International Continence Society Classification Research Articles

Association Between Irritable Bowel Syndrome and Lower Urinary Tract Symptomatology: A Cross-sectional Study in Mexican Population.

This study aimed to investigate the clinical phenotype of urinary symptoms in patients diagnosed with irritable bowel syndrome, the factors associated with this overlap, and the impact of urinary symptoms on their quality of life. Irritable bowel syndrome is a common disorder, affecting up to 3.8% of the population. The overlap with other disorders of the gut-brain interaction, psychiatric disorders, and other somatic disorders is common. Moreover, the association between irritable bowel syndrome and urinary symptoms has been recognized, but the clinical phenotype remains unclear. This cross-sectional study involved patients with irritable bowel syndrome according to Rome IV. Lower urinary tract symptoms were classified using the International Continence Society's classification. Data on demographics, medical history, medication use, anxiety, depression, and quality of life were collected and analyzed using logistic regression analysis. The study included 428 subjects, 86 diagnosed with irritable bowel syndrome. Patients exhibited a higher prevalence of lower urinary tract symptoms (60.5%, 95% CI: 50.5-71.9). Multivariate analysis revealed associations between irritable bowel syndrome and lower urinary tract symptoms (OR: 2.49, 95% CI: 1.48-4.18, P=0.001), particularly storage urinary symptoms (OR: 1.94, 95% CI: 1.10-3.40, P=0.021). Patients with urinary symptoms reported significantly lower quality of life compared with those without these symptoms (50.8±17.2 vs. 76.7±21.8, P<0.001). Irritable bowel syndrome is associated with lower urinary tract symptoms, contributing to a significant reduction in quality of life. Clinicians should consider referring patients with irritable bowel syndrome and lower urinary tract symptoms to experts in urodynamics to provide targeted management.

Different Neurogenic Bladders in Patients with Cervical and Thoracic Myelopathy: Direct Comparison from a Prospective Case Series.

Background/Objectives: This study aimed to identify the unique characteristics of neurogenic bladders and associated symptoms in patients with cervical or thoracic myelopathy using clinical surveys and urodynamic studies (UDSs). Methods: Patients with degenerative cervical (DCM) or thoracic (DTM) myelopathy and lower urinary tract symptoms (LUTSs) scheduled for decompressive surgery were prospectively enrolled. A UDS was performed one day preceding surgery to evaluate the preoperative urological function. Subjective symptoms were evaluated using the International Prostate Symptom Score (IPSS) and the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire before surgery and one year postoperatively. Results: Sixty-two patients (DCM: 50, DTM: 12) with a mean age of 63.2 years (men: 30, women: 32) were enrolled. The UDS revealed that 5 (8.1%) patients, all with DCM, exhibited completely normal UDS results, and the remaining 57 had at least one abnormal finding. Based on the International Continence Society classification, an underactive bladder was significantly more common in patients with DTM compared to patients with DCM (75.0% vs. 18.0%, p < 0.001). The results of the questionnaire showed that the voiding symptom IPSS were significantly worse, preoperatively, in patients with DTM (5.0 ± 4.4 [DCM] vs. 8.7 ± 4.5 [DTM]; p = 0.013). One year postoperatively, the IPSS grade of 24.0% of patients with DCM improved, whereas only one (8.3%) patient with DTM showed improvement. Conclusions: Patients with DTM reported worse voiding symptoms and exhibited more underactive bladders on UDS than patients with DCM before decompression. One year postoperatively, more patients with DCM showed subjective improvements in urinary function than those with DTM.

Age May Be the Only Variable Effecting Microhematuria Prevalance in Pelvic Organ Prolapse

Objective: We aimed to estimate the prevalence of microscopic hematuria in women with pelvic organ descent and compare the results in terms of severity and accompanying urinary symptoms. We hypothesized that microhematuria incidence would be higher in advanced prolapse and accompanying urinary symptoms.Study Design: Women who presented to our clinic from January 2013 to July 2016 were analyzed using our electronic medical record system. Those who were classified in the system under the "N81: female genital prolapse" code were included. Records were checked to certify that samples were acquired properly. Urogynecological examinations were performed by specialist gynecologists and documented according to the international continence society classification system. After ruling out urinary tract infections urinalysis was performed by an integrated system composed of an urine strip analyzer and a sediment autoanalyzer.Results: Gravidity, parity, menopause onset, smoking status and presence of systemic disease were similar for both groups. Women in the hematuria group were older (p&lt;0.001). Hematuria prevalance was greater ininternational continence society Stage 3-4 anterior prolapse and total prolapse (p=0.03) compared to early stage prolapse. However after logistic regression analysis; age was the only factor left in association with hematuria.Conclusions: Women who were older and with advanced stage prolapse ( ≥ international continence society stage 3) were more likely to have microscopic hematuria. Urine tests are requested routinely in the work-up of urogynecological patients. As the prevalance is microhematuria is high in this population; we believe that evidence based algorithms should be set as guidelines when hematuria is encountered in patients with organ prolapse.

