Usefulness of urodynamic examination in female urinary incontinence--lessons from a population-based, randomized, controlled study of conservative treatment

Rosier P, Serati M, Solomon E, van Koeveringe G, Bachmann LM, Kessler TM. Randomised Controlled Trials Assessing the Clinical Value of Urodynamic Studies: A Systematic Review and Meta-analysis

Context

The role of urodynamic studies (UDSs) in the diagnosis of lower urinary tract symptoms (LUTS) is crucial. Although expert statements and guidelines underline their value for clinical decision-making in various clinical settings, the academic debate as to their impact on patient outcomes continues.

Objective

To summarise the evidence from all randomised controlled trials assessing the clinical usefulness of UDS in the management of LUTS.

Evidence acquisition

For this systematic review, searches were performed without language restrictions in three electronic databases until November 18, 2020. The inclusion criteria were randomised controlled study design and allocation to receive UDS or not prior to any clinical management. Quality assessment was performed by two reviewers independently, using the Cochrane Collaboration’s tool for assessing the risk of bias. A random-effect meta-analysis was performed on the uniformly reported outcome parameters.

Evidence synthesis

Eight trials were included, and all but two focused on women with pure or predominant stress urinary incontinence (SUI). A meta-analysis of six studies including 942 female patients was possible for treatment success, as defined by the authors (relative risk 1.00, 95% confidence interval: 0.93–1.07), indicating no difference in efficacy when managing women with UDS.

Conclusions

Although UDSs are not replaceable in diagnostics, since there is no other equivalent method to find out exactly what the lower urinary tract problem is, there are little data supporting its impact on outcomes. Randomised controlled trials have focussed on a small group of women with uncomplicated SUI and showed no added value, but these findings cannot be extrapolated to the overall patient population with LUTS, warranting further well-designed trials.

Patient summary

Despite urodynamics being the gold standard to assess lower urinary tract symptoms (LUTS), as it is the only method that can specify lower urinary tract dysfunction, more studies assessing the clinical usefulness of urodynamic studies (UDSs) in the management of LUTS are needed. UDS investigation is not increasing the probability of success in the treatment of stress urinary incontinence.

No. 397 - Conservative Care of Urinary Incontinence in Women

OBJECTIVE

To outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women.

INTENDED USERS

Relevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists.

TARGET POPULATION

Women (>18 years of age) with urinary incontinence.

OPTIONS

Assessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices.

OUTCOMES

To provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women.

EVIDENCE

The Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded.

VALIDATION METHODS

The evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, AND COSTS

Evidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit.

GUIDELINE UPDATE

This SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The role of urodynamics in females with lower urinary tract symptoms

Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used.

Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: ‘female urology’, ‘lower urinary tract symptoms’, ‘urodynamic’, ‘incontinence’, ‘overactive bladder’, ‘bladder outlet obstruction’. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society.

Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS.

Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity.

Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence

The role of urodynamics in the management of female stress urinary incontinence

AIM

The role of urodynamic study (UDS) in the management of female stress urinary incontinence (SUI) is one of the most controversial and debated topic in urogynecology. Here, we aimed to systematically assess the most relevant available evidence on urodynamics' value in the management of women with stress urinary incontinence.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in May 2018. Only randomized clinical trials, prospective studies, or retrospective studies articles evaluating the use of urodynamic studies in women with stress urinary incontinence were included.

RESULTS

After screening a total of 3055 records, 39 studies published from 1996 to 2018 were included.

CONCLUSIONS

In an uncomplicated population of women with SUI, it is not demonstrated that preoperative urodynamic evaluation can improve the outcome of continence surgery; however, UDS provides additional information regarding lower urinary tract function that could guide the physician to make the right therapeutic choice. UDS should be considered mandatory before surgery in complicated patients, but its use should also be evaluated in index patients when the results may help counseling and management of these women.

The impact of urodynamics on treatment and outcomes in women with an overactive bladder: a longitudinal prospective follow-up study

INTRODUCTION AND HYPOTHESIS

The aim of this study was to establish if the management of women with overactive bladder (OAB) and patient-reported outcomes differed based on the findings of urodynamics (UDS).

METHODS

A prospective, longitudinal observational study conducted in urogynaecology clinics in 22 UK hospitals participating in the Diagnostic Accuracy of Bladder Ultrasound Study (BUS). A total of 687 women with OAB symptoms or urgency-predominant mixed urinary incontinence were recruited into a diagnostic study that used UDS as the reference standard. Detailed clinical history and International Consultation on Incontinence OAB Short Form (ICIQ-OAB sf) questionnaire responses were obtained before the UDS test was carried out. These questionnaires were subsequently collected at a mean of 7 and 20 months, along with patient global impression of improvement and details on medical and surgical treatments. The relationship between UDS diagnosis and treatment was examined using a multinomial regression model; logistic and repeated measures regressions were used to examine other outcomes.

RESULTS

We recruited 687 women and the response rate was 69% at 20 months. Treatment subsequent to UDS was highly associated with diagnosis (p < 0.0001). Women who received treatment concordant with their UDS findings were more likely to report an improvement in bladder symptoms (57% vs 45%; p = 0.02) and ICIQ-OAB sf scores (0.5 points, 95%CI: 0.1 to 0.9; p = 0.02).

CONCLUSIONS

Urodynamics influenced treatment decisions made by clinicians in determining treatment pathways in women presenting with OAB. Women treated based on UDS diagnoses appear to have greater reductions in symptoms than those who do not.

INVESTIGATE-I (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?): a mixed-methods study to assess the feasibility of a future randomised controlled trial of invasive urodynamic testing prior to surgery for stress urinary incontinence in women

BACKGROUND

The position of invasive urodynamic testing in the diagnostic pathway for urinary incontinence (UI) is unclear. Systematic reviews have called for further trials evaluating clinical utility, although a preliminary feasibility study was considered appropriate.

OBJECTIVES

To inform the decision whether or not to proceed to a definitive randomised trial of invasive urodynamic testing compared with clinical assessment with non-invasive tests, prior to surgery in women with stress UI (SUI) or stress predominant mixed UI (MUI).

DESIGN

A mixed-methods study comprising a pragmatic multicentre randomised pilot trial; economic evaluation; survey of clinicians' views about invasive urodynamic testing; qualitative interviews with clinicians and trial participants.

SETTING

Urogynaecology, female urology and general gynaecology units in Newcastle, Leicester, Swansea, Sheffield, Northumberland, Gateshead and South Tees.

PARTICIPANTS

Trial recruits were women with SUI or stress predominant MUI who were considering surgery after unsuccessful conservative treatment. Relevant clinicians completed two online surveys. Subsets of survey respondents and trial participants took part in separate qualitative interview studies.

INTERVENTIONS

Pilot trial participants were randomised to undergo clinical assessment with non-invasive tests (control arm); or assessment as controls, plus invasive urodynamic testing (intervention arm).

MAIN OUTCOME MEASURES

Confirmation that units can identify and recruit eligible women; acceptability of investigation strategies and data collection tools; acquisition of outcome data to determine the sample size for a definitive trial. The proposed primary outcome for the definitive trial was International Consultation on Incontinence Modular Questionnaire (ICIQ) Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) (total score) 6 months after surgery or the start of non-surgical treatment; secondary outcomes included: ICIQ-FLUTS (subscales); ICIQ Urinary Incontinence Short Form; ICIQ Lower Urinary Tract Symptoms Quality of Life; Urogenital Distress Inventory; EuroQol-5D; costs, quality-adjusted life-years (QALYs) and incremental cost per QALY, Short Form 12; 3-day bladder diary.

RESULTS

Of 284 eligible women, 222 (78%) were recruited; 165/219 (75%) returned questionnaires at baseline and 125/200 (63%) who were sent questionnaires at follow-up. There were few missing data items in returned questionnaires, with individual outcome scales calculable for 81%-94%. Most women underwent surgery; management plans were changed in 19 (19%) participants following invasive urodynamic testing. Participant Costs Questionnaires were returned by 53% 6 months after treatment; complete data to undertake cost-utility analysis were available in 27% (intervention) and 47% (control). While insufficient to recommend changes in practice, the results suggest further research would be valuable. All clinicians responding to the survey had access to invasive urodynamic testing, and most saw it as essential prior to surgery in women with SUI with or without other symptoms; nevertheless, 70% considered the research question underlying INVESTIGATE important and most were willing to randomise patients in a definitive trial. Participants interviewed were positive about the trial and associated documentation; the desire of some women to avoid invasive urodynamic testing contrasted with opinions expressed by clinicians through both survey and interview responses.

