Questions to ask
Q1. Does the patient need this test?
Q2. What questions do I need to answer?
Q3. How should the test be designed to answer the pre-study questions?
Q4. What provocative maneuvers if any do I need to perform?
During the test
Q1. Is the study designed appropriately to answer the questions?
Q2. Is the study performed appropriately?
Q3. Are there any artifacts or technical problems?
Q4. Am I able to reproduce the patient’s symptoms?
Q5. If the patient’s symptoms are not reproduced, are there any provocative tests that may reproduce them?
Q1. Was the study technically performed well?
Q2. Were there any artifacts that needed to be accounted for during interpretation?
Q3. Were the patient’s symptoms reproduced during the study?
Q4. Were the pretest question/s answered?
Why do I need to perform this test?
What information do I need?
What UDS test(s) do I need to perform to understand the patient’s problems?
Will the information acquired during the study help in diagnosing the problem and the decision-making process for treatment?
How can I reproduce the patient’s problems during the study?
At the conclusion of the study, the physician asks the questions
“Were the patients’ symptoms reproduced during the study?”
“Did the results of the study correlate with the patient symptoms?”
It is important to recognize that a UDS study is most meaningful when the patient’s symptoms are reproduced during test. This should be addressed with the patient during and after the study.
Physicians should consider UDS testing when the clinical data obtained is insufficient to determine the factors contributing to LUTS [8, 9]. Obtaining such knowledge will help to decide the appropriate treatment for the patient . For example, performing multichannel UDS in patients with neurogenic bladder can not only evaluate bladder function but can also help assess risk factors that could lead to upper tract deterioration. It also helps in counseling patients regarding possible therapeutic outcomes and identifying possible causes behind treatment failure.
A working diagnosis is necessary prior to the multichannel UDS study and the test should be individualized to answer questions generated for each patient prior to initiation of the study. The study is most helpful when the clinical symptoms being investigated are reproduced during the study. If the examiner is unable to reproduce the symptoms, then it is essential to consider tailoring the study or changing the environment to reproduce the symptoms to facilitate a successful study . The following questions, considered prior to and during the study, can help define this process.
What questions do I need to answer?
What symptoms do I need to reproduce?
How can I reproduce the symptom while performing the study?
What provocative tests do I need to perform to reproduce these symptoms?
UDS testing is considered a minimally invasive procedure; however, the patient may view it differently. Patients often perceive this test as an intrusion into their privacy and they may experience a great deal of anxiety associated with several aspects of the test including the environment of the test, urethral and rectal catheterization, voiding in front of strangers, and the embarrassment associated with being exposed. Proper patient counseling including a face-to-face explanation of the test as well as supplemental handouts can reduce this anxiety. A variety of online sources are available which patients can use as additional informational resources. Studies [11, 12] have demonstrated that most of the patients who undergo multichannel UDS testing would not object to repeat testing if needed and that the test causes only minimal anxiety and discomfort. However this does not preclude the fact that pretest counseling is important to prepare the patient for the test. It is crucial to explain to the patient about the expectation of catheterization during the study. Physician–patient communication should continue during the study to alleviate any anxiety or concern.
The successful UDS study depends on a team effort. Properly trained staff is crucial in order to perform a good quality study. The staff should be familiar with the patient’s history, study requirements, the technique, and the machine settings. Proper interpretation of the study also requires the ability to reliably identify artifacts that occurred during the study. This requires a good understanding of the technique and an open communication between the nurse or technician who is performing the test and the physician interpreting the study. The physician or nurse/technician performing the study must carefully record observations that were made during the study [13, 14]. Annotating the graph appropriately noting such activity as changes associated with changes in position, and provocative maneuvers (coughing, straining, command to void, etc.) will aid in accurately interpreting the study. This requires paying attention to fine details while performing the test and the clinical experience to initiate such maneuvers appropriately and record them succinctly on the study graph and/or event summary .
Preparing for UDS Evaluation
History of Lower Urinary Tract Symptoms
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 .
Pretest evaluation for patients undergoing UDS
− History of present illness including using validated questionnaires
− Past medical and neurologic history
− Drug history
− Obstetric history
− Past surgical history
− Genitourinary examination
− Abdominal examination
− Rectal examination
− Vaginal examination
− Pelvic floor examination
− Focused neurological examination
− Pad test
− Voiding diary
− Post-void residual urine (PVR)
− Urinalysis, culture, and sensitivity
− Cystoscopy or imaging if indicated
LUTS based on International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction 
Urinary incontinence symptoms
The voluntary control of bladder and bowel function
Urinary Incontinence (UI)
Complaint of any involuntary loss of urine
Urgency Urinary Incontinence (UUI)
Complaint of involuntary loss of urine associated with urgency
Stress Urinary Incontinence (SUI)
Complaint of involuntary loss of urine on effort or physical exertion or on sneezing or coughing
Postural (urinary) Incontinence
Complaint of involuntary loss of urine associated with change of body position such as rising from a seated or lying position
Complaint of involuntary urinary loss which occurs during sleep
Mixed Urinary Incontinence
Complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing
Continuous Urinary Incontinence
Complaint of continuous involuntary loss of urine
Insensible Urinary Incontinence
Complaint of urinary loss where the individual is unaware of how it occurred
Complaint of involuntary loss of urine with coitus
Bladder storage symptoms
Increased urinary frequency
Complaint of voiding occurs more frequently during waking hours than previously deemed normal 
Complaint of voiding too frequent while awake. Eight voids per day or voiding ≤2 h 
Complain of interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep 
It is waking up at night to void. Zero to one episodes in adults <65 years of age or up to 2 in older adults is considered normal 
A sudden and compelling desire to pass urine that is difficult to defer
Overactive Bladder symptoms (OAB, Urgency)
Urinary urgency, usually accompanied by frequency and nocturia with or without urgency urinary incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology
Complaint of a delay in initiating micturition
Complaint of a urinary stream perceived as slower compared to previous performance or in comparison with others
Complaint of urine flow that stops and starts on one or more occasions during voiding
Straining to void
Complaint of the need to make an intensive effort (by abdominal straining, Valsalva or suprapubic pressure) to either initiate, maintain, or improve the urinary stream
Spraying (splitting) of urinary stream
Complaint that urine passage is a spray or split rather than a single discrete stream
Feeling of incomplete bladder emptying
Complaint that the bladder does not feel empty after micturition
Need to immediately re-void
Complaint that the bladder does not feel empty after micturition
Complaint of having to take specific position to be able to micturate spontaneously or to improve bladder emptying
Complaint of burning or other discomfort during micturition, discomfort may be intrinsic to the lower urinary tract or external
Complaint of the inability to pass urine despite persistent effort
Complaint of a further involuntary passage of urine following the completion of micturition
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 .
Past Medical History
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 . Any physical or cognitive impairment should be noted as it may require additional arrangements for patient preparation and management during the UDS study .
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 . 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.
Past Surgical History
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 .
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  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
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Focused Neurologic Examination
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  include: