Review article| Volume 244, P141-153, January 2020

Does pre-operative urodynamics lead to better outcomes in management of urinary incontinence in women? A linked systematic review and meta-analysis

Published:November 15, 2019DOI:


      The use of preoperative urodynamics as a standard investigation for urinary incontinence (UI) has long been a subject of debate, with a lack of robust evidence to demonstrate improved patients’ outcomes. We aim to compare the clinical and cost effectiveness of urodynamics versus office clinical evaluation only, prior to the treatment of UI. We conducted three linked systematic reviews and meta-analyses of randomised controlled trials (RCTs) comparing urodynamics assessment versus clinical evaluation only in women prior to 1) non-surgical treatment of UI, 2a) surgical treatment of stress urinary incontinence (SUI) and 2b) invasive treatment for overactive bladder (OAB). Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded. Primary outcomes were patient-reported and objective success post-treatment. Secondary outcomes were adverse events, quality of life, sexual function and health economic measures. We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases for each category, which was last updated on January 2019. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. The random effects model was used to assess risk ratio and mean difference with 95% confidence interval. Statistical heterogeneity was assessed by I2 statistics and the quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.
      Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of pelvic floor muscle training, with or without pharmacological therapy. Meta-analysis of 150 women showed no evidence of significant difference in the patient-reported and objective success rates between groups (P = 0.520, RR: 0.91, 95% Cl 0.69–1.21, I2 = 0% and P = 0.470, RR:0.87, 95% Cl 0.59–1.28, I2 = n/a, respectively). Seven RCTs were identified for surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Meta-analysis of 1149 women showed no evidence of significant difference in patient-reported (P = 0.850, RR:1.01, 95% CI 0.88–1.16, I2 = 53%) and objective success between groups (P = 0.630, RR:1.02, 95% CI 0.95–1.08, I2 = 28%). There was no significant difference in incidence of voiding dysfunction, de novo urgency, and urinary tract infection between groups. No RCTs were identified for invasive management of OAB.
      In conclusion, limited evidence shows that routine urodynamics prior to non-surgical management of UI or surgical management of SUI is not associated with improved treatment outcomes, when compared to clinical evaluation only. Well-designed clinical trials are needed to evaluate the clinical and cost-effectiveness of routine urodynamics prior to surgical management of SUI and OAB.


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        • Farage M.
        • Miller K.
        • Berardesca E.
        • Maibach H.
        Psychosocial and societal burden of incontinence in the aged population: a review.
        Arch Gynecol Obstet. 2007; 277: 285-290
        • Kwon B.
        • Kim G.
        • Son Y.
        • Roh Y.
        • You M.
        Quality of life of women with urinary incontinence: a systematic literature review.
        Int Neurourol J. 2010; 14: 133
        • Nygaard I.E.
        • Lemke J.H.
        Urinary incontinence in rural older women: prevalence, incidence and remission.
        J Am Geriatr Soc. 1996; 44: 1049-1054
        • Irwin D.
        • Kopp Z.
        • Agatep B.
        • Milsom I.
        • Abrams P.
        Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction.
        BJU Int. 2011; 108: 1132-1138
        • Bates C.P.
        • Whiteside C.G.
        • Turner-Warwick R.
        Synchronous cine-pressure-flow-cysto-urethrography with special reference to stress and urge incontinence.
        Br J Urol. 1970; 42: 714-723
        • Martin J.
        • Williams K.
        • Abrams K.
        • Turner D.
        • Sutton A.
        • Chapple C.
        • et al.
        Systematic review and evaluation of methods of assessing urinary incontinence.
        Health Technol Assess. 2006; 10
        • Ku J.
        • Kim S.
        • Kim H.
        • Paick J.
        • Son H.
        • Oh S.
        Patient experience with a urodynamic study: a prospective study in 208 patients.
        J Urol. 2004; 171: 2307-2310
        • Foon R.
        • Toozs-Hobson P.
        • Latthe P.
        Prophylactic antibiotics to reduce the risk of urinary tract infections after urodynamic studies.
        Cochrane Database Syst Rev. 2012; CD008224
        • Rachaneni S.
        • McCooty S.
        • Middleton L.
        • Parker V.
        • Daniels J.
        • Coomarasamy A.
        • et al.
        Bladder ultrasonography for diagnosing detrusor overactivity: test accuracy study and economic evaluation.
        Health Technol Assess. 2016; 20: 1-150
        • Irwin D.E.
        • Milsom I.
        • Hunskaar S.
        • et al.
        Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study.
        Eur Urol. 2006; 50 (discussion 1314-5): 14
        • Digesu G.A.
        • Salvatore S.
        • Fernando R.
        • Khullar V.
        Mixed urinary symptoms: what are the urodynamic findings?.
