Urological Open Access Journal, 2012, 2, 11-15
Published Online February 2012 (http://www.SciRP.org/journal/uoaj) 11
Urodynamic Findings in Young Women of Less Than Forty
Years Old with Lower Urinary Tract Symptoms*
Hosein Karami, Alireza Bagher Tabrizi, Babak Javanmard,
Hooman Mokhtarpour, Behzad Lotfi
Urology and Nephrology Research Center (UNRC), Shohada Medical Center,
Shahid Beheshti University, Tehran, Iran
Received November 24, 2011; revised January 15, 2012; accepted January 25, 2012
ABSTRACT
Purpose: The aim of the study was to determine urodynamic findings in young women (<40 years old) with bothersome
lower urinar y tract symptoms. Materials and Methods: Th e records of 315 women were reviewed during 2002 to 2010.
Those with neurological disease, history of urogenital malignancies, urethral stricture or trauma, acute UTI, unsterile
urine analysis, congenital urological disease, pelvic organ prolapse, diabetes mellitus or a primary complaint of stress
incontinence were excluded. All completed the American Urological Association Symptom Index (AUASI) and under-
went urodynamic studies. Results: Bladder dysfunction was diagnosed in 78.4% of the patients with urge incontinence.
Bladder and voiding phase dysfunction were found in 134 (42.5%) and 110 (34.9%) of patients, respectively. Occult
neurological disease was later diagnosed in 10 women (3.17%) with urge incontinence and bladder dysfunction. Dis-
cussion: Urge incontinence and voiding symptoms are frequently associated with urodynamical abnormalities. Urge
incontinence and bladder dysfunction may be a sign of occult neurological disease in this population. The presenting
symptoms are useful in determining the advantage of urodynamic study in this population.
Keywords: Ur ge Incontinence; Wom e n; Ur odynamics
1. Introduction
Young women with LUTS are a difficult group of pa-
tients to diagnose and treat. Irritative symptoms (fre-
quency, nocturia, urgency, incontinence) and obstructive
symptoms (straining, weak stream, intermittency, and
hesitancy) have different etiologies in this group. Preg-
nancy and delivery can initiate the changes that cause
LUTS in this population. The prevalence of LUTS in the
young women has not been extensively studied yet. Pre-
vious studies have paid attention on the prevalence of
stress incontinence [1]. The symptom of urge inconti-
nence has not been investigated extensively, unless in
studies that the prevalence of incontinence is explained
[2-5]. The association of LUTS with urodynamic abnor-
malities in young wo men has not be en studied before. In
this study, we intended to determine urodyn amic find ing s
in this group. This information could be useful in select-
ing patients for urodynamic evaluation.
2. Materials and Methods
The records of 315 young (<40 years) women who un-
derwent urodynamic assessment for LUTS during 2002
to 2010 were reviewed. Those with neurologic disease,
history of previous incontinence or lower urinary tract re-
constructive surgery, and tho se with urogenital malignan-
cies, urethral stricture or trauma, acute UTI, unsterile urine
analysis, congenital urological disease, pelvic organ pro-
lapse, diabetes mellitus or a primary complaint of stress
incontinence according to history and/or physical ex-
amination were excluded . All patients provided complete
urological and gynecological history and underwent com-
plete physical examination. All women completed the Ame-
rican Urological Association Symptom Index (AUASI)
before testing [6]. The index was divided into 3 groups:
1) Total score
2) Obstructive score
3) Irritative score
Urodynamic tests were completed in all patients.
Methods, units and definitions, conformed to the stan-
dards suggested by the International Continence Society
[7]. EMG was taken by surface electrodes. Filling cysto-
metery was performed too. The existence of involuntary
detrusor contractions or detrusor overactivity (DO), im-
paired compliance, and sensory urgency during filling
were noted. Impaired compliance was defined as <12.5
ml/cm H2O [8]. Impaired contractility was defined as a
*The authors declare that they have no conflict of interes t.

