their age appropriateness, basic neurological evaluation including back and spine and a
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focused neuro-urological examination. Bowel function should be evaluated in detail too [3]. Recently, Colaco et al. [10 ] studied the relationship between temperament, sex and childhood dysfunctional voiding. The authors’ findings in female participants were puzzling. The only dimension to show a meaningful finding was surgency, and it was found that surgency was positively correlated with dysfunctional voiding. This finding is surprising because surgency is generally considered to be a positive trait. As such, it seems counterintuitive that such a trait would be associated with a maladaptive behaviour such as dysfunctional voiding. In addition, whereas in men, effortful control was an integral (and expected) factor, in women, this was not the case: effortful control was not significantly higher in the nondysfunctional voiding group than the dysfunctional voiding group. One possible explanation to these findings is in the nature of surgency itself and its subsequent impact on women [10 ]. Although surgency is associated with positive social skills, it is likewise associated with an increased risk of emotional dysregulation and subsequent externalizing behaviour problems. Furthermore, poor emotional regulation has been found to be a stronger predictor of externalizing behaviour problems in girls, whereas boys’ problems have been better predicted by inattention. Thus, it is possible that dysfunctional voiding represents a manifestation of such an externalized problem, and consequently shares the same temperament associations. For the women with dysfunctional voiding, there appears to be a significant emotional aspect associated with the physical dysfunction. Dysfunctional voiding therapy for female children should address this finding and may be more successful if it involves psychological intervention to address emotional concerns, in addition to the physical therapy [10 ]. Given the multifactorial cause of dysfunctional voiding and the likely behavioural component, it therefore seems reasonable that the impact of temperament reflects other behavioural problems. Further research is needed to replicate and extend these findings [10 ]. Toilet training is an important marker of physical and psychosocial development in children and is considered to be a key developmental milestone. Comparing the effectiveness of parentoriented toilet training methods with child-oriented toilet training methods, Colaco et al. [11 ] looked at the rates of dysfunctional voiding between populations of patients trained using each method. This case-control study showed that the method used for toilet training had no association with the development of dysfunctional voiding symptoms [11 ]. This information may be helpful for parents of children &
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with dysfunctional voiding who feel guilty for using the wrong training method. Further research should be conducted to substratify the toilet training methods in order to find any significant difference, but as of now, parent-oriented and child-oriented toilet training should be considered equally effective [11 ]. Brucker et al. [12] tried to characterize the symptoms and urodynamic findings of anatomical BOO and functional BOO in adult women and to determine if future endeavours at defining BOO in women can group these entities together. One hundred and fifty-seven women were retrospectively identified, of which 86 (54.8%) were classified as having anatomical BOO and 71 (45.2%) were classified as having functional BOO. Patients were categorized as having anatomical BOO if obstruction was due to an anatomical cause: prolapse, anti-incontinence surgery, stricture, or extrinsic obstruction [2]. Patients categorized as having functional BOO showed PBNO, dysfunctional voiding, or detrusorexternal sphincter dyssynergia (DESD). Because dysfunctional voiding and DESD have considerable overlap in mechanisms of obstruction, the authors also specifically compared the clinical and urodynamic findings between the two [12]. They did not document any differences in symptoms between anatomical and functional BOO. Moreover, they did not observe any difference in the mean detrusor pressure at Qmax between the two groups. There was a difference in the Qmax between anatomical and functional BOO (P ¼ 0.004), but there was considerable overlap between the values in these two groups. Although Qmax was significantly lower in women with anatomical BOO, because of a large overlap in this parameter, urodynamics cannot be considered useful in differentiating anatomical from functional BOO. The main goals in the treatment of FDV are to normalize micturition patterns and prevent complications. Training with pelvic floor physiotherapy and biofeedback has been shown to be effective and has become the first-line treatment for women with dysfunctional voiding [13]. Because certain individuals with FDV demonstrated significant psychological abnormalities, this group of patients may benefit from a multidisciplinary approach, including a psychologist or other mental health professional [13]. Other possible therapeutic options are gammaaminobutyric acid receptor agonists, vaginal and oral benzodiazepine, botulinum toxin injected into the external urethral sphincter (EUS), antiadrenergic drugs and sacral neuromodulation (SNM). Unfortunately, none can be recommended with a high level of evidence because of poor quality, limited data, or nonspecificity for FDV. &
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Dysfunctional voiding Artibani and Cerruto
OTHER CAUSES OF FEMALE VOIDING DYSFUNCTION AND URINARY RETENTION Other causes of voiding dysfunction and urinary retention in women, after exclusion of mechanical or neurological causes, include Fowler’s syndrome, PBNO, idiopathic detrusor underactivity (IDU), pseudo-chronic intestinal obstruction, and postoperative urinary retention (POUR). Fowler’s syndrome was first described in 1988 as a syndrome characterized by a failure of urethral relaxation on electromyographic studies of the EUS in young women with unexplained urinary retention associated with polycystic ovary syndrome [14] Recently, Osman and Chapple [5 ] published an exhaustive narrative review, discussing the contemporary literature relating to the epidemiology, cause, pathogenesis and management options of this rare syndrome. From this review, it emerged that most studies of Fowler’s syndrome are limited due to small cohorts with no control group and a lack of video-urodynamic data. Whether Fowler’s syndrome represents a distinct cause of urinary retention or results from a maladaptive behaviour similar to dysfunctional voiding is unclear. Application