OVERACTIVE bladder (OAB) affects 12–14% of women in the UK, significantly disrupting their quality of life. Beyond the physical discomfort, the condition affects social and psychological wellbeing, as well as work productivity. In more severe cases, many women avoid employment, 60% avoid leaving their homes, and 50% report avoiding sexual activity.
First-line treatments for OAB include lifestyle changes, bladder retraining, pelvic floor exercises, and medication. However, 40% of women do not respond to these methods and are classified as having refractory OAB. In such cases, the National Institute for Health and Care Excellence (NICE) recommends urodynamics, a diagnostic test, before more invasive treatments like botulinum toxin A (BoNT-A) injections or sacral neuromodulation. Yet, the effectiveness and value of urodynamics has remained uncertain.
The FUTURE study, the largest randomised controlled trial of its kind, compared outcomes between women receiving a comprehensive clinical assessment (CCA) alone and those undergoing both CCA and urodynamics. The findings are clear: urodynamics did not improve participant-reported outcomes. Women who received only CCA were more likely to receive earlier treatment and reported better short-term results.
Moreover, urodynamics did not improve long-term outcomes or reduce adverse events, while being more expensive. At a funding threshold of £20,000 per QALY gained, a benchmark for NHS cost-effectiveness, urodynamics had only a 34% chance of being worthwhile. That figure drops to 23% when longer-term treatment patterns are considered.
Though urodynamics altered the diagnosis in 13% of women, sometimes leading to alternative treatments like surgery, this did not translate to improved outcomes. Notably, most participants received BoNT-A, reflecting current UK practice.
The study concludes that for women with refractory OAB or urgency-predominant mixed urinary incontinence, adding urodynamics to clinical assessment does not enhance outcomes and is not cost-effective. These results support more streamlined, patient-centred care without unnecessary diagnostic interventions.
Reference
Abdel-Fattah M et al. Invasive urodynamic investigations in the management of women with refractory overactive bladder symptoms (FUTURE) in the UK: a multicentre, superiority, parallel, open-label, randomised controlled trial. Lancet. 2025;405(10484):1057-1068.
