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Background: Bladder diaries represent a fundamental component in the assessment of patients presenting with lower urinary tract symptoms. Nevertheless, their importance often remains underappreciated and undervalued within clinical practice. This paper aims to conduct a comprehensive review of the existing literature concerning the utility of bladder diaries, underscore the criticality of their precision, elucidate the factors contributing to noncompliance with bladder diary completion, and investigate potential strategies for enhancing patient compliance. Materials and Methods: A review of the English‐language scientific literature available in the domains of Medline, Embase, Emcare, Midirs, and Cinahl was conducted. This was supplemented by discussion at the International Consultation on Incontinence Research Society Proposal session to define knowledge and identify gaps in knowledge surrounding the utility of bladder diaries. The existing evidence and outcome of the relevant discussion held in the meeting are presented. Results: Bladder diaries (BD) serve to characterize the nature and severity of storage lower urinary tract symptoms (LUTS) and provide an objective record of an individual's urination patterns. They aid in the refinement and customization of treatment strategies based on the clinical responses documented in the diary, optimizing treatment outcomes. Notably, both BD and urodynamic studies (UDS) play complementary yet distinct roles in LUTS evaluation. BD offers a more comprehensive and accessible approach to assessing specific storage LUTS, particularly due to their affordability and widespread availability, especially in resource‐limited settings. Nevertheless, the absence of a standardized BD format across global healthcare systems presents a significant challenge. Despite being recognized as reliable, noninvasive, validated, and cost‐effective tools for evaluating patients with LUTS, the implementation and completion of BD have proven to be complex. The introduction of automated bladder diaries heralds an era of precise, real‐time data collection, potentially enhancing the patient–clinician relationship. Completion of bladder diaries depends on an array of individual, social, and healthcare‐specific factors. Compliance with bladder diary completion could be enhanced with clear instructions, patient education, regular follow‐ups and positive re‐enforcement. This study has identified four critical areas for future research: Addressing healthcare disparities between affluent and developing nations, enhancing the current functionality and effectiveness of bladder diaries, exploring the feasibility of incorporating bladder diaries into the treatment and education process and improving the quality and functionality of existing bladder diaries. Conclusion: Bladder diaries play a pivotal role in the evaluation and management of patients with LUTS, providing a holistic perspective. When their complete potential is harnessed, they have the capacity to revolutionize the paradigm of LUTS management, ushering in a patient‐centered era of care. [ABSTRACT FROM AUTHOR]

Introduction: A "Think Tank" at the International Consultation on Incontinence‐Research Society meeting held in Bristol, United Kingdom in June 2023 considered the progress and promise of machine learning (ML) applied to urodynamic data. Methods: Examples of the use of ML applied to data from uroflowmetry, pressure flow studies and imaging were presented. The advantages and limitations of ML were considered. Recommendations made during the subsequent debate for research studies were recorded. Results: ML analysis holds great promise for the kind of data generated in urodynamic studies. To date, ML techniques have not yet achieved sufficient accuracy for routine diagnostic application. Potential approaches that can improve the use of ML were agreed and research questions were proposed. Conclusions: ML is well suited to the analysis of urodynamic data, but results to date have not achieved clinical utility. It is considered likely that further research can improve the analysis of the large, multifactorial data sets generated by urodynamic clinics, and improve to some extent data pattern recognition that is currently subject to observer error and artefactual noise. [ABSTRACT FROM AUTHOR]

The International Consultation on Incontinence (ICI) captures current evidence on incontinence. The conference 'Incontinence: The Engineering Challenge XIII' in November 2021 heard an update on the most recent ICI summary on urodynamic testing. This paper summarises the ICI recommendations for future research in urodynamics, with a view to informing engineers of issues and challenges that could benefit from engineering solutions. Engineers are encouraged to contribute to the following areas of research, which will have a direct and positive effect on patients' quality of life and overall health: (a) Urine flow measurement: home- and app-based devices, machine learning analysis of flow shape, (b) Pressure measurement: normal values for and validation of new technologies, including air-filled, non-invasive and urethral pressure reflectometry, (c) Ultrasound imaging: bladder wall biomechanics, bladder shape analysis, (d) Assess normal and abnormal value ranges, and diagnostic performance and (e) Specific trials in understudied patient groups including those with symptoms resistant to treatment, children and the frail elderly. [ABSTRACT FROM AUTHOR]

Aims: The working group (WG) initiated by the International Continence Society Standardization Steering Committee and supported by the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction has revised the (1997) ICS Standard for pressure flow studies. Methods: Based on the ICS standard for developing evidence‐based standards, the WG developed this new ICS standard in the period from May 2020 to December 2022. A draft was posted on the ICS website in January 2023 to facilitate public discussion and the comments received have been incorporated into this final release. Results: The WG summarizes the theory and recommends the practice and the terms used for the diagnosis of voiding dysfunction for adult female and male patients without relevant neurological abnormalities, in part 1 of this standard. The WG has also recommended standard principles and parameters for objective and continuous grading of urethral resistance and detrusor voiding contraction on the basis of pressure flow studies in part 2. The recommendations for practice in this part have also the aim to increase the understanding of the physiology as well as the psychology of voiding. The potential effects of the laboratory situation of the test on the voiding as well as the role of the urodynamicist in this regard are discussed. The WG has recommended to use for diagnosis only the voidings that are considered representative by the patient. Conclusion: A pressure flow study is the gold standard to assess voiding function and to quantify dysfunction. This part of the standard explains the clinical background, gives recommendations for the execution of a pressure flow study and lists relevant terms, parameters, and units of measurements. [ABSTRACT FROM AUTHOR]