of SNM in patients diagnosed with Fowler’s syndrome can restore normal voiding, in the absence of any effective pharmacotherapy or surgical treatment. Actually, SNM is an effective, minimally invasive technique for the management of nonobstructive urinary retention (NOUR). Peeters et al. [15 ] published their long-term results in the treatment of lower urinary tract dysfunction (LUTD) with SNM. They analysed 217 patients who received an implantable pulse generator (IPG) implant for LUTD from 1996 to 2010. At a mean follow-up of 46.8 months, success and cure rates for idiopathic retention was 73 and 58%, respectively, which is better than urgency incontinence (70 and 20%, respectively) and urgency frequency syndrome (68 and 33%, respectively) [15 ]. Overall SNM appears efficacious in the long term with a success rate after definitive impulse generator implant of approximately 70% and complete cure rates ranging between 20 and 58%, depending on indication. Patients with idiopathic retention appear to do best [15 ]. Thus, it should be the first choice after failure of maximal conservative therapy in the management of functional urinary retention. In order to optimize the duration of assessment of stage 1 SNM in women with NOUR, Elneil et al. [16] assessed 24 female patients with NOUR after stage 1 SNM over an 8-week period and asked to record the restoration of normal bladder sensation and voiding. Qualitative and quantitative statistics were used to assess the outcomes and the influence of prognostic factors. Normal bladder sensation was &
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restored on the same day as switching on the battery after stage 1 in seven patients (29.2%), whereas in 17 patients, it occurred between days 2 and 31 (mean 9 days). Similarly, the mean onset of voiding was also 9 days (range 2–31 days). After day 15, 21% of the patients voided. The mean lag time between the restoration of bladder sensation and voiding was 3.6 days. By day 17, a cumulative percentage of 90% of patients had a normalized bladder sensation and 80% had commenced voiding. Stage 1 SNM may be left in situ for up to 4 weeks to ensure the maximum chance of restoring normal bladder function in this complex group of patients [16]. Also percutaneous tibial nerve stimulation (PTNS) has been proposed for the treatment of NOUR, but the experience in this field is limited to few published papers. According to these papers, the rates of patients successfully treated are good, ranging from 41 to 100%, according to the parameters chosen to classify ‘success’ [17 ]. These promising results have to be confirmed by randomized controlled studies. Further studies are needed to assess the exact role of PTNS in these indications and to evaluate the long-term durability of the treatment. Primary bladder neck obstruction is a condition in which the flow of urine is impaired due to incomplete bladder neck opening. Initial management is with alpha-blockers. When medical therapy fails, transurethral incision of the bladder neck (TUI-BN) has been used effectively. Encouraging short-term results have been obtained using a transurethral bladder neck incision with 2-micron continuous wave laser (RevoLix) in the management of 14 women with BOO [18]. Idiopathic detrusor underactivity is a common urologic problem in elderly patients presenting with urine retention and LUTS. Its treatment goal for detrusor underactivity is focused on reducing PVR urine volume and preventing urinary tract infection. Medical treatment of detrusor underactivity does not always achieve satisfactory results. For this reason, Jhang et al. [19] retrospectively reported the surgical outcomes of TUI-BN in 31 women with detrusor underactivity and urine retention in whom medical treatment failed. PVR urine volume, voiding efficiency, and Qmax significantly improved after TUI-BN. PVR urine volume decreased by 56.3% overall. Intermittent catheterization was needed in 27 patients before surgery and in only seven after TUI-BN. There were 14 (45.2%), 11 (35.5%), and six (19.3%) patients with excellent, moderate, and poor surgical outcomes, respectively. Baseline urodynamic parameters, age, and causes did not impact surgical outcome. Three patients developed transient urinary incontinence, and one developed vesico-vaginal fistula after TUI-BN. TUI-BN is an
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unproven procedure to improve PVR urine volume, Qmax, and voiding efficiency in women with IDU and urine retention. A prospective study should be performed to validate the effectiveness of TUI-BN in female patients with IDU. Underlying cause, baseline PVR, urodynamic parameters, and age did not impact therapeutic results. Postoperative urinary retention is quite common after anaesthesia and surgery, and reported incidence is between 5 and 70% [20]. Comorbidities, type of surgery, and type of anaesthesia influence the development of POUR. Its pathogenesis is uncertain. Male sex and advanced age are known risk factors. POUR is highly prevalent in hip fracture patients, and in female (but not male) patients, it has been found to be predictive of adverse motor functional independence measure gain (P ¼ 0.046) [21]. Possible risk factors of POUR after hip surgery for femoral neck fracture in elderly women may be the indwelling period of the urethral catheter, and preoperative dementia and/or delirium [22]. Postoperative urinary retention is also a recognized complication of laparoscopic surgery. NesbittHawes et al. [23] carried out a prospective observational study of 147 women undergoing laparoscopic gynaecological surgery for benign pathology, with the aim of determining the incidence of urinary retention following laparoscopic gynaecological surgery with or without the use of 4% icodextrin solution, which in a previous study had been associated to urinary retention. The women in the nonicodextrin group were significantly older (P ¼ 0.007) and had a higher BMI (P ¼ 0.03) than those in the icodextrin group. Following surgery, 21.8% of women had POUR. Icodextrin was associated with significantly more urinary retention (P ¼ 0.017), but did not extend hospital admission significantly [22]. The administration of icodextrin was associated with resection of moderate or severe-stage endometriosis involving multiple surgical sites, whereas women in the nonicodextrin group were more likely to be having a hysterectomy [22]. In this nonrandomized study, there were significantly more women with POUR when icodextrin was used; however, this did not contribute to an extended hospital admission. Although there may be confounding factors, women receiving icodextrin should be warned of the possibility of urinary retention postoperatively, but that this is unlikely to affect their stay in the hospital [22].