H. KARAMI ET AL.
12
detrusor contraction of <20 cm H2O, with a flow of <12
ml/s [9,10]. Patients voided in the seating position that
detrusor pressure, flow rate, EMG activity, and post void
residual were evaluated. Bladder dysfunction was de-
fined as DO and/or impaired compliance. Voiding phase
dysfunction was defined as bladder outlet obstruction or
impaired contractility. The diagnosis of dysfunctional
voiding was proposed when external sphincter activity
was increasing during voluntary voiding with accompa-
nying EMG evidence [11].
Patients were divided into 6 groups according to their
sy mptoms (Table 1).
Urodynamic findings, consisting of the prevalence of
bladder and voiding phase dysfunction, were evaluated in
different symptoms groups. Symptoms (including AUASI
and urge incontinence) and age were compared in wo-
men with or without bladder dysfunction and with or
without voiding phase dysfunction. Analysis of variance
(ANOVA) was used for age and AUASI, and for the
fixed variable of urge incontinence a Chi-square test was
used. A p value of less than 0.05 was considered as sta-
tistically significant.
3. Results
In the study, the mean age of all patients was 27 years
old (ranging betw een 18 and 39 years o ld). The d istribu-
tion of women for different chief complaints is summa-
rized in Table 1. Some 134 patients (42%) had a com-
plaint of urge incontinence.
1) Frequency and urgency: 5 (9%) had DO, 30 (53%)
had sensory urgency, and 22 (38%) had a normal cysto-
metrogram. Some 18 patients with sensory urgency and
the other 4 with DO also had dysfunctional voiding.
2) Frequency, urgency, and pain: A number of 52 pa-
tients (72.2%) had sensory urgency, 8 (11.11%) had DO,
5 (6.94%) had impaired compliance, and 7 (9.72%) had
normal urodynamics. Of those patients with sensory ur-
gency, some 28 had dysfunctional voiding; 3 patients
impaired compliance, and 1 patient with DO had dys-
functional voiding.
3) Frequency, urgency, and urge incontinence: 88 pa-
tients (65.6%) had DO, 6 (4.4%) impaired compliance,
11 (8.2%) impaired compliance and DO, 17 (12.6%) sen-
sory urgency, and 12 (9%) had a normal CMG, respec-
tively. Of those patients with DO, 15 had dysfunctional
voiding, and 5 were later diagnosed as MS. Some 5 pa-
tients with DO and impaired compliance had abnormal
sphincter activity through void ing an d all were later diag-
nosed with neurological diseases (3 tethered cord and 2
spinal cord hemangioma). Therefore, the total 10 of 134
women (7.46%) with urge incontinence were later diag-
nosed with neurological disease. Two patients with DO
had an obstructing urethral stricture; 11 patients with sen-
sory urgency had dysfunctional vo iding; one patient with
impaired compliance plus 4 patients with impaired com-
pliance and DO had dysfunctional voiding. Three patients
with a normal CMG had prim ary bladder neck obst ructi on.
4) Obstructive or voiding symptoms: Some 8 patients
(25%) had DO, 3(9.3%) had impaired compliance, 14
(43.7%) had sensory urgency, and 7 (21.8%) had a nor-
mal CMG. A number of 5 patients with DO, 12 patients
with sensory urgency, 2 patients with impaired compli-
ance and also 6 patients with normal CMG had dysfunc-
tional voiding. Thus, 25 of 32 patients (78%) had urody-
namic evidence of obstruction.
5) True incontinence: Ten patients.
6) Suprapubic pain only: Three had sensory urgency
and others had normal CMG.
Table 2 includes the prevalence of urodynamic find-
ings of bladder dysfunction and voiding phase dysfunc-
tion among patients with different symptoms.
Some 134 women had bladder dysfunction totally that
105 women (78.35%) of this group had urge inconti-
nence (Table 3). Patients who had urge incontinence had
Table 1. Patients were divided into 6 groups according to
their symptoms.
Chief complaint Number (%)
Frequency/urgency 57 (18)
Frequency/urgency and pai n 72 (23)
Frequency/urgency and urge incontinence 134 (42)
Obstructive or voiding symptoms 32 (11)
True incontinence 10 (3)
Suprapubic pain only 10 (3)
Table 2. Prevalence of bladder and voiding phase dysfunction among patients with different symptoms.
