Which Patients With Dysfunctional Voiding Respond Well to Sacral Neuromodulation? ICI-RS 2025

Dysfunctional voiding (DV) is characterised by fluctuating or intermittent urinary flow during voiding in neurologically normal individuals. Given the different definitions used and heterogeneous pathophysiologies, outcomes following sacral neuromodulation/sacral nerve stimulation (SNM/SNS) are variably reported. The aim was to identify the areas of research required to be able to accurately predict response to SNM/SNS in adults with DV.

The relevant literature was reviewed by a multidisciplinary panel and the findings were discussed at the ICI-RS meeting held in 2025 in the UK. The outcomes of this discussion are presented.

DV has unique diagnostic features, typically requiring pressure-flow studies and uroflowmetry to establish the diagnosis. Further investigations such as electromyography and urethral pressure profilometry help to better understand the pathophysiology. Phenotyping the lower urinary tract dysfunction helps to identify patterns of abnormalities, and it is likely that certain groups show a better response to SNM/SNS than others, such as in Fowler's syndrome. Older age and change in body weight following implantation are associated with a worse outcome, though not specifically in DV. Studies evaluating the impact of neuropsychiatric co-morbidities on SNM/SNS outcomes show mixed results. Central dysregulation of micturition networks possibly contribute to DV and could represent an additional therapeutic target of SNM.

Precise phenotyping of individuals with DV integrating clinical, urodynamic, neurophysiological, and neuropsychiatric factors is essential to predict which adults respond best to SNM/SNS. Future research should focus on establishing criteria for patient selection and designing comprehensive prospective interventional studies to assess efficacy and complications.