CONCLUSION In 2013, many diagnostic and therapeutic questions in FDV remain unsolved. However, some data began to emerge. FDV is an inhomogeneous entity not well 334
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understood and underdiagnosed, with several possible distinct causes that can lead to it, causing a dyssinergic sphincter activity in the absence of a clearly defined neurological reason. It is part of a ‘female voiding dysfunction complex’, whose diagnostic work-up and treatment are problematic. Women with dysfunctional voiding did not demonstrate a difference in effortful control, but did demonstrate a higher rate of surgency. These findings are in line with temperamental associations with other externalizing troubled behaviours and may inform potential treatment strategies for FDV. Toilet training method in childhood does not seem to have any long-term effect on dysfunctional voiding. As such, clinicians should advise parents that both methods are acceptable. Training with pelvic floor physiotherapy and biofeedback represents the firstline treatment for women with dysfunctional voiding. None of the other therapeutic options proposed in the literature may be recommended with a high level of evidence because of poor quality, limited data, or specificity for FDV. In the management of other causes of female voiding dysfunction and urinary retention, SNM demonstrated a satisfying longterm efficacy in the treatment of Fowler’s syndrome and NOUR. PTNS may have a role in the management of NOUR too. In the treatment of urodynamically proven PBNO, when medical therapy fails, TUI-BN can be used safely and effectively. POUR is highly prevalent in elderly hip fracture patients. It adversely affects the functional outcome of female patients, but is not associated with increased mortality rates. Possible risk factors of POUR after hip surgery for femoral neck fracture in elderly women may be the indwelling period of the urethral catheter, and preoperative dementia and/or delirium. Women receiving icodextrin during laparoscopic gynaecological surgery for benign pathology should be warned of the possibility of POUR, but that this is unlikely to affect their stay in hospital. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003; 61:37–49.
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Dysfunctional voiding Artibani and Cerruto 2. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4–20. 3. Sinha S. Dysfunctional voiding: a review of the terminology, presentation, evaluation and management in children and adults. Indian J Urol 2011; 27:437–447. 4. Haifler M, Stav K. Dysfunctional voiding in adults. IMAJ 2013; 15:315–319. &
This narrative review aimed at characterizing dysfunctional voiding in adults, highlighting its confounding aspects. 5. Osman NI, Chapple CR. Fowler’s syndrome: a cause of unexplained urinary & retention in young women? Nat Re Urol 2014; 11:87–98. This narrative review discusses the contemporary literature relating to the epidemiology, cause, pathogenesis and management options of this rare female syndrome. 6. Carlson KV, Fiske J, Nitti VW. Value of routine evaluation of the voiding phase when performing urodynamic testing in women with lower urinary tract sympt oms. J Urol 2000; 164:1614–1618. 7. Groutz A, Blaivas JG, Pies C, et al. (Nonneurogenic, neurogenic bladder) among adults. Neurourol Urodyn 2001; 20:259–268. 8. Choi YS, Kim JC, Lee KS, et al. Analysis of female voiding dysfunct ion: a prospective, multicenter study. Int Urol Nephrol 2013; 45:989–994. 9. Carlson KV, Rome S, Nitti VW. Dysfunctional voiding in women. J Urol 2001; 165:143–147. 10. Colaco M, Dobkin RD, Sterling M, et al. The relationship between temperament, & gender, and childhood dysfunctional voiding. Clin Pediatr 2013; 52:753–758. This case-control study aimed at identifying whether temperament among dysfunctional voiding patients was different than among non-dysfunctional voiding patients. Surprisingly, women with dysfunctional voiding demonstrated a higher rate of surgency. 11. Colaco M, Johnson K, Schneider D, Barone J. Toilet training method is not & related to dysfunctional voiding. Clin Pediatr 2013; 52:49–53. This case-control study showed that toilet training method does not seem to have any long-term effect on dysfunctional voiding. As such, clinicians should advise parents that both methods are acceptable. 12. Brucker BM, Shah S, Mitchell S, et al. Comparison of urodynamic findings in women with anatomical versus functional bladder outlet obstruction. Female Pelvic Med Reconstr Surg 2013; 19:46–50.
