Neurourology and Urodynamics 26:518–524 (2007)

Psychogenic Urinary Dysfunction:

A Uro-Neurological Assessment
Ryuji Sakakibara,1* Tomoyuki Uchiyama,1 Yusuke Awa,2 Zhi Liu,1 Tatauya Yamamoto,1
Takashi Ito,1 Kaori Yamamoto,2 Mika Kinou,2 Chiharu Yamaguchi,3
Tomoyuki Yamanishi,4 and Takamichi Hattori1
1
Department of Neurology, Chiba University, Chiba, Japan
2
Department of Urology, Chiba University, Chiba, Japan
3
Central Laboratory Unit, Chiba University Hospital, Chiba, Japan
4
Department of Urology, Dokkyo Medical College, Tochigi, Japan

Aims: The diagnosis of psychogenic urinary dysfunction (PUD) is one of exclusion, particularly from urologic and neurologic causes, and is usually
accompanied by more obvious psychologic/ psychiatric features. We here describe patients with PUD who were diagnosed in our uro-
neurological laboratory. Materials and Methods: We reviewed the digitized records of 2,300 urodynamic cases treated in the past 6 years to identify
patients who fulfilled the diagnostic criteria of PUD. All 2,300 patients had completed a urinary questionnaire and undergone both electromyography
(EMG)-cystometry and a detailed neurological examination. In addition, pressure-flow analysis, neurophysiology tests including sphincter EMG
analysis, and MRI of the brain and spinal cord were performed as applicable. Results: PUD was seen in 16 cases (0.7%): 6 men, 10 women, mean age 37
years. Lower urinary tract symptoms (LUTS) included overactive bladder (OAB) alone in 5, difficult urination alone in one, and both in 10. LUTS
commonly occurred in particular situations, for example, OAB only while riding the train. Some patients showed extremely infrequent toileting. The
urodynamic findings were normal except for increased bladder sensation (50%) for OAB and acontractile detrusor (31%) for difficulty. The final
diagnosis was conversion reaction in six followed by anxiety in four. Conclusions: PUD patients experienced the situational occurrence of OAB and/or
difficult urination and, in some patients, extremely infrequent toileting. The main urodynamic abnormalities were increased bladder sensation and
acontractile detrusor. However, even in cases suggestive of PUD, a non-PUD pathology behind the symptoms should be explored. Neurourol. Urodynam.
26:518–524, 2007. ß 2007 Wiley-Liss, Inc.

Key words: emotional stress; increased bladder sensation; overactive bladder; psychogenic urinary dysfunction; urinary retention