Chief complaint Bladder dysfunction (%)a Voiding phase dysfunction (%)b
Frequency/urgency 9 38.59
Frequency/urgency and pai n 18 44.44
Frequency/urgency and urge incontinence 78.2 23.18
Obstructive symptoms 34.3 78.12
True incontinence 0 0
Suprapubic pain 0 0
aBladder dysfunction was defined as DO and/or impaired compliance; bVoiding phase dysfunction was defined as bladder outlet obstruction or impaired con-
tractility.

H. KARAMI ET AL. 13
Table 3. Patients with or without bladder dysfunction characteristics and scores.
Bladder dysfunction (n = 134) No bladder dysfunctio n (n = 181) P
Mean age 27.5 26.6 0.43*
Mean AUASI scores
Total score 20.5 22.7 0.13*
Irritative score 11.5 10.4 0.14*
Obstructive score 9.3 12.4 0.018*
Urge incontinence 105 (78.35%) 29 (16%) <0.0001**
*Analysis of variance; **Chi-square test.
a significantly higher incidence of bladder dysfunction
than those without it, 78.2% vs. 14.3% (p < 0.0001). Pa-
tients with or without bladder dysfunction had similar
total and Irritative AUASI scores, but obstructive scores
were higher in patients without bladder dysfunction (Ta-
ble 3).
Some 110 women had voiding phase dysfunction. Only
32 of those (22.7%) had a chief complaint of obstructive
symptoms. Of the total of 32 patients with a chief com-
plaint of voiding symptoms, some 25 patients (78%) had
urodynamical voiding phase dysfunction. There was a
significant difference between the incidence of the urge
incontinence in the patients with voiding phase dysfunc-
tion (28%) and those without it (50%). Patients with
voiding phase dysfunction had significantly higher ob-
structive and total AUASI scores, but similar irritative
scores if compared with those withou t it (Table 4).
4. Discussion
The prevalence of urinary incontinence has been reported
to be 5% - 20% in the prior studies that stress inconti-
nence was the most prevalent type in many studies [1,2,4,
5,12,13]. Few studies have focused on urge incontinence
in young women. A French study reported the prevalence
of isolated urge incontinence to be zero in women with
the age of less than 25 years old and 1.5% in those be-
tween 25 and 39 years old [14]. A study in central Swe-
den reported the rise in incontinence prevalence with age
and parity, and that prevalence of pure urge incontinence
was only 2.1% in 20 - 59 years old women [15].
The urodynamic study before LUTS treatment enables
us to diag nose problems created by d angerous cond itions
such as occult neurological diseases. Since urodynamics
has low morbidity, it is better for young women to un-
dergo urodynamics before starting the treatment.
Our study showed that urge incontinence was highly
suggestive of urodynamic abnormalities. In our study,
82.8% of women with urge incontinence presented DO,
voiding phase dysfunction, or both in urodynamic study,
however, 73.8% of them had DO only. Ten women in
this group (7.46%) were considered as occult neurologi-
cal disease after neurological workup. Of those patients
with the chief complaint of obstructive symptoms, 78%
had voiding phase dysf unction.
Urge incontinence and obstructive symptoms are good
predictors of a diagnostic urodynamic study. The com-
plete neurological evaluatio n must be done for th e young
women with significant urodynamic abnormalities that
can not be justified by other conditions. In this study,
neurological evaluation was performed for 30 patients.
The diagnosis of neurological disease was proposed in 10
of them, 5 with detrusor overactivity, and 5 with both
detrusor overactivity and impaired compliance.
AUASI is a helpful score for explaining LUTS in
women. AUASI has been used to evaluate LUTS in wo-
men [16,17], and has shown the degree of bother from
symptoms and quality of life in both men and women
[18]. Women with voiding phase dysfunction had higher
total and obstructive scores than those without it. Irrita-
tive scores were similar to each other. Thus, in women
without obstructive symptoms, th e AUASI could be use-
ful in deciding to perform urodynamics. This shows the
benefit of voiding phase evaluation when perform uro-
dynamic study [16]. The total and irritative scores in the
Table 4. Patients with or without voiding phase dysfunction characteristics and scores.
