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28.04.

2015

Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment
Authors
CharlesWNager,MD
JasmineTanKim,MD

SectionEditor
DeputyEditor
LindaBrubaker,MD,FACS,FACOG KristenEckler,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Mar2015.|Thistopiclastupdated:Sep24,2014.
INTRODUCTIONPelvicorganprolapse(POP)andstressurinaryincontinence(SUI)coexistinupto80
percentofwomenwithpelvicfloordysfunction[1,2].Whiletheseconditionsareoftenconcurrent,onemaybemild
orasymptomatic.WomenwithoutsymptomsofSUIwhoundergosurgeryforprolapseareatriskforpostoperative
urinaryincontinence[3].SUImayalsoworsenafterprolapserepair.
DecidingwhethertoperformacombinedsurgicalproceduretotreatbothprolapseandSUIorasingleprocedure
thataddressesonlyoneconditionrequiresbalancingtheriskofincompletetreatmentwiththeriskofexposingthe
patienttounnecessarysurgery[4].Thisdecisionmustbebasedonthebestapproachtoaddressthepatient's
goals,ratherthansimplyonanatomiccorrection[5,6].Therateofconcurrentprolapserepairandcontinence
proceduresappearstobeincreasing.DatafromtheUnitedStatesNationalInpatientsampleshowedthatforapical
prolapserepairprocedures,therateofconcurrentcontinencesurgeryincreasedfrom38percentin2001to47
percentin2009[7].
Challengesinsurgicaldecisionmakinginthisclinicalcontextincludeappropriateassessmentofresultsof
preoperativeevaluation,someofwhichmaybeambiguous(eg,prolapsenotedonexaminationinapatientwithno
prolapserelatedsymptomsorapatientwithadvanceprolapsewithnoleakageonprolapsereductiontesting).
CombinedsurgicaltreatmentforPOPandSUIwillbereviewedhere.Otherapproachestosurgicalandmedical
treatmentoftheseconditionsandothertypesofurinaryincontinencearediscussedseparately.(See"Pelvicorgan
prolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement"and
"Approachtowomenwithurinaryincontinence"and"Surgicalmanagementofstressurinaryincontinencein
women:Choosingaprimarysurgicalprocedure".)
TERMINOLOGY
Stressurinaryincontinence(SUI)Leakageofurinewithincreasedintraabdominalpressure(eg,cough,
laughter).(See"Approachtowomenwithurinaryincontinence".)
OccultSUISUIthatisnotsymptomatic,butbecomesapparentonlyduringclinicalorurodynamicurinary
functiontestingwhentheprolapseisreduced(ie,stresstestingwithreductionofprolapsedstructures).
Occultstressincontinenceisalsoreferredtoaslatent,hidden,iatrogenic,orpotential.
ThedefinitionofoccultSUIisinconsistentinthemedicalliterature.Whilesomeauthorsusethetermto
describeonlyincontinencewhichhasbeendemonstratedonurinaryfunctiontesting(asinthistopicreview),
othersusethetermoccultincontinencetosignifythatthereisapossibilitythatSUIwilloccurafterprolapse
repair.
DenovourinaryincontinenceUrinaryincontinencethatisnewlysymptomatic,asanexample,incontinence
symptomsthatdevelopaftersurgeryinapreviouslycontinentpatient.Thetypeofnewincontinenceshould
bespecified(eg,stress,urge).Asanexample,apatientwithurgencyincontinenceandnoSUIbefore
surgerymayhavepersistenturgencyincontinenceanddenovostressincontinenceaftersurgery.
ProlapsereductiontestingElevationofprolapsedstructurestoapproximatenormalpelvicsupportduring
pelvicexaminationorclinicalorurodynamicurinaryfunctiontesting.Thisisperformedincombinationwitha
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urinarystresstest(coughtest)toattempttodetectoccultSUI.(See"Approachtowomenwithurinary
incontinence",sectionon'Evaluation'.)
CLINICALPRESENTATIONPelvicorganprolapse(POP)andstressurinaryincontinence(SUI)maypresent
aloneorconcurrentlyinavarietyofcombinations.
SymptomaticprolapseandincontinenceSymptomsofbothPOPandSUImaybepartofthepresenting
complaint.Ontheotherhand,POPsymptomsmaybenonspecific(pelvicpressureordiscomfort)andsome
womenonlyrecognizetheseasrelatedtoPOPafterevaluationbyaclinician.Thesymptomsofprolapseand
incontinencemaybeequallybothersomeoroneconditionmaypredominate.(See"Approachtowomenwith
urinaryincontinence",sectionon'Clinicaltests'.)
ProlapsewithnosymptomsofincontinenceAdvancedPOP(pelvicorganprolapsequantitationsystem
[POPQ]stageIItoIV)commonlycoexistswithSUI,however,formanywomentheSUImaybecomeapparent
onlywhentheprolapsehasbeencorrected[1].ThisphenomenonisknownasoccultSUI.TestingforoccultSUI
isdiscussedbelow(see'Detectingoccultincontinence'below).
Anatomically,thisoccursbecauseinwomenwithsignificantanteriororapicalprolapse(usuallyprolapsepastthe
vaginalintroitus),thebladderneckisdisplacedposteriorlyandtheurethraiskinked,resultinginurethral
obstruction.Theobstructionthenbecomesthemechanismofcontinence(figure1)[8].
Whentheprolapsedstructuresareelevated(approximatingnormalanatomy)duringprolapsereductiontestingin
womenwithurethralobstructionduetoadvancedPOP,theurethraisunblockedandSUIoftenbecomesevident
whenaurinarystresstestisperformed.Ontheotherhand,womenwithstageIPOPareunlikelytohaveurethral
obstructionandresultantoccultSUI[912].(See'Detectingoccultincontinence'below.)
