Occult incontinence in women with pelvic organ prolapse - Does it matter?

Evaluation and Treatment of Urinary Incontinence in Women

This review focuses on the diagnosis, evaluation, and treatment of urinary incontinence (UI). UI is a common diagnosis that is encountered among women in their lifetime. Stress, urge (overactive bladder), and overflow are the most commonly encountered types of incontinence, but anatomic and neurologic causes are important to rule out. There are many treatment options available for the management of UI, and most patients will benefit from conservative strategies including weight loss, timed voiding, fluid intake reduction, pelvic floor strengthening exercises, and medications. For those who do not achieve adequate improvement with conservative measures, surgical intervention can provide good symptom relief.

Incidence and characteristics of

BACKGROUND Some patients who undergo pelvic floor reconstruction for pelvic organ prolapse (POP) may experience a de novo stress urinary incontinence (SUI) postoperatively. We aimed to investigate the incidence and characteristics of de novo SUI in patients who underwent pelvic floor reconstruction at the national referral hospital in Indonesia. METHODS This cross-sectional study evaluated 108 patients who underwent pelvic floor reconstruction due to POP between January 2016 and December 2017. Per the inclusion criteria, 75 women were enrolled using a consecutive sampling. The incidence of de novo SUI was determined 6–12 months postoperatively using the Indonesian version of the questionnaire for urinary incontinence diagnosis and objectively using the cough stress test during gynecologic examination after a negative preoperative prolapse reduction stress test. RESULTS The average age, parity, body mass index, and years since menopause onset were 56.17 (4.67) years, 3.17 (1.07), 28.58 (5.18) kg/m2, and 12.8 (7.0) years, respectively. De novo SUI was seen in 8.0% (6 of 75) patients at 6–7 months postoperatively, with 3 (50.0%) had severe POP and 3 (50.0%) had a mild POP. Most of these patients (4 of 6, 66.7%) had undergone procedures other than colpocleisis for POP reconstruction. CONCLUSIONS The incidence of de novo SUI after gynecologic surgery for POP at a national referral hospital in Indonesia is 8%. Most patients were aged <60 years, had a parity of <4, were nonobese, were menopausal, and had diabetes.

Le Fort colpocleisis: An evaluation of results and quality of life at intermediate-term follow-up

OBJECTIVES

To assess postoperative complications, intermediate-term anatomic and subjective success rates, and quality of life following obliterative Le Fort colpocleisis (LFC) for advanced pelvic organ prolapse (POP).

STUDY DESIGN

We conducted a retrospective cohort study with 53 subjects who underwent LFC surgery between January 2012 and April 2019. Demographic and treatment data were retrieved from a hospital database. Data on postoperative anatomic results were gathered from individual examinations of study subjects. The Clavien-Dindo classification was used to evaluate the complications. The Prolapse-Quality of Life (P-QoL) questionnaire was administered in person or over the telephone before and after the operation. Low scores on the P-QoL reflect a high quality of life.

RESULTS

The mean age at operation was 73 ± 7.1 years. The mean time between LFC and the postoperative questionnaire and interview was 30.8 ± 15.7 months (range: 12-82). Ninety-two percent of subjects had at least one comorbidity. When subjects were classified using the Pelvic Organ Prolapse (POP) Quantification System, seven (13.2 %) had Stage 3 POP and 46 (86.8 %) had Stage 4 POP. The overall rate of minor peri-operative complications rate was 11.3 % (six subjects). The objective success rate of LFC at intermediate-term follow-up was 98.1 %, and the subjective success rate was 96.2 %. The mean time between LFC and the postoperative questionnaire and interview was 30.8 ± 15.7 months (range: 12-82). There was a statistically significant decrease in the postoperative P-QoL score (p < 0.001).

CONCLUSIONS

Based on positive intermediate-term anatomic and subjective outcomes, including a significant decrease in P-QoL questionnaire scores and a lack of regret, obliterative LFC should be considered a first-choice procedure for elderly and sexually inactive women with advanced POP.