13. Hickling D, Aponte M, Nitti V. Evaluation and management of outlet obstruction in women without anatomical abnormalities on physical exam or cystoscopy. Curr Urol Rep 2012; 13:356–362. 14. Fowler CJ, Christmas TJ, Chapple CR, et al. Abnormal electromyographic activity of the urethral sphincter, voiding dysfunction, and polycystic ovaries: a new syndrome? Br Med J 1988; 297:1436–1438. 15. Peeters K, Sahai A, de Ridder D, van der Aa F. Long term follow up of sacral & neuromodulation for lower urinary tract dysfunction. BJU Int 2013. This long-tem analysis of 217 patients with a definitive implant of SNM for LUTD showed a success rate of 70% and a cure rate up to 58% depending on indication, obtaining the best results in patients with idiopathic retention. 16. Elneil S, Abtahi B, Helal M, et al. Optimizing the duration of assessment of stage-1 sacral neuromodulation in nonobstructive chronic urinary retention. Neuromodulation 2014; 17:66–70. 17. Gaziev G, Topazio L, Iacovelli V, et al. Percutaneous tibial nerve stimulation & (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC Urol 2013; 13:61. This systematic review of four nonrandomized clinical trials about NOUR showed promising results that have to be confirmed by RCT. 18. Sharifiaghdas F, Kardoust Parizi M, Ahadi B. Efficacy of transurethral bladder neck incision with 2-micron continuous wave laser (RevoLix) for the management of bladder outlet stricture in women. Urol J 2013; 10: 790–794. 19. Jhang JF, Jiang YH, Kuo HC. Transurethral Incision of the bladder neck improves voiding efficiency in female patients with detrusor underactivity. Int Urogynecol J 2014; 25:671–676. 20. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009; 110: 1139–1157. 21. Adunsky A, Nenaydenko O, Koren-Morag N, et al. Perioperative urinary retention, short- term functional outcome and mortality rates of elderly hip fracture patients. Geriatr Gerontol Int 2014; doi: 10.1111/ggi.12229. [Epub ahead of print] 22. Tobu S, Noguchi M, Hashikawa T, Uozumi J. Risk factors of postoperative urinary retention after hip surgery for femoral neck fracture in elderly women. Gerontol Int 2013; doi: 10.1111/ggi.12150. [Epub ahead of print] 23. Nesbitt-Hawes EM, Zhang CS, Won HR, et al. Urinary retention following laparoscopic gynaecological surgery with or without 4% icodextrin antiadhesion solution. Aust N Z J Obstet Gynaecol 2013; 53:305–309.
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Dysfunctional voiding Walter Artibani and Maria A. Cerruto
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. Keywords dysfunctional voiding, female urinary retention, female urology, Fowler’s syndrome, lower urinary tract dysfunction
INTRODUCTION The field of female urology covers a broad spectrum of pelvic and lower urinary tract disorders prevalent in women, including female voiding dysfunction and urinary retention. Normal voiding in women is achieved by an initial (voluntary) reduction in intraurethral pressure (urethral relaxation) [1,2]. This is generally followed by a continuous detrusor contraction that leads to complete bladder emptying within a normal time span. Many women will void successfully [normal flow rate and no postvoid residual (PVR) urine volume] by urethral relaxation alone, without a rise in detrusor pressure [1,2]. Failure of any of these synergic mechanisms leads to voiding dysfunction and consequently urinary retention. This pathological condition – female dysfunctional voiding (FDV) – may be initiated as a learned response to bladder outlet obstruction (BOO) or detrusor underactivity or acontractility. BOO is the generic term for obstruction during www.co-urology.com
voiding [1,2]. It is a reduced urine flow rate and/or presence of a raised PVR and an increased detrusor pressure. It is usually diagnosed by studying the synchronous values of urine flow rate and detrusor pressure. Female BOO may be due to either anatomical [vaginal prolapse, anti-incontinence surgery, urethral stricture, urethral diverticulum, urethral tumours, primary bladder neck obstruction (PBNO)] or functional (detrusor-sphincter dyssinergia, or dysfunctional voiding) causes. FDV is considered a learned behaviour and is defined as an intermittent and/or fluctuating flow due to involuntary intermittent contractions of the periurethral Urology Clinic, University Hospital of Verona, Verona, Italy Correspondence to Walter Artibani, MD, EAU Adjunct Secretary General & Executive Member Science, Professor and Chair of Urology, University Hospital of Verona, Verona, Italy. e-mail: [email protected] Curr Opin Urol 2014, 24:330–335 DOI:10.1097/MOU.0000000000000074 Volume 24 Number 4 July 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dysfunctional voiding Artibani and Cerruto
KEY POINTS FDV is the most common described disorder of a nonneurogenic, nonstructural cause leading to voiding difficulty in women. FDV is part of a ‘female voiding dysfunction complex’, whose diagnostic work-up and treatment are problematic. Females with dysfunctional voiding did not demonstrate a difference in effortful control, but did demonstrate a higher rate of surgency. Sacral neuromodulation demonstrated a satisfying longterm efficacy in the treatment of Fowler’s syndrome.
