Dysfunctional Voiding (DV) is characterized by an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated or levator muscles during voiding in neurologically and anatomically intact women. These patients clinically present usually with voiding difficulty,frequency and incomplete emptying of their bladder, a clinical condition very similar to Underactive Bladder (UAB). This study investigates the clinical presentation and the urodynamic characteristics in women with DV.

This was an prospective study including 300 non-neurological women with  LUTS according to Questionaire module(ICIQ-FLUTS) pooled from the urodynamic office from 2010 to 2023 of our department. Among them, we have identified 38 women diagnosed with DV. Clinical urinary symptoms and the UDS characteristics of these patients were statistically analyzed using a combined cut-off value of Qmax<15ml/sec and PdetQmax>20cmH2O including EMG.The voiding pattern has been clasified according to Solomon-Greenwell nomogram.

According to the UDS findings,Bladder Outlet Obstruction(BOO) was the diagnosis and was present in all women in combination with significant electromyographic activity during voiding .Detrusor pressure over 20cmH2O during voiding, low maximum flow rate and large post-void residual volume were the rest of the UDS observations. Regarding the clinical presentation, 24 patients reported  voiding symptoms as their main issue, 14 patients reported storage symptoms. Difficulty in urination was the predominant complaint (main symptom) in 20 women, followed by frequency in 10 women and post-micturition LUTS in the rest 8 women.

The differential diagnosis of DV among other LUTS in adult women is difficult due to the non-specific symptoms. The time lag to diagnosis may be several years if it is based on the patient’s history in combination with the lack of physicians’ awareness.
In our study, women with DV complain of not only voiding symptoms but of storage symptoms, as well. In that respect, women with Underactive Bladder (UAB) usually present with poor, intermittent flow pattern in combination with a high PVR and complain of LUTS. In this case, overflow incontinence can imitate frequency. Although uroflowmetry and residual volume are sometimes useful screening tools for voiding dysfunction, UDS can clear up the situation(2). The definitive diagnosis is established by the additional demonstration of significant electromyographic activity during voiding.The present study has a limitation. Although we 
used a cut-off value for the UDS-based diagnosis of DV, there 
is a lack of established urodynamic criteria for the diagnosis 
of DV at present.

Voiding or storage symptoms and UDS findings of Bladder Outlet Obstruction (BOO) were present in most women with DV. UDS is necessary for accurate diagnosis in women with LUTS that can distinguish Underactive Bladder Syndrome from Dysfunctional Voiding.

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