Aims: The Working Group (WG), initiated by the International Continence Society (ICS) Standardisation Steering Committee and supported by the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, has revised the ICS Standard for pressure‐flow studies of 1997. Methods: Based on the ICS standard for developing evidence‐based standards, the WG developed this new ICS standard in the period from May 2020 to December 2022. A draft was posted on the ICS website in December 2022 to facilitate public discussion and the comments received have been incorporated into this final release. Results: The WG has recommended analysis principles for the diagnosis of voiding dysfunction for adult men and women without relevant neurological abnormalities. New standard terms and parameters for objective and continuous grading of urethral resistance (UR), bladder outflow obstruction (BOO) and detrusor voiding contraction (DVC) are introduced in this part 2 of the standard. The WG has summarized the theory and recommendations for the practice of pressure‐flow study (PFS) for patients in part 1. A pressure‐flow plot is recommended for the diagnosis of every patient, in addition to time‐based graphs. Voided percentage and post void residual volume should always be included in PFS analysis and diagnosis. Only parameters that represent the ratio or subtraction of pressure and synchronous flow are recommended to quantify UR and only parameters that combine pressure and flow in a product or sum are recommended to quantify DVC. The ICS BOO index and the ICS detrusor contraction index are introduced in this part 2 as the standard. The WG has suggested clinical PFS dysfunction classes for male and female patients. A pressure‐flow scatter graph including every patient's pdet at maximum flow (pdetQmax) with maximum flow rate (Qmax) point should be included in all scientific reports considering voiding dysfunction. Conclusion: PFS is the gold standard used to objectively assess voiding function. Quantifying the dysfunction and grading of abnormalities are standardized for adult males and females. [ABSTRACT FROM AUTHOR]

Aim: To develop and test a scoring system for the technical quality of a urodynamic trace Methods: Rasch analysis was used to select the most discriminating questions relating to good urodynamic practices. The questions were taken from International Continence Society standard documents and tested on 60 traces of varying quality and from different sources. Results: Twenty‐five questions were selected by this process. These were tested with 10 traces by seven scorers, and with 60 traces by a single scorer. A pass quality score of 75% resulted in good discrimination between good and poor traces. Further editing and clarification resulted in a final score sheet of 23 Yes/No questions. Conclusion: A proposed scoring system, "Bristol UTraQ," for the technical quality of urodynamic traces has been developed and tested. We suggest a score above 75% indicates acceptable trace technical quality. High technical quality is the essential first step in ensuring that urodynamic studies can answer the urodynamic questions for every patient. Plans for further validation are outlined. [ABSTRACT FROM AUTHOR]

This paper sets out the rationale and design for a more physiologically representative bladder/urethral model than the current rigid funnel industry standard. We suggest this flexible model can better serve as a basis for evaluating new catheters. We investigated the parameters and the validation tests required to construct and test with more flexible materials. The protocol includes static and impact force tests, while measuring internal retention balloon pressure. We have designed a flexible elastomer bladder floor and urethral model and tested it with a Foley balloon catheter. The tests showed that the model could hold the catheter with static loads up to 0.7 kg, but that the catheter was pulled out by impact forces from dropped weights. The Foley catheter design and its associated standards make no provision to mitigate urethral injury in the surprisingly common event of removal with a filled balloon. Our design is a more realistic model for testing retention and extraction characteristics of a urethral catheter. Validation tests have confirmed the feasibility of measuring urethral dilation and balloon pressure, both under traction and during progressive deflation. We suggest this model improves upon the current standard tests and will enable the design of safer catheters. [ABSTRACT FROM AUTHOR]

Introduction: To ensure quality, the International Continence Society recommends asking the patient to cough every minute or 50 ml of infused volume. However, on occasions, it was noticed that if cough transmission was poor, Valsalva maneuvers could show pressure transmission was satisfactory. Hence, a study was designed to compare the two methods. Methods: Cough and Valsalva maneuver pressures were compared in 40 patients, 20 consecutive men and 20 consecutive women, undergoing urodynamics at three time points: baseline (20 ml filling), prevoid and postvoid. Results: At baseline, the percentage difference between pabd and pves was significantly lower for Valsalva maneuvres compared with coughs for all patients (median 5.1% vs. 10.2%). This association was consistent in male patients, but not for female. At prevoid, this was reversed with coughs providing more consistent pressure spikes than Valsalva maneuvers (median 7.0% vs. 24.1%), for all patients. Postvoid, no difference was noted in either men or women. Conclusions: Quality control during urodynamics is important to ensure diagnostic accuracy. This is the first study to compare two methods of quality control, coughs, and Valsalva maneuvers. Coughs are a useful indicator of pressure transmission quality at all time points throughout urodynamic studies. However, at low volumes, Valsalva maneuvers give a better indication of quality, with lower variability, whereas at cystometric capacity coughs performed better. Therefore, if poor pressure transmission occurs with cough during urodynamics, particularly at low volumes, it is recommended that a Valsalva maneuver is used to further assess whether pressure transmission and thus urodynamic quality is satisfactory. [ABSTRACT FROM AUTHOR]

