Abstract: To address the issue of prioritizing routine maintenance and repair of urban sewer pipelines, this paper proposes an evaluation method for the health assessment of urban sewer pipelines that incorporates hydraulic simulation. By constructing a hydraulic model, key hydraulic indicators are obtained through simulation. A comprehensive health assessment model is established by integrating analytic hierarchy process (AHP) and decision-making trial and evaluation laboratory (DEMATEL) for weight determination, and considering defect factors, operating conditions, and social environmental factors. The results show that the DEMATEL method can consider the mutual influence among indicators, contributing to the optimization of traditional AHP weight distribution outcomes. Load condition and flow velocity are important indicators in evaluating the health of urban sewer pipelines, accounting for 70.61%. Finally, this established model is applied to assess the health of the Li Jiao sewer trunk in Guangzhou. The results effectively identify problematic pipelines, providing a scientific and rational decision-making basis for the drainage management department to determine pipeline maintenance priorities.