        Neurourol Urodyn. 2008; 27: 372-375
        • Mobley D.F.
        • Baum N.
        Etiology, evaluation, and management of nocturia in elderly men and women.
        Postgrad Med. 2014; 126: 147-153
        • Hilton P.
        • Bryant A.
        • Howel D.
        • McColl E.
        • Buckley B.
        • Lucas M.
        • et al.
        Assessing professional equipoise and views about a future clinical trial of invasive urodynamics prior to surgery for stress urinary incontinence in women: A survey within a mixed methods feasibility study.
        Neurourol Urodyn. 2012; 31: 1223-1230
        • Rachaneni S.
        • Latthe P.
        Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis.
        BJOG. 2014; 122: 8-16
        • Clement K.
        • Lapitan M.
        • Omar M.
        • Glazener C.
        Urodynamic studies for management of urinary incontinence in children and adults.
        Cochrane Database Syst Rev. 2013;
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6: e1000097
      1. Higgins J.P.T. Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011 (Available from
        • Schünemann H.J.
        • Oxman A.D.
        • Vist G.E.
        • Higgins J.P.T.
        • Deeks J.J.
        • Glasziou P.
        • et al.
        Chapter 12: interpreting results and drawing conclusions.
        in: Higgins J.P. Green S. Cochrane handbook for systematic reviews of inverventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011 (Available from
      2. Review manager (RevMan) [Computer program]. Version 5.3. Copenhagen: the nordic cochrane centre, the cochrane collaboration.
        • Mantel N.
        Chi-square tests with one degree of freedom; extensions of the Mantel- Haenszel Procedure.
        J Am Stat Assoc. 1963; 58: 690
        • Gałecki A.
        • Burzykowski T.
        Linear mixed-effects models using R.
        Springer, New York2013
        • Ramsay I.
        • Ali H.
        • Hunter M.
        • Stark D.
        • Donaldson K.
        A randomised controlled trial of urodynamic investigations prior to conservative treatment of urinary incontinence in the female.
        Int Urogynecol J Pelvic Floor Dysfunct. 1995; 6: 277-281
        • Khullar V.
        • Salvatore S.
        • Cardozo L.
        • Howland E.
        • Digesu A.
        • Kelleher C.
        • et al.
        Randomised study of ambulatory urodynamics versus symptomatic treatment of symptomatic women without a urodynamic diagnosis.
        in: Proceedings of the International Continence Society (ICS), 30th Annual Meeting; 2000 Aug 28-31, Tampere, Finland2000
        • Majumdar A.
        • Latthe P.
        • Toozs-Hobson P.
        Urodynamics prior to treatment as an intervention: a pilot study.
        Neurourol Urodyn. 2010; 29: 522-526
        • Holtedahl K.
        • Verelst M.
        • Schiefloe A.
        A population based, randomised, controlled trial of conservative treatment for urinary incontinence in women.
        Acta Obstet Gynecol Scand. 1998; 77: 671-677
        • Choe J.M.
        Sling surgery performed with and without preoperative urodynamics: a comparative outcomes analysis (Abstract).
        in: Proceedings of the International Continence Society (ICS), 31st Annual Meeting; 2001 Sept 18-21, Seoul, Korea2001 (Abstract 175)
        • Hilton P.
        • Armstrong N.
        • Brennand C.
        • Howel D.
        • Shen J.
        • Bryant A.
        • et al.
        INVESTIGATE-I (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?): a mixed-methods study to assess the feasibility of a future randomised controlled trial of invasive urodynamic testing prior to surgery for stress urinary incontinence in women.
        Health Technol Assess. 2015; 19: 1-274
        • Nager C.W.
        • Brubaker L.
        • Litman H.J.
        • Zyczynski H.M.
        • Varner R.E.
        • Amundsen C.
        • et al.
        A randomized trial of urodynamic testing before stress‐incontinence surgery.
        N Engl J Med. 2012; 366: 1987-1997
        • Romero M.J.
        • Ortiz G.M.A.
        • Gomez P.L.
        Does pressure flow study improve the outcome of surgery in women with SUI?.
        Eur Urol Suppl. 2010; 9: 228
        • Van Leijsen S.A.L.
        • Kluivers K.B.
        • Mol B.W.
        • Broekhuis S.R.
        • Milani A.L.
        • et al.
        Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non‐inferiority randomised controlled trial.
        Neurourol Urodyn. 2012; 31: 1118-1123
        • Agarwal A.
        • Rathi S.
        • Patnaik P.
        • Shaw D.
        • Jain M.
        • Trivedi S.
        • et al.
        Does preoperative urodynamic testing improve surgical outcomes in patients undergoing the transobturator table procedure for stress urinary incontinence? A prospective randomised trial.
