Urodynamics, An Issue of Urologic Clinics (eBook)

Benjamin M Brucker (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-32046-7 (ISBN)

Infos

This issue of the Urologic Clinics will focus on urodynamic testing in men, women and special situations. Appropriate urodynamic testing options including video urodynamics, pressure flow studies, and neurogenic voiding discussion will be discussed. Dr. Nitti and Dr. Brucker have assembled well known experts in their fields to provide current clinical information for urodynamic evaluation, diagnosis, and treatment.

Textauszug

AUA/SUFU Adult Urodynamics Guideline

A Clinical Review

Clinton W. Collins, MDa and J. Christian Winters, MDb∗[e-mail],     aDivision of Urology, University of Mississippi Health Sciences Center, 2500 North State Street, Jackson, MS 39216, USA; bDepartment of Urology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Room 547, New Orleans, LA 70112, USA

∗Corresponding author.

The American Urological Association/Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction Adult Urodynamics Guideline was published with the intent of guiding the clinician in the role of urodynamics in the evaluation and management of complex lower urinary tract conditions. This article examines each guideline statement and attempts to provide clinical context for each statement. Key points are emphasized in the form of clinical case scenarios, which demonstrate application of the principles stressed in this guideline. It is hoped the reader will have a better clinical frame of reference relative to each statement in these guidelines.

Keywords

Uroflow

PVR

Pressure-flow study

Videourodymanics

Cystometrogram

Overactive bladder

Stress urinary incontinence

Lower urinary tract symptoms

Pelvic organ prolapse

Neurogenic bladder

Key points

• In women with stress urinary incontinence (SUI), urodynamics (UDS) is an option in the preoperative assessment.

• If UDS is performed, urethral function should be measured.

• In patients with urinary urgency incontinence and mixed incontinence, the absence of detrusor overactivity (DO) on a single urodynamic study does not exclude it as a causative agent for their symptoms.

• Patients with relevant neurogenic conditions (at risk for upper tract complications) should undergo multichannel cystometrogram or pressure flow study (PFS) whether they have symptoms or not.

• The only way to accurately diagnose bladder outlet obstruction (BOO) is by PFS.

Introduction

UDS has long been considered a useful tool for the diagnosis and treatment of lower urinary tract symptoms (LUTS), incontinence, voiding dysfunction, and neurogenic bladder. There has been recent controversy regarding the specific role of UDS. The Value of Urodynamic Education (ValUE) trial reported no improvement in 12-month outcomes between women with stress-predominant urinary incontinence randomized preoperatively to an office evaluation alone versus office evaluation plus preoperative UDS. However, diagnoses were changed in some patients who underwent UDS, as the surgeons were more likely to diagnose intrinsic sphincteric deficiency and less likely to diagnose overactive bladder (OAB), suggesting that UDS did change the clinician’s diagnosis before surgery.1 The utility of pressure-flow studies (PFS) in men before surgery for LUTS secondary to benign prostatic enlargement has long been debated.2,3 The American Urological Association (AUA) and the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction (SUFU) published guidelines for the use of UDS in adults, and this article reviews this update and places these findings in clinical perspective.

Traditionally, physicians have used UDS for the following scenarios: (1) to identify factors contributing to lower urinary tract dysfunction and assess their relevance, (2) to predict the consequences of lower urinary tract dysfunction on the upper tracts, (3) to predict the consequences and outcomes of therapeutic intervention, (4) to confirm and/or understand the effects of interventional techniques, and (5) to investigate the reasons for treatment failure.4 Because pretesting anxiety and urethral catheterization is necessary for some forms of UDS, the risks (bleeding, infection, urethral trauma, and pain) should be weighed with the potential benefits. UDS is not a static diagnostic examination that provides a diagnosis for lower urinary tract conditions. UDS is an interactive examination, which assesses lower urinary tract function and serves as an adjunct to the comprehensive evaluation of patients with LUTS. In most patients presenting with lower urinary tract disorders, UDS is usually not necessary in the routine initial evaluation or even before empiric treatment in most cases. The clinician should always formulate the urodynamic questions before any examination. The physician should always ask, “What am I hoping to gain from this test? What conditions do I need to assess during UDS testing? What symptoms need to be reproduced during the examination? And, will this test likely change my treatment plan?” If the physician cannot answer these questions and ensure that the patient complaints are reproduced, it is unlikely that the testing will be beneficial.5

The AUA/SUFU Urodynamics Guideline in adults reviewed publications from January 1990 through March 2011 with focus on the use of postvoid residual (PVR), uroflowmetry, cystometry, PFS, videourodynamic studies (VUDS), electromyography (EMG), and urethral function tests (Valsalva leak point pressure [VLPP], urethral pressure profile). These UDS tests were evaluated by themselves or if used in combination with any other UDS test. Four lower urinary tract conditions were assessed: stress incontinence and pelvic organ prolapse (POP), urinary urgency and urgency incontinence, LUTS (comprising predominately obstructive symptoms), and neurogenic bladder. The role of UDS in these urinary conditions was evaluated in 4 categories: diagnosis, prognosis, clinical management decisions, and patient outcomes. Studies that did not report findings separately for men and women were excluded. The AUA methodology for Guidelines Statements was used. Each guideline statement is based on the strength of the evidence and is standard in the AUA Guidelines process.6,7 The nomenclature system for establishing guideline statement based on levels of evidence is included in Table 1.

Table 1

AUA nomenclature system

Statement Type: Definition

Evidence Strength

Standards: Directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken

Grade A or B

Recommendations: Directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken

Grade C

Options: Nondirective because the balance between benefits and risks/burdens seems equal or unclear

Grade A, B, or C

Clinical Principle: Statement about a component of clinical care that is widely agreed upon by urologists or other clinicians

Insufficient publications to address certain questions from an evidence basis

Expert Opinion: Statement achieved by consensus of the Panel that is based on members’ clinical training, experience, knowledge, and judgment

There may be no evidence

These guidelines offer guidance statements with attention given to certain clinical scenarios, represented by the various lower urinary tract conditions within the guideline. The guideline statements represent the role of UDS in the evaluation in management of patients with these urinary disorders. Thus, the intent of this guideline is that following a symptom assessment, physical examination, and incontinence assessment, physicians can determine which scenario, and thus which recommendation, fits their patient. These differences in clinical presentation often guide the decision of whether UDS is indicated or not. Taking the guidelines into consideration, it is ultimately the physician’s decision regarding what is best for each patient.

There are a total of 19 Guidelines Statements in each of the 4 clinical conditions. This article presents each Guideline Statement and offers clinical context and case scenarios.

Stress urinary incontinence and pelvic organ prolapse

1. Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function. (Recommendation; Evidence Strength: Grade C)

A During multichannel UDS testing, all the instrumentation is in place to assess urethral function (without additional procedures). The assessment of urethral function is performed by the following tests:

i. Urethral pressure profilometry/maximal urethral closure pressure

ii. Abdominal leak point pressure (ALPP) (Valsalva/cough leak point pressure)—this measurement is easily obtained during demonstration of urodynamic SUI.

B Because some treatments have been shown to be less effective in patients with poor urethral function,8–10 it is recommended that urethral function be evaluated when UDS has been determined...

Produkt-Details

• Erscheint lt. Verlag: 28.8.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Urologie
• ISBN-10: 0-323-32046-5 / 0323320465
• ISBN-13: 978-0-323-32046-7 / 9780323320467