Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection and predicting outcome?

PURPOSE OF REVIEW: Disagreement exists as to the extent of evaluation required prior to offering surgical intervention for the treatment of stress urinary incontinence in women. While few would argue that additional information can be gleaned from a properly performed urodynamic investigation, it remains unclear exactly which women would most benefit from such preoperative study, and if urodynamic evaluation definitively improves treatment outcome. Since such invasive studies may not be widely available in certain areas, can be costly, and are associated with a low, but defined risk of bladder infection, it is imperative that the appropriate indication for preoperative urodynamic evaluation be carefully defined. This review highlights recent reports and controversies concerning the use of urodynamics (focusing on leak point pressure testing and urethral pressure profilometry) prior to surgical treatment for stress urinary incontinence. RECENT FINDINGS: There remains no clear consensus as to whether urodynamic testing enhances surgical outcome of stress urinary incontinence treatments by improving case selection or altering the surgical approach based on study findings. As treatment strategies for stress urinary incontinence have developed over the last several years to a more uniform approach, it is less clear that the severity of stress urinary incontinence, based on either abdominal leak point pressure or urethral pressure profilometry will influence the choice of surgical technique. Furthermore, there is little evidence to suggest that patients with more severe forms of stress urinary incontinence by urodynamic testing fare more poorly after the most commonly offered surgical treatment than those with less severe forms. There are certain sub-populations of women who appear to be at higher risk of voiding dysfunction following incontinence surgery, and urodynamic testing may aid in identifying this group. SUMMARY: It is not apparent that either abdominal leak point pressure measurement or urethral pressure profilometry can accurately predict which patients will achieve the best outcome of surgical treatment for stress urinary incontinence. Other parameters assessed during urodynamic evaluation might provide prognostic information regarding the risk of voiding dysfunction postoperatively and the possibility of persistent urge-related leakage following surgery, though not directly predict cure. A multi-institutional randomized study comparing the outcome between patients in whom treatment was determined with the urodynamic information known, compared with patients in whom this information was unknown would further enhance our understanding of the usefulness of urodynamics in the preoperative evaluation of women with stress urinary incontinence.     

Urodynamics in Female Urology

Urodynamics in female urology are often indicated when empiric or conservative treatment does not improve lower urinary tract symptoms. Based on the expected underlying lower urinary tract dysfunction, the urodynamic evaluation is designed by the clinician to reproduce a patient's symptoms and to identify underlying pathophysiological mechanisms, as well as to analyse other functions of the lower urinary tract which may be relevant for planning further (invasive) treatment. In this review, we describe the available urodynamic tests, the normal findings, and the evidence for the role of urodynamics, and on the specific measurements and parameters used to evaluate female lower urinary tract symptoms.In women with a suspected storage dysfunction, filling cystometry allows identification of detrusor overactivity or reduced bladder compliance as possible underlying causation of overactive bladder. Most women with stress incontinence have other storage and/or voiding symptoms and urodynamics should always be performed prior to invasive treatment. In the minority with pure stress urinary incontinence, urodynamic observations can guide the type of surgery chosen, but this has not yet been shown to change treatment outcome.Voiding dysfunction in women has recently received more research attention and various urodynamic parameters are being evaluated on their ability to distinguish detrusor underactivity from bladder outlet obstruction in pressure-flow studies. Video-urodynamics can provide a useful addition when anatomical information is needed in complex patients (eg, prior surgery or neurogenic patients).Finally, ambulatory urodynamics can be used when symptoms cannot be reproduced or explained by conventional urodynamics.     

The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women

OBJECTIVE: To compare the cost-effectiveness of preoperative testing strategies in women with stress incontinence symptoms, as although urodynamic testing is used to improve the diagnostic accuracy in women with incontinence, the clinical and economic consequences of different levels of testing have not been evaluated. MATERIALS AND METHODS: Decision analysis was used to evaluate basic office assessment (BOA) and urodynamic testing for women with stress incontinence symptoms who were candidates for primary surgical treatment. Costs were calculated using the Federal Register. Parameter estimates for the effectiveness of treatment for different diagnoses of incontinence were based on published reports. Incremental cost-effectiveness was defined as the cost in dollars per additional patient cured of incontinence. RESULTS: Urodynamics did not improve the effectiveness of treatment; both strategies of a BOA and urodynamic testing resulted in a cure rate of 96% after initial and secondary treatments. The mean cost of care (including initial and secondary treatments and outcomes) was similar for the two strategies ($5042 for BOA, $5046 for urodynamic testing). With BOA reduced testing costs were balanced by increased costs for patients who failed the initial treatment. Under baseline assumptions, one additional cure of incontinence (incremental cost-effectiveness) using the urodynamic strategy cost $3847, compared with BOA. By sensitivity analyses, BOA was less costly than urodynamics when the prevalence of genuine stress incontinence was > or = 80%. CONCLUSION: These findings do not support the routine use of urodynamics before surgery in women likely to have genuine stress incontinence, and provide the justification for randomized trials of preoperative testing strategies.     

