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OfficialreprintfromUpToDate www.uptodate.com2015UpToDate
AuthorsCharlesWNager,MDJasmineTanKim,MD
SectionEditorLindaBrubaker,MD,FACS,FACOG
DeputyEditorKristenEckler,MD,FACOG
Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.Literaturereviewcurrentthrough:Mar2015.|Thistopiclastupdated:Sep24,2014.
INTRODUCTIONPelvicorganprolapse(POP)andstressurinaryincontinence(SUI)coexistinupto80percentofwomenwithpelvicfloordysfunction[1,2].Whiletheseconditionsareoftenconcurrent,onemaybemildorasymptomatic.WomenwithoutsymptomsofSUIwhoundergosurgeryforprolapseareatriskforpostoperativeurinaryincontinence[3].SUImayalsoworsenafterprolapserepair.
DecidingwhethertoperformacombinedsurgicalproceduretotreatbothprolapseandSUIorasingleprocedurethataddressesonlyoneconditionrequiresbalancingtheriskofincompletetreatmentwiththeriskofexposingthepatienttounnecessarysurgery[4].Thisdecisionmustbebasedonthebestapproachtoaddressthepatient'sgoals,ratherthansimplyonanatomiccorrection[5,6].Therateofconcurrentprolapserepairandcontinenceproceduresappearstobeincreasing.DatafromtheUnitedStatesNationalInpatientsampleshowedthatforapicalprolapserepairprocedures,therateofconcurrentcontinencesurgeryincreasedfrom38percentin2001to47percentin2009[7].
Challengesinsurgicaldecisionmakinginthisclinicalcontextincludeappropriateassessmentofresultsofpreoperativeevaluation,someofwhichmaybeambiguous(eg,prolapsenotedonexaminationinapatientwithnoprolapserelatedsymptomsorapatientwithadvanceprolapsewithnoleakageonprolapsereductiontesting).
CombinedsurgicaltreatmentforPOPandSUIwillbereviewedhere.Otherapproachestosurgicalandmedicaltreatmentoftheseconditionsandothertypesofurinaryincontinencearediscussedseparately.(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement"and"Approachtowomenwithurinaryincontinence"and"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)
TERMINOLOGY
Stressurinaryincontinence(SUI)Leakageofurinewithincreasedintraabdominalpressure(eg,cough,laughter).(See"Approachtowomenwithurinaryincontinence".)
OccultSUISUIthatisnotsymptomatic,butbecomesapparentonlyduringclinicalorurodynamicurinaryfunctiontestingwhentheprolapseisreduced(ie,stresstestingwithreductionofprolapsedstructures).Occultstressincontinenceisalsoreferredtoaslatent,hidden,iatrogenic,orpotential.
ThedefinitionofoccultSUIisinconsistentinthemedicalliterature.Whilesomeauthorsusethetermtodescribeonlyincontinencewhichhasbeendemonstratedonurinaryfunctiontesting(asinthistopicreview),othersusethetermoccultincontinencetosignifythatthereisapossibilitythatSUIwilloccurafterprolapserepair.
DenovourinaryincontinenceUrinaryincontinencethatisnewlysymptomatic,asanexample,incontinencesymptomsthatdevelopaftersurgeryinapreviouslycontinentpatient.Thetypeofnewincontinenceshouldbespecified(eg,stress,urge).Asanexample,apatientwithurgencyincontinenceandnoSUIbeforesurgerymayhavepersistenturgencyincontinenceanddenovostressincontinenceaftersurgery.
ProlapsereductiontestingElevationofprolapsedstructurestoapproximatenormalpelvicsupportduringpelvicexaminationorclinicalorurodynamicurinaryfunctiontesting.Thisisperformedincombinationwitha
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CLINICALPRESENTATIONPelvicorganprolapse(POP)andstressurinaryincontinence(SUI)maypresentaloneorconcurrentlyinavarietyofcombinations.
SymptomaticprolapseandincontinenceSymptomsofbothPOPandSUImaybepartofthepresentingcomplaint.Ontheotherhand,POPsymptomsmaybenonspecific(pelvicpressureordiscomfort)andsomewomenonlyrecognizetheseasrelatedtoPOPafterevaluationbyaclinician.Thesymptomsofprolapseandincontinencemaybeequallybothersomeoroneconditionmaypredominate.(See"Approachtowomenwithurinaryincontinence",sectionon'Clinicaltests'.)
ProlapsewithnosymptomsofincontinenceAdvancedPOP(pelvicorganprolapsequantitationsystem[POPQ]stageIItoIV)commonlycoexistswithSUI,however,formanywomentheSUImaybecomeapparentonlywhentheprolapsehasbeencorrected[1].ThisphenomenonisknownasoccultSUI.TestingforoccultSUIisdiscussedbelow(see'Detectingoccultincontinence'below).
Anatomically,thisoccursbecauseinwomenwithsignificantanteriororapicalprolapse(usuallyprolapsepastthevaginalintroitus),thebladderneckisdisplacedposteriorlyandtheurethraiskinked,resultinginurethralobstruction.Theobstructionthenbecomesthemechanismofcontinence(figure1)[8].
Whentheprolapsedstructuresareelevated(approximatingnormalanatomy)duringprolapsereductiontestinginwomenwithurethralobstructionduetoadvancedPOP,theurethraisunblockedandSUIoftenbecomesevidentwhenaurinarystresstestisperformed.Ontheotherhand,womenwithstageIPOPareunlikelytohaveurethralobstructionandresultantoccultSUI[912].(See'Detectingoccultincontinence'below.)
OccultSUIisdiagnosedusingpreoperativeprolapsereductiontestingin31to80percentofwomenwithsymptomaticand/oradvancedPOPwhoareplanningsurgicaltreatment[1326].Accordingly,whenwomenwithoccultSUIundergoprolapserepairwithoutaconcomitantcontinenceprocedure,therateofpostoperativedenovoSUIrangesinstudiesfrom13to72percent(mean51percent)(algorithm1)[13].
However,womenwhohavenegativepreoperativetestingforoccultSUIandundergoprolapserepairwithoutacontinenceproceduremaystilldevelopSUIaftersurgery,butatalowerratethanwomenwhotestpositiveforoccultSUIwithpreoperativeprolapsereductiontesting.Therateofpostoperativeincontinenceinwomenwithnegativepreoperativeoccultstresstestingrangesinstudiesfrom0to42percent(mean26percent)(algorithm1)[1416,18,2731].
IncontinencewithnosymptomsofprolapseWomenwhopresentwithSUIwilloftenhavePOPofvaryingdegrees.TreatmentisindicatedonlyforsymptomaticPOP.Approximately40percentofwomenarefoundtohavestageIIorgreaterprolapseatannualgynecologicexaminationhowever,symptomsrelatedtoprolapseoftendonotcorrespondwithanatomicalfindings[912].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Clinicalmanifestations'.)
PREOPERATIVEEVALUATIONWomenwhoareconsideringpelvicreconstructivesurgeryforpelvicorganprolapse(POP)orstressurinaryincontinence(SUI)shouldhaveacomprehensiveevaluationtoguidesurgicalplanning.
GeneralevaluationAnevaluationincludes:
urinarystresstest(coughtest)toattempttodetectoccultSUI.(See"Approachtowomenwithurinaryincontinence",sectionon'Evaluation'.)
MedicalhistoryandsymptomsrelatedtoPOPandSUI(avoidingdiarymaybeuseful(figure2))
Pelvicexaminationwithobjectivequantificationofprolapse
Clinicalorurodynamicurinarystresstestingwithandwithoutreductionofprolapse
Assessmentofpatientgoalsandqualityoflife
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ThediagnosticandpreoperativeevaluationofwomenwithPOPorSUIisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Diagnosticevaluation"and"Surgicalmanagementofstressurinaryincontinenceinwomen:Preoperativeevaluationforaprimaryprocedure".)
DetectingoccultincontinenceOccultSUIcanbedetectedbymedicalhistoryandclinicalorurodynamictestingwithreductionofprolapsedstructures.
CluesinthehistorythatsuggestoccultSUIinclude(1)incontinencethatimprovedorresolvedasprolapseworsened(2)theneedtomanuallyreplacetheprolapsedstructuresintothevaginatovoidor(3)worseningordevelopmentofSUIwithuseofapessary[9].
Onclinicalbladderfunctiontestingorurodynamictesting,womenwithPOPshouldbeevaluatedwithandwithoutreductionofprolapse.Thepurposeistosimulatethepatient'svaginalarchitectureaftersurgicalrepair.ReducingtheprolapsewilloftenreduceapreviouslyelevatedpostvoidresidualandunmaskSUI.
Prolapsereductionshouldbeperformedwhilethepatientisstanding.Whileelevatingtheprolapsedstructures,itisimportanttoavoidobstructingtheurethra,whichwouldmaskincontinence.Oneshouldalsoavoidplacingtheanteriorvaginalwallunderexcessivetension,whichcoulddistortthepelvicanatomy.(See"Approachtowomenwithurinaryincontinence",sectionon'Physicalexamination'.)
Themostcommonmethodsofprolapsereductionusethefollowingtoelevatethestructures:examiner'sfingers,largecottonswab,singlespeculumblade,ringforceps,orpessary.Whiletherearefewdatacomparingthesemethods,usingapessarymaybelesseffectiveatdetectingSUIthanothermethods[16,32].Thisislikelybecauseincontinencepessariesincreasethemaximumurethralclosurepressureandfunctionalurethrallengthand,thus,areoftenusedtotreatSUI[33].Somedatasuggestthatthebladdershouldbefilledtoatleast300mLinonestudy,occultSUIidentifiedwithuseofabladdervolumeof300mLwasmorelikelythan100mLtobeassociatedwithpostoperativeSUI[34].
Inthelargeststudytoevaluateprolapsereductiontesting,dataregardingprolapsereductionusingfivemethods(manual,swab,speculum,forceps,pessary)werecollectedinwomenwithadvancedprolapse,butwithoutsymptomsofSUI(n=322)[16].ThesensitivityfordetectionofoccultSUIwassimilaramongmostreductiontestingmethods(17to39percent),withtheexceptionofthepessary,whichwaslesssensitive(5percent).Inourpractice,weuseoneortwolargecottonswabsbecauseitiswelltoleratedbypatientsandtheswabsarelongenoughtoapproximateasurgicalsuspensionofthevaginalapex.
ProlapsereductiontestingmaybeperformedaspartofofficetestingofSUIorduringurodynamicevaluation.BothapproachesappeartohaveasimilarpredictivevalueforthedevelopmentofpostoperativeSUI.Thisisbasedupondatafromtwoprospectivestudiesofwomenwhounderwentpreoperativeprolapsereductiontestingandweretreatedwithaprolapserepairprocedure,butnocontinenceprocedure.Urodynamicevaluationwasusedinonestudy,andtherateofpostoperativedenovoSUIwas58percentforwomenwhotestedpositiveforpreoperativeoccultSUIand38percentforthosewhotestednegative[16].Intheotherstudy,officetestingwasused,andtherateofdenovoSUIwas72percentforwomenwhotestedpositiveand38percentforwomenwhotestednegative[13].
MoststudiesdefineoccultSUIasleakagewithprolapsereductionduringofficetestingorurodynamicevaluation,butsomereportsusedmaximumurethralclosurepressuresorpressuretransmissionratiosof
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procedureand16percentwithanincontinenceprocedure.Inasymptomaticwomenwhohavenegativeprolapsereductiontesting,therateofpostoperativeSUIis26percentwithoutanincontinenceprocedureand17percentwithanincontinenceprocedure.
IntheabsenceofmoreeffectivemethodstodetectoccultSUI,however,reductiontestingshouldbeperformedinallwomenplanningvaginalpelvicfloorreconstructivesurgery.Furtherstudyisneededtoidentifyothermethods.
InformedconsentandpatientgoalsWomenplanningsurgicalcorrectionofpelvicfloorreconstructivesurgeryshouldbecounseledaboutthepotentialforincompleteresolutionofsymptoms,ornewsymptomsofSUI,urinaryretentionorurgencyincontinence.
Discussingpatientgoalsandsettingexpectationscanalsohelpboththepatientandsurgeonmeasuresurgicalsuccess.Achievementofpatientgoals,includingsymptomresolution,orimprovementinlifestyle,activity,orsexualfunction,correlatewithpostoperativesatisfaction[5,6].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Establishingpatientgoals'.)
CHOOSINGANABDOMINALORVAGINALAPPROACHForwomenwithbothstressurinaryincontinence(SUI)andpelvicorganprolapse(POP),thesurgicalroute(vaginalorabdominal,includinglaparoscopicorroboticprocedures)ischosenthatismostappropriatefortheanatomicsiteofprolapse(ie,anterior,apical,posterior)withthegoalofavoidingincisionsintwosites.AnabdominalapproachtypicallyincludesasacrocolpopexyandBurchcolposuspension,whileavaginalapproachmayincludeauterosacralligamentfixation(orothertransvaginalprocedure)andsuburethralsling(typicallyamidurethralsling).
Additionalfactorstoconsiderinchoosingarouteare:
Mostcombinedproceduresareperformedvaginallyforseveralreasons.Midurethralslingplacement,avaginalapproach,isthepreferredprocedureformostwomenwithSUI.Also,repairofanteriorandposteriorprolapseareusuallyperformedvaginally.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)
Theexceptiontothisisapicalprolapse,whichiscommonlyrepairedusinganabdominal(openorlaparoscopic)sacrocolpopexy.Apicalprolapsecanalsoberepairedviaavaginalroute,withsacrospinousoruterosacralligamentsuspension.Thechoiceofrouteforwomenwithapicalprolapsethendependsuponthebestcombinationofprocedures:(1)midurethralslingandsacrospinousoruterosacralligamentsuspensionor(2)Burchcolposuspensionandabdominalsacrocolpopexy.Evidencefromrandomizedtrialshasdemonstratedthatabdominalrepairsaremoredurable,whilevaginalrepairshavefewercomplications,includingforeignbodycomplications.Comparisonofsurgicaloutcomesforspecificproceduresisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Surgicalrepairofapicalprolapse(uterineorvaginalvaultprolapse)",sectionon'Abdominalversusvaginalapproach'.)
Alternatively,somesurgeonscombinesacralcolpopexywithamidurethralsling,particularlywhenalaparoscopicorroboticapproachisused.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",sectionon'Apicalprolapse'.)
