The negative predictive value of preoperative urodynamics for stress urinary incontinence following prolapse surgery

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Pelvic Organ Prolapse Syndrome and Lower Urinary Tract Symptom Update: What's New?

(1) Background: This narrative review aimed to analyze the epidemiological, clinical, surgical, prognostic, and instrumental aspects of the link between pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS), collecting the most recent evidence from the scientific literature. (2) Methods: We matched the terms "pelvic organ prolapse" (POP) and "lower urinary tract symptoms" (LUTS) on the following databases: Pubmed, Embase, Scopus, Google scholar, and Cochrane. We excluded case reports, systematic reviews, articles published in a language other than English, and studies focusing only on a surgical technique. (3) Results: There is a link between POP and LUTS. Bladder outlet obstruction (BOO) would increase variation in bladder structure and function, which could lead to an overactive bladder (OAB). There is no connection between the POP stage and LUTS. Prolapse surgery could modify the symptoms of OAB with improvement or healing. Post-surgical predictive factors of non-improvement of OAB or de novo onset include high BMI, neurological pathologies, age > 65 years, and the severity of symptoms; predictors of emptying disorders are neurological pathologies, BOO, perineal dysfunctions, severity of pre-surgery symptoms, and severe anterior prolapse. Urodynamics should be performed on a specific subset of patients (i.e., stress urinary incontinence, correct surgery planning), (4) Conclusions: Correction of prolapse is the primary treatment for detrusor underactivity and for patients with both POP and OAB.

A web-based fuzzy risk predictive-decision model of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery

Background:

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions affecting women's health and quality of life. In 50% of cases, SUI occurs after POP surgery, which is called de novo SUI. Predicting the risk of de novo SUI is a complex multi-attribute decision-making process. The current study made available a Decision Support System in the form of a fuzzy calculator web-based application to help surgeons predict the risk of de novo SUI.

Materials and methods:

We first identified 12 risk factors and the diagnostic criteria for de novo SUI by means of a systematic review of the literature. Then based upon an expert panel, all risk factors were prioritized. A set of 232 fuzzy rules for the prediction of de novo SUI was determined. A fuzzy expert system was developed using MATLAB software and Mamdani Inference System. The risk prediction model was then evaluated using retrospective data extracted from 30 randomly selected medical records of female patients over the age of 50 without symptoms of urinary incontinence who had undergone POP surgery. Finally, the proposed results of the predictive system were compared with the results of retrospective medical record data review.

Results:

The results of this online calculator show that the accuracy of this risk prediction model, at more than 90%, compared favorably to other SUI risk prediction models.

Conclusions:

A fuzzy logic-based clinical Decision Support System in the form of an online calculator for calculating SUI prognosis after POP surgery in women can be helpful in predicting de novo SUI.

Determining the risk factors and characteristics of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery: A systematic review

OBJECTIVE

Stress urinary incontinence (SUI) is a common problem in women that affects their quality of life. According to the current evidence, 15%-50% of severe pelvic organ prolapse (POP) surgeries lead to de novo urinary incontinence (UI). This study aimed at determining the risk factors and characteristics of de novo SUI after POP surgeries in a systematic review.

MATERIAL AND METHODS

We conducted a systematic search of articles in English related to the risk of UI after POP surgery published until December 2019 in the selected bibliographic databases, including PubMed, EMBASE, Scopus, Cochrane Library, and ProQuest.

RESULTS

The initial search resulted in 2,363 studies, and after reviewing the titles and abstracts, 146 studies were identified. Moreover, 2 independent reviewers, using the Joanna Briggs Institute checklists, evaluated the risk of biases in the selected studies. Finally, 40 studies met the inclusion criteria. The most important predictors of UI after POP surgery were positive pessary testing, age >50 years, and maximum urethral closure pressure (MUCP) <60 cmH₂O.

CONCLUSION

Positive pessary testing, older age, and low MUCP were the most important risk factors for de novo incontinence after POP surgeries.

Impact of preoperative urodynamics on women undergoing pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling.

METHODS

We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery.

RESULTS

Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement.

CONCLUSIONS

UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.