Female voiding dysfunction: A review of clinical presentation, urodynamic diagnosis and management

Purpose: This review is based on the International Continence Society (ICS) Workshop on Female Voiding Dysfunction (FVD) presented at the Annual Congress in Vienna in September 2022. The workshop was designed to highlight and address important lacunae in our clinical approach to FVD including an absence of relevant terminologies in the International Continence Society glossary, lack of minimum standards for making a diagnosis, and the lack of good evidence as well as condition-specific guidelines. Materials and methods: The review follows the structure adopted by the workshop, where FVD is discussed in four sections: clinical presentation, specific urodynamics findings, urodynamics criteria of obstruction and underactivity, and management of female voiding dysfunction. Women with anatomical or iatrogenic obstruction or those with underlying neurological conditions, were excluded. Results: The clinical presentation of FVD is varied and consists of both voiding and storage symptoms. Urodynamics can enable a precise diagnosis of underactivity, primary bladder neck obstruction or dysfunctional voiding, but needs combination with imaging (video-urodynamics or asynchronous voiding cystourethrogram). Women with high-tone non-relaxing sphincter who fail to void at conventional urodynamics need urethral pressure profilometry for making a diagnosis. While several criteria for making a diagnosis of obstruction or underactivity have been described, there is lack of consensus in key definitions. Criteria developed for men are inappropriate for use in women. While initial empirical therapy is reasonable, precise diagnosis can enable condition-specific therapies such as bladder neck incision, pelvic floor relaxation training or neuromodulation. Conclusions: The application of advanced urodynamic techniques can help in making a precise diagnosis of female voiding dysfunction enabling specific therapy. Current ICS terminology and clinical practice guidelines have significant lacunae. Awareness of these techniques and limitations is important for clinicians practicing functional urology.