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