Fourth International Consultation On Incontinence (ICI) - Dynamic Testing Committee Highlights

Main Category: Urology / Nephrology
Article Date: 25 Jul 2008 - 0:00 PDT

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PARIS, FRANCE (UroToday.com) - Dr. Hosker first outlined the committee's charge, including evaluation of urodynamic testing (UDS) and anorectal physiology studies (ARPS). With respect to urodynamics, Dr. Hosker noted advances since the last consultation, such as non-invasive measurements of vesical pressure and flow, new measurements of urethral resistance (URP), and objective testing of bladder sensation during cystometry. Unfortunately, there have been no new studies on ambulatory urodynamics and little evidence regarding the value of UDS on predicting treatment outcomes. He noted that the sensitivity and specificity of UDS in OAB and UI are not 100%. This led the committee to conclude that practitioners should consider both clinical symptoms and UDS results in directing treatment. Provocative manoeuvres for eliciting DO have not been shown to be useful. He also noted one study that showed UDS is not cost-effective in the evaluation of uncomplicated SUI. The previous consultation recommended the development of formal training and accreditation for UDS, and this committee recommended further study of these areas to determine their implementation and results.

With respect to SUI, there is new evidence that urethral pressure profiles (Level 3) and valsalva leak point pressures (Level 2) are predictive of outcomes after tension-free vaginal tape and transobturator tape procedures. Also, patients with urge symptoms or urodyanamic DO have a higher risk of OAB after surgery, although prediction of voiding difficulties is more problematic. In addition, there is little evidence that urodynamics can predict outcomes after POP surgery with respect to de novo urgency or SUI.

Dr. Hosker next focused on UDS in the male patient and noted that most patients with post-prostatectomy incontinence suffer from sphincteric deficiency and many will also have decreased compliance and/or DO. The committee recommended (Grade D) that UDS is necessary in evaluating male SUI, although the ability of testing to predict outcomes after corrective surgery has not been established. There is little evidence regarding UDS in patients treated with radiotherapy for prostate cancer, and the committee suggested further study in this area.

The committee made several recommendations regarding UDS in children with myelodysplasia. Due to alterations in compliance, bladder-sphincter synergy, and the frequent presence of overactivity, the committee concluded that UDS is advised in all of these patients since clinical signs and symptoms may be misleading. Information regarding the timing and frequency of studies is lacking, although the committee recommended that the initial testing be performed early in the neonatal period. UDS testing in children with sacral agenesis, cerebral palsy, spinal cord injury and imperforate anus can be useful and should be tailored to the individual. Clinicians should consider at least an initial UDS in children with potential bladder outlet obstruction from posterior urethral valves, ectopic ureterocele, urethral stricture and bladder exstrophy UDS is also relevant in children with UI refractory to conservative treatment.

With respect to adults with neurogenic voiding dysfunction, UDS is recommended, although the frequency and timing of the studies is controversial and should be individualized. Dr. Hosker commented on UDS in the elderly and stated that they should be evaluated with respect to their physiological rather than chronological age. He reminded us of the difficulties in performing and interpreting UDS in the frail elderly and that UDS should only be considered if the results will identify reversible causes or direct future therapy.

Lastly, Dr. Hosker discussed ARPS and the various tests including manometry, balloon distention, continence tests and neurophysiological testing. The committee noted the prevalence of ARPS in clinical practice, although there is little standardization or data supporting the ability to predict treatment outcomes. Further study in this area was strongly recommended.

Gordon Hosker, MD, Committee Chair

Moderated by Saad Khoury, MD, and Tomohiro Ueda, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.

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