The Role of Urodynamic Testing Prior to Third-Line OAB Therapy

This review outlines current guidelines and evidence for the use of urodynamic testing prior to the initiation of third-line overactive bladder (OAB) treatment options. OAB currently affects many patients with a significant impact on quality of life as well as health care resources. Treatment algorithms proceed from least to most invasive in an attempt to ameliorate symptoms, namely, urgency, frequency, and urgency incontinence. The current third-line OAB management strategies include percutaneous tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS), and onabotulinumtoxinA injection. These modalities are reserved for patients that have gained insufficient symptom control or are intolerant of less invasive treatments. Urodynamic studies (UDS) are typically performed to help guide treatment planning and/or to evaluate for harmful urologic conditions. Currently available studies do not show a clear link between UDS results and treatment OAB success. The finding of detrusor overactivity (DO) has not been clearly established as a prerequisite to have clinical benefit with third-line OAB treatments in the uncomplicated idiopathic OAB patient population. There is some evidence that patients with DO on UDS may benefit more; however, additional blinded placebo-controlled studies are needed. Urodynamics should be used judiciously for patients with known or suspected voiding phase dysfunction, those with rapidly changing symptoms, those in whom the diagnosis is not clear, those who have medical or urological histories that can affect outcomes of treatment, and in those with known or suspected neurological disease. Although urodynamics may influence clinical decision-making, our review does not support the role of these investigations as predictors of outcomes in patients with uncomplicated, idiopathic overactive bladder.