Editing Functional: Urodynamics (section)

== Clinical applications of UDS ==

* Women with SUI
** UDS will not provide much useful information in women with pure SUI without urgency symptoms who empty normally and demonstrate SUI on physical exam
** Many women with SUI who are considering surgical correction have mixed symptoms or emptying difficulties; UDS may have a role in these cases
** '''AUA urodynamics guideline panel recommends:'''
*** '''“Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function.”'''
**** If UDS is performed, an assessment of urethral function (e.g., ALPP or MUCP) should be performed.
***** This seems reasonable as an ALPP may for some surgeons affect the type of surgery performed, because inferior outcomes have been found for some procedures in patients with low ALPP and/or MUCP.
*** '''“Patients with SUI considering invasive therapy should be evaluated for PVR.”'''
**** An elevated PVR may prompt a change in treatment for additional testing such as UDS.
*** '''“Clinicians may perform multichannel UDS in patients with both symptoms and physical findings of SUI who are considering invasive, potentially morbid, or irreversible treatments.”'''
**** This statement allows the clinician to make a decision on the selective use of preoperative UDS based on patient symptoms, how the study will influence choice of surgery, and the degree of confidence that the surgeon has in the diagnosis.
*** '''“Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing.”'''
**** It is well established that some women will not demonstrate SUI with a catheter in place. This maneuver is especially important in a woman who does not demonstrate SUI on physical examination.
*** '''“In women with high-grade pelvic organ prolapse but without the symptom of SUI, perform stress testing with reduction of the prolapse. Multichannel UDS with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS.”'''
**** Prolapse reduction is extremely important if the demonstration of occult SUI on UDS will influence the type of prolapse surgery performed (i.e., a simultaneous anti-incontinence with prolapse repair).
** UDS may be most useful in women who have:
**# Significant urgency and/or urgency incontinence
**# Bladder emptying problems
**# Prior stress incontinence surgery
**# Uncertain diagnosis or inability to demonstrate SUI on physical examination
**# History of pelvic radiation
**# History of neurologic disease
**# Very severe symptoms (total or near total).
* Men and Women with LUTS
** AUA urodynamics guideline panel recommends:
*** “Clinicians should perform pressure-flow studies in men when it is important to determine if urodynamic obstruction is present in men with LUTS, particularly when invasive, potentially morbid, or irreversible treatments are considered.”
**** Literature mixed on UDS before surgical treatment for BPH.
*** “Clinicians may perform pressure-flow studies in women when it is important to determine if obstruction is present.”
* '''Significantly impaired compliance remains the only absolute urodynamic indication for treating bladder outlet obstruction.'''
** AUA urodynamics guideline panel recommends:
*** “Clinicians may perform multichannel filling cystometry when it is important to determine if altered compliance, DO or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid, or irreversible treatments are considered.”
*** “Clinicians may perform multi-channel filling cystometry when it is important to determine if DO or other abnormalities of bladder filling/urine storage are present in patients with LUTS, particularly when invasive, potentially morbid, or irreversible treatments are considered is consistent with the available information.”
* '''Evaluation of Neurogenic Lower Urinary Tract Dysfunction (See 2019 CUA NLUTD Guideline Notes)'''
** In addition to symptomatic presentation, neurogenic lower urinary tract dysfunction can present as upper urinary tract decompensation with hydroureteronephrosis and renal insufficiency without bothersome symptoms. The goal of management in these patients is to prevent upper tract decompensation and relieve symptoms.
** Not all neurogenic lower urinary tract dysfunction requires UDS before observation or treatment. Conditions in which high storage pressures are not suspected (e.g., urgency incontinence after a stroke or women with multiple sclerosis with a low PVR) often can be managed initially without UDS. But '''in cases in which the neurologic condition/lesion can cause potentially harmful storage situations (spinal cord injury, myelomeningocele), UDS is essential both before treatment and also in ongoing follow-up of the condition and to monitor the response to treatment'''. In the middle are situations in which UDS can be helpful in guiding management (e.g., men with possible BPO and Parkinson disease or multiple sclerosis).
** The AUA Guidelines contains 5 statements regarding UDS in neurogenic lower urinary tract dysfunction:
*** "Clinicians should perform PVR assessment, either as part of complete urodynamic study or separately, during the initial urologic evaluation of patients with relevant neurologic conditions (e.g., spinal cord injury, myelomeningocele), and as part of ongoing follow-up when appropriate."
*** "Clinicians should perform a complex CMG during initial urologic evaluation of patients with relevant neurologic conditions with or without symptoms and as part of ongoing follow-up when appropriate. In patients with other neurologic diseases, physicians may consider CMG as an option in the urologic evaluation of patients with LUTS."
*** "Clinicians should perform pressure-flow analysis in patients with relevant neurologic disease with or without symptoms or in patients with other neurologic disease and elevated PVR or urinary symptoms."
*** "When available, clinicians may perform VUDS in patients with relevant neurolosgic disease at risk for neurogenic lower urinary tract dysfunction or in patients with other neurologic disease and elevated PVR or urinary symptoms."
*** "Clinicians should perform EMG in combination with CMG with or without pressure-flow studies in patients with relevant neurologic disease at risk for neurogenic lower urinary tract dysfunction or in patients with other neurologic disease and elevated PVR or urinary symptoms."