Abstract
Fowler’s Syndrome is a rare condition characterized by urinary retention and voiding dysfunction, often seen in young females. It presents with symptoms such as dysuria, overflow incontinence, and nocturnal enuresis. This case report discusses a 12-year-old female with a history of recurrent dysuria, voiding dysfunction, and overflow incontinence, who was diagnosed with Fowler’s Syndrome after extensive evaluation. This report highlights her symptoms, diagnostic workup, and management plan, emphasizing the importance of early diagnosis and appropriate treatment for effective symptom management.

Case Report
A 12-year-old female presented for follow-up with a history of recurrent dysuria, urinary incontinence, and nocturnal enuresis. Her urinary symptoms were described as dysuria, which was not associated with any positive urine cultures, suggesting a non-infectious etiology. The patient also reported experiencing overflow incontinence, with episodes occurring 1-3 times per day. Her bladder diary revealed urinary incontinence during the day, but she did not experience nocturia or significant abdominal pain.
The patient had not yet started her menses but reported vaginal discharge without significant abdominal discomfort. Additionally, the patient's mother noted occasional fecal incontinence, which started with small amounts and occurred alongside the sensation of needing to use the bathroom. The patient denied any significant gynecological symptoms, and there was no history of recurrent UTIs or hematuria, although she had experienced an episode of spotting, which was uncertain in origin.

The patient reported experienced fecal and flatus incontinence but had no history of pelvic floor exercises, anticholinergic use, or prolapse symptoms. A normal ultrasound showed a stable bladder with normal compliance and capacity. Review of systems was negative, except for the documented urinary and fecal symptoms. Diagnostic workup revealed normal ultrasound findings, a urinary diary indicating overflow incontinence and sensory voiding issues, and urodynamics showing stable bladder function with no urge incontinence (no USI). Neurological evaluation suggested possible S1 and S2 impairment, but further tests were not performed. External genital examination showed vaginal discharge with no obstruction or abnormal vulvar findings. Given these results, the patient was referred to neurology for nerve conduction studies and to colorectal surgery for fecal incontinence evaluation, with future consideration for sacral nerve stimulation (SNS) implantation

Discussion
The patient’s clinical presentation and diagnostic workup point toward a diagnosis of Fowler’s Syndrome, a condition typically characterized by voiding dysfunction due to sensory impairment of the bladder, often due to neurological issues. The absence of UTIs in this case is a key feature, as repeated negative urine cultures further suggest a neurological cause rather than an infectious one. The findings of overflow incontinence, dysuria, and fecal incontinence are consistent with the dysfunction seen in Fowler’s Syndrome, with sensory voiding dysfunction as the primary issue.
The lack of symptoms like hesitancy and post-void dribbling, combined with the patient's good stream and volume, suggests the problem lies not in bladder outlet obstruction but in the sensation and awareness of bladder fullness. Neurological impairment affecting the S2-S4 sacral spinal segments could be responsible for these sensory voiding issues.
The patient’s occasional fecal incontinence further supports the possibility of neurological impairment, as this can often coincide with bladder dysfunction in Fowler’s Syndrome. It is important to note that this condition is often misdiagnosed, as its symptoms can overlap with other urological or gynecological disorders

Conclusion
This case highlights the need to consider Fowler’s Syndrome in young females with urinary retention, overflow incontinence, and dysuria without infection. A thorough evaluation with a bladder diary, ultrasound, and urodynamics is essential for diagnosis. Early diagnosis and management, including bladder training and sacral nerve stimulation (SNS), can improve outcomes. Neurological referral is recommended for further testing

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•  Kuo, H. C., & Chen, C. H. (2010). Diagnosis and management of Fowler’s syndrome in a female with urinary retention and voiding dysfunction. Urology, 76(4), 1004-1009.
Chancellor, M. B., & De Wachter, S. (2011). Sacral neuromodulation in the treatment of Fowler's syndrome. Current Urology Reports, 12(6), 451-455.