BHN Healthcare Blog

Recently, a large-scale study of men referred to urologists in England for difficulty urinating has published results (Lewis Eur Urol 2019). This trial, called UPSTREAM, recruited over 800 men for two dozen locations across England. In addition to the usual history, physical and baseline evaluation for the voiding issues, some men were randomized to undergoing a urodynamics test (UDS) and the authors have recently reported some of their data.

During a urodynamics study (UDS), there are a variety of pieces of data coming in to the urologist and technician performing the study. Information will be obtained that is both subjective and objective in nature and the question is, who do you believe? Do you believe yourself and the objective data you are reviewing? Or, do you believe what the patient is telling you during the study? This blog post will explore this in detail.

Urodynamics (UDS) testing is usually performed in conjunction with a slew of other urologic tests and functions in concert with other diagnostics. This blog post will explore other common tests used in patients who will be having UDS testing and explains the indications and data that come from those other assessments.

            All patients who have UDS will undergo a comprehensive history, physical and laboratory testing. The history will focus on the specific urologic complaints the patient has, but also bowel issues, neurologic disorders and whatever medications the patient is on as well. Surgical history, especially related to urinary tract and anti-incontinence surgery is critical as is diet information. Lab testing will include a urinalysis to search for blood or infection, urine culture if infection is suspected, and many patients will have serum lab testing to assess kidney function.

          

Since urodynamics (UDS) is a relatively time consuming test, physicians who perform and interpret UDS are reliant on ancillary medical staff to perform much of the UDS study. This role is often performed by a mid-level provider, such as a nurse practitioner (NP), physician’s assistant (PA), registered nurse (RN) and even by a medical assistant or other trained technician (MA). The degree of medical knowledge needed to successfully perform a UDS test does not need to be extensive, hence providers do not need a medical or advanced degree to perform UDS; however, they do need to be proficient in setting the patient up for the test, know the key steps, know how to manage basic artifacts and when to engage the physician during a test.

UDS is a critical procedure in the practice of urology and the management of voiding dysfunction in men and women. All urologists receive exposure to UDS testing during residency training. In the United States, residents are required to perform and interpret 10 UDS studies in order to graduate from residency. In addition, some residents choose to undertake fellowship training in Female Pelvic Medicine and Reconstructive Surgery (FPMRS), where substantial exposure to UDS is had. UDS testing certainly is utilized in significantly more patients and a part of care for many other patients encounter during training; however, as with many other skills, there will be a wide range of exposure during training and quality will certainly vary between programs.

As with many of the practical aspects of urodynamics (UDS) testing, the rate at which the bladder is filled during the cystometric portion of the exam influences the test results. Generally speaking, filling during UDS can be at rates below physiologic levels, at physiologic levels or at supra-physiologic levels. There are distinct pros and cons to filling at either physiologic rates or rates above that, while filling at a rate below the natural rate of bladder filling is both inefficient and unnatural.

As with many aspects of medical practice, a solid training foundation is critical to best practices and the safe delivery of care. When it comes to performing urodynamics (UDS), as with many other procedures, the question of what level of training is requisite to perform UDS appropriately is a reasonable one. And the natural extension of this is whether or not a specific certification process is warranted to perform UDS.

In any urology practice, critical questions related to what services to offer, who will provide them and where the services will be performed are the foundation of practice management. When establishing or managing a practice, one decision you must make is whether urodynamics (UDS) is a foundational and core offering the practice will offer or an ancillary service. As with many things in urology, the answer is not straightforward and in reality, it is a little bit of both, though I tend to think of UDS as an ancillary service for most practices.

Core services urologists must offer include basic history and examination ability, cystoscopy and access to and interpretation of relevant lab and/or radiologic studies of the urinary tract. A urologist who cannot offer these basic services is really not practicing urology. UDS is an important test that urologists offer; however, a urology practice can exist without offering UDS and still thrive.

 

Urodynamics (UDS) testing is a critical tool for the urologist managing voiding dysfunction and incontinence.

 

Like all tests, there are certain scenarios where the results are more helpful than others and times when using a test is critical.

 

This blog posts explores several key situations when UDS is a critical test to consider.

 

            Proper quality control before and during urodynamics (UDS) is critical to obtaining optimal test results. There are several key maneuvers that should be performed before the study begins and in the event of issues during the test, several remedial actions that can be taken. The International Continence Society (ICS) has previously published on quality control during UDS and the work of both Blaivas and Abrams has expanded our understanding of both quality control and artifacts (Abrams, 2012). The reader should review the excellent manuscript from Abrams for further details, as much of this blog post refers to these works.