Abdominal sacrocolpopexy with Pelvicol xenograft and concomitant Burch colposuspension.

PurposeTo evaluate the efficacy of Pelvicol xenograft use during abdominal sacrocolpopexy to repair pelvic organ prolapse (POP).Patients and methodsA total of 27 consecutive women with symptomatic POP were included in this study. A POP-quantification system and International Continence Society classification were used. Functional and anatomical outcomes were assessed. Subjective outcomes and physical activity after surgery were evaluated due to modified quality of life questionnaire.ResultsMedian follow-up was 21 months (range: 16 to 41 months). Twenty-four (89%) patients were available for anatomical and subjective evaluation. Preoperative POP-quantification classification was: stage I: 11.1%, stage II: 25.9%, stage III: 48.2%, and stage IV: 14.8%. Overall, pad usage significantly decreased (mean 4.8 vs 1 pads, P=0.001). Stress urinary incontinence significantly improved after surgery in nine women (P=0.001). An additional five women were completely continent. No de-novo incontinence developed. Six women with preoperative urinary retention improved in the amount of residual urine postoperative (mean 35 vs 165 mL). Failure rate was 8.3% at 3 and 11 months after surgery, requiring a second reconstruction. There was no graft related complications or graft rejections necessitating removal occurring. Response rate of the questionnaire was 67%. Two women reported no interference in physical activity after 2 postoperative months, five women after 5 months, and five women 1 year later. Pelvic pain (vaginal pain) was partly improved in eight patients, postoperatively, and ten patients had complete resolution of pain after surgery.ConclusionThis study demonstrates that abdominal sacrocolpopexy is an effective surgical treatment in correcting POP. The use of Pelvicol is associated with a high recurrence rate and increased failure rate compared to traditional sacrocolpopexy with mesh. Larger clinical trials to evaluate the functional and anatomical outcomes are needed.

Is There a Correlation Between the Presence of Idiopathic Detrusor Overactivity and the Degree of Bladder Outlet Obstruction?

To assess the factors associated with the presence of idiopathic detrusor overactivity (IDO) in male patients with clinical benign prostatic hyperplasia (BPH). We prospectively evaluated 193 men who presented with lower urinary tract symptoms. Each patient underwent urodynamic evaluation, International Prostate Symptom Score (IPSS), uroflowmetry, residual volume check, and transrectal ultrasound for estimation of prostate volume. IDO was defined according to the new International Continence Society classification (2002) as involuntary detrusor contractions during cystometry, which may be spontaneous or provoked, regardless of amplitude. Patients were divided into groups according to the presence of detrusor overactivity and bladder outlet obstruction index (BOOI) greater than 40. Variables associated with the presence of IDO were analyzed using Student's t-test, chi-square test, linear-by-linear association test, and logistic regression analysis. Of 193 patients, IDO was present in 49 (25.4%). BOOI and prostate volume showed significant but weak correlation. On univariate analysis, patients with IDO were older and showed smaller maximal bladder capacity (MBC), higher BOOI, higher maximal detrusor pressure at maximal flow rate, and higher irritative IPSS subscores. On logistic regression analysis, MBC and BOOI were the factors affecting the presence of IDO, with odds ratios of 0.981 and 1.046, respectively. Positive linear association was noted between BOOI and prevalence of DO by linear association test with prevalence of DO rising continuously with increasing BOOI. BOO is responsible for IDO and because the prevalence of IDO is inversely associated with the degree of obstruction, the treatment of BOO is potentially able to reverse the DO.

Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results, quality of life and perioperative outcome—a prospective study with 101 cases

Our prospective study evaluates laparoscopic sacrocolpopexy for vaginal vault prolapse focusing on perioperative data, objective anatomical results using the pelvic organ prolapse quantification (POP-Q) system and postoperative quality of life using the Kings Health questionnaire. One hundred one patients completed the study. Fifty five had laparoscopic supracervical hysterectomy and sacrocolpopexy for uterine prolapse and 46 had laparoscopic sacrocolpopexy for post-hysterectomy prolapse. Median follow-up was 12 months. The subjective cure rate was 93% the objective cure rate (no prolapse in any compartment) according to the International Continence Society classification of prolapse was 98%. The main site of objective recurrence (6%) was the anterior compartment. No apical recurrences and no vaginal mesh erosion occurred. Postoperatively overall quality of life and sexual quality showed significant improvement with less than 1% de-novo dyspareunia. The procedure is recommended for experienced laparoscopic surgeons because of severe intraoperative complications like bladder or rectal injuries.

Dynamic magnetic resonance imaging for grading pelvic organ prolapse according to the international continence society classification: Which line should be used?

To assess and compare the reliability of dynamic MRI to quantify pelvic organ prolapse (POP) according to the International Continence Society (ICS) using two different reference lines, and to determine which line gives the best concordance with clinical examination. Forty-seven patients with genital prolapse underwent physical examination and dynamic MRI. Five nulliparous, symptom-free female volunteers underwent dynamic MRI as control subjects. Two distinct observers performed the MRI measurements of POP according to the ICS using two distinct reference lines: the mid-pubic line and a new one, the perineal line that provides a better match with the hymen plane. Measurements were repeated twice according to each line. The intra-class coefficient was used to estimate intra-observer and inter-observer reliability; the Altman and Bland plot was used to assess the agreement between MRI and clinical measurements. The intra-observer and inter-observer reliability of MRI measurements were in general excellent. Intra-class coefficients were better for the mid-pubic line than the perineal line. Although the MRI measurements correlate significantly with the physical measurements, the Altman and Bland plot shows an unacceptable magnitude of discrepancy between clinical and MRI examinations. Although dynamic MRI shows excellent inter- and intra-observer reliability, its agreement with clinical examination is poor whatever the line used.

Age and Bladder Outlet Obstruction Are Independently Associated with Detrusor Overactivity in Patients with Benign Prostatic Hyperplasia

BackgroundDetrusor overactivity is one known cause of lower urinary tract symptoms and has been linked to bladder storage symptoms (urgency, frequency, or urge incontinence). ObjectiveTo determine clinical and urodynamic parameters associated with detrusor overactivity in patients with suspected benign prostatic hyperplasia. Design, Setting, and ParticipantsDuring 1993–2003, urodynamic investigations were performed in patients aged 40 yr or older and with lower urinary tract symptoms, benign prostatic enlargement, and/or suspicion of bladder outlet obstruction (maximum flow rate < 15ml/s or postvoid residual urine > 50ml). MeasurementsDetrusor overactivity was defined according to the new International Continence Society classification (2002) as involuntary detrusor contractions during cystometry, which may be spontaneous or provoked, regardless of amplitude. The Schäfer algorithm was used to determine bladder outlet obstruction. ResultsIn total, 1418 men were investigated (median age: 63 yr) of whom 864 men (60.9%) had detrusor overactivity. In univariate analysis, men with detrusor overactivity were significantly older, more obstructed, had larger prostates, higher irritative International Prostate Symptoms Score subscores, a lower voiding volume at free uroflowmetry, and a lower bladder capacity at cystometry. The prevalence of detrusor overactivity rose continuously with increasing bladder outlet obstruction grade. Multivariate analysis showed that only age and bladder outlet obstruction grade were independently associated with detrusor overactivity. After age adjustment, the odds ratios of detrusor overactivity compared to Schäfer class 0 were 1.2 for class I, 1.4 for class II, 1.9 for class III, 2.5 for class IV, 3.4 for class V, and 4.7 for class VI. ConclusionsIn patients with clinical benign prostatic hyperplasia, detrusor overactivity is independently associated with age and bladder outlet obstruction. The probability of detrusor overactivity rises with increasing age and bladder outlet obstruction grade.

