What are the key recommendations for patients following SUFU (Society of Urologic Oncology Fellowships and Universities) guidelines?

SUFU Guidelines Overview

The Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), in collaboration with the American Urological Association (AUA), provides evidence-based clinical practice guidelines across multiple urologic conditions including microhematuria, overactive bladder, stress urinary incontinence, neurogenic bladder, and urodynamic testing.

Key SUFU/AUA Guideline Areas

Microhematuria (2025 Update)

Risk stratification is mandatory for all patients presenting with microhematuria (≥3 RBCs/HPF), categorizing them as low/negligible-, intermediate-, or high-risk for genitourinary malignancy. 1

Risk Stratification Criteria:

• Low-risk patients: Women <60 years old with <10 pack-years smoking history and no additional risk factors for urothelial cancer 1
• Intermediate-risk patients: Women ≥60 years old, men <60 years with 10-30 pack-years smoking, or presence of any additional risk factors 1
• High-risk patients: Men ≥60 years, >30 pack-years smoking history, or one or more risk factors plus any high-risk feature (gross hematuria, history of pelvic irradiation, chronic indwelling foreign body, exposure to benzene chemicals) 1

Critical update: Women cannot be categorized as high-risk based on age alone in the 2025 guideline—they require additional high-risk features beyond age ≥60 years. 1

Evaluation Requirements:

• Complete smoking history with pack-year quantification is mandatory at initial consultation 1
• Blood pressure measurement and genitourinary examination are required 1
• Cystoscopy for macrohematuria with clots or unequivocal lesions on imaging should proceed immediately to TURBT 1
• No cancers were detected in validated low-risk groups (0% malignancy rate), justifying less aggressive evaluation 1

Overactive Bladder (Non-Neurogenic) Management

Behavioral treatments should be offered as first-line therapy before pharmacologic intervention, with anti-muscarinics reserved for patients who fail conservative measures or desire additional treatment. 1

Treatment Algorithm:

• Initial management: Patient education on normal urinary tract function, benefits/risks of treatment alternatives, and establishment of treatment goals 1
• First-line: Behavioral treatments (pelvic floor exercises, bladder training, fluid management) 1
• Second-line: Anti-muscarinics with active management of adverse events (dry mouth, constipation); consider dose modification or alternate agent if effective but intolerable side effects occur 1
• Third-line options: Peripheral tibial nerve stimulation, intravesical onabotulinumtoxinA, or sacral neuromodulation for refractory cases 1

Urgency—the sudden, compelling desire to void that is difficult to defer—is the hallmark symptom required for OAB diagnosis. 1

Stress Urinary Incontinence in Women (2023 Update)

Index patients (healthy females with minimal/no prolapse desiring surgical therapy for pure SUI or stress-predominant mixed incontinence) should be counseled on all treatment options including observation, pelvic floor muscle training, pessaries, and surgical intervention before proceeding. 1

Preoperative Counseling Requirements:

• Mandatory discussion: Specific risks and benefits of synthetic mesh, FDA safety communications regarding midurethral slings, and alternatives to mesh slings 1
• Pre-operative counseling regarding mesh complications results in reduced patient concern, greater willingness to proceed, and higher satisfaction 1
• Degree of symptom bother must be assessed—minimal bother warrants conservative therapy over surgery 1

Diagnostic Evaluation:

• Positive stress test or witnessed involuntary urine loss from urethral meatus with increased abdominal pressure (coughing, Valsalva) is required for definitive diagnosis 1
• Cystoscopy should NOT be performed in index patients unless concern exists for urinary tract abnormalities 1
• Urodynamic testing may be performed in non-index patients with: prior anti-incontinence surgery, prior prolapse surgery, significant voiding dysfunction, urgency-predominant symptoms, elevated post-void residual, or neurogenic dysfunction 1

Surgical Success Rates:

• Reported success rates range 51-88% with data exceeding 15 years follow-up 1
• Intraoperative cystoscopy is mandatory with midurethral slings or fascial pubovaginal slings to confirm lower urinary tract integrity 1

Neurogenic Lower Urinary Tract Dysfunction

Patients with relevant neurologic disease at risk for neurogenic bladder should undergo video urodynamic study (VUDS) when available, as it distinguishes etiology, identifies vesicoureteral reflux grade, and detects anatomic abnormalities not apparent on standard urodynamics. 1, 2

Risk Stratification and Follow-up:

• Treatment decisions must balance urologic symptoms, urodynamic findings, cognition, hand function, neurologic disease type, mobility, bowel function, and social support 1
• Follow-up intensity is based primarily on risk stratification after initial treatment 1
• In spina bifida patients, VUDS is encouraged at 3 months and yearly at ages 1-3 years 2

VUDS-Specific Considerations:

• Radiation exposure is additive—studies must provide clinical information at lowest possible radiation dose 2
• Benefits must be weighed against infection risk and autonomic dysreflexia 2
• Clinicians performing VUDS in at-risk patients must be adept in detecting and promptly managing autonomic dysreflexia 2

Urodynamic Testing Indications

Urodynamic studies should be performed when functional information about bladder filling, storage, and emptying is needed that cannot be obtained through history, physical examination, and basic evaluations alone. 1

Key Principles:

• Formulate specific urodynamic questions before testing: "What information do I need?" and "What is the most appropriate UDS technique?" 1
• Main goal is to reproduce patient symptoms when present and determine the cause 1
• Post-void residual, uroflowmetry, cystometry, and pressure-flow studies can be performed singly or in combination based on clinical question 1

Implementation Considerations

Guidelines are recommendations, not recipe books—they may have limitations and require clinical judgment for individual patient application. 3, 4

• Successful implementation requires addressing barriers from both physician and patient perspectives 5
• Physician knowledge, attitudes, skills, experiences, beliefs, and values fundamentally influence guideline adherence 6
• Patient values, preferences, comorbid conditions, and costs must be considered when applying recommendations 7
• Strong recommendations indicate benefits clearly outweigh risks; weak recommendations indicate more equal balance requiring individualized decision-making 7, 4