Behavioral Voiding Dysfunction Pseudodyssynergia

Bladder outlet obstruction may also occur in the setting of an anatomically normal male patient owing to a dynamic obstruction caused by a lack of coordination between the detrusor and bladder neck smooth muscle (bladder neck dyssynergia) or striated muscle external sphincter (pseudodyssynergia). While psydodyssynergia generally implies a condition in a neurologically intact patient, similar conditions may be the result of a neurologic lesion (detrusor external sphincter dyssynergia, DESD) or in neurologically intact children (Hinman's bladder). Although the exact etiology of this condition is unknown, it is generally considered to be a learned behavior of failed pelvic relaxation. It has been postulated that the condition may arise as reaction to a negative response to micturition such as pain, and frequently is seen in younger male patients who have been treated for long periods for chronic prostatitis. Although not an absolute part of the syndrome, there is a preponderance of patients who are generally apprehensive and nervous young men who could be described as type A personalities.

Typically, patients may complain of either obstructive or irritative symptoms with otherwise unremarkable prostatic examination and post-void residual determination. The definitive diagnosis of pseudodyssynergia requires the use of pressure-flow-EMG studies. The presence of increased striated sphincter activity corresponding with detrusor contraction in the absence of abdominal straining is consistent with the diagnosis. On voiding cystourethrography, there may be a demonstration of narrowing of the urethra at the level of the membranous urethra. As in any condition of bladder outlet obstruction, secondary bladder responses may be manifest in the form of detrusor hypertrophy, diminished capacity and compliance, and instability, or bladder decompensation with larger capacity and residual volumes.

Therapy in these cases may frequently be started with a trial of alpha-Mockers though this usually meets with minimal success. Preferred therapy for such patients include behavioral modification and biofeedback, with symptomatic improvement seen in over 80% of patients over a 6-mo period (35).

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