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.

After radical prostatectomy (RP), nearly 5-10% of men may experience substantial issues with urine control. Immediately after surgery many men have issues, especially with stress leakage; however, most will regain an acceptable level of continence within 6-12 months of surgery. For this smaller group of men with persistent incontinence, however, urine control can be a substantial issue and some require additional intervention to restore continence. Urodynamics can be a helpful adjunct in this population.

Patients with neurogenic lower urinary tract dysfunction (NLUTD) are at high risk of having poor bladder compliance, making upper urinary tract injury a distinct possibility. Given the wide variety of causes of NLUTD and the risk of upper tract damage, it is critical to perform surveillance of these patients for deterioration in bladder function and upper tract injury. Two of the most popular methods of surveillance for these issues are annual renal ultrasound and annual urodynamics (UDS) testing.

 

One of the most vexing clinical situations happens to be one of the best uses of urodynamics (UDS): ongoing symptoms after female incontinence surgery. These cases are challenging and patients are often not happy to have ongoing symptoms, new symptoms or worsening symptoms; however, appropriately utilized and interpreted, UDS can be key to helping these patients.

Surgical management of stress urinary incontinence (SUI) is a commonplace procedure, usually indicated on the basis of the clinical history and exam findings alone. In fact, Level I evidence from the VALUE trial suggests that urodynamics (UDS) makes no difference in the outcome of SUI surgery in straightforward cases.¹ Nonetheless, in many situations UDS is a critical part of evaluating SUI patients for surgery; moreover, in some instances UDS will spare women surgery that may not be beneficial.²

One clear-cut area where UDS is very helpful is for the patient who has previously undergone surgery for SUI and/or pelvic organ prolapse (POP). These patients may present complex anatomy, obstruction from prior surgery, changes in bladder compliance, and a very high valsalva leak point pressure. UDS may help guide the decision as to what intervention(s) may be necessary in these patients.

Strategic Partnering.

Is your OBGYN practice a failing business? BHN (Brighter Health Network) would like to know. So should you.You’re busy. Your parking lot has a brisk turnover and your lunches are hurried. CME costs much more than tuition when you add up the money lost while out of your office. You have good months most of the time, but you also have your “marginal” months. All the more confusing is that today’s shortfall is based on what you did six weeks ago, while the piper who demands payment demands it today.

Prior to performing a TURP, there are several key tests that most urologists employ.

Aside from a history, exam, IPSS score, PSA and urinalysis, most will assess residual urine volume, perform a cystoscopy and measure the prostate – either with a formal TRUS, or based on a CT, MRI or abdominal ultrasound. Urodynamic testing (UDS) is used to varying degrees before a TURP by urologists. On one end of the spectrum there are purists who will only offer a TURP to someone with UDS-proven obstruction;