Completing an appropriate and relevant history is an important part of the preparation for UDS testing. History (Table 5.2) should start with a detailed inquiry about the patient’s symptoms and analysis of these symptoms (Table 5.3). Symptoms can be quantified with the aid of available validated questionnaires. Examples of such questionnaires include the International Prostate Symptom Score (IPSS), King’s Health Questionnaire (ICIQ-LUTSqol), Symptoms Severity Index (SSI), and Urogenital Distress Inventory-6 (UDI-6). LUT symptoms are often quantitated by means of a voiding diary and pad test. It should be clarified if the patients’ symptoms are related to lower urinary pathology, patient physiology, or being practiced out of habit/convenience (e.g., increased urinary frequency secondary to increased fluid intake, using pads as precautionary measures for fear of incontinence) or secondary to other comorbidities (e.g., congestive heart failure or sleep apnea). Documentation should include the duration of symptoms, severity and impact of the symptoms [15].

For example, if the patient has urinary incontinence, it should be properly characterized. Is it associated with physical activity (SUI), Urgency Urinary Incontinence (UUI), or other factors? How severe is the leakage? What situations or maneuvers reproduce leakage? How forceful is the urinary stream? Is there any history of treatment or surgery for leakage? Does the patient wear any pads? How many pads? How saturated are the pads? Does the patient wear pads out of convenience for fear of incontinence? Also if the patient has prolapse, does she use any special maneuvers to be able to void such as digital splinting or positioning in order to be able to void [16].

The physician should inquire about any other comorbid conditions that can affect the patient’s urinary tract. One should specifically ask about any history of any neurological conditions such as lumbosacral intervertebral disc problems, or back/spine surgery, Cerebro-vascular accidents (CVA), Parkinson’s disease, and other cerebral abnormalities. In cases of problems with the spinal cord such as spinal cord injuries or spina bifida, the level of the spinal cord lesion should be determined? Other symptoms that may suggest neurological disorders should be kept in mind such as double vision, numbness, or tingling which could be secondary to multiple sclerosis (MS). A history of diabetes and neuropathy is important to elicit, including the duration of the disease. Previous exposure to radiation therapy especially pelvic radiation should be assessed as this could be associated with radiation cystitis, small bladder capacity, and low compliance. It is also important to inquire about a history of constipation as this could affect the bladder function as well as UDS test performance [17]. Any physical or cognitive impairment should be noted as it may require additional arrangements for patient preparation and management during the UDS study [15].

Inquiring about drug history is important as some medications can affect the LUT such as narcotics, antihistaminics, antimuscarinics, and sympathomimetics. Also the physician should decide on whether the patient should continue or discontinue any given medication at the time of the study [15]. Discontinuing such medication provides a baseline assessment whereas continuing medications allows an assessment of the patient as they currently exist on the medication.

It is important to know about the obstetric history including the number of vaginal deliveries, any trauma during delivery, size of the babies, and difficulty during delivery with use of additional equipment (e.g., forceps) to facilitate delivery.

It is imperative to obtain the past surgical history as pelvic surgeries could have some effects on bladder function. A prior history of radical hysterectomy or abdomino-perineal resection (APR) could lead to detrusor dysfunction including poor contractility with or without compliance abnormalities. Also a history of prior surgery for prolapse, or incontinence procedures such as slings might suggest alternative diagnoses such as bladder outlet obstruction for which customization of the study would be beneficial. A history of prostate or urethral diseases and/or surgeries in men should be collected as these might suggest difficulties with catheterization for the UDS study.

It is important to obtain a good genitourinary (GU) examination prior to the UDS study. The GU examination should include abdominal examination to evaluate for masses, hernia, and/or a distended bladder. The physician can confirm the presence of stress urinary incontinence during the examination by means of a cough stress test. Any urethral abnormalities should be noted. In male patients, a prostate examination should be performed.

The presence of scars from previous surgery especially pelvic surgery is noted. A lower abdominal examination should assess for any evidence of suprapubic fullness indicating a full bladder or urinary retention. Fecal impaction should be noted as this could affect placement of rectal catheters, and in addition, rectal distention due to constipation can significantly affect bladder function [18].

Rectal examination is used to assess for anal sphincter tone and strength. It also helps to assess for abnormalities of sacral innervation (S2–S4) via the bulbo-cavernosus reflex, anal wink, and sensation around the saddle area.

Vaginal examination is extremely important [19] prior to UDS testing. The introitus should be examined for the presence of vaginal atrophy or urethral abnormalities. The presence of vaginal prolapse should be assessed and the degree should be documented. The presence of prolapse can affect LUT function [15, 16] and also may suggest the need to pursue additional maneuvers during UDS testing. For example, if there is significant pelvic organ prolapse, one may choose to reduce it with a pessary during the study in order to assess for occult SUI or alternatively to examine the potential obstructive effects of the prolapse on voiding. The presence of any scar tissue or a urethral abnormality from previous incontinence surgery such as a swan neck deformity should be documented.

Pelvic floor muscle resting tone and function should be assessed during physical examination and should be noted if it is normal, overactive, underactive, or non-functioning [13, 20, 21].

Neurologic examination should be a part of the evaluation of patients with voiding dysfunction undergoing UDS assessment. The physician should observe for any gait abnormalities and any lower extremity weakness. Sensation of the saddle area and rectal tone is an important part of the neurological examination. Assessment of the sacral is reflexes that should be considered to test for sacral nerve integrity. These reflexes are centrally integrated at S2 to S4. The reflex arc is mediated via afferent and efferent limbs within the pelvic nerves. The reflexes [22] include: