Voiding dysfunction

In this episode of PodMD,  highly experienced and certified urogynaecologist Dr Rebecca Young will be discussing the topic of voiding dysfunction, including how a patient would typically present, the risks of the condition, the treatment options available, the warning signs to look out for, when to refer and more.


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  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Rebecca Young

    Dr Rebecca Young is a highly experienced and certified Urogynaecologist specialising in the treatment of conditions such as prolapse and urinary incontinence, as well as providing general gynaecological care to women.

    Dr Young completed her obstetrics and gynaecology training at Royal North Shore Hospital in Sydney, with rotations at Northern Beaches, Port Macquarie, and Gosford Hospitals. Dr Young furthered her expertise with advanced gynaecological and laparoscopic training at Westmead Hospital, earning her the Fellowship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG). Dr Young went on to complete 3 years of subspeciality training in Urogynaecology at Gold Coast University and St George Hospital, before commencing private practice

    Today, we’ll be discussing the topic of voiding dysfunction.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Rebecca, thanks for talking with us on PodMD today.

    Rebecca : Thank you for having me

    Question 1
    The topic of today’s discussion is voiding dysfunction. Rebecca, can you give us a brief overview about voiding dysfunction?

    Rebecca: Voiding dysfunction is when there is an impairment in how the bladder empties. It is characterised by a slow urine flow rate as well as raised postvoid residuals – typically of at least 50ml. The diagnosis is confirmed on repeated measurements and varies in severity. Causes can be divided into those due to obstruction of the bladder outlet, underactivity and poor contractility of the bladder’s detrusor muscle, or in some cases there can be dysfunction of both.

    For female patients common causes of bladder outlet obstruction include advanced prolapse, urethral stricture, or prior incontinence surgery. Less common causes include conditions such as dysfunctional voiding and Fowler’s syndrome. Poor contractility of the bladder detrusor muscle can be due to age, previous severe acute urinary retention causing overdistension or neurogenic causes such as multiple sclerosis, stroke or nerve damage.

    Question 2
    How would a patient with voiding dysfunction typically present?

    Rebecca: Patients may present with dribbling of urine, notice a reduction in their ability to pass urine as quickly, or the feeling that their bladder is not completely empty. Less obvious symptoms are urinary urgency, incontinence or nocturia. Often patients will present with recurrent urinary tract infections.

    Question 3
    What are the risks and outcomes of the condition?

    Rebecca: Repeated urinary tract infections can result in multiresistant organisms unresponsive to antibiotics or can cause urinary sepsis. Severe voiding dysfunction can cause ureteric reflux and hydronephrosis. Left untreated voiding dysfunction may worsen with time, though this is also dependent on the cause.

    Question 4
    What are the treatment options?

    Rebecca: Double voiding can help to reduce the residual urine volume. Urinary tract infections should be treated and hipprex or prophylactic antibiotics can be used to prevent infections from occurring.

    If the bladder outlet is obstructed then this should be addressed. In patients following a previous continence procedure this may involve urethral dilatation, dividing or partially excising the sling, or with urethrolysis. Cystourethroscopy can exclude urethral stenosis. If there is a prolapse causing obstruction this may improve with reduction using a pessary device, or with surgical repair.

    For patients with detrusor underactivity or a neurogenic cause the main treatment options are intermittent self catheterisation or sacral neuromodulation. For severe cases where self catheterisation is not an option a suprapubic catheter may be required.

    Question 5
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Rebecca: There has been an increase in the use of sacral neuromodulation for non obstructive chronic voiding dysfunction, with success rates of up to 70%. This can mean the ability to stop needing to self catheterise for some women, which can have a significant impact on quality of life.

    Studies on new pharmacological agents to improve bladder contractility are occurring, however so far there is limited evidence for the success of these. In patients who develop recurrent urinary tract infections due to self catheterisation or secondary to poor voiding where other treatment options are unsuccessful consideration can be given to use of the sublingual UTI vaccine Uromune. This has recently become available in Australia, however there is no evidence specific to patients with recurrent urinary tract infections in the context of voiding dysfunction.

    Question 6
    Are there any warning signs a GP or their patient can look out for?

    Rebecca: If patients develop any symptoms of voiding dysfunction or new urinary symptoms it is important to check the post void residual volume. This can be done with a pre and post void bladder ultrasound.

    Question 7
    When should a GP refer?

    Rebecca: If it is causing symptoms or the residual volume is >100ml consistently then I would recommend referral to a urogynaecologist so that further assessment and treatment can occur. Consideration should be given to performing urodynamics and cystourethroscopy. For patients with longstanding voiding dysfunction they should be referred back for review if there is a deterioration in their condition, for example if developing recurrent urinary tract infections or they have increasing post void residual volumes, as management of the condition may need to be changed.

    Question 8
    What role does the GP play in the treatment of the condition?

    Rebecca: GP’s have a crucial role in identifying patients with symptoms and implementing initial management such as double voiding and UTI prevention. It is important that neurological causes are excluded as part of the initial history and examination so that appropriate management for these occurs. As it is usually a chronic condition patients will require long term management and support from their GP and may require multidisciplinary input from physiotherapists, continence nurses as well as specialists.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on voiding dysfunction.

    Rebecca:
    1. Voiding dysfunction refers to a condition where the bladder is unable to empty properly, though there are numerous different potential causes.
    2. It is important that it is treated to prevent worsening symptoms and complications such as urinary tract infections.
    3. Treatment depends on the cause and severity. Sacral neuromodulation has been shown to be of benefit for non obstructive causes, with success rates of approximately 70%

    Thanks for your time and the insights you’ve provided.

    Rebecca: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.