Value of Routine Evaluation of the Voiding Phase when Performing Urodynamic Testing in Women with Lower Urinary Tract Symptoms

Purpose: Lower urinary tract symptoms in women are often evaluated by cystometrography. We only assessed the bladder response to filling and not the impact of abnormal voiding, which is known to cause lower urinary tract symptoms. We determined the prevalence of voiding abnormalities in women with lower urinary tract symptoms and compared cystometrography to cystometrography plus voiding pressure flow study for evaluating this condition. We also determined whether storage or voiding symptoms predicted abnormal voiding.

Materials And Methods: We reviewed the records of 134 women who underwent video urodynamics with cystometrography and voiding pressure flow study to evaluate lower urinary tract symptoms. Patients with a history of neurological disease, grade 4 pelvic prolapse or a primary complaint of stress incontinence were excluded from study. All participants completed an American Urological Association symptom index and scores were subclassified as total, storage and voiding. A diagnosis was made in each case based on cystometrography findings, while any additional diagnoses when applicable were based on the voiding pressure flow study. Symptom scores were compared in women in whom the voiding study did and did not add information.

Results: Mean patient age was 53.1 years (range 19 to 90). Voiding studies added information in 44 cases (33%), including dysfunctional voiding in 16, obstruction due to a moderate cystocele in 6, primary bladder neck obstruction in 6, external-detrusor sphincter dyssynergia as the initial presentation of neurological disease in 5, obstruction after incontinence surgery in 3, urethral stricture in 3, post-void contraction mimicking symptoms in 2, impaired contractility in 2 and an obstructing urethral diverticulum in 1. A total of 32 patients (24%) did not void during the study. Those with voiding abnormalities had higher total and voiding but similar storage symptom scores (23.1 versus 18.5, 12.3 versus 8.0 and 10.8 versus 10.5 points, p = 0.0008, 0.0001 and 0.58, respectively).

Conclusions: Women with lower urinary tract symptoms may have voiding abnormalities that are missed by cystometrography only. Voiding studies are useful for properly diagnosing and treating such cases. Women with abnormal voiding seem to have more severe voiding symptoms than those without such abnormalities. Occult neurological disease may also be identified in patients with lower urinary tract symptoms and voiding abnormalities.