Urodynamics testing forms the cornerstone of investigations when it comes to lower urinary tract dysfunction. It has to be done to the highest standards by following the International Continence Society Good Urodynamics Practice protocols. However, with the COVID‐19 pandemic, certain adaptations to the urodynamics procedure need to be considered especially when it comes to quality control. This article aims to define these adaptations to help urodynamicists in their daily practice. [ABSTRACT FROM AUTHOR]

Aims: To assess the state of technologies for urodynamics that are less invasive than standard cystometry and pressure‐flow studies and to suggest areas needing research to improve this. Methods: A summary of a Think Tank debate held at the 2019 meeting of the International Consultation on Incontinence Research Society is provided, with subsequent analysis by the authors. Less‐invasive techniques were summarized, classified by method, and possible developments considered. Discussions and recommendations were summarized by the co‐chairs and edited into the form of this paper by all authors. Results: There is a full spectrum of technologies available for less‐invasive assessment, ranging from simple uroflowmetry through imaging techniques to emerging complex technologies. Less‐invasive diagnostics will not necessarily need to replace diagnosis by, or even provide the same level of diagnostic accuracy as, invasive urodynamics. Rather than aiming for a technique that is merely less invasive, the priority is to develop methods that are either as accurate as current invasive methods, or spare patients from the necessity of invasive methods by improving early triaging. Conclusions: Technologies offering less‐invasive urodynamic measurement of specific elements of function can be potentially beneficial. Less‐invasive techniques may sometimes be useful as an adjunct to invasive urodynamics. The potential for current less‐invasive tests to completely replace invasive urodynamic testing is considered, however, to be low. Less‐invasive techniques must, therefore, be tested as screening/triaging tools, with the aim to spare some patients from invasive urodynamics early in the treatment pathway. [ABSTRACT FROM AUTHOR]

Aims: Lower urinary tract (LUT) function can be investigated by urodynamic studies (UDS) to establish underlying functional abnormalities in the LUT. A multicentre registry could present an opportunity to improve the scientific evidence base for UDS. During the International Consultation on Incontinence Research Society (ICI‐RS) meeting in Bristol, United Kingdom 2019, an expert panel discussed the potential of a multicentre urodynamic registry to improve the quality of urodynamic output. Methods: the potential importance of a multicentre urodynamic registry, parameter inclusion, quality control, and pitfalls during a registry roll‐out were reviewed and discussed. Results and Conclusions: The clinical utility, evaluation, and effectiveness of UDS remain poorly defined due to a lack of high quality evidence and large study populations. Therefore, the ICI‐RS proposes formation of a urodynamic panel for future roll‐out of a registry. The inclusion of basic parameters was discussed and the essential parameters were defined as well as the potential pitfalls of a registry roll‐out. The discussion and recommendations in this paper form the base for future urodynamic registry development. [ABSTRACT FROM AUTHOR]

Introduction: Widely accepted consensus terminology and calculations of detrusor contractility in females do not exist but may be useful. We report the output of a proposal session at the International Consultation on Incontinence Research Society meeting 2019, addressing the title topic. Methods: Three formal presentations and a lively discussion addressed several questions including: which is the optimal cutoff value of female bladder voiding efficiency during uroflow to suspect obstruction or detrusor underactivity? Is there a definition of pure underactive and pure obstructed voiding in females? Is there a place to distinguish those relatively obstructed from those relatively underactive females especially in those cases of equivocal obstruction? Current measures of contractility were reviewed for their usefulness in women. Results: No recommendation for a specific index or calculation can be made based on current knowledge. "Contractility" may be context‐dependent regarding clinical care, clinical prognostication, and physiologic research. Conclusions: This group proposes that context‐sensitive definitions of "Contractility" deserve attention by international leadership. Cooperative clinical and physiologic expertise will be needed to achieve this goal. Following initial recommendations based on expert opinion, the development of final definitions and measures of contractility should be iterative, based upon validation studies to be considered as part of the definitional process. [ABSTRACT FROM AUTHOR]

Aim: The International Continence Society (ICS) has standardized quality control and interpretation of uroflowmetry and urodynamics. We evaluated traces from two large studies of male lower urinary tract symptoms (UPSTREAM and UNBLOCS) against ICS standards of urodynamic equipment and practice. Methods: Ten percent of uroflowmetry and urodynamics traces were selected at random from hospital sites. A data capture template was designed from the ICS Fundamentals of Urodynamic Practice checklist. Two pretrained blinded assessors extracted the data, with a third assessor to arbitrate. Departmental records of calibration checks and equipment maintenance were scrutinized. Results: Seven out of twenty‐five (28%) departments reported no calibration checks. Four sites (16%) could not provide annual service records. In 32 out of 296 (10.8%) uroflowmetry traces, findings were affected by artifact. One hundred ten urodynamic study traces were reviewed; in 11 records (10%), key pressure traces were incompletely displayed. In 30 (27.2%), reference zero was not set to atmospheric pressure. Resting pressures were outside the expected range for 36 (32.7%). Pressure drift was seen in 18 traces (16.4%). At pressure‐flow study commencement, permission to void was omitted in 15 (13.6%). Cough testing after voiding was done in 71.2%, but the resulting cough spikes were significantly different in 16.5%. Erroneous diagnosis of bladder outlet obstruction (BOO) was identified in six cases (5.5%). Conclusions: Erroneous diagnosis of BOO is a serious error of interpretation, as it could lead to unnecessary surgery. Other errors of standardization, testing, and interpretation were identified with lower risk of adverse implications. Inconsistent documentation of service records mean equipment accuracy is uncertain. [ABSTRACT FROM AUTHOR]