INTRODUCTION
Psychogenic urinary dysfunction (PUD) is a well-recognized
condition reviewed in several textbooks1–3 and reported in
urology and psychiatry journals.4–8 In those reports, PUD has
been defined as: (1) a diagnosis of exclusion, particularly from
urologic, gynecologic, and neurologic causes; and (2) a con-
dition usually accompanied by more obvious psychologic/
psychiatric features. Therefore, PUD is regarded as a psychoso-
matic disorder of the bladder due to neurosis/psychosis.
Among the defining criteria of PUD, recent advances in the
exclusion diagnosis of neurologic causes by means of electro-
physiology, sphincter electromyography (EMG), and magnetic
resonance imaging (MRI) have allowed us to diagnose neuro-
logic causes more accurately. As a result, PUD might present
itself in a more clear-cut manner than in the past. To answer
this question we present our data concerning PUD as
diagnosed in our uro-neurological laboratory.
MATERIALS AND METHODS
Materials
We retrospectively analyzed PUD cases in our laboratory.
Our database included 2,300 case records accumulated in
the past 6 years; these were digitized using File Maker Pro
personal computer database software. These records includ-
ed data from a lower urinary tract (LUT) symptoms (LUTS)
questionnaire, from a urodynamic study, and from neurolo-
gical examinations. Most patients were referred from the
departments of neurology, urology, collagen/metabolic dis-
eases, pediatrics, psychiatry, orthopedic surgery, or neurosur-
gery at our university hospital for the assessment of LUT
function.
Methods
LUTS questionnaire. All patients had completed a LUTS
questionnaire, which included questions about storage
(urinary urgency, daytime and nighttime frequency, and in-
continence; or overactive bladder, OAB) and voidingsymptoms
(retardation, poor flow/prolongation, intermittency, straining,
sensation of residuals).9 The patients had also responded to
a quality-of-life index scaled from 0 (none) to 3 (severely
dissatisfied) and completed questionnaires on bowel and
sexual function. The questionnaires were completed by the
patients and their families. In addition, a detailed medical
history, including pelvic surgery and diabetes, was taken.
Urodynamic studies. All patients had undergone urody-
namic studies, in which post-void residual volume (PVR) was
measured by transurethral catheterization and by medium-fill
(50 ml/min) water cystometry.10 In addition, external anal
sphincter EMG was performed by a urodynamic computer
(Janus; Lifetec, Inc., Houston, TX) and an EMG computer
(Neuropack Sigma; Nihon Kohden, Inc., Tokyo, Japan). The
normal ranges of urodynamic parameters are as follows: PVR,
<30 ml; first sensation, >100 ml but <300 ml; bladder
capacity, >200 ml but <600 ml. Increased bladder sensation
was indicated by low first-sensation volume and/or bladder
No conflict of interest reported by the author(s).
*Correspondence to: Ryuji Sakakibara, MD, Department of Neurology, Chiba
University, 1-8-1 Inohana Chuo-ku, Chiba 260-8670, Japan.
E-mail: kumar.n@thomsondigital.com
Received 13 April 2006; Accepted 20 June 2006
Published online 13 March 2007 in Wiley InterScience
(www.interscience.wiley.com)
DOI 10.1002/nau.20321

ß 2007 Wiley-Liss, Inc.


