Female Voiding Dysfunction: Prevalence and Common Associations Bernard T. Haylen, MB, BS, MD Corresponding author Bernard T. Haylen, MB, BS, MD University of New South Wales and St. Vincent’s Clinic, Suite 904, 438 Victoria Street, Darlinghurst 2010, New South Wales, Australia. E-mail: haylen@optusnet.com.au Current Urology Reports 2009, 10:421–427 Current Medicine Group LLC ISSN 1527-2737 Copyright © 2009 by Current Medicine Group LLC The understanding of voiding dysfunction has been greatly assisted by the current introduction of clear defnitions for its diagnosis and for the abnormalities of urine fow rates and postvoid residuals that are its basis. Its prevalence in women with symptoms of pel- vic foor dysfunction is up to 40%. Most of the recent research has centered on the associations of voiding dysfunction with age, pelvic organ prolapse, and prior continence surgery. The effects of parity, medications, and pelvic tumors have also been explored. Introduction In 2009, voiding dysfunction will receive recognition as a key diagnosis in the Joint Report on Terminology for Female Pelvic Floor Dysfunction of two international organizations, the International Urogynecological Asso- ciation (IUGA) and the International Continence Society (ICS) [1••]. Clarity in its defnition—abnormally slow and/or incomplete micturition—as judged by symptoms and urodynamic investigations will assist clinicians and researchers. It is recommended that previous references to the alternate term of voiding dif fculty be discontinued. Abnormal values of urodynamic parameters screen- ing for voiding dysfunction, urine fow rates (UFRs), and postvoid residuals (PVRs) have been subject to recent updates and the addition of new research data. The lack of absolute consensus for appropriate cutoff levels for these parameters remains a limitation on the comparison of different studies for the prevalence of female voiding dysfunction. New data suggest that it may be the third most prevalent diagnosis in female pelvic foor dysfunc- tion after urodynamic stress incontinence (USI) and pelvic organ prolapse (POP). Recent research regarding the etiology of female voiding dysfunction has focused on two key factors: 1) the infuence of POP and 2) prior pelvic surgery, particularly suburethral tapes among other continence surgeries for USI. The imme- diate effects of childbirth, in terms of voiding dysfunction postpartum (particularly after cesarean section), have been studied. The longer-term effect of parity on the prevalence of POP and, in turn, voiding dysfunction, has been rein- forced. There have been many interesting case reports of acute urinary retention due to different causes. Defnitions in Female Voiding Dysfunction The IUGA–ICS terminology report on female voiding dysfunction covers the following: 1) voiding symptoms, 2) urofowmetry and PVRs, and 3) the diagnosis defni- tion noted above [1••]. This report emphasizes that the diagnosis should be based on a repeated measurement to confrm abnormality. Further evaluation by pressure-fow studies is desirable to evaluate the cause of any voiding dysfunction. Possible causes are detrusor underactivity, detrusor acontractility, or bladder outfow obstruction; alternate presentations include acute or chronic reten- tion. Of the 10 voiding symptoms outlined in the report, none has a high specifcity for an abnormality of voiding function, although hesitancy, a poor stream, and the need to strain to void have been recently shown again to be slightly more relevant in history [2]. Lowenstein et al. [3] recently studied self-reported bother from obstructive voiding symptoms as a possible predictor of an elevated PVR (defned as “more than 150 mL” in their series); however, they found poor sensitivity and specifcity in women with pelvic foor disorders. Defning abnormal voiding function in women A common medical dictionary defnition for dysfunction is abnormal or dif fcult function. In the case of voiding function, this means an abnormally slow urine fow rate or an abnormally high PVR. International consensus for cutoff levels for abnormality has not been reached for either of these urodynamic parameters. This makes comparison of prevalence data for voiding dysfunction dif fcult. Recommendations for abnormality of UFRs are easier than for PVRs due to its more accurate and stan- dardized measurement methodology. Urofowmetry has an accuracy of ± 5% with modern, regularly calibrated urofowmeters [4••]. With the known