        Korean J Urol. 2014; 55: 821-827
        • National Institute for Health and Care Excellence
        Urinary incontinence and pelvic organ prolapse in women: management (NICE Guideline 123).
        (Available at: [Accessed: 5 June 2019])2019
        • van Leijsen S.A.L.
        • Van Evert J.S.H.
        • Mol B.W.J.
        • Vierhout M.E.
        • Milani A.L.
        • et al.
        The correlation between clinical and urodynamic diagnosis in classifying the type of urinary incontinence in women. A systematic review of the literature.
        Neurourol Urodyn. 2011; 30: 495-502
        • Paick J.S.
        • Ku J.H.
        • Shin J.W.
        • Son H.
        • Oh S.J.
        • Kim S.W.
        Tension-free vaginal tape procedure for urinary incontinence with low Valsalva leak point pressure.
        J Urol. 2004; 172: 1370-1373
        • O’Connor R.
        • Nanigian D.
        • Lyon M.
        • Ellison L.
        • Bales G.
        • Stone A.
        Early outcomes of mid-urethral slings for female stress urinary incontinence stratified by valsalva leak point pressure.
        Neurourol Urodyn. 2006; 25: 685-688
        • Houwert R.M.
        • Venema P.L.
        • Aquarius A.E.
        • Bruinse H.W.
        • JPWR Roovers
        • Vervest H.A.M.
        Risk factors for failure of retropubic and transobturator midurethral slings.
        Obstet Gynecol Surv. 2009; 64: 795-796
        • van Leijsen S.A.L.
        • Kluivers K.
        • Mol B.
        • Vierhout M.
        • Heesakkers J.
        The value of preoperative urodynamics according to gynecologists and urologists with special interest in stress urinary incontinence.
        Int Urogynecol J. 2011; 23: 423-428
        • Riad M.
        • Familusi A.
        • El Sayed M.
        • Abdel-Fattah M.
        Current practice in the UK for the assessment and management of recurrent stress urinary incontinence in women.
        Int Urogynecol J. 2011; 22: S1-195
        • Sirls L.T.
        • Richter H.E.
        • Litman H.J.
        • Kenton K.
        • Lemack G.E.
        • Lukacz E.S.
        • et al.
        The effect of urodynamic testing on clinical diagnosis, treatment plan and outcomes in women undergoing stress urinary incontinence surgery.
        J Urol. 2013; 189: 204-209
        • Cho S.T.
        • Song H.C.
        • Song H.J.
        • Lee Y.G.
        • Kim K.K.
        Predictors of postoperative voiding dysfunction following transobsturator sling procedures in patients with stress urinary incontinence.
        Int Neurourol J. 2010; 14: 26-33
        • Mostafa A.
        • Madhuvrata P.
        • Abdel-Fattah M.
        Preoperative urodynamic predictors of short-term voiding dysfunction following a transobturator tension-free vaginal tape procedure.
        Int J Gynecol Obstet. 2011; 115: 49-52
        • Homer T.
        • Shen J.
        • Vale L.
        • McColl E.
        • Tincello D.G.
        • Hilton P.
        Invasive urodynamic testing prior to surgical treatment for stress urinary incontinence in women: cost-effectiveness and value of information analyses in the context of a mixed methods feasibility study.
        Pilot Feasibility Stud. 2018; 4: 1-11
        • Norton P.
        • Nager C.
        • Brubaker L.
        • Lemack G.
        • Sirls L.
        • Holley R.
        • et al.
        The cost of preoperative urodynamics: A secondary analysis of the ValUE trial.
        Neurourol Urodyn. 2014; 35: 81-84
        • Digesu G.A.
        • Khullar V.
        • Cardozo L.
        • Salvatore S.
        Overactive bladder symptoms: Do we need urodynamics?.
        Neurourol Urodyn. 2003; 22: 105-108
        • Rovner E.
        • Kennelly M.
        • Schulte-Baukloh H.
        • Zhou J.
        • et al.
        Urodynamic results and clinical outcomes with intradetrusor injections of onabotulinumtoxinA in a randomised, placebo-controlled dose-finding study in idiopathic overactive bladder.
        Neurourol Urodyn. 2011; 30: 556-562
        • Brubaker L.
        • Richter H.E.
        • Visco A.
        • et al.
        Refractory idiopathic urge urinary incontinence and botulinum A injection.
        J Urol. 2008; 180: 217-222
        • Groenendijk P.M.
        • Lycklama a Nyeholt A.A.
        • Heesakkers J.P.
        • et al.
        Urodynamic evaluation of sacral neuromodulation for urge urinary incontinence.
        BJU Int. 2008; 101: 325-329
      3. FUTURE [Internet]. 2019 [cited 10 March 2019]. Available from: