This article is based on a panel discussion, “Survivor Debate: Optimal Evaluation of Complicated Male Lower Urinary Tract Symptoms,” at the 2025 AUA meeting held in Las Vegas, Nevada, April 26-29, 2025.

The AUA2025 Survivor Debate offered an informative and provocative discussion around the optimal evaluation of complicated male lower urinary tract symptoms (LUTS). Moderated by Dr Bradley Gill, associate professor at the Cleveland Clinic, this case-based discussion explored whether traditional, noninvasive, or no urodynamic (UDS) testing is best suited for diagnosis and management. Using real-world clinical cases, the debate illuminated the clinical nuances and controversies around the use of UDS in modern urology.

Complicated male LUTS may result from multiple causes: bladder outlet obstruction (BOO), detrusor overactivity, hypocontractility, sphincter dysfunction/dyssynergia, pelvic radiation, or a combination of the aforementioned. Testing can help untangle these etiologies and guide treatment, but are preprocedural studies always necessary?

The Debaters and Their Positions

• Dr Lara MacLachlan, associate professor at Lahey Hospital & Medical Center, championed traditional invasive UDS, arguing it remains the gold standard, especially in patients with neurologic risk factors or unclear diagnosis.
• Dr Frank Lin, assistant professor at University of Wisconsin–Madison, promoted noninvasive UDS, such as the UroCuff (SRS Medical) penile cuff test, citing its patient comfort and tolerability, usefulness in measuring voiding pressure, and ability to differentiate BOO from poor contractility.
• Dr Toby Chai, professor and chair of the Department of Urology at Boston University, advocated for no UDS, questioning the clinical utility of these tests in many scenarios and emphasizing reliance on simpler diagnostics and empiric treatment.

Case 1: A Parkinson’s Patient With Bothersome Frequency

A 68-year-old man with Parkinson’s disease, urinary frequency, weak stream, and a 151-g prostate with a bladder diverticulum raised diagnostic and therapeutic concerns.

• Dr MacLachlan emphasized adherence to AUA guidelines, which recommend multichannel UDS in patients with neurologic risk and unknown risk categorization due to elevated postvoid residuals.¹
• Dr Lin countered that noninvasive testing like UroCuff could sufficiently assess voiding pressures and avoid patient discomfort.²
• Dr Chai argued against both, saying UDS and UroCuff fail to localize obstruction, particularly in Parkinson’s patients, where striated muscle dysfunction at the external urethral sphincter might be the key issue. He recommended empiric benign prostatic hyperplasia treatment without UDS.

Case 2: Postprostatectomy Incontinence

A 56-year-old diabetic man, 9 months after radical prostatectomy with persistent incontinence, presented a common but complex challenge. The patient’s diabetes is managed with a sodium-glucose cotransporter-2 inhibitor, and he has glucosuria on urinalysis.

• Dr Chai urged a pragmatic approach, using bladder diaries and stress tests to classify incontinence type and guide therapy without UDS.
• Dr Lin argued that noninvasive evaluation can be especially helpful after surgery, offering functional insights while avoiding the invasiveness of traditional UDS.
• Dr MacLachlan reminded the panel that the AUA guidelines permit UDS in uncertain diagnoses prior to surgical intervention for stress urinary incontinence. UDS could distinguish stress urinary incontinence, overactive bladder, or neurogenic bladder, refining treatment plans.

Case 3: A Tired Patient With Weak Stream and Nocturia

A 74-year-old rheumatologist with a complex history—bladder radiation, transurethral resection of the prostate, and failed medications—illustrated the frustration patients and clinicians face when symptoms persist despite interventions.

• Dr Lin advocated for UroCuff as a first step, noting the patient’s aversion to further invasive testing. It could objectively assess detrusor function and obstruction.
• Dr Chai urged clinicians to think beyond LUTS, suggesting workup for nocturnal polyuria, sleep apnea, and structural issues via cystoscopy instead of further functional testing.
• Dr MacLachlan emphasized that uncertainty justifies traditional UDS, as recommended by both LUTS/benign prostatic hyperplasia and overactive bladder guidelines, especially before another surgical step is taken.^3,4

Evidence Vs Experience

The debate highlighted a common tension in urology: reliance on evidence-based guidelines vs clinical intuition and patient-centered care. The UPSTREAM trial⁵ was referenced, which showed that UDS in uncomplicated LUTS did not influence rates of surgery for treating BOO. Routine use of UDS in all patients may be unjustified, and a tailored approach appears most reasonable.

The Case for Individualized Testing

Ultimately, the debate concluded with consensus on 1 point: UDS is a tool and not a mandate. Tests should answer specific clinical questions. UDS may clarify uncertain diagnoses and aid in patient counseling and surgical planning. However, it also brings discomfort, infection risk, and cost—and may not replicate a patient’s real-world symptoms.

Key Takeaways

• Traditional UDS provides comprehensive insights but is invasive and not always necessary.
• Noninvasive options like UroCuff offer promising diagnostic value with greater comfort.
• Empiric and symptom-driven management can be safe and effective in well-selected patients.
• Guidelines support discretion, allowing urologists to tailor diagnostic strategies to the individual.

In evaluating complicated male LUTS, clinicians should ask: “What do I need to know to help this patient?” If UDS will meaningfully influence diagnosis or therapy, then it is justified. However, if treatment is clear from clinical presentation and simpler tests, it may be best to move forward—without the catheters.

Conflict of Interest Disclosure: Bradley C. Gill serves as a consultant for Boston Scientific and Sumitomo Pharma. All other authors have no disclosures.