Volume 154, Issue 1 , Pages 105-107, January 2011
Concomitant surgical correction of occult stress urinary incontinence by TOT in patients with pelvic organ prolapse
Article Outline
Abstract
Objectives
To assess the post-operative urinary incontinence states of pelvic organ prolapse cases operated on with concomitant trans-obturator tape (TOT) procedure.
Study design
Urodynamic evaluation of 79 patients with pelvic organ prolapse, before and after operation, while reducing the prolapsed organs by ring forceps placed bilaterally on the anterolateral sulcuses avoiding urethral compression. According to urodynamic tests, 25 patients were diagnosed as having occult stress urinary incontinence.
Results
Post-operative overactive bladder, stress urinary incontinence and mixed incontinence were found in three (12%), two (8%) and one (4%) patients of the occult stress urinary incontinence group, respectively. The corresponding numbers were six (11%), five (9%) and three (6%) in the continent group. No significant difference was found between the groups in terms of post-operative overactive bladder symptoms, stress urinary incontinence and mixed incontinence (Kruskal–Wallis test, X2
=0.52, p=0.820).
Conclusions
This retrospective study suggests that a complete pre-operative urodynamic evaluation, including urodynamic tests at the time of POP reduction by placing ring forceps on the anterolateral sulcuses, is an efficient method for the diagnosis of occult symptomatic stress urinary incontinence (SUI). Prospective randomized studies are needed to establish the benefits and the risks of concomitant prophylactic surgery in patients with pelvic organ prolapse.
Keywords: Pelvic organ prolapse, Stress urinary incontinence, De novo detrussor overactivity, Occult SUI, TOT
1. Introduction
Pelvic organ prolapse (POP) often accompanies either occult or symptomatic stress urinary incontinence (SUI). Occult SUI is defined as urinary leakage which is prevented by POP and only becomes symptomatic after surgical correction of the pelvic anatomy. It is unclear whether increased intra-urethral pressure secondary to urethral kinking and/or external urethral compression masks the symptoms of an incompetent urethra [1].
Pre-operative urodynamic investigation as part of the diagnostic work-up in patients with advanced POP is recommended by the International Continence Society. It has been reported that after reduction of the prolapsed organs with a pessary, vaginal pack or surgical correction, 36–80% of continent women with severe POP are at risk of symptomatic SUI. Nevertheless, surgical correction of occult incontinence is still controversial [2]. The purpose of the present study was to assess the results of the concomitant surgical correction of occult incontinence in patients with POP.
2. Materials and methods
This retrospective study included patients diagnosed as having POP without symptomatic urinary incontinence at our outpatient clinic (Zeynep Kamil Hospital, İstanbul, Turkey) between October 2006 and December 2008. All participants underwent a thorough pelvic examination in the lithotomy position, including Valsalva maneuver, to assess the degree of the prolapse according to the pelvic organ prolapse quantification (POP-Q) system as proposed by International Continence Society in 1995 [3]. Symptomatic stage II (presenting part of the prolapse beyond the hymenal ring), stage III and IV prolapse cases were enrolled into the study.
Presence of symptomatic SUI, urge incontinence or a history of pelvic surgery were the exclusion criteria. Diagnosis of occult SUI was established solely on urodynamic findings. All patients underwent a full urodynamic evaluation pre- and post-operatively, including provocative twin-channel subtracted cystometry at a filling rate of 100ml/min and pressure flow studies. Pre-operatively, and (if needed) post-operatively, urodynamic testing was performed after reduction of the POP by using two ring forceps bilaterally, each placed on the vaginal anterolateral sulcus. The prolapsed organs were pushed back to their original position as much as possible, while avoiding any compression to the urethra, in order to unmask urodynamic findings of stress incontinence.
The methods, definitions and units conformed to the standards proposed by the International Continence Society [3]. During filling cystometry, the observation of urinary leakage provoked by coughing or the Valsalva maneuver without vesical contractions after reduction of the prolapsed organs at 200ml bladder volume was accepted as occult SUI.
