Fowler’s syndrome: What it is and what it’s not

We review the clinical problem of idiopathic non-obstructive urinary retention and voiding difficulty in young women, thought by Fowler
and associates to be due to urinary sphincter spasm. We conclude that this voiding disorder in Fowler’s syndrome (FS) is not due to sphincter
spasm associated with a so-called characteristic electromyography pattern in the urinary rhabdosphincter, since the latter has been shown
to occur in normal young women. We point out that non-obstructive urinary retention and voiding difficulty is also a feature of the posterior
fornix syndrome (PFS) and we suggest that these two syndromes are one and the same. In idiopathic non-obstructive urinary retention,
as described in PFS and in FS, the voiding disorder is usually associated with laxity of the uterosacral ligament (USL)with resultant loss of
balance in the pelvic floor muscular vectors, causing impaired opening of the urethra for voiding. The various associated features of these
two syndromes, especially enlarged bladder, urgency and frequency, chronic pelvic pain, and secondary psychological symptoms are all
relieved when voiding difficulty is resolved by successful management strategies, including physiotherapy, tape-based reinforcement of the
USL, and neuromodulatory management. We suggest that, given its simplicity and long-term effectiveness, surgical reinforcement of the USL,
by plication in younger women or tape reinforcement after the menopause, is the optimal first line treatment for posterior fornix syndrome
(PFS). Nonetheless, we caution that our conclusions described here do not exclude other, central neurological causations for this voiding
disorder in some patients.