When should urodynamics testing be performed?

Many physicians involved in pelvic health medicine state that urodynamics must be performed prior to any surgery involving the bladder or lower urinary tract. Others cite recent medical publications that state urodynamics testing is not required in many situations, such as prior to surgery for simple stress incontinence. It is likely this debate will continue for several years before medical consensus is reached. At a high-level, urodynamics testing may be prescribed for one of the following reasons:

• the patient has moderate to severe involuntary release of urine
• other tests do not determine the cause of incontinence
• the patient appears to have more than one cause of incontinence
• the patient is considering having surgery

At a more detailed level, urodynamic testing is typically prescribed for one of the following reasons:

• Neurogenic Bladder (NGB) - If a patient is believed to have NGB, then urodynamic testing (including complex cystometrogram and electromyography) are often performed. Clinicians should perform PVR assessment, either as part of a complete urodynamic study or separately, during the initial urological evaluation of patients with relevant neurological conditions (e.g., spinal cord injury and myelomeningocele) and as part of ongoing follow-up, when appropriate. Additionally, Clinicians should perform a complex cystometrogram (CMG) during initial urological evaluation of patients with relevant neurological conditions with or without symptoms and as part of ongoing follow-up when appropriate. In patients with other neurological diseases, physicians may consider CMG as an option in the urological evaluation of patients with LUTS.(source AUA/SUFU Guidelines for Adult Urodynamics)
• LUTS - Clinicians may perform PVR in patients with LUTS as a safety measure to rule out significant urinary retention, both initially and during follow up. Uroflow may be used by clinicians in the initial and ongoing evaluation of male patients with LUTS when an abnormality of voiding/emptying is suggested. 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. Clinicians should perform pressure flow studies (as part of a urodynamics test) 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. (source AUA/SUFU Guidelines for Adult Urodynamics)
• Stress Urinary Incontinence and Prolapse - Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function, and Surgeons considering invasive therapy in patients with SUI should assess post-void residual (PVR) urine volume. 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. Additionally, Clinicians should perform stress testing with reduction of the prolapse in women with high-grade pelvic organ prolapse (POP) but without the symptom of SUI. Multi-channel urodynamics with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS. (source AUA/SUFU Guidelines for Adult Urodynamics)
• Overactive Bladder (OAB) - It is theorized that not all patients with symptoms of urinary urgency (and subsequently diagnosed with OAB) share the same pathophysiology. Urodynamics can be used to help stratify he underlying causes and pathophysiology by providing detailed and valuable data. In particular, OAB is a symptom syndrome which includes either sensory dysfunction or a combination of sensory and motor disorders of the bladder. Urodynamic testing is an established tool to prove detrusor overactivity (DO), one of the primary causes of OAB. (Source: The Role of Urodynamic Study in the Evaluation and Management of Overactive Bladder by Hann-Chorng Kuo, M.D.)

The physician primarily responsible for the patient's care has the authority and responsibility to determine if urodynamics testing is needed. However, the physician can only typically prescribe what will be reimbursed by insurance so there is money available to cover the cost of the test. Given this fact, Blue Cross Blue Shield of Alabama has one of the clearest policies regarding when urodynamics testing should be prescribed. Their policy is summarized below. A link to the full policy is further below.

Summary of Blue Cross Blue Shield of Alabama Policy #315 Regarding the Use of Urodynamics:

• The diagnosis with respect to the type of urinary incontinence is uncertain, after the initial history and physical examination.
• The patient’s symptoms do not correlate with the objective physical findings.
• The patient has mixed symptoms (stress and urge urinary incontinence).
• The patient fails to improve with treatment or has failure of prior incontinence procedures.
• The patient is being considered for surgical intervention and has a complicated diagnostic situation and is at high surgical risk.
• The patient has a history of extensive pelvic surgeries, prior radiation therapy to the pelvis, or has neurologic abnormalities.
• The patient has symptomatic pelvic organ prolapse (Grade III or higher).
• For men, the patient has benign prostatic hypertrophy (BPH ).
• For men, pressure flow studies for the evaluation of urinary symptoms in men with maximum flow rates above 10ml./sec. with abnormal presentations.
• For men, for the evaluation of urinary symptoms in patients who have failed prior invasive therapy for the treatment of BPH.
• For men, the patient has a history of extensive pelvic surgeries, prior radiation therapy to the pelvis, or has neurological abnormalities.

In summary, the above provides highlights of when prescribing urodynamics is logical and prudent. However, the above is a very high-level summary. It may also be helpful to review the following documents to better understand the clinical guidelines for the use of urodynamics:

• Adult Urodynamics: AUA/SUFU Guideline
• The Role of Urodynamic Study in the Evaluation and Management of Overactive Bladder
• Blue Cross and Blue Shield of Alabama Policy #315: Urodynamic Testing to Evaluate Urinary Incontinence
• International Continence Society - Committee on Urodynamics
• Pressure Flow Urodynamic Studies: The Gold Standard for Diagnosing Bladder Outlet Obstruction