Cough stress tests to diagnose stress urinary incontinence in women with pelvic organ prolapse with indication for surgical treatment

AIMS

To evaluate the diagnostic ability of different cough stress tests (CSTs) in women with pelvic organ prolapse (POP), performed during outpatient urogynaecological exams.

METHODS

Prospective, multicentre observational study involving women on waiting lists for POP surgery. With a subjectively full bladder, patients were asked to perform five different CSTs: without prolapse reduction ([a] standing, followed by [b] semilithotomy position); keeping semilithotomy position with prolapse reduced (by [c] posterior speculum, followed by [d] pessary); [e] standing again with the pessary in place. Primary outcome was positive CST in at least one of the five CSTs. Bladder volume was measured and symptoms of stress urinary incontinence (SUI) were detected by two validated questionnaires.

RESULTS

A total of 297 women completed all CSTs and were included in the analyses. Mean (SD) age, parity, and body mass index were 64.8 (9.9) years, 2.7 (1.3) deliveries, and 26.6 (3.4) kg/m² , respectively. In total, 99 women (33.3%) reported SUI symptoms. At least one positive CST was recorded in 152 patients (51.1%), and in 90 (59.2%) of these 152, a positive CST was observed only when POP was reduced (occult SUI). The CST was positive in 92 (92.9%) of the 99 patients with coexisting SUI symptoms and in 60 (30.3%) of the 205 asymptomatic patients. The percentage of patients with a positive CST was significantly lower when bladder volume was <200 mL vs ≥200 mL (P = .046).

CONCLUSIONS

The identification of urinary leakage cases with CSTs is best achieved using multiple different patient positions, different prolapse reduction methods, and bladder volumes ≥200 mL.

Stress urinary incontinence after transvaginal mesh surgery for anterior and apical prolapse: preoperative risk factors

INTRODUCTION AND HYPOTHESIS

Debate persists over whether surgery to correct pelvic organ prolapse (POP) should be combined with midurethral sling (MUS) insertion. The aim of this study was to evaluate the incidence of stress urinary incontinence (SUI) up to 12 months after transvaginal mesh surgery, with or without MUS, and to identify risk factors for postoperative SUI.

METHODS

This retrospective single-center study included patients who underwent transvaginal mesh surgery with Uphold™ between October 2010 and December 2017. The primary outcome was the prevalence of SUI at 12 months postoperatively. Univariate and multivariate logistic regression was used to identify risks factors for postoperative SUI.

RESULTS

Of the 308 women included, 123 (40%) were continent (no SUI), 108 (35%) had SUI, and 76 (25%) had occult SUI. Forty-nine patients (15.9%) had a concomitant MUS procedure. At 12 months after surgery, 35.9% of patients without concomitant MUS had SUI vs 14.3% with (p = 0.003). Thirty-five patients (29%) developed de novo SUI. Postoperative complications were more common in patients with concomitant MUS (30.6% vs 17%; p = 0.003). The best predictor of postoperative SUI was the presence of preoperative SUI (OR 2.52 (1.25-5.09). Concomitant MUS (p < 0.001), and prior POP surgery (p = 0.034) were protective factors for postoperative SUI.

CONCLUSION

Preoperative SUI is the most important risk factor for postoperative SUI. However, given the higher risk of postoperative complications with concomitant MUS and the acceptable rate of de novo SUI rate without it, two-stage surgery seems preferable for patients with preoperative SUI.

Three-Dimensional Transperineal Ultrasonography for Diagnosis of Female Occult Stress Urinary Incontinence

Background

We evaluated the utility of three-dimensional transperineal ultrasonography in detecting occult stress urinary incontinence in women undergoing anterior pelvic floor reconstruction surgery for severe cystocele.

