The Complete Guide to Urodynamics Testing

When it comes to diagnosing patients right the first time, urologists, obstetricians, gynecologists, and healthcare professionals who want to improve the services they offer to patients all need to have access to the right testing options for diagnosing specific issues. The same is true when it comes to monitoring the health of the lower urinary system, with urodynamics being the only testing option specifically designed to monitor patient urinary health.

What Is Urodynamics?

Urodynamics refers specifically to the study of how the bladder, urethra, and associated sphincters in the body do their job of storing and releasing urine. Urodynamic testing therefore refers to the set of tests that provide healthcare professionals with valuable information on the health and function of a patient’s urinary system.

Urodynamic testing is appropriate for helping healthcare professionals diagnose the causes for symptoms such as the inability to properly empty the bladder, issues with commencing urination, frequent and sudden urges to urinate, painful urination, urine leakage, and incontinence. Urodynamic testing helps to diagnose causes of urinary incontinence and other lower urinary tract symptoms in both men and women by measuring nerve and muscle function, bladder pressure, urine flow rates, and more.

Why Is Urodynamics Important for Incontinence Care?

There are a number of different causes for urinary incontinence, however the three most common are stress incontinence, urge incontinence, and overflow incontinence. Through urodynamic testing, it is possible to take the patient’s symptoms, apply the appropriate urodynamic tests to monitor the function of their bladder, urethra, muscles, and sphincters, and come to an accurate diagnosis of the cause for their urinary incontinence. This approach becomes even more useful when patients have a combination of causes for incontinence.

Stress incontinence is perhaps the most common type, where the internal pressure of the bladder becomes too great for the bladder’s outlet control to handle, resulting in the uncontrolled leakage of urine. This often happens when the patient’s pelvic floor muscles are weakened.

Urge incontinence, also referred to as an unstable or overactive bladder, is where a patient frequently experiences an urgent need to urinate resulting in the bladder muscles contracting too early. This may be caused by an infection, a neurological disorder, or in some cases, diabetes.

Overflow incontinence is the constant or frequent dribbling of urine caused by the bladder not being able to empty properly.

Urodynamic testing plays a crucial role in providing healthcare professionals with the multidisciplinary approach that is required for a successful incontinence care pathway. The information generated by urodynamic testing not only plays an important part in distinguishing between the different causes of urinary incontinence, it also provides insights into the health of the urinary system so that the best and most effective therapies can be designed. Urodynamic testing can additionally help to track a patient’s recovery as they progress through the care pathway.

The Different Types of Urodynamic Tests

There are generally seven different types of urodynamic tests that measure bladder, urethral, muscular, and sphincter activity in the patient. They are:

• Post-void residual (PVR) measurement

The PVR measurement measures the amount of urine that is left in the bladder after urination, with the remaining urine being referred to as the post-void measure. PVR measurements can be made quickly and easily by using either ultrasound equipment or a catheter. With an ultrasound, a complete image of the bladder can be generated from which the PVR measurement is made. Alternatively, a catheter can be inserted after urination to fully drain the bladder of its post-void residual urine, which can then be measured.

• Uroflowmetry

Uroflowmetry involves measuring the volume and speed of urine during urination. By measuring the flow rate along with the quantity of urine produced, it is possible to see how long it takes the bladder to reach maximum flow rate and whether there are any changes in the flow rate that may indicate abnormal behavior in the bladder or associated muscles and sphincters. Uroflowmetries are measured using a specialized device that monitors the patient’s urination and simultaneously models the information with specialized software.

• The Cystometric test

Cystometrograms measure bladder capacity, how much pressure builds up inside of the bladder, and at what level of capacity the urge to urinate starts. It can also effectively identify involuntary bladder contractions related to urinary incontinence. This test is done using a series of catheters to first completely empty the bladder of urine, and then slowly fill it with sterile water, measuring the volume as the bladder is filled. During this process, the patient will indicate when they feel the need to urinate, while small electrodes within the catheters measure bladder pressure.

