Editorial Comment on “Usefulness of the Toronto Voiding Symptom Score in the Diagnosis of Occult Tethered Cord Syndrome”

The authors present a study that investigated whether the Toronto Dysfunctional Voiding Symptom Score could be used to screen for occult tethered cord syndrome (OTCS) in children with daytime urinary incontinence [1]. The DVSS tool is widely used for the initial diagnostic assessment and posttreatment follow-up of patients presenting with dysfunctional voiding [2]. A score above 8.5 on the DVSS indicates dysfunctional voiding [3]. On the other hand, this study has shown that a DVSS score of at least 10 points is more effective at distinguishing between the OTCS and non-OTCS groups [1]. Examining each item of the DVSS individually revealed that the frequency of daytime urinary incontinence constituted the main difference between the two groups [OTCS vs. non-OTCS groups: median 3 (IQR: 3–3) vs. median 2 (IQR: 1–3), p = 0.018]. However, it is unclear whether the median DVSS of 10 (IQR: 8.3–12.8) in the OTCS group and 9 (IQR: 6–11.8) in the control group represents a clinically significant difference. The authors specified that the cut-off value of 10 was determined using ROC curve analysis to find the optimal balance between sensitivity and specificity. The authors state that requesting a lumbosacral MRI scan would be more cost-effective when the DVSS score is greater than 10, since the likelihood of OTCS increases in these cases. However, unnecessary lumbosacral MRIs can be avoided in patients with a DVSS below 10 due to the low probability of OTCS. However, as the authors have mentioned, using the DVSS as the sole discriminator for the diagnostic accuracy of the OTCS limits its clinical application due to its low specificity and positive predictive value. This situation also lends weight to the authors' argument that the DVSS should be used for initial screening rather than diagnosis. Taking into account the limitations outlined by the authors, the DVSS method can be used on a case-by-case basis for this purpose, provided that other clinical findings are present. Nevertheless, the DVSS is a tool that has found clinical use in the assessment of a wide variety of lower urinary tract dysfunctions, particularly dysfunctional voiding [4, 5]. It should therefore be noted that it may be applied as part of a number of basic assessment tools rather than being used alone for this purpose in neurogenic cases [4]. Clearly, further research is needed to investigate this topic using new, noninvasive diagnostic and monitoring tools, as well as predictors, in current multicentre studies. Ismail Selvi: conceptualization, writing – original draft, writing – review and editing, supervision. The author declares no conflicts of interest. This article is linked to https://doi.org/10.1111/iju.70279.