capacity, whereas impaired bladder sensation was indicated
by high first-sensation volume and/or bladder capacity. An
abnormal bladder-filling phase was indicated by detrusor
overactivity (DO, i.e., involuntary bladder contractions with a
detrusor pressure rise of more than 10 cmH2O during the
filling phase of cystometry) and uninhibited sphincter relaxa-
tion (USR, i.e., involuntary relaxation of the sphincter during
the filling phase). An abnormal bladder-voiding phase was
indicated by detrusor-sphincter dyssynergia (DSD, i.e., the
inability to relax the sphincter on voiding detrusor contrac-
tion) and underactive/acontractile detrusor (i.e., the inability
to contract the detrusor and produce urinary flow). In patients
who were able to void, pressure-flow analysis was performed
to the extent possible. A weak or very weak detrusor
contraction (assessed by Schäfer’s nomogram) was taken as
evidence of an underactive detrusor. We also graded outlet
obstruction on a scale of 0–6 (a larger number indicates more
severe obstruction). A grade of 3 or more (assessed by Schäfer’s
nomogram) indicated an obstruction. Sphincter EMG analysis
was performed via a concentric needle electrode in the anal
sphincter muscle. Neurogenic sphincter EMG abnormalities
were diagnosed according to the published criteria.11
Neurological examinations. All patients had undergone
neurological examinations, which included gait disturbance,
motor weakness and deep tendon reflexes of the lower
extremities, and sensation in the lower half of the body
including the perineal area. When searching for Fowler’s
syndrome in young women with retention but without
apparent neurological abnormalities, we explored urethral
sphincter EMG to the extent possible to detect any ‘whale
noise’ or complex repetitive discharge. When the neurological
examination suggested peripheral neuropathy, we added a
nerve conduction study. Similarly, when the examination
suggested spinal cord or brain diseases, we added MRI of the
brain and spinal cord.
Other investigations. All patients had undergone blood
chemistry analysis and urinalysis to exclude diabetes and other
organic causes of neuropathies. When assessing men of middle
age or older who exhibited outlet obstruction by the pressure-
flow study, we performed further prostate examinations
including an ultrasound echography. When searching for
interstitial cystitis in patients with pain or hematuria, we
performed a cystoscope under hydrodistension with local
anesthesia to detect any glomerulation or ulceration. We
referred women with uterine prolapse to our hospital’s
gynecology department for further examinations.
RESULTS
After carefully excluding urologic and neurologic causes, in
the present study PUD was seen in 0.7% (16 cases) of our 2,300
urodynamic cases: 6 men, 10 women, mean age 37 years (15–
69 years; Table I). The most common precipitating factors to
trigger LUTS were a traffic accident in three cases (in two of
which LUTS appeared just after the accident, whereas in the
other LUTS appeared 3 months after the accident; in one case
the accident was still in litigation) and an inability to cope
with families in three cases, followed by divorcing parents
in two cases. The 16 LUTS cases included OAB alone in 5,
difficult urination alone in one, and both OAB and
difficult urination in 10 (Table II). LUTS often occurred only
in particular situations. For example, in one case (case 5), OAB
occurred only when the patient was riding on a train with
many people standing in the aisle. Some patients had
Neurourology and Urodynamics DOI 10.1002/nau
Psychogenic Urinary Dysfunction 519
extremely infrequent toileting (once or twice a day; cases 2,
4) in addition to OAB and difficult urination.
In most patients, there was a dissociation between LUTS in
their daily life and urodynamic findings (Tables II and III).
These findings were normal except for the following. The
major urodynamic abnormality in the patients with OAB was
increased bladder sensation without DO or low-compliance
detrusor, which was noted in 50% of all patients (Table III). The
major urodynamic abnormality in patients with difficult
urination was underactive/acontractile detrusor, which was
noted in 31% of patients. None of the patients had DSD or USR.
Final diagnoses in our patients were made with regard
to other somatic findings. The most common disease was
conversion disorder (hysteria) in 6, followed by anxiety
disorder in 4 (Table I). Most patients had more obvious mental
disorders in addition to LUTS. However, in one patient (case
12), LUTS was the sole initial presentation; we considered it to
be a conversion disorder in the bladder (combined with
physical stress incontinence). There were three reasons for this
decision: her urinary dysfunction appeared just after a traffic
accident, her LUTS was dissociated from urodynamic findings,
and other potential causes (including urologic/neurologic
causes) were carefully excluded. The main therapies,
which benefited patients moderately, were the use of a minor
tranquilizer, antidepressant, or LUT drug (alpha-blocker), or
referral to a psychiatrist (Table III).
DISCUSSION
The diagnosis of PUD is basically exclusionary, particularly
from urologic, gynecologic, and neurologic causes, and this
disorder accompanies more obvious psychologic/ psychiatric
features.1–3,8,12 Within this context, neurologic diseases are
not always easy to diagnose, since they may present with LUT
dysfunction as the sole initial manifestation, as seen in spinal
bifida occulta and multiple system atrophy.13 In the present
study we carefully excluded such patients to the extent
possible by means of neurological examination and, where
applicable, electrophysiology, sphincter EMG, and MRI. The
results revealed PUD in 0.7% (16 cases) of our 2,300
urodynamic cases, which comprise mostly an adult popula-
tion of patients in a university hospital. The prevalence rate in
the present study was slightly lower than those reported in
studies with similar sample sizes, for example, 2% among
1,015 adult urodynamic cases,12 2.7% among 1,300 urody-
namic cases,14 and 2.9% among 103 women with acute
retention in a midsized British city.6 Moreover, the rate in
our study was much lower than in other studies, which found
a 20% incidence among urodynamic referrals and 50% within
a urological practice.3 In light of these previous figures, our
findings indicate that the incidence of PUD in urodynamic
practice is lower than has been thought, and this change
seems to be a consequence of our detailed exclusion of other
causes. The sex ratio of our patients was 6 men to 10 women,
and the patients were relatively young (mean 37 years), all
consistent with previous findings.3 Since previous reports
handled LUTS as either OAB or voiding difficulty/retention
(also called paruresis8 or bashful bladder syndrome15) sepa-
rately, the proportion of each type of LUTS remains unclear. In
the present study PUD comprised OAB in 5 cases, difficult
urination in one, and both OAB and difficult urination in 10;
therefore OAB is common, but many patients had both OAB
and difficult urination simultaneously.
In our patients, a specific aspect of LUTS was that they often
occurred only in certain situation. In those cases, there was a
dissociation of LUTS between one occasion and another. For
 520

TABLE I. Patients

Age Duration Cognitive Neurological

No. pt (years) Sex Final diagnosis (years) Background Outstanding features disorder examination Imaging/other investigations

1 MA 15 F Hypochondria, physical 1.5 LUTS appeared 4 months after None None Normal Lumbar MRI, pad test, laboratory
stress incontinence traffic accident; mother examination: normal
convinced the accident caused
her daughter’s incontinence
2 TM 16 M Autism, mental retardation 1 Staying indoors, abulia, not going None Mental Normal Brain MRI, laboratory examination:
Sakakibara et al.

to toilet retardation normal

3 KK 20 M Anxiety disorder 1.5 Unknown None None Normal Lumbar MRI, laboratory
examination: normal
4 TS 21 M Obsession disorder 1 Parents divorced, strict mother; Insomnia, obsessive hand None Normal except for Brain MRI: cerebellar arachnoid cyst,
worm phobia, bullied, staying washing night blind retinal degeneration, laboratory
indoors, suicide attempt examination: normal
5 KY 23 M Anxiety disorder 1 Unknown None None Normal Laboratory examination: normal
6 HS 24 F Panic disorder 4 Parents divorced, quarreling with None None Normal Lumbar MRI/myelography, NCS,
stepfather; presenting initially laboratory examination: normal

Neurourology and Urodynamics DOI 10.1002/nau

with retention
7 MS 29 F Conversion disorder 8 Unknown Abnormal wet sensation in the None Normal Gynecological examination,
lower half of body thermography, SSR, SFR, pad test,
indigocarmine test, laboratory
examination: normal
8 NY 29 M Depression 2 Mother having depression None (communication difficult) Presumably Normal Laboratory examination: normal
none
9 RK 31 F Anxiety disorder 1 Enuresis until 10 years; dental Fatigue None Normal Laboratory examination: normal
technician; quarreling with
husband, separation, no
children
10 KT 38 F Conversion disorder 4 LUTS appeared immediately after Left shoulder involuntary None Normal except for Brain/cervical MRI, NCS, SEP, EEG,
traffic accident, still on lawsuit movement, patchy dysesthesia involuntary nEMG, laboratory examination:
in the face/body movement normal
11 MK 50 F Conversion disorder >7 Parents having industrial organic Left-side body weakness, None Normal Brain/cervical MRI, LP, NCS,
mercury poisoning in numbness in the extremities, laboratory examination: normal
Minamata, Japan wheelchair
12 SN 51 F Conversion disorder in 1 LUTS appeared immediately after None None Normal Cervical X-ray: mild spondylosis at
urination, physical stress traffic accident C5/6, lumbar X-ray, laboratory
incontinence examination: normal
13 HJ 59 F Conversion disorder 0.2 Unknown Numbness in the extremities None Normal Laboratory examination: normal
14 MY 59 M Anxiety disorder 2 Unknown Insomnia None Normal Brain MRI, laboratory examination:
normal
15 SF 64 F Conversion disorder 2 Unknown Abnormal explosive feeling in None Normal Brain/cervical/lumbar MRI,
the mouth, trunk, abdomen, laboratory examination: normal
buttock; refusal to sit;
afterwards, wheelchair
16 TI 69 F Senile psychosis 2 Home alone Insomnia, headache, shoulder Cognitive Normal Brain MRI, laboratory examination:
pain, appetite loss, impairment normal
hallucination, behavioral (MMSE 21/30)
disorder (throwing trash from
windows)

LUTS, lower urinary tract symptoms; MMSE, mini-mental state examination (normal > 24). MRI, magnetic resonance imaging; NCS, nerve conduction study of the extremities; SSR, sympathetic sweat response;
SFR, sympathetic flow response.
 TABLE II. Results of Urinary Questionnaire

Lower urinary tract symptom

Urinary
Urinary incontinence urgency/frequency Difficult urination
Quality-of-life Quality-of-life Sexual Quality-of-life
No. Patient Type Frequency Volume Frequency Type and frequency Others index Bowel movement index function index