• Leak point pressure (LPP) measurement

This measurement is taken during the cystometric test with a catheter, measuring the maximum pressure that the bladder can reach before involuntary urination. It is also common for an LLP measurement to be taken when an increase in abdominal pressure, such as with a cough, occurs. This is a valuable measurement for anyone who may be experiencing stress incontinence.

• Pressure flow study

After the cystometric test, a pressure flow study can be carried out as a patient empties their bladder where the specific flow rate is measured in relation to bladder pressure. By measuring the flow rate generated by different bladder pressures, it is possible to identify bladder outlet blockages, like an enlarged prostate in men. Women may also benefit from this type of study to monitor for any blockages after surgery for urinary incontinence.

• Electromyography

Electromyography involves the use of sensors that measure the electrical activity of the muscles and nerves of the bladder and associated sphincters in instances where urinary problems may be caused by nerve or muscle damage. Through this, it is possible to see whether the messages sent by the nerve impulses to the bladder and sphincters are synchronized correctly.

• Video urodynamic tests

Video urodynamic tests may be used as a replacement for the above test options, and can be carried out using either X-rays or ultrasound. They involve taking pictures or videos of the bladder and urinary system while the bladder is full so that healthcare professionals can get a clear image of what is happening, although due to the cost and the fact that the same information can be found using other test methods, this is not commonly used.

Urodynamics, Medicare, and Insurance

Although urodynamic testing is somewhat expensive and does require advanced training of healthcare professionals to carry out each test effectively, it is important to note that Medicare and all insurance companies cover urodynamic testing.

This means that you can be reimbursed for the urodynamic tests that are carried out which ensures that this vital practice can be easily integrated into practices that have not previously utilized urodynamics. A general pattern that will affect reimbursement is that private insurance providers tend to have a higher reimbursement rate when compared with both Medicare and Medicaid when it comes to urodynamics. Private insurance will generally reimburse between 140% and 180% of Medicare, while Medicaid will reimburse at a rate 50% to 75% of Medicare.

Because of this, a common practice for health care providers is to aim to secure more patients with private insurance. When seeking reimbursement, it is essential to know the right CPT codes for each specific urodynamic test. You can make use of the following CPT codes for the most common urodynamic tests:

Offering Urodynamics within Practices and Hospital Settings

Urodynamics is offered in both medical office and hospital settings. To offer urodynamics, practices and hospitals have two options. The first option is to “vertically integrate” and acquire the equipment, software, supplies, staff, and training. This requires a major upfront investment of time and capital. Additionally, it involves more risk because it is difficult to project into the future and know that urodynamics patient testing volumes will provide an adequate return on invested time and capital.  Vertically integrating is also a further challenge if the practice/hospital has multiple locations because this requires having equipment and trained staff available at each location.

The second option is to use a service provider (such as Brighter Health Network) that provides urodynamics testing “as a service”. The service provider would provide the equipment, supplies, software, and trained staff in a turn-key manner.   The service provider will come to your location on specific dates (typically a recurring monthly schedule) to perform urodynamics testing. Furthermore, the service provider’s service is offer at a price well below the Medicare and private insurance reimbursement rates enabling the practice/hospital to make a sound profit. This profit can be attained without the upfront investment of time and capital. Therefore, service providers can make it much easier to offer urodynamics and can mitigate much of the risk.

The most significant limiting factor in offering urodynamics is human capital. It never makes economic sense to have a physician or advanced practitioners (such as Nurse Practitioners or Physicians Assistants) offering urodynamics, because their time is so much more valuable elsewhere within practices and hospitals. Therefore, training nurses (LPNs and RNs) properly for urodynamics is the best option. However, training and retaining nurses is often a challenge. The practice that vertically integrates and trains a nurse and that nurse departs, then the ability to offer urodynamics walks out the door. Additionally, training properly for urodynamics is much more than a 3-day course. It takes weeks and weeks of supervised testing to become proficient and be able to deliver a quality test result. A service provider can mitigate the human capital issue for practices and hospitals because they bear the burden of hiring, training, and retaining staff, and they often have considerable staff redundancy.