Voiding Disorders

Voiding disorders are common in women. As many as 14% of women who present at the Urogynaecology Centre with bladder symptoms were found to have voiding disorders. It may be defined by an abnormally slow flow of urine during voiding, when the maximum urine flow rate is less than 15 ml per second, or a sensation of incomplete emptying of the bladder, when the residual urine volume is over 30 ml, within one minute post voiding.

What are the complications that may arise?

It is important to diagnose voiding disorders because if left unrecognised, it may predispose one to frequent urinary tract infections. In more severe case, the kidneys may be damaged by the continuous back pressure that is created by a full bladder.

Symptoms of voiding disorders include:

• Delay in initiating urination
• Slow urinary flow
• Sensation of incomplete emptying of bladder
• The need to immediately re-void
• The need to strain to void
• Dribbling of urine after completing bladder emptying

Patients with voiding disorders may also present with symptoms such as frequency, urgency, passing urine more than once at night, urinary incontinence, and urinary tract infection. Some patients may have associated prolapse of the womb, bladder or rectum.

What are the causes of voiding disorders?

There are many causes of voiding disorders in women. Some may be temporary while others may be permanent. The causes include:

• Acute inflammation such as genital or urinary tract infection
• Drugs such as epidural anaesthesia, oxybutynin, detrusitol and antidepressants
• Nerve damage such as spinal cord injury and diabetic neuropathy
• Psychological influences such as anxiety, hysteria and depression
• Pelvic surgery and vaginal delivery
• Obstruction due to pelvic organ prolapse, faecal impaction and urethral narrowing
• Overdistension of the bladder
• Inability to relax the urethral sphincter during voiding

What are the investigations of voiding disorders?

When you consult your doctor, a detailed history is first obtained, followed by a comprehensive urogynaecological and neurological examination to ascertain the possible causes of voiding disorders. Various investigations may be ordered and these include:

• Uroflowmetry: It measures the rate of urine flow during voiding.
• Residual Urine Volume: It is the amount of urine remaining in the bladder after voiding. It is measured either by scan or by putting a tube into the bladder to drain out the urine.
• Cystometry: The bladder pressure is measured during voiding. It can diagnose the bladder muscle that is not contracting normally during voiding.
• Electromyography: It defects the contractions of the sphincter muscles during voiding.
• Radiology: It includes X-rays and ultrasound scan to look for tumour, diverticulum and foreign body of the bladder, or enlarged kidneys caused by voiding disorders.
• Cystoscopy: To look into the bladder and the urethra for foreign body, diverticulum or tumour.

What are the treatment options for voiding disorders?

• Prevention and early recognition: Prevention of voiding disorders is important. After pelvic or continence surgery, the use of temporary catheterisation can prevent immediate post-operative bladder overdistension. Early recognition of postnatal urinary retention and early catheterisation is crucial to early return of normal urinary function subsequently.
• Medication: Drugs may be used to treat the underlying cause of the voiding disorders. A course of antibiotics or antiseptic may be used if there is an infection. In patients with anxiety disorders, a small dose of anti-anxiety medication or sleeping tablets may help. Vaginal oestrogen pessaries may be used if atrophic changes are implicated in the voiding difficulties. Some drugs may be used to improve bladder muscle contraction.
• Clean Intermittent Self Catherisation (CISC): In CISC, the patient is taught to insert a urinary catheter under clean conditions at regular intervals. This procedure is easy to learn. The use of CISC enables many women to live normal lives with efficient bladder emptying, free from discomfort and distress. For patients not willing or unsuitable to use CISC, indwelling catheters may be used.
• Surgical treatment: In cases where the urethral opening is narrowed, it may be dilated using metal rods called Hegar dilators. However, the main disadvantage is that voiding difficulty may recur following healing and scarring of the dilated area. Often, repeated dilatations are needed. If the woman is having bladder or uterine prolapse, it should be dealt with surgically.

Conclusion

Voiding disorders are common in women. If left unrecognised, it may lead to permanent damage to the bladder and kidneys. Hence treatment should be started early and the causes dealt with promptly.