Key points

Introduction

POP is a common clinical condition that affects millions of women. There is an estimated 11.1% lifetime risk that a woman will undergo surgery for POP or incontinence by 80 years of age, with a 30% reoperation rate. POP and urinary incontinence have a significant impact on quality of life and health care costs. The number of patients seeking treatment of POP and urinary incontinence is predicted to increase dramatically over the next several years. The incidence of POP and urinary incontinence has been found to increase with advanced age. According to United Nations World Population Ageing data, the number of persons age 60 or older has surpassed 700 million and it is projected that by 2050 2 billion persons 60 years or older will be alive. Luber and colleagues note that women over the age of 60 are more likely to seek medical care for pelvic floor disorders and predicte a 45% increase in the demand for treatment of pelvic floor disorders including POP over the next 30 years.

Urodynamics (specifically, filling cystometrogram and pressure flow urodynamics) has become a standard part of the evaluation of patients with POP and/or urinary incontinence for many providers. The routine use of preoperative urodynamics in all patients, however, has been under increasing amounts of scrutiny as the medical community seeks to practice evidence-based medicine. POP can be associated with various lower urinary tract symptoms, including storage symptoms, urinary incontinence and voiding symptoms; however, it is often unclear how these symptoms will correlate with urodynamic findings. It is also unclear if urodynamic findings will correlate with postoperative outcomes or how the data should have an impact on patient counseling and surgical planning.

Introduction

POP is a common clinical condition that affects millions of women. There is an estimated 11.1% lifetime risk that a woman will undergo surgery for POP or incontinence by 80 years of age, with a 30% reoperation rate. POP and urinary incontinence have a significant impact on quality of life and health care costs. The number of patients seeking treatment of POP and urinary incontinence is predicted to increase dramatically over the next several years. The incidence of POP and urinary incontinence has been found to increase with advanced age. According to United Nations World Population Ageing data, the number of persons age 60 or older has surpassed 700 million and it is projected that by 2050 2 billion persons 60 years or older will be alive. Luber and colleagues note that women over the age of 60 are more likely to seek medical care for pelvic floor disorders and predicte a 45% increase in the demand for treatment of pelvic floor disorders including POP over the next 30 years.

Urodynamics (specifically, filling cystometrogram and pressure flow urodynamics) has become a standard part of the evaluation of patients with POP and/or urinary incontinence for many providers. The routine use of preoperative urodynamics in all patients, however, has been under increasing amounts of scrutiny as the medical community seeks to practice evidence-based medicine. POP can be associated with various lower urinary tract symptoms, including storage symptoms, urinary incontinence and voiding symptoms; however, it is often unclear how these symptoms will correlate with urodynamic findings. It is also unclear if urodynamic findings will correlate with postoperative outcomes or how the data should have an impact on patient counseling and surgical planning.

Evaluation for stress incontinence on prolapse reduction (occult stress urinary incontinence)

Stress incontinence on prolapse reduction, also known as occult SUI or latent stress incontinence, is SUI that occurs in women with POP only after the prolapse is reduced. It is thought related to kinking of the urethra that is relieved with prolapse reduction. Prolapse reduction has been reported to unmask SUI on prolapse reduction in 36% to 80% of clinically continent women with severe POP. In a review of the records of 24 continent women with stage 3 or 4 prolapse, Chaikin and colleagues found that 14 (58%) had demonstrable SUI on urodynamic testing with a pessary in place. Gordon and colleagues evaluated 45 clinically continent women with stage 3 POP, of whom 30 (67%) demonstrated SUI after repositioning the prolapse with a ring pessary during preoperative urodynamic evaluation. Ghoniem and colleagues found that in 11 of 16 (69%) continent women with large cystoceles, SUI was noted on evaluation after prolapse reduction with vaginal packing.

In addition, POP repair was previously shown to result in postoperative SUI in 11% to 22% of clinically continent women. Stanton and colleagues reported an 11% rate of postoperative SUI within 3 months in a group of patients undergoing anterior colporrhaphy with or without vaginal hysterectomy. Borstad and Rud found that 22% of clinically continent women undergoing a Manchester procedure for POP had postoperative SUI.

Several studies have documented the use of urodynamics to demonstrate stress incontinence on prolapse reduction in women with POP; however, its impact on postoperative outcomes remains highly debated. Most investigators agree that in patients with POP and symptomatic SUI, a simultaneous anti-incontinence procedure should be performed. Urodynamics is often used to evaluate patients with POP who do not have clinical SUI in an effort to identify those patients who are at risk for developing postoperative SUI and thus may benefit from simultaneous anti-incontinence procedure. The question remains, however: Can preoperative urodynamics be relied on to accurately predict those patients who will develop postoperative SUI without a simultaneous anti-incontinence procedure? And, should those patients without SUI demonstrated on urodynamics with reduction of prolapse be recommended to have POP repair alone?

