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Guidelines for Practice and Research in Urogynecology
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Synopsis: Evidence-based guidelines for urogynecologic practice and research are offered by the IUGA Research and Development Committee.
Source: Ghoniem G, et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:5-33.
To incorporate evidence-based guidelines into both practice and research, the Research and Development Committee of the International Urogynecological Association embarked on a lengthy process, which included a literature review, creation of recommendations, incorporation of expert consultant opinion, writing a white paper for association members, final revision, and then publication in its journal.
Outcomes were categorized into primary and secondary. The primary outcomes included the following topics: initial clinical evaluation, voiding diary, stress testing, grading of SUI and Pad testing, quality-of-life measures, urethral mobility, patient satisfaction, and prolapse assessment. Secondary topics included: urodynamic testing, neurophysiological testing, surgical complications, and cost effectiveness.
This is a unique article, mainly because it focuses on both research (which makes some readers yawn) and practice (where the rubber meets the road for all of us). The committee went through a very lengthy process, starting in 2004. One could argue that the end product is, by definition, dated, but I would suggest even to the cynics out there that this is an article worth cutting out and keeping readily available. Why am I so positive about an article that was created by a group that is directly connected to the journal in which it is published? Could it possibly be objective and meet the criteria for peer review? I offer my support because it is practical, easily interpreted, and can make your life as a practicing provider of women's health that much easier.
For example, the authors used a systematic literature review, including the vitally important Cochrane database, along with expert opinion to make concrete "Recommended/Optional/Not Recommended" judgements. They tried to avoid the typical wishy-washy conclusions that so often clutter articles and don't necessarily help make clinical decisions. Each section has specific conclusions and recommendations, which, although not perfect, are at least the result of efforts to find consensus. These are clearly not the ramblings of a single author who has an axe to grind. As a result, the reader can file this article away to use as a reference when reading other urogynecologic literature to determine how appropriate study designs and/or conclusions might be. The reader can, therefore, become more discriminating with regard to the literature and less susceptible to the newest gadget or mesh or technique that is written about.
Anytime expert opinions are offered, we should all look at who the "expert" is, and whether this person is truly an "expert" in the field. Recall the definition of an expert as proffered by some very insightful soul years ago: An expert is someone who knows more and more about less and less. (The less serious illogical extension is that the ultimate expert is someone who knows everything about nothing). In this case, we are able to glean useful information and a balanced world view. For example, allow me to quote the recommendations within the "Initial clinical evaluation" for blood tests and imaging. This will give you a taste of the wisdom contained in the article. For blood tests, it says, "Standard metabolic evaluation of renal function with measurement of serum creatinine and blood urea levels is recommended when renal impairment is suspected." For imaging it states, "Imaging is not routinely recommended. It is indicated when upper urinary tract pathology is suspected. Specific indications include neurogenic bladder, chronic high-grade pelvic organ prolapse, low compliance of the bladder, or high residual urine volumes."
I really do strongly urge you to get the article and keep it available to use both clinically to improve your care of patients with stress incontinence and academically to better sort out the wheat from the chaff in your readings.