Invasively Estimated International Continence Society Obstruction Classification Versus Noninvasively Assessed Bladder Outlet Obstruction Probability in Treatment Recommendation for LUTS Suggestive of BPH

To investigate the contribution of urodynamically proven presence or absence (International Continence Society classification) of bladder outlet obstruction (BOO) to treatment recommendations for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia, and to investigate the impact of the replacement of the invasively estimated BOO classification with the noninvasively assessed BOO probability on treatment recommendations. Mandatory tests, recommended tests, and pressure-flow studies (with BOO classification) were performed in 150 consecutive men with LUTS suggestive of BPH. Three experienced urologists proposed, independently of each other, the treatment for each patient: watchful waiting, pharmacologic treatment, or surgery. After repeat randomization of the patients and replacement of the BOO classification with the BOO probability, the procedure was repeated 1 month later. A third treatment proposal was done after repeat randomization and after replacement of the BOO probability with the BOO classification. The symptom score and quality-of-life score were the most decisive in the treatment recommendations, followed by the BOO probability and BOO classification. The medical history, physical status, and duration of the complaints did not significantly affect the treatment recommendations. The intraindividual agreement between the judgments that included the BOO classification and the judgments that included the BOO probability was comparable to the agreement between both judgments that included BOO classification. The interindividual agreement between the judgments that included the BOO classification was not significantly different from that of the judgments that included the BOO probability. The symptom score and quality-of-life score were the most decisive in the medical treatment recommendations, followed by the BOO probability and BOO classification. The noninvasively assessed BOO probability was as valuable as the invasively estimated BOO classification in the medical treatment recommendations.

Quality of life in relation to TVT procedure for the treatment of stress urinary incontinence

The aim of the study was to assess the impact of tension-free vaginal tape (TVT) procedure as anti-incontinence surgery on patients' urinary symptoms and quality of life. Ninety-eight patients participated in the study. All patients were operated for urodynamic stress incontinence with the TVT procedure. Patients with prolapse more than first degree according to International Continence Society classification, previous anti-incontinence surgery, detrusor overactivity, or intrinsic sphincter deficiency were excluded from the study. Patients' quality of life assessment was performed with the use of the short form of Incontinence Impact Questionnaire and short form of Urinary Distress Inventory (UDI-6). Mean follow-up time was 12.4 +/- 4.2 months (range: 6-18 months). The cure rate for TVT procedure was 87.6%. There was a statistically significant improvement of quality of life postoperatively. In addition, the domains of UDI-6 concerning irritative symptoms and stress urinary incontinence symptoms showed statistically significant improvement postoperatively, while the domain concerning obstructive symptoms did not show statistically significant difference. Tension-free vaginal tape procedure as anti-incontinence surgery significantly improves the quality of life in female patients with urodynamic stress incontinence.

Regarding “Quality of life in relation to TVT procedure for the treatment of stress urinary incontinence”

Background. The aim of the study was to assess the impact of tension-free vaginal tape (TVT) procedure as anti-incontinence surgery on patients’ urinary symptoms and quality of life. Methods. Ninety-eight patients participated in the study. All patients were operated for urodynamic stress incontinence with the TVT procedure. Patients with prolapse more than first degree according to International Continence Society classification, previous anti-incontinence surgery, detrusor overactivity, or intrinsic sphincter deficiency were excluded from the study. Patients’ quality of life assessment was performed with the use of the short form of Incontinence Impact Questionnaire and short form of Urinary Distress Inventory (UDI-6). Results. Mean follow-up time was 12.4 ±4.2 months (range: 6–18 months). The cure rate for TVT procedure was 87.6%. There was a statistically significant improvement of quality of life postoperatively. In addition, the domains of UDI-6 concerning irritative symptoms and stress urinary inco...

LONG-TERM FUNCTIONAL AND URODYNAMIC RESULTS OF 50 PATIENTS RECEIVING A MODIFIED SIGMOID NEOBLADDER CREATED WITH A SHORT DISTAL SEGMENT

We assessed the long-term functional and urodynamic outcomes of a modified sigmoid neobladder. A total of 50 patients received a sigmoid neobladder with a short distal segment after radical cystoprostatectomy. Patients were followed at 3-month intervals the first year and every 6 months thereafter. Continence and voiding patterns were assessed using questionnaires and interview. The International Continence Society classification was used after 1996. Urodynamic assessment was performed 3 times during followup. Mean sigmoid segment length +/- SD was 18 cm (+/- 2.8). Mean followup was 38 months (+/- 24.8). Ureter stricture and reflux were present in 8% and 17% of the reimplanted units, respectively. Mean creatinine serum levels did not change after surgery and remained stable during followup. At 2 years 89% of the patients were continent in the daytime and 90% had good or satisfactory daytime continence according to the International Continence Society classification. At 3 years 77% of the patients voided every 3 or 4 hours during the day. Nighttime continence was poor. Only 10% of the patients complied with an alarm program. Mean maximal capacity of the reservoir was 300 ml and remained stable during followup. Mean intrareservoir pressure at maximal capacity decreased from 61 to 51 cm H2O from the first to the third urodynamic evaluation. No patient required clean intermittent catheterization. This modified sigmoid neobladder offers good daytime continence with low post-void residual and adequate daytime micturition frequency. Nighttime continence is poor. The presence of high intrareservoir pressures did not impair renal function.