CONCLUSIONS

All elements of a definitive trial and economic evaluation were rehearsed; several areas for protocol modification were identified. Such a trial would require to 400-900 participants, depending on the difference in primary outcome sought.

FUTURE WORK

A definitive trial of invasive urodynamic testing versus clinical assessment prior to surgery for SUI or stress predominant MUI should be undertaken.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71327395.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis

BACKGROUND

Urodynamics is widely used in the investigation of urinary incontinence. The existing evidence questions its add-on value in improving the outcome of surgical treatment for stress urinary incontinence (SUI).

OBJECTIVES

To compare the surgical outcomes in women with SUI or stress-predominant mixed urinary incontinence (MUI) based on urodynamic diagnoses compared with diagnoses based on office evaluation without urodynamics.

SEARCH STRATEGY

We searched Cochrane, MedLine, Embase, CINAHL, LILACS, metaRegister of Controlled Trials (mRCT) and Google Scholar databases from inception until March 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only.

DATA COLLECTION AND ANALYSIS

Two independent reviewers (S.R. and P.L.) extracted the data and analysed it using review manager (revman) 5.2 software.

MAIN RESULTS

Of the 388 articles identified, only four RCTs met our criteria. The data from one study are as yet unpublished. In the other three RCTs, the women with SUI or stress-predominant MUI were randomised either to office evaluation and urodynamics (n = 388) or to office evaluation only (n = 387). There was no statistical difference in the risk ratio (RR) of subjective cure in the two groups (RR 1.02, 95%CI 0.90-1.15, P = 0.79, I(2) = 45%), objective cure (RR 1.01, 95%CI 0.93-1.11, P = 0.28, I(2) = 20%) or complications such as voiding dysfunction (RR 1.54, 95%CI 0.61-3.89, P = 0.27, I(2) = 18%) or urinary urgency (RR 0.80, 95%CI 0.28-2.3, P = 0.19, I(2) = 40%).

AUTHORS' CONCLUSIONS

In women undergoing primary surgery for SUI or stress-predominant MUI without voiding difficulties, urodynamics does not improve outcomes - as long as the women undergo careful office evaluation.

Urodynamic studies for management of urinary incontinence in children and adults: A short version Cochrane systematic review and meta-analysis

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make an objective diagnosis. The investigations are invasive and time consuming.

OBJECTIVES

To determine if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, leads to more effective clinical care and better clinical outcomes.

SEARCH METHODS

Cochrane Incontinence Group Specialized Register (searched February 19, 2013); reference lists of relevant articles.

SELECTION CRITERIA

Randomized and quasi-randomized trials in people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another.

DATA COLLECTION AND ANALYSIS

At least two independent review authors carried out trial assessment, selection, and data abstraction.

RESULTS

We found eight trials but data were available for only 1,036 women in seven trials. Women undergoing urodynamics were more likely to have their management changed (17% vs. 3%, risk ratio [RR] 5.07, 95% CI 1.87-13.74). Two trials suggested that women were more likely to receive drugs (RR 2.09, 95% CI 1.32-3.31), but, in five trials, women were not more likely to undergo surgery (RR 0.99, 95% CI 0.88-1.12). There was no statistically significant difference in urinary incontinence in women who had urodynamics (37%) compared with those undergoing history and clinical examination alone (36%) (RR 1.02, 95% CI 0.86-1.21).

AUTHORS' CONCLUSIONS

While urodynamics did change clinical decision-making, there was some high-quality evidence that this did not result in lower urinary incontinence rates after treatment.

Comprehensive evaluation of embarrassment and pain associated with invasive urodynamics

AIMS

To evaluate pain and embarrassment associated with invasive urodynamics and to determine underlying factors.

METHODS

One hundred seventy one consecutive patients referred to our department for invasive urodynamics were evaluated using visual numeric rating scales for sensations of apprehension, pain, and embarrassment during several steps of the procedure (scores ranging from 0 [no symptom] to 10 [worst imaginable symptom]). We also investigated the influence of sex, age, information provided before urodynamics, and medical indication on these sensations. The Spearman correlation, non-parametric test, and logistic regression analysis were performed to determine explicative factors for the most painful sensations.