1 MA Physical stress/ Weekly, but Minimum — — 2 1/1 day 1 Not applicable

unwitting daytime alone
2 TM Overflow, due Daily Large — — Infrequent voider 3 Not answered Not answered
to holding (1–2 times only
urine when forced by
parents)
3 KK — — — 22 times, but daytime Retardation, prolongation, 3 1/1 day 0 None 0
only straining; daily
4 TS — — — — Retardation, prolongation, Infrequent voider 3 1/2 days 0 Erectile dysfunction 2
intermittency, straining; (less than
daily 3 times a day)
5 KY — — — Daytime alone, only — 3 1/1 day 0 None 0
on walking to the

Neurourology and Urodynamics DOI 10.1002/nau

station/on the train
6 HS — — — 9 times, but daytime only Retardation, prolongation, 3 1/2 days 0 Not applicable
intermittency, sensation of
residual; daily
7 MS Unwitting Daily, but Moderate Urgency, weekly — 2 1/1 day 1 Not applicable
daytime alone
8 NY Urge/enuresis Weekly Moderate 22 times, daytime; Prolongation, intermittency, 3 1/4 days 1 None 0
7 times, nighttime straining, sensation of
residual; daily
9 RK Urge/enuresis Monthly Minimum 10 times, daytime; — 2 Not answered Not applicable
3 times, nighttime
10 KT Unwitting Daily Little 13 times, daytime; Retardation, prolongation, 1 1/7 days 1 Not applicable
3 times, nighttime intermittency; daily
11 MK Urge Weekly Little Urgency, weekly Retardation, prolongation, 2 Not answered Not applicable
intermittency, straining,
sensation of residual; weekly
12 SN Mixed Daily Moderate 11 times, daytime — 3 1/1 day 0 Not applicable
13 HJ — — — Urgency, daily Retardation, prolongation, 2 Not answered Not applicable
intermittency, straining,
sensation of residual;
daily
14 MY — — — 3 times, nighttime Retardation, prolongation, 2 1/1 day 0 None 0
intermittency, straining,
sensation of residual;
daily
15 SF Urge Daily Moderate 12 times, daytime; Retardation, prolongation, 3 Not answered Not applicable
4 times, nighttime intermittency, straining;
daily
16 TI — — — 3 times, nighttime — 1 Not answered Not applicable

Quality-of-life index: 0, satisfied; 1, mildly dissatisfied; 2, moderately dissatisfied; 3, severely dissatisfied.

Psychogenic Urinary Dysfunction
521
 522

TABLE III. Results of Urodynamic Study

Free flowmetry EMG-cystometry Pressure-flow study Sphincter EMG

Sakakibara et al.

Post-void
Volume Qmax Qave residual First Bladder Urethral Bladder Neurogenic
No. patient (ml) (ml/sec) (ml/sec) (ml) sensation (ml) capacity (ml) obstruction contractility MUP CRD Treatment

1 MA 30 12 5 0 130 350 2 Normal n.p.

2 TM n.p. 0 30 400 No flow Acontractile n.p.
detrusor
3 KK n.p. 30 65 240 1 Normal Normal None Diazepam
4 TS n.p. 0 270 500 No flow Acontractile Normal None Urapidil; zopiclone,

Neurourology and Urodynamics DOI 10.1002/nau

detrusor bromazepam; keen to use
balloon catheter though
no residuals
5 KY 100 8 5 0 122 320 2 Normal n.p. Diazepam
6 HS n.p. 20 50 450 No flow Underactive Normal None (urethra) Urapidil
detrusor
7 MS n.p. 0 280 490 n.p. Normal n.p.
8 NY n.p. 8 658 2 Strong n.p. Flunitrazepam, etizolam
9 RK 400 22 185 350 n.p. Normal n.p. Impiramine,
10 KT 23 5 3 40 26 426 No flow Underactive n.p. Refused treatment
detrusor
11 MK 50 8 4 5 50 240 0 Normal Normal None
12 SN 370 33 14 50 20 680 0 Normal n.p.
13 HJ 170 30 15 10 80 300 No flow Acontractile Normal None (urethra) Imipramine, diazepam
detrusor
14 MY n.p. 0 200 300 n.p. Normal n.p.
15 SF 100 11 7 10 170 498 1 Normal n.p. Flutoprazepam, tiapride,
olanzapine
16 TI n.p. 0 100 180 n.p. Normal n.p. Mianserin, etizolam,
tiapride

