Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical treatment

INTRODUCTION

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) coexist in up to 80 percent of women with pelvic floor dysfunction [1,2]. While these conditions are often concurrent, one may be mild or asymptomatic. Women without symptoms of SUI who undergo surgery for prolapse are at risk for postoperative urinary incontinence [3]. SUI may also worsen after prolapse repair.

Deciding whether to perform a combined surgical procedure to treat both prolapse and SUI or a single procedure that addresses only one condition requires balancing the risk of incomplete treatment with the risk of exposing the patient to unnecessary surgery [4]. This decision must be based on the best approach to address the patient's goals, rather than simply on anatomic correction [5,6].

Challenges in surgical decision-making in this clinical context include appropriate assessment of results of preoperative evaluation, some of which may be ambiguous (eg, prolapse noted on examination in a patient with no prolapse-related symptoms or a patient with advance prolapse with no leakage on prolapse reduction testing).

Combined surgical treatment for POP and SUI will be reviewed here. Other approaches to surgical and medical treatment of these conditions and other types of urinary incontinence are discussed separately. (See "An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapse in women" and "Approach to women with urinary incontinence" and "Stress urinary incontinence in women: Choosing a primary surgical procedure".)

TERMINOLOGY

Stress urinary incontinence (SUI) – Leakage of urine with increased intraabdominal pressure (eg, cough, laughter). (See "Approach to women with urinary incontinence", section on 'Classification'.)

                     