SELECTIONOFPROCEDUREThecombinationofsymptomsandfindingsonpreoperativeevaluationguidethechoiceofprocedurefortreatmentofpelvicorganprolapse(POP)and/orstressurinaryincontinence(SUI).ChoosingaprocedurethataddresseseitherPOPorSUIoracombinedprocedurefordifferentclinicalscenariosisdiscussedhere.
ThechoiceofaprimaryprocedurefortreatmentofSUIisdiscussedindetailseparately.(See"Surgical
Medicalhistorycomorbidities,priorsurgeriesProcedureefficacythisdependsuponprocedureandsurgeon'sexperience[47]Patientpreference
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managementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)
SymptomaticPOPandSUIForwomenwithsymptomsofbothPOPandSUI,werecommendaconcomitantprolapserepairandcontinenceprocedureratherthanPOPrepairalone.DatafromprospectivecomparativestudiesofwomenwithbothsymptomaticPOPandSUIshowasignificantlylowerrateofpostoperativeSUIinwomenwhoundergobothPOPrepairandacontinenceprocedurecomparedwiththosewhoundergoPOPrepairalone(0to40versus36to71percent)(algorithm1)[35,42,4446].
ThereisnosingleprocedurethatadequatelytreatsbothPOPandSUI.Historically,theonlyexampleofaPOPrepairprocedurethatwasperformedwiththeintentionoftreatingSUIwasanteriorcolporrhaphyaloneorwithaKellyKennedyplication.ThisapproachhasbeenfoundtobelesseffectivefortreatmentofSUIthanaBurchcolposuspensionbaseduponrandomizedtrialdata.Likewise,availablecontinenceprocedures(suburethralslings,Burchcolposuspension)arenoteffectivefortreatingsymptomsassociatedwithPOP[42].(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",sectionon'Proceduresnolongerrecommended'.)
POPwithnosymptomsofSUIThemanagementofwomenwithsymptomaticPOP,butnoSUIsymptomsiscontroversial.ContinentwomenwithstageIPOPwhoareplanningprolapserepairareunlikelytohaveurethralobstructionandresultantoccultSUI,andthusareunlikelytobenefitfromaconcomitantcontinenceprocedure.However,forwomenwithadvancedprolapse,thereisahighlikelihoodthattheywilldevelopSUIpostoperatively.
TherearethreepossibleapproachesforaddressingpotentialSUIatthetimeofPOPtreatment:
Thechoicebetweentheseapproachesisbestsupportedbydatafromtwolargerandomizedtrials,oneforanabdominalsurgicalapproachandoneforavaginalapproach.
Regardinganabdominalapproach,theColpopexyandUrinaryReductionEfforts(CARE)trialsupportstheuniversalapproach.IntheCAREtrial,womenwithoutSUIsymptomswithstageIItoIVprolapsewereassignedtoundergoopensacrocolpopexywithorwithoutBurchcolposuspension[3,4850].Postoperatively,womenwhodevelopeddenovoSUIwereidentifiedusingquestionnaires,medicalvisitsseekingtreatmentforSUI,andpositivefindingsonstresstesting.Majorfindingswere:
UniversalAcontinenceprocedureisperformedatthetimeofPOPsurgery,regardlessofpreoperativeprolapsereductionandurinarystresstesting.
SelectivePreoperativeprolapsereductionandurinarystresstestingisperformed.IfoccultSUIisdetected,acontinenceprocedureisperformedatthetimeofPOPrepair.IfoccultSUIisnotdetected,POPrepairaloneisperformed.
StagedPOPrepairisperformedwithoutaconcomitantSUIprocedure,regardlessofpreoperativeprolapsereductionandurinarystresstesting.AsubsequentcontinenceprocedureisperformedifSUIsymptomsdevelopandthepatientdesiressurgicaltreatment.
InwomenwithadvancedPOPwhowerecontinentbeforesurgery,prophylacticBurchcolposuspensionatthetimeofopenabdominalsacrocolpopexyreducedpostoperativeSUI.TherateofSUIwasstatisticallysignificantlylowerintheBurchversusnoBurchgroupat3month(24and44percent)and24monthfollowup(32and45percent)[3,50].
TherateofpostoperativeSUIwashigherinwomenwithoccultSUIonpreoperativeurodynamicprolapsereductionandurinarystresstesting,butwasalsopresentatclinicallysignificantratesinwomenwithnooccultSUI.Inasubsetanalysisdividedintogroupsbypreoperativetestingresults,theratesofdenovopostoperativeSUIatthreemonthswere[14]:
OccultSUI:37percentintheBurchgroup60percentinthenoBurchgroup
NooccultSUI:20percentintheBurchgroup39percentinthenoBurchgroup
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Regardingavaginalapproach,theOutcomesFollowingVaginalProlapseRepairandMidurethralSling(OPUS)trialfoundasimilardegreeofbenefitinpreventingdenovoSUIasintheCAREtrial,buttheriskofcomplicationswashigherinwomenwhounderwentacontinenceprocedure.IntheOPUStrial,womenwithoutSUIsymptomswithstageIItoIVprolapsewereassignedtoundergotransvaginalprolapserepair(apicalsuspension,anteriorrepair,colpocleisis)witheitheraretropubicmidurethralsling(TVT)orshambilateralsuprapubicincisions[13].
Postoperatively,womenwhodevelopeddenovoSUIwereidentifiedusingquestionnaires,medicalvisitsseekingtreatmentforSUI,andpositivefindingsonstresstesting.Majorfindingswere:
Baseduponthedatafromthesetwotrials,theapproachtocontinentwomenplanningPOPrepairdependsuponthesurgicalapproachandwhethertheywerefoundtohaveoccultSUIonpreoperativeprolapsereductionandurinarystresstesting.
ContinencecalculatorInaddition,acalculatorhasbeendevelopedtopredictpostoperativeSUIinstresscontinentwomenwhoareplanningprolapserepairsurgery[52].UsingdataregardingtherateofpostoperativeSUIfromtheOPUStrial,thecalculatorhadaconcordancescoreof0.72comparedwithascoreof0.62forprediction
TheadditionoftheBurchdidnotincreasethefrequencyofurinaryretention,urgencyincontinence,urinaryurgency,urinarytractinfection(UTI),orotherperioperativecomplications.Althoughcolposuspensionisnotatreatmentforurgencyincontinence,therateofurgencysymptomswaslowerintheBurchgroupat24monthfollowup(32versus45percent),butthedifferencewasnotstatisticallysignificant.
TherateofbothersomeSUIsymptomswassignificantlylowerintheBurchgroupat24monthfollowup(12versus25percent),andtherateofsubsequenttreatmentforSUIwaslowerintheBurchgroup,butthisdidnotreachstatisticalsignificance(13versus20percent).
Atsevenyearfollowup,theestimatedprobabilitiesoftreatmentfailurefortheurethropexygroupandthenourethropexygroup,respectively,were0.62and0.77forSUIand0.75and0.81foroverallUI[51].
InwomenwithadvancedPOPwhowerecontinentbeforesurgery,aprophylacticretropubicmidurethralslingatthetimeofvaginalprolapserepairreducedtherateofpostoperativeurinaryincontinence.Therateofincontinence(stress,urge,ormixed)ortreatmentforincontinencewassignificantlylowerintheslingversusshamgroupatthreemonthfollowup(24versus49percent).Therateofurinaryincontinencecontinuedtobesignificantlylowerintheslinggroupat12monthfollowup(27and43percent).