striated or levator muscles during voiding in neurologically normal women [1,2]. This type of voiding may also result from abdominal straining to compensate for an acontractile detrusor (abdominal voiding). Electromyography (EMG) or video-urodynamics is required to distinguish between the two entities [1,2]. FDV should replace the plethora of terms that are used to describe dyssynergic voiding without an apparent neurological cause in women [3]. It should be clearly recognized that the diagnosis would be made by exclusion of a neurological cause and/or EMG pattern of a guarding after initiation of the detrusor contraction. In some women with FDV, a revised diagnosis of detrusor sphincter dyssynergia may be established in case a neurological problem was to surface subsequently [3]. This is particularly possible in patients with multiple sclerosis. Otherwise, such disturbances are best called ‘voiding dysfunction’, a term that does not specify any particular cause [3]. Within the spectrum of female voiding dysfunction and urinary retention different entities and syndromes can be considered [4 ,5 ]. The aim of this study is to give a brief comprehensive review of the most recent progresses in female voiding dysfunction, outlining possible key advances in this field. &
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FEMALE DYSFUNCTIONAL VOIDING Female dysfunctional voiding is probably one of the most common disorders of a non-neurogenic, nonstructural cause leading to voiding difficulty in women [6]. Its true estimate in the general population is not well known and its reported estimates are based on questionable methodology, and its wide variability depends on different definition used and methodology adopted. It occurs in up to 2% of adults referred for urodynamic assessment [7].
Choi et al. [8] performed a prospective, multicentre study at nine hospitals to investigate the characteristics and prevalence of female voiding dysfunction. A total of 1415 women visited urology clinics in nine hospitals from September to December 2005. Among them, 792 patients presented with lower urinary tract symptoms (LUTS). The authors analysed these urinary symptoms with an International Prostate Symptom Score (IPSS) and obtained objective data using uroflowmetry, PVR urine volume, and urinalysis. The authors hereby defined voiding dysfunction as maximum flow rate (Qmax) of 15 ml/s or less, which may be due to either BOO or bladder dysfunction caused by detrusor underactivity. BOO was defined as Qmax less than 15 ml/s with detrusor pressure greater than 20 cmH2O at Qmax, and detrusor underactivity was defined as Qmax less than 15 ml/s with detrusor pressure greater than 20 cmH2O at Qmax on pressure flow studies. One hundred and two patients (12.8%) from a total of 792 LUTS patients complained of voiding difficulty. Among the IPSS categories, incomplete emptying was the most common symptom followed by weak stream. Eighty-nine patients (87.2%) from a total of 102 voiding dysfunction patients showed BOO, whereas 13 patients (12.8%) showed detrusor underactivity. Concomitant diseases observed with voiding dysfunction were overactive bladder (OAB) (32 patients), stress urinary incontinence (SUI) (25), detrusor underactivity (13), previous SUI surgery (12), pelvic organ prolapse (4), and anatomical obstruction (3 patients). The authors concluded that the prevalence of voiding difficulty in female urology patients who visit urologic office clinic was 7.2 of all patients and 12.8 of those with LUTS. Moreover, voiding symptoms were more common than storage symptoms, whereas functional BOO was more prevalent than detrusor underactivity in FDV patients [8]. Adult women with FDV often present with a history of voiding difficulty or unexplained retention. It is thought to represent a learned behaviour in response to an adverse event or condition such as inflammation, infection, trauma or irritation in childhood or adult life [1,7,9]. 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 [7]. 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, and the careful search for a primary neurological cause. Clinical examination must include an assessment of higher mental functions and their age appropriateness, basic neurological evaluation including back and spine and a
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focused neuro-urological examination. Bowel function should be evaluated in detail too [3]. Recently, Colaco et al. [10 ] studied the relationship between temperament, sex and childhood dysfunctional voiding. The authors’ findings in female participants were puzzling. The only dimension to show a meaningful finding was surgency, and it was found that surgency was positively correlated with dysfunctional voiding. This finding is surprising because surgency is generally considered to be a positive trait. As such, it seems counterintuitive that such a trait would be associated with a maladaptive behaviour such as dysfunctional voiding. In addition, whereas in men, effortful control was an integral (and expected) factor, in women, this was not the case: effortful control was not significantly higher in the nondysfunctional voiding group than the dysfunctional voiding group. One possible explanation to these findings is in the nature of surgency itself and its subsequent impact on women [10 ]. Although surgency is associated with positive social skills, it is likewise associated with an increased risk of emotional dysregulation and subsequent externalizing behaviour problems. Furthermore, poor emotional regulation has been found to be a stronger predictor of externalizing behaviour problems in girls, whereas boys’ problems have been better predicted by inattention. Thus, it is possible that dysfunctional voiding represents a manifestation of such an externalized problem, and consequently shares the same temperament associations. For the women with dysfunctional voiding, there appears to be a significant emotional aspect associated with the physical dysfunction. Dysfunctional voiding therapy for female children should address this finding and may be more successful if it involves psychological intervention to address emotional concerns, in addition to the physical therapy [10 ]. Given the multifactorial cause of dysfunctional voiding and the likely behavioural component, it therefore seems reasonable that the impact of temperament reflects other behavioural problems. Further research is needed to replicate and extend these findings [10 ]. Toilet training is an important marker of physical and psychosocial development in children and is considered to be a key developmental milestone. Comparing the effectiveness of parentoriented toilet training methods with child-oriented toilet training methods, Colaco et al. [11 ] looked at the rates of dysfunctional voiding between populations of patients trained using each method. This case-control study showed that the method used for toilet training had no association with the development of dysfunctional voiding symptoms [11 ]. This information may be helpful for parents of children &
