The American Urological Association (AUA) has put forth guidelines for clinicians who perform urodynamic testing for adults experiencing common lower urinary tract symptoms1. These guidelines are intended to assist the clinician in better understanding the role of urodynamics in the assessment of complex disorders of the lower urinary tract.
The AUA’s urodynamics guidelines were developed after systematic review of urodynamics literature2 from the MEDLINE and EMBASE databases of all peer-reviewed publications on urodynamic testing for diagnosis, prognosis, and clinical management decisions for urologic conditions. Publications utilized for these urodynamics guidelines were published between January 1, 1990 and March 10, 2011. Overall, 393 studies were reviewed for the production of these guiding principles.
Stress Urinary Incontinence/Prolapse
When a patient presents symptoms of stress urinary incontinence or pelvic organ prolapse, the AUA asserts that urethral function should be assessed before making an official diagnosis.
Before performing an invasive therapy for a patient experiencing stress urinary incontinence3, the patient’s post-void residual urine volume should be assessed.
For patients who display physical symptoms of stress incontinence in conjunction with appropriate physical evidence of the disorder, clinicians should perform multi-channel urodynamics before invasive, irreversible, or potentially morbid treatments.
For patients suspected of experiencing stress urinary incontinence, clinicians should repeat stress testing with the urethral catheter removed if stress urinary incontinence is not demonstrated with the urethra catheter in place during urodynamic testing.
For women with high grade pelvic organ prolapse who do not show signs of stress urinary incontinence, stress testing should be performed with prolapse reduction. Multi-channel urodynamics can also be used to diagnose occult stress incontinence and detrusor dysfunction for these women.
Overactive Bladder4, Urgency Urinary Incontinence, Mixed Incontinence
Multi-channel filling cystometry can be performed when determining if detrusor overactivity, altered compliance, or other urodynamic abnormalities are present for patients experiencing urgency incontinence and are also considering invasive, irreversible, or potentially morbid treatments.
After bladder outlet procedures clinicians can perform pressure flow studies to evaluate for bladder outlet obstruction in patients with urinary incontinence.
For patients experiencing urgency incontinence and mixed incontinence, clinicians should inform patients that the absence of detrusor overactivity during a single urodynamic study does not exclude it as an aggravating factor for their symptoms.
Neurogenic Bladder
For patients with relevant neurological conditions5 such as spinal cord injury and myelomeningocele, clinicians should perform a post-void residual urine volume assessment before and after treatment, when appropriate.
A complex cystometrogram should be performed during initial urological assessment of any patient with relevant neurological conditions regardless of symptoms. For patients with other neurological disorders, a complex cystometrogram is an option when lower urinary tract symptoms are presented.
For patients with relevant neurological conditions, regardless of symptoms, clinicians should perform pressure flow analysis during initial urological evaluation and during follow-up appointments. For patients with other neurological disorders who exhibit elevated post-void residual volume or in patients with persistent symptoms, a pressure flow analysis is also recommended.
Electromyography should be performed in conjunction with a cystometrogram with or without pressure flow studies for patients with neurologic disease that place them at greater risk for neurogenic bladder. The same is true for patients with other neurologic disease who exhibit elevated post-void residual urine volume, or in patients with relevant urinary symptoms.
Patients who have neurologic disease that places them at increased risk for neurogenic bladder, who have neurologic disease and elevated post-void residual urine volume, and patients with urinary symptoms may also have fluoroscopy performed during urodynamics assessment.
Lower Urinary Tract Symptoms
For patients with lower urinary tract symptoms6, clinicians can perform post-void residual urine volume assessment to determine significant urinary retention during initial and follow-up exams.
For male patients with lower urinary tract symptoms, clinicians may perform uroflow studies when an abnormality of voiding or emptying is observed.
When determining whether detrusor overactivty or bladder filling/urinary storage problems are present for patients with lower urinary tract symptoms, clinicians may perform multi-channel filling cystometry, especially when invasive, irreversible, or potentially morbid treatments are considered.
Clinicians can perform pressure flow studies in women to determine if obstruction is present.
Video urodynamics may be performed in properly selected patients to determine the exact level of obstruction, especially for the diagnosis of primary bladder neck obstruction.
For more information and to view a complete list of references, please visit the American Urological Association website.
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References
- Roehrborn, C. G. (2005). Combination Medical Therapy for Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia. Reviews in Urology, 7(Suppl 8), S43–S51. Link
- Shoskes, D. A., & Morey, A. F. (2011). American Urological Association educational review manual in urology. New York: Castle Connolly Grad Med. Link
- Zimmern, P., Litman, H., Nager, C., Sirls, L., Kraus, S. R., Kenton, K., . . . Norton, P. (2013). Pre-operative urodynamics in women with stress urinary incontinence increases physician confidence, but does not improve outcomes. Neurourology and Urodynamics, 33(3), 302-306. doi:10.1002/nau.22398 Link
- Digesu, G. A., Khullar, V., Cardozo, L., & Salvatore, S. (2003). Overactive bladder symptoms: Do we need urodynamics? Neurourology and Urodynamics, 22(2), 105-108. doi:10.1002/nau.10099 Link
- Neurogenic Bladder: The Effect of Neurologic Lesions on Micturition. (n.d.). Atlas of Urodynamics, 145-151. doi:10.1002/9780470692141.ch12
- Colhoun, A., Goudelocke, C., & Rovner, E. S. (2011). Reproduction of Female Lower Urinary Tract Symptoms on Urodynamics. LUTS: Lower Urinary Tract Symptoms, 4(2), 59-62. doi:10.1111/j.1757-5672.2011.00114.x Link