TherateofpostoperativeurinaryincontinencewashigherinwomenwithoccultSUIonpreoperativeofficebasedprolapsereductionandurinarystresstesting,butwasalsopresentatclinicallysignificantratesinwomenwithnooccultSUI.Inasubsetanalysisdividedintogroupsbypreoperativetestingresults,theratesofurinaryincontinenceatthreemonthswere:
OccultSUI:30percentintheslinggroup72percentintheshamgroup.
NooccultSUI:21percentintheslinggroup38percentintheshamgroup.
Therateofseriousadverseeventsdidnotdiffersignificantlybetweentheslingandshamgroups(17versus12percent).However,womenintheslinggrouphadsignificantlyhigherratesofbladderperforation(11versus0women7versus0percent)incompletebladderemptying(atsixweekspostoperatively)(6versus0women4versus0percent)andurinarytractinfection(31versus18percent).Allbladderperforationwasmanagedintraoperativelywithremovalandreplacementofthetrocar.
Therateofsubsequenttreatmentforincontinencewaslowerintheslinggroup,butsomewomenintheslinggrouprequiredsubsequentsurgeryforvoidingdysfunction.At12monthfollowup:
Slinggroup:12womenweretreatedforincontinence(7.3percent),including1whohadsurgery(0.6percent),and4womenhadsurgeryforvoidingdysfunction(2.4percent)
Shamgroup:19womenweretreated(11.0percent),including8whounderwentsurgery(4.7percent).
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byagroupof22experturogynecologicsurgeonsand0.54forapreoperativeprolapsereductionurinarystresstest.Thecalculatorisavailableathttp://www.rcalc.com/ExistingFormulas.aspx?filter=CCQHS.
AbdominalapproachForcontinentwomenwithstageIIorgreaterPOPwhoareundergoingabdominalsacrocolpopexywithoutconcurrenttransvaginalrepairs(eg,colporrhaphy),auniversalapproachisoptimal.Forthesewomen,regardlessoftheresultsofpreoperativetestingforoccultSUI,werecommendaconcomitantBurchcolposuspensionratherthansacrocolpopexyalone.
Aconcomitantprocedureavoidsthemorbidityandrecoverytimerequiredfortwoseparateabdominalsurgeries.TheevidencetosupportthiscomesfromtheCAREstudy,asdiscussedabove,inwhichbenefitwasobservedinthosewitheitherpositiveornegativeprolapsereductiontestingandnoincreaseinadverseeventswasobservedinwomenwhounderwentaBurchprocedure[3,50].
VaginalapproachThebestapproachtomanagementislessclearforwomenwithPOPbutnosymptomsofSUIwhoareundergoingvaginalsurgery.Ashareddecisionmakingprocesswiththepatientisrequired.Patientcounselingshouldincludethepotentialbenefitsoftheprophylacticcontinencesurgery(basedupontheresultsofpreoperativeprolapsereductionandurinarystresstesting),potentialcomplications,andpatientgoalsandpreferences.
ThebestevidencetoguideclinicaldecisionmakingforthesewomenisfromtheOPUStrial,asdiscussedabove,whichdemonstratedthatthesewomenreceiveadegreeofbenefitfromprophylacticcontinencesurgerythatissimilartowomenwhoundergoabdominalsurgery[13].However,theadditionofaprophylacticmidurethralslingincreasestheriskofcomplications.ComplicationssuchasbladderperforationorUTItypicallydonotaddsignificantlytopostoperativemorbidity,andresolveeitherwithintraoperativetreatmentorshorttermuseofabladdercatheterorantibiotictherapy.However,somewomenwillhavepersistentvoidingdysfunctionfollowingmidurethralslingsurgery,requiringprolongedcatheterizationandpotentiallyasubsequentsurgicalprocedure.TherateofurethrolysisintheOPUStrial(2.4percent)wasconsistentwiththerateofpostslingpersistentvoidingdysfunctionreportedinotherstudies(0.6to2.0percent)[53,54].Thisisanimportantconsideration,sinceoneoftheprincipalbenefitsofprophylacticcontinencesurgeryisavoidingtheneedforasubsequentsurgery.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Retropubicmidurethralslings",sectionon'Voidingdysfunction'.)
Giventheavailableevidenceandclinicalconsiderations,forwomenundergoingvaginalsurgeryweuseaselectiveapproach,butsomewomenwithnegativepreoperativetestingforoccultSUImayreasonablychooseastagedapproach.
BasedupontheOPUStrialdata,usingauniversalapproach,thenumberneededtotreatinordertopreventonecaseofurinaryincontinenceat12monthswas6.3,althoughtherewasmodestevidencetosuggestthatpatientswithapositiveprolapsereductionstresstestbeforesurgeryreceivedmorebenefitthanthosewithanegativetest.
ManyexpertsconsiderwomenwithpositivetestingforoccultSUItobesimilartowomenwhopresentwithSUIsymptoms,andadviseacombinedprocedureforprolapseandSUI.WomenwithapositivepreoperativeprolapsereductionstresstestareatthehighestriskofpostoperativeSUI.IntheOPUStrial,therewasmodestevidencetosuggestthatpatientswithapositiveprolapsereductionstresstestbeforesurgeryreceivedmorebenefitthanthosewithanegativetest.TheoverallpositivepredictivevalueofthepreoperativeprolapsereductionstressforpostoperativeSUIbaseduponmultiplestudiesis51percent(algorithm1)anditwas72percentintheOPUStrial[1316,35,55,56].Usingaselectiveapproachandperformingcontinencesurgeryonlyinwomenwithapositiveprolapsereductionstresstest,thenumberneededtotreatinordertopreventonecaseofurinaryincontinenceatthreemonthswas2.4.
ForwomenwithstageIIorgreaterPOPandpositivepreoperativetestingforoccultSUI,werecommendacombinedprocedureforprolapseandSUIratherthanprolapserepairalone.
Ontheotherhand,womenwithnegativepreoperativetestingforoccultSUIshouldbecounseledaboutthe
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availableoptionsandtherisksofurinaryincontinence,perioperativecomplications,andvoidingdysfunction.Managementofthesewomendependsupontheirvaluesandpreferences.
ConcomitantcontinencesurgeryintheOPUStrialinthispatientpopulationresultedinanabsoluteriskreductionforpostoperativeurinaryincontinenceof17percent[13].Thisratewasclinicallysignificant,butmustbeconsideredinrelationtotheriskofslingrelatedcomplicationsandassociatedmorbidity.
Ifastagedapproachisused,apatientwithstageIIorgreaterPOPwithoutsymptomsofSUIwouldonlyundergosurgeryforPOPwithnoconcomitantcontinenceprocedure.ThestagedproceduretypicallytakesplacewithinoneyearoftheoriginalprolapserepairanditisperformedonlyifthepatientdevelopssymptomsofbothersomeSUIrequiringcorrection.Theadvantageofthisapproachisthatunnecessaryprocedureswouldbeavoided.TheOPUStrialdemonstratedthat,forwomenwhounderwentonlyvaginalPOPrepair,49percentdevelopedSUI,butonly5percenthadaslingprocedureinthefirstyear.Comparedwithauniversalapproach,thestagedapproachresultedina95percentreductioninthenumberofslingsplaced.
