Voiding Disorders

What is a voiding disorder?

A voiding disorder is when there's a problem with how your bladder stores or empties urine. This can mean your bladder leaks unexpectedly, doesn't empty fully, or you have to strain to pass any urine at all.

What are the symptoms of a voiding disorder?

Symptoms vary depending on the type of voiding disorder, but can include:

• leaking urine without meaning to, for example when you cough, laugh, exercise or a sudden strong urge to go
• needing to urinate more often than usual, including at night, or more than 8 times a day
• difficulty starting to urinate, or straining or pushing to pass urine
• a weak stream, or one that starts and stops
• a feeling that your bladder hasn't fully emptied
• needing to urinate very rarely, or being unable to empty your bladder at all

What are the causes of voiding disorders and who is at risk?

Voiding disorders can be caused by problems in different parts of the urinary system, or by how the bladder, its muscles and its nerves work together. Broadly, causes fall into two groups:

• Physical or functional causes, such as weak bladder muscles, an overactive or underactive bladder, a blockage (for example, an enlarged prostate or a narrowing of the urethra), constipation, or habits like regularly ignoring the urge to go.
• Neurological causes, where the nerve signals between the bladder and brain are damaged or interrupted, for example by a spinal cord injury, spina bifida, multiple sclerosis, or other conditions affecting the nervous system.

Are there different types of voiding disorders?

Yes. Voiding disorders are often grouped by whether the problem is with storing urine or emptying it, and by whether the cause involves the nervous system.

• Storage problems cause incontinence, where urine leaks out unintentionally. This includes stress incontinence (leaking with coughing, laughing or exercise), urge incontinence (a sudden strong need to go, followed by leakage), mixed incontinence (a combination of the two), and overflow incontinence (leaking because the bladder never fully empties).
• Emptying problems cause urinary retention, where you're unable to empty your bladder either partly or fully, sometimes leaving a small amount of urine behind (residual urine) that can raise your risk of infection.
• Overactive bladder is a common condition causing a sudden urge to urinate, or bladder spasms, even when your bladder isn't full.

Voiding disorders are also described as neurogenic, when nerve signals between the bladder and brain are disrupted, or non-neurogenic, when the nervous system isn't involved and the problem lies with the bladder muscle, the urethra, or learned habits.

How are voiding disorders diagnosed?

A doctor will usually start by asking about your symptoms and medical history and may examine you, which can include a pelvic examination or, in men, a rectal examination to check the prostate. You may be asked to keep a bladder diary, recording how much you drink, when and how much you urinate, and any leaks.

Common tests include:

• a urine test, to check for infection
• an ultrasound scan, to see how much urine is left in your bladder after you go, and to check your kidneys
• urodynamic testing, which measures how well your bladder and urethra work together
• cystoscopy, where a thin camera is passed into your urethra to look inside your bladder

If there are signs that your kidneys or upper urinary tract might be affected, or if your symptoms are severe, you may be referred for more detailed testing and imaging to check for an underlying neurological cause.

How are voiding disorders treated?

Treatment depends on the type of voiding disorder you have, what's causing it, and how severe your symptoms are. Many people improve significantly with non-surgical treatment, and surgery is generally only used if other options haven't worked well enough.

Non-surgical treatment for voiding disorders

First-line treatment usually involves:

• bladder training, where you go to the toilet at set times to help retrain your bladder
• pelvic floor exercises (Kegel exercises), sometimes guided by biofeedback, to strengthen or learn to relax the right muscles
• cutting back on foods and drinks that irritate the bladder, such as caffeine, alcohol and spicy or acidic food
• treating constipation, which can make voiding disorders worse

If these don't fully resolve your symptoms, your doctor may suggest medication. Different medicines work in different ways: some relax an overactive bladder muscle, some relax the muscle around the neck of the bladder to help it empty, and others target the nerve signals involved in bladder control. Botulinum toxin (Botox) injections into the bladder muscle are another option for an overactive bladder, usually needing to be repeated every few months.

For nerve-related bladder problems, treatments include nerve stimulation therapies, such as percutaneous tibial nerve stimulation (using a small electrode near your ankle) or sacral nerve stimulation (a device implanted near the base of your spine), both aiming to help your bladder and brain communicate more normally.

If your bladder can't empty on its own, your doctor may teach you intermittent self-catheterisation, where you pass a thin, disposable catheter into your bladder to drain it at regular intervals. This can help prevent infections and other complications caused by urine being left in the bladder.

Surgical treatment for voiding disorders

Surgery is usually considered when other treatments haven't worked well enough, and the type of operation depends on the specific problem.

For stress incontinence, options include injecting a bulking agent into the urethra to add resistance, or sling surgery, where a strip of tissue or synthetic mesh is placed under the urethra to support it. In men, an artificial urinary sphincter, a device with a cuff, pump and pressure-regulating balloon, can restore good bladder control in more than 7 in 10 men with stress incontinence.

If your bladder is too small or overactive despite other treatments, a procedure called bladder augmentation can enlarge it so it holds more urine, though this is rarely needed.

When should I see a doctor?

See a doctor as soon as you notice ongoing problems with urinating, and especially if you have:

• an inability to pass urine at all for an extended period
• blood in your urine, or urine that's unusually cloudy or strong-smelling
• pain when you urinate
• a fever, chills or feeling generally unwell alongside your symptoms
• constipation that doesn't improve

If you're completely unable to pass urine, or you have severe pain in your lower tummy along with this, seek urgent medical help, as a very full bladder that can't empty needs prompt treatment.