Urodynamics in the Evaluation of Overactive Bladder

Overactive bladder (OAB) is a clinical syndrome characterized by urinary urgency, frequency, and nocturia with or without accompanying urinary incontinence. Thus, using this operational definition based on symptoms at presentation, urodynamic testing is not required for an initial diagnosis of OAB. An increasing body of evidence suggests that, although there is a relationship between the urodynamic finding of detrusor overactivity and OAB, these are quite separate findings, and successful response to nonsurgical and surgical interventions for OAB does not depend on finding detrusor overactivity on urodynamic testing. The role of urodynamics in the setting of OAB is not well defined at present, but there are several clinical scenarios where such testing may be useful. However, at this time, the evidence to support their routine use in patients with OAB is limited.     

Value of the patient's case history in diagnosing urinary incontinence in general practice

What is the value of the case history in diagnosing urinary incontinence in general practice? A total of 103 women with urinary incontinence presented to their general practitioner (GP) and underwent a standard history-taking, physical examination and urodynamic testing. The urodynamic diagnoses were analysed against symptoms and symptom complexes. Symptoms of stress incontinence in the absence of symptoms of urge incontinence had a sensitivity of 78%, specificity of 84% and predictive value of 87%. Symptoms of urge incontinence in the absence of symptoms of stress incontinence excluded genuine stress incontinence. Information on age, parity, enuresis, nocturia, frequency, urgency, cystocele, prolapse and hysterectomy did not contribute to a correct diagnosis. It was concluded that urodynamics are unnecessary in most women presenting with urinary incontinence in general practice.     

Removal of transurethral catheter during urodynamics may unmask stress urinary incontinence

PURPOSE: The measurement of Valsalva leak point pressure may have an important role in the treatment algorithm of women with stress urinary incontinence. However, some patients with stress urinary incontinence may not have leakage during standard urodynamic studies and, thus, the Valsalva leak point pressure cannot be determined. We hypothesized that the transurethral catheter may inhibit leakage during urodynamics. MATERIALS AND METHODS: We evaluated 21 consecutive women presenting with complaints of stress urinary incontinence who failed to have leakage on urodynamic studies. Bedside cystometry was performed, followed by urodynamics using a 6Fr transurethral catheter. When stress urinary incontinence was not noted, the catheter was removed and the Valsalva leak point pressure was measured using the intraabdominal pressure catheter. RESULTS: No woman had leakage on urodynamic studies with the catheter in place, although 11 of 21 had leakage after the catheter was removed and 15 had leakage on bedside cystometry. All 11 patients with leakage at catheter removal showed leakage on bedside stress testing. Mean Valsalva leak point pressure in those with leakage was 67 cm. water. CONCLUSIONS: Patients with a history of stress urinary incontinence and those with a positive bedside stress test who do not have leakage during a Valsalva maneuver on urodynamic studies should repeat the Valsalva maneuver with the catheter out. This technique may unmask stress urinary incontinence and allow the measurement of Valsalva leak point pressure.     

