Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures

doi:10.1016/S0090-4295(00)00856-6

Urology

Volume 57, Issue 1, January 2001, Pages 40-44

https://doi.org/10.1016/S0090-4295(00)00856-6 Get rights and content

Abstract

Objectives. To compare the difference in abdominal leak point pressures (ALPPs) between patients with large cystoceles and severe vaginal vault prolapse and to assess the frequency of occult stress urinary incontinence (SUI) in these groups.

Methods. A total of 24 adult female patients with pelvic prolapse underwent prospective fluorourodynamic testing to determine the change in ALPP with and without reduction of the pelvic prolapse. Twelve patients had grade III-IV vaginal vault prolapse and 12 had large cystoceles without vault prolapse. ALPP testing was performed with the prolapse unreduced and then reduced using gauze packing and a vaginal speculum.

Results. In patients with vault prolapse, the frequency of occult SUI was 50% (6 of 12) and the mean decrease in ALPP was 59 cm H₂O after prolapse reduction. In the patients with cystocele, all patients had overt SUI, and the mean change in ALPP was 11 cm H₂O after prolapse reduction. A component of intrinsic sphincter deficiency was identified in 9 (75%) of 12 women with vault prolapse after reduction, and 8 (66%) of 12 women with no vault prolapse had a component of intrinsic sphincter deficiency before reduction, with an additional 2 (17%) of 12 patients after reduction.

Conclusions. There is a high incidence of occult SUI in patients with vault prolapse and the ALPP after reduction is decreased to a much greater degree in patients with vaginal vault prolapse than in patients with cystocele alone. By reducing the pelvic prolapse during urodynamic testing, an accurate ALPP can be obtained, allowing the appropriate incontinence procedure to be performed.

Section snippets

Material and methods

A total of 24 consecutive neurologically intact female patients with pelvic prolapse with or without incontinence were prospectively evaluated with a pelvic examination and fluorourodynamic evaluation. The patients were divided into two groups of 12 based on whether or not significant (grade 3 or 4) vaginal vault prolapse was present. Each group had a variety of associated cystoceles and rectoceles (Table I). The median age was 58 years in both groups. The types and grades of pelvic prolapse

Results

Table II compares the changes in ALPP before and after prolapse reduction between those with and without vault prolapse. The mean ALPP for those with vault prolapse before reduction was 138 cm H₂O (range 115 to 150) and was 78 cm H₂O (range 55 to 125) after reduction (P = 0.0000004). The mean change after reduction was 59 cm H₂O. This is in comparison to those without vault prolapse, who had a mean ALPP of 82 cm H₂O (range 44 to 105) before reduction and 71 cm H₂O (range 32 to 93) after

Comment

Urinary incontinence that develops after the repair of significant pelvic prolapse has previously been labeled as either occult, iatrogenic, latent, or potential stress incontinence. It is clear that in most cases, the SUI was present preoperatively and was simply “masked” by a number of possible mechanisms. The rotation of the urethra with straining may cause “kinking” or compression of the urethra, effectively closing it off15 (Fig. 1). A recent study demonstrated that these patients also

Conclusions

Although all forms of pelvic prolapse can affect the ALPP, vault prolapse appears to be the most significant. The preoperative evaluation of patients with significant pelvic prolapse should include an ALPP with the prolapse reduced because the history and patient’s subjective complaints are unreliable indicators of incontinence and a high incidence of occult SUI exists in these patients. If leakage is discovered, the operating physician can then perform the appropriate incontinence procedure

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It has been reported that up to 11–22% [9] of patients with prolapse develop postoperative incontinence following corrective surgery. Occult urinary stress incontinence has been reported to occur in 36–80% of patients with severe prolapse [10]. Diagnosis of occult incontinence is made by stress tests during urodynamics.
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A recent study confirmed this by looking at abdominal leak point pressures in association with vault prolapse. They showed that there was a 50% incidence of occult stress incontinence with the prolapse in situ [43]. However, a mean decrease of 59% of the leak point pressure was noted following the reduction of the prolapse.
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¹: The opinions contained herein are those of the authors and are not to be construed as reflecting the views of the United States Air Force or Department of Defense.

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Adult urologyOccult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures1

Abstract

Section snippets

Material and methods

Results

Comment

Conclusions

Am J Obstet Gynecol

J Urol

Am J Obstet Gynecol

Clin Obstet Gynaecol

J Urol

Am J Obstet Gynecol

J Urol

Am J Obstet Gynecol

J Urol

Am J Obstet Gynecol

J Urol

Adult urology
Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures¹