Jalesh N. Panicker

Chronic idiopathic urinary retention and Fowler's syndrome are a debilitating problem primarily affecting women, characterised by an inability to urinate in the absence of any identifiable structural or other cause. An increasingly wide range of multifactorial predisposing, precipitating, and perpetuating biopsychosocial factors are being recognised. This has led to interest in nonsurgical treatments that may complement existing surgical approaches. We reviewed existing literature on nonsurgical management and combined this information with collective multidisciplinary professional and lived experience, to produce a new definition of chronic idiopathic urinary retention (the Fife Definition) and a framework for the assessment and nonsurgical treatment for women with chronic idiopathic urinary retention. The article provides a stepped care approach to nonsurgical treatment including explanation and formulation, basic bladder healthcare, optimising catheterisation, management of relevant comorbidities, multidisciplinary treatment and additional treatment options and emerging therapies.

Purpose of Review: Lower urinary tract symptoms (LUTS) may precede or accompany the other symptoms of neurologic disease and may be the presenting clinical manifestations of central, peripheral, or autonomic nervous system dysfunction. In clinical practice, urologists are often the first specialists to evaluate these patients, potentially before underlying neurologic disease has been identified. Early recognition of neurologic contributors to LUTS may help prevent diagnostic delay. This review aims to provide a symptom-based framework that highlights common urologic presentations associated with underlying neurologic disease, along with urodynamic findings of concern, to support earlier recognition of neurological disease in patients presenting with LUTS. Recent Findings: Recent work has characterized neurologic diseases associated with LUT dysfunction using disease-based frameworks. Despite this, gaps persist in routine urologic evaluation, including inconsistent screening for neurological symptoms and limited incorporation of focused neurologic history and examination. Certain urodynamic patterns are increasingly recognized as suggestive of neurological pathology but are not consistently interpreted within this context. Barriers to timely neurologic evaluation, including limited specialist availability and prolonged wait times, further contribute to diagnostic delay. As a result, there is growing recognition of the need for urologists to identify clinical features within LUTS presentation that should prompt consideration of neurologic disease, though practical strategies for integrating these insights into routine care remain limited. Summary: A symptom-based framework for evaluating LUTS can enhance early detection of neurologic disease in urologic practice. Urologists and pelvic health specialists should have a broad understanding of what clinical characteristics associated with LUTS should trigger concern for underlying neurological disease and should always consider neurological disease in the differential diagnosis. This review provides a practical, clinically oriented overview of neurologic disease in LUTS assessment, including guidance on screening questions, initial testing considerations, urodynamic interpretation, and referral, particularly in the settings with limited neurology access. Algorithms are provided to facilitate early recognition of occult neurological disease within routine urologic practice.

Symptoms related to bladder, bowel and sexual dysfunction are common in patients with neurological diseases and are associated with significant morbidity and impacts on quality of life. However, compared with other neurological problems, they are often less visible, under-ascertained and under-treated. This review aims to provide neurologists with an evidence-based, structured approach to evaluating bladder, bowel and sexual dysfunction in patients with neurological disorders. As with any other presenting concern, this requires a structured approach to history, examination and the judicious use of investigations.

Aims: 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. Methods: 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. Results: 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. Conclusion: 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.

Aims: To explore the boundary of clinical use of sacral nerve stimulation (SNS) in neurogenic lower urinary tract dysfunction (NLUTD), identifying barriers to approval and early‐impact research questions. Methods: This review is derived from a proposal discussion at the International Consultation on Incontinence‐Research Society in Bristol in June 2025. Results: Current evidence for predicting NLUTD symptom improvement or functional recovery after SNS remains mainly from small retrospective cohorts. Definitive trials are a research priority, accordingly. The influence of SNS on urodynamic parameters is uncertain due to the lack of studies with urodynamics as the primary endpoint. Additionally, there is no core outcome set for NLUTD treated with SNS. Use of closed‐loop SNS in NLUTD to adjust stimulation parameters may improve outcome and device longevity. Hence, we need to elucidate how SNS modulates LUT control network over time and across disease stages. Optimal stimulation parameters need to be defined for patient populations, but also for individuals, with dynamic strategies for adjustment. Use of SNS in NLUTD needs to enable ongoing use of MRI scanning for neurological evaluation, especially in progressive conditions. An MR Conditional SNS device means it can be safely scanned in specific MR environments. Use of such a device needs to factor in the range of further electronic implants that might be used in complex medical conditions. Conclusions: The application of SNS to NLUTD is likely to increase. A key aspiration is nuanced patient selection, using functional assessment and urodynamic findings. To translate SNS into standard clinical practice, interdisciplinary collaboration and robust clinical trials are essential.

Aims: To discuss the relationships between mental health problems (MHP) and lower urinary tract symptoms (LUTS). To propose an assessment plan for identifying MHP in patients presenting with LUTS. Methods: This review is the outcome of a global multi‐disciplinary think tank at the International Consultation on Incontinence (ICI‐RS 2025) meeting held in June 2025 in Bristol, United Kingdom that examined the broad issue of mental health and LUTS. The relationship of MHP and LUTS in adults and children, and the possible underlying mechanisms, is presented. Results: Robust evidence was noted for an association between MHP and LUTS, including storage symptoms, voiding symptoms, and bladder pain. However, the underlying mechanisms that underpin this relationship remain unclear. Clinical markers that might indicate MHP and screening tools for assessment by clinicians involved with LUTS care, are discussed. Recommendations are made with regard to key areas for future research. Conclusions: There is a consensus on the existence of a relationship between mental health problems and lower urinary tract symptoms. A better understanding of the nature of this relationship, the mechanisms that underlie it, and the best methods to assess it, is crucial to improving clinical care.

Purpose: The existing literature on the sacral dermatomal evoked potentials (dSEPs) is limited. This study aims to develop stimulating parameters and establish normative values for S2, S3, and S4 sacral dermatomes in healthy adult populations. Methods: Twenty healthy adult volunteers were enrolled in the study. The study was ethically approved, and written consent for participation was provided. All participants underwent tibial, pudendal, S2, S3, and S4 dSEPs. Stimulating and recorded parameters were established for all evoked potentials. P40 latency, amplitude, and interpeak parameters were calculated for each waveform. A comparison was made between tibial, pudendal somatosensory evoked potentials, and all sacral dSEPs. Normative values were generated for sacral dSEPs based on various height, age, and Body Mass Index (BMI) parameters. Results: The sacral dSEPs were well tolerated and recorded in all participants. S2 latency was mildly influenced by age and height, while S3 and S4 latencies were unaffected by age or height. BMI does not affect the S2 and S3 latencies but mildly affects the S4 latency. Sacral dSEP latencies were comparable with pudendal SEPS but not with the tibial somatosensory evoked potential. Conclusions: The S2, S3, and S4 sacral dSEPs can be used as diagnostic tools to evaluate sacral nerve lesions such as cauda equina syndrome and Tarlov cysts, complementary to pudendal and tibial somatosensory evoked potentials.