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with dysfunctional voiding who feel guilty for using the wrong training method. Further research should be conducted to substratify the toilet training methods in order to find any significant difference, but as of now, parent-oriented and child-oriented toilet training should be considered equally effective [11 ]. Brucker et al. [12] tried to characterize the symptoms and urodynamic findings of anatomical BOO and functional BOO in adult women and to determine if future endeavours at defining BOO in women can group these entities together. One hundred and fifty-seven women were retrospectively identified, of which 86 (54.8%) were classified as having anatomical BOO and 71 (45.2%) were classified as having functional BOO. Patients were categorized as having anatomical BOO if obstruction was due to an anatomical cause: prolapse, anti-incontinence surgery, stricture, or extrinsic obstruction [2]. Patients categorized as having functional BOO showed PBNO, dysfunctional voiding, or detrusorexternal sphincter dyssynergia (DESD). Because dysfunctional voiding and DESD have considerable overlap in mechanisms of obstruction, the authors also specifically compared the clinical and urodynamic findings between the two [12]. They did not document any differences in symptoms between anatomical and functional BOO. Moreover, they did not observe any difference in the mean detrusor pressure at Qmax between the two groups. There was a difference in the Qmax between anatomical and functional BOO (P ¼ 0.004), but there was considerable overlap between the values in these two groups. Although Qmax was significantly lower in women with anatomical BOO, because of a large overlap in this parameter, urodynamics cannot be considered useful in differentiating anatomical from functional BOO. The main goals in the treatment of FDV are to normalize micturition patterns and prevent complications. Training with pelvic floor physiotherapy and biofeedback has been shown to be effective and has become the first-line treatment for women with dysfunctional voiding [13]. Because certain individuals with FDV demonstrated significant psychological abnormalities, this group of patients may benefit from a multidisciplinary approach, including a psychologist or other mental health professional [13]. Other possible therapeutic options are gammaaminobutyric acid receptor agonists, vaginal and oral benzodiazepine, botulinum toxin injected into the external urethral sphincter (EUS), antiadrenergic drugs and sacral neuromodulation (SNM). Unfortunately, none can be recommended with a high level of evidence because of poor quality, limited data, or nonspecificity for FDV. &
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Dysfunctional voiding Artibani and Cerruto
OTHER CAUSES OF FEMALE VOIDING DYSFUNCTION AND URINARY RETENTION Other causes of voiding dysfunction and urinary retention in women, after exclusion of mechanical or neurological causes, include Fowler’s syndrome, PBNO, idiopathic detrusor underactivity (IDU), pseudo-chronic intestinal obstruction, and postoperative urinary retention (POUR). Fowler’s syndrome was first described in 1988 as a syndrome characterized by a failure of urethral relaxation on electromyographic studies of the EUS in young women with unexplained urinary retention associated with polycystic ovary syndrome [14] Recently, Osman and Chapple [5 ] published an exhaustive narrative review, discussing the contemporary literature relating to the epidemiology, cause, pathogenesis and management options of this rare syndrome. From this review, it emerged that most studies of Fowler’s syndrome are limited due to small cohorts with no control group and a lack of video-urodynamic data. Whether Fowler’s syndrome represents a distinct cause of urinary retention or results from a maladaptive behaviour similar to dysfunctional voiding is unclear. Application of SNM in patients diagnosed with Fowler’s syndrome can restore normal voiding, in the absence of any effective pharmacotherapy or surgical treatment. Actually, SNM is an effective, minimally invasive technique for the management of nonobstructive urinary retention (NOUR). Peeters et al. [15 ] published their long-term results in the treatment of lower urinary tract dysfunction (LUTD) with SNM. They analysed 217 patients who received an implantable pulse generator (IPG) implant for LUTD from 1996 to 2010. At a mean follow-up of 46.8 months, success and cure rates for idiopathic retention was 73 and 58%, respectively, which is better than urgency incontinence (70 and 20%, respectively) and urgency frequency syndrome (68 and 33%, respectively) [15 ]. Overall SNM appears efficacious in the long term with a success rate after definitive impulse generator implant of approximately 70% and complete cure rates ranging between 20 and 58%, depending on indication. Patients with idiopathic retention appear to do best [15 ]. Thus, it should be the first choice after failure of maximal conservative therapy in the management of functional urinary retention. In order to optimize the duration of assessment of stage 1 SNM in women with NOUR, Elneil et al. [16] assessed 24 female patients with NOUR after stage 1 SNM over an 8-week period and asked to record the restoration of normal bladder sensation and voiding. Qualitative and quantitative statistics were used to assess the outcomes and the influence of prognostic factors. Normal bladder sensation was &
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restored on the same day as switching on the battery after stage 1 in seven patients (29.2%), whereas in 17 patients, it occurred between days 2 and 31 (mean 9 days). Similarly, the mean onset of voiding was also 9 days (range 2–31 days). After day 15, 21% of the patients voided. The mean lag time between the restoration of bladder sensation and voiding was 3.6 days. By day 17, a cumulative percentage of 90% of patients had a normalized bladder sensation and 80% had commenced voiding. Stage 1 SNM may be left in situ for up to 4 weeks to ensure the maximum chance of restoring normal bladder function in this complex group of patients [16]. Also percutaneous tibial nerve stimulation (PTNS) has been proposed for the treatment of NOUR, but the experience in this field is limited to few published papers. According to these papers, the rates of patients successfully treated are good, ranging from 41 to 100%, according to the parameters chosen to classify ‘success’ [17 ]. These promising results have to be confirmed by randomized controlled studies. Further studies are needed to assess the exact role of PTNS in these indications and to evaluate the long-term durability of the treatment. Primary bladder neck obstruction is a condition in which the flow of urine is impaired due to incomplete bladder neck opening. Initial management is with alpha-blockers. When medical therapy fails, transurethral incision of the bladder neck (TUI-BN) has been used effectively. Encouraging short-term results have been obtained using a transurethral bladder neck incision with 2-micron continuous wave laser (RevoLix) in the management of 14 women with BOO [18]. Idiopathic detrusor underactivity is a common urologic problem in elderly patients presenting with urine retention and LUTS. Its treatment goal for detrusor underactivity is focused on reducing PVR urine volume and preventing urinary tract infection. Medical treatment of detrusor underactivity does not always achieve satisfactory results. For this reason, Jhang et al. [19] retrospectively reported the surgical outcomes of TUI-BN in 31 women with detrusor underactivity and urine retention in whom medical treatment failed. PVR urine volume, voiding efficiency, and Qmax significantly improved after TUI-BN. PVR urine volume decreased by 56.3% overall. Intermittent catheterization was needed in 27 patients before surgery and in only seven after TUI-BN. There were 14 (45.2%), 11 (35.5%), and six (19.3%) patients with excellent, moderate, and poor surgical outcomes, respectively. Baseline urodynamic parameters, age, and causes did not impact surgical outcome. Three patients developed transient urinary incontinence, and one developed vesico-vaginal fistula after TUI-BN. TUI-BN is an
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unproven procedure to improve PVR urine volume, Qmax, and voiding efficiency in women with IDU and urine retention. A prospective study should be performed to validate the effectiveness of TUI-BN in female patients with IDU. Underlying cause, baseline PVR, urodynamic parameters, and age did not impact therapeutic results. Postoperative urinary retention is quite common after anaesthesia and surgery, and reported incidence is between 5 and 70% [20]. Comorbidities, type of surgery, and type of anaesthesia influence the development of POUR. Its pathogenesis is uncertain. Male sex and advanced age are known risk factors. POUR is highly prevalent in hip fracture patients, and in female (but not male) patients, it has been found to be predictive of adverse motor functional independence measure gain (P ¼ 0.046) [21]. Possible risk factors of POUR after hip surgery for femoral neck fracture in elderly women may be the indwelling period of the urethral catheter, and preoperative dementia and/or delirium [22]. Postoperative urinary retention is also a recognized complication of laparoscopic surgery. NesbittHawes et al. [23] carried out a prospective observational study of 147 women undergoing laparoscopic gynaecological surgery for benign pathology, with the aim of determining the incidence of urinary retention following laparoscopic gynaecological surgery with or without the use of 4% icodextrin solution, which in a previous study had been associated to urinary retention. The women in the nonicodextrin group were significantly older (P ¼ 0.007) and had a higher BMI (P ¼ 0.03) than those in the icodextrin group. Following surgery, 21.8% of women had POUR. Icodextrin was associated with significantly more urinary retention (P ¼ 0.017), but did not extend hospital admission significantly [22]. The administration of icodextrin was associated with resection of moderate or severe-stage endometriosis involving multiple surgical sites, whereas women in the nonicodextrin group were more likely to be having a hysterectomy [22]. In this nonrandomized study, there were significantly more women with POUR when icodextrin was used; however, this did not contribute to an extended hospital admission. Although there may be confounding factors, women receiving icodextrin should be warned of the possibility of urinary retention postoperatively, but that this is unlikely to affect their stay in the hospital [22].
CONCLUSION In 2013, many diagnostic and therapeutic questions in FDV remain unsolved. However, some data began to emerge. FDV is an inhomogeneous entity not well 334
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understood and underdiagnosed, with several possible distinct causes that can lead to it, causing a dyssinergic sphincter activity in the absence of a clearly defined neurological reason. It is part of a ‘female voiding dysfunction complex’, whose diagnostic work-up and treatment are problematic. Women with dysfunctional voiding did not demonstrate a difference in effortful control, but did demonstrate a higher rate of surgency. These findings are in line with temperamental associations with other externalizing troubled behaviours and may inform potential treatment strategies for FDV. Toilet training method in childhood does not seem to have any long-term effect on dysfunctional voiding. As such, clinicians should advise parents that both methods are acceptable. Training with pelvic floor physiotherapy and biofeedback represents the firstline treatment for women with dysfunctional voiding. None of the other therapeutic options proposed in the literature may be recommended with a high level of evidence because of poor quality, limited data, or specificity for FDV. In the management of other causes of female voiding dysfunction and urinary retention, SNM demonstrated a satisfying longterm efficacy in the treatment of Fowler’s syndrome and NOUR. PTNS may have a role in the management of NOUR too. In the treatment of urodynamically proven PBNO, when medical therapy fails, TUI-BN can be used safely and effectively. POUR is highly prevalent in elderly hip fracture patients. It adversely affects the functional outcome of female patients, but is not associated with increased mortality rates. Possible risk factors of POUR after hip surgery for femoral neck fracture in elderly women may be the indwelling period of the urethral catheter, and preoperative dementia and/or delirium. Women receiving icodextrin during laparoscopic gynaecological surgery for benign pathology should be warned of the possibility of POUR, but that this is unlikely to affect their stay in hospital. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003; 61:37–49.
