指南呼吁医生进行单纯性压力性尿失禁术前评估

美国妇产科医师学会（ACOG）及美国妇科泌尿协会（AUGS）首次联合发布指南建议，临床医师在为单纯性压力性尿失禁（SUI）女性患者进行尿道中段悬吊手术前应进行简单的六步评估。

《妇产科杂志》6月刊刊登的指南委员会意见指出，该评估步骤剔除了术前尿动力测试，因为其未被证明可改善单纯性SUI患者的术后转归（2014;123:1403-7）。

AUGS主席、ACOG的妇科泌尿实践小组委员会（参与本次指南起草）委员、加州大学圣地亚哥分校女性骨盆医学与重建手术研究办公室主任、妇产科教授Charles Nager博士介绍到，“至今为止，单纯性SUI术前评估一直未被统一，本次ACOG和AUGS两大专业组织首次联合发表的指南专门为临床医师设置术前评估标准流程。”指南并“不要求每位患者都接受尿动力学测试，”。

妇产科教授Cheryl Iglesia博士说，如果简单的六步评估能够确认单纯性SUI的存在，“就不再需要花费上千美元进行尿动力学测试，且该测试也无法改变最终结果，”。

推荐的六步评估如下：

1、详细询问泌尿科、内科、神经科病史及用药史。

2、进行尿液检测排除尿路感染。

3、进行体格检查评估影响因素，包括尿道憩室，阴道分泌物，尿道外尿失禁，盆腔器官脱垂（如果脱垂超出了处女膜则诊断为复杂性SUI）。

4、进行咳嗽压力测试证实SUI。

5、进行尿道流动性评估抗尿失禁手术成功的可能性。

6、进行残余尿测量判断是膀胱排空异常还是慢性尿潴留所致尿失禁。

单纯性SUI患者进行咳嗽压力测试时会出现尿道口漏尿症状，尿液检查正常则可排除尿路感染，盆腔器官脱垂未超过处女膜，残余尿量正常，符合以上标准且对保守治疗无效的患者无需再进行术前尿动力学测试。

指南认为，相比之下，复杂性SUI患者 “更适合在术前进行尿动力学检测，”。 “对于此类患者，六步评价法和临床判断的结果决定了是否进行术前多通道尿动力学测试。”

随刊评述

不必要的术前尿动力学测试

“健康保健服务比以往任何时候都更加重视临床效率和成本效益，” Lee Richter博士说。 “这些指南及时地为原发性单纯性SUI患者解决了这两方面的问题。”

SUI患者的主治医师应该在治疗（手术）前遵循指南提出的六步诊断评估，“基于办公室的评估结果，单纯性SUI患者则能在不另行尿动力学测试的情况下开展悬吊手术，” Richter博士说。

研究人员在2012年的尿动力学评价的价值研究（VALUE）报告中指出，术前尿动力学测试没有为单纯性SUI（N. Engl. J. Med. 2012;366:1987-97）患者的悬吊手术带来更好的结果。在这些研究结果发表之前，医师缺乏明确的证据来判断是否应该进行尿动力学测试，新指南则统一了女性尿失禁的诊断方法。

“女性SUI的六步评估法是由悬吊手术更易成功人群的特征发展而来的，” Richter博士指出， “而未来的研究则主要集中在悬吊手术失败的风险因素分析以及具有挑战性的临床治疗上。”

Richter博士是女性骨盆医学与重建手术研究办公室MEDSTAR华盛顿医院中心的成员，言论来自Frontline Medical News的采访摘录。

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By: AMY KARON, Ob.Gyn. News Digital Network

FROM OBSTETRICS AND GYNECOLOGY

Preop urodynamic testing unnecessary

Clinicians should perform a basic six-step evaluation of women with symptoms of uncomplicated stress urinary incontinence before these patients undergo midurethral sling surgery, according to first-time guidelines from the American College of Obstetricians and Gynecologists and the American Urogynecologic Society.

