Independent Reviews of Urodynamic Testing including UroCuff and Resulting Patient Outcomes, For Physicians Tracing its routes back to the 1800’s when instruments were first developed to measure bladder pressure and urine flow rate,UroCuff Urodynamic Testing has become much more specialized over the course of history and its implementation has increased exponentially to understand the medical science involved with the physiology and pathophysiology of the lower urinary tract. No longer is a specialization in urology required in order to diagnose most causes of lower urinary pathology including causes of incontinence, but some treatments do require the knowledge and expertise that only Urologists are familiar with. Women, due to their specific physiology and anatomy, are more prone to problems involving incontinence, but men do face issues involving the lower urinary tract as well. The value of urodynamic testing has been contested over the years but one main point remains, urodynamic testing can help evaluate the cause whether it be involved with stress incontinence, urge, functional, or overflow. The main issue with urodynamic testing is treatment, not diagnosis. Stress incontinence is usually due to increases in abdominal pressure, caused by everyday activities ranging from laughing, coughing, and sneezing to exercising. Pregnancy and childbirth are some of the main causes of stress incontinence due to the stretching and weakening of pelvic floor muscles. Other causes include patients being overweight/obese, problems with prostate, or even consumption of certain medications. Urge incontinence, also known as overactive bladder, is characterized by individuals being struck with a sudden need to urinate but finding that they do not make it to the restroom in time. Neuromuscular issues usually are the cause of urge incontinence. Multiple sclerosis, Parkinson’s, diabetes, and stroke are all causes of nerve damage. Bladder infections, stones, and certain medications can also cause urge incontinence. Overflow incontinence is characterized as not being able to empty the bladder completely. Mainly found in male patients, it is characterized by dribbling. Once the bladder is full, leakage/dribbling may occur. Weak bladder muscles, blockage of the urethra, prostate enlargement, tumors, and constipation are all causes of overflow incontinence. Functional incontinence is usually caused by a physical problem like arthritis or a cognitive problem like dementia. Testing: Post-void residual volume testing: A urinary catheter is inserted once a patient has completely emptied their bladder. Urine volume is measured, illustrating how efficiently the bladder empties. Uroflowmetry: Measures how fast the patient can empty his or her bladder. Additional measurements can be made that describe bladder and rectal pressures. This testing can describe reasons in difficulty of voiding. Multichannel Cystometry: Measures the pressure in the rectum and the bladder utilizing two separate pressure catheters. It demonstrates bladder wall contractions during bladder filling. Urethral strength can also be tested through Valsalva to help distinguish cause. Electromyography – can help characterize nerve and muscle activity in the bladder neck Other tests – various other tests are utilized to help characterize and identify problems specific to each patient. Review of Urodynamic Testing Utilization: While agreement of results is highly discordant due to the questions posed by those reviewing urodynamic testing, one thing can be agreed upon: Urodynamic Testing does indeed influence clinical decision making and is essential when specific types of incontinence, such as stress incontinence, are diagnosed. Utilizing randomized and quasi-randomized trials in people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another, it has been determined that clinical decision making is influenced by testing results. It is hard to distinguish whether actual incontinence rates are changed by urodynamic testing as that is what the study of urodynamics is: testing and diagnosing, not direct treatment of incontinence. Other studies involving urodynamics have inconclusive results due to the lack of scope and not including male patients, children, patients with neurological disease,             Urodynamic Testing

and scattered data on female patients. Larger definitive trials are needed to determine if performance of urodynamic testing results in higher continence rates after treatment. Though independent reviews of urodynamic testing seem inconclusive, they all lack definitive results and fail to focus on the real questions involving cause and effect and types of incontinence. As physicians are trained to take a complete history and combine that knowledge with objective results, we understand that many tests influence treatment and help improve patient outcome. Previous independent reviews of urodynamic testing seemingly put the “chicken before the egg” by focusing on whether testing improves outcome when they should be focusing on how the knowledge gained from testing is used to efficiently identify and then treat pathology involving lower urinary tract symptoms and incontinence. These same reviews point out that clinical decisions are influenced by urodynamic testing but fail to make the jump from this influence to how treatment is changed and patient outcome improved. Empirical treatment versus a diagnostic approach, evidence based medicine has been proven to be more efficient and cost effective several times over. – Nikolaus Hagedorn