Giventheavailabledataandclinicalconsiderations,forwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohaveNEGATIVEpreoperativetestingforoccultSUI,wesuggestprolapserepairaloneratherthanacombinedprocedureforprolapseandSUI.ConcomitantPOPrepairandcontinencesurgeryisareasonableoptionforwomenwhoplaceahighpriorityonavoidingpostoperativeurinaryincontinenceandarewillingtoacceptanincreasedriskofperioperativecomplicationsandvoidingdysfunction.
ConcomitantversusstagedproceduresSomeexpertshavequestionedwhethertheSUIcurerateisimpacteddependinguponwhetherthecontinencesurgeryisperformedaloneorconcomitantwithaPOPrepairprocedure,butthereappearstobenodifferencebaseduponavailabledata.
ThisissuewasevaluatedinamulticenterrandomizedtrialofwomenwithPOPandSUIwhowereassignedtohaveatensionfreevaginaltape(TVT)eitherconcomitantwithprolapserepairorastagedprocedure(prolapserepairfollowedbyTVTthreemonthslater)[46].Inanintenttotreatanalysis,atoneyearfollowup,therewasnosignificantdifferencebetweentheconcomitantcomparedwithstagedgroupsinSUIcurerate(95versus89percent)ortotaloperativecomplications(18versus13percent).Ofnote,inthestagedgroup,TVTwasultimatelyperformedonlyinwomenwhohadconfirmedSUIatthreemonthsafterprolapserepair(56percent).AmongthewomeninthestagedgroupwhodidnotundergoTVT,oneyearoutcomeswereasfollows:27percentwerestillcontinentand15percenthadsomeSUI,butdeclinedTVT.
Inobservationaldatafromanothertrial,inwhichwomenwererandomizedtoundergoeitheraretropubicortransobturatormidurethralsling,thosewhodidversusdidnothaveconcomitantsurgeryhadsignificantlyhigherobjectivecurerates(88versus79percent),butnotsubjectivecurerates(62versus58percent)[57].Inaddition,observationalcomparativestudieshavefoundnosignificantdifferenceintheSUIcurerateforwomenwhounderwentmidurethralslingplacementalonecomparedtoslingplacementcombinedwithvaginalsurgery(hysterectomyorprolapserepair)[5860].Inaprospectivecohortstudy,womenwhounderwentprolapserepairconcomitantlywithmidurethralslingplacement,comparedwiththosewhoplannedastagedprocedure,hadnosignificantdifferencesinSUIsymptoms(22versus21percent),changeinseverityofSUI,orsatisfaction(8.8verus9.2ona10pointscale)atoneyearfollowup[61].Ofnote,only33percentofthewomenintheplannedstagedgroupunderwentslingplacementwithinthestudyperiod.
SUIwithasymptomaticPOPProlapse,particularlystagesIorII,isoftenasymptomatic[912].Thus,womenwhopresentwithsymptomsofSUIonly,buthavePOPonexamination,presentatreatmentdilemma.Theissueiswhetherrepairofasymptomaticprolapseprovidesawomanwithalongtermbenefit(eg,preventionofsubsequentsymptomsorsurgery)orifitonlyincreasestheriskofperioperativecomplications.
Animportantquestioniswhetherprolapseinthesewomenwillworsenand/orbecomesymptomaticwithageoraftermenopause.Surprisingly,thenaturalhistoryofprolapsedoesnotfollowaprogressivecourseinallwomen.Datasuggestthatthecourseisprogressiveuntilmenopause,afterwhichthedegreeofprolapsemayfollowacourseofalternatingprogressionandregression[6264].
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WomenwithongoingriskfactorsforPOParelikelytohaveprogression.Theseincludeincreasingparity,hysterectomy,obesity,andchronicconstipation.Forobesewomen,weightlossdoesnotappeartoresultinregression[65].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Riskfactors'.)
Althoughnaturalregressionofprolapsemayoccur,combinedsurgicaltreatmentforSUIandPOPappearstoreducetheriskofsubsequentsurgery.Thiswasillustratedinaretrospectivestudyofinsuranceclaimsbyover1000womenwhounderwentaslingprocedureforSUI[47].Comparedtowomenwhodidnotundergoconcomitantprolapserepair,womenwhohadaconcomitantrepairweresignificantlylesslikelytohavesubsequentsurgeryforSUIorprolapsewithinoneyearoftheinitialsurgery(SUI:5versus10percentPOP:14versus22percent)[47].However,womenwhohadacombinedSUIandPOPrepairwerealsosignificantlymorelikelytohavepostoperativeurethralobstruction(9versus6percent).Thisstudywaslimitedbythelackofdataonthestageofprolapseandwhethersymptomswerepresent,thusmakingituncertainwhethertheresultsapplytoasymptomaticwomen.
Additionalsurgicalproceduresincreaseoperativetimeandmayincreasetheriskofperioperativecomplications[3,66].Inthestudydescribedabove,concurrentsurgeryforSUIandPOPwasassociatedwithanincreaseinpostoperativeurethralobstruction.However,itiscontroversialwhethercombinedproceduresleadtoanincreaseinobstructiveurinarysymptoms[47,6670].TherearenohighqualitystudiesofcombinedsurgeryforwomenwithSUIandmildorasymptomaticprolapse.
Giventheavailabledataandclinicalconsiderations,forwomenwithstageIasymptomaticprolapse,wesuggestNOTperformingprolapserepairatthetimeofcontinencesurgery.SinceprolapsehasnotbeenproventobeprogressiveandstageIprolapseisalmostneversymptomatic,repairinthesewomenappearstobeunnecessary.TreatmentofwomenwithstageIIorgreaterprolapsewhoareasymptomaticmustbeindividualizedbaseduponadiscussionwiththepatientabouthertreatmentgoalsandtheriskofsubsequentsurgery.(See'Informedconsentandpatientgoals'above.)
MANAGEMENTOFSPECIALPOPULATIONS
WomenathighsurgicalriskDependingonthedegreeofsurgicalrisk,womenwithstressurinaryincontinence(SUI)andpelvicorganprolapse(POP)canbetreatedusingconservativemeasures(eg,pessary,pelvicfloorexercises),however,surgerymaybeanoptionforsome.Colpocleisis(surgicalobliterationofthevaginallumen)istheprocedureofchoiceinwomenathighsurgicalriskwhoarenotplanningfurthersexualintercourseanddesiresurgicaltreatment.Thisprocedureinvolvesminimalsurgicalriskandcanbecombinedsafelyandeffectivelywithaslingprocedure[7072].(See"Pelvicorganprolapseinwomen:Obliterativeprocedures(colpocleisis)".)
WomenplanningfuturepregnancyWomenplanningfuturepregnancyshouldnotundergopelvicfloorreconstructivesurgery,sincepelvicsupportmaybedisruptedduringpregnancyanddeliveryandfurthersurgerymaybenecessaryafterpregnancy.Conservativemeasuresareappropriatetreatmentforthesepatients.(See"Vaginalpessarytreatmentofprolapseandincontinence"and"Treatmentandpreventionofurinaryincontinenceinwomen".)
SUMMARYANDRECOMMENDATIONS
Pelvicorganprolapse(POP)andstressurinaryincontinence(SUI)coexistinupto80percentofwomenwithpelvicfloorsymptoms.Thiscorrelationbetweentheseconditionsisduetotheircommonpathophysiology.(See'Introduction'above.)