OccultSUIisdiagnosedusingpreoperativeprolapsereductiontestingin31to80percentofwomenwith
symptomaticand/oradvancedPOPwhoareplanningsurgicaltreatment[1326].Accordingly,whenwomenwith
occultSUIundergoprolapserepairwithoutaconcomitantcontinenceprocedure,therateofpostoperativedenovo
SUIrangesinstudiesfrom13to72percent(mean51percent)(algorithm1)[13].
However,womenwhohavenegativepreoperativetestingforoccultSUIandundergoprolapserepairwithouta
continenceproceduremaystilldevelopSUIaftersurgery,butatalowerratethanwomenwhotestpositivefor
occultSUIwithpreoperativeprolapsereductiontesting.Therateofpostoperativeincontinenceinwomenwith
negativepreoperativeoccultstresstestingrangesinstudiesfrom0to42percent(mean26percent)(algorithm1)
[1416,18,2731].
IncontinencewithnosymptomsofprolapseWomenwhopresentwithSUIwilloftenhavePOPofvarying
degrees.TreatmentisindicatedonlyforsymptomaticPOP.Approximately40percentofwomenarefoundtohave
stageIIorgreaterprolapseatannualgynecologicexaminationhowever,symptomsrelatedtoprolapseoftendo
notcorrespondwithanatomicalfindings[912].(See"Pelvicorganprolapseinwomen:Anoverviewofthe
epidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Clinicalmanifestations'.)
PREOPERATIVEEVALUATIONWomenwhoareconsideringpelvicreconstructivesurgeryforpelvicorgan
prolapse(POP)orstressurinaryincontinence(SUI)shouldhaveacomprehensiveevaluationtoguidesurgical
planning.
GeneralevaluationAnevaluationincludes:
MedicalhistoryandsymptomsrelatedtoPOPandSUI(avoidingdiarymaybeuseful(figure2))
Pelvicexaminationwithobjectivequantificationofprolapse
Clinicalorurodynamicurinarystresstestingwithandwithoutreductionofprolapse
Assessmentofpatientgoalsandqualityoflife
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ThediagnosticandpreoperativeevaluationofwomenwithPOPorSUIisdiscussedindetailseparately.(See
"Pelvicorganprolapseinwomen:Diagnosticevaluation"and"Surgicalmanagementofstressurinaryincontinence
inwomen:Preoperativeevaluationforaprimaryprocedure".)
DetectingoccultincontinenceOccultSUIcanbedetectedbymedicalhistoryandclinicalorurodynamic
testingwithreductionofprolapsedstructures.
CluesinthehistorythatsuggestoccultSUIinclude(1)incontinencethatimprovedorresolvedasprolapse
worsened(2)theneedtomanuallyreplacetheprolapsedstructuresintothevaginatovoidor(3)worseningor
developmentofSUIwithuseofapessary[9].
Onclinicalbladderfunctiontestingorurodynamictesting,womenwithPOPshouldbeevaluatedwithandwithout
reductionofprolapse.Thepurposeistosimulatethepatient'svaginalarchitectureaftersurgicalrepair.Reducing
theprolapsewilloftenreduceapreviouslyelevatedpostvoidresidualandunmaskSUI.
Prolapsereductionshouldbeperformedwhilethepatientisstanding.Whileelevatingtheprolapsedstructures,itis
importanttoavoidobstructingtheurethra,whichwouldmaskincontinence.Oneshouldalsoavoidplacingthe
anteriorvaginalwallunderexcessivetension,whichcoulddistortthepelvicanatomy.(See"Approachtowomen
withurinaryincontinence",sectionon'Physicalexamination'.)
Themostcommonmethodsofprolapsereductionusethefollowingtoelevatethestructures:examiner'sfingers,
largecottonswab,singlespeculumblade,ringforceps,orpessary.Whiletherearefewdatacomparingthese
methods,usingapessarymaybelesseffectiveatdetectingSUIthanothermethods[16,32].Thisislikely
becauseincontinencepessariesincreasethemaximumurethralclosurepressureandfunctionalurethrallength
and,thus,areoftenusedtotreatSUI[33].Somedatasuggestthatthebladdershouldbefilledtoatleast300mL
inonestudy,occultSUIidentifiedwithuseofabladdervolumeof300mLwasmorelikelythan100mLtobe
associatedwithpostoperativeSUI[34].
Inthelargeststudytoevaluateprolapsereductiontesting,dataregardingprolapsereductionusingfivemethods
(manual,swab,speculum,forceps,pessary)werecollectedinwomenwithadvancedprolapse,butwithout
symptomsofSUI(n=322)[16].ThesensitivityfordetectionofoccultSUIwassimilaramongmostreduction
testingmethods(17to39percent),withtheexceptionofthepessary,whichwaslesssensitive(5percent).Inour
practice,weuseoneortwolargecottonswabsbecauseitiswelltoleratedbypatientsandtheswabsarelong
enoughtoapproximateasurgicalsuspensionofthevaginalapex.
ProlapsereductiontestingmaybeperformedaspartofofficetestingofSUIorduringurodynamicevaluation.Both
approachesappeartohaveasimilarpredictivevalueforthedevelopmentofpostoperativeSUI.Thisisbasedupon
datafromtwoprospectivestudiesofwomenwhounderwentpreoperativeprolapsereductiontestingandwere
treatedwithaprolapserepairprocedure,butnocontinenceprocedure.Urodynamicevaluationwasusedinone
study,andtherateofpostoperativedenovoSUIwas58percentforwomenwhotestedpositiveforpreoperative
occultSUIand38percentforthosewhotestednegative[16].Intheotherstudy,officetestingwasused,andthe
rateofdenovoSUIwas72percentforwomenwhotestedpositiveand38percentforwomenwhotestednegative
[13].