Studies on bladder dysfunction (BD), more specifically functional‐urodynamic changes in the bladder as a result of bladder outlet obstruction (BOO) have been summarized for this TT. Based on available, but limited evidence from human studies a three‐stage model can be hypothesized to characterize BOO‐induced bladder remodeling: hypertrophy, compensation (increased detrusor contractility during the voiding phase, often in combination with filling phase detrusor overactivity) followed by the phase of decompensation [detrusor underactivity]. The time between the start of compensation and eventual decompensation seems to be determined by age of onset, severity, and type of obstruction and clinical mitigating factors such as vascular and metabolic problems. Understanding the relative contributions of these factors may allow the development of personalized timelines and probabilities for these obstructed patients. [ABSTRACT FROM AUTHOR]

Introduction: Different patterns of detrusor overactivity (DO) have been described and included in several standardization terminology documents. However, it is unclear if these different patterns have any clinical significance. Methods: This is a report of the proceedings of Proposal 3: "Are there different patterns of detrusor overactivity which are clinically relevant?" from the annual International Consultation on Incontinence—Research Society (ICIRS) meeting, which took place from 14 to 16 June 2018, in Bristol, UK. Results: We have collected and discussed, as a committee, the evidence about different urodynamic (UD) patterns of detrusor overactivity and their potential clinical significance. We reviewed the important previous basic research and clinical studies and compiled summaries. The discussion focused on clinical relevance of different UD patterns of DO and what further research is required. Conclusions: There are several UD definitions of patterns of detrusor overactivity, however the clinical relevance of these definitions remains unclear. Future research should concentrate on defining the pattern of DO in relation to clinical diagnosis, gender, age, and treatment outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The quality of urodynamic measurements in clinical practice has been debated as a matter of concern. It is considered plausible that this has a direct bearing on patient care and the perceived value of urodynamic testing. Methods: This is a report of the proceedings of the Think Tank: "Is the value of urodynamics undermined by poor technique?" from the Annual International Consultation on Incontinence—Research Society, which took place in June 2018 in Bristol, UK. The Think Tank discussed the evidence for deficiencies in urodynamic test quality and considered the implications of improvements for clinical diagnosis and practice. Results: There is evidence that technique affects urodynamic quality, and that urodynamic practice is variable. Factors such as team skill set, technologies used, and training received will also affect the quality of urodynamic service. Questions exist regarding the influence of technique on the utility and perceived value of urodynamics. Conclusions: We suggest research questions that will provide the necessary evidence on the link between technique, reporting, and outcome, and clarify the role of good practice in the utility of urodynamic testing. [ABSTRACT FROM AUTHOR]

Aims: The International Consultation on Incontinence has published an update of the recommendations for the diagnosis and management of urine incontinence (ICI2016). This manuscript summarizes the consultations committee—recommendations with regard to urodynamic assessment. Methods: Expert consensus on the basis of structured evidence assessment has been the basis of the consultations publication and has been summarized by the committee for this manuscript. Results: Patients that are not satisfied with their initial management on the basis of their reported signs and symptoms of urinary incontinence, as well as all patients with neurological abnormalities that are potentially relevant for the function of the lower urinary tract, may very likely profit from objective diagnosis and staging and grading of their dysfunction, with urodynamic testing, regardless their age, vulnerability and/or comorbidities. The principles and technical innovations as well as the principal recommendations for the utilization of (invasive) urodynamic assessment for women, men, children, and vulnerable elderly, with or without neurogenic lower urinary tract dysfunction with urinary incontinence are provided in this abbreviated ICI recommendations‐document. Conclusions: The ICI2016 committee on urodynamics presents an executive summary of the most important reasons and recommendations for the use of urodynamic investigations for patients with urinary incontinence. [ABSTRACT FROM AUTHOR]

Aims: To test the significance of association between a validated index of detrusor contractility, vCE, the Watts Factor, and the Detrusor Contractility Parameter, t20‐80; and to test whether t20‐80 depends on outflow tract resistance as indicated by Bladder Outlet Obstruction Index (BOOI). Methods: Thirty‐seven pressure‐flow traces from 20 male and 17 female patients were analyzed and forms of the Watts Factor, t20‐80 and BOOI were compared with vCE. Results: The Detrusor Contractility Parameter, t20‐80, is significantly associated with vCE for both women and men without a high degree of bladder outlet obstruction. The Watts Factor only had a significant association with vCE at the point of maximum flow in women. Conclusions: The Detrusor Contractility Parameter (DCP) (t20‐80), can be measured easily from the pressure flow curves of a urodynamic test. The Watts Factor at maximum urine flow, WFQmax, can be readily calculated, but is only applicable to women. In both women and men without a high degree of bladder outlet obstruction, DCP is better associated with true detrusor contractility than any Watts Factor analysis. [ABSTRACT FROM AUTHOR]

