Abstract
Our objective was to determine the availability and utilization of urodynamic investigations by gynecologists in the preoperative evaluation of women with urinary incontinence. Gynecologists in the UK, USA, Australia, New Zealand and Canada were asked what urodynamic investigations were required for four clinical scenarios. Analysis was restricted to frequent operators. Urodynamic investigations were available to 70% of frequent operators. For uncomplicated stress incontinence, cystometry was utilized by 72% of subspecialists and 44% of generalists (P<0.001) who had access to urodynamic investigations. For stress incontinence and straining to void, uroflowmetry was utilized by 73% of subspecialists and 46% of generalists (P<0.001) who had access to urodynamic investigations. We concluded that many gynecologists who frequently operate for female urinary incontinence do not have access to urodynamic investigations or do not utilize urodynamic investigations, or utilize investigations in a way that may be inadequate for the clinical problem. There are differences in utilization between subspecialists and generalists that are not explained by access. These observations could be explained by poor understanding or a lack of belief in the value of urodynamic investigations.
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Editorial Comment: Previous investigators have assessed urodynamic testing relative to its suboptimal diagnostic accuracy. More recently, decision-analyses have described the potential limitations of testing from a cost-effectiveness standpoint. Although considered to be a ‘gold standard’, urodynamic testing remains anything but standardized. Much of the controversy is fueled, in part, by the lack of agreement in testing parameters themselves (e.g. MUCP vs LLP to diagnose ISD?), and more importantly, the absence of defined clinical outcomes in the treatment of urinary incontinence. The present survey reflects the inconsistencies surrounding the use of urodynamic testing among practitioners who see and treat female incontinence. This descriptive study describes a wide variety in urodynamic availability and utilization among generalist gynecologists and self-reported expert subspecialists in the UK, USA, Canada and Australia. Overall, subspecialists reported a higher use of urodynamic testing for patients with all sub-types of proposed urinary incontinence when compared with generalists. In addition, the specific types of testing used varied across the board among practitioners, as well as between types of urinary incontinence, without any particular recurring pattern. Urodynamic testing is not inexpensive, is not readily available in all communities, and carries a small but real risk of lower urinary tract infection. The authors of this study cite the merits of prospective, randomized investigation in order to answer a very important question: what impact does urodynamic study (of all types) have on treatment outcome? Until we have a reasonable scientific answer, one could expect ongoing variation in physician utilization or urodynamic testing.
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Duggan, P.M., Wilson, P.D., Norton, P. et al. Utilization of preoperative urodynamic investigations by gynecologists who frequently operate for female urinary incontinence. Int Urogynecol J 14, 282–287 (2003). https://doi.org/10.1007/s00192-003-1039-2
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DOI: https://doi.org/10.1007/s00192-003-1039-2