Dynamic testing in SUI & Pelvic Prolapse
Urodynamics : which test and when?
• In recent years the role of urodynamics in the assessment of stress urinary incontinence (SUI) has become contentious.
• Proponents and Opponents
• Result: the literature is contradictory and lacks adequate
evidence, rendering meaningful conclusions difficult.
Cons: The NICE document
The Guideline states :
• Pre-op UDS are NOT necessary for women with “ pure symptoms of SUI “
The management of Urinary incontinence in women.NICE Clinical Guideline 40 ,2006
Pro: Agur et a , 2009
Agur et a , 2009
Cons: Limited effect of UDS on decision-making and outcome
Pro : Griffiths D , ICI Report on Dynamic Testing , 2005
• All patients in any symptom group ( i.e, SUI ) have similar underlying pathophysiology requiring similar treatment , and so UDS cannot classify them any better than symptoms alone
• Current treatments are so non-specific that underlying dysfunction is unimportant : treatment works equally well or poorly in any case
Pro : Digesu et a.,2009
Risk factors in SUI & Prolapse surgery
• Detrusor dysfunction ( including de novo urgency)• ISD vs Hypofunctional urethra• Emptying problems
Detrusor dysfunction( including de novo urgency )
Pro: Flisser A & Blaivas J , J.Urol , 2003 Urgency : the spectrum of urodynamics
Cons : G. Hosker - Committee 6 -Dynamic testing
ICI ,2008
Urethral function studies
VLPP - MUCP
Artibani W , Point - Counterpoint , AUA 2010
Emptying problems
Cons :
Emptying problemsThe Fact Sheet
Pro:• Almost half of all women with advanced POP experienced incomplete
bladder emptying Dain L,Auslander R,Rosen T et a.Urodynamic findings in women with pelvic organ prolapse and obstructive voiding symptoms.Int J
Gynaecol Obstet , 2010
• Recent evidence suggests that 35.5% of women with SUI have a PVR greater than 50 ml and 15.9% have a PVR greater than 100 ml .
Tseng LH, Liang CC, Chang YL, et al. Postvoid residual urine in women with stress incontinence. Neurourol Urodyn 2008; 27:48–51.
• Approx. 25% of patients with SUI show detrusor underactivity or acontractile detrusor accounting for 36% failure rate after mid-urethral sling placement.
Kuo HC. Effect of detrusor function on the therapeutic outcome of sub-urethral sling procedure using a polypropilene sling for stress urinary incontinence in women.Scand J Urol Nephrol 2007;41:138-43
Cons:
• The satisfaction rate was 98.1% in patients with normal detrusor function, 82% in patients with detrusor underactivity or an acontractile detrusor and 75% in patients with detrusor overactivity (p<0.05).
Cons : Conclusions
Pro : Conclusions 1
• SUI has a complex multifactorial mechanism which at present is poorly understood
• Urodynamic evaluation may be rather primitive and questionable
BUT
• Today we have nothing better
Pro: Conclusions 2
• Any urodynamic parameter must be correctly interpreted• Any incongruence with the clinical picture should act as a
red flag and imply a more detailed evaluation• Risk stratification is the basis of rational treatment
recommendations in the context of scientific available evidence