Aims: To review the descriptors and definitions of urine flow rate curve shape with a view to promoting greater clarity and to propose standard terms Methods: A search was made in the PubMed and ICS standardization documents on urine flow rate curve shape. Results: The flow shape descriptors and their definitions are summarized and presented. "Normal" was widely used for describing a bell‐shaped flow curve, and "plateau" was mostly used where the ICS describe "constrictive" flow shape. The use of shape descriptors "fluctuating," "compressive," "tower‐shaped," and "intermittent" varied in the literature. Conclusion: This survey provides an overview of flow shape descriptors and their definitions. We suggest it is clearer to use only descriptors that describe shape alone, that is, normal, fluctuating, intermittent, and plateau, with comments on symmetry and Qmax. [ABSTRACT FROM AUTHOR]

Objectives: To compare the initial resting intravesical pressure (pves) and abdominal pressure (pabd) in the sitting position with the typical range of values, to assess the correlation between such pressures and patient xipho‐pubic distance, body weight, height and body mass index (BMI), and to estimate if xipho‐pubic distance can be a guide to interpret initial resting pressures in urodynamic testing. Methods: Women with lower urinary tract symptomatology referred for urodynamic testing were consecutively enrolled in a prospective study. Conventional cystometry was done following “good urodynamic practices”. The correlation between initial resting pves and pabd and xipho‐pubic distance, body weight, height and BMI were studied using simple and multiple linear regression analysis. Statistical significance was defined as P < 0.05. Results: One hundred women aged (mean ± SD) 59.2 ± 13.3 were studied. There was a significant correlation between both pves and pabd, and xipho‐pubic distance, body weight and BMI and no correlation with height. Over the multiple analysis, xipho‐pubic distance and body weight correlated independently with pves; body weight correlated independently with pabd. Three patients had pves and/or pabd out of typical range, with BMIs values of 18.48, 18.72 and 35.81 kg/m2. There was a wide range of difference between xipho‐pubic distance and initial resting pressures. Conclusions: Out of range initial resting pressures occur in underweight (or close to) or severely obese patients. Xipho‐pubic distance and body weight correlated independently with pves. Body weight correlated independently with pabd. Xipho‐pubic distance cannot be a guide to interpret the initial resting pressures. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to determine what difference the inclusion of patients with coexisting detrusor overactivity (DO) makes to the signs and symptoms of patients with detrusor underactivity (DU). Methods: A total of 250 male and 435 female urodynamic tests were analyzed retrospectively. Signs and symptoms which showed a statistically significant difference between DU without DO and DU with DO were identified. Results: Males with DO in addition to DU had higher age and number of daily micturitions, and were more likely to report urgency with or without urgency incontinence than males with DU without DO. They also had lower volumes for first desire to void, volume voided, and post void residual urine, lower abdominal pressure at Qmax and were less likely to report a history of retention or reduced bladder filling sensation than males with DU without DO. Females with DO in addition to DU had higher age and BMI, and were more likely to report urgency incontinence, higher day and night pad usage, constipation and have reduced anal tone than females with DU without DO. They also had lower volumes for first desire to void, volume voided, and post void residual urine, and lower abdominal pressure at Qmax than females who had DU without DO. Conclusions: There are differences in signs and symptoms between patients who have DU without DO, compared to patients having DU with DO. This understanding will help future studies investigating treatment options for DU patients. [ABSTRACT FROM AUTHOR]

Aims: To review the recommendations on uroflowmetry in the International Continence Society (ICS) Standardization documents in order to identify a systematic approach to the delivery and interpretation of free flow rate testing in clinical practice. Methods: Expectations of service and good practice in uroflowmetry described in the ICS standards on Urodynamic Practice, Urodynamic Equipment, and Terminology for Lower Urinary Tract Function were identified and summarized. Results: Urodynamic centers should provide a suitable uroflowmetry testing environment. Equipment should be calibrated and maintained according to manufacturer requirements. Patients should be well‐informed in advance of the test. They should be advised to avoid: knocking the machine; allowing the stream to move; squeezing the urethra; and body movements. It is generally appropriate to get more than one flow trace for each patient. Voided volume should be representative for the patient, for example by comparing with values recorded on a Bladder Diary. Post void residual (PVR) should be measured soon after testing. After the test, the urodynamicist should review the trace and ensure maximum flow rate and end of micturition are correctly identified in case the equipment has inappropriately taken the values from a trace artefact. Conclusions: The summary provides a systematic approach to ensure a representative, high quality, non‐invasive flow test is carried out for individual patients. [ABSTRACT FROM AUTHOR]