The role of urodynamic assessment in the diagnosis of lower urinary tract disorders

The relationship between clinical symptomatology and urodynamic findings was studied prospectively in 1000 unselected women with symptoms of lower urinary tract dysfunction. Women in the study were subjected to both clinical and multichannel urodynamic assessment. The symptom of stress incontinence was confirmed by urodynamic assessment to be associated with genuine stress incontinence (95%). However, it was also associated with sensory urgency (96%) and detrusor instability (64%). Other lower urinary tract symptoms were associated with a range of abnormal urodynamic findings. It was concluded that urodynamic assessment provided useful information in women with lower urinary tract disorders, in developing principles of diagnosis and management. EDITORIAL COMMENT: Once again the utility of urodynamic evaluation of women with lower urinary tract symptomatology is clearly apparent. Lower urinary tract symptoms are too unspecific to be the sole basis of treatment, especially surgical intervention. Although this conclusion has been reached by other investigators, there remain far too many clinicians in the fields of primary care, gynecology and urology who continue to doubt urodynamic testing. The fact remains, as shown again by Dr Clarke, that urodynamic assessment is essential in making a diagnosis and formulating a treatment plan.     

The impact of detrusor overactivity on the management of stress urinary incontinence in women

The presence of overactive bladder symptoms, urodynamic detrusor overactivity, and urge incontinence can complicate the diagnosis and management of stress urinary incontinence in women. The exact pathophysiology of mixed incontinence is not well characterized; in some patients, the stress and urge etiology may be pathologically linked. The role of urodynamics in evaluating patients with mixed incontinence remains controversial. Conservative therapies, such as bladder training, pelvic floor exercise, biofeedback, and electrical stimulation, offer moderate success in women with mixed incontinence. Surgery (colposuspension, bladder neck pubovaginal slings, and midurethral slings) offers excellent subjective and objective cure rates in patients with mixed incontinence. Preoperative detrusor overactivity is cured consistently ≥ 50% of the time with colposuspension and slings. Overall, the presence of preoperative detrusor overactivity does not appear to significantly worsen the outcome of conservative and surgical treatments for stress urinary incontinence in women.     

Objective assessment of urinary incontinence in women: comparison of the one-hour and 24-hour pad tests

OBJECTIVE: To compare the performance and clinical usefulness of the one-hour and 24-hour pad tests in terms of the relationship with reported symptoms and urodynamic diagnosis. METHODS: 341 women aged 40 years and over reporting lower urinary tract symptoms who were recruited to a nurse led continence service, and went on to receive urodynamics, a one-hour and a 24-hour pad test and completed a urinary diary. RESULTS: For both pad tests, there was a significant difference in the amount of urine leaked between the different urodynamic diagnoses (p<0.0001, for the one-hour and p=0.001 for the 24-hour test). Women with sphincter incompetence leaked significantly more than women with detrusor instability, or those with no abnormality. There was a significant difference between the proportion of women dry on a one-hour pad test and those dry on a 24-hour pad test (26.0% versus 38.4%, difference 12.4%; CI 5.5; 19.4). There is a positive relationship between amount of urine leakage and symptom severity expressed in terms of number of incontinent episodes for both pad tests. CONCLUSION: Both pad tests bore little relationship to the underlying urodynamic diagnosis but there was a positive relationship with symptom severity. The 24-hour pad test appears to be clinically a more useful too than the one-hour test. The two types of pad test are probably assessing incontinence in different ways. We suggest that the minimum data set should include structured questions, diaries and the 24-hour pad test.     

Results and Complications of Tension-Free Vaginal Tape (TVT) for Surgical Treatment of Female Stress Urinary Incontinence

Thirty-one patients with stress urinary incontinence were operated on using tension-free vaginal tape (TVT). All were evaluated preoperatively with urodynamics, pad test and stress test. Conservative treatment was without significant effect. Three months after the operation no patients had stress incontinence but 1 with mixed incontinence experienced deterioration of her urge incontinence and 2 experienced de novo urge incontinence. The de novo urge incontinence was significantly improved and the urodynamic investigation normal after approximately 5 months. One patient with a previous operation with Kelly sutures under the urethra developed a urethrovaginal fistula. Fifteen patients were observed for 1 year. One patient who was continent after 3 months developed slight stress incontinence.     