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Dysfunctional voiding Artibani and Cerruto 2. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4–20. 3. Sinha S. Dysfunctional voiding: a review of the terminology, presentation, evaluation and management in children and adults. Indian J Urol 2011; 27:437–447. 4. Haifler M, Stav K. Dysfunctional voiding in adults. IMAJ 2013; 15:315–319. &
This narrative review aimed at characterizing dysfunctional voiding in adults, highlighting its confounding aspects. 5. Osman NI, Chapple CR. Fowler’s syndrome: a cause of unexplained urinary & retention in young women? Nat Re Urol 2014; 11:87–98. This narrative review discusses the contemporary literature relating to the epidemiology, cause, pathogenesis and management options of this rare female syndrome. 6. Carlson KV, Fiske J, Nitti VW. Value of routine evaluation of the voiding phase when performing urodynamic testing in women with lower urinary tract sympt oms. J Urol 2000; 164:1614–1618. 7. Groutz A, Blaivas JG, Pies C, et al. (Nonneurogenic, neurogenic bladder) among adults. Neurourol Urodyn 2001; 20:259–268. 8. Choi YS, Kim JC, Lee KS, et al. Analysis of female voiding dysfunct ion: a prospective, multicenter study. Int Urol Nephrol 2013; 45:989–994. 9. Carlson KV, Rome S, Nitti VW. Dysfunctional voiding in women. J Urol 2001; 165:143–147. 10. Colaco M, Dobkin RD, Sterling M, et al. The relationship between temperament, & gender, and childhood dysfunctional voiding. Clin Pediatr 2013; 52:753–758. This case-control study aimed at identifying whether temperament among dysfunctional voiding patients was different than among non-dysfunctional voiding patients. Surprisingly, women with dysfunctional voiding demonstrated a higher rate of surgency. 11. Colaco M, Johnson K, Schneider D, Barone J. Toilet training method is not & related to dysfunctional voiding. Clin Pediatr 2013; 52:49–53. This case-control study showed that toilet training method does not seem to have any long-term effect on dysfunctional voiding. As such, clinicians should advise parents that both methods are acceptable. 12. Brucker BM, Shah S, Mitchell S, et al. Comparison of urodynamic findings in women with anatomical versus functional bladder outlet obstruction. Female Pelvic Med Reconstr Surg 2013; 19:46–50.
13. Hickling D, Aponte M, Nitti V. Evaluation and management of outlet obstruction in women without anatomical abnormalities on physical exam or cystoscopy. Curr Urol Rep 2012; 13:356–362. 14. Fowler CJ, Christmas TJ, Chapple CR, et al. Abnormal electromyographic activity of the urethral sphincter, voiding dysfunction, and polycystic ovaries: a new syndrome? Br Med J 1988; 297:1436–1438. 15. Peeters K, Sahai A, de Ridder D, van der Aa F. Long term follow up of sacral & neuromodulation for lower urinary tract dysfunction. BJU Int 2013. This long-tem analysis of 217 patients with a definitive implant of SNM for LUTD showed a success rate of 70% and a cure rate up to 58% depending on indication, obtaining the best results in patients with idiopathic retention. 16. Elneil S, Abtahi B, Helal M, et al. Optimizing the duration of assessment of stage-1 sacral neuromodulation in nonobstructive chronic urinary retention. Neuromodulation 2014; 17:66–70. 17. Gaziev G, Topazio L, Iacovelli V, et al. Percutaneous tibial nerve stimulation & (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC Urol 2013; 13:61. This systematic review of four nonrandomized clinical trials about NOUR showed promising results that have to be confirmed by RCT. 18. Sharifiaghdas F, Kardoust Parizi M, Ahadi B. Efficacy of transurethral bladder neck incision with 2-micron continuous wave laser (RevoLix) for the management of bladder outlet stricture in women. Urol J 2013; 10: 790–794. 19. Jhang JF, Jiang YH, Kuo HC. Transurethral Incision of the bladder neck improves voiding efficiency in female patients with detrusor underactivity. Int Urogynecol J 2014; 25:671–676. 20. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009; 110: 1139–1157. 21. Adunsky A, Nenaydenko O, Koren-Morag N, et al. Perioperative urinary retention, short- term functional outcome and mortality rates of elderly hip fracture patients. Geriatr Gerontol Int 2014; doi: 10.1111/ggi.12229. [Epub ahead of print] 22. Tobu S, Noguchi M, Hashikawa T, Uozumi J. Risk factors of postoperative urinary retention after hip surgery for femoral neck fracture in elderly women. Gerontol Int 2013; doi: 10.1111/ggi.12150. [Epub ahead of print] 23. Nesbitt-Hawes EM, Zhang CS, Won HR, et al. Urinary retention following laparoscopic gynaecological surgery with or without 4% icodextrin antiadhesion solution. Aust N Z J Obstet Gynaecol 2013; 53:305–309.
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