Aims: To review the recommendations on basic urodynamic testing in the International Continence Society (ICS) standardization documents, specifying key recommendations for delivery and interpretation in clinical practice. Methods: Fundamental expectations described in the ICS standards on good urodynamic practices, urodynamic equipment, and terminology for lower urinary tract (LUT) function were identified and summarized. Results: The ICS standard urodynamic protocol includes clinical history, including symptom and bother score(s), examination, 3‐day voiding chart/diary, representative uroflowmetry with post‐void residual, and cystometry with pressure‐flow study (PFS). Liquid filled catheters are connected to pressure transducers at the same vertical pressure as the patient's pubic symphysis, taking atmospheric pressure as the zero value. Urodynamic testing is done to answer specific therapy‐driven questions for treatment selection; provocations are applied to give the best chance of reproducing the problem during the test. Quality of recording is monitored throughout, and remedial steps taken for any technical issues occurring during testing. Labels are applied during the test to document events, such as patient‐reported sensation, provocation tests, and permission to void. After the test, the pressure and flow traces are scrutinized to ensure artefacts do not confound the findings. An ICS standard urodynamic report details the key aspects, reporting clinical observations, technical, and quality issues. Urodynamic services must maintain and calibrate equipment according to manufacturer stipulations. Conclusions: The review provides a succinct summary of practice expectations for a urodynamic unit offering cystometry and pressure flow studies (PFS) to an appropriate standard. [ABSTRACT FROM AUTHOR]

Aims: In recent years urodynamic innovations, although well researched, have failed to follow a standardized development pathway specifically in terms of clinical trials undertaken to demonstrate efficacy. This was discussed at the International Consultation on Incontinence Research Society (ICI‐RS) in Bristol, United Kingdom, 2017 with the aim of defining minimum standards for future urodynamic research. Methods: The recent recommendations from the IDEAL (innovation, development, exploration, assessment, and long‐term study) collaboration regarding surgical research were reviewed. Two examples of recent novel urodynamic technologies, the penile cuff test and air charged urodynamic catheters were used as case studies and the research programmes behind their development were critiqued. Results: The rigorous and standardized model of surgical research proposed by the IDEAL collaboration was endorsed as an appropriate model for future urodynamic research. A methodical approach to research can fulfil a host of objectives including illustration of the clinical need, help with design and refinement of technique and proving efficacy for any new test or device. The penile cuff test is a novel urodynamic measurement technique that has been well researched and is now used in clinical practice. Further research is needed before air charged catheters can be recommended for widespread clinical use and the IDEAL framework provides a template for ongoing development. Conclusions: In the future, these recommendations should lead to a more standardized and uniform programme of urodynamic research and enable a thorough evaluation of new technologies prior to wider clinical uptake. [ABSTRACT FROM AUTHOR]

Aims: To gauge the current level of diagnostic utility of uroflowmetry and to suggest areas needing research to improve this. Methods: A summary of the debate held at the 2017 meeting of the International Consultation on Incontinence Research Society, with subsequent analysis by the authors. Results: Limited diagnostic sensitivity and specificity exist for maximum flow rates, multiple uroflow measurements, and flow‐volume nomograms. There is a lack of clarity in flow rate curve shape description and uroflow time measurement. Conclusions: There is a need for research to combine uroflowmetry with other non‐invasive indicators. Better standardizations of test technique, flow‐volume nomograms, uroflow shape descriptions, and time measurements are required. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to identify signs and symptoms which show differences between men with detrusor underactivity (DU) compared to those with both DU and bladder outlet obstruction (BOO). Methods: One thousand six hundred and twelve urodynamic tests on male patients were analyzed retrospectively. Signs and symptoms which showed a statistically significant difference between patients with DU alone and patients with both DU+BOO were identified. Results: In the DU only group, considering only patients without a history of bladder outlet surgery, the number of daytime micturitions was lower, maximum voided volume on the bladder diary was higher, and slow stream was reported less often, whereas urinary tract infections were reported more often than for DU+BOO males. The average urine flow rate and abdominal pressure at maximum flow were greater in the DU males, compared to the DU+BOO males. Conclusions: These data suggest that by combining symptoms, medical history and signs, that could be measured without the need for invasive urodynamics, it may be possible to identify men with DU in a non‐invasive way. By doing so, men with DU could be separated from men with both DU+BOO, with sufficient specificity to allow the use of any new non‐surgical treatment modalities, such as new and effective medical therapy. [ABSTRACT FROM AUTHOR]

Aims: To quantify the inaccuracy of pressure measurement by water‐filled systems, with a view to recommending better practice. Methods: Papers examining quality of measurements were reviewed, and standards documents examined. Technical data from manufacturers were gathered and summarized. Measurements were made on two different urodynamic systems. Individual inaccuracies were combined using the root sum of squares method. Results: The total inaccuracy in measurement may reach up to 9.6 cmH2O on pdet, but with good practice this may be mitigated to 1.3 cmH2O. Conclusions: Water‐filled systems, while being the recommended method for urodynamic measurements, are subject to a potential inaccuracy during poor use of up to approximately 10 cmH2O on pdet. Good practice can reduce this inaccuracy to a tolerable level, that is, approximately 1 cmH2O. [ABSTRACT FROM AUTHOR]

