This document discusses urodynamics testing and its role in evaluating stress urinary incontinence and pelvic organ prolapse. Some key points: - Urodynamics does not always accurately reproduce a patient's symptoms and has poor predictive value for surgical outcomes. - Pre-operative urodynamics may be useful when planning concurrent surgeries to identify issues like detrusor overactivity or voiding dysfunction. - Barrier tests to identify occult stress incontinence have low sensitivity but those with pre-op leakage are at higher risk of developing post-op incontinence. - About half of patients with pelvic organ prolapse are continent after prolapse repair alone and may not need

1. In God we trust, all others must have data

2. Incontinenza & Prolasso Michele Meschia - Giancarlo Vignoli

9. “ Urodynamic investigation should be part of the diagnostic workup in patients with POP who are candidates for surgical repair”

10. Genital Prolapse

11. Frequency / Urgency: 85% Voiding dysfunction: 34-62% Difficulty empting: 49% Incomplete voiding: 62% Hesitancy: 34% POP and urinary symptoms 237 women with POP Urinary incontinence: 73% Stress: 13% Urgency: 5% Mixed: 76% Ellerkmann, 2001

12. OAB and POP Digesu et al, 2007 Symptoms and diagnoses before and 1 year after POP surgery Symptoms Pre-op Post-op P Frequency 100% 41% 0.02 Urgency 100% 30% 0.001 Urge incont. 62% 17% 0.001 Diagnoses Pre-op Post-op DO 61% 34% Mixed incont 30% 23% Normal urod. 9% 33%

13. Postoperative resolution of urinary retention in patients with advanced POP Inclusion criteria Postvoid residual volume > 100 ml Urodynamics with voiding study (POP reduced) Results 89% had normal PVR after surgery Pre-op voiding study as predictor of  post-op PVR 66% sensitivity; 46% specificity 12% positive predictive value 93% negative predictive value FitzGerald, 2000

16. Occult Stress Urinary Incontinence 36% to 80% of continent women with POP are at risk to develop SUI after reconstructive surgery (Kleeman et al 2006; Reena et al 2007) These women, considered to have occult stress incontinence, can be identified by performing a barrier test

18. The Care Trial Women with pre-op positive barrier test were more likely to report POSUI regardless concomitant colposuspension Incidence of post-op SUI Brubaker et al, 2006 Burch No Burch P Total 23.8% 44.1% < .001 Pos barrier test 32% 58% .04 Neg barrier test 21% 38% .007

23. Prophylactic bladder neck plication is commonly performed at the time of POP repair OSUI and vaginal surgery Do nothing Bump 1996 Colombo 1997 Meschia 2004 Patient number 29 73 50 Type of study Random Random Random Procedure EPF plic Needle PU lig plic Needle EPF plic TVT Follow-up (mo.) 6 mo 5 y 2 y Cure rate of SUI 93% vs 86% 50% vs 76% 56% vs 92% “ de novo urge” 1% vs 14% 4% vs 2% 4% vs 12%

25. POP and occult urodynamic SUI Concomitant procedures The high rate of POSUI legitimates the choice of a systematic anti-SUI procedure Groutz 2004 Yamada 2001 Barnes 2002 Chaikin 2000 Klutke 2000 Patient number 100 10 38 14 55 Type of study Prospect Prospect Retrospect Prospect Retrospect Procedure TVT SU sling PV Sling PV sling Burch Follow-up (mo.) 27 mo 51 mo 15 mo 47 mo 3-5 y Cure rate of SUI 98% 99% 93% 86% 96% “ de novo urge” 8% 10% 9.5% 7% 30%