Awomanmayfindsymptomsofprolapseandincontinenceequallybothersomeoroneconditionmaypredominateorbeasymptomatic.(See'Clinicalpresentation'above.)
Upto80percentofwomenwithadvancedPOPhaveoccultSUIcausedbyurethralobstruction.ThesewomenareatriskofdevelopingSUIafterprolapserepair.(See'Prolapsewithnosymptomsofincontinence'
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REFERENCES
above.)
Allwomenwhoareconsideringpelvicreconstructivesurgeryshouldhaveacomprehensiveevaluationforbothprolapseandurinaryincontinencebeforetreatmentisplanned,including:assessmentofurinarysymptoms,pelvicexaminationwithobjectivequantificationofprolapse,clinicalorurodynamicurinarystresstestingwithreductionofprolapse,anddiscussionofpatientgoalsandqualityoflife.(See'Preoperativeevaluation'above.)
Preoperativeprolapsereductiontestinghasapositivepredictivevalueabove50percentforpostoperativeSUI.
ForwomenwithsymptomsofbothPOPandSUI,werecommendaconcomitantprolapserepairandcontinenceprocedureratherthanPOPrepairalone(Grade1B).(See'SymptomaticPOPandSUI'above.)
ForwomenwithsymptomaticPOPandnoSUIsymptoms(see'Prolapsewithnosymptomsofincontinence'above):
ContinentwomenwithstageIPOPwhoareplanningprolapserepairareunlikelytohaveurethralobstructionandresultantoccultSUI,andthusareunlikelytobenefitfromaconcomitantcontinenceprocedure.
ForwomenwithstageIIorgreaterPOPwhoareundergoingabdominalsacrocolpopexywithoutconcurrentvaginalrepairs,regardlessoftheresultsofpreoperativetestingforoccultSUI,werecommendaconcomitantBurchcolposuspensionratherthansacrocolpopexyalone(Grade1B).(See'Abdominalapproach'above.)
ForwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohavePOSITIVEpreoperativetestingforoccultSUI,orhaveahighprobabilityofpostoperativestressincontinenceusingthecontinencecalculator,werecommendaconcomitantPOPrepairandcontinenceprocedureratherthanprolapserepairalone(Grade1B).(See'Vaginalapproach'aboveand'Continencecalculator'above.)
ForwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohaveNEGATIVEpreoperativetestingforoccultSUI,orhavealowprobabilityofpostoperativestressincontinenceusingthecontinencecalculator,wesuggestprolapserepairaloneratherthanacombinedprocedureforprolapseandSUI(Grade2B).ConcomitantPOPrepairandcontinencesurgeryisareasonableoptionforwomenwhoplaceahighpriorityonavoidingpostoperativeurinaryincontinenceandarewillingtoacceptanincreasedriskofperioperativecomplicationsandvoidingdysfunction.(See'Vaginalapproach'aboveand'Continencecalculator'above.)
WomenwithSUIandasymptomaticprolapse(see'SUIwithasymptomaticPOP'above):
ForwomenwithstageIprolapse,wesuggestNOTperformingprolapserepairatthetimeofcontinencesurgery(Grade2C).
TreatmentofwomenwithstageIIorgreaterprolapsemustbeindividualizedaccordingtopatienttreatmentgoalsandtheriskofsubsequentsurgery.
Choiceofanabdominalorvaginalapproachismadebasedonthefollowingfactors:anatomiclocationoftheprolapse,medicalhistory,procedureefficacy,patientpreference,andsurgeon'sexperience.(See'Choosinganabdominalorvaginalapproach'above.)
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1. BaiSW,JeonMJ,KimJY,etal.Relationshipbetweenstressurinaryincontinenceandpelvicorganprolapse.IntUrogynecolJPelvicFloorDysfunct200213:256.
2. MaherCM,FeinerB,BaesslerK,GlazenerCM.Surgicalmanagementofpelvicorganprolapseinwomen:theupdatedsummaryversionCochranereview.IntUrogynecolJ201122:1445.
3. BrubakerL,CundiffGW,FineP,etal.AbdominalsacrocolpopexywithBurchcolposuspensiontoreduceurinarystressincontinence.NEnglJMed2006354:1557.
4. WintersJC.Acriticalappraisalofpreventiveslingsandprolapsesurgerywhat'saurologisttodo?JUrol2008180:809.
5. ElkadryEA,KentonKS,FitzGeraldMP,etal.Patientselectedgoals:anewperspectiveonsurgicaloutcome.AmJObstetGynecol2003189:1551.
6. MahajanST,ElkadryEA,KentonKS,etal.Patientcenteredsurgicaloutcomes:theimpactofgoalachievementandurgeincontinenceonpatientsatisfactiononeyearaftersurgery.AmJObstetGynecol2006194:722.
7. RamanSV,RakerCA,SungVW.Concomitantapicalprolapserepairandincontinenceprocedures:trendsfrom20012009intheUnitedStates.AmJObstetGynecol2014211:222.e1.
8. MuellerER,KentonK,MahajanS,etal.Urodynamicprolapsereductionaltersurethralpressurebutnotfillingorpressureflowparameters.JUrol2007177:600.
9. EllerkmannRM,CundiffGW,MelickCF,etal.Correlationofsymptomswithlocationandseverityofpelvicorganprolapse.AmJObstetGynecol2001185:1332.
10. GutmanRE,FordDE,QuirozLH,etal.Isthereapelvicorganprolapsethresholdthatpredictspelvicfloorsymptoms?AmJObstetGynecol2008199:683.e1.
11. SwiftS,WoodmanP,O'BoyleA,etal.PelvicOrganSupportStudy(POSST):thedistribution,clinicaldefinition,andepidemiologicconditionofpelvicorgansupportdefects.AmJObstetGynecol2005192:795.
12. Mouritsen,L,Larsen,JP.Symptoms,botherandPOPQinwomenreferredwithpelvicorgan.13. WeiJT,NygaardI,RichterHE,etal.Amidurethralslingtoreduceincontinenceaftervaginalprolapse
repair.NEnglJMed2012366:2358.14. LiangCC,ChangYL,ChangSD,etal.Pessarytesttopredictpostoperativeurinaryincontinenceinwomen
undergoinghysterectomyforprolapse.ObstetGynecol2004104:795.15. ReenaC,KekreAN,KekreN.Occultstressincontinenceinwomenwithpelvicorganprolapse.IntJ
GynaecolObstet200797:31.16. ViscoAG,BrubakerL,NygaardI,etal.Theroleofpreoperativeurodynamictestinginstresscontinent
womenundergoingsacrocolpopexy:theColpopexyandUrinaryReductionEfforts(CARE)randomizedsurgicaltrial.IntUrogynecolJPelvicFloorDysfunct200819:607.
17. BumpRC,FantlJA,HurtWG.Themechanismofurinarycontinenceinwomenwithsevereuterovaginalprolapse:resultsofbarrierstudies.ObstetGynecol198872:291.
18. ChaikinDC,GroutzA,BlaivasJG.Predictingtheneedforantiincontinencesurgeryincontinentwomenundergoingrepairofsevereurogenitalprolapse.JUrol2000163:531.
19. GallentineML,CespedesRD.Occultstressurinaryincontinenceandtheeffectofvaginalvaultprolapseonabdominalleakpointpressures.Urology200157:40.
20. GordonD,GoldRS,PauznerD,etal.Combinedgenitourinaryprolapserepairandprophylactictensionfreevaginaltapeinwomenwithsevereprolapseandoccultstressurinaryincontinence:preliminaryresults.Urology200158:547.
21. GroutzA,GoldR,PauznerD,etal.Tensionfreevaginaltape(TVT)forthetreatmentofoccultstressurinaryincontinenceinwomenundergoingprolapserepair:aprospectivestudyof100consecutivecases.NeurourolUrodyn200423:632.
22. RichardsonDA,BentAE,OstergardDR.Theeffectofuterovaginalprolapseonurethrovesicalpressuredynamics.AmJObstetGynecol1983146:901.
23. RosenzweigBA,PushkinS,BlumenfeldD,BhatiaNN.Prevalenceofabnormalurodynamictestresultsincontinentwomenwithseveregenitourinaryprolapse.ObstetGynecol199279:539.
24. SinhaD,ArunkalaivananAS.Prevalenceofoccultstressincontinenceincontinentwomenwithseveregenitalprolapse.JObstetGynaecol200727:174.
28.04.2015 Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment
http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F8 12/20
25. StantonSL,HiltonP,NortonC,CardozoL.Clinicalandurodynamiceffectsofanteriorcolporrhaphyandvaginalhysterectomyforprolapsewithandwithoutincontinence.BrJObstetGynaecol198289:459.
26. GroutzA,LevinI,GoldR,etal."Insideout"transobturatortensionfreevaginaltapeformanagementofoccultstressurinaryincontinenceinwomenundergoingpelvicorganprolapserepair.Urology201076:1358.
27. BergmanA,KooningsPP,BallardCA.Predictingpostoperativeurinaryincontinencedevelopmentinwomenundergoingoperationforgenitourinaryprolapse.AmJObstetGynecol1988158:1171.
28. ColomboM,MaggioniA,ZanettaG,etal.Preventionofpostoperativeurinarystressincontinenceaftersurgeryforgenitourinaryprolapse.ObstetGynecol199687:266.
29. KlutkeJJ,RamosS.Urodynamicoutcomeaftersurgeryforsevereprolapseandpotentialstressincontinence.AmJObstetGynecol2000182:1378.
30. AlMandeelH,RossS,RobertM,MilneJ.Incidenceofstressurinaryincontinencefollowingvaginalrepairofpelvicorganprolapseinobjectivelycontinentwomen.NeurourolUrodyn201130:390.
31. KasturiS,DiazSI,McDermottCD,etal.Denovostressurinaryincontinenceafternegativeprolapsereductionstresstestingfortotalvaginalmeshprocedures:incidenceandriskfactors.AmJObstetGynecol2011205:487.e1.
32. VeronikisDK,NicholsDH,WakamatsuMM.Theincidenceoflowpressureurethraasafunctionofprolapsereducingtechniqueinpatientswithmassivepelvicorganprolapse(maximumdescentatallvaginalsites).AmJObstetGynecol1997177:1305.
33. BhatiaNN,BergmanA,GunningJE.Urodynamiceffectsofavaginalpessaryinwomenwithstressurinaryincontinence.AmJObstetGynecol1983147:876.
34. SvenningsenR,BorstadE,SpydslaugAE,etal.Occultincontinenceaspredictorforpostoperativestressurinaryincontinencefollowingpelvicorganprolapsesurgery.IntUrogynecolJ201223:843.
35. deTayracR,GervaiseA,ChauveaudLamblingA,FernandezH.Combinedgenitalprolapserepairreinforcedwithapolypropylenemeshandtensionfreevaginaltapeinwomenwithgenitalprolapseandstressurinaryincontinence:aretrospectivecasecontrolstudywithshorttermfollowup.ActaObstetGynecolScand200483:950.
36. BarnesNM,DmochowskiRR,ParkR,NittiVW.Pubovaginalslingandpelvicprolapserepairinwomenwithoccultstressurinaryincontinence:effectonpostoperativeemptyingandvoidingsymptoms.Urology200259:856.
37. OlsenAL,SmithVJ,BergstromJO,etal.Epidemiologyofsurgicallymanagedpelvicorganprolapseandurinaryincontinence.ObstetGynecol199789:501.
38. SubakLL,WaetjenLE,vandenEedenS,etal.CostofpelvicorganprolapsesurgeryintheUnitedStates.ObstetGynecol200198:646.
39. BorstadE,RudT.Theriskofdevelopingurinarystressincontinenceaftervaginalrepairincontinentwomen.Aclinicalandurodynamicfollowupstudy.ActaObstetGynecolScand198968:545.
40. BumpRC,HurtWG,TheofrastousJP,etal.RandomizedprospectivecomparisonofneedlecolposuspensionversusendopelvicfasciaplicationforpotentialstressincontinenceprophylaxisinwomenundergoingvaginalreconstructionforstageIIIorIVpelvicorganprolapse.TheContinenceProgramforWomenResearchGroup.AmJObstetGynecol1996175:326.
41. ColomboM,MaggioniA,ScalambrinoS,etal.Surgeryforgenitourinaryprolapseandstressincontinence:arandomizedtrialofposteriorpubourethralligamentplicationandPereyrasuspension.AmJObstetGynecol1997176:337.
42. ColomboM,VitobelloD,ProiettiF,MilaniR.RandomisedcomparisonofBurchcolposuspensionversusanteriorcolporrhaphyinwomenwithstressurinaryincontinenceandanteriorvaginalwallprolapse.BJOG2000107:544.
43. GroutzA,GordonD,WolmanI,etal.TheuseofprophylacticStameybladdernecksuspensiontopreventpostoperativestressurinaryincontinenceinclinicallycontinentwomenundergoinggenitourinaryprolapserepair.NeurourolUrodyn200019:671.
44. PartollLM.Efficacyoftensionfreevaginaltapewithotherpelvicreconstructivesurgery.AmJObstetGynecol2002186:1292.
45. WilleS,BraunM,HeidenreichA,etal.SacralcolpopexywithconcurrentBurchcolposuspensioninpatientswithvaginalvaultprolapse.UrolInt200676:339.
28.04.2015 Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment
http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F8 13/20
46. BorstadE,AbdelnoorM,StaffAC,KulsengHanssenS.Surgicalstrategiesforwomenwithpelvicorganprolapseandurinarystressincontinence.IntUrogynecolJ201021:179.
47. AngerJT,LitwinMS,WangQ,etal.Theeffectofconcomitantprolapserepaironslingoutcomes.JUrol2008180:1003.
48. BrubakerL,CundiffG,FineP,etal.Arandomizedtrialofcolpopexyandurinaryreductionefforts(CARE):designandmethods.ControlClinTrials200324:629.
49. BurgioKL,NygaardIE,RichterHE,etal.Bladdersymptoms1yearafterabdominalsacrocolpopexywithandwithoutBurchcolposuspensioninwomenwithoutpreoperativestressincontinencesymptoms.AmJObstetGynecol2007197:647.e1.
50. BrubakerL,NygaardI,RichterHE,etal.Twoyearoutcomesaftersacrocolpopexywithandwithoutburchtopreventstressurinaryincontinence.ObstetGynecol2008112:49.