Material/Methods

We enrolled 207 women with stage III–IV cystocele without urinary stress incontinence. One week before the operation, the patients underwent pelvic floor ultrasonography. We measured the vertical distance between the bladder neck and posterior margin of the pubic symphysis, the posterior vesicourethral angle, the urethral rotation angle, the formation of funnel shape, the hiatus area, and the length of the urethra and the funnel shape. Postoperatively, the patients were evaluated for symptoms of stress urinary incontinence and with the 20-minute pad test.

Results

The posterior vesicourethral angle with Valsalva maneuver, the difference in the posterior vesicourethral angle between the resting state and with the Valsalva state, and the angle of the proximal urethra were larger in the incontinence-positive group than in the incontinence-negative group (P<0.05). Funnel shape urethra was longer in the incontinence-positive group than in the incontinence-negative group (P<0.05). The cutoff value was 137.5° for the posterior vesicourethral angle with Valsalva maneuver, 39.5° for the difference in the posterior vesicourethral angle, 44.5° for the angle of the proximal urethra, and 0.35 cm for the length of the funnel shape. Multivariate analysis revealed that the difference between the posterior vesicourethral angle in the resting state and with Valsalva, the angle of the proximal urethra, and the length of funnel shape were strongly correlated with occult stress urinary incontinence.

Conclusions

Ultrasonography is an effective method for identifying occult stress urinary incontinence.

De novo urinary incontinence after pelvic organ prolapse surgery-a national database study

INTRODUCTION AND HYPOTHESIS

To investigate the prevalence and risk factors of de novo urinary incontinence (UI) after pelvic organ prolapse (POP) surgery.

METHODS

Data from 2013 to 2016 were collected from the Danish Urogynecological Database, where registration for any urogynecological procedure performed in Denmark is mandatory. Inclusion criteria were urinary continent women who underwent POP surgery. A woman was urinary continent if her total score on the International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form (ICIQ-UI-sf) was 0 and she answered 'never' to 'When does urine leak?' Postoperatively, the women were categorized as continent or women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI), mixed urinary incontinence (MUI) or undefined UI. We performed multivariate logistic regression analyses. The included parameters were preoperative POP stage (POP-Q), compartment, BMI and age. P values < 0.05 were considered statistically significant.

RESULTS

We included 1198 women. The risk of de novo UI was 15%; 45% had SUI, 30% had UUI, 16% had MUI, and 10% had undefined UI. BMI was highly associated with de novo UI; the risk was 12% for women with BMI < 25, 16% for women with BMI 25 - < 30 and 23% for women with BMI ≥ 30. Age, compartment and POP stage were not associated with de novo UI.

CONCLUSIONS

The prevalence of de novo UI is the same regardless of the involved compartment/s and POP stage. BMI is significantly associated with de novo UI; twice as many women with BMI ≥ 30 had de novo UI compared with women with BMI < 25.

Clinical efficacy of pelvic autologous tissue reconstruction in treating pelvic organ prolapse in 36 patients

This study aims to search for a new, economic, convenient, and low recurrence rate operation for the surgical management of pelvic organ prolapse (POP). The clinical value of the operation for treating POP was determined through retrospective case series. The new operation was called, pelvic autologous tissue reconstruction.Women with symptomatic uterine prolapse, who required surgery, were recruited. A total of 97 women [stage III to IV, according to POP quantification (POP-Q) staging] were collected from January 2010 to December 2016. Among these women, 61 women underwent a traditional operation (TO, vaginal hysterectomy and vaginal anterior and posterior wall repair), while the remaining women underwent pelvic autologous tissue reconstruction.First, there was no statistically significant difference in intraoperative blood loss, indwelling urethral catheter time, in-hospital time, and the time of passage of gas through the anus between the pelvic autologous reconstruction (PAR) and TO groups (P > .05). The average operation time in the PAR group was significantly longer than that in the TO group (P < .05). Second, ultrasonic parameters before and after the operation between the 2 groups were compared. The postoperative rotation angle of the urethra (UR), posterior vesicourethral angle (PVA), and bladder neck descent (BND) significantly decreased in the PAR group (P < .05). There was no statistically significant difference in UR between before and 12 months after surgery in the TO group (P > .05). Furthermore, BND increased in the TO group at 12 months after the operation, compared with that at 3 months after the operation (P < .05). There was no significant difference in PVA and UR before the surgery and at 3 and 12 months after the surgery between the 2 groups (P > .05). In addition, BND was significantly smaller in the PAR group than in the TO group at 3 and 12 months after the surgery (P < .05). Third, there was no statistically significant difference in PFIQ-7 and PISG-12 in both groups after surgery.The stability of the pelvic floor structure was better in the PAR group than in the TO group. Furthermore, PAR is better for preventing the occurrence of pelvic floor prolapse and stress urinary incontinence after surgery.

