Urodynamics is the most reliable way to determine the cause of lower urinary tract symptoms and therefore, the best way to determine which treatment methods are most appropriate.
A Care Pathway is an evidenced-based framework to build a treatment plan upon, beginning with the primary physician, continuing to specialist referrals if necessary, and following the patient through to the end of their treatment (including follow-up care).
They typically follow a common path that starts with patient history, followed by clinical assessment, provisional diagnosis, first line management, specialist management, and follow-up care.
Some examples are listed here:
Incontinence
History
The physician determines the frequency, duration, and volume of the incontinence, along with when the incontinence occurs (when performing a certain activity, for example).
Clinical Assessment
This includes a general health assessment, along with quality-of-life assessment and inquiring about patient’s desire for treatment. The physician will then assess urinary symptoms, perform a physical exam and cough test, followed by Urinalysis and pelvic floor muscle function assessment.
Provisional Diagnosis
The provider will determine either Stress Urinary Incontinence, Mixed Urinary Incontinence, or Urge Urinary Incontinence.
First Line Management
Continence products will be considered for temporary support, or lifestyle interventions including weight loss and avoiding chronic straining will be prescribed. Supervised pelvic floor muscle therapy and vaginal devices may also be prescribed, as well as the minimization or elimination of bladder irritants.
Specialist Management
If the patient is still exhibiting symptoms, they will be referred to a specialist. Urodynamics will determine the potential cause of the patient's Incontinence and an appropriate treatment plan will be developed.
Follow Up
Follow-up visit with the specialist, determining that the patient is keeping pace with the full course of treatment, and ensuring that recovery is complete (or scheduling additional visits if not).
Nocturia
History
The physician determines the frequency and duration of the Nocturia, as well as any related symptoms the patient may be experiencing. Fluid intake, medications and medical conditions will also be assessed, and a physical exam completed.
Clinical Assessment
Urinalysis and measurement of post-void residual volume are performed, as well as a full Urodynamics panel or select elements of Urodynamics (Cystometrogram or Uroflowmetry, for example), if warranted.
Provisional Diagnosis
Nocturia (or Nocturnal Polyuria) diagnosis is based on specific factors of individual cases.
First Line Management
Lifestyle interventions such as minimizing fluid intake before bed, restricting total fluids, increasing physical exercise, reducing salt intake, and weight loss may be recommended.
Specialist Management
Referral to Urologist may occur if symptoms persist after all the above measures have been taken. If Urodynamics has not yet been performed, the specialist will likely recommend it here.
Follow-Up
Follow-up visits and ensuring the patient is staying on track with treatment. Further visits may be warranted if the patient’s symptoms persist.
Urinary Retention
History
A complete medical history of patient is taken, including possible conditions to rule out (diabetes, liver failure, and heart failure, for example). Current medications will be discussed, a physical exam given, and a urinary frequency volume chart will be completed by the patient.
Clinical Assessment
Urinalysis, specifically presence of blood, protein, and glucose identification, as well as a Prostate exam.
Provisional Diagnosis
Diagnosis will largely depend on the individual. Possibilities include Renal Stones, Prostate Cancer, recurring UTI, and Nocturnal Enuresis.
First Line Management
If UTI is diagnosed, antibiotics are prescribed. If another diagnosis is determined, the patient will likely be referred to the correlating specialist, possibly a Urologist.
Specialist Management
If the patient is referred to a Urologist, Urodynamics testing will be performed to determine the cause of Urine Retention and create an appropriate treatment plan.
Follow-Up
Dependent on diagnosis. However, a follow-up visit will be scheduled for all diagnoses, as well as keeping patients on track with treatment and ensuring recovery is complete.
Overactive Bladder
History
Onset, frequency, and duration will be determined, as well as identifying potential contributing conditions and fluid intake. A physical exam will also be given.
Clinical Assessment
Urinalysis and post void residual urine will be collected, and patient will be instructed to complete a bladder diary.
Provisional Diagnosis
Overactive Bladder will only be diagnosed after all other possible causes of symptoms have been successfully ruled out. The diagnosis may be for Refractory Uncomplicated OAB, or Complicated OAB.
First Line Management
Urge suppression, bladder training, and dietary modification therapies may be prescribed, and possibly combined with medication at the physician’s discretion.
Specialist Management
Urodynamic evaluation may be warranted to rule out factors such as foreign body, obstruction, elevated post-void residual urine volume, or hydronephrosis. The specialist will then determine whether advanced therapy is appropriate.
Follow-Up
Dependent on the diagnosis and success of treatment; however, a follow-up visit is standard as well as keeping the patient on track with the treatment plan until complete recovery (or until successful symptom management is achieved and sustained).
Oliguria
History
The physician will determine onset, frequency and duration of the symptoms, whether any medications the patient is taking could be the cause and perform a physical exam with a focus on ruling out potential dehydration or urinary tract blockage.
Clinical Assessment
Urinalysis, blood work, and CT scan/ultrasound may be performed. Urine output will also be measured. A referral to a specialist to perform Urodynamics, specifically a Cystometrogram, may be warranted.
Provisional Diagnosis
Determining the cause of symptoms will shape the diagnosis. Dehydration, blockage, and medications are all potential causes, as are physical trauma, infections, and substantial blood loss.
First Line Management
Increased fluid intake may be prescribed, as well as antibiotics if an infection is present. Diuretics may also be prescribed.
Specialist Management
For cases that require further investigation, a specialist referral is in order. This allows for further specialized testing to determine the underlying cause.
Follow-Up
Depending on the cause of the symptoms. If prescribed, confirming that the patient completes the required course of medication, and determining if follow-up visits to the provider will be necessary.
Conclusion
As shown here, there are many Care Pathways in which Urodynamics plays a vital role. The possibilities listed here have barely scratched the surface of the potential to provide a higher standard care when combining Urodynamics and a well-planned Care Pathway for Urology patients.
Urodynamics continues to be the most thorough method for identifying the cause of lower urinary tract issues thanks to its multi-faceted approach and partnering with the proper Care Pathway only serves to boost its effectiveness.
If you are a physician or part of a medical practice, and you need assistance with urodynamics or urodynamics staffing – please consider using Brighter Health Network (BHN) for your urodynamics needs. Click the button below to get more info.