Preoperative 1-h pad test with pessary insertion as a predictor of the need for a mid-urethral sling following pelvic prolapse surgery: a prospective cohort study

Abstract

BackgroundA subgroup of patients with pelvic organ prolapse who do not have symptoms of stress urinary incontinence might show such symptoms after prolapse surgery (ie, occult stress urinary incontinence), and no optimal preoperative screening method is available at present. The aim of this study was to estimate the effectiveness of the preoperative 1-h pad test with pessary insertion as a predictor of the need for a mid-urethral sling after prolapse surgery. Methods206 patients with advanced prolapse who did not self-report urinary incontinence were enrolled in this prospective cohort study. Exclusion criteria included previous or concomitant anti-incontinence surgery. Before pelvic prolapse surgery, a urinary stress test, the 1-hour pad test, and uroflowmetry were done, along with prolapse reduction. The primary outcome was postoperative de-novo urinary incontinence. The median follow-up was 31 months (range 12–48 months). All participants were informed about the procedures and signed informed consent forms. The study was approved by the ethics committee of Peking Union Medical College Hospital, Beijing, China. FindingsOf 206 patients, 45 (22%) had evidence of occult stress urinary incontinence preoperatively, 62 (30%) showed de-novo urinary incontinence postoperatively, and only 13 (6%) opted for mid-urethral slings. Patients with occult stress urinary incontinence had a higher de-novo urinary incontinence rate after surgery than had patients without occult stress urinary incontinence (53·3% vs 23·6%; p=0·0001). Occult stress urinary incontinence (hazard ratio [HR] 4·19 [95% CI 1·99–8·86]; p=0·0001) and concomitant hysterectomy (HR 2·86 [1·02–7·99]; p=0·044) were identified as independent risk factors of de-novo urinary incontinence. We used a receiver operating characteristic curve analysis to assess the effectiveness of the preoperative 1-h pad test. The area under the curve was 0·816 (SD 0·085, 95% CI 0·649–0 ·983); the cutoff value was 1·9 g (sensitivity 80·0%; specificity 83·9%). InterpretationThe preoperative 1-h pad test with prolapse reduction is feasible for screening of occult stress urinary incontinence, and a result of more than 1·9 g might be a practical indicator of a need for mid-urethral slings after pelvic prolapse surgery. FundingNone.