Management of Urinary Incontinence before and after Total Pelvic Reconstruction for Advanced Pelvic Organ Prolapse with and without Incontinence

Background:

The effectiveness of an anti-incontinence procedure concomitant with prolapse reconstruction for pelvic organ prolapse (POP) in preventing urinary incontinence (UI) after surgery remains controversial. Our study aimed to describe the incidence of pre- and postoperative UI for pelvic reconstructive surgery and evaluate the management of POP associated with UI.

Methods:

A total of 329 patients who underwent total pelvic reconstruction between June 2009 and February 2015 at a single institution were identified. These patients were divided into two groups (Group A [Prolift reconstruction]: n = 190 and Group B [modified total pelvic reconstruction]: n = 139). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student's t-tests were used for two independent samples.

Results:

A total of 115 patients presented with UI preoperatively. The average follow-up time was 46.5 months, with 20 patients lost to follow-up (6.1%). The cure rates of stress UI (SUI), urgency UI (UUI), and mixed UI (MUI) were 51% (30/59), 80% (16/20), and 48% (14/29), respectively. The cure rate of UUI after total pelvic reconstruction (80% [16/20]) was higher than that of SUI (50.8% [30/59], χ²= 5.219, P = 0.03), and the cure rate of MUI (48%, 14/29) was the lowest. The cure rate of patients with UI symptoms postoperatively was lower than that of those with symptoms preoperatively (9.1% [28/309] vs. 16.2% [50/309], χ²= 7.101, P = 0.01). There was no difference in the incidence of UI postoperatively between Groups A and B (P > 0.05). The cure rate of SUI in patients undergoing tension-free vaginal tape-obturator was not higher than that in those who did not undergo the procedure (42.9% [6/14] vs. 53.3% [24/45], χ²= 0.469, P = 0.49). There were no differences in the cure rate for POP or UI between these two types of reconstructions (P > 0.05).

Conclusions:

No correlation between the incidence of UI and POP was identified. The results suggest that UI treatment should be performed after POP surgery for patients with both conditions.

Trends in pelvic organ prolapse management in Latin America

AIMS

To describe practice patterns and perspectives regarding pelvic organ prolapse (POP) management among urologists, gynecologists, and urogynecologists in Latin America (LATAM).

METHODS

A cross-sectional study was conducted from April to September 2016 using a 37-item internet-based survey applied to members of urologic and gynecologic associations from 18 countries. Participants were asked about their background and practice patterns. Descriptive statistics were employed.

RESULTS

A total of 673 responses were obtained. Most came from Colombia (33.6%) and Brazil (24.7%). The number of practitioners who perform at least one POP procedure per month and were eligible to finish the survey was 529 (78.6%), out of which 323 (61.0%) were urologists, 156 (29.5%) gynecologists, and 50 (9.5%) urogynecologists. Mesh-based POP repairs were used by 57.1% of participants. Out of non-mesh users, the most frequent vaginal procedures were sacrospinous fixation (30%), colporrhaphy (25%), and uterosacral fixation (12%). Regarding the impact of FDA warnings, 75.2% participants indicated that the use of mesh has declined, and 41.9% considered this has had a negative effect in the use of incontinence tapes as well. Only two physicians reported legal disputes related to mesh procedures, and 75.8% said they would still indicate mesh repairs in certain cases.