51. NygaardI,BrubakerL,ZyczynskiHM,etal.Longtermoutcomesfollowingabdominalsacrocolpopexyforpelvicorganprolapse.JAMA2013309:2016.
52. JelovsekJE,ChaginK,BrubakerL,etal.Amodelforpredictingtheriskofdenovostressurinaryincontinenceinwomenundergoingpelvicorganprolapsesurgery.ObstetGynecol2014123:279.
53. RardinCR,RosenblattPL,KohliN,etal.Releaseoftensionfreevaginaltapeforthetreatmentofrefractorypostoperativevoidingdysfunction.ObstetGynecol2002100:898.
54. LaurikainenE,KiilholmaP.Anationwideanalysisoftransvaginaltapereleaseforurinaryretentionaftertensionfreevaginaltapeprocedure.IntUrogynecolJPelvicFloorDysfunct200617:111.
55. EnnemoserS,SchnfeldM,vonBodungenV,etal.Clinicalrelevanceofoccultstressurinaryincontinence(OSUI)followingvaginalprolapsesurgery:longtermfollowup.IntUrogynecolJ201223:851.
56. JundtK,WagnerS,vonBodungenV,etal.OccultincontinenceinwomenwithpelvicorganprolapseDoesitmatter?EurJMedRes201015:112.
57. RichterHE,AlboME,ZyczynskiHM,etal.Retropubicversustransobturatormidurethralslingsforstressincontinence.NEnglJMed2010362:2066.
58. MeltomaaS,BackmanT,HaaralaM.Concomitantvaginalsurgerydidnotaffectoutcomeofthetensionfreevaginaltapeoperationduringaprospective3yearfollowupstudy.JUrol2004172:222.
59. RafiiA,PaolettiX,HaabF,etal.Tensionfreevaginaltapeandassociatedprocedures:acasecontrolstudy.EurUrol200445:356.
60. HuangKH,KungFT,LiangHM,etal.ConcomitantpelvicorganprolapsesurgerywithTVTprocedure.IntUrogynecolJPelvicFloorDysfunct200617:60.
61. JoYH,KimK,RheeJE,etal.Theaccuracyofemergencymedicineandsurgicalresidentsinthediagnosisofacuteappendicitis.AmJEmergMed201028:766.
62. BradleyCS,ZimmermanMB,QiY,NygaardIE.Naturalhistoryofpelvicorganprolapseinpostmenopausalwomen.ObstetGynecol2007109:848.
63. HandaVL,GarrettE,HendrixS,etal.Progressionandremissionofpelvicorganprolapse:alongitudinalstudyofmenopausalwomen.AmJObstetGynecol2004190:27.
64. DietzHP.Prolapseworsenswithage,doesn'tit?AustNZJObstetGynaecol200848:587.65. KudishBI,IglesiaCB,SokolRJ,etal.Effectofweightchangeonnaturalhistoryofpelvicorganprolapse.
ObstetGynecol2009113:81.66. YipSK,PangMW.Tensionfreevaginaltapeslingprocedureforthetreatmentofstressurinaryincontinence
inHongKongwomenwithandwithoutpelvicorganprolapse:1yearoutcomestudy.HongKongMedJ200612:15.
67. WangKH,WangKH,NeimarkM,DavilaGW.VoidingdysfunctionfollowingTVTprocedure.IntUrogynecolJPelvicFloorDysfunct200213:353.
68. Ballert,KN,Biggs,G,Isenalumhe,A,RosenblumNandNittiVW.Managingtheurethraatthetimeoftransvaginalpelvicorganprolapserepair:aurodynamicapprach(abstract).NeurourolUrodyn200827:147.
69. SokolAI,JelovsekJE,WaltersMD,etal.IncidenceandpredictorsofprolongedurinaryretentionafterTVTwithandwithoutconcurrentprolapsesurgery.AmJObstetGynecol2005192:1537.
70. AbbasyS,LowensteinL,PhamT,etal.Urinaryretentionisuncommonaftercolpocleisiswithconcomitantmidurethralsling.IntUrogynecolJPelvicFloorDysfunct200920:213.
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http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F8 14/20
71. AgarwalaN,HasiakN,ShadeM.Graftinterpositioncolpocleisis,perineorrhaphy,andtensionfreeslingforpelvicorganprolapseandstressurinaryincontinenceinelderlypatients.JMinimInvasiveGynecol200714:740.
72. MooreRD,MiklosJR.Colpocleisisandtensionfreevaginaltapeslingforsevereuterineandvaginalprolapseandstressurinaryincontinenceunderlocalanesthesia.JAmAssocGynecolLaparosc200310:276.
Topic8068Version22.0
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GRAPHICS
Anatomyofoccultstressurinaryincontinence
(A)Advancedanteriororapicalpelvicorganprolapse(usuallyprolapsepastthevaginalintroitus)displacesthebladderneckposteriorlyandtheurethraiskinked,resultinginurethralobstruction.Theobstructionthenbecomesthemechanismofcontinence.(B)Whentheprolapsedstructuresareelevated(approximatingnormalanatomy)duringprolapsereductiontestinginwomenwithurethralobstructionduetoadvancedprolapse,theurethraisunblockedandstressurinaryincontinenceoftenbecomesevidentwhenaurinarystresstestisperformed.
CourtesyofJasmineTanKim,MD.
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Riskofdevelopingpostoperativestressurinaryincontinenceinwomenundergoingsurgeryforpelvicorganprolapse
SUP:suburethralplicationTVT:tensionfreevaginaltapeRPU:retropubicurethropexyNS:needlesuspensionPS:pubovaginalsling%:percent.*Symptomsrecordedperpatientreport.
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Denotesabdominalprocedures,allotherprocedureswereperformedvaginally.
Graphic66014Version4.0
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http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F8 18/20
Voidingdiary
Thisdiarywillhelpusdeterminewhyyouhavetroubleholdingyoururine,orwhyyougotothebathroomveryoftenKeepthisrecordforatleast2days.Pleasewritedown4thingseverytimeyoupassorleakurine:
1. Thetime(forexample,"10:30AM")
28.04.2015 Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment
http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F8 19/20
2. Theamountofurinethatyoupass3. Whetheryouleakedanyurine(were"wet")ornot(were"dry")4. Whetheranythingspecialmayhavecausedyoutogo(forinstance,"justhad
coffee,""coughed,""wasrunningtothebathroom,""justtookmywaterpill")Starttherecordinthemorningthefirsttimeyougotothebathroomafteryougetup.Pleasewriteontheformthetimeyougotupandthetimeyouwenttobed.Tomeasuretheamountofurineyoupass,wewillgiveyouaspecialreceptacle(calleda"hat").Placethehatinthetoilettocatchtheurineeverytimeyougo.Lookathowhightheurinefillsthehat,andwritedowntheamountfromthenumbersontheinsideofthehat.Remembertoemptythehataftereachtimeyougo.Ifyouleakurineandcannotmeasuretheamountthatcameout,writedownyourbestguess.
Graphic69130Version2.0
28.04.2015 Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment
http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F8 20/20
Disclosures:CharlesWNager,MDNothingtodisclose.JasmineTanKim,MDGrant/Research/ClinicalTrialSupport:BostonScientific[vaginalmesh(midurethralslings)].todisclose.Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.Conflictofinterestpolicy
Disclosures