Key points

Introduction

UDS has long been considered a useful tool for the diagnosis and treatment of lower urinary tract symptoms (LUTS), incontinence, voiding dysfunction, and neurogenic bladder. There has been recent controversy regarding the specific role of UDS. The Value of Urodynamic Education (ValUE) trial reported no improvement in 12-month outcomes between women with stress-predominant urinary incontinence randomized preoperatively to an office evaluation alone versus office evaluation plus preoperative UDS. However, diagnoses were changed in some patients who underwent UDS, as the surgeons were more likely to diagnose intrinsic sphincteric deficiency and less likely to diagnose overactive bladder (OAB), suggesting that UDS did change the clinician’s diagnosis before surgery. The utility of pressure-flow studies (PFS) in men before surgery for LUTS secondary to benign prostatic enlargement has long been debated. The American Urological Association (AUA) and the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction (SUFU) published guidelines for the use of UDS in adults, and this article reviews this update and places these findings in clinical perspective.

Traditionally, physicians have used UDS for the following scenarios: (1) to identify factors contributing to lower urinary tract dysfunction and assess their relevance, (2) to predict the consequences of lower urinary tract dysfunction on the upper tracts, (3) to predict the consequences and outcomes of therapeutic intervention, (4) to confirm and/or understand the effects of interventional techniques, and (5) to investigate the reasons for treatment failure. Because pretesting anxiety and urethral catheterization is necessary for some forms of UDS, the risks (bleeding, infection, urethral trauma, and pain) should be weighed with the potential benefits. UDS is not a static diagnostic examination that provides a diagnosis for lower urinary tract conditions. UDS is an interactive examination, which assesses lower urinary tract function and serves as an adjunct to the comprehensive evaluation of patients with LUTS. In most patients presenting with lower urinary tract disorders, UDS is usually not necessary in the routine initial evaluation or even before empiric treatment in most cases. The clinician should always formulate the urodynamic questions before any examination. The physician should always ask, “What am I hoping to gain from this test? What conditions do I need to assess during UDS testing? What symptoms need to be reproduced during the examination? And, will this test likely change my treatment plan?” If the physician cannot answer these questions and ensure that the patient complaints are reproduced, it is unlikely that the testing will be beneficial.

The AUA/SUFU Urodynamics Guideline in adults reviewed publications from January 1990 through March 2011 with focus on the use of postvoid residual (PVR), uroflowmetry, cystometry, PFS, videourodynamic studies (VUDS), electromyography (EMG), and urethral function tests (Valsalva leak point pressure [VLPP], urethral pressure profile). These UDS tests were evaluated by themselves or if used in combination with any other UDS test. Four lower urinary tract conditions were assessed: stress incontinence and pelvic organ prolapse (POP), urinary urgency and urgency incontinence, LUTS (comprising predominately obstructive symptoms), and neurogenic bladder. The role of UDS in these urinary conditions was evaluated in 4 categories: diagnosis, prognosis, clinical management decisions, and patient outcomes. Studies that did not report findings separately for men and women were excluded. The AUA methodology for Guidelines Statements was used. Each guideline statement is based on the strength of the evidence and is standard in the AUA Guidelines process. The nomenclature system for establishing guideline statement based on levels of evidence is included in Table 1 .

These guidelines offer guidance statements with attention given to certain clinical scenarios, represented by the various lower urinary tract conditions within the guideline. The guideline statements represent the role of UDS in the evaluation in management of patients with these urinary disorders. Thus, the intent of this guideline is that following a symptom assessment, physical examination, and incontinence assessment, physicians can determine which scenario, and thus which recommendation, fits their patient. These differences in clinical presentation often guide the decision of whether UDS is indicated or not. Taking the guidelines into consideration, it is ultimately the physician’s decision regarding what is best for each patient.

There are a total of 19 Guidelines Statements in each of the 4 clinical conditions. This article presents each Guideline Statement and offers clinical context and case scenarios.

Introduction

UDS has long been considered a useful tool for the diagnosis and treatment of lower urinary tract symptoms (LUTS), incontinence, voiding dysfunction, and neurogenic bladder. There has been recent controversy regarding the specific role of UDS. The Value of Urodynamic Education (ValUE) trial reported no improvement in 12-month outcomes between women with stress-predominant urinary incontinence randomized preoperatively to an office evaluation alone versus office evaluation plus preoperative UDS. However, diagnoses were changed in some patients who underwent UDS, as the surgeons were more likely to diagnose intrinsic sphincteric deficiency and less likely to diagnose overactive bladder (OAB), suggesting that UDS did change the clinician’s diagnosis before surgery. The utility of pressure-flow studies (PFS) in men before surgery for LUTS secondary to benign prostatic enlargement has long been debated. The American Urological Association (AUA) and the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction (SUFU) published guidelines for the use of UDS in adults, and this article reviews this update and places these findings in clinical perspective.