Voiding phase dysfunction (n = 110) No voiding phase dysfunction (n = 205) P
Mean age 26.1 27.2 0.31*
Mean AUASI scores
Total score 24.7 20.5 0.02*
Irritative score 11.3 10.9 0.4*
Obstructive score 13.7 9.9 0.009*
Urge incontinence 31 (28.18%) 103 (50.24%) <0.001**
*
Analysis of variance; **Chi-square test.

H. KARAMI ET AL.
14
women with or without bladder dysfunction are similar
to each other. Voiding scores were higher in women
without bladder dysfunction than thos e with it. Therefore,
the AUASI is a useful instrument in selecting young
women for urodynamic performance.
Other indexes evaluated in our study were voiding
diaries, intake diaries, uroflowmetery, and postvoid re-
sidual volume. Diaries were especially useful in diagno-
sis of excessive fluid intake as a cause of high urine out-
put in young women. The urodynamic study was not
helpful in those patients. When uroflowmetery or PVR
are abnormal, it may show voiding phase dysfunction.
Therefore, urodynamic study could be useful in such
patients.
It may be concluded that when young women have
only overactive bladder symptoms, without any obstruc-
tive complaints or neurological signs and symptoms,
with normal emptying, nor mal urine analysis, and nor mal
physical examination, could be treated empirically. We
can also perform empiric therapy when uroflowmetery is
normal.
5. Conclusion
Young women present different symptoms of lower uri-
nary tract. Urodynamic study may be helpful in the
evaluation of this group. In particular, patients with urge
incontinence and voiding symptoms may have urody-
namic abnormalities. Urge incontinence and bladder dys-
function can predict an occult neurologic disease. A neu-
rological assessment is recommended for the patients that
show significant urodynamic abnormalities that cannot
be justified otherwise. When young women have only
overactive bladder symptoms, without any obstructive
and neurological signs and symptoms, with normal emp-
tying, urine analysis, and physical examination, could be
treated empirically.
REFERENCES
[1] S. A. E. Hunskaar, K. Burgio, et al., “Epidemiology and
Natural History of Urinary Incontinence,” In: P. K. S.
Abrams and A. Wein Eds., “Incontinence: First Interna-
tional Consultation on Incontinence,” Plymbridge, Ply-
mouth, 1999, pp. 199-226.
[2] L. H. Wolin, “Stress Incontinence in Young, Healthy
Nulliparous Female Subjects,” Journal of Urology, Vol.
101, No. 4, 1969, pp. 545-549.
[3] Z. Simeonova and C. Bengtsson, “Prevalence of Urinary
Incontinence among Women at a Swedish Primary Health
Care Centre,” Scandinavian Journal of Primary Health
Care, 1990, Vol. 8, No. 4, pp. 203-206.
doi:10.3109/02813439008994959
[4] H. Sandvik, S. Hunskaar, A. Seim, R. Hermstad, A. Van-
vik and H. Bratt, “Validation of a Severity Index in Fe-
male Urinary Incontinence and Its Implementation in an
Epidemiological Survey,” Journal of Epidemiology &
Community Health, Vol. 47, No. 6, 1993, pp. 497-499.
doi:10.1136/jech.47.6.497
[5] D. Hagglund, H. Olsson and J. Leppert, “Urinary Incon-
tinence: An Unexpected Large Problem among Young
Females. Results from a Population-Based Study.” Fam-
ily Practice, Vol. 16, No. 5, 1999, pp. 506-509.
doi:10.1093/fampra/16.5.506
[6] M. J. Barry, F. J. Fowler Jr., M. P. O’Leary, et al., “The
American Urological Association Symptom Index for
Benign Prostatic Hyperplasia,” Journal of Urology, Vol.
148, No. 5, 1992, pp. 1549-1557.
