The role of complex preoperative urodynamic testing of continent women when planning surgery for pelvic organ prolapse

Abstract

Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. After the surgery for prolapse 19-30 % of the patients identify “occult” urinary incontinence due to a weak urethral sphincter. The aim of this study is to evaluate the role of complex urodynamic testing to identify “occult” urinary incontinence, neuromuscular dysfunction of the bladder and urethra for adequate combined therapy. Methods: 257 female patients with no urinary incontinence at the age of 30-86 years old were examined, before the surgery the pelvic organ prolapse of II-IV stages was reduced by Simps vaginal speculum: 102 women were clinically tested, and 155 women were complexly (clinically and urodynamically) evaluated. In addition to clinical examination urodynamic testing was made. Complex examination was repeated to all of them after 1-3 and 12-36 months after the operation. Results: Decrease of values of abdominal pressure transmission (APT) of less than 100 % was found significantly more often (38 ± 3.9 %) compared to a positive cough test while clinical exami-nation(19.4 ± 3.2 %) P < 0.001. Preoperatively detrusor overactivity was diagnosed in 12.5 ± 3.5 % and 11.8 ± 4.2 % cases, urethral instability - in 3.1 ± 1.7 % and 5.1 ± 2.8 % cases, detrusor sphincter dyssynergy - in 3.1 ± 1.7 % and 1.7 ± 1.6 % cases, detrusor hypotonia in 9.4 ± 3.0 % and 13.5 ± 4.4 % cases of patients with APT of more than 100 % and less than 100 % respectively. Patients with detrusor overactivity, urethral instability, detrusor hypotonya got medical preoperation treatment during 3 months and longer. 6 patients with detrusor-sphincter dyssynergy, detrusor hypotension were contraindicated for sling operation. Patients who had clinically and urodynamically confirmed urinary incontinence underwent simultaneous sling operations (13 women in a clinical group and 51 - in a complex group). In 12-36 months after the surgery no patient with APT of more than 100 % showed urinary incontinence. Clinically examined patients revealed totally 7 out of 102 (7.14 ± 2.5 %) complications after 12-36 months after surgery (mixed urinary incontinence in 4 cases and difunctional urination due to hypotonia detuzor in 3 cases). There are no these complications in the group of complexly examined women. Conclusions: Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence and difunctional urination so that prophylactic measures can be undertaken. In cases when neuromuscular dysfunction is corrected and values of APT are less than 100 % simultaneous sling operation is reasonable.