Effect of Pelvic Organ Prolapse Surgery on Overactive Bladder Symptoms

1. Effect of Pelvic Organ Prolapse Surgery on Overactive Bladder Symptoms Ng PY, Pue LB, Tan GI, J Ravi.Urogynaecology Unit, Obstetrics and Gynaecology Department, Hospital Kuala Lumpur . Objectives Methods Results Conclusions INTRODUCTION Urogenital prolapse and overactive bladder is a common condition affecting women, especially in the older age group. It has been estimated that 50% of parous women have some degree of urogenital prolapse and 20% of these are symptomatic (1). Overactive bladder (OAB) is defined as urgency with or without urgency incontinence, usually with frequency and nocturia, in the absence of urinary tract infection or other obvious bladder pathology (2). OAB and anterior vaginal wall prolapse often co-exist (3). Community and hospital based studies showed that the prevalence of OAB symptoms was higher in patients with POP than without POP (4). It has been suggested that this may be due to descend of the trigone into anterior vaginal wall prolapse or obstruction of the urethra due to vaginal prolapse (5,6). Basu & Duckett (2009) postulated that the bladder may be overactive due to hypercontractility in order to overcome the obstructive element (7). Relief of the obstruction by restoring the anatomy of the anterior compartment may be expected to improve bladder emptying and lead to resolution of OAB symptoms and objective resolution of detrusor overactivity (7). Surgical repair remains the gold standard of treatment of women with pelvic organ prolapse (POP), however the effect of vaginal surgery on concomitant OAB symptoms is still not known (3). De Boer et al. reported an improvement in OAB complaints as well as in the sign of detrusor overactivity with treatment of POP both surgically or conservatively using pessaries with the improvement rate reported as high as 69 % (4). OBJECTIVE The aim of our study is to find out whether POP surgery improves or cures OAB symptoms or voiding dysfunction in our centre in Kuala Lumpur Hospital. METHODS This is a cross sectional study done in the urogynaecology unit in Kuala Lumpur Hospital who underwent surgery from 1st October 2007 till 30th September 2011. All female patients with pelvic organ prolapse who had suffered from symptoms of overactive bladder for at least 3 months were enrolled in this study. Inclusion Criteria: -Women aged > 18 years Exclusion criteria: -Women who had concomitant stress urinary incontinence surgery -Women with neurological disorder or bladder pathology identified by imaging techniques or cystoscopy -Women with urinary tract infection. All the women in the study were assessed preoperatively with a detailed urogynaecology history and examination. The grade of urogenital prolapse was classified according to the Baden-walker system (8). Women with lower urinary tract symptoms underwent standard urodynamic studies. A ring pessary was used to reduce Grade 3 and 4 prolapse prior to cystometry. All women underwent a standard fascial anterior repair for cystocele which was performed together with other compartments if indicated. Thy had prophylactic antibiotic cover and an indwelling bladder catheter was left in-situ for 2 days post operatively. Post operative assessment was undertaken one month after surgery. using a direct questionnaire on the symptoms of frequency, urgency, nocturia, urgency incontinence, and voiding dysfunction, assessing comparative severity prior to and after surgery. The data was entered into Microsoft excel database. A Fisher Exact test was used for discrete data. A P value < 0.05 was considered significant. All patients consented for the study. No ethical committee approval needed as the above pre & post operative management were the recommended standard of care. RESULTS A total of 297 patients underwent POP surgeries without incontinence surgeries during the study period. However only 274 were included in the analysis of this study as 23 cases had missing or incomplete data. The demographic data of the patients is as follows: The surgeries include vaginal hysterectomy (VH), anterior repair (AP), posterior repair (PR), sacrospinous fixation (SSF) or Manchester repair. Changes in symptoms following surgery: DISCUSSION Our study shows that POP surgery improves OAB symptoms (nocturia, urge incontinence and voiding dysfunction). Previous studies have showed that an improvement of OAB symptoms after prolapse surgery is found in up to 69% of the women (4,6). In line with the theory of pathophysiology for OAB with POP, we explained our findings by the restoration of normal vaginal and pelvic floor anatomy thus correcting the urethral outlet obstruction of women with anterior vaginal wall prolapse. Salvatore et al reported that women with anterior vaginal wall prolapse with OAB are less likely to have improved symptoms with anticholinergics, which support the theory that anatomical distortion is likely the cause (9).  There were other studies which reported a conflicting results regarding improvement of OAB after POP surgeries. Schimpf et al found that there was no association between anterior vaginal wall prolapse and OAB symptoms and voiding dysfunction (10). A Cochrane review of the surgical management of POP noted that level 1a evidence concerning anterior repair and urinary symptoms is limited and inconclusive (11). Our studies suggests that surgical intervention for pelvic organ prolapse does improve OAB symptoms. References 1. Beck RP, McCormick S, Nordstrom L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol 1991; 78(6):1011–1018 2. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2010; 21:5–26. 3. Digesu GA, Salvatore S, Chaliha C, et al. Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse? Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:1439–1443. 4. De Boer TA, Salvatore S, Cardozo L, et al. Pelvic organ prolapse and overactive bladder. Neurourol Urodyn 2010; 29:30–39. 5. Digesu GA, Chaliha C, Salvatore S, et al. The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 2005; 112(7):971–976 6. Brading AF, Turner WH. The unstable bladder: towards a common mechanism. Br J Urol 1994; 73(1):3–8 7. Basu M, Duckett J. Effect of prolapse repair on voiding and the relationship to overactive bladder and detrusor overactivity. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:499-504 8. Baden W, Walker T. Genesis of the vaginal profile: a correlated classification of vaginal relaxation. Clin Obstet Gynecol 1972;15:1048 9. Salvatore S, Serati M, Ghezzi F, Uccella S, Cromi A, Bolis P. Efficacy of Tolterodine in women with detrusor overactivity and anterior wall vaginal prolapse: is it the same? BJOG 2007; 114:1436–1438. 10. Schimpf M, O’Sullivan D, LaSala C, Tulikangas P. Anterior wall vaginal prolapse and voiding dysfunction in urogynaecology patients. Int Urogynecol J 2007; 18:721–725. 11. Maher C, Baessler K, Glazener C, Adams E, Hagen S. Surgical management of pelvic organ prolapse in women. The Cochrane Library, Wiley. Cochrane Database of Systematic Reviews 2006:CD004014.