Management of Postoperative Lower Urinary Tract Symptoms (LUTS) After Pelvic Organ Prolapse (POP) Repair
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Purpose of Review
Pelvic organ prolapse (POP) is a common condition for which approximately 200,000 US women annually undergo surgical repair [Am J Obstet Gynecol 188:108–115, 2003]. After surgical correction, persistent or new lower urinary tract symptoms (LUTS) can be present. We provide guidance on the current tools to predict, counsel, and subsequently handle postoperative LUTS. The current literature is reviewed regarding LUTS diagnosis and management in the setting of prolapse surgery with an emphasis on newer developments in this area.
More severe stages of prolapse are positively correlated with obstructive symptoms [Am J Obstet Gynecol 185:1332–1337, 2001], but not with other LUTS [Adv Urol 2013:5673753, 2013, Eur J Obstet Gynecol Reprod Biol 177:141–145, 2014, Am J Obstet Gynecol 199:683, 2008, Int Urogynecol J 21:1143–1149, 2010].
One-week ambulatory pessary trial is an effective way to approximate postoperative results—one study correctly predicted persistent urgency and frequency in addition to occult stress urinary incontinence in 20% of study population [Obstet Gynecol Int 2012:392027, 2012].
No preoperative overactive bladder (OAB) symptom was the best predictor for the absence of de novo OAB symptoms postoperatively [Int Urogynecol J 21:1143–1149, 2010].
Urge incontinence patients respond favorably to sacral neuromodulation [Neurourol Urodyn 26: 29–35, 2007], botulinum toxin, and anticholinergic therapy [Res Rep Urol 8:113–122, 2016 , N Engl J Med, 367:1803–1813, 2012].
Primary bladder outlet obstruction (BOO) can be treated effectively with alpha antagonists or anticholinergics, timed voiding, and pelvic physiotherapy as first-line therapy.
Counseling regarding postoperative LUTS is key when planning POP surgery. A thorough understanding of patient history is crucial to successful repair. Patients with significant preoperative symptoms, history of neurologic disease, pelvic floor dysfunction, bladder neck obstruction, or higher stages of anterior wall prolapse may be higher risk for postoperative LUTS. UDS with or without reduction and an ambulatory pessary trial can help prognosticate. Patients will likely maintain a positive therapeutic relationship postoperatively for LUTS if counseled preoperatively.
KeywordsPelvic organ prolapse surgery Urodynamics LUTS Female incontinence Female voiding dysfunction Complications Overactive bladder Frequency Urgency Urge incontinence Overactive bladder
Compliance with Ethical Standards
Conflict of Interest
Annie Chen, Brian McIntyre, and Elise J.B. De each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 2.•• Haylen BT, Maher CF, Barber MD, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016;27(4):655–84. https://doi.org/10.1007/s00192-016-3003-y. An important comprehensive guide for standardized terminology for reporting outcomes for POP Surgery. CrossRefPubMedGoogle Scholar
- 3.International Continence Society. (2005). ICS Factsheet. Retrieved from www.ics.org/documents/documentsdownload.aspx?documentID=148
- 4.Glazener CM, Breeman S, Elders A, Hemming C, Cooper KG, Freeman RM, et al. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT). Lancet. 2017;389(10067):381–92. https://doi.org/10.1016/S0140-6736(16)31596-3.CrossRefPubMedGoogle Scholar
- 5.Buca DIP, Liberati M, Falo E, et al. Long-term outcome after surgical repair of pelvic organ prolapse with elevate prolapse repair system. J Obstet Gynaecol. 2018:1–6. https://doi.org/10.1080/01443615.2017.1419462.