Neurogenic Bladder in Patients with Cervical Compressive Myelopathy

We examined the urinary disturbances in 56 consecutive patients with cervical compressive myelopathy using the latest International Continence Society classification. Of the 56 patients with cervical compressive myelopathy, 29 (52%) had some urinary subjective complaints, whereas the remaining 27 (48%) had none. Urologic examination indicated that 8 of these 29 (28%) patients with urinary complaints had urologic disorders other than neurogenic bladder. Of the remaining 21 patients, only 6 (25%) were judged to have neurogenic bladder on urodynamic study. Urodynamic study may be of limited value in diagnosing urinary disturbance in cervical myelopathy. Further, four cases (83%) showed underactive bladder activity in voiding phase, and only one case (17%) showed overactive bladder activity in filling phase. These results were contrary to those of previous studies indicating that cervical compressive myelopathy is associated with overactive bladder activity in filling phase. There were no significant differences in motor or sensory Japanese Orthopedic Association scores between the patients with and without urinary complaints. However, the patients with urinary complaints had significantly longer durations of myelopathy and delayed motor evoked potential latencies than those without urinary complaints. After surgery, 19 of the 21 (90%) patients with urinary complaints showed recovery from urinary disturbance. Operations in patients with cervical myelopathy were also effective against urinary disturbance. Urinary complaints may be an indication for surgical treatment despite the results of urodynamic study.

Q-Tip Test and Tension-Free Vaginal Tape in the Management of Female Patients with Genuine Stress Incontinence

Introduction: To compare the Q-tip test before and after performance of the tension-free vaginal tape (TVT) procedure in women with genuine stress incontinence, and to determine the value of the Q-tip test in order to predict the outcome of TVT. Methods: Thirty-one patients with a diagnosis of stress incontinence but without previous anti-incontinence surgery (group I) and 10 patients with stress incontinence and a history of previous anti-incontinence surgery (group II) participated in the study. None of these patients had an anterior vaginal wall prolapse of greater than stage I according to the International Continence Society Classification and, therefore, the TVT procedure was the only operation performed on these patients. Urethral mobility using the Q-tip test was assessed by the same examiner at the initial physical examination and at the 6-month follow-up examination. Cure was defined as no leakage of urine postoperatively either subjectively or objectively, while failure was defined the objective loss of urine during the stress test. Results: The mean preoperative and postoperative Q-tip measurement in patients without previous operation (group I) was 43.5 ± 5.84 and 33.38 ± 4.77(mean difference 10.12%. The mean preoperative and postoperative Q-tip measurement in patients with previous operation (group II) was 17.5 ± 4.44, and 11.1 ± 6.88°), while the cure rate was 40%. Conclusions: Adequate mobility of the proximal urethra is associated with a high success rate of the TVT procedure.

Comparison of Pelvic Organ Prolapse in the Dorsal Lithotomy Compared With the Standing Position

In Brief Objective To determine if there is a significant difference in the degree of pelvic organ prolapse assigned during examination in the standing position compared with the dorsal lithotomy position with the patient performing maximal Valsalva maneuver. Methods Fifty-one women with symptoms of pelvic organ prolapse were examined in both the dorsal lithotomy position, while performing maximal Valsalva, and in the standing position at the same visit by one of two examiners. Nine site-specific measures and summary stages were recorded, as outlined by the International Continence Society's classification system for pelvic organ prolapse. The data were analyzed by Wilcoxon signed-rank test and correlation coefficients. Results The mean age was 52 ± 15 years. Excellent correlation was noted between all six points representing the vaginal prolapse. The R values for point Aa were 0.97, Ba 0.96, C 0.98, Ap 0.97, Bp 0.96, and D 0.97. The total vaginal length, perineal body, and genital hiatus measurements were performed in the dorsal lithotomy position with the patient at rest and were not repeated. The stages were identical in 48 of 51 patients. The average stage in the dorsal lithotomy position was 2.3 and in the standing position, 2.3. There was no statistically significant difference between the stage or any of the measured points in the dorsal lithotomy and standing examinations. Conclusion The degree of pelvic organ prolapse can be assessed adequately in the dorsal lithotomy position with the patient performing maximal Valsalva. It is not necessary to routinely repeat the examination in the standing position. The degree of prolapse assigned during examination in the lithotomy position is similar to that assigned in the standing position.

