SUFU Winter Meeting 2013 - Overview of AUA/SUFU urodynamics guidelines - Session Highlights

LAS VEGAS, NV USA ( - Dr. J. Christian Winters started his talk by thanking the panel members and the AUA staff involved in creating these guidelines, they have spent many hours during the last 18 months developing the adult UDS guidelines.

The panel recognizes that UDS is only one part of the comprehensive evaluation of lower urinary tract symptoms (LUTS). The goal in creating UDS guidelines was to assist the physician/clinician in selecting the appropriate test following an appropriate evaluation and symptom characterization.

sufuThe work started with a systematic review of the literature of published articles relevant to the use of UDS. The articles used were published between January 1, 1990 to March 10, 2011 and they were from either the MEDLINE® or EMBASE databases. After the review, 393 articles were used to create an evidence table after the inclusion/exclusion criteria were applied. The quality of each study was assigned a strength rating based on the instruments tailored to the study.

The following UDS tests were incorporated individually, or included as any combination of these tests:

  • PVR
  • Uroflow
  • Cystometry
  • Pressure Flow Study (PFS)
  • Urethral Function Tests (ALPP/UCP)
  • Videourodynamics
  • EMG
  • Combination of tests

These tests were defined consistent with the ICS Standards of Good Urodynamics Practice. 

The UDS tests were then evaluated in the following lower urinary tract conditions:

  • SUI/Prolapse
  • Urinary Urgency or Urge Incontinence (UUI)
  • Neurogenic Bladder (NGB)
  • LUTS

The definitions seen here are, for the most part, in line with the ICS terminology for these conditions. However, since the panel specifically looked at UDS in urinary urgency and UUI, for the purpose of this specific document, LUTS relates to voiding symptoms, which are largely obstructive, in women and men. As these conditions were examined, the panel specifically looked at UDS in the areas of diagnosis, prognosis, management, and outcomes in each of these lower urinary tract conditions. As a result, the evidence tables graphically look like this: for each LUT condition, each urodynamic test, or any combination of those, were evaluated in each of the four areas of diagnosis, prognosis, management and outcome. The rating of evidence strength was determined for each scenario, i.e. noted in each cell of the diagram below.

sufu winters thumb

The methodology for rating of evidence strength in this case used the Cochrane levels of evidence:

  • A – Well-conducted randomized controlled trials (RCTs) or exceptionally strong observational studies
  • B – RCTs with some weakness or strong observational studies
  • C – observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data

Then the Level of Evidence is linked to type of statement:

  • Standard
    • Level of evidence A or B
    • Benefits are > or < than the risks/burdens (benefits must outweigh the risks)
  • Recommendation
    • Level of evidence C
    • Benefits are > or < than the risks/burdens (benefits must outweigh the risks)
  • Option
    • Level of evidence A, B or C
    • Benefits are = to the risks

In addition, there are a couple of statements that can be made when there is insufficient evidence in the literature. These can be based on:

  • Clinical Principle – a statement of clinical care that is widely agreed on by urologists or other clinicians for which there may or may not be evidence in the literature
  • Expert Opinion – a statement, achieved by consensus of the Panel, that is based on members’ clinical training, experience, knowledge, and judgment -- for which there is no evidence

There are 19 statements in this UDS guideline and below are a few examples for SUI/Prolapse:

  • “Surgeons considering invasive therapy in patients with SUI should assess PVR urine volume.” (Expert Opinion)
  • “Clinicians may perform multi-channel UDS in patients with both symptoms and physical findings of SUI who are considering invasive, potentially morbid, or irreversible treatments.” (Option; Evidence Strength: Grade C)
  • “Clinicians should perform repeat stress testing, with the urethral catheter removed, in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing.” (Recommendation; Evidence Strength: Grade C)
  • “In women with high-grade pelvic organ prolapse (POP) but without the symptom of SUI, clinicians should perform stress testing with reduction of the prolapse. Multi-channel urodynamics with prolapse reduction may be used to assess for occult SUI and detrusor dysfunction in these women with associated LUTS.” (Option; Evidence Strength: Grade C)

Here are a few examples of guideline statements for urgency and UUI:

  • “Clinicians may perform pressure-flow studies in patients with refractory urgency incontinence after bladder outlet procedures to evaluate for bladder outlet obstruction (BOO).” (Expert Opinion)
  • “Clinicians should counsel patients with urgency incontinence and mixed incontinence that the absence of detrusor overactivity on a single urodynamic study does not exclude it as a causative agent for their symptoms.” (Clinical Principle)

Below find one example of guideline statement for NGB:

  • “Clinicians should perform complex CMG or pressure-flow study during initial urological evaluation of patients with relevant neurological conditions with or without symptoms, and as part of ongoing follow-up when appropriate. In patients with other neurologic diseases, physicians may consider these studies as an option in the urological evaluation of LUTS.” (Recommendation; Evidence Strength: Grade C)

The panel believes that the maintenance of low urinary storage pressures is the hallmark of good practice in the management of patients with neurogenic bladder. These measures emphasize PVR, cystometry, and pressure flow studies as means to achieve this outcome. 

Finally, some examples of guideline statements for male LUTS:

  • “Uroflow may be used by clinicians in the initial and ongoing evaluation of male patients with LUTS that suggest an abnormality of emptying/voiding.” (Recommendation; Evidence Strength: Grade C)
  • “Clinicians should perform PFS in men when it is important to determine if urodynamic obstruction is present, particularly when invasive, potentially morbid, or irreversible treatments are considered.” (Standard; Evidence Strength: Grade B)

Dr. Winters concluded that this was only an overview/summary of the AUA/SUFU adult urodynamics guidelines and the panel’s goal is to present clinical principles that will facilitate more evidence-based selection and application of urodynamic studies. He also stated that the panel realizes that each patient with LUTS is unique, and they hope that the UDS guidelines will serve as a tool to help meet the particular needs of the individual patient. 

Please click here to view the adult UDS guidelines as posted on the AUA website.


Presented by J. Christian Winters, MD at the Society for Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) 2013 Winter Meeting - February 26 - March 2, 2013 - Caesar's Palace - Las Vegas, NV USA

Louisiana State University, New Orleans, LA, USA

Written by Anna Forsberg, medical reporter for 

View Full SUFU Winter Meeting 2013 Coverage