The author and colleagues previously evaluated a urodynamic protocol used for managing the urethra at the time of transvaginal POP repair, looking at 105 patients with stages 2–4 POP in which a simultaneous midurethral synthetic sling was performed at the time of transvaginal POP repair if urodynamic SUI or SUI on prolapse reduction was demonstrated. If there was no demonstrable SUI on urodynamics with or without prolapse reduction, then a sling was not performed. Using this protocol, when a midurethral synthetic sling was placed, the risk of intervention due to obstruction (8.5%) was found essentially equal to the risk of subsequent intervention for SUI (8.3%) when no clinical, urodynamic, or SUI on prolapse reduction was present and no sling was placed. These data suggest that urodynamics may identify a subset of patients who may not need a prophylactic anti-incontinence procedure at the time of transvaginal POP repair. Also, in patients who reported clinical SUI but did not demonstrate SUI on urodynamic with or without reduction of prolapse, and thus did not have a simultaneous sling, the risk of postoperative intervention for SUI was 30%. It could be argued that based on the 30% risk of repeat surgery, a simultaneous sling should be performed in all patients with clinical SUI regardless of urodynamic findings indicating that preoperative urodynamics may not be necessary in these patients. Conversely, the urodynamic results could be used to counsel the small subset of patients with clinical SUI but no urodynamic SUI or SUI on prolapse reduction that there is a 70% chance that they would not require a second surgery.

In another study, Chermansky and colleagues evaluated postoperative incontinence and patient satisfaction using selective management of the urethra at the time of POP repair. They evaluated 42 patients with advanced apical and/or anterior compartment POP. Patients with clinical, occult, or urodynamic SUI were treated with a simultaneous sling procedure. Those without clinical or demonstrable SUI were treated with POP repair alone: 30 patients completed all of the postoperative questionnaires (Urogenital Distress Inventory [UDI-6], Patient Global Impression of Improvement [PGI-I], and Medical, Epidemiological, and Social Aspects of Aging [MESA]); 14 of the patients underwent only POP repair; and 16 patients had a POP repair with sling. There was no statistically significant difference in questionnaire results between those patients who underwent POP repair alone and those who had a simultaneous sling procedure. The mean of both groups reported their condition as “much better” on the PGI-I questionnaire. Only 1 patient in the POP repair–only group returned with postoperative SUI and underwent a subsequent sling procedure. The investigators also evaluated the cost variance between the 2 groups and found an estimated total cost savings of $55,804 using selective management.

Elser and colleagues evaluated the use of preoperative urodynamics to determine the need for an anti-incontinence procedure at the time of abdominal sacrocolpopexy. They retrospectively reviewed 463 patients who underwent abdominal sacrocolpopexy; 204 patients had SUI on preoperative urodynamics either with or without prolapse reduction and 237 patients had no SUI. All of the patients with preoperative SUI underwent a simultaneous anti-incontinence procedure; 157 patients (77%) underwent a midurethral synthetic sling (either retropubic or transobturator) and 47 patients (23%) underwent Burch urethropexy. Charts were available for review on 441 patients. At 6 weeks postoperatively, 178 (87.3%) of the patients who had SUI and underwent an anti-incontinence procedure and 220 (92.8%) of the patients without preoperative SUI, and thus no anti-incontinence procedure, reported no incontinence. The authors concluded that urodynamics is useful in determining the need for an anti-incontinence procedure at the time of abdominal sacrocolpopexy and recommended that patients without preoperative SUI (including SUI with reduction of prolapse) not undergo simultaneous anti-incontinence surgery.

In addition to these studies, several other small studies have suggested that clinically continent patients without urodynamic SUI with reduction of prolapse are unlikely to develop postoperative SUI after POP repair. Some also demonstrate a high rate of postoperative SUI in patients with SUI on prolapse reduction who did not undergo a simultaneous anti-incontinence procedure.

In a study by Chaikin and colleagues, 24 women without clinical symptoms of SUI were evaluated; 14 patients were found to have SUI on prolapse reduction during urodynamic evaluation and underwent an autologous fascia sling. Of the 10 patients who did not have a sling, none developed postoperative SUI at an average of almost 4 years’ follow-up. Another small retrospective study by Araki and colleagues evaluated the utility of preoperative urodynamics to predict postoperative urinary symptoms. They evaluated records of 87 patients who underwent surgery for POP. Of the 22 patients with SUI on prolapse reduction, 13 did not undergo simultaneous transobturator midurethral synthetic sling. Of those 13 patients, 62% developed symptomatic postoperative SUI; 49 patients did not demonstrate SUI on prolapse reduction on preoperative urodynamics; and only 2 (4%) developed postoperative SUI.