Aims Air filled catheters (AFCs) have been actively marketed for the past few years and in some geographic areas are widely used. However, as the scientific basis for introduction of this technology for pressure measurement in urodynamics was not clear, a study group examined the evidence. Methods A search of the peer reviewed literature was carried out. Results Four papers were identified, of which two were laboratory experiments and two were clinical papers, in female patients, that compared the pressures recorded by AFCs and those recorded using the traditional water filled catheters (WFCs). These data show that there are differences between the pressures measured by the two types of catheters. As yet, the reasons for these differences are not clear. Conclusions There should be further systematic laboratory and clinical research before AFCs can be recommended for routine clinical use. We would recommend that a professional worldwide multidisciplinary scientific society, such as the International Continence Society, should work with manufacturers and regulatory bodies to ensure that this urodynamic method is properly scientifically evaluated, in the wider interests of patient safety. [ABSTRACT FROM AUTHOR]

The diagnosis of bladder outlet obstruction (BOO) in the male is dependent on measurements of pressure and flow made during urodynamic studies. The procedure of urodynamics and the indices used to delineate BOO are well standardized largely as a result of the work of the International Continence Society. The clinical utility of the diagnosis of BOO is however, less well defined and there are several shortcomings and gaps in the currently available medical literature. Consequently the International Consultation on Incontinence Research Society (ICI-RS) held a think tank session in 2015 entitled 'Male bladder outlet obstruction: Time to re-evaluate the definition and reconsider our diagnostic pathway?' This manuscript details the discussions that took place within that think tank setting out the pros and cons of the current definition of BOO and exploring alternative clinical tests (alone or in combination) which may be useful in the future investigation of male patients with lower urinary tract symptoms. The think tank panel concluded that pressure-flow studies remain the diagnostic gold-standard for BOO although there is still a lack of high quality evidence. Newer, less invasive, investigations have shown promise in terms of diagnostic accuracy for BOO but similar criticisms can be levelled against these tests. Therefore, the think tank suggests further research with regard to these alternative indicators to determine their clinical utility. [ABSTRACT FROM AUTHOR]

Aims To describe parameters from urodynamic pressure recordings that describe urinary bladder contractility through the use of principles of muscle mechanics. Methods Subtracted detrusor pressure and voided flow were recorded from patients undergoing filling cystometry. The isovolumetric increase of detrusor pressure, P, of a voluntary bladder contraction before voiding was used to generate a plot of (dP/dt)/P versus P. Extrapolation of the plot to the y-axis and the x-axis generated a contractility parameter, vCE (the maximum rate of pressure development) and the maximum isovolumetric pressure, P0, respectively. Similar curves were obtained in ex vivo pig bladders with different concentrations of the inotropic agent carbachol and shown in a supplement. Results Values of vCE, but not P0, diminished with age in female subjects. vCE was most significantly associated with the 20-80% duration of isovolumetric contraction t20-80; and a weaker association with maximum flow rate and BCI in women. P0 was not associated with any urodynamic variable in women, but in men was with t20-80 and isovolumetric pressure indices. Conclusions The rate of isovolumetric subtracted detrusor pressure (t20-80) increase shows a very significant association with indices of bladder contractility as derived from a derived force-velocity curve. We propose that t20-80 is a detrusor contractility parameter (DCP). Neurourol. Urodynam. 36:1009-1014, 2017. © 2016 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Background The clinical diagnosis of detrusor underactivity (DU) is hampered by the need for invasive pressure flow studies (PFS) in combination with a lack of knowledge of the associated signs and symptoms. This has contributed to a lack of awareness of DU and underactive bladder, and to the assumption that symptoms are always due to bladder outlet obstruction (BOO). Objective To investigate the signs and symptoms recorded in a large urodynamic database of patients who met the diagnoses of DU, BOO, and normal, to identify the clinical features associated with DU. Design, setting, and participants From the database of 28 282 adult PFS records, 1788 patients were classified into: (1) those with DU without BOO; (2) those with BOO without DU; and (3) those with normal PFS. Results Patients with DU reported a statistically significantly higher occurrence of decreased and/or interrupted urinary stream, hesitancy, feeling of incomplete bladder emptying, palpable bladder, and absent and/or decreased sensation compared with patients with normal PFS. Other differences were found between men with DU and BOO, and between women with DU and normal PFS. Conclusions There are signs and symptoms that can distinguish DU patients from patients with normal PFS and further distinguish between DU and BOO, which is traditionally invasively diagnosed. This is a first step to better understand the clinical presentation of DU patients, is consistent with the recent underactive bladder working definition, and justifies further exploration of the signs and symptoms of DU. Patient summary The clinical diagnosis of detrusor underactivity is hampered by the need for invasive urodynamics in combination with a lack of knowledge of the associated signs and symptoms. This study has shown that there are signs and symptoms that can distinguish men and women patients with DU from patients with either normal urodynamic studies or with BOO. [ABSTRACT FROM AUTHOR]

