This document discusses occult stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP). [1] Between 36-80% of women with POP have occult SUI that is only revealed when the prolapse is reduced. [2] There is no standardized method for diagnosing occult SUI. Methods to reduce the prolapse include pessaries, vaginal packs, and speculums. Cough tests during filling cystometry can identify urine leakage indicative of SUI. [3] Treatment options include postponing or performing concomitant anti-incontinence surgery with POP repair. More studies are needed to determine best practices for diagnosing and treating occult SUI.
1. IRCCS Ospedale San Raffaele Milano
Università Vita-Salute San Raffaele
PROLASSO ED INCONTINENZA ASSOCIATI:
COSA E COME FARE
STEFANO SALVATORE
2. SUI E POP 1-
40% of women with POP report SUI symptoms
Grody
Occult SUI ranges from 36% to 80%
Bergman/Richardson
11-22% preoperatively continent women developed
SUI after POP repair
Stanton/ Borstad and Rud
3. SUI E POP 2-
CONCOMITANT SUI
GENITAL
PROLAPSE OCCULT SUI
4. Latent (Occult) urinary stress
incontinence
What is it?
How and when to diagnose?
If, when and how to treat?
8. In women presenting with POP w/o SUI the rate of urodynamic
stress incontinence detection is lower with pessary than with
speculum prolapse reduction (LE1)
The pessary test has also been suggested to predict the result
of POP surgery on urinary symptoms. In this indication the
predictive value of the pessary test remains unclear (LE3), and
it is not recommended to use it routinely (Grade C)
Different methods for POP reduction:
Large swab placed at the apex
Posterior blade of a bivalve
speculum
Sims speculum
Vaginal pessary
9. OCCULT SUI -HOW TO
DIAGNOSE?-
Pessary test procedure:
Pessary placed at maximum cystometric capacity or at
400mls (whatever reached first)
Patients were asked to cough repeatedly for 5-6 times
10. OCCULT SUI -HOW TO
DIAGNOSE?-
VAGINAL
PACK
Pessaries have a tendency to fall out in the
absence of the uterus and it is difficult to know
whether the prolapse is adequately reduced and
whether urethral obstruction has occured -> use
of vaginal pack
Gallentine
11. OCCULT SUI -DIAGNOSIS-
Filling cystometry at 400-500 ml CC
Cough test at CC in sitting position repeated 3
times before flowmetry
Loss of urine after 1 cough -> severe IUS
Loss of urine after 3 cough -> moderate IUS
Loss of urine after 5 cough -> mild IUS
12. OCCULT SUI -DIAGNOSIS-
Prolapse reduced by pessary
In case of pessary loss -> use of vaginal
pack
13. VAGINAL VAULT PROLAPSE AND
OCCULT SUI
Patients with vault prolapse have high incidence of
uccult SUI
The change in ALPP is much higher than in patients
with vault prolapse than in patients with moderate
grade cystoceles and rectoceles
14. POSTERIOR VAGINAL DEFECTS AND
OCCULT SUI
Pessary test procedure:
A posterior blade of a Pederson speculum was used
Bladder filled up to 300 mls
Patients performed three separate sets of Valsalva
maneuvers, and urine leakage was noted
Results:
12 (54%) of 22 women revealed occult SUI
16. 322 women randomized
157 underwent abdominal sacrocolpopexy with Burch
colposuspension (Burch group)
165 underwent only abdominal sacrocolopexy (controls)
RESULTS:
23.8% Burch group vs 44.1% controls had stress incontinence after
surgery
CONCLUSIONS:
Burch colposuspension singnificantly reduced post-operative
symptoms of
stress incontinence
17. OCCULT SUI -HOW TO TREAT-
Abdominal POP
POP repair
repair + Burch
alone
colposuspension
Incontinence
rate 54.2% 39.1%
after surgery
CONCLUSIONS: Burch colposuspension does not provide any
benefity in POP repair in patients with urinary incontinence
18. OCCULT SUI -HOW TO TREAT-
Anterior plication of
Objective rate Subjective rate
endopelvic fascia
+ TVT 92% 96%
- TVT 56% 64%
19. OCCULT SUI -HOW TO TREAT-
UROLOGY 76: 1358–1363, 2010
117 women with POP and occult SUI who had
concomitant prolapse repair and TVT-O
RESULTS:
Subjective cure rate: 97.8%
Objective cure rate: 86%
21. OCCULT SUI -POSSIBLE
SOLUTIONS-
Perform anti-incontinence surgery in ALL patients
undergoing POP surgery
Perform anti-incontinence surgery in NO patients
undergoing POP surgery
Perform anti-incontinence surgery in SOME patients
undergoing POP surgery based on some set of clinical
predictors (i.e. presence of symptons of SUI, clinical
observation of SUI on stress testing or occult SUI on
stress testing with prolapse reduction)
23. PATIENT INFORMATION
Risk of develop postoperative SUI
Need of preoperative urodynamic evaluation to
reveal occult SUI
Decide for prophylactic anti-incontinence
precedure in case of occult SUI
Decide the more effective and safer anti-
incontinence procedure
24. CONCLUSIONS
Standardized defintion by ICS/IUGA since 2010
No standardized method for prolapse reduction and evaluation of
occult SUI
Treatment choice include postponed or concomitant anti-
incontinence procedure with prolapse repair
Overall success rate on a short, medium and long term basis
should be part of preoperative counseling as well as LUT
functional effects
Latent (Occult) urinary stress incontinence. What is it? How and
when to diagnose? If, when and how to treat?