Reductive surgery alone was performed on patients with normal urodynamic tests, while those with a diagnosis of occult SUI underwent a concomitant prophylactic trans-obturator tape (TOT) operation by the same operating team. Surgical procedures performed for the correction of POP were vaginal hysterectomy with or without anterior/posterior colporrhaphy, sacrospinous fixation, and McCall culdoplasty, where clinically appropriate. Urodynamic examinations were repeated at approximately the 20th month post-operatively (20±9.72 months). All patients were also scored by using the Turkish versions of the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) [4].
All values were given as mean±standard deviation. Statistical analysis was performed using SPSS 11.5 software. Student's t, Kruskal–Wallis, Mann–Whitney U and Pearson's chi square tests were performed where appropriate; p=0.05 was accepted as the degree of significance.
3. Results
Among 79 evaluated patients with POP, 54 were continent according to pre-operative urodynamic evaluations, while 25 were diagnosed as having occult SUI and operated on appropriately. There was no significant difference in age, body mass index and parity between the patients with and without occult SUI (Table 1). Ten patients of the occult SUI group and 19 patients of the no-occult SUI group had a history of a macrosomic infant (>4000g). No significant difference was found between the groups in terms of having a history of vaginal delivery of macrosomic infants (Pearson's chi square test, X2=0.064, p=0.801).
Table 1. Age, body mass index (BMI) and parity of the pelvic organ prolapse patients (symptomatic stage II–IV) with or without occult stress urinary incontinence (data are shown as mean±standard deviation, two-tailed Student t-test, p>0.05).
| Occult SUI (n=25) | No-occult SUI (n=54) | t | p | |
|---|---|---|---|---|
| Age (years) | 52.76±8.32 | 53.74±10.11 | 0.423 | 0.674 |
| BMI | 28.32±5.27 | 28.04±4.84 | −0.235 | 0.815 |
| Parity | 3.48±1.23 | 4.17±1.95 | 1.615 | 0.110 |
Pre-operative urodynamic findings of the groups were as follows. Average (and maximal) flow rates of the patients with or without occult SUI were 10.46±2.89 (20.36±7.15) and 6.25±1.75 (10.5±2.62)ml/s, respectively. Valsava leak point pressure of the occult SUI patients was 145.41±44.58cmH2O. Detrusor pressure of these patients was 30.05±16.51 whereas that of the patients without occult SUI was 21.325±6.46cmH2O.
Among the 54 patients with no-occult SUI, 40 (74%) were continent, six (11%) had overactive bladder, five (9%) had SUI and three (6%) had mixed incontinence findings on post-operative urodynamic evaluations. In the occult SUI group (n=25) these findings were: overactive bladder in three (12%), SUI in two (8%) and mixed incontinence in one (4%) patients; 19 patients (76%) were found to be continent. No significant difference was found between the continence statuses of the patients with or without occult SUI (Kruskal–Wallis test, X2=0.52, p=0.820); these results are shown in Table 2. Post-operative UDI-6 and IIQ-7 scores of the patients also did not differ significantly between groups (Mann–Whitney U-test, p>0.05) (Fig. 1).
Table 2. Pre-op POP-Q and post-op continence states of the POP patients.
| Pre-op POP stage | Post-op continence | |||||
|---|---|---|---|---|---|---|
| Continent | OB | SUI | Mixed | Total | ||
| Reductive surgery only n (%) | 2 | 11 | 2 | 0 | 0 | 13 |
| 3 | 20 | 3 | 5 | 3 | 31 | |
| 4 | 9 | 1 | 0 | 0 | 10 | |
| Total | 40 (74) | 6 (11) | 5 (9) | 3 (6) | 54 (100) | |
| Concomitant TOT n (%) | 2 | 4 | 2 | 1 | 0 | 7 |
| 3 | 13 | 1 | 0 | 1 | 15 | |
| 4 | 2 | 0 | 1 | 0 | 3 | |
| Total | 19 (76) | 3 (12) | 2 (8) | 1 (4) | 25 (100) | |
Fig. 1.
