In 1971, Hinman [24] presented 14 boys with typical characteristics of the nonneurogenic, neurogenic bladder syndrome and suggested that these changes were behavioral as demonstrated by their reversal by suggestion hypnosis, and by the absence of any detectable neurological or obstructive abnormality. Hinman concluded that “since these children usually are toilet trained initially, the incoordination appears to be a learned behavior or habit, perhaps as a response to underappreciated detrusor contractions. Reversal of the syndrome is achieved by suitable medication and by some form of suggestion or retraining.” Typically, children with a nonneurogenic, neurogenic bladder present with frequency, urgency, urinary incontinence, recurrent urinary tract infections, or occasionally, encopresis. Further evaluation may reveal signs of obstructive uropathy , such as trabeculated bladder, elevated postvoid residual urine volume, hydronephrosis, and vesicoureteral reflux, in the absence of any identifiable neurological or obstructive abnormality. Urodynamically, these children have uncontrolled detrusor contractions that they fail to inhibit, and they do not coordinate these contractions with concomitant sphincteric relaxation. In time, not only do they find it difficult to inhibit detrusor contractions, but they also find it difficult to keep the sphincter relaxed when voiding occurs.

In children, functional voiding dysfunction is usually acquired after toilet training, reaches its peak of destructiveness in late childhood, and tends to resolve after puberty [24–27]. Although it may persist, or even first manifest, later in life, data concerning functional voiding dysfunction in adults are scarce. George and Slade [28] reported a series of 16 men (mean age, 42 years; range, 29 ± 55 years) referred for evaluation of refractory LUTS. Their main symptoms were urinary frequency, hesitancy, intermittent stream, and the inability to void in public places. These symptoms were found to be associated with a high incidence of dyspepsia and anxiety. The investigators suggested the existence of a chronic systemic state and proposed the term “anxious bladder.” Jorgensen et al. [29] reported the symptomatology and clinical manifestations of “idiopathic detrusor sphincter dyssynergia” in neurologically normal patients referred for evaluation of voiding symptoms. Diagnosis was established by the following criteria: (1) two flow curves obtained in privacy showing a characteristic intermittent pattern and (2) simultaneous record of pressure-flow parameters and electromyography (EMG) demonstrating intermittent pelvic floor activity during micturition. Twenty-three patients (0.5 % of the study population) fulfilled these criteria. The mean age of these patients was 27.4 years (range, 5–72). Further differentiation between children and adults was not carried out. Groutz et al. [30] suggested the term “learned voiding dysfunction” and used the following clinical and urodynamic criteria to establish the diagnosis: (1) a suggestive clinical history, i.e., LUTS and difficulty in voiding in public places, or during uroflowmetry/urodynamics , having to concentrate, relax, touch genitalia, listen to running water, etc.; (2) intermittent “free” uroflow pattern; (3) exclusion of neurological disorders, or anatomical causes of bladder outlet obstruction; and (4) demonstration of typical external urethral sphincter contractions during micturition with either needle EMG, or fluoroscopic visualization of the urethra during voiding. The urethra is usually dilated to the level of the external sphincter, while the bladder neck is wide open, distinguishing dysfunctional voiding from primary bladder neck obstruction. Using these strict criteria, 2 % of 1015 consecutive adults referred for video-urodynamic evaluation of LUTS were found to have learned voiding dysfunction. Other patients, with presumed learned voiding dysfunction, who did not undergo video-urodynamics were not included. Thus, the prevalence of learned voiding dysfunction among adults referred for evaluation of LUTS is likely to be even higher. Contrary to children, in whom the main subjective hallmarks of the syndrome are urinary incontinence and recurrent urinary tract infections, adult patients present mainly with obstructive and/or irritative symptoms, while urinary incontinence is less prominent [30, 31]. Functional voiding dysfunction may also be associated with transient postoperative urinary retention. FitzGerald and Brubaker [32] studied 10 women who underwent Burch colposuspension , or sub-urethral sling surgery. Voiding trials were performed 1–2 days after surgery under simultaneous monitoring of the urethral sphincter EMG activity and intravesical pressure. Six patients were unable to void and demonstrated persistent EMG activity. Four of these demonstrated no detrusor contraction, whereas two demonstrated detrusor contractions. The authors concluded that failure of relaxation of the striated urethral sphincter contributes to postoperative urinary retention.