Traditionally, physicians have used UDS for the following scenarios: (1) to identify factors contributing to lower urinary tract dysfunction and assess their relevance, (2) to predict the consequences of lower urinary tract dysfunction on the upper tracts, (3) to predict the consequences and outcomes of therapeutic intervention, (4) to confirm and/or understand the effects of interventional techniques, and (5) to investigate the reasons for treatment failure. Because pretesting anxiety and urethral catheterization is necessary for some forms of UDS, the risks (bleeding, infection, urethral trauma, and pain) should be weighed with the potential benefits. UDS is not a static diagnostic examination that provides a diagnosis for lower urinary tract conditions. UDS is an interactive examination, which assesses lower urinary tract function and serves as an adjunct to the comprehensive evaluation of patients with LUTS. In most patients presenting with lower urinary tract disorders, UDS is usually not necessary in the routine initial evaluation or even before empiric treatment in most cases. The clinician should always formulate the urodynamic questions before any examination. The physician should always ask, “What am I hoping to gain from this test? What conditions do I need to assess during UDS testing? What symptoms need to be reproduced during the examination? And, will this test likely change my treatment plan?” If the physician cannot answer these questions and ensure that the patient complaints are reproduced, it is unlikely that the testing will be beneficial.

The AUA/SUFU Urodynamics Guideline in adults reviewed publications from January 1990 through March 2011 with focus on the use of postvoid residual (PVR), uroflowmetry, cystometry, PFS, videourodynamic studies (VUDS), electromyography (EMG), and urethral function tests (Valsalva leak point pressure [VLPP], urethral pressure profile). These UDS tests were evaluated by themselves or if used in combination with any other UDS test. Four lower urinary tract conditions were assessed: stress incontinence and pelvic organ prolapse (POP), urinary urgency and urgency incontinence, LUTS (comprising predominately obstructive symptoms), and neurogenic bladder. The role of UDS in these urinary conditions was evaluated in 4 categories: diagnosis, prognosis, clinical management decisions, and patient outcomes. Studies that did not report findings separately for men and women were excluded. The AUA methodology for Guidelines Statements was used. Each guideline statement is based on the strength of the evidence and is standard in the AUA Guidelines process. The nomenclature system for establishing guideline statement based on levels of evidence is included in Table 1 .

These guidelines offer guidance statements with attention given to certain clinical scenarios, represented by the various lower urinary tract conditions within the guideline. The guideline statements represent the role of UDS in the evaluation in management of patients with these urinary disorders. Thus, the intent of this guideline is that following a symptom assessment, physical examination, and incontinence assessment, physicians can determine which scenario, and thus which recommendation, fits their patient. These differences in clinical presentation often guide the decision of whether UDS is indicated or not. Taking the guidelines into consideration, it is ultimately the physician’s decision regarding what is best for each patient.

There are a total of 19 Guidelines Statements in each of the 4 clinical conditions. This article presents each Guideline Statement and offers clinical context and case scenarios.

Stress urinary incontinence and pelvic organ prolapse

• 1.
  

  Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function. (Recommendation; Evidence Strength: Grade C)

  
  
  
  
  • A.
    

    During multichannel UDS testing, all the instrumentation is in place to assess urethral function (without additional procedures). The assessment of urethral function is performed by the following tests:

    
    
    
    
    • i.
      

      Urethral pressure profilometry/maximal urethral closure pressure

      
      
    • ii.
      

      Abdominal leak point pressure (ALPP) (Valsalva/cough leak point pressure)—this measurement is easily obtained during demonstration of urodynamic SUI.

    
    
    
    
  • B.
    

    Because some treatments have been shown to be less effective in patients with poor urethral function, it is recommended that urethral function be evaluated when UDS has been determined beneficial in the preoperative evaluation of SUI. In surgeons performing midurethral sling procedures, there are data suggesting that a retropubic sling is more effective in patients with intrinsic sphincteric deficiency. Thus, there may be benefit in the assessment of urethral function in patients already selected for UDS before surgical intervention to help decide which procedure may be most effective.

  
  
  
  
• 2.
  

  Surgeons considering invasive therapy in patients with SUI should assess PVR urine volume. (Expert Opinion)

  
  
  
  
  • A.
    

    Although the exact threshold for elevated PVR is not clearly defined, it seems prudent that before performing surgery for SUI, which will have an effect on outlet function, a PVR assessment should be performed to provide information on the emptying status before surgery. The PVR assessment is safe, of little risk, and serves as a screen for disorders of emptying that may be identified preoperatively. In addition, this value can be a useful comparison in patients who develop emptying symptoms after surgery.

    
    
  • B.
    

    Usually, more than one PVR value should be obtained, and an elevated PVR should prompt further testing.

  
  
  
  
• 3.
  

  Clinicians may perform multichannel UDS in patients with both symptoms and physical findings of SUI who are considering invasive, potentially morbid, or irreversible treatments. (Option; Evidence Strength: Grade C)

  
  
  
  
  • A.
    

    Information obtained from a UDS study before surgery can confirm the diagnosis and as stated earlier may facilitate selection of the surgical procedure. In addition, these studies may provide other confounding data (DO or impaired contractility) that may enhance preoperative counseling. Although it is routinely accepted as an option in the evaluation of an uncomplicated case of SUI, preoperative UDS can be considered to obtain additional information. Although studies have not shown improved outcomes with the addition of UDS to the preoperative evaluation, diagnoses and treatment decisions were altered in some cases.

    
    
  • B.
    

    In complex, complicated patients, preoperative UDS may be particularly helpful. These recommendations are congruent with the AUA Guidelines in the Surgical Management of SUI. That Guideline listed several indications for further UDS testing, including the inability to make a definitive diagnosis based on symptoms and initial evaluation; the presence of mixed incontinence; prior surgery to the urinary tract, including anti-incontinence procedures; known or suspected neurogenic bladder; negative stress test; elevated PVR; grade III or greater POP; and any evidence of dysfunctional voiding ( Table 2 ).

    
    
    
    

    Table 2

    
    

    Clinical case scenario 1 (SUI)

    
    

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

    42-y-Old with Chief Complaint of SUI	42-y-Old with Chief Complaint of SUI
    Symptoms: Leaks with exertion Denies difficulty emptying No urgency symptoms or UUI	Symptoms: Leaks with exertion Denies difficulty emptying Has moderate urgency without UUI
    History: No prior GU surgery No comorbidity	History: Previous bladder lift No comorbidity
    Physical examination: Urethral hypermobility No prolapse + Stress test PVR 20 mL	Physical examination: Urethral hypermobility No prolapse + Stress test PVR 20 mL
    Recommendation: Discussion of treatment options	Recommendation: Pressure flow studies with ALPP assessment
    Discussion: In this patient, the scenario is that of uncomplicated SUI symptoms with a normal PVR and positive stress test result. It is reasonable in this scenario to proceed to discussion of treatment options including surgery without UDS tests	Discussion: In this patient, the scenario is that of complex storage symptoms of urgency and SUI. In addition, a previous procedure was performed. This scenario is more complicated, and preoperative UDS may be helpful. When doing UDS in this complex setting, urethral function should be measured

    
    

    Abbreviations: GU, genitourinary; UUI, urgency urinary incontinence.
    
    

  
  
  
  
• 4.
  

  Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during UDS. (Recommendation; Evidence Strength: Grade C)

  
  
  
  
  • A.
    

    Some patients who complain of SUI or demonstrate SUI on examination may not leak during UDS with the catheter in place. It is recommended that these women should have their urethral catheter removed and stress testing repeated without the catheter in place. More than 50% of women with SUI symptoms and up to 35% of men with postprostatectomy incontinence who do not demonstrate SUI with the urethral catheter in place do so when it is removed.

    
    
    
    
    • i.
      

      In practice, the voiding study (PFS) is performed with the catheter in place, the bladder is filled with this catheter, and the catheter is removed for the attempt at demonstrating SUI with the catheter removed. Alternatively, the catheter is removed, SUI is demonstrated with the catheter out, and an uncontaminated catheter is replaced for completion of PFS.

    
    

  
  
  
  
• 5.
  

  In women with high-grade POP but without the symptom of SUI, clinicians should perform stress testing with reduction of the prolapse. Multichannel UDS with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS. (Option; Evidence Strength: Grade C)

  
  
  
  
  • A.
    

    Patients with high-grade anterior and middle compartment prolapse should undergo stress testing with the prolapse reduced. In these patients without LUTS, a stress test without the prolapse is all that may be needed, if the decision to repair the prolapse has been made. In women with concomitant LUTS, this may be performed during multichannel UDS testing to evaluate these symptoms.

    
    
  • B.
    

    There are a significant number of women who have occult SUI (stress incontinence demonstrated after reduction of the prolapse) detected, and surgical intervention for SUI should be considered in these patients.

    
    
  • C.
    

    Those performing prolapse reduction should be mindful that the instruments used to reduce prolapse (pessary, vaginal pack, or ring forceps) can produce BOO by compressing the urethra, which may mask SUI or increase VLPP ( Table 3 ).

    
    
    
    

    Table 3

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