[7] W. Schafer, P. Abrams, L. Lia o, A. Mattiasson, F. Pesce,
A. Spangberg, A. M. Sterling, N. R. Zinner and P. van
Kerrebroeck, “Good Urodynamic Practices: Uroflowme-
try, Filling Cystometry, and Pressure-Flow Studies,” Neu-
rourology and Urodynamics, Vol. 21, No. 3, 2002, pp.
261-274.doi:10.1002/nau.10066
[8] E. Gary, M. D. Leach and K. Y. Scott, “Post-Prostatec-
tomy Incontinence: Part I. The Urodynamic Findings in
107 Men,” Neurourology and Urodynamic, Vol. 11, No.
2, 1992, pp. 91-97. doi:10.1002/nau.1930110203
[9] V. W. Nitti, L. M. Tu, J. Gitlin, “Diagnosing Bladder
Outlet Obstruction in Women,” Journal of Urology, Vol.
161, No. 5, 1999, pp. 1535-1540.
doi:10.1016/S0022-5347(05)68947-1
[10] J. G. Blaivas and A. Groutz, “Bladder Outlet Obstruction
Nomogram for Women with lower Urinary Tract Symp-
tomatology,” Neurourology and Urodynamic, Vol. 19,
No. 5, 2000, pp. 553-564.
doi:10.1002/1520-6777(2000)19:5<553::AID-NAU2>3.0.
CO;2-B
[11] K. V. Carlson, S. Rome and V. W. Nitti, “Dysfunctional
Voiding in Women,” Journal of Urology, Vol. 165, No. 1,
2001, pp. 143-147.
doi:10.1097/00005392-200101000-00035
[12] T. Crist, H. M. Singleton and G. G. Koch, “Stress Incon-
tinence and the Nulliparous Patient,” Obstetrics & Gyne-
cology, 1972, Vol. 40, No. 1, pp. 13-17.
[13] K. Bo, R. Stien, S. Kulseng-Hanssen and M. Kristoffer-
son, “Clinical and Urodynamic Assessment of Nullipa-
rous Young Women with and without Stress Incontinence
Symptoms: A Case-Control Study,” Obstetrics & Gyne-
cology, 1994, Vol. 84, No. 6, pp. 1028-1032.
[14] L. Peyrat, O. Haillot, F. Bruyere, J. M. Boutin, P. Ber-
trand, Y. Lanson, “Prevalence and Risk Factors of Uri-
nary Incontinence in Young and Middle-Aged Women,”
British Journal of Urology International, 2002, Vol. 89,
No. 1, pp. 61-66.
doi:10.1046/j.1464-410X.2002.02546.x
[15] E. Samuelsson, A. Victor and K. Svardsudd, “Determi-
nants of Urinary Incontinence in a Population of Young
and Middle-Aged Women,” Acta Obstetricia et Gyne-
cologica Scandinavica, Vol. 79, No. 3, 2000, pp. 208-215.
doi:10.1080/j.1600-0412.2000.079003208.x
[16] K. V. Carlson, J. Fiske, V. W. Nitti, “Value of Routine
Evaluation of the Voiding Phase when Performing Uro-
dynamic Testing in Women with Lower Urinary Tract

H. KARAMI ET AL. 15
Symptoms. Journal of Urology, Vol. 164, No. 5, 2000, pp.
1614-1618. doi:10.1097/00005392-200011000-00036
[17] A. Groutz, J. G. Blaivas, G. Fait, A. M. Sassone, D. C.
Chaikin and D. Gordon, “The Significance of the Ameri-
can Urological Association Symptom Index Score in the
Evaluation of Women with Bladder Outlet Obstruction,”
Journal of Urology, Vol. 163, No. 1, 2000, pp. 207-211.
doi:10.1016/S0022-5347(05)68007-X
[18] H. M. Scarpero, J. Fiske, X. Xue and V. W. Nitti,
“American Urological Association Symptom Index for
Lower Urinary Tract Symptoms in Women: Correlation
with Degree of Bother and Impact on Quality of Life,”
Urology, Vol. 61, No. 6, 2003, pp. 1118-1122.
doi:10.1016/S0090-4295(03)00037-2