RESULTS

The mean age was 61.0 (standard deviation ± 15 years). The mean (95% confidence interval [CI]) apprehension level was 2.9/10 (2.4; 3.4). The mean (95% CI) pain levels at installation on urodynamic table, transurethral catheter insertion (cystometry), and catheter repositioning (urethral pressure profilometry) were 0.3/10 (0.1; 0.5), 1.9/10 (1.6; 2.3), and 1.3/10 (1.0; 1.7), respectively. At catheter insertion, 25% of patients reported a pain level ≥ 4/10. The mean embarrassment level due to urination in front of the doctor was 1.9/10 (1.4; 2.3). Painful sensations reported during the different steps were strongly correlated with each other and with levels of apprehension and embarrassment. Age <54 years (lower quartile) and apprehension level were the only factors associated with painful sensation.

CONCLUSIONS

Our study confirms that invasive urodynamics is a well-tolerated procedure. However, some patients experience high levels of pain and embarrassment throughout the procedure. Younger age and apprehension were the most influential factors.

Urodynamic studies for management of urinary incontinence in children and adults

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive, objective diagnosis. The aim is to help select the treatment most likely to be successful. The investigations are invasive and time consuming.

OBJECTIVES

The objective of this review was to determine if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of people with urinary incontinence and better clinical outcomes.The intention was to test the following hypotheses in predefined subgroups of people with incontinence:(i) urodynamic investigations improve the clinical outcomes;(ii) urodynamic investigations alter clinical decision making;(iii) one type of urodynamic test is better than another in improving the outcomes of management of incontinence or influencing clinical decisions, or both.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process, handsearching of journals and conference proceedings (searched 19 February 2013), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another were included. Trials were excluded if they did not report clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Eight trials involving around 1100 people were included but data were only available for 1036 women in seven trials, of whom 526 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was significant evidence that the tests did change clinical decision making. Women in the urodynamic arms of three trials were more likely to have their management changed (proportion with change in management compared with the control arm 17% versus 3%, risk ratio (RR) 5.07, 95% CI 1.87 to 13.74), although there was statistical heterogeneity. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31). On the other hand, in five trials women undergoing treatment following urodynamic investigation were not more likely to undergo surgery (RR 0.99, 95% CI 0.88 to 1.12).There was no statistically significant difference however in the number of women with urinary incontinence if they received treatment guided by urodynamics (37%) compared with those whose treatment was based on history and clinical findings alone (36%) (for example, RR for the number with incontinence after the first year 1.02, 95% CI 0.86 to 1.21). It was calculated that the number of women needed to treat was 100 women (95% CI 86 to 114 women) undergoing urodynamics to prevent one extra individual being incontinent at one year.One trial reported adverse effects and no significant difference was found (RR 1.10, 95% CI 0.81 to 1.50).

AUTHORS' CONCLUSIONS

While urodynamic tests did change clinical decision making, there was some evidence that this did not result in better outcomes in terms of a difference in urinary incontinence rates after treatment. There was no evidence about their use in men, children, or people with neurological diseases. Larger definitive trials are needed in which people are randomly allocated to management according to urodynamic findings or to management based on history and clinical examination to determine if performance of urodynamics results in higher continence rates after treatment.

Can urodynamic stress incontinence be diagnosed by ultrasound?

INTRODUCTION AND HYPOTHESIS

Multichannel urodynamic testing is commonly used to diagnose urodynamic stress incontinence (USI). It has been claimed that USI may be diagnosed by imaging. In this study we determined the predictive value of ultrasound findings for USI.

METHODS

This is an observational study utilising data obtained during urodynamic testing. Data sets were analysed in 209 patients in order to determine the predictive value of sonographic findings for the diagnosis of USI.

RESULTS

Bladder neck descent and maximal urethral pressure were the only independent predictors of USI identified by multivariate logistic regression. The finding of a cystourethrocele with funnelling increased the odds of a diagnosis of USI by 2.5 (95 % confidence interval 1.17-5.4, p = 0.018).

CONCLUSIONS

Translabial ultrasound can identify an anatomical configuration that is associated with USI. However, sonographic findings are insufficient to predict USI and can not replace urodynamic testing.

Urodynamic studies in adults: AUA/SUFU guideline

PURPOSE

The authors of this guideline reviewed the literature regarding use of urodynamic testing in common lower urinary tract symptoms. The findings are intended to assist clinicians in the appropriate selection of urodynamic tests, following an evaluation and symptom characterization.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (searched from 1/1/90 to 3/10/11) was conducted to identify peer-reviewed publications relevant to using urodynamic tests for diagnosis, determining prognosis, guiding clinical management decisions and improving patient outcomes in patients with various urologic conditions. The review yielded an evidence base of 393 studies after application of inclusion/exclusion criteria. These publications were used to create the evidence basis for characterizing the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinion.

