CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 Credits TM can be earned in 2008. Instructions for how CME credits can be earned appear on the last page of the Table of Contents. Female Voiding Dysfunction Stergios K. Doumouchtsis, MD, PhD, MRCOG,* Stephen Jeffery, MD,† and Michelle Fynes, MD, MRCOG, DU‡ *Subspecialty Training Fellow in Urogynaecology and Senior Specialist Registrar in Obstetrics and Gynaecology, †Subspecialty Training Fellow in Urogynaecology and Senior Specialist Registrar in Obstetrics and Gynaecology, ‡Consultant Urogynaecologist, Department of Pelvic Reconstructive Surgery and Urogynaecology, St George’s Hospital, London, United Kingdom Female voiding dysfunction unrelated to childbirth is common but poorly understood, and most often occurs as a result of detrusor hypotonia and less frequently in association with bladder outlet obstruc- tion. Specific causes include anti-incontinence surgery, bladder over-distension, painful infective, allergic or chemical reactions of the urogenital tissues, bladder outlet obstruction, dyssynergia of the bladder-urethral sphincter mechanism, neurogenic, pharmacological, and psychogenic causes. A thorough history and examination is essential in the clinical assessment. It should be followed by investigations including urine microbiology, frequency volume diaries, ultrasound scan, uroflowmetry, and, when indicated, subtracted voiding cystometry, electromyography, and cystourethroscopy. The main treatment modalities are catheterization (self-intermittent, suprapubic, urethral, in order of pref- erence), bladder retraining, biofeedback, and, rarely, surgery or sacral neuromodulation. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to distinguish between different categories of chronic voiding dysfunction, demonstrate accurate pre-operative counseling regarding risks of voiding dysfunction prior to gynecologic surgery, and make a systematic evaluation of a patient with voiding dysfunction. The prevalence of voiding dysfunction (VD) in women varies between 2% and 25% and appears to increase with age (1–5). There is often no corre- lation between the subjective and objective evi- dence of voiding difficulty. Suboptimal voiding is regularly demonstrated at urodynamics in asymp- tomatic women, whereas other women with voiding symptoms often have no measurable explanation on urodynamic investigation (3). The International Continence Society states that “nor- mal voiding is achieved by a voluntarily-initiated continuous detrusor contraction that leads to com- plete bladder emptying within a normal time span, and in the absence of obstruction” (6). A broad range of definitions of VD in women have been suggested. Stanton et al defined it as “a condition in which the bladder fails to empty completely and easily after micturition.” Urodynamic evidence of voiding diffi- culty was defined as repeated peak flow rates of 15 ml/s and/or 200 ml or more of residual urine (2). The term lower urinary tract symptoms was intro- duced in 1994 and encompasses storage, voiding, and Dr. Fynes has disclosed that she was an advisor/consultant for Boston Scientific. All other authors have disclosed that they have no financial relationships with or interests in any commercial com- panies pertaining to this educational activity. The Faculty and Staff in a position to control the content of this CME activity have disclosed that they have no financial relation- ships with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc. has identified and resolved all faculty conflicts of interest regarding this educational activity. Reprint requests to: Stergios K. Doumouchtsis, MD, PhD, MRCOG, Department of Pelvic Reconstructive Surgery and Urogynaecology, 4th Floor Lanesborough Wing, St. George’s Hospital, Blackshaw Road, Tooting, London SW17 0RE. E-mail: sdoum@yahoo.com. CME REVIEWARTICLE Volume 63, Number 8 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright © 2008 by Lippincott Williams & Wilkins 22 519