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2014. | This topic last updated: May 6, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Bai SW, Jeon MJ, Kim JY, et al. Relationship between stress urinary incontinence and pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13:256.
  2. Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445.
  3. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006; 354:1557.
  4. Winters JC. A critical appraisal of preventive slings and prolapse surgery--what's a urologist to do? J Urol 2008; 180:809.
  5. Elkadry EA, Kenton KS, FitzGerald MP, et al. Patient-selected goals: a new perspective on surgical outcome. Am J Obstet Gynecol 2003; 189:1551.
  6. Mahajan ST, Elkadry EA, Kenton KS, et al. Patient-centered surgical outcomes: the impact of goal achievement and urge incontinence on patient satisfaction one year after surgery. Am J Obstet Gynecol 2006; 194:722.
  7. Mueller ER, Kenton K, Mahajan S, et al. Urodynamic prolapse reduction alters urethral pressure but not filling or pressure flow parameters. J Urol 2007; 177:600.
  8. Ellerkmann RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001; 185:1332.
  9. Gutman RE, Ford DE, Quiroz LH, et al. Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms? Am J Obstet Gynecol 2008; 199:683.e1.
  10. Swift S, Woodman P, O'Boyle A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol 2005; 192:795.
  11. Mouritsen, L, Larsen, JP. Symptoms, bother and POPQ in women referred with pelvic organ.
  12. Wei JT, Nygaard I, Richter HE, et al. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012; 366:2358.
  13. Liang CC, Chang YL, Chang SD, et al. Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse. Obstet Gynecol 2004; 104:795.
  14. Reena C, Kekre AN, Kekre N. Occult stress incontinence in women with pelvic organ prolapse. Int J Gynaecol Obstet 2007; 97:31.
  15. Visco AG, Brubaker L, Nygaard I, et al. The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: the Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:607.
  16. Bump RC, Fantl JA, Hurt WG. The mechanism of urinary continence in women with severe uterovaginal prolapse: results of barrier studies. Obstet Gynecol 1988; 72:291.
  17. Chaikin DC, Groutz A, Blaivas JG. Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse. J Urol 2000; 163:531.
  18. Gallentine ML, Cespedes RD. Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures. Urology 2001; 57:40.
  19. Gordon D, Gold RS, Pauzner D, et al. Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence: preliminary results. Urology 2001; 58:547.
  20. Groutz A, Gold R, Pauzner D, et al. Tension-free vaginal tape (TVT) for the treatment of occult stress urinary incontinence in women undergoing prolapse repair: a prospective study of 100 consecutive cases. Neurourol Urodyn 2004; 23:632.
  21. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on urethrovesical pressure dynamics. Am J Obstet Gynecol 1983; 146:901.
  22. Rosenzweig BA, Pushkin S, Blumenfeld D, Bhatia NN. Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol 1992; 79:539.
  23. Sinha D, Arunkalaivanan AS. Prevalence of occult stress incontinence in continent women with severe genital prolapse. J Obstet Gynaecol 2007; 27:174.
  24. Stanton SL, Hilton P, Norton C, Cardozo L. Clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence. Br J Obstet Gynaecol 1982; 89:459.
  25. Groutz A, Levin I, Gold R, et al. "Inside-out" transobturator tension-free vaginal tape for management of occult stress urinary incontinence in women undergoing pelvic organ prolapse repair. Urology 2010; 76:1358.
  26. Bergman A, Koonings PP, Ballard CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988; 158:1171.
  27. Colombo M, Maggioni A, Zanetta G, et al. Prevention of postoperative urinary stress incontinence after surgery for genitourinary prolapse. Obstet Gynecol 1996; 87:266.
  28. Klutke JJ, Ramos S. Urodynamic outcome after surgery for severe prolapse and potential stress incontinence. Am J Obstet Gynecol 2000; 182:1378.
  29. Al-Mandeel H, Ross S, Robert M, Milne J. Incidence of stress urinary incontinence following vaginal repair of pelvic organ prolapse in objectively continent women. Neurourol Urodyn 2011; 30:390.
  30. Kasturi S, Diaz SI, McDermott CD, et al. De novo stress urinary incontinence after negative prolapse reduction stress testing for total vaginal mesh procedures: incidence and risk factors. Am J Obstet Gynecol 2011; 205:487.e1.
  31. Veronikis DK, Nichols DH, Wakamatsu MM. The incidence of low-pressure urethra as a function of prolapse-reducing technique in patients with massive pelvic organ prolapse (maximum descent at all vaginal sites). Am J Obstet Gynecol 1997; 177:1305.
  32. Bhatia NN, Bergman A, Gunning JE. Urodynamic effects of a vaginal pessary in women with stress urinary incontinence. Am J Obstet Gynecol 1983; 147:876.
  33. Svenningsen R, Borstad E, Spydslaug AE, et al. Occult incontinence as predictor for postoperative stress urinary incontinence following pelvic organ prolapse surgery. Int Urogynecol J 2012; 23:843.
  34. de Tayrac R, Gervaise A, Chauveaud-Lambling A, Fernandez H. Combined genital prolapse repair reinforced with a polypropylene mesh and tension-free vaginal tape in women with genital prolapse and stress urinary incontinence: a retrospective case-control study with short-term follow-up. Acta Obstet Gynecol Scand 2004; 83:950.