Liang and colleagues reported on 79 patients with severe POP but without clinical SUI; 30 patients did not demonstrate SUI on prolapse reduction on preoperative urodynamics and underwent POP repair alone. None of the 30 patients developed SUI postoperatively. Furthermore, in the 49 patients who had SUI on prolapse reduction on preoperative urodynamics, POP repair alone was performed in 17 patients and simultaneous tension-free vaginal tape (TVT) was performed in 32 patients. The investigators found that patients with SUI on prolapse reduction who underwent POP repair alone had a significantly higher rate of subjective and objective SUI compared with patients who underwent simultaneous TVT placement (64.7% and 53% vs 10% and 0%, respectively). In the author and colleagues’ study (discussed previously), 22 of 24 women (91.7%) without symptomatic or SUI on prolapse reduction did not require further intervention for SUI after POP repair.

There are also studies that question the utility of stress testing during urodynamics in women with prolapse. Recently, the Outcomes Following Vaginal Prolapse Repair and Mid Urethral Sling (OPUS) Trial found that a prophylactic midurethral synthetic sling performed at the time of transvaginal POP repair resulted in lower rates of urinary incontinence at 3 and 12 months postoperatively regardless of preoperative prolapse reduction stress testing. In this study Wei and colleagues evaluated 337 women with anterior prolapse (stage 2 or higher) without symptoms of SUI who were planning to undergo transvaginal POP repair. Evaluation included a preoperative prolapse reduction stress test (at a bladder volume of 300 mL with the prolapse reduced with 1 or 2 large swabs) but did not include preoperative urodynamic evaluation. Women were randomly assigned to undergo simultaneous midurethral synthetic sling or sham incisions during the POP repair. All the slings placed were performed in a retropubic fashion (Gynecare TVT, Ethicon, Bridgewater, NJ, USA); however, the transvaginal procedures performed to address the POP varied.

Of the randomized patients, 327 (97%) completed 1-year follow-up. At 3 months’ follow-up, 23.6% who had a sling and 49.4% of patients in the sham group had postoperative SUI. At 12 months, urinary incontinence (allowing for subsequent treatment) was present in 27.3% and 43.0%, respectively. The number needed to treat with a sling to prevent 1 case of urinary incontinence at 1 year was 6.3. Preoperatively, 33.5% of women had a positive prolapse reduction stress test. At 3 months, 29.6% of the sling group versus 71.9% of the sham group had urinary incontinence, indicating that women with a positive stress test preoperatively received more benefit from a sling than those with a negative test. This difference was not statistically significant at 12 months, however. During the first year postoperatively, 1 woman (0.6%) in the sling group underwent surgery for urinary incontinence and 4 (2.4%) underwent surgery for voiding dysfunction. Adverse events, including bladder perforation, major bleeding complications, and incomplete bladder emptying in the first 6 weeks after surgery, were also all more common in the sling group than in the sham group.

Visco and colleagues questioned the utility of stress testing specifically during urodynamics in women with prolapse based on findings from the Colpopexy and Urinary Reduction Efforts (CARE) trial. The CARE trial found that a significant number of patients who did not leak during preoperative testing developed postoperative SUI. In the trial, 322 patients undergoing abdominal sacrocolpopexy for stages II–IV POP were randomized to concomitant Burch colposuspension (157 patients) or to the control group (165 patients). Of the women in each group, 36% had SUI on prolapse reduction on preoperative urodynamics. In the control group (no Burch), postoperative SUI occurred in 38% with a negative stress reduction test.

The CARE trial has been cited as level 1 evidence that a Burch colposuspension should routinely be performed at the time of abdominal sacrocolpopexy. At 3 months postoperatively, 23.6% of the women who underwent Burch colposuspension versus 44.1% of controls met at least 1 criterion for SUI. Furthermore, Burch colposuspension decreased SUI postoperatively even in the patients who did not have SUI on prolapse reduction preoperatively (20.8% vs 38.2%). Togami and colleagues pointed out, however, that in the CARE trial, 62% of patients did not leak after abdominal sacrocolpopexy alone, highlighting that greater than 50% of patients would be overtreated. They also noted that Burch colposuspension only resulted in an 18% reduction in postoperative SUI.

The CARE trial found that women who demonstrated preoperative urodynamic SUI on prolapse reduction were more likely to have postoperative SUI regardless of whether they underwent a simultaneous Burch procedure. In the control group, 58% percent of patients with a positive stress reduction test developed postoperative SUI compared with 38% of those with a negative stress reduction test. In the group who underwent simultaneous Burch, 32% with a positive stress test experienced postoperative SUI compared with 21% of patients with a negative test. The investigators acknowledged that this information could be used for preoperative counseling but questioned whether it would have an impact on patient management.