Aims At present, existing bladder outlet obstruction (BOO) nomograms for women are still not universally accepted. Moreover, only limited information is available regarding bladder contractility in women. The aim is to present the discussions and recommendations from the think tank session 'Can we construct and validate contractility and obstruction nomograms for women?' held at the 2014 International Consultation on Incontinence-Research Society (ICI-RS) meeting in Bristol, UK. Methods An overview of clinical significance, bladder mechanics and modelling, lack of existing nomograms for women, and development of new nomograms were presented and discussed in a multidisciplinary think tank session. This think tank session was based on a collaboration between physicians, engineers, and researchers and consensus was achieved on future research initiatives. Results and Conclusions Based on the think tank discussion, the ICI-RS panel put forward the following recommendations: the need to acquire normative age-matched data in women to define 'normal' and 'pathological' values of urodynamic parameters; the inclusion of additional clinical data in new nomograms and the use of this extra dimension to develop clinically applicable nomograms for female BOO and contractility; and finally, the need to take into account the variability of BOO in women when developing female bladder contractility nomograms. Neurourol. Urodynam. 35:307-311, 2016. © 2016 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Aims To debate and evaluate the evidence base regarding the added value of video to urodynamics in adults and to define research questions. Methods In the ICI-RS Meeting 2014 a Think Tank analyzed the current guidelines recommending video urodynamics (VUD) and performed a literature search to determine the level of evidence for the additional value of the imaging with urodynamic assessment of both neurogenic and non-neurogenic lower urinary tract dysfunction. Results Current guidelines do not specify the added value of imaging to urodynamics. Recommendations are based on single center series and expert opinion. Standard imaging protocols are not available and evidence regarding the balance between number and timing of pictures, patient positioning, and exposure time on the one hand and diagnosis on the other hand is lacking. On the basis of expert consensus VUD is relevant in the follow-up of patients with spinal dysraphism. Evidence for the value of VUD in non-neurogenic lower urinary tract dysfunction is sparse. There is some evidence that VUD is not necessary in uncomplicated female SUI, but expert opinion suggests it might improve the evaluation of patients with recurrent SUI. Conclusions There is only low level evidence for the addition of video to urodynamics. The ICI-RS Think Tank encourages better reporting of results of imaging and systematic reporting of X-ray doses. Specific research hypotheses regarding the added value of imaging are recommended. The panel suggests the development of standards for technically optimal VUD that is practically achievable with machines that are on the market. Neurourol. Urodynam. 35:324-329, 2016. © 2016 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Aims To assess whether current methods of urethral function assessment are sufficient for clinical requirement. Methods A summary of the debate held at the 2013 meeting of the International Consultation on Incontinence Research Society, with subsequent analysis by the authors. Results All reported methods of assessment were reviewed and a summary of reported efficacy and clinical application for each is given. Every method of assessment has limitations as to its use, and in some cases the methods have yet to be proved reliable. Conclusions A gap exists between clinical requirements and the capacity of current urethral function assessments to assist diagnosis. Recommendations are therefore made for future research topics. Neurourol. Urodynam. 33:587-590, 2014. © 2014 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

These guidelines provide benchmarks for the performance of urodynamic equipment, and have been developed by the International Continence Society to assist purchasing decisions, design requirements, and performance checks. The guidelines suggest ranges of specification for uroflowmetry, volume, pressure, and EMG measurement, along with recommendations for user interfaces and performance tests. Factors affecting measurement relating to the different technologies used are also described. Summary tables of essential and desirable features are included for ease of reference. It is emphasized that these guidelines can only contribute to good urodynamics if equipment is used properly, in accordance with good practice. Neurourol. Urodynam. 33:370-379, 2014. © 2014 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Aims The aims of this study are to compile a list of common features and artefacts found in urodynamics, to produce definitions of these features, and describe any necessary remedial action. An image and word description for each event has been included as well as statistics providing information on the prevalence and frequency of each event. Methods In order to identify the most common features and artefacts 200 consecutive urodynamic traces were reviewed. A random 10% sample was cross-checked to ensure event classification accuracy. To extract significant pressure peaks from the data, an algorithm was written capable of detecting initial resting pressure and updating it as necessary. Significant pressure peaks were defined as those that differed from resting pressure values by 10 cmH2O or more. When describing the events, standard sources were consulted for published definitions. The images selected for each event are typical examples but do not represent the variation that can occur between examples. The patients whose files were used in this study suffered from a variety of lower urinary tract disorders so that it is likely that they cover all common or important urodynamic pressure events. Results In total 10,355 pressure events were identified and classified into 19 different categories. For each category, a description, example image and remedial action are included. Where published definitions do not exist, new ones are proposed. Conclusions All common or important urodynamic pressure events have been included in this study and descriptions of the events have been included in one article for the first time. Neurourol. Urodynam. 31:1104-1117, 2012. © 2012 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Half the message is just mess: judging the value of urodynamics based on partial or poor-quality results The debate on the value of urodynamics (UDS) in the patient pathway continues in the literature. The role of urodynamics in the evaluation of urinary incontinence: the European Association of Urology recommendations in 2016. [Extracted from the article]

Aims To present the ICS Teaching Module on artefacts in urodynamics pressure traces. Methods Slides from three urodynamics centres were assembled. Descriptions and labels were agreed by the authors and the module presented at the ICS Annual Scientific Meeting in Brazil 2014. Results Ten artefacts that should be recognized while using water-filled urodynamic systems are presented and remedial action described. Conclusions This manuscript serves as scientific background for the slide set made available on the ICS website. By following the guidelines in this teaching module, good quality urodynamics can be more readily achieved. Neurourol. Urodynam. 36:35-36, 2017. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]