Guidelines call for minimum presurgical evaluation in uncomplicated SUI

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Preop urodynamic testing unnecessary

"More than ever before, health care delivery is focused on clinical efficiency and cost effectiveness," said Dr. Lee Richter. "These guidelines are timely in that they address the work-up of patients with primary uncomplicated stress urinary incontinence [SUI] from both of these perspectives."

The new guidelines outline six diagnostic steps that physicians who manage patients with SUI should follow prior to intervention. "Based on office evaluation results, the uncomplicated SUI patient may be able to proceed to sling surgery without further urodynamic work-up," Dr. Richter said.

In 2012, researchers from the VALUE (Value of Urodynamic Evaluation) trial reported that preoperative urodynamic testing did not lead to better outcomes from sling surgery in women with uncomplicated SUI (N. Engl. J. Med. 2012;366:1987-97). Before these results were published, physicians lacked clear evidence to guide decision making in urodynamics, said Dr. Richter. The new guidelines may lead to more uniform diagnostic approaches for women who present with urinary incontinence.

"This six-step evaluation for women with SUI is developed from what we know about who is likely to succeed with primary sling surgery," Dr. Richter said. "Further research on risk factors for sling failure and management of those challenging clinical situations is a focus for the future."

Dr. Richter is a fellow in female pelvic medicine and reconstructive surgery with Medstar Washington (D.C.) Hospital Center. Her remarks were excerpted from an interview with Frontline Medical News.



Clinicians should perform a basic six-step evaluation of women with symptoms of uncomplicated stress urinary incontinence before these patients undergo midurethral sling surgery, according to first-time guidelines from the American College of Obstetricians and Gynecologists and the American Urogynecologic Society.

The recommended steps exclude preoperative urodynamic testing, which has not been shown to improve surgical outcomes in patients with uncomplicated SUI, stated Committee Opinion No. 603, published in the June issue of Obstetrics and Gynecology (2014;123:1403-7).

"Until now, there has never been any consistency in the evaluation of uncomplicated SUI before surgery," said Dr. Charles Nager, professor of obstetrics and gynecology and director of female pelvic medicine and reconstructive surgery at the University of California, San Diego. "This is the first time the leading specialty organizations, ACOG and the American Urogynecologic Society [AUGS], have set a standard for physicians to follow before they operate on patients with uncomplicated SUI."

The criteria are common sense, are evidence based, and "don’t require that everyone undergo urodynamic testing," added Dr. Nager, who is president of AUGS and a member of ACOG’s subcommittee on urogynecology of the Committee on Gynecologic Practice, which was involved in drafting the guidelines.

The opinion guides clinicians in evaluating women with urinary leakage without necessarily requiring a costly work-up, said Dr. Cheryl Iglesia, who also contributed to the guidelines and is director of female pelvic medicine and reconstructive surgery at MedStar Washington (D.C.) Hospital Center and professor of obstetrics, gynecology, and urology at Georgetown University, Washington. If the minimum six-step evaluation confirms uncomplicated SUI, "you don’t need to do a test that would run upwards of thousands of dollars and doesn’t change the outcome," she said.

The recommended six-step evaluation includes:

1. A urologic, medical, neurologic, and medication history.

2. A urinalysis to rule out urinary tract infection.

3. A physical examination to assess for contributing or confounding factors, including urethral diverticulum, vaginal discharge, extraurethral incontinence, and pelvic organ prolapse (which leads to a diagnosis of complicated SUI if the prolapse is beyond the hymen).

4. A cough stress test to demonstrate SUI.

5. A urethral mobility assessment to help determine the likelihood of success from anti-incontinence surgery.

6. Measurement of postvoid residual urine volume to identify bladder-emptying abnormalities or incontinence resulting from chronic urinary retention.

Women with uncomplicated SUI will have urinary leakage from the urethra by provocative stress measures such as the cough test, a normal urinalysis that rules out urinary tract infection, no pelvic organ prolapse beyond the hymen, and a normal postvoid residual urine volume, the guidelines specify, adding that patients who meet these criteria and have not responded to conservative interventions do not need urodynamic testing before proceeding to surgery.

In contrast, women with complicated SUI "may benefit from multichannel urodynamic testing, particularly before surgical treatment," the guidelines stated. "In these women, the results of the basic six-step evaluation and clinical judgment should guide the decision to perform preoperative multichannel urodynamic testing."

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