RESULTS

The evidence-based guideline statements are provided for diagnosis and overall management of common LUTS conditions.

CONCLUSIONS

The Panel recognizes that each patient presenting with LUTS is unique. This Guideline is intended to serve as a tool facilitating the most effective utilization of urodynamic testing as part of a comprehensive evaluation of patients presenting with LUTS.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women. This is an update of a Cochrane review first published in 2003 and subsequently updated in 2009.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 21 June 2012) which includes searches of MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for risk of bias and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed by grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty-four trials were identified which included approximately 19,676 incontinent women of whom 9599 received oestrogen therapy (1464 involved in trials of local vaginal oestrogen administration). Sample sizes of the studies ranged from 16 to 16,117 women. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.The combined result of six trials of systemic administration (of oral systemic oestrogens) resulted in worse incontinence than on placebo (risk ratio (RR) 1.32, 95% CI 1.17 to 1.48). This result was heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year. All of the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen were combined also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or pessaries) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.One small trial showed that women were more likely to have an improvement in incontinence after pelvic floor muscle training (PFMT) than with local oestrogen therapy (RR 2.30, 95% CI 1.50 to 3.52).The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Urinary incontinence may be improved with the use of local oestrogen treatment. However, there was little evidence from the trials on the period after oestrogen treatment had finished and no information about the long-term effects of this therapy was given. Conversely, systemic hormone replacement therapy using conjugated equine oestrogen may worsen incontinence. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence comparing routes of administration. The risk of endometrial and breast cancer after long-term use of systemic oestrogen suggests that treatment should be for limited periods, especially in those women with an intact uterus.

The effect of urodynamic testing on clinical diagnosis, treatment plan and outcomes in women undergoing stress urinary incontinence surgery

PURPOSE

We evaluated the influence of preoperative urodynamic studies on diagnoses, global treatment plans and outcomes in women treated with surgery for uncomplicated stress predominant urinary incontinence.

MATERIALS AND METHODS

We performed a secondary analysis from a multicenter, randomized trial of the value of preoperative urodynamic studies. Physicians provided diagnoses before and after urodynamic studies and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification and nonoperative therapy. Treatment plan changes and surgical outcomes between office evaluation and office evaluation plus urodynamic studies were compared by the McNemar test.

RESULTS

Of 315 subjects randomized to urodynamic studies after office evaluation 294 had evaluable data. Urodynamic studies changed the office evaluation diagnoses in 167 women (56.8%), decreasing the diagnoses of overactive bladder-wet (41.6% to 25.2%, p <0.001), overactive bladder-dry (31.4% to 20.8%, p = 0.002) and intrinsic sphincter deficiency (19.4% to 12.6%, p = 0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p <0.001). After urodynamic studies physicians canceled surgery in 4 of 294 women (1.4%), changed the incontinence procedure in 13 (4.4%) and planned to modify mid urethral sling tension (more or less obstructive) in 20 women (6.8%). Nonoperative treatment plans changed in 40 of 294 women (14%). Urodynamic study driven treatment plan changes were not associated with treatment success (OR 0.96, 95% CI 0.41, 2.25, p = 0.92) but they were associated with increased postoperative treatment for urge urinary incontinence (OR 3.23, 95% CI 1.46, 7.14, p = 0.004).

CONCLUSIONS

Urodynamic studies significantly changed clinical diagnoses but infrequently changed the global treatment plan or influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for postoperative urgency urinary incontinence.

Urodynamic studies for management of urinary incontinence in children and adults

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive objective diagnosis. The aim is to help to select the treatment most likely to be successful. The investigations are invasive and time consuming.

OBJECTIVES

The objective of this review was to discover if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of urinary incontinence and better clinical outcomes.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 24 May 2011), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamics against another. Trials were excluded if they did not report clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Seven small trials involving around 400 people were included but data were only available for 385 women in five trials, of whom 197 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was some evidence that the tests did change clinical decision making. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31) but not, in three trials, surgery (RR 1.75, 95% CI 0.39 to 7.75). Women in the urodynamic arms of two trials were more likely to have their management changed but this did not quite reach statistical significance (proportion with no change in management 76% versus 99%, RR 0.79, 95% CI 0.57 to 1.10).However, there was not enough evidence to demonstrate whether or not this resulted in a clinical benefit. For example there was no statistically significant difference in the number of women with urinary incontinence if they received treatment guided by urodynamics (70%) versus those whose treatment was based on history and clinical findings alone (62%) (e.g. RR for number with incontinence after first year 1.23, 95% CI 0.60 to 2.55).No trials reported whether or not there were any adverse effects.