MoststudiesdefineoccultSUIasleakagewithprolapsereductionduringofficetestingorurodynamicevaluation,
butsomereportsusedmaximumurethralclosurepressuresorpressuretransmissionratiosof<0.9or1.0during
urodynamicevaluationtoindicateapositivetest.Duringurodynamictesting,prolapsereductiondecreases
maximalurethralclosurepressure,butdoesnotalteranyotherfillingorpressureflowparameter[8].(See
"Urodynamicevaluationofwomenwithincontinence".)
Thepredictivevalueofprolapsereductiontestingislimited.Theresultsofnumerousstudiesevaluatingtheriskof
postoperativeSUIinwomenundergoingprolapsesurgerywithvariousclinicalscenariosaresummarizedinthe
figure(algorithm1)[1416,18,20,21,2729,3546].Overall,inwomenwithoutsymptomsofSUIwhohavepositive
preoperativeprolapsereductiontesting,therateofpostoperativeSUIis51percentwithoutanincontinence
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procedureand16percentwithanincontinenceprocedure.Inasymptomaticwomenwhohavenegativeprolapse
reductiontesting,therateofpostoperativeSUIis26percentwithoutanincontinenceprocedureand17percent
withanincontinenceprocedure.
IntheabsenceofmoreeffectivemethodstodetectoccultSUI,however,reductiontestingshouldbeperformedin
allwomenplanningvaginalpelvicfloorreconstructivesurgery.Furtherstudyisneededtoidentifyothermethods.
InformedconsentandpatientgoalsWomenplanningsurgicalcorrectionofpelvicfloorreconstructivesurgery
shouldbecounseledaboutthepotentialforincompleteresolutionofsymptoms,ornewsymptomsofSUI,urinary
retentionorurgencyincontinence.
Discussingpatientgoalsandsettingexpectationscanalsohelpboththepatientandsurgeonmeasuresurgical
success.Achievementofpatientgoals,includingsymptomresolution,orimprovementinlifestyle,activity,or
sexualfunction,correlatewithpostoperativesatisfaction[5,6].(See"Pelvicorganprolapseinwomen:Anoverview
oftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Establishingpatient
goals'.)
CHOOSINGANABDOMINALORVAGINALAPPROACHForwomenwithbothstressurinaryincontinence
(SUI)andpelvicorganprolapse(POP),thesurgicalroute(vaginalorabdominal,includinglaparoscopicorrobotic
procedures)ischosenthatismostappropriatefortheanatomicsiteofprolapse(ie,anterior,apical,posterior)with
thegoalofavoidingincisionsintwosites.AnabdominalapproachtypicallyincludesasacrocolpopexyandBurch
colposuspension,whileavaginalapproachmayincludeauterosacralligamentfixation(orothertransvaginal
procedure)andsuburethralsling(typicallyamidurethralsling).
Additionalfactorstoconsiderinchoosingarouteare:
Medicalhistorycomorbidities,priorsurgeries
Procedureefficacythisdependsuponprocedureandsurgeon'sexperience[47]
Patientpreference
Mostcombinedproceduresareperformedvaginallyforseveralreasons.Midurethralslingplacement,avaginal
approach,isthepreferredprocedureformostwomenwithSUI.Also,repairofanteriorandposteriorprolapseare
usuallyperformedvaginally.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosinga
primarysurgicalprocedure".)
Theexceptiontothisisapicalprolapse,whichiscommonlyrepairedusinganabdominal(openorlaparoscopic)
sacrocolpopexy.Apicalprolapsecanalsoberepairedviaavaginalroute,withsacrospinousoruterosacral
ligamentsuspension.Thechoiceofrouteforwomenwithapicalprolapsethendependsuponthebestcombination
ofprocedures:(1)midurethralslingandsacrospinousoruterosacralligamentsuspensionor(2)Burch
colposuspensionandabdominalsacrocolpopexy.Evidencefromrandomizedtrialshasdemonstratedthat
abdominalrepairsaremoredurable,whilevaginalrepairshavefewercomplications,includingforeignbody
complications.Comparisonofsurgicaloutcomesforspecificproceduresisdiscussedindetailseparately.(See
"Pelvicorganprolapseinwomen:Surgicalrepairofapicalprolapse(uterineorvaginalvaultprolapse)",sectionon
'Abdominalversusvaginalapproach'.)
Alternatively,somesurgeonscombinesacralcolpopexywithamidurethralsling,particularlywhenalaparoscopic
orroboticapproachisused.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosinga
primarysurgicalprocedure",sectionon'Apicalprolapse'.)
SELECTIONOFPROCEDUREThecombinationofsymptomsandfindingsonpreoperativeevaluationguide
thechoiceofprocedurefortreatmentofpelvicorganprolapse(POP)and/orstressurinaryincontinence(SUI).
ChoosingaprocedurethataddresseseitherPOPorSUIoracombinedprocedurefordifferentclinicalscenariosis
discussedhere.
ThechoiceofaprimaryprocedurefortreatmentofSUIisdiscussedindetailseparately.(See"Surgical
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managementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)
SymptomaticPOPandSUIForwomenwithsymptomsofbothPOPandSUI,werecommendaconcomitant
prolapserepairandcontinenceprocedureratherthanPOPrepairalone.Datafromprospectivecomparativestudies
ofwomenwithbothsymptomaticPOPandSUIshowasignificantlylowerrateofpostoperativeSUIinwomen
whoundergobothPOPrepairandacontinenceprocedurecomparedwiththosewhoundergoPOPrepairalone(0
to40versus36to71percent)(algorithm1)[35,42,4446].
