Treatment of Dysfunctional Voiding
The recommended first-line treatment for dysfunctional voiding is urotherapy with biofeedback, which has demonstrated success rates of 70-80% in most patients. 1, 2
Understanding Dysfunctional Voiding
Dysfunctional voiding is characterized by inappropriate sphincter and pelvic floor contraction during voiding in neurologically normal individuals. It presents with:
- Dyssynergic striated sphincter activity during voiding
- Abnormal urinary flow patterns (staccato, interrupted, or slow)
- Post-void residual urine
- Potential complications including UTIs, vesicoureteral reflux, and in severe cases, upper tract damage
Treatment Algorithm
First-Line Treatment: Urotherapy
- Comprehensive elimination education
- Timed voiding schedules (every 2-3 hours)
- Voiding diaries for monitoring progress
- Fluid management (adequate hydration during day, limiting evening fluids)
- Avoidance of bladder irritants 3
Second-Line Treatment: Biofeedback Therapy
Two main approaches to biofeedback exist 1:
Real-time flow rate visualization programs
- Patient views voiding curve during active voiding
- Requires fewer sessions (average 3.7 sessions)
- Quicker return to normal flow pattern
- Requires flowmeter with real-time feedback
Muscle isolation with EMG surface electrode feedback
- Uses perineal surface electrodes to monitor pelvic floor activity
- More sessions required
- Better suited for patients with mixed dysfunctions
- Helps develop proper guarding reflex and muscle relaxation
During biofeedback therapy:
- Weekly sessions until consistent pelvic floor relaxation is achieved
- Monitoring with uroflow studies and pelvic floor EMG
- Regular assessment of post-void residual volumes 4
Third-Line Treatment: Pharmacological Interventions
For patients with mixed disorders or refractory symptoms:
- Anticholinergics/antimuscarinics for overactive bladder component
- Alpha-blockers may help with outflow obstruction 3, 2
Fourth-Line Treatment: Advanced Interventions
For refractory cases:
- Transcutaneous electrical nerve stimulation
- Botulinum toxin injection
- Further evaluation with full urodynamic studies or MRI 1, 2
Monitoring Treatment Success
Treatment success should be measured by:
- Improved voiding and bowel diary parameters
- Normalized flow rate patterns
- Reduced post-void residual urine
- Decreased frequency and severity of incontinence episodes
- Reduced UTI recurrence 1
Special Considerations
Comorbid Conditions
- Constipation: Present in 33-56% of patients with dysfunctional voiding; aggressive management is essential for successful treatment 5
- Detrusor underactivity: May coexist with dysfunctional voiding, requiring additional management strategies 1
- Behavioral/psychiatric comorbidities: Should be addressed concurrently 1
High-Risk Markers
Patients with the following should receive prompt formal urodynamic evaluation:
- Hydronephrosis
- Vesicoureteral reflux
- Renal dysfunction
- Marked voiding difficulty 6
Treatment Pitfalls to Avoid
- Inadequate assessment: Ensure proper diagnosis with uroflowmetry and, when indicated, EMG or video-urodynamics 7
- Overlooking constipation: Failure to address constipation significantly reduces treatment success 5
- Premature escalation: Allow sufficient time for urotherapy and biofeedback before advancing to medications
- Insufficient follow-up: Regular monitoring is essential to ensure continued improvement and prevent relapse
The escalating treatment approach described above has demonstrated success rates of 90-100% when properly implemented 1. Biofeedback therapy, though initially labor-intensive, yields sustained positive results in most patients within a relatively short time 4.