Patients’ experience with ambulatory urodynamics

Acceptability and perceived value of urodynamics from the patient perspective: A narrative review

Background

The value and application of urodynamic evaluation (UDS) have been a controversial topic in recent years. Gaining robust data on the patient viewpoint in this area is important since, even when UDS findings do not change the management plan, the objective diagnostic information gained from UDS may be valued by patients. Moreover, insights from UDS may empower treating physicians to counsel patients more effectively and manage their expectations regarding treatment outcomes.

Objective

This expert narrative review aims to analyze the findings of published studies in this area, looking at two topics in turn: (a) the tolerability and acceptability of the UDS procedure itself from the patient perspective and (b) patient perceptions of the clinical value of insights provided by UDS.

Design, Setting, Participants, and Outcome Measurements

An evidence assessment was conducted using selected articles from the literature reporting data on patients' perspectives on the tolerability, acceptability, utility, and value of the urodynamic investigation.

Results and Limitations

Although pain, discomfort, and infection risks are frequently used as a rationale to skip UDS when initial management fails, there is good evidence that, from the patients' perspective, the procedure is very well tolerated in most cases. There are only a few articles available that assess patient perceptions of the usefulness of UDS, but those that do exist appear to demonstrate that the insights gained from UDS are widely welcomed by patients in the interest of receiving a more tailored and personalized treatment approach.

Conclusion

From the patient perspective, UDS appears to be a well‐accepted and well‐tolerated diagnostic tool in patients with lower urinary tract symptoms, particularly when an appropriate explanation is provided before the examination. Our review also highlights that patients value the objective information provided by UDS and that this outweighs the temporary invasiveness of the test. This information is particularly relevant in light of the relative lack of evidence in the literature about patient expectations of specialist care in functional urology, which may have hindered progress with quality of care.

Urodynamics tests for the diagnosis and management of bladder outlet obstruction in men: the UPSTREAM non-inferiority RCT

BACKGROUND

Lower urinary tract symptoms (LUTS) in men may indicate bladder outlet obstruction (BOO) or weakness, known as detrusor underactivity (DU). Severe bothersome LUTS are a common indication for surgery. The diagnostic tests may include urodynamics (UDS) to confirm whether BOO or DU is the cause, potentially reducing the number of people receiving (inappropriate) surgery.

OBJECTIVES

The primary objective was to determine whether a care pathway including UDS is no worse for symptom outcome than one in which it is omitted, at 18 months after randomisation. Rates of surgery was the key secondary outcome.

DESIGN

This was a pragmatic, multicentre, two-arm (unblinded) randomised controlled trial, incorporating a health economic analysis and qualitative research.

SETTING

Urology departments of 26 NHS hospitals in England.

PARTICIPANTS

Men (aged ≥ 18 years) seeking further treatment, potentially including surgery, for bothersome LUTS. Exclusion criteria were as follows: unable to pass urine without a catheter, having a relevant neurological disease, currently undergoing treatment for prostate or bladder cancer, previously had prostate surgery, not medically fit for surgery and/or unwilling to be randomised.

INTERVENTIONS

Men were randomised to a care pathway based on non-invasive routine tests (control) or routine care plus invasive UDS (intervention arm).

MAIN OUTCOME MEASURES

The primary outcome was International Prostate Symptom Score (IPSS) at 18 months after randomisation and the key secondary outcome was rates of surgery. Additional secondary outcomes included adverse events (AEs), quality of life, urinary and sexual symptoms, UDS satisfaction, maximum urinary flow rate and cost-effectiveness.

RESULTS

A total of 820 men were randomised (UDS, 427; routine care, 393). Sixty-seven men withdrew before 18 months and 11 died (unrelated to trial procedures). UDS was non-inferior to routine care for IPSS 18 months after randomisation, with a confidence interval (CI) within the margin of 1 point (-0.33, 95% CI -1.47 to 0.80). A lower surgery rate in the UDS arm was not found (38% and 36% for UDS and routine care, respectively), with overall rates lower than expected. AEs were similar between the arms at 43-44%. There were more cases of acute urinary retention in the routine care arm. Patient-reported outcomes for LUTS improved in both arms and satisfaction with UDS was high in men who received it. UDS was more expensive than routine care. From a secondary care perspective, UDS cost an additional £216 over an 18-month time horizon. Quality-adjusted life-years (QALYs) were similar, with a QALY difference of 0.006 in favour of UDS over 18 months. It was established that UDS was acceptable to patients, and valued by both patients and clinicians for its perceived additional insight into the cause and probable best treatment of LUTS.

LIMITATIONS

The trial met its predefined recruitment target, but surgery rates were lower than anticipated.

CONCLUSIONS

Inclusion of UDS in the diagnostic tests results in a symptom outcome that is non-inferior to a routine care pathway, but does not affect surgical rates for treating BOO. Results do not support the routine use of UDS in men undergoing investigation of LUTS.

FUTURE WORK

Focus should be placed on indications for selective utilisation of UDS in individual cases and long-term outcomes of diagnosis and therapy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56164274.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 42. See the NIHR Journals Library website for further project information.

Wireless intravesical device for real-time bladder pressure measurement: Study of consecutive voiding in awake minipigs

Traditional urodynamics have poor correlation with urological symptoms. Ambulatory urodynamics may improve this correlation but the need for a transurethral catheter and the time-consuming nature of this examination limits its use. Therefore, the objective of this study was to develop a wireless real-time bladder pressure measurement device for repeated and prolonged-term measurement of bladder behavior in awake pigs. The Bladder Pill is an intravesical device with a pressure microsensor and a 3-dimensional inductive coupling coil for energy supply. A corresponding external coil provides wireless power transmission and real-time communication of bladder pressure data. To test the correlation between the pressure data measured by the device and by standard methods, we compared static water column pressures with this device and water-filled urodynamic catheter systems. In vivo assessment of awake voiding by the pill was done by introducing the bladder pill into the bladder of Göttingen minipigs. An air-charged urodynamic catheter was introduced transurethrally as control for pressure measurements. The optimal physical configuration of the pill was investigated to maximize the containment in the bladder. We used two versions of external signal receivers (one waistband and one rectangular frame) to test the optimal external signal capture. Next to that, we performed short-term and medium-term comparative pressure studies. The in vitro static pressure measurement demonstrated a mean difference of less than 1 cm H₂O between the methods. The optimal design of the pill for maximal retainment in the bladder proved to be a pigtail configuration. The bending of the device during bladder contractions caused offset of 2.7 +/- 1.4 cm H₂O (mean +/- SD) on the pressure measurements. The rectangular frame performed signal capture during 5 consecutive voids with a good correlation of the pressure measurements. The device can be inserted through the urethra and is retrieved using string or endoscopic extraction. In conclusion, wireless long-term measurement of bladder pressure is demonstrated and yields comparable results to current available catheter methods of measurement in a pig model.

Recommendations for conducting invasive urodynamics for men with lower urinary tract symptoms: Qualitative interview findings from a large randomized controlled trial (UPSTREAM)

Aims

To capture in‐depth qualitative evidence regarding attitudes to and experiences of urodynamic testing among men with lower urinary tract symptoms (LUTS) at each end of the clinical pathway.

Methods

Semi‐structured interview study conducted within the Urodynamics for Prostate Surgery: Randomized Evaluation of Assessment Methods (UPSTREAM) trial, which randomized men to a care pathway including urodynamics or routine non‐invasive tests from 26 secondary care urology sites across England. Men were interviewed after assessments but prior to treatment, or after surgery for LUTS. Men were purposively sampled to include those who had urodynamics and those who did not, and diversity in demographic characteristics and symptom burden. Interviews were analyzed using inductive thematic analysis.

Results

Forty‐one men participated (25 pre‐treatment, 16 post‐surgery), ages 52‐89. The 16 men who had not previously experienced urodynamics said they would accept the test in their assessment, but some were apprehensive or wanted more information. The 25 men who had experienced urodynamics all found it acceptable, though some reported pain, infection, or embarrassment. Embarrassment was minimized by informing patients what the procedure would be like, and ensuring privacy. Urodynamics was valued for its perceived diagnostic insight. Information deficits were reported before, during, and after the test. How and when results were explained and the adequacy of explanations varied.

Conclusions

Urodynamics is acceptable to men with LUTS and generally well‐tolerated. To ensure patients are prepared and informed, good communication before and during the procedure is essential. Privacy should be prioritized, and test results discussed promptly and in sufficient detail. Staff require training and guidance in these areas.

The effects of a heating pad on anxiety, pain, and distress during urodynamic study in the female patients with stress urinary incontinence

AIMS

Although generally well tolerated, a urodynamic study is an unpleasant and stressful procedure for some patients. This study evaluated the effects of a heating pad on anxiety, pain, and distress during urodynamic studies in female patients with stress urinary incontinence.

METHODS

A total of 74 female patients with stress urinary incontinence who underwent a urodynamic study between May 2015 and October 2015 were randomized to either the experimental group using a heating pad (n = 37) or control group (n = 37). In the experimental group, a heating pad was applied on the patient's sacrum during the urodynamic study. All patients completed the State-Trait Anxiety Inventory (20-80) before and after the procedure and assessed their degree of pain and distress after the procedure by the visual analog scale (0-10). Systolic and diastolic blood pressure and pulse rate were also checked before and after the procedure.

RESULTS

Demographic characteristics, mean age, procedure duration, pre and post-procedural systolic, and diastolic blood pressures, and pulse rate were statistically similar between the experimental and control groups. The mean State-Trait Anxiety Inventory was significantly lower in the experimental group than in the control group (30.9 ± 7.5 vs 42.5 ± 10.1, P < 0.001). The experimental group showed significantly lower pain and distress scores (Visual Analog Scale, 2.7 ± 1.5, 3.0 ± 1.5) compared with the control group (4.0 ± 1.6, 4.7 ± 2.0, both P < 0.001).