n.p., not performed; Qmax, maximum urinary flow rate; Qave, average urinary flow rate, hatched area: increased sensation, for example, volume less than normal value (first sensation, 100<normal<300;
bladder capacity, 200<normal<600), urethral obstruction (Schäfer): grade 0, normal; grade 2, equivocal; grade 3<, obstruction (a larger number indicates more severe obstruction); MUP, motor unit potentials;
CRD, complex repetitive discharge.

example, in one case, OAB occurred only when the patient was
riding on a train in which many people were standing in the
aisle. The psychodynamics underlying these patients may
well be reproduced by healthy individuals under stressful
conditions in daily life, for example, a person may need to use
the toilet just before starting an important presentation3 or
have difficulty urinating when in close proximity to another
person.8,16 The severity of such a phenomenon is usually
mild and the duration is short. However, if an individual feels
such symptoms are an extreme bother, he or she may
have hypochondria or a phobia involving toileting (mental
disorder caused by toileting); or, if the symptoms are severe
and long, the individual has PUD (urinary dysfunction caused
by mental disorder). Both conditions could occur together.
In addition to OAB and difficult urination, two of our patients
also showed extremely infrequent voiding or even an unwill-
ingness to use the toilet. Similar episodes have been described
before.17 Toileting phobia has been reported to underlie this
condition, originating from previous pain in micturition as a
result of a urinary tract infection14 or painful urological
investigations.17 However, no such histories were obtained in
our patients. In our cases, the most common factors preci-
pitating LUTS were traffic accidents in three cases and an
inability to cope with family in three; followed by divorcing
parents in two. These episodes are mostly in accordance
with those in previous reports.3 Among the precipitating
factors, traffic accidents are well known to produce conver-
sion disorder. In our cases, there was no apparent history of
sexual abuse or other sexually related episodes generating
LUTS.5,18
Compared with the severe LUTS in our patients, the
urodynamic findings were dissociated. For example, they
were mostly normal except for increased bladder sensation in
50% and underactive/acontractile detrusor in 31% of all
patients. Dissociation between a patient’s complaint and
somatic/laboratory findings is a general feature of conversion
disorder.1,3 Increased bladder sensation19 is clinically relevant
in the bladders of patients with PUD or interstitial cystitis as
well as in a small proportion of neurologic patients, such as
thosewith diabetic neuropathy (unpublished data). Despite
the relative lack of urodynamic literature concerning psycho-
genic OAB, Macaulay et al.19 showed higher incidences
of anxiety, depression, and phobia in patients with in-
creased bladder sensation than in those with physical stress
incontinence. Increased bladder sensation most probably
reflects psychologic/psychiatric disorders, in which biological
changes do occur, particularly in brain areas associated with
emotion (amygdala, hippocampus, hypothalamus, and medial
prefrontal cortices). A positron emission tomography (PET)
study showed decreased g-aminobutyric acid (GABA)-A/
benzodiazepine receptor bindings in the right orbitofrontal
cortex and insula of unmedicated patients with panic
disorder.20 Benzodiazepine is a mainstay in the treatment of
panic and anxiety disorders, whereas micturition is under
tonic inhibition of GABA.21,22 Another PET study showed
decreased serotonin 1A-receptor bindings in the cingulate
cortex and raphe in panic disorder patients.23 Serotonergic
drugs, such as selective serotonin reuptake inhibitors and
serotonin-noradrenaline reuptake inhibitors, are widely used
to treat panic disorder and depression, and have recently been
used to treat OAB as well.24 These drugs are thought to act on
both efferent and afferent fibers from the bladder. On the
other hand, brain corticotropin-releasing factor (CRF) has
anxiogenic effects and increases bladder sensation.25 Irritable
bowel syndrome is highly prevalent in anxiety and mood
disorders, and CRF receptor antagonist could ameliorate
Neurourology and Urodynamics DOI 10.1002/nau
Psychogenic Urinary Dysfunction 523
26
increased bowel sensation in those patients. These findings
suggest that increased bladder sensation can be a reflection
of biological changes in both the emotion and micturi-
tion circuits within the brain. In contrast, the emotional
mechanism underlying the underactive/acontractile detrusor
is not well understood. Neurogenic cases such as brain
tumor and stroke27,28 and functional imaging studies29 have
suggested that the cingulate cortex and insular cortex are
the key areas for the generation of micturition impulses,
which are sent to the brainstem structures. Therefore,
functional changes in these areas might also occur in patients
with PUD.
Taken together, the present results agree with the notion,
although not common in urodynamic practice, that PUD is an
important category that all urologists have to deal with.3
Regarding urologic aspects, PUD is basically a diagnosis of
exclusion, particularly from urologic, gynecologic, and neuro-
logic causes. In light of the present results, the characteristics
of LUTS in PUD are the situational occurrence of OAB and/or
difficult urination and, in some patients, extremely infrequent
toileting. The characteristics of urodynamics in PUD are
increased bladder sensation during bladder filling and under-
active/acontractile detrusor during voiding. Regarding neuro-
psychiatric aspects, PUD is usually accompanied by more
obvious psychologic/psychiatric features. In fact, the majority
of our patients had conversion disorder and anxiety disorder.
In particular, anxiety is a universal human emotion, closely
allied with appropriate fear or external stressors. As described
above, when healthy individuals are placed under stressful
conditions, some of them do develop mild urinary dysfunc-
tion. Alteration in both emotion and micturition under such
conditions most probably originates from the brain, which
may reflect functional alteration in GABAergic, serotonergic,
and CR Fergic neuronal circuits. However, urinary dysfunction
in healthy individuals under stressful conditions must be
further clarified before the mechanism of PUD can be fully
understood.
However, we still do not know to what extent psychologic/
psychiatric disorders might cause urodynamic abnormalities.
Previously, the concept of ‘PUD’ included non-situational,
long-standing retentions in any environment that might
require catheterization for bladder emptying. These ‘psycho-
genic’ reports have shown almost all types of urodynamic
abnormalities, for example, DO3,30,31 and low-compliance
detrusor3,32 during bladder filling; and poor flow, large PVR,
vesicoureteral reflux,3,31 underactive/acontractile detrusor3,31
and intermittent contraction,12 and (pseudo-)DSD3,31,33,34
during voiding. Among these, many of our patients showed
increased bladder sensation during bladder filling or under-
active/acontractile detrusor during voiding. Otherwise, none
of our patients had DO or DSD. We still have several patients
with urinary dysfunction of undetermined etiology. Some of
them exhibit slight neurotic features, presumably secondary
to their LUTS per se. We are following these patients for
urinary dysfunction of possible neurogenic/myopathic origin,
since these disorders may present with urinary dysfunction as
the sole initial manifestation. One such male patient turned
out to have multiple system atrophy. Ochoa’s urofacial
syndrome (boys and girls with a peculiar smile; LUT disorder
similar to that in Hinman’s cases; a potential gene mapped to
chromosome 10q23-q24);35 and Fowler’s syndrome (young
women; sphincter hypertonicity with ‘whale noise’)36 should
also be considered, since both diseases have been separated
historically from ‘psychogenic’ patients. Therefore, even in
cases suggestive of PUD, a non-PUD pathology behind the
symptoms should be explored.
524 Sakakibara et al.
CONCLUSIONS
In our laboratory, PUD was found to be rare (0.7% among
2,300 urodynamic cases). PUD patients revealed situational
occurrence of OAB and/or difficult urination and, in some
patients, extremely infrequent toileting. The main urody-
namic abnormalities were increased bladder sensation and
acontractile detrusor. However, even in cases suggestive of
PUD, a non-PUD pathology behind the symptoms should be
explored.
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