AUA releases guidelines on OAB, hematuria, vasectomy, urodynamics

The 2012 AUA annual meeting in Atlanta saw the debut of new practice guidelines for overactive bladder, hematuria, vasectomy, and urodynamics.

The OAB guidelines emphasize behavioral therapies as a first-line treatment, followed by medications and neuromodulation. Patients who present with symptoms of OAB should be evaluated with a careful medical history, physical exam, and urinalysis to exclude other conditions that could be responsible. In some patients, urine cultures or postvoid residual assessment may need to be performed. Additionally, patients may be asked to complete voiding diaries or symptom assessment questionnaires.

Once the diagnosis has been validated, clinicians should first offer behavior modification therapies, including bladder training, bladder control strategies, pelvic floor muscle training, and fluid management. Second-line treatments include oral antimuscarinic medications. In some patients with severe refractory symptoms or for those in which antimuscarinics are not acceptable, sacral neuromodulation, percutaneous neuromodulation, or off-label use of onabotulinim toxin A may be an option.

Previous recommendations for hematuria called for a full exam to be completed only after two of three properly collected samples test positive for microhematuria on microscopy. The new guidelines state that a single positive urinalysis with microscopy for asymptomatic microhematuria is enough to warrant a complete urologic examination.

Assessment for asymptomatic patients presenting with microhematuria includes a careful history as well as a physical examination and laboratory testing, including an estimate of renal function and, for patients over 35 years of age, a cystoscopy. The initial evaluation for microhematuria should also include a radiologic evaluation to rule out tumors in the kidney and to evaluate the upper urinary tract urothelium.

The new guidelines for vasectomy cover preoperative evaluation and consultation of prospective vasectomy patients; techniques for local anesthesia, isolation of the vas deferens, and occlusion of the vas deferens during vasectomy; postoperative follow-up; post-vasectomy semen analysis; and potential complications and consequences of vasectomy.

The newest urodynamics guidelines present the principles of application and technique to guide the clinician in the role of urodynamics in complex lower urinary tract symptom disorders. The findings of this guideline are intended to assist the clinician in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization. Among the statements in the guidelines are the following:

• Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function.
• Surgeons considering invasive therapy in patients with stress urinary incontinence should assess postvoid residual urine volume.
• Clinicians may perform multi-channel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid, or irreversible treatments.
• Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having stress incontinence who do not demonstrate this finding with the catheter in place during urodynamic testing.
• Clinicians should perform stress testing with reduction of the prolapse in women with high-grade pelvic organ prolapse but without the symptom of stress incontinence. Multi-channel urodynamics with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS.

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