AUTHORS' CONCLUSIONS

While urodynamic tests may change clinical decision making, there was not enough evidence to suggest whether this would result in better clinical outcomes. There was no evidence abut their use in men, children or people with neurological diseases. Larger definitive trials are needed, in which people are randomly allocated to management according to urodynamic findings or to standard management based on history and clinical examination.

The correlation between clinical and urodynamic diagnosis in classifying the type of urinary incontinence in women. A systematic review of the literature

AIMS

To determine the reclassification rate of clinically diagnosed stress, mixed, and urge urinary incontinence after urodynamic investigation.

METHODS

A systematic review of the published literature in MEDLINE and EMBASE of clinical trials among women with urinary incontinence. Studies were included in case the diagnosis based on symptoms and/or signs was compared with the diagnosis after urodynamic investigation.

RESULTS

Twenty-three articles involving 6,282 women with urinary incontinence met the inclusion criteria. A clinical diagnosis of stress urinary incontinence was reclassified into mixed urinary incontinence in 9% of women and into detrusor overactivity (DO) in 7% of cases. The pooled reclassification rate was highest among patients with symptoms of mixed urinary incontinence, where 46% of the patients had stress urinary incontinence and 21% had DO on urodynamic investigation. The available literature does not allow the identification of the additional value of non-invasive test, such as stress test and voiding diary, accessory to symptoms. None of the studies had therapeutic effects as an outcome measure.

CONCLUSIONS

This review of clinical studies shows that the level of agreement between classification based on clinical evaluation and based on urodynamic investigation is poor. Urodynamic observations are regarded as gold standard, but based on the poor correlation, this assumption should be questioned.

The Hordaland Women's Cohort: prevalence, incidence, and remission of urinary incontinence in middle-aged women

INTRODUCTION AND HYPOTHESIS

The aim of study is to prospectively investigate the prevalence, incidence, and remission of urinary incontinence (UI) in a cohort of middle-aged women.

METHODS

In 1997-1999, 2,229 randomly selected women aged 41-45 agreed to participate in the Hordaland Women's Cohort, and six almost identical postal questionnaires were sent them during the following 10 years. Response rate was 95.7% at inclusion and has remained 87% to 93% in subsequent waves; 64.1% answered all six questionnaires. UI variables include type, amount, frequency, and severity.

RESULTS

Prevalence of UI increased by age until a peak in age group 51-52 years for any (50.3%) and significant (10.0%) UI. There was then a decrease in prevalence caused by a decrease in incidence and decrease in remission. Stress UI was the major type and most UI was of low severity.

CONCLUSION

Prevalence of any UI is high in middle-aged women but reaches a peak followed by a decrease.

Urogynecology triage clinic: a model of healthcare delivery

INTRODUCTION AND HYPOTHESIS

To establish whether a nurse-led urogynecology triage clinic (UTC) is effective in terms of patient journey (from primary referral to first hospital contact until discharge), diagnosis, management, and outcomes.

METHODS

The case notes of 300 patients attending the UTC in a university hospital between January 2006 and November 2007 were randomly selected for review.

RESULTS

The mean interval from referral to first visit improved from 15.6 weeks (range = 12-32 weeks) to 4.6 weeks (range = 1-11 weeks, SD = 1.97) after UTC. Compared to pre-UTC, the mean period from first visit to final outcome improved from 11 months (range = 3.0-23.0 months) to 8.8 weeks (range = <1-60 weeks, SD = 11.15). Fifty-nine percent were discharged from the UTC without being seen by a specialist.

CONCLUSIONS

By service redesigning, the UTC has reduced the number of clinic visits and patient journey time and has also shown that the majority of women with incontinence can be adequately managed by a specialist nurse.

The Hordaland Women's Cohort: a prospective cohort study of incontinence, other urinary tract symptoms and related health issues in middle-aged women

Background

Urinary incontinence (UI) is a prevalent symptom in middle-aged women, but data on incidence is limited and rarely reported. In order to analyze incidence, remission, or development patterns of severity and types of UI, we have established a 15-year prospective cohort (1997–2012).

