This is the current release of the guideline.

Abnormal bladder function, including:

• Urinary tract dysfunction
• Urinary incontinence

Diagnosis
Evaluation

Family Practice
Internal Medicine
Obstetrics and Gynecology
Surgery
Urology

Advanced Practice Nurses
Physician Assistants
Physicians

To provide a description of the components of urodynamic testing for the evaluation of urinary tract dysfunction and the indications for these tests

Patients with abnormal bladder function

Urodynamic testing

Effectiveness of urodynamic testing

Searches of Electronic Databases

A search of PubMed and the Cochrane Library identified the relevant literature.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Systematic Review

Not stated

Expert Consensus

Not stated

Classification of Recommendations*

A.   There is good evidence to recommend the clinical preventive action

B.   There is fair evidence to recommend the clinical preventive action

C.   The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D.   There is fair evidence to recommend against the clinical preventive action

E.   There is good evidence to recommend against the clinical preventive action

I.   There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

*Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
Internal Peer Review

This committee opinion has been prepared by the Sub-Committee on Urogynaecology and approved by the Executive of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

The quality of evidence (I-III) and classification of recommendations (A-E) are defined at the end of the "Major Recommendations."

Summary Statements and Recommendations

1. Urodynamic testing is an objective tool that helps to clarify confusing or complex urinary tract symptoms.
2. Urodynamic testing is not recommended prior to:
   1. Conservative management of urinary incontinence (III-C)
   2. Primary surgery for stress incontinence when the diagnosis is clear (III-C)
3. Urodynamic testing is recommended:
   1. When the diagnosis remains uncertain after an initial history and physical examination (III-C)
   2. When patient symptoms do not correlate with objective physical findings (III-C)
   3. If the patient fails to improve with treatment (III-C)
   4. In a clinical trial setting (III-C)
4. Significant controversy exists about the use of urodynamics in the clinical setting. A Cochrane review found no evidence that urodynamic testing prior to treatment affected outcomes and recommended larger prospective trials.

Summary

Controversies remain with respect to the indications for urodynamic testing. Urodynamics is an objective tool that is invaluable, when used by experts trained in its interpretation, in clarifying confusing or complex urinary tract symptoms. It is also invasive and can be embarrassing for patients. It is not cost-effective to apply a universal policy of urodynamic testing. Experts agree that it is not necessary to perform urodynamic testing on patients prior to instituting conservative management but that it is necessary to perform these tests on any patient undergoing repeat incontinence surgery. To date, no published studies have demonstrated that the performance of urodynamic testing improves clinical outcomes; however, it is undoubtedly true that urodynamic testing is an indispensable tool in the evaluation of urinary tract complaints. Further research is needed to better elucidate the most appropriate patient criteria for urodynamic testing.

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Classification of Recommendations**

A.   There is good evidence to recommend the clinical preventive action

B.   There is fair evidence to recommend the clinical preventive action

C.   The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D.   There is fair evidence to recommend against the clinical preventive action

E.   There is good evidence to recommend against the clinical preventive action

I.   There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

**Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

None provided

The type of supporting evidence is identified and graded for most of the recommendations (see "Major Recommendations").

Appropriate urodynamic testing for the evaluation of abnormal bladder function

Urodynamic testing has a number of pitfalls: (1) lack of standardization of values and parameters being evaluated, (2) the artificial testing settings may not represent what happens to the patient during normal daily activities, (3) inconsistent reproducibility within the same patient, (4) the wide range of physiologic values in normal asymptomatic patients (5) false negatives; the absence of a specific abnormality during urodynamic testing does not necessarily exclude its existence, and (6) not all abnormalities found during urodynamic testing are clinically significant.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.

An implementation strategy was not provided.

Getting Better

Effectiveness

Not applicable: The guideline was not adapted from another source.

2008 Aug

Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society

Society of Obstetricians and Gynaecologists of Canada

Sub-Committee on Urogynaecology

Principal Authors: Baharak Amir, MD, Halifax NS; Scott A. Farrell, MD, Halifax NS

Committee Members: Danny Lovatsis, MD, Toronto ON; William Easton, MD, Scarborough ON; Annette Epp, MD, Saskatoon SK; Scott A. Farrell (Chair), MD, Halifax NS; Lise Girouard, RN, Winnipeg MB; Chander Gupta, MD, Winnipeg MB; Marie-Andrée Harvey, MD, Kingston ON; Annick Larochelle, MD, St. Lambert QC; Barry McMillan, MD, London ON; Magali Robert, MD, Calgary AB; Sue Ross, PhD, Calgary AB; Joyce Schachter, MD, Ottawa ON; Jane A. Schulz, MD, Edmonton AB; David Wilkie, MD, Vancouver BC

Disclosure statements have been received from all members of the committee.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on March 23, 2009. The information was verified by the guideline developer on March 25, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.