- 9.Kc K, Sa A. Native tissue repair for incontinence and prolapse. New York, NY: Springer Berlin Heidelberg; 2017.Google Scholar
- 19.Guzman Rojas R, Kamisan Atan I, Shek KL, Dietz HP. The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients. Int Urogynecol J. 2016;27(6):939–44. https://doi.org/10.1007/s00192-015-2914-3.CrossRefPubMedGoogle Scholar
- 21.Van Der Ploeg JM, Zwolsman SE, Posthuma S, et al. The predictive value of demonstrable stress incontinence during basic office evaluation and urodynamics in women without symptomatic urinary incontinence undergoing vaginal prolapse surgery. Neurourol Urodyn. 2018;37(3):1011–8. https://doi.org/10.1002/nau.23384.CrossRefPubMedGoogle Scholar
- 22.•• Lo TS, Nagashu S, Hsieh WC, et al. Predictors for detrusor overactivity following extensive vaginal pelvic reconstructive surgery. Neurourol Urodyn. 2018;37(1):192–9. https://doi.org/10.1002/nau.23273. This prospective study comprised of 1503 women with POPQ stage 3 or higher who underwent POP surgery. Age ≥66 year, neurological factors, preoperative maximum urethral closure pressure MUCP ≥60 cmH2 O, maximum flow rate MFR < 15 mL, detrusor pressure at maximal flow “Dmax” ≥ 20 cmH2O, and post void residual (PVR) ≥ 200 mL were independent risk factors for developing postoperative detrusor overactivity (DO). CrossRefPubMedGoogle Scholar
- 23.Frigerio M, Manodoro S, Cola A, Palmieri S, Spelzini F, Milani R. Detrusor underactivity in pelvic organ prolapse. Int Urogynecol J. 2017; https://doi.org/10.1007/s00192-017-3532-z.
- 24.Visco AG, Brubaker L, Nygaard I, Richter HE, Cundiff G, Fine P, 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(5):607–14. https://doi.org/10.1007/s00192-007-0498-2.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Nguyen LN, Gruner M, Killinger KA, Peters KM, Boura JA, Jankowski M, et al. Additional treatments, satisfaction, symptoms and quality of life in women 1 year after vaginal and abdominal pelvic organ prolapse repair. Int Urol Nephrol. 2018;50:1031–7. https://doi.org/10.1007/s11255-018-1846-5.CrossRefPubMedGoogle Scholar
- 29.Lleberia-Juanos J, Bataller-Sanchez E, Pubill-Soler J, et al. De novo urgency after tension-free vaginal tape versus transobturator tape procedure for stress urinary incontinence. Eur J Obstet Gynecol Reprod Biol. 2011;155(2):229–32. https://doi.org/10.1016/j.ejogrb.2010.12.026.CrossRefPubMedGoogle Scholar
- 33.Khullar V, Amarenco G, Angulo JC, Cambronero J, Høye K, Milsom I, et al. Efficacy and tolerability of mirabegron, a beta(3)-adrenoceptor agonist, in patients with overactive bladder: results from a randomised European-Australian phase 3 trial. Eur Urol. 2013;63(2):283–95. https://doi.org/10.1016/j.eururo.2012.10.016.CrossRefPubMedGoogle Scholar
- 34.Starkman J. S., Wolter C. E., Scarpero H. M., Milam D. F., Dmochowski R. R. (2007). Management of refractory urinary urge incontinence following urogynecological surgery with sacral neuromodulation. Neurourol Urodyn, 26(1), 29–35; discussion 36. https://doi.org/10.1002/nau.20360
- 36.Rosier P. F.W.M., Schaefer W., Lose G., et al. International continence society good urodynamic practices and terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study. Neurourol Urodyn. 2016;9999:1–18.Google Scholar
- 39.Bascsu C, Zimmern P. Complications of treatment of urinary incontinence and pelvic organ prolapse. Rev Méd Clín Condes. 2013;24(2):229–37.Google Scholar
- 43.Giannis G, Bousouni E, Mueller MD, Imboden S, Mohr S, Raio L, et al. Can urethrolysis resolve outlet obstruction related symptoms after Burch colposuspension for stress urinary incontinence? Eur J Obstet Gynecol Reprod Biol. 2015;195:103–7. https://doi.org/10.1016/j.ejogrb.2015.09.033.CrossRefPubMedGoogle Scholar