Detrusor Sphincter Dyssynergia: Mechanistic Descriptor or Independent Pathophysiologic Entity?

Purpose of review Detrusor sphincter dyssynergia (DSD) is a common manifestation of suprasacral neurologic disease. DSD is characterized by impaired coordination of detrusor contraction and urethral sphincter relaxation during voiding. DSD was historically regarded as an important contributor to upper urinary tract deterioration and other complications in neurogenic lower urinary tract dysfunction (NLUTD), but its independent prognostic significance remains incompletely understood. We review pathophysiology, clinical implications, diagnosis, and management of DSD, with emphasis on its interpretation within the broader context of bladder pressure dynamics and physiology. Recent findings Emerging evidence suggests that the clinical significance of DSD depends less on its presence versus absence but rather on its impact on bladder compliance, detrusor pressure generation, urinary emptying, and autonomic patterns. In this way, DSD may be a contributing factor to elevated storage and voiding pressures, urinary stasis, recurrent urinary tract infection, autonomic dysreflexia, and upper tract deterioration. The available literature highlights limitations in the qualitative diagnosis of DSD and increasing interest in quantitative characterization through pressure-flow relationships, urethral pressure measurements, and videourodynamic assessment. Therapeutic approaches remain individualized and include optimization of bladder storage dynamics, catheterization strategies, alpha blockade, sphincteric botulinum toxin injection, and sphincterotomy in selected cases. Summary DSD remains an important physiologic phenomenon in NLUTD, but its interpretation requires integration with broader measures of bladder and outlet physiology rather than reliance on a binary diagnosis alone. Future advances in DSD assessment will likely require more quantitative and mechanistic characterization integrating sphincter dynamics, bladder pressure physiology, imaging, and clinical outcomes.