Int Urogynecol J (2009) 20:1301–1306 DOI 10.1007/s00192-009-0954-2
ORIGINAL ARTICLE
Incontinence and detrusor dysfunction associated with pelvic organ prolapse: clinical value of preoperative urodynamic evaluation Isao Araki & Yaburu Haneda & Yuki Mikami & Masayuki Takeda
Received: 10 April 2009 / Accepted: 21 June 2009 / Published online: 14 July 2009 # The International Urogynecological Association 2009
Abstract Introduction and hypothesis We examined how preoperative urodynamic findings are related to the urinary problems following surgical repair of pelvic organ prolapse (POP). Methods The clinical records of 87 women who underwent surgery for POP were reviewed retrospectively. Preoperatively, cough stress test and urodynamic testing, including pressure-flow study, were performed with prolapse reduction. Postoperative evaluation included uroflowmetry, postvoid residuals, and symptom assessment using questionnaires. Results A cough stress test with simple filling was sufficient for diagnosis of occult stress urinary incontinence (SUI). The presence of detrusor overactivity was a good predictor of postoperative persistence of urgency and urge urinary incontinence. Postvoid residuals (PVR) largely increased immediately after surgery, but usually recovered within 1 month. Poor detrusor contractility was the best predictor of large PVR occurrence. Conclusions Preoperative urodynamic evaluation of SUI and detrusor function was useful for predicting postoperative urinary conditions in POP patients. Its cost-effectiveness remains to be examined. Keywords Bladder dysfunction . Detrusor overactivity . Incontinence . Pelvic organ prolapse . Urodynamics
I. Araki (*) : Y. Haneda : Y. Mikami : M. Takeda Department of Urology, University of Yamanashi Faculty of Medicine, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan e-mail:
[email protected]
Introduction Advanced pelvic organ prolapse (POP) is associated with lower urinary tract dysfunction (LUTD), such as stress urinary incontinence (SUI), bladder outlet obstruction (BOO), and detrusor dysfunction [1, 2]. However, the effects of surgical repair of POP on the LUTD are not completely understood. Some POP patients complain of concomitant SUI. Furthermore, a certain percentage of SUI is masked preoperatively since advanced POP may cause urethral kinking and external urethral compression [1–7]. However, the outcome of preoperatively diagnosed occult SUI following POP surgery has been rarely reported [4, 6]. The coexisting rate of overactive bladder syndrome (OAB) or detrusor overactivity (DO) is also high in advanced POP [1, 2, 8, 9]. There is significant resolution of OAB after POP surgery, suggesting that urethral obstruction is associated with the induction of OAB in advanced POP [1, 8–10]. However, OAB persists or newly develops after the surgery in a minority of POP patients whose demographic and urodynamic characteristics have been little studied [10, 11]. Urethral obstruction is usually resolved by surgical correction of POP [12], but large postvoid residual urine (PVR) occasionally develops after POP surgery, especially when performing concurrent prolapse and continence surgeries [13–15]. The involvement of detrusor underactivity (DUA) in postoperative voiding dysfunction is unknown in POP [1, 12]. The International Continence Society (ICS) recommends urodynamic evaluation in the diagnostic workup of patients with POP scheduled for surgical repair [16], although its cost-effectiveness on surgical outcomes has not been clarified [13, 17, 18]. BOO usually resolves after POP surgery [12]. Our aim in preoperative urodynamic evalua-
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tion is therefore to diagnose occult SUI and detrusor dysfunction. After prolapse is reduced with a pessary or vaginal packing, occult SUI may become evident [1–7], and parameters of detrusor function may be not affected [19]. Using urodynamic testing with prolapse reduction, we examined how precisely preoperative evaluation of lower urinary tract function can predict postoperative urinary problems in POP.
Materials and methods Patients After obtaining Institutional Review Board approval, we reviewed the records of all 87 women who underwent surgery for symptomatic POP during the 19-month period beginning February 2007. Degree of POP was staged according to the pelvic-organ-prolapse quantification (POP-Q) system. The International Prostate Symptom Score (IPSS) and International Consultation on Incontinence Questionnaire Short Form for urinary incontinence (ICIQ-UI) were used for evaluation of lower urinary tract symptoms (LUTS). The IPSS originally developed for BPH has been subsequently extended to evaluate LUTS in a variety of conditions in both men and women [20, 21]. Women were considered to have UI if they reported symptoms of UI on the ICIQ-UI and required a pad usage during activities of daily living and as having urgency if score was ≥2 in the question on urgency in the IPSS. POP repair was performed with the use of polypropylene mesh (GyneMesh PSTM, Ethicon, USA) cut by the surgeon according to the Trans-Vaginal Mesh (TVM) technique described previously [22, 23]. In the case of patients who had not undergone hysterectomy previously, the uterus was preserved. Whenever the patients with symptomatic SUI and/or a positive stress test wished for operative correction or prevention, the trans-obturator mid-urethral sling (TOT) procedure was performed concurrently.
Int Urogynecol J (2009) 20:1301–1306
detrusor contraction was not provoked by coughing. Occult SUI was defined as a positive stress test without history of SUI symptoms. Urodynamic testing included free uroflowmetry with ultrasound measurement of PVR, filling cystometry and pressure-flow study (PFS). For cystometry, warm saline was infused into the bladder through a 9French double lumen catheter at a rate of 50 ml/min in a sitting position. Abdominal pressure was determined by a rectal balloon catheter and detrusor pressure by subtracting abdominal from intravesical pressure. DO was diagnosed by an involuntary detrusor contraction during filling phase. At maximum cystometric capacity, patients were permitted to void voluntarily for PFS. There is no reliable definition of DUA for women. Thus, for grading female detrusor contractility, Schafer’s nomogram was employed as a tentative clinical index, and detrusor contractility was classified into six classes: strong (ST), normal+ (N+), normal− (N−), weak+ (W+), weak− (W−), and very weak (VW) [26]. Postoperative evaluation At 3 days, 1 month, and 3 months after POP surgery, uroflowmetry with PVR measurement was performed in all of the patients. Postoperative SUI and UUI were determined by symptom assessment and a pad usage 6 months after surgery. SUI symptoms were verified by stress testing. Statistical analysis Statistical analysis was made using the paired t test for comparison between pre- and postoperative values. For estimating the predictive power of preoperative urodynamic findings for postoperative urinary problems, the Fisher’s exact probability test was used. Logistic multiple regression analysis was performed to examine the relationships between urodynamic findings and age and POP stage, and the correlations of urodynamic abnormalities with postoperative occurrence of large PVR. A level of p