CONCLUSIONS

This is the first report on POP practice patterns in LATAM. Preferences regarding surgical management of POP are not very different from international trends. Despite intense scrutiny and media exposure, mesh-based procedures are still largely used in LATAM.

The value of the preoperative 1-h pad test with pessary insertion for predicting the need for a mid-urethral sling following pelvic prolapse surgery: a cohort study

PURPOSE

Part of the patients with pelvic organ prolapse but without symptoms of stress urinary incontinence (SUI) may demonstrate SUI after prolapse surgery (occult SUI), and no optimal preoperative screening method is currently available for it. The aim of this study was to estimate the value of the preoperative 1-h pad test with pessary insertion for predicting the need for a mid-urethral sling (MUS) following prolapse surgery.

METHODS

Two hundred and six patients were enrolled for advanced prolapse without complaining of urinary incontinence (UI) in this prospective cohort study. Exclusion criteria included prior or concomitant anti-incontinence surgery. Preoperatively, a stress test, the 1-h pad test and uroflowmetry were performed with prolapse reduction. Primary outcome was postoperative de novo UI. Median follow-up was 31 months (range 12-48 months).

RESULTS

Of the 206 patients, 45 (21.8 %) had evidence of occult SUI preoperatively, 62 (30.1 %) exhibited de novo UI postoperatively, and only 13 (6.3 %) opted MUSs. Patients with occult SUI experienced higher de novo UI rate (53.3 vs. 23.6 %; P = 0.000). The OSUI and concomitant hysterectomy were identified as independent risk factors related to de novo UI (P = 0.000, P = 0.044). We performed receiver operating characteristic (ROC) curve analysis to evaluate the value of preoperative 1-h pad test. The area under ROC curve was 0.816 ± 0.085 (95 % CI 0.649-0.983); the cutoff value was 1.9 g (sensitivity 80.0 %, specificity 83.9 %).

CONCLUSIONS

The preoperative 1-h pad test with prolapse reduction is feasible for screening occult SUI, and more than 1.9 g may be a practical indicator of a postoperative subsequent MUS.

Clinical relevance of occult stress urinary incontinence (OSUI) following vaginal prolapse surgery: long-term follow-up

INTRODUCTION AND HYPOTHESIS

Patients with genital prolapse and occult stress urinary incontinence (OSUI) are typically treated with prolapse surgery and anti-incontinence surgery based on either a one-step approach or a two-step approach. The aim of our study was to determine whether anti-incontinence surgery is necessary based on the occurrence of OSUI in a study cohort with a long follow-up period.

METHODS

Prolapse surgery was performed using a vaginal approach. Preoperatively, a stress test, a pad test and an assessment of the urodynamics were performed with and without prolapse reduction. Over a follow-up period of 2-8 years, the patients with preoperative evidence of OSUI underwent urogynaecological examinations, stress tests and pad tests.

RESULTS

Of 113 patients with preoperative evidence of OSUI, 57 (50.4 %) were followed up for an average of 5.7 years (range 2-8) after prolapse surgery. Of 57 patients, 16 (28.1 %) had objective and/or subjective stress urinary incontinence (SUI) during the follow-up period, but only 3 patients (5.3 %) required subsequent tension-free vaginal tape (TVT) surgery. In 17 of 57 patients (29.8 %), prolapse recurred.

CONCLUSIONS

Despite the preoperative evidence of OSUI, the manifestation of SUI rarely occurs, with 28.1 % of patients experiencing SUI over long-term follow-up after vaginal prolapse surgery. Anti-incontinence surgery was necessary in only three cases (5.3 %). These results indicate that with the one-step approach, 54 of 57 patients (94.7 %) would have received prophylactic anti-incontinence surgery unnecessarily. In conclusion, we recommend the two-step approach in the management of vaginal prolapse surgery in patients with OSUI.