EURURO Vol. 71 No. 4

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the Patient Global Impression of Improvement at 12 mo.
Some 630 women were enrolled in the study, with
538 included in the final intention-to-treat analysis. The
result was 76.9% treatment success in the urodynamic
testing group versus 77.2% in the office evaluation–only
group, consistent with noninferiority. Interestingly, the
study did show that women undergoing urodynamics were
less likely to receive a diagnosis of overactive bladder (25%
vs 41%) and more likely to be diagnosed with voiding phase
dysfunction (11.9% vs 2.2%), but this did not to lead to any
significant differences in treatment selection or outcomes.
The principal finding of this, and some of the secondary
analyses, was that while the diagnosis may have changed
after urodynamics, it was uncommon for the surgical
procedure to be altered. In addition, regardless of any
change in diagnosis or surgical plan, the outcome was not
affected by performing urodynamics in this select group of
patients. Importantly, this study was based on a very select
group of women with SUI unlikely to suffer postoperative
complications.
A similar European study randomised 109 women for
whom urodynamics results were discordant with clinical
assessment to either immediate surgery or individually
tailored therapy based on urodynamics. They concluded
that immediate surgery, irrespective of the result of
urodynamic studies, did not result in inferior outcomes.
This brings us to the conundrum of the true utility of
urodynamics in investigating[1_TD$DIFF] patients[5_TD$DIFF]’ UI. Most practi-
tioners accept the evidence that there is poor same-session
repeatability and even interoperator repeatability for
urodynamics. Furthermore, if we accept the available
evidence that urodynamic studies do not influence the
outcomes of conservative or drug management for any type
of UI or outcomes after surgery for uncomplicated SUI ,
then it becomes essential to ask whether there is a role for
urodynamics as a preliminary investigation in patients
with UI.
The answer, as is so often the case in functional urology,
is not a straightforward one. The EAU guideline panel has
taken a pragmatic approach and states that urodynamics,
when used, should always be performed to a standard
adhering to ICS guidelines with good quality control, always
aim to replicate the patient’s symptoms and always
be interpreted based on the individual clinical context.
We further state that it should not be used routinely
before offering treatment for uncomplicated UI, but may be
performed if the findings may change the choice of invasive
treatment. This leaves the decision very much in the hands
of the consulting clinician, and this is quite deliberate. The
aim of the guideline is to provide the clinician with an
appraisal of the available evidence that is aimed to help
themmake the most appropriate decision for the individual
patient.
As discussed in the section devoted to treatment of the
patient with complicated incontinence, there are certain
clinical scenarios where urodynamics can clearly provide
unique and valuable information that cannot be easily
obtained elsewhere. Patients who have had prior surgical
treatments and have persistent or worsening incontinence,
or patients with mixed incontinence who have not
responded to conservative and medical management are
two good examples for which urodynamic evaluation may
help in guiding management. Other examples are noted in
In summary, there is currently quality evidence demon-
strating that in a patient with straightforward stress
incontinence (no significant postvoid residual, no prior
lower urinary tract surgeries, either pure SUI or stress-
Table 1 – Recommendations by international guideline groups on the role of urodynamics in the management of urinary incontinence
European Association of Urology urinary incontinence guideline recommendations
Clinicians carrying out urodynamics in patients with urinary incontinence should:
- Ensure that the test replicates the patient’s symptoms
- Interpret results in the context of the clinical problem
- Check recordings for quality control
- Remember there may be physiological variability within the same individual (grade C)
Advise patients that the results of urodynamics may be useful in discussing treatment options, although there is limited evidence that performing urodynamics
will predict the outcome of treatment for uncomplicated urinary incontinence (grade C)
Do not routinely carry out urodynamics when offering treatment for uncomplicated urinary incontinence (grade B)
Perform urodynamics if the findings may change the choice of invasive treatment (grade B)
National Institute for Health and Care Excellence (2015)
Do not perform multichannel cystometry, ambulatory urodynamics or videourodynamics before starting conservative management (2006, amended 2013)
After undertaking a detailed clinical history and examination, perform multichannel filling and voiding cystometry before surgery in women who have:
- Symptoms of OAB leading to a clinical suspicion of detrusor overactivity, or
- Symptoms suggestive of voiding dysfunction or anterior compartment prolapse, or
- Had previous surgery for stress incontinence (2006, amended 2013)
Do not perform multichannel filling and voiding cystometry in the small group of women where pure SUI is diagnosed based on a detailed clinical history and
examination (2006, amended 2013)
Consider ambulatory urodynamics or videourodynamics if the diagnosis is unclear after conventional urodynamics (2006, amended 2013)
Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction/American Urological Association (2012)
‘‘Clinicians may perform multi-channel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive,
potentially morbid or irreversible treatments’’ (option; evidence strength: grade C)
‘‘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’’ (recommendation; evidence strength: grade C)
OAB = overactive bladder; SUI = stress urinary incontinence
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