Two major UK randomised controlled trials, UPSTREAM and FUTURE, compared comprehensive clinical assessment (CCA) alone with CCA plus urodynamics (UDS), incorporating filling cystometry and pressure–flow studies. Both trials involved patients in whom diagnostic uncertainty suggested a potential role for UDS before invasive treatment. This editorial considers whether confounding factors may have masked the value of UDS in these studies. UDS was developed to provide objective measurements because lower urinary tract symptoms (LUTS) are often unreliable and non-disease specific. Studies such as EPIC show that LUTS components occur similarly in both sexes, highlighting the limitations of symptom-based diagnoses. While structured symptom scores like the International Prostate Symptom Score (IPSS) offer consistency, they do not confer diagnostic specificity. Consequently, UDS has traditionally been used to clarify the causes of LUTS, such as benign prostatic obstruction (BPO), detrusor overactivity (DO), underactivity (DU), or stress incontinence, especially when CCA alone is inconclusive. Guidelines from the European Association of Urology (EAU) and American Urological Association (AUA) acknowledge that men with DU respond less well to prostate surgery, yet voiding symptoms alone cannot reliably distinguish DU from BPO. Similarly, women with mixed urinary incontinence require differentiation of stress and urgency components for optimal outcomes. Although trials such as VALUE showed no benefit from routine UDS in uncomplicated female stress incontinence, more complex presentations remain challenging. UPSTREAM and FUTURE both demonstrated non-inferiority of CCA alone and found no overall clinical or economic advantage for routine UDS. However, neither study was powered to detect benefits in specific subgroups. Secondary analyses identified patient profiles in which UDS could meaningfully refine diagnosis and improve counselling prior to surgery. Overall, the evidence suggests that routine, unselected UDS is unnecessary, but selective use remains important. UDS retains value when CCA findings are ambiguous, when symptoms are complex, or when identifying factors that may predict poorer surgical outcomes. Its role is to provide diagnostic clarity that supports genuinely informed, individualised decision-making.
Are urodynamics still useful?
Reviewed by Asif H Ansari
From clinical trials to routine practice: are urodynamics still useful?