CONCLUSIONS

Using a heating pad for female patients with stress urinary incontinence during a urodynamic study is a simple, economical, and effective therapy that enhances patient comfort and decreases anxiety, pain, and distress.

Differentiation of lower urinary tract dysfunctions: The role of ambulatory urodynamic monitoring

OBJECTIVES

To determine the value of ambulatory urodynamic monitoring in the assessment of patients with lower urinary tract symptoms.

METHODS

This was a cross-sectional study including patients who underwent both conventional urodynamic and ambulatory urodynamic assessment at our Center between December 2002 and February 2013. The ambulatory urodynamic studies were interpreted in a standardized way by a resident experienced with urodynamic measurements, and one staff member who specialized in incontinence and urodynamics.

RESULTS

A total of 239 patients (71 male and 168 female) were included in the present study. The largest subgroup of patients, 79 (33%), underwent ambulatory urodynamic monitoring based on suspicion of an acontractile bladder. However, 66 of these patients (83.5%) still showed contractions on ambulatory urodynamics. Other groups that were analyzed were patients with suspected storage dysfunction (47 patients), inconclusive conventional urodynamic studies (68 patients) and incontinence of unclear origin (45 patients). Particularly in this last group, ambulatory urodynamics appeared to be useful for discrimination between different causes of incontinence.

CONCLUSIONS

Ambulatory urodynamic monitoring is a valuable discriminating diagnostic tool in patients with lower urinary tract symptoms who have already undergone conventional urodynamics, particularly in the case of patients with suspected bladder acontractility and incontinence of unclear origin during ambulatory urodynamics. Further study is required to determine the clinical implications of the findings and their relationship with treatment outcome.

Latissimus dorsi detrusor myoplasty to restore voiding in patients with an acontractile bladder - fact or fiction?

Multiple causes at any level between the brain and the bladder can lead to diminished voiding efficiency and bladder acontractility. Treatment options for patients with an acontractile bladder have been limited as most patients were forced to perform lifelong self-catheterization at the moment. The latissimus dorsi detrusor myoplasty (LDDM) is a recent and promising therapeutic surgical option to restore adequate bladder emptying on demand. This article critically reviews the available literature on LDDM and focuses particularly on the preoperative diagnostic evaluation and patient selection, treatment outcome and the postoperative contractility measurement.

The additional value of ambulatory urodynamic measurements compared with conventional urodynamic measurements

OBJECTIVES

To study the additional diagnostic value of ambulatory urodynamic measurements/monitoring (AUM) in patients with lower urinary tract symptoms (LUTS).

PATIENTS AND METHODS

We reviewed the urodynamic data, collected at the urology department of our University Hospital between 2002 and 2007. During this period, 2393 urodynamic investigations were conducted. In 108 patients both conventional urodynamic measurements (CUM) and AUM were conducted.

RESULTS

In 25 patients an AUM was conducted for bladder evacuation problems due to absent bladder contractility, seen on CUM. In 21 cases, AUM showed the presence of contractility of the bladder under normal conditions at home. Their symptoms were due to other factors such as a concomitant non-relaxation of the urinary sphincter or pelvic floor, psychological reasons or obstruction, for all of which treatment could be initiated. In 32 cases, the indication for AUM was an inconclusive CUM. Of these patients 16 had clear overactive contractions on AUM.

CONCLUSION

AUM has a more important place in the second-line diagnostic evaluation of patients with LUTS than generally considered. In half of the cases (16 of 32) in which CUM could not provide a diagnosis, AUM helped us to diagnose overactive bladder. Moreover, in the absence of AUM, many patients would have been misdiagnosed with an acontractile bladder based on their CUM results, which would most probably have resulted in life-time clean intermittent self-catheterization.

Clinical usefulness of ambulatory urodynamics in the diagnosis and treatment of lower urinary tract dysfunction

OBJECTIVE

Ambulatory urodynamics is reported to be useful for the detection of detrusor overactivity. However, the procedure is time-consuming, technically challenging and expensive. Its clinical usefulness for the detection and treatment of bladder dysfunction has not been studied in detail.

MATERIAL AND METHODS

Twenty-five patients (17 men, eight women, median age 59 years) with lower urinary tract symptoms underwent ambulatory urodynamic examination.

RESULTS

In six out of 25 patients (24%), ambulatory urodynamics was not evaluable. Where the procedure was technically feasible, diagnosis was possible in 72%. Treatment was modified in 63%, leading to satisfactory results in 42% of the patients.

CONCLUSIONS

Ambulatory urodynamics is the most sensitive tool for the detection or exclusion of detrusor overactivity. Therefore, the method is valuable when all other diagnostic means have failed to detect the underlying lower urinary tract dysfunction. In these cases, treatment decisions can safely be based on the results of ambulatory urodynamics.