CONVENTIONAL AND AMBULATORY URODYNAMIC FINDINGS IN WOMEN WITH SYMPTOMS SUGGESTIVE OF BLADDER OVERACTIVITY

PURPOSE: We compared ambulatory urodynamics and conventional video cystometry findings in women with symptoms of bladder overactivity. MATERIALS AND METHODS: In a prospective randomized crossover study 106 women with symptoms of urinary urgency with or without incontinence were comprehensively investigated by video cystometry and ambulatory urodynamics in random order. In addition, all women completed a validated symptoms questionnaire and voiding diary. RESULTS: Involuntary detrusor activity was detected in 32 and 70 cases on video cystometry and ambulatory urodynamics, respectively (p <0.001). Video cystometry done according to International Continence Society standards diagnosed detrusor instability in 4 women with no involuntary detrusor activity on ambulatory urodynamics. Involuntary detrusor activity resulting in incontinence was observed in 39 cases on ambulatory urodynamics, including 20 (51%) with stable video cystometry results. Stress incontinence was diagnosed in 42 cases on video cystometry and in 34 on ambulatory urodynamics (p = 0.629). Increasingly severe urge and stress incontinence reported in the symptoms questionnaire correlated positively with the subsequent detection of detrusor overactivity and stress incontinence, respectively, on the 2 urodynamic tests. CONCLUSIONS: In contrast to video cystometry, ambulatory urodynamics provides objective evidence of clinically important bladder overactivity in the majority of women with symptoms suggestive of bladder overactivity. The correlation of symptoms with ambulatory urodynamic findings implies that greater reliance may be placed on symptomatic diagnosis of bladder overactivity. Improved objective assessment of detrusor function provided by ambulatory urodynamics has implications for the definition of bladder overactivity and relevance of conventional cystometry in this context. In women who complain of urgency stable conventional cystometrography findings should be interpreted with caution.     

The Diagnosis of Urinary Incontinence: Urodynamics, More or Less?

The symptoms of urinary incontinence are not generally disease-specific, and a clinical diagnosis based on symptoms alone will be incorrect in around in one in five cases. Detailed assessment of bladder function using more complex urodynamic studies is needed in any patient prior to invasive therapy, where previous therapy has proved unsuccessful, where there is neurological causation, or in other circumstances where there is an unusual history. Urodynamic assessment encompasses a spectrum of different techniques including volume voided charts, flow rates, residuals, simple cystometry and video cystometry. The frequency volume chart is the simplest. The flow rate to assess voiding function is combined with a residual measurement most commonly carried out by ultrasound. Although catheterisation will often provide a more accurate result, this is more invasive and therefore less acceptable to patients. Assessment of leakage can be carried out in a semi-quantitative fashion by pad testing using either a 1-hour or 24-hour pad test. As a general rule, the 1-hour pad test is the most useful and can be subdivided into three sessions of 20 minutes with increasing levels of activity. Filling and voiding cystometry can be carried out either using saline or contrast. Contrast allows the concomitant assessment of anatomy and identification of incontinence during coughing and stress during the course of the study.     

The effect of bladder training, pelvic floor muscle training, or combination training on urodynamic parameters in women with urinary incontinence. Continence Program for Women Research Group.

The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral closure pressure, mean urethral closure pressure, maximum Kegel urethral closure pressure, mean Kegel urethral closure pressure, functional urethral length, pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.     

Indikationen zur urodynamischen Untersuchung

Background

The aim of urodynamic testing is to obtain objective information regarding urinary bladder storage and voiding function. Basic investigations provide information of the underlying incontinence form. Depending on the individual situation and findings, further urodynamic investigations are helpful or indicated. Prior to conservative therapy, a routine urodynamic investigation is not indicated.

Objectives

Due to limited evidence of preoperative urodynamic investigations on postoperative results, the urodynamic results may be helpful when considering various treatment options.

Results

Urodynamic investigations should be performed preoperatively, especially in case of overactive bladder symptoms, prior incontinence surgery, or disordered bladder emptying. The assessment of urethral function should be considered in the urodynamic investigation of stress urinary incontinence. In patients with pelvic prolapse, urodynamic investigations should be performed during prolapse reposition.

     

When Are Urodynamics Indicated in Patients with Stress Urinary Incontinence?

Despite technical and procedural advances in urodynamics over the past decade, the role of urodynamics in women with stress urinary incontinence (SUI) remains controversial. Many of these advancements have been the result of multicentric studies in the United States, such as the UITN and PFDN, which will be highlighted in this article. It appears to be the consensus that urodynamics may not be needed in pure stress incontinence. Urodynamics can be valuable in unmasking stress urinary incontinence in prolapse, although its impact on the ultimate management of occult incontinence remains debated. This article reviews the indications for urodynamic testing in women with SUI but will exclude more complex conditions such as mixed or recurrent incontinence which are outside the scope of this review.     

Sacral root neuromodulation in the treatment of refractory urinary urge incontinence: a prospective randomized clinical trial

OBJECTIVES: To compare the effectiveness of sacral root neuromodulation with that of conservative management in ameliorating symptoms of refractory urinary urge incontinence and enhancing quality of life, to assess the objective response to neuromodulation as revealed by urodynamic testing, and to delineate the long-term outcomes of neuromodulation. METHODS: Forty-four patients with refractory urge incontinence were randomized to undergo neuromodulation with an implantable impulse generator (n = 21) or to continue their prior conservative management (n = 23). At 6 months the control group was eligible for crossover to implant. Patient evaluation included voiding diaries, quality of life questionnaires, urodynamic testing, and documentation of adverse events. Long-term follow-up evaluations were conducted at 6-month intervals up to 36 months. RESULTS: At 6 months mean leakage episodes, leakage severity and pad usage in the implant group were significantly lower by 88% (p < 0.0005), 24% (p = 0.047) and 90% (p < 0.0005), respectively, than the corresponding control group mean values. Improvements in leakage episodes and pad usage of >/=90% were attained by 75 and 85% of the implant group, respectively, but none of the control group. One third of implant patients, but none of the control patients, achieved >/=50% improvement in leakage severity. Over half of the implant patients (56%) were completely dry compared with 1 control patient (4%). Implant patients, but not control patients, exhibited significant improvement with respect to two quality of life measures. Neuromodulation resulted in increases of 220% (p < 0.0005) and 39% (p = 0.013), respectively, in urodynamically assessed bladder volume at first contraction and maximum fill. At 36 months the actuarial rate of treatment failure was 32.4% (95% CI, 17.0-56.0%). Adverse events most frequently involved pain at the implant site, and the incidence of serious complications was low. CONCLUSIONS: Neuromodulation is markedly more effective than conservative management in alleviating symptoms of refractory urge incontinence. Quality of life and urodynamic function are also improved by neuromodulation. The effects of neuromodulation are long-lasting, and associated morbidity is low.     

Is the bladder a reliable witness for predicting detrusor overactivity?

PURPOSE: We determined how well the symptoms of OAB syndrome correlate with urodynamic DO using International Continence Society definitions. MATERIALS AND METHODS: The study included adult males and females 18 years or older who attended a tertiary referral center for urodynamics from February 2002 to February 2004. Patients were selected based on OAB syndrome symptoms (urgency, urgency urinary incontinence and frequency). The percent of patients who had symptoms alone or in combination and DO was calculated. RESULTS: There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women. Of men 69% and 44% of women with urgency (OAB dry) had DO, while 90% of men and 58% of women with urgency and urgency urinary incontinence (OAB wet) had DO. Stress urinary incontinence seems to have accounted for the decreased rates in women since 87% of women with urgency urinary incontinence also had the symptom of stress urinary incontinence. The ICS definition does not specify what constitutes abnormal voiding frequency. Analysis of results showed that increasing voiding frequency did not have any effect on increasing the accuracy of diagnosis of DO except in women with 10 or more daytime micturition episodes. CONCLUSIONS: The bladder is a better and more reliable witness in men than in women with a greater correlation between OAB symptoms and urodynamic DO, more so in the OAB wet than in OAB dry patients.     

“Overactive bladder”: Main urinary symptoms and urodynamic patterns in the elderly

Overactive bladder is the most frequent type of urinary incontinence in the elderly; its main symptoms are frequency, urgency and urge-incontinence. The diagnosis is based on urodynamic testing; however, a few years ago Abrams and Wein proposed a new clinical approach to overactive bladder. Aims: The main aims of this study were: firstly to determine the prevalence of overactive bladder in elderly patients with established urinary incontinence; secondly, to describe the main clinical features of this condition; and finally to describe its urodynamic patterns. Methods: A retrospective study of the medical records and urodynamic data of 682 older patients with urinary incontinence who underwent urodynamic testing. Results: The sample included 682 patients (350 men, and 332 women), with a mean age of 73.24 years. The most frequent symptoms were: frequency; urge-incontinence and incontinence at cough. Mixed types of overactive bladder were more common than isolated overactive bladder; bladder outlet obstruction was associated chiefly with overactive bladder. A postvoiding residual urine over >100 ml was found in 136 patients (20 of the entire sample). In this subgroup, the urinary symptoms were similar to those of the rest of the sample. Conclusion: Our results suggest that the urodynamic study is very useful in identifying the type of urinary incontinence.