Methods

The Cohort is based on the national collection of health data gathered from county studies (CONOR). Hordaland Health Study (HUSK) is one of them from Hordaland County. Each of the county studies may have local sub-studies and our Cohort is one of them. The Cohort included women aged 40–45 in order to have a broad approach to women's health including UI and other lower urinary tract symptoms (LUTS). A onefifth random sampling from HUSK was used to create the Cohort in 1997–1999. For the necessary sample size a preliminary power calculation, based on a 70% response rate at inclusion and 5% annual attrition rates was used. The Cohort is planned to collect data through questionnaires every second year for the 15-year period from 1997–2012.

Discussion

The Cohort represents a relatively large random sample (N = 2,230) of about 15% of the total population of women born between 1953–57 in the county of Hordaland. Our data shows that the cohort population is very similar to the source population. The baseline demographic, social and medical characteristics of the Cohort are compared with the rest of women in HUSK (N = 7,746) and there were no significant differences between them except for the level of education (P = 0.001) and yearly income (P = 0.018), which were higher in the Cohort population. Urological characteristics of participants from the Cohort (N = 1,920) were also compared with the other participants (N = 3,400). There were no significant statistical differences except for somewhat more urinary continence (P = 0.04), more stress incontinence (P = 0.048) and smaller amount of leakage (P = 0.015) in the Cohort. In conclusion, the Cohort ispopulation-based, with little selection bias, and thus is a rather unique study forinvestigating UI and LUTS in comparison with many other projects with similar purposes.

Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection and predicting outcome?

PURPOSE OF REVIEW

Disagreement exists as to the extent of evaluation required prior to offering surgical intervention for the treatment of stress urinary incontinence in women. While few would argue that additional information can be gleaned from a properly performed urodynamic investigation, it remains unclear exactly which women would most benefit from such preoperative study, and if urodynamic evaluation definitively improves treatment outcome. Since such invasive studies may not be widely available in certain areas, can be costly, and are associated with a low, but defined risk of bladder infection, it is imperative that the appropriate indication for preoperative urodynamic evaluation be carefully defined. This review highlights recent reports and controversies concerning the use of urodynamics (focusing on leak point pressure testing and urethral pressure profilometry) prior to surgical treatment for stress urinary incontinence.

RECENT FINDINGS

There remains no clear consensus as to whether urodynamic testing enhances surgical outcome of stress urinary incontinence treatments by improving case selection or altering the surgical approach based on study findings. As treatment strategies for stress urinary incontinence have developed over the last several years to a more uniform approach, it is less clear that the severity of stress urinary incontinence, based on either abdominal leak point pressure or urethral pressure profilometry will influence the choice of surgical technique. Furthermore, there is little evidence to suggest that patients with more severe forms of stress urinary incontinence by urodynamic testing fare more poorly after the most commonly offered surgical treatment than those with less severe forms. There are certain sub-populations of women who appear to be at higher risk of voiding dysfunction following incontinence surgery, and urodynamic testing may aid in identifying this group.

SUMMARY

It is not apparent that either abdominal leak point pressure measurement or urethral pressure profilometry can accurately predict which patients will achieve the best outcome of surgical treatment for stress urinary incontinence. Other parameters assessed during urodynamic evaluation might provide prognostic information regarding the risk of voiding dysfunction postoperatively and the possibility of persistent urge-related leakage following surgery, though not directly predict cure. A multi-institutional randomized study comparing the outcome between patients in whom treatment was determined with the urodynamic information known, compared with patients in whom this information was unknown would further enhance our understanding of the usefulness of urodynamics in the preoperative evaluation of women with stress urinary incontinence.

Continence nurse treatment of women's urinary symptoms

The aim of this study was to establish how accurately a trained continence nurse could allocate appropriate second-line conservative treatment to women without urodynamic investigations. Depending on the number of patients coming taking up the service, there were between five and 12 nurses operating at any one time. Women aged 40 years and over, of which there were 2421 reporting lover urinary tract symptoms, were randomly allocated to a new nurse-led continence service. Of these women, 450 subsequently underwent urodynamic investigation, before which the nurses documented which second-line conservative treatment would be appropriate. The results showed that of all women with detrusor overactivity, 79.1% were correctly allocated anticholinergic treatment, and 64.8% were allocated pelvic floor exercises (PFE). Of all women with urodynamic stress incontinence, 88.8% were allocated only one treatment. This study showed that a trained continence nurse is able to allocate conservative treatment appropriately to the majority of women without the need for urodynamic investigation. This indicated that the management of urinary dysfunction by a team of trained, dedicated nurses has the potential to reduce waiting lists for urodynamic investigation, avoid unnecessary investigations and achieve greater patient satisfaction.

A comparison of anticipatory and postprocedure pain perception in patients who undergo urodynamic procedures

OBJECTIVE

The purpose of this study was to compare anticipatory and postprocedure pain perception in female patients who undergo multichannel urodynamic evaluation in an office setting.

STUDY DESIGN

One hundred consecutive patients completed a visual analogue pain scale before and after urodynamic testing.

RESULTS

The mean postprocedure pain score of 2.32 cm was significantly lower than the anticipatory pain rating of 4.35 cm (P<.05). The lower postprocedure pain score was not influenced by previous hysterectomy, body mass index, menopausal status, estrogen replacement therapy, or analgesic or psychiatric medication usage. Patients who had undergone previous anti-incontinence surgery reported significantly higher levels of pain during the procedure (mean visual analogue pain scale score, 3.10 cm vs 2.06 cm; P=.027).

CONCLUSION

Patients who undergo urodynamic testing anticipate higher degrees of discomfort than they perceive during the procedure. Previous anti-incontinence surgery appears to lower the pain threshold.

Are urodynamic tests useful tools for the initial conservative management of non-neurogenic urinary incontinence? A review of the literature

OBJECTIVES

To summarise the evidence for the role of urodynamic tests in the diagnosis and classification of urinary incontinence.

METHODS

Reference lists in relevant papers were reviewed and MEDLINE searches conducted.

RESULTS

The mean sensitivity (specificity) of clinical history versus urodynamic tests was 0.82 (0.57) for stress incontinence, 0.69 (0.60) for urge incontinence/overactive bladder, and 0.51 (0.66) for patients with mixed incontinence. The proportion of women with a clinical diagnosis of urinary incontinence but with normal findings from urodynamic tests ranged from 3 to 8%. Overall sensitivity of urodynamic tests was about 85-90% in the diagnosis of urodynamic stress incontinence, but generally lower following diagnosis of urge and mixed incontinence. No relationship emerged between urodynamic test results and response to medical treatment.

CONCLUSIONS

This literature review shows that the sensitivity of clinical history versus urodynamic tests was 0.82, 0.69 and 0.51 respectively for stress, urge and mixed urinary incontinence. It also suggests that urodynamic diagnosis does not predict response to treatment. These data add to the ongoing 'urodynamics or no urodynamics' debate in the evaluation of urinary incontinence and show that urodynamic testing may not be helpful for patients receiving initial non-invasive therapy. These data are in line with the conclusions of the 1st and 2nd International Consultations on incontinence.

Should measurement of maximum urinary flow rate and residual urine volume be a part of a "minimal care" assessment programme in female incontinence?

OBJECTIVE

The aim of this study was to evaluate the value of routine measurements of urinary flow rate and residual urine volume as a part of a "minimal care" assessment programme for women with urinary incontinence in detecting clinical significant bladder emptying problems.

MATERIAL AND METHODS

Four hundred and eight women were examined and treated in an open-access, interdisciplinary incontinence clinic. A standardized programme for investigation and primarily non-surgical treatment of incontinence was applied.

RESULTS

Of the 408 women 43% reported subjectively incomplete bladder emptying. Twenty-six per cent had a maximum flow rate less than 15 ml/s, but only 4% at a voided volume > or =200 ml. Residual urine more than 149 ml was found in 6%. Two women had chronic retention with overflow incontinence. Both had typical symptoms with continuous leakage, stranguria and chronic cystitis. Another woman had an urethral stricture with massive bladder emptying symptoms. In the remaining 172 women with symptoms suggesting bladder emptying problems, all but 3 were managed by triple voiding and timed micturition. In these 3 patients, who also had chronic cystitis, the treatment was supplemented with clean intermittent self-catheterization.

CONCLUSION

The few women (6 (1.5%)) in whom measurements of urinary flow rate and residual urine volume had a clinical therapeutic consequence, cannot justify these measurements to be routine in a "minimal care" programme for assessment of primary, uncomplicated female urinary incontinence. Thus, primary health care providers can assess women based on simple guidelines without expensive equipment for assessment of urine flow rate and residual urine.