Diagnosis and significance of idiopathic overactive bladder

Objectives To offer a critical overview of the basis for the International Continence Society (ICS) classification of detrusor instability, to summarize current diagnostic methodologies, and to outline the etiologic factors that should be excluded in the diagnosis of idiopathic overactive bladder. Methods The current ICS definitions of overactive bladder are discussed. Issues related to the diagnosis of detrusor instability (DI) are addressed through a review of the literature. Results The term idiopathic overactive bladder reflects the present lack of knowledge concerning vesicourethral function and dysfunction. The term is used to apply to a wide spectrum of different conditions that may have a common final pathophysiologic pathway. This heterogeneous group of conditions could be subdivided on the basis of presumptive etiopathogenesis, urodynamic patterns, and response to treatment. The diagnosis of DI, its rate of detection, and its urodynamic patterns depend on the type of urodynamic test used and the way the test is performed. The ICS definitions of DI have been called into question by the results of studies using urodynamic tests in addition to, or instead of, provocative cystometry—for instance, ambulatory urodynamics, urethrocystometry, the ice-water test, and evaluation of the voiding phase. The literature supports a broadening of the ICS criteria for excluding all known causes of DI when establishing the diagnosis of idiopathic overactive bladder. Conclusions Appropriate longitudinal studies, using contemporary urodynamic tests and knowledge, are needed to improve the identification of subsets of patients with overactive bladder who have different prognoses and outcomes. The ICS definitions and classification should be updated.

The functional anatomy of the urethra: Role of the pubourethral ligaments

OBJECTIVE: This clinical study examines and defines the functional anatomy of the urethra as it relates to the Valsalva and Kegel maneuvers and to urethral stability. STUDY DESIGN: Dissection of embalmed cadavers and examination of 60 patients were performed to study adjunct structures in urethral stability. Provocative maneuvers (Valsalva and Kegel) were used in all 60 patients. Urethral prolapse was graded with use of the International Continence Society classification. RESULTS: Cadaveric dissection confirmed the structural anatomy of the pubourethral muscles and ligaments. Physical examination in 30 patients revealed a lack of urethral stability in all patients with stress urinary incontinence. In 30 patients acting as normal controls, no urinary incontinence was present, and all maintained urethral stability with provocation. The urethrovesical junction was mobile in all patients in performing a Valsalva maneuver. CONCLUSION: Intact pubourethral ligamentous and muscular attachments aid in stabilizing the urethra to its normal anatomic position. This helps maintain continence. (Am J Obstet Gynecol 1997;176:1200-5.)

Toward a new classification of overactive bladders.

Based on a large retrospective series, this study compares the International Continence Society's (ICS) classification of overactive bladders and a functional subtyping of our own, founded on clinical and urodynamic parameters. Functionally identical symptoms and urodynamic patterns were found within the Detrusor Hyperreflexia as well as the Unstable Detrusor categories. There are strong arguments for a revision of the current ICS classification system.

Mechanisms of Continence and Voiding, with International Continence Society Classification of Dysfunction

The two functions of the lower urinary tract are storage of urine within the bladder and timely expulsion of urine from the urethra. Bladder filling occurs with little or no increase in intravesical pressure, despite large increases in urine volume. This process, called accommodation, results from viscoelastic properties of the bladder wall and reflex inhibition of detrusor contractility. Urinary continence is maintained at rest by outflow resistance generated by the urethral sphincteric mechanism. With increases in intra-abdominal pressure, urethral resistance is augmented by passive pressure transmission to the bladder neck and proximal urethra and possibly by reflex muscular activity within the urogenital diaphragm. Normal voiding is a reflex act under voluntary control that involves relaxation of the urethra and sustained contraction of the bladder until emptying is complete. The ICS has classified lower urinary tract dysfunction as disorders of the filling or storage phase and as disorders of the emptying phase. Although urodynamic testing is not always necessary, some evaluation of both bladder and urethral function in each phase is required for accurate diagnosis.