Post-operative Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) scores of the patients who underwent prolapse reduction only and concomitant trans-obturator tape (TOT) patients (UDI- 1,2: irritative symptoms; UDI- 3,4: stress symptoms; UDI- 5,6: obstructive symptoms; Mann–Whitney U-test, p1–4
>0.05).
Pre- and post-operative POP-Q scores of the patients were shown in Table 3. No difference was found between groups in terms of pre- and post-operative grades of prolapse (Mann–Whitney U-test, p1=0.512, p2=0.579, respectively).
Table 3. Pre- and post-operative POP-Q scores of the patients with pelvic organ prolapse (symptomatic stage II–IV) who underwent reductive surgery alone or concomitant TOT (Mann–Whitney U-test, p1,2=>0.05).
| Reductive surgery only (n=54) | Concomitant TOT (n=25) | ||||
|---|---|---|---|---|---|
| Pre-op | Post-op | Pre-op | Post-op | ||
| POP stage n (%) | 0 | – | 16 | – | 8 |
| 1 | – | 10 | – | 6 | |
| 2 | 13 | 16 | 7 | 6 | |
| 3 | 31 | 8 | 15 | 5 | |
| 4 | 10 | 4 | 3 | 0 | |
4. Comments
Occult SUI often becomes symptomatic after surgical correction of the pelvic anatomy by unmasking an incompetent urethra. In this study, 25 (31%) of the 79 POP patients without urinary incontinence were diagnosed as having occult SUI and all of them underwent a concomitant TOT and prolapse operation. Post-operatively, two patients had SUI, three had de novo overactive bladder, and one patient was found to have mixed incontinence. Fifty-four patients with POP were urodynamically continent at the time of diagnosis, and underwent POP surgery alone. Post-operatively, among these 54 patients, five had SUI, six developed de novo overactive bladder, and three had mixed incontinence. No difference was found among groups in terms of post-operative SUI, detrusor instability and mixed incontinence rates (Kruskal–Wallis test, Table 2).
Concomitant surgical correction of POP and occult SUI is still controversial [5], [6], [7], [8]. Roovers and Oelke reported an extensive review of the literature about this issue [2]. They highlighted the increased risk of overactive bladder symptoms after anti-incontinence operations and suggested that those patients, as they did not report incontinence before the operation, would find it more difficult to accept the overactive bladder symptoms compared with patients who were treated successfully. Moreover, there have been some reports of a wide range of operative reduction rates of occult SUI in the literature. This might be a result of the absence of universal criteria for the diagnosis of occult SUI (i.e., cough test, urodynamic investigation) and the techniques performed for reduction of the prolapse (i.e., vaginal pack, pessary, speculum, forceps) which might result in urethral compression during tests. The types of the operative techniques of POP and anti-incontinence surgery and the degree of incontinence of the patients are also heterogeneous in the literature [2].
In the present study, post-operative SUI, de novo overactive bladder and mixed incontinence rates of the patients with concomitant TOT were not different from those of the patients with POP correction only. Nineteen out of 25 TOT operated patients (76%) were found to be free of any type of incontinence. This means that concomitant prophylactic TOT operation on the POP patients with occult SUI prevented the suggested increment of the post-operative SUI rate and did not increase the rate of de novo overactive bladder as compared with the POP patients without occult SUI (Table 2). However, due to lack of data about patients with occult SUI who have not undergone a concomitant TOT operation, this study fails to prove a beneficial role of TOT in such patients.
The authors of this retrospective study suggest that a complete pre-operative urodynamic evaluation, including urodynamic tests at the time of POP reduction by placing ring forceps on the anterolateral sulcuses, is an efficient method for the diagnosis of occult SUI. Management of the POP cases by concomitant anti-incontinence surgery is still controversial, and randomized studies would help to clearly establish the benefits and the risks of this strategy.
References
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PII: S0301-2115(10)00409-4
doi:10.1016/j.ejogrb.2010.08.003
© 2010 Elsevier Ireland Ltd. All rights reserved.
Volume 154, Issue 1 , Pages 105-107, January 2011