The recommended steps exclude preoperative urodynamic testing, which has not been shown to improve surgical outcomes in patients with uncomplicated SUI, stated Committee Opinion No. 603, published in the June issue of Obstetrics and Gynecology (2014;123:1403-7).

"Until now, there has never been any consistency in the evaluation of uncomplicated SUI before surgery," said Dr. Charles Nager, professor of obstetrics and gynecology and director of female pelvic medicine and reconstructive surgery at the University of California, San Diego.

"This is the first time the leading specialty organizations, ACOG and the American Urogynecologic Society [AUGS], have set a standard for physicians to follow before they operate on patients with uncomplicated SUI."

The criteria are common sense, are evidence based, and "don’t require that everyone undergo urodynamic testing," added Dr. Nager, who is president of AUGS and a member of ACOG’s subcommittee on urogynecology of the Committee on Gynecologic Practice, which was involved in drafting the guidelines.

The opinion guides clinicians in evaluating women with urinary leakage without necessarily requiring a costly work-up, said Dr. Cheryl Iglesia, who also contributed to the guidelines and is director of female pelvic medicine and reconstructive surgery at MedStar Washington (D.C.) Hospital Center and professor of obstetrics, gynecology, and urology at Georgetown University, Washington. If the minimum six-step evaluation confirms uncomplicated SUI, "you don’t need to do a test that would run upwards of thousands of dollars and doesn’t change the outcome," she said.

The recommended six-step evaluation includes:

1. A urologic, medical, neurologic, and medication history.

2. A urinalysis to rule out urinary tract infection.

3. A physical examination to assess for contributing or confounding factors, including urethral diverticulum, vaginal discharge, extraurethral incontinence, and pelvic organ prolapse (which leads to a diagnosis of complicated SUI if the prolapse is beyond the hymen).

4. A cough stress test to demonstrate SUI.

5. A urethral mobility assessment to help determine the likelihood of success from anti-incontinence surgery.

6. Measurement of postvoid residual urine volume to identify bladder-emptying abnormalities or incontinence resulting from chronic urinary retention.

Women with uncomplicated SUI will have urinary leakage from the urethra by provocative stress measures such as the cough test, a normal urinalysis that rules out urinary tract infection, no pelvic organ prolapse beyond the hymen, and a normal postvoid residual urine volume, the guidelines specify, adding that patients who meet these criteria and have not responded to conservative interventions do not need urodynamic testing before proceeding to surgery.

In contrast, women with complicated SUI "may benefit from multichannel urodynamic testing, particularly before surgical treatment," the guidelines stated. "In these women, the results of the basic six-step evaluation and clinical judgment should guide the decision to perform preoperative multichannel urodynamic testing."

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Preop urodynamic testing unnecessary

"More than ever before, health care delivery is focused on clinical efficiency and cost effectiveness," said Dr. Lee Richter. "These guidelines are timely in that they address the work-up of patients with primary uncomplicated stress urinary incontinence [SUI] from both of these perspectives."

The new guidelines outline six diagnostic steps that physicians who manage patients with SUI should follow prior to intervention. "Based on office evaluation results, the uncomplicated SUI patient may be able to proceed to sling surgery without further urodynamic work-up," Dr. Richter said.

In 2012, researchers from the VALUE (Value of Urodynamic Evaluation) trial reported that preoperative urodynamic testing did not lead to better outcomes from sling surgery in women with uncomplicated SUI (N. Engl. J. Med. 2012;366:1987-97). Before these results were published, physicians lacked clear evidence to guide decision making in urodynamics, said Dr. Richter. The new guidelines may lead to more uniform diagnostic approaches for women who present with urinary incontinence.

"This six-step evaluation for women with SUI is developed from what we know about who is likely to succeed with primary sling surgery," Dr. Richter said. "Further research on risk factors for sling failure and management of those challenging clinical situations is a focus for the future."

Dr. Richter is a fellow in female pelvic medicine and reconstructive surgery with Medstar Washington (D.C.) Hospital Center. Her remarks were excerpted from an interview with Frontline Medical News.