     

Transcutaneous electrical nerve stimulation in the treatment of neurological patients with urinary symptoms

OBJECTIVE: To determine whether transcutaneous electrical nerve stimulation (TENS) benefits patients with urinary symptoms caused by neurological diseases. PATIENTS AND METHODS: Patients with urinary symptoms from any kind of neurological disease were prospectively recruited between October 1996 and July 1998. Before attending the first assessment patients were asked to complete a week's diary recording the frequency of micturition, incontinence episodes, and frequency of pad and clothes changing. At the first assessment the patients completed the Frimodt-Moller urinary symptom questionnaire, and quality-of-life scales including the Nottingham Health Profile and Short-Form 36. Demographic and disability data (Barthel Index and Frenchay Aphasia Screening Test) were recorded, and patients underwent a neurological examination and urodynamic studies. The placing of electrode pads on the sacral dermatomes 2.5 cm either side of and 2.5 cm above the natal cleft was demonstrated, and the patient instructed to use TENS for 90 min twice a day. The current strength applied was set to that which the patient could tolerate, at a square-wave of 20 Hz and 200-micros duration. Six weeks later the patients were further assessed, where the diary exercise, questionnaires and urodynamics were repeated. In all, 44 patients (13 men and 33 women, mean age 50.8 years) were recruited. RESULTS: The commonest disease was multiple sclerosis and the commonest impairments para/tetraplegia or hemiplegia. There was no change in the neurological status of the 34 patients completing the study. Irritative voiding symptoms were significantly decreased (0.68-0.61, P = 0.003) and diaries also showed significant improvements in the 24 h frequency of micturition (P = 0.01), incontinence episodes (P = 0.04) and clothes changes (P = 0.02). Urodynamics showed detrusor hyper-reflexia in most patients. The only significant changes after TENS were an increased postvoid residual volume (from a mean of 134 mL to 160 mL, P = 0.03) and an increase in the volume leaked during the urodynamic study with TENS on (from a mean of 4.7 mL to 12 mL, P = 0.003). There were no significant changes in the quality-of-life scores. Of the 34 patients completing the study, half still reported a benefit from TENS at 1 year, although some patients found it took 3-4 weeks to work. CONCLUSION: TENS applied to the sacral dermatomes of neurological patients with urinary symptoms had a minimal effect on urodynamic data but significantly improved irritative urinary symptoms, 24-h urinary frequency, incontinence and clothes changing. The lack of effect on quality-of-life measures probably reflects the lack of sensitivity in the tools used in this group of patients. We therefore recommend using TENS in this often problematical group of patients.     

Federal guidelines for the management of urinary incontinence in the United States: Which patients should undergo urodynamic testing?

In 1992, the United States Agency for Health Care Policy and Research (AHCPR) proposed a guideline for the management of adults with urinary incontinence. The purpose of this study is to evaluate the criteria proposed by the AHCPR for the selective use of urodynamic testing in women complaining of stress incontinence. In order to examine the efficacy of these criteria, we retrospectively determined urodynamic diagnoses for 101 women presenting with the complaint of stress incontinence. These were then compared to the AHCPR recommendations for each subject's management. We found that the AHCPR algorithm would have recommended treatment without urodynamic testing for 65% of the population. If the AHCPR guideline had been followed, 32% of the overall population could have received inappropriate treatment. These results suggest that the implementation of the AHCPR guideline could result in inappropriate treatment for onethird of women presenting with symptoms of stress incontinence.Editorial Comment: The federal guidelines for the management of urinary incontinence in the United States emphasize medical management prior to any diagnostic urodynamic studies beyond those that can be obtained by a physical examination and prior to surgical management. The guidelines are not adequate to triage patients for the therapy of urinary incontinence, as is pointed out by this article. This has been recognized at a federal level as well, and new guidelines are being prepared. It is not anticipated that they will differ to any great degree with respect to the need for medical management prior to any definitive urodynamic testing or surgical therapy. Hopefully the new guidelines will be more useful in the triage of patients to earlier urodynamic testing in those cases where medical management will predictably fail, and more appropriate therapy for incontinence can be instituted from the beginning.