  35. Barnes NM, Dmochowski RR, Park R, Nitti VW. Pubovaginal sling and pelvic prolapse repair in women with occult stress urinary incontinence: effect on postoperative emptying and voiding symptoms. Urology 2002; 59:856.
  36. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89:501.
  37. Subak LL, Waetjen LE, van den Eeden S, et al. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001; 98:646.
  38. Borstad E, Rud T. The risk of developing urinary stress-incontinence after vaginal repair in continent women. A clinical and urodynamic follow-up study. Acta Obstet Gynecol Scand 1989; 68:545.
  39. Bump RC, Hurt WG, Theofrastous JP, et al. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group. Am J Obstet Gynecol 1996; 175:326.
  40. Colombo M, Maggioni A, Scalambrino S, et al. Surgery for genitourinary prolapse and stress incontinence: a randomized trial of posterior pubourethral ligament plication and Pereyra suspension. Am J Obstet Gynecol 1997; 176:337.
  41. Colombo M, Vitobello D, Proietti F, Milani R. Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. BJOG 2000; 107:544.
  42. Groutz A, Gordon D, Wolman I, et al. The use of prophylactic Stamey bladder neck suspension to prevent post-operative stress urinary incontinence in clinically continent women undergoing genitourinary prolapse repair. Neurourol Urodyn 2000; 19:671.
  43. Partoll LM. Efficacy of tension-free vaginal tape with other pelvic reconstructive surgery. Am J Obstet Gynecol 2002; 186:1292.
  44. Wille S, Braun M, Heidenreich A, et al. Sacral colpopexy with concurrent Burch colposuspension in patients with vaginal vault prolapse. Urol Int 2006; 76:339.
  45. Borstad E, Abdelnoor M, Staff AC, Kulseng-Hanssen S. Surgical strategies for women with pelvic organ prolapse and urinary stress incontinence. Int Urogynecol J 2010; 21:179.
  46. Anger JT, Litwin MS, Wang Q, et al. The effect of concomitant prolapse repair on sling outcomes. J Urol 2008; 180:1003.
  47. Brubaker L, Cundiff G, Fine P, et al. A randomized trial of colpopexy and urinary reduction efforts (CARE): design and methods. Control Clin Trials 2003; 24:629.
  48. Burgio KL, Nygaard IE, Richter HE, et al. Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol 2007; 197:647.e1.
  49. Brubaker L, Nygaard I, Richter HE, et al. Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Obstet Gynecol 2008; 112:49.
  50. Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013; 309:2016.
  51. Jelovsek JE, Chagin K, Brubaker L, et al. A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery. Obstet Gynecol 2014; 123:279.
  52. Rardin CR, Rosenblatt PL, Kohli N, et al. Release of tension-free vaginal tape for the treatment of refractory postoperative voiding dysfunction. Obstet Gynecol 2002; 100:898.
  53. Laurikainen E, Kiilholma P. A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:111.
  54. Ennemoser S, Schönfeld M, von Bodungen V, et al. Clinical relevance of occult stress urinary incontinence (OSUI) following vaginal prolapse surgery: long-term follow-up. Int Urogynecol J 2012; 23:851.
  55. Jundt K, Wagner S, von Bodungen V, et al. Occult incontinence in women with pelvic organ prolapse - Does it matter? Eur J Med Res 2010; 15:112.
  56. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010; 362:2066.
  57. Meltomaa S, Backman T, Haarala M. Concomitant vaginal surgery did not affect outcome of the tension-free vaginal tape operation during a prospective 3-year followup study. J Urol 2004; 172:222.
  58. Rafii A, Paoletti X, Haab F, et al. Tension-free vaginal tape and associated procedures: a case control study. Eur Urol 2004; 45:356.
  59. Huang KH, Kung FT, Liang HM, et al. Concomitant pelvic organ prolapse surgery with TVT procedure. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:60.
  60. Jo YH, Kim K, Rhee JE, et al. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010; 28:766.
  61. Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol 2007; 109:848.
  62. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol 2004; 190:27.
  63. Dietz HP. Prolapse worsens with age, doesn't it? Aust N Z J Obstet Gynaecol 2008; 48:587.
  64. Kudish BI, Iglesia CB, Sokol RJ, et al. Effect of weight change on natural history of pelvic organ prolapse. Obstet Gynecol 2009; 113:81.
  65. Yip SK, Pang MW. Tension-free vaginal tape sling procedure for the treatment of stress urinary incontinence in Hong Kong women with and without pelvic organ prolapse: 1-year outcome study. Hong Kong Med J 2006; 12:15.
  66. Wang KH, Wang KH, Neimark M, Davila GW. Voiding dysfunction following TVT procedure. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13:353.
  67. Ballert, KN, Biggs, G, Isenalumhe, A, Rosenblum N and Nitti VW. Managing the urethra at the time of transvaginal pelvic organ prolapse repair: a urodynamic apprach (abstract). Neurourol Urodyn 2008; 27:147.
  68. Sokol AI, Jelovsek JE, Walters MD, et al. Incidence and predictors of prolonged urinary retention after TVT with and without concurrent prolapse surgery. Am J Obstet Gynecol 2005; 192:1537.
  69. Abbasy S, Lowenstein L, Pham T, et al. Urinary retention is uncommon after colpocleisis with concomitant mid-urethral sling. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:213.
  70. Agarwala N, Hasiak N, Shade M. Graft interposition colpocleisis, perineorrhaphy, and tension-free sling for pelvic organ prolapse and stress urinary incontinence in elderly patients. J Minim Invasive Gynecol 2007; 14:740.
  71. Moore RD, Miklos JR. Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia. J Am Assoc Gynecol Laparosc 2003; 10:276.