Beyond the Abstract - Voiding dysfunction in the female patient: Is the "syndrome" paradigm valid, by Hari Tunuguntla, MD, Philip Zhao, MD, and Malini Rao, MD

BERKELEY, CA ( - The recent paradigm shift to group female voiding dysfunction into one of the few lower urinary tract syndromes (LUTS), i.e., overactive bladder (OAB), interstitial cystitis (IC), and painful bladder syndrome (PBS) should be seriously looked into as such a classification results in a disservice to patients.


play btn xListen to an audio commentary by Philip Zhao, MD
Resident, Division of Urology/Dept. of  Surgery,UMDNJ-Robert Wood Johnson Medical School
New Brunswick, NJ  USA

Limiting the female lower urinary tract symptoms into these 3 defined groups significantly deemphasizes the underlying cause of many symptoms and protean manifestations of LUTS and therefore leads to suboptimal diagnosis and treatment.

Many women can have concurrent pain symptoms as well as storage or voiding symptoms. They may also have mixed urinary incontinence, necessitating treating the stress and urge components separately. The spectrum of clinical presentation in female voiding dysfunction (VD) and LUTS is distinctly different for women and must be fully evaluated prior to beginning any treatment regimens.

VD in women may present as any condition when the bladder fails to empty completely and easily after micturition while LUTS manifest as storage, voiding, or post-voiding groups of symptoms. VD is not mutually exclusive of LUTS. Although VD and LUTS have been classified by the International Continence Society (ICS) into overactive bladder (OAB) and IC/PBS, there are multiple subjective components that may need to be assessed individually.

OAB symptoms are due to involuntary detrusor contractions during bladder filling. While working up OAB patients, the clinician must first rule out urinary tract infections (UTI) and perform a complete history and physical with supplemental urinalysis, metabolic panel, bladder diary, and quality-of-life assessments. Urodynamics play a role in quantifying the voiding parameters, but is not essential to make the diagnosis. Treatment is divided into first line, comprising lifestyle modifications, pelvic floor exercises, and bladder training with or without antimuscarinic therapy; and second-line, which consists of minimally invasive modalities such as sacral neuromodulation, intradetrusor botulinum toxin type A injections, and augmentation cystoplasty.

On the other hand, IC/PBS encompasses a much larger conglomeration of symptoms usually secondary to continuous bladder injury from infections, inflammations, autoimmune disorders, and genetic predispositions. Histologically, there is significant mast cell and C-fiber activation that leads to increased potassium influx into the interstitium of the bladder further accelerating the injury process. Diagnosis is based on criteria of exclusion, and workup is usually similar to that for OAB. Cystoscopy and hydrodistention are optional, but not crucial tools to help in the evaluation for IC by visualizing Hunner’s ulcers and punctate petechial hemorrhages. However, these pathognomonic changes are not seen with all cases of IC/PBS. The treatment spectrum in patients with IC/PBS runs widely and ranges from those used for OAB, to greater utilization of oral and intravesical medications, to more invasive procedures. Not uncommonly, the pelvic pain can persist after surgery and patients should be aware of such outcomes prior to intervention.

Despite new and remarkable advances in elucidating the pathophysiology of LUTS, sparse scientific evidence exists that provide the linkage between voiding symptoms and their underlying pathology. Although the underlying root cause for all of these symptoms remains underappreciated, a symptom-based approach, rather than a syndrome-based one, is more appropriate and effective in the evaluation and treatment and offers a better quality of life for women with VD and LUTS.

Written by:
Hari Tunuguntla, MD, Philip Zhao, MD, and Malini Rao, MD as part of Beyond the Abstract on This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Corresponding Author:
Hari Tunuguntla, MD
One Robert Wood Johnson Place, MEB 588
New Brunswick, NJ 08901, USA


Voiding dysfunction in the female patient: Is the "syndrome" paradigm valid - Abstract



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