13. OABand POP
• OAB & POP are both common
conditions
• POP is not a causative factor of OAB
but is a coincidental finding…
• ...but there is a causal link
14. OABand POP
• