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

ß 2007 Wiley-Liss, Inc.


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

Neurourology and Urodynamics DOI 10.1002/nau


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

Neurourology and Urodynamics DOI 10.1002/nau


524 Sakakibara et al.
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1429–30.
In our laboratory, PUD was found to be rare (0.7% among 16. Nicolau R, Toro J, Prado CP. Behavioral treatment of a case of psychogenic
2,300 urodynamic cases). PUD patients revealed situational urinary retention. J Behav Ther Exp Psychiat 1991;22:63–68.
occurrence of OAB and/or difficult urination and, in some 17. Khan WU. Psychogenic urinary retention in a boy. J Urol 1971;106:432–4.
18. Ellsworth PI, Merguerian PA, Copening ME. Sexual abuse: Another causative
patients, extremely infrequent toileting. The main urody- factor in dysfunctional voiding. J Urol 1995;153:773–6.
namic abnormalities were increased bladder sensation and 19. Macaulay AJ, Stern RS, Holmes DM, et al. Micturition and the mind:
acontractile detrusor. However, even in cases suggestive of Psychological factors in the aetiology and treatment of urinary symptoms in
PUD, a non-PUD pathology behind the symptoms should be women. Br Med J 1987;294:540–3.
20. Malizia AL, Cunningham VJ, Bell CJ, et al. Decreased brain GABA(A)-
explored. benzodiazepine receptor binding in panic disorder: Preliminary results from
a quantitative PET study. Arch Gen Psychiatry 1998;55:715–720.
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Neurourology and Urodynamics DOI 10.1002/nau