Table 1.

Symptoms and signs that can be observed in dysfunctional voiding

Obstructive level (distal to proximal)	Symptoms	Signs
1. External urethral sphincter	Voiding symptoms • Difficulty with initiating or maintaining stream • Abnormal stream	Physical: observed interrupted or varying urinary stream Urodynamics: staccato, interrupted uroflow/voiding EMG activity Radiology: spinning top urethra on fluoroscopy
2. Proximal urethra	Urethral (usually penile) pain during voiding due to abnormal flow Hematuria	Physical: urethritis on cystoscopy Radiology: spinning top urethra
3. Detrusor –compensatory hypertrophy Detrusor overactivity Decreased detrusor compliance Decreased bladder capacity	Storage symptoms: • Urgency • Urge incontinence • Frequency	Physical: evidence of incontinence, holding manoeuvres Urodynamics: Small MVV from bladder diary Detrusor overactivity and/or low compliance on invasive urodynamics Radiology: thickened bladder wall, trabeculation, diverticulae
4. Detrusor –myogenic decompensation/failure	Voiding symptoms • Difficulties with initiating and maintaining void • Infrequent voiding • Abdominal straining • Sitting to void in boys • Unusual voiding e.g., situation-specific, only in the bath • Urinary retention	Physical: Palpable bladder with no sensation of need to void. Abdominal straining during observed voiding Urodynamics: infrequent voiding/large MVV on bladder diary Interrupted uroflow. Abdominal EMG activity during voiding. Radiology: Distended large volume bladder on ultrasound
5. Vesicoureteric reflux	Urinary tract infection +/− loin pain/pyelonephritis	Radiology: Dilated ureter, urothelial thickening, hydronephrosis, post-void residual on ultrasound. VUR on fluoroscopy. Pseudo post-void residual due to VUR on fluoroscopy. Nuclear medicine: VUR on indirect cystogram
6. Renal damage	Poor growth, polydipsia, polyuria	Physical: uremia, hypertension Laboratory: raised serum creatinine plus other ERF markers Radiology: renal scarring, hydronephrosis
Other findings	Symptoms	Signs
7. Incomplete bladder emptying	Sensation of incomplete emptying at end of void Need to return shortly after voiding to try again Significant leakage shortly after voiding	Physical: Passage of significant volume of urine on double void Radiology: Evidence of post void residual on ultrasound. Incomplete bladder emptying fluoroscopy. Nuclear medicine: incomplete bladder emptying on indirect cystogram
8. Asymptomatic bacteriuria	Urinary odor (distinctive)	Physical: Child well Laboratory: urine dipstick may be positive for white cells, nitrites, blood. Microscopy may show bacterial growth but insignificant white cells.
9. Urinary tract infection	Dysuria, frequency, urgency, smelly urine, abdominal or loin pain, systemic features of being unwell	Laboratory: Urine dipstick and urine microscopy, culture suggestive of infection