ThereisnosingleprocedurethatadequatelytreatsbothPOPandSUI.Historically,theonlyexampleofaPOP
repairprocedurethatwasperformedwiththeintentionoftreatingSUIwasanteriorcolporrhaphyaloneorwitha
KellyKennedyplication.ThisapproachhasbeenfoundtobelesseffectivefortreatmentofSUIthanaBurch
colposuspensionbaseduponrandomizedtrialdata.Likewise,availablecontinenceprocedures(suburethralslings,
Burchcolposuspension)arenoteffectivefortreatingsymptomsassociatedwithPOP[42].(See"Surgical
managementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",sectionon
'Proceduresnolongerrecommended'.)
POPwithnosymptomsofSUIThemanagementofwomenwithsymptomaticPOP,butnoSUIsymptomsis
controversial.ContinentwomenwithstageIPOPwhoareplanningprolapserepairareunlikelytohaveurethral
obstructionandresultantoccultSUI,andthusareunlikelytobenefitfromaconcomitantcontinenceprocedure.
However,forwomenwithadvancedprolapse,thereisahighlikelihoodthattheywilldevelopSUIpostoperatively.
TherearethreepossibleapproachesforaddressingpotentialSUIatthetimeofPOPtreatment:
UniversalAcontinenceprocedureisperformedatthetimeofPOPsurgery,regardlessofpreoperative
prolapsereductionandurinarystresstesting.
SelectivePreoperativeprolapsereductionandurinarystresstestingisperformed.IfoccultSUIis
detected,acontinenceprocedureisperformedatthetimeofPOPrepair.IfoccultSUIisnotdetected,POP
repairaloneisperformed.
StagedPOPrepairisperformedwithoutaconcomitantSUIprocedure,regardlessofpreoperativeprolapse
reductionandurinarystresstesting.AsubsequentcontinenceprocedureisperformedifSUIsymptoms
developandthepatientdesiressurgicaltreatment.
Thechoicebetweentheseapproachesisbestsupportedbydatafromtwolargerandomizedtrials,oneforan
abdominalsurgicalapproachandoneforavaginalapproach.
Regardinganabdominalapproach,theColpopexyandUrinaryReductionEfforts(CARE)trialsupportsthe
universalapproach.IntheCAREtrial,womenwithoutSUIsymptomswithstageIItoIVprolapsewereassigned
toundergoopensacrocolpopexywithorwithoutBurchcolposuspension[3,4850].Postoperatively,womenwho
developeddenovoSUIwereidentifiedusingquestionnaires,medicalvisitsseekingtreatmentforSUI,and
positivefindingsonstresstesting.Majorfindingswere:
InwomenwithadvancedPOPwhowerecontinentbeforesurgery,prophylacticBurchcolposuspensionat
thetimeofopenabdominalsacrocolpopexyreducedpostoperativeSUI.TherateofSUIwasstatistically
significantlylowerintheBurchversusnoBurchgroupat3month(24and44percent)and24monthfollowup
(32and45percent)[3,50].
TherateofpostoperativeSUIwashigherinwomenwithoccultSUIonpreoperativeurodynamicprolapse
reductionandurinarystresstesting,butwasalsopresentatclinicallysignificantratesinwomenwithno
occultSUI.Inasubsetanalysisdividedintogroupsbypreoperativetestingresults,theratesofdenovo
postoperativeSUIatthreemonthswere[14]:
OccultSUI:37percentintheBurchgroup60percentinthenoBurchgroup
NooccultSUI:20percentintheBurchgroup39percentinthenoBurchgroup
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TheadditionoftheBurchdidnotincreasethefrequencyofurinaryretention,urgencyincontinence,urinary
urgency,urinarytractinfection(UTI),orotherperioperativecomplications.Althoughcolposuspensionisnota
treatmentforurgencyincontinence,therateofurgencysymptomswaslowerintheBurchgroupat24month
followup(32versus45percent),butthedifferencewasnotstatisticallysignificant.
TherateofbothersomeSUIsymptomswassignificantlylowerintheBurchgroupat24monthfollowup(12
versus25percent),andtherateofsubsequenttreatmentforSUIwaslowerintheBurchgroup,butthisdid
notreachstatisticalsignificance(13versus20percent).
Atsevenyearfollowup,theestimatedprobabilitiesoftreatmentfailurefortheurethropexygroupandtheno
urethropexygroup,respectively,were0.62and0.77forSUIand0.75and0.81foroverallUI[51].
Regardingavaginalapproach,theOutcomesFollowingVaginalProlapseRepairandMidurethralSling(OPUS)trial
foundasimilardegreeofbenefitinpreventingdenovoSUIasintheCAREtrial,buttheriskofcomplicationswas
higherinwomenwhounderwentacontinenceprocedure.IntheOPUStrial,womenwithoutSUIsymptomswith
stageIItoIVprolapsewereassignedtoundergotransvaginalprolapserepair(apicalsuspension,anteriorrepair,
colpocleisis)witheitheraretropubicmidurethralsling(TVT)orshambilateralsuprapubicincisions[13].
Postoperatively,womenwhodevelopeddenovoSUIwereidentifiedusingquestionnaires,medicalvisitsseeking
treatmentforSUI,andpositivefindingsonstresstesting.Majorfindingswere:
InwomenwithadvancedPOPwhowerecontinentbeforesurgery,aprophylacticretropubicmidurethralsling
atthetimeofvaginalprolapserepairreducedtherateofpostoperativeurinaryincontinence.Therateof
incontinence(stress,urge,ormixed)ortreatmentforincontinencewassignificantlylowerintheslingversus
shamgroupatthreemonthfollowup(24versus49percent).Therateofurinaryincontinencecontinuedtobe
significantlylowerintheslinggroupat12monthfollowup(27and43percent).
TherateofpostoperativeurinaryincontinencewashigherinwomenwithoccultSUIonpreoperativeoffice
basedprolapsereductionandurinarystresstesting,butwasalsopresentatclinicallysignificantratesin
womenwithnooccultSUI.Inasubsetanalysisdividedintogroupsbypreoperativetestingresults,therates
ofurinaryincontinenceatthreemonthswere:
OccultSUI:30percentintheslinggroup72percentintheshamgroup.
NooccultSUI:21percentintheslinggroup38percentintheshamgroup.
Therateofseriousadverseeventsdidnotdiffersignificantlybetweentheslingandshamgroups(17versus
12percent).However,womenintheslinggrouphadsignificantlyhigherratesofbladderperforation(11
versus0women7versus0percent)incompletebladderemptying(atsixweekspostoperatively)(6versus
0women4versus0percent)andurinarytractinfection(31versus18percent).Allbladderperforationwas
managedintraoperativelywithremovalandreplacementofthetrocar.
Therateofsubsequenttreatmentforincontinencewaslowerintheslinggroup,butsomewomeninthesling
grouprequiredsubsequentsurgeryforvoidingdysfunction.At12monthfollowup:
Slinggroup:12womenweretreatedforincontinence(7.3percent),including1whohadsurgery(0.6
percent),and4womenhadsurgeryforvoidingdysfunction(2.4percent)
Shamgroup:19womenweretreated(11.0percent),including8whounderwentsurgery(4.7percent).
Baseduponthedatafromthesetwotrials,theapproachtocontinentwomenplanningPOPrepairdependsupon
thesurgicalapproachandwhethertheywerefoundtohaveoccultSUIonpreoperativeprolapsereductionand
urinarystresstesting.
ContinencecalculatorInaddition,acalculatorhasbeendevelopedtopredictpostoperativeSUIinstress
continentwomenwhoareplanningprolapserepairsurgery[52].UsingdataregardingtherateofpostoperativeSUI
fromtheOPUStrial,thecalculatorhadaconcordancescoreof0.72comparedwithascoreof0.62forprediction
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byagroupof22experturogynecologicsurgeonsand0.54forapreoperativeprolapsereductionurinarystresstest.
Thecalculatorisavailableathttp://www.rcalc.com/ExistingFormulas.aspx?filter=CCQHS.
AbdominalapproachForcontinentwomenwithstageIIorgreaterPOPwhoareundergoingabdominal
sacrocolpopexywithoutconcurrenttransvaginalrepairs(eg,colporrhaphy),auniversalapproachisoptimal.For
thesewomen,regardlessoftheresultsofpreoperativetestingforoccultSUI,werecommendaconcomitantBurch
colposuspensionratherthansacrocolpopexyalone.
Aconcomitantprocedureavoidsthemorbidityandrecoverytimerequiredfortwoseparateabdominalsurgeries.
TheevidencetosupportthiscomesfromtheCAREstudy,asdiscussedabove,inwhichbenefitwasobservedin
thosewitheitherpositiveornegativeprolapsereductiontestingandnoincreaseinadverseeventswasobserved
inwomenwhounderwentaBurchprocedure[3,50].
VaginalapproachThebestapproachtomanagementislessclearforwomenwithPOPbutnosymptoms
ofSUIwhoareundergoingvaginalsurgery.Ashareddecisionmakingprocesswiththepatientisrequired.Patient
counselingshouldincludethepotentialbenefitsoftheprophylacticcontinencesurgery(basedupontheresultsof
preoperativeprolapsereductionandurinarystresstesting),potentialcomplications,andpatientgoalsand
preferences.
ThebestevidencetoguideclinicaldecisionmakingforthesewomenisfromtheOPUStrial,asdiscussedabove,
whichdemonstratedthatthesewomenreceiveadegreeofbenefitfromprophylacticcontinencesurgerythatis
similartowomenwhoundergoabdominalsurgery[13].However,theadditionofaprophylacticmidurethralsling
increasestheriskofcomplications.ComplicationssuchasbladderperforationorUTItypicallydonotadd
significantlytopostoperativemorbidity,andresolveeitherwithintraoperativetreatmentorshorttermuseofa
bladdercatheterorantibiotictherapy.However,somewomenwillhavepersistentvoidingdysfunctionfollowing
midurethralslingsurgery,requiringprolongedcatheterizationandpotentiallyasubsequentsurgicalprocedure.The
rateofurethrolysisintheOPUStrial(2.4percent)wasconsistentwiththerateofpostslingpersistentvoiding
dysfunctionreportedinotherstudies(0.6to2.0percent)[53,54].Thisisanimportantconsideration,sinceoneof
theprincipalbenefitsofprophylacticcontinencesurgeryisavoidingtheneedforasubsequentsurgery.(See
"Surgicalmanagementofstressurinaryincontinenceinwomen:Retropubicmidurethralslings",sectionon'Voiding
dysfunction'.)
Giventheavailableevidenceandclinicalconsiderations,forwomenundergoingvaginalsurgeryweusea
selectiveapproach,butsomewomenwithnegativepreoperativetestingforoccultSUImayreasonablychoosea
stagedapproach.
BasedupontheOPUStrialdata,usingauniversalapproach,thenumberneededtotreatinordertopreventone
caseofurinaryincontinenceat12monthswas6.3,althoughtherewasmodestevidencetosuggestthatpatients
withapositiveprolapsereductionstresstestbeforesurgeryreceivedmorebenefitthanthosewithanegativetest.
ManyexpertsconsiderwomenwithpositivetestingforoccultSUItobesimilartowomenwhopresentwithSUI
symptoms,andadviseacombinedprocedureforprolapseandSUI.Womenwithapositivepreoperativeprolapse
reductionstresstestareatthehighestriskofpostoperativeSUI.IntheOPUStrial,therewasmodestevidenceto
suggestthatpatientswithapositiveprolapsereductionstresstestbeforesurgeryreceivedmorebenefitthan
thosewithanegativetest.Theoverallpositivepredictivevalueofthepreoperativeprolapsereductionstressfor
postoperativeSUIbaseduponmultiplestudiesis51percent(algorithm1)anditwas72percentintheOPUStrial
[1316,35,55,56].Usingaselectiveapproachandperformingcontinencesurgeryonlyinwomenwithapositive
prolapsereductionstresstest,thenumberneededtotreatinordertopreventonecaseofurinaryincontinenceat
threemonthswas2.4.
ForwomenwithstageIIorgreaterPOPandpositivepreoperativetestingforoccultSUI,werecommenda
combinedprocedureforprolapseandSUIratherthanprolapserepairalone.
Ontheotherhand,womenwithnegativepreoperativetestingforoccultSUIshouldbecounseledaboutthe
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availableoptionsandtherisksofurinaryincontinence,perioperativecomplications,andvoidingdysfunction.
Managementofthesewomendependsupontheirvaluesandpreferences.
ConcomitantcontinencesurgeryintheOPUStrialinthispatientpopulationresultedinanabsoluteriskreduction
forpostoperativeurinaryincontinenceof17percent[13].Thisratewasclinicallysignificant,butmustbe
consideredinrelationtotheriskofslingrelatedcomplicationsandassociatedmorbidity.
Ifastagedapproachisused,apatientwithstageIIorgreaterPOPwithoutsymptomsofSUIwouldonlyundergo
surgeryforPOPwithnoconcomitantcontinenceprocedure.Thestagedproceduretypicallytakesplacewithinone
yearoftheoriginalprolapserepairanditisperformedonlyifthepatientdevelopssymptomsofbothersomeSUI
requiringcorrection.Theadvantageofthisapproachisthatunnecessaryprocedureswouldbeavoided.TheOPUS
trialdemonstratedthat,forwomenwhounderwentonlyvaginalPOPrepair,49percentdevelopedSUI,butonly5
percenthadaslingprocedureinthefirstyear.Comparedwithauniversalapproach,thestagedapproachresulted
ina95percentreductioninthenumberofslingsplaced.
Giventheavailabledataandclinicalconsiderations,forwomenwithstageIIorgreaterPOPwhoareundergoing
vaginalsurgeryandwhohaveNEGATIVEpreoperativetestingforoccultSUI,wesuggestprolapserepairalone
ratherthanacombinedprocedureforprolapseandSUI.ConcomitantPOPrepairandcontinencesurgeryisa
reasonableoptionforwomenwhoplaceahighpriorityonavoidingpostoperativeurinaryincontinenceandare
willingtoacceptanincreasedriskofperioperativecomplicationsandvoidingdysfunction.
ConcomitantversusstagedproceduresSomeexpertshavequestionedwhethertheSUIcurerateis
impacteddependinguponwhetherthecontinencesurgeryisperformedaloneorconcomitantwithaPOPrepair
procedure,butthereappearstobenodifferencebaseduponavailabledata.
ThisissuewasevaluatedinamulticenterrandomizedtrialofwomenwithPOPandSUIwhowereassignedto
haveatensionfreevaginaltape(TVT)eitherconcomitantwithprolapserepairorastagedprocedure(prolapse
repairfollowedbyTVTthreemonthslater)[46].Inanintenttotreatanalysis,atoneyearfollowup,therewasno
significantdifferencebetweentheconcomitantcomparedwithstagedgroupsinSUIcurerate(95versus89
percent)ortotaloperativecomplications(18versus13percent).Ofnote,inthestagedgroup,TVTwasultimately
performedonlyinwomenwhohadconfirmedSUIatthreemonthsafterprolapserepair(56percent).Amongthe
womeninthestagedgroupwhodidnotundergoTVT,oneyearoutcomeswereasfollows:27percentwerestill
continentand15percenthadsomeSUI,butdeclinedTVT.
Inobservationaldatafromanothertrial,inwhichwomenwererandomizedtoundergoeitheraretropubicor
transobturatormidurethralsling,thosewhodidversusdidnothaveconcomitantsurgeryhadsignificantlyhigher
objectivecurerates(88versus79percent),butnotsubjectivecurerates(62versus58percent)[57].Inaddition,
observationalcomparativestudieshavefoundnosignificantdifferenceintheSUIcurerateforwomenwho
underwentmidurethralslingplacementalonecomparedtoslingplacementcombinedwithvaginalsurgery
(hysterectomyorprolapserepair)[5860].Inaprospectivecohortstudy,womenwhounderwentprolapserepair
concomitantlywithmidurethralslingplacement,comparedwiththosewhoplannedastagedprocedure,hadno
significantdifferencesinSUIsymptoms(22versus21percent),changeinseverityofSUI,orsatisfaction(8.8
verus9.2ona10pointscale)atoneyearfollowup[61].Ofnote,only33percentofthewomenintheplanned
stagedgroupunderwentslingplacementwithinthestudyperiod.
SUIwithasymptomaticPOPProlapse,particularlystagesIorII,isoftenasymptomatic[912].Thus,women
whopresentwithsymptomsofSUIonly,buthavePOPonexamination,presentatreatmentdilemma.Theissue
iswhetherrepairofasymptomaticprolapseprovidesawomanwithalongtermbenefit(eg,preventionof
subsequentsymptomsorsurgery)orifitonlyincreasestheriskofperioperativecomplications.
Animportantquestioniswhetherprolapseinthesewomenwillworsenand/orbecomesymptomaticwithageor
aftermenopause.Surprisingly,thenaturalhistoryofprolapsedoesnotfollowaprogressivecourseinallwomen.
Datasuggestthatthecourseisprogressiveuntilmenopause,afterwhichthedegreeofprolapsemayfollowa
courseofalternatingprogressionandregression[6264].
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WomenwithongoingriskfactorsforPOParelikelytohaveprogression.Theseincludeincreasingparity,
hysterectomy,obesity,andchronicconstipation.Forobesewomen,weightlossdoesnotappeartoresultin
regression[65].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinical
manifestations,andmanagement",sectionon'Riskfactors'.)
Althoughnaturalregressionofprolapsemayoccur,combinedsurgicaltreatmentforSUIandPOPappearsto
reducetheriskofsubsequentsurgery.Thiswasillustratedinaretrospectivestudyofinsuranceclaimsbyover
1000womenwhounderwentaslingprocedureforSUI[47].Comparedtowomenwhodidnotundergoconcomitant
prolapserepair,womenwhohadaconcomitantrepairweresignificantlylesslikelytohavesubsequentsurgeryfor
SUIorprolapsewithinoneyearoftheinitialsurgery(SUI:5versus10percentPOP:14versus22percent)[47].
However,womenwhohadacombinedSUIandPOPrepairwerealsosignificantlymorelikelytohave
postoperativeurethralobstruction(9versus6percent).Thisstudywaslimitedbythelackofdataonthestageof
prolapseandwhethersymptomswerepresent,thusmakingituncertainwhethertheresultsapplytoasymptomatic
women.
Additionalsurgicalproceduresincreaseoperativetimeandmayincreasetheriskofperioperativecomplications
[3,66].Inthestudydescribedabove,concurrentsurgeryforSUIandPOPwasassociatedwithanincreasein
postoperativeurethralobstruction.However,itiscontroversialwhethercombinedproceduresleadtoanincreasein
obstructiveurinarysymptoms[47,6670].Therearenohighqualitystudiesofcombinedsurgeryforwomenwith
SUIandmildorasymptomaticprolapse.
Giventheavailabledataandclinicalconsiderations,forwomenwithstageIasymptomaticprolapse,wesuggest
NOTperformingprolapserepairatthetimeofcontinencesurgery.Sinceprolapsehasnotbeenproventobe
progressiveandstageIprolapseisalmostneversymptomatic,repairinthesewomenappearstobeunnecessary.
TreatmentofwomenwithstageIIorgreaterprolapsewhoareasymptomaticmustbeindividualizedbasedupona
discussionwiththepatientabouthertreatmentgoalsandtheriskofsubsequentsurgery.(See'Informedconsent
andpatientgoals'above.)
MANAGEMENTOFSPECIALPOPULATIONS
WomenathighsurgicalriskDependingonthedegreeofsurgicalrisk,womenwithstressurinary
incontinence(SUI)andpelvicorganprolapse(POP)canbetreatedusingconservativemeasures(eg,pessary,
pelvicfloorexercises),however,surgerymaybeanoptionforsome.Colpocleisis(surgicalobliterationofthe
vaginallumen)istheprocedureofchoiceinwomenathighsurgicalriskwhoarenotplanningfurthersexual
intercourseanddesiresurgicaltreatment.Thisprocedureinvolvesminimalsurgicalriskandcanbecombined
safelyandeffectivelywithaslingprocedure[7072].(See"Pelvicorganprolapseinwomen:Obliterative
procedures(colpocleisis)".)
WomenplanningfuturepregnancyWomenplanningfuturepregnancyshouldnotundergopelvicfloor
reconstructivesurgery,sincepelvicsupportmaybedisruptedduringpregnancyanddeliveryandfurthersurgery
maybenecessaryafterpregnancy.Conservativemeasuresareappropriatetreatmentforthesepatients.(See
"Vaginalpessarytreatmentofprolapseandincontinence"and"Treatmentandpreventionofurinaryincontinencein
women".)
SUMMARYANDRECOMMENDATIONS
Pelvicorganprolapse(POP)andstressurinaryincontinence(SUI)coexistinupto80percentofwomenwith
pelvicfloorsymptoms.Thiscorrelationbetweentheseconditionsisduetotheircommonpathophysiology.
(See'Introduction'above.)
Awomanmayfindsymptomsofprolapseandincontinenceequallybothersomeoroneconditionmay
predominateorbeasymptomatic.(See'Clinicalpresentation'above.)
Upto80percentofwomenwithadvancedPOPhaveoccultSUIcausedbyurethralobstruction.These
womenareatriskofdevelopingSUIafterprolapserepair.(See'Prolapsewithnosymptomsofincontinence'
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above.)
Allwomenwhoareconsideringpelvicreconstructivesurgeryshouldhaveacomprehensiveevaluationfor
bothprolapseandurinaryincontinencebeforetreatmentisplanned,including:assessmentofurinary
symptoms,pelvicexaminationwithobjectivequantificationofprolapse,clinicalorurodynamicurinarystress
testingwithreductionofprolapse,anddiscussionofpatientgoalsandqualityoflife.(See'Preoperative
evaluation'above.)
Preoperativeprolapsereductiontestinghasapositivepredictivevalueabove50percentforpostoperative
SUI.
ForwomenwithsymptomsofbothPOPandSUI,werecommendaconcomitantprolapserepairand
continenceprocedureratherthanPOPrepairalone(Grade1B).(See'SymptomaticPOPandSUI'above.)
ForwomenwithsymptomaticPOPandnoSUIsymptoms(see'Prolapsewithnosymptomsofincontinence'
above):
ContinentwomenwithstageIPOPwhoareplanningprolapserepairareunlikelytohaveurethral
obstructionandresultantoccultSUI,andthusareunlikelytobenefitfromaconcomitantcontinence
procedure.
ForwomenwithstageIIorgreaterPOPwhoareundergoingabdominalsacrocolpopexywithout
concurrentvaginalrepairs,regardlessoftheresultsofpreoperativetestingforoccultSUI,we
recommendaconcomitantBurchcolposuspensionratherthansacrocolpopexyalone(Grade1B).(See
'Abdominalapproach'above.)
ForwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohavePOSITIVE
preoperativetestingforoccultSUI,orhaveahighprobabilityofpostoperativestressincontinenceusing
thecontinencecalculator,werecommendaconcomitantPOPrepairandcontinenceprocedurerather
thanprolapserepairalone(Grade1B).(See'Vaginalapproach'aboveand'Continencecalculator'
above.)
ForwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohave
NEGATIVEpreoperativetestingforoccultSUI,orhavealowprobabilityofpostoperativestress
incontinenceusingthecontinencecalculator,wesuggestprolapserepairaloneratherthanacombined
procedureforprolapseandSUI(Grade2B).ConcomitantPOPrepairandcontinencesurgeryisa
reasonableoptionforwomenwhoplaceahighpriorityonavoidingpostoperativeurinaryincontinence
andarewillingtoacceptanincreasedriskofperioperativecomplicationsandvoidingdysfunction.(See
'Vaginalapproach'aboveand'Continencecalculator'above.)
WomenwithSUIandasymptomaticprolapse(see'SUIwithasymptomaticPOP'above):
ForwomenwithstageIprolapse,wesuggestNOTperformingprolapserepairatthetimeofcontinence
surgery(Grade2C).
TreatmentofwomenwithstageIIorgreaterprolapsemustbeindividualizedaccordingtopatient
treatmentgoalsandtheriskofsubsequentsurgery.
Choiceofanabdominalorvaginalapproachismadebasedonthefollowingfactors:anatomiclocationofthe
prolapse,medicalhistory,procedureefficacy,patientpreference,andsurgeon'sexperience.(See'Choosing
anabdominalorvaginalapproach'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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71. AgarwalaN,HasiakN,ShadeM.Graftinterpositioncolpocleisis,perineorrhaphy,andtensionfreeslingfor
pelvicorganprolapseandstressurinaryincontinenceinelderlypatients.JMinimInvasiveGynecol2007
14:740.
72. MooreRD,MiklosJR.Colpocleisisandtensionfreevaginaltapeslingforsevereuterineandvaginal
prolapseandstressurinaryincontinenceunderlocalanesthesia.JAmAssocGynecolLaparosc2003
10:276.
Topic8068Version22.0

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GRAPHICS
Anatomyofoccultstressurinaryincontinence

(A)Advancedanteriororapicalpelvicorganprolapse(usuallyprolapsepastthevaginal
introitus)displacesthebladderneckposteriorlyandtheurethraiskinked,resultingin
urethralobstruction.Theobstructionthenbecomesthemechanismofcontinence.
(B)Whentheprolapsedstructuresareelevated(approximatingnormalanatomy)during
prolapsereductiontestinginwomenwithurethralobstructionduetoadvancedprolapse,
theurethraisunblockedandstressurinaryincontinenceoftenbecomesevidentwhena
urinarystresstestisperformed.
CourtesyofJasmineTanKim,MD.
Graphic85778Version1.0

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Riskofdevelopingpostoperativestressurinaryincontinencein
womenundergoingsurgeryforpelvicorganprolapse

SUP:suburethralplicationTVT:tensionfreevaginaltapeRPU:retropubicurethropexyNS:needle
suspensionPS:pubovaginalsling%:percent.
*Symptomsrecordedperpatientreport.
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Denotesabdominalprocedures,allotherprocedureswereperformedvaginally.
Graphic66014Version4.0

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Voidingdiary

Thisdiarywillhelpusdeterminewhyyouhavetroubleholdingyoururine,orwhyyougo
tothebathroomveryoften
Keepthisrecordforatleast2days.
Pleasewritedown4thingseverytimeyoupassorleakurine:
1. Thetime(forexample,"10:30AM")
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2. Theamountofurinethatyoupass
3. Whetheryouleakedanyurine(were"wet")ornot(were"dry")
4. Whetheranythingspecialmayhavecausedyoutogo(forinstance,"justhad
coffee,""coughed,""wasrunningtothebathroom,""justtookmywaterpill")
Starttherecordinthemorningthefirsttimeyougotothebathroomafteryougetup.
Pleasewriteontheformthetimeyougotupandthetimeyouwenttobed.
Tomeasuretheamountofurineyoupass,wewillgiveyouaspecialreceptacle(calleda
"hat").Placethehatinthetoilettocatchtheurineeverytimeyougo.Lookathowhigh
theurinefillsthehat,andwritedowntheamountfromthenumbersontheinsideofthe
hat.Remembertoemptythehataftereachtimeyougo.
Ifyouleakurineandcannotmeasuretheamountthatcameout,writedownyourbest
guess.
Graphic69130Version2.0

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Disclosures

Disclosures:CharlesWNager,MDNothingtodisclose.JasmineTanKim,MDGrant/Research/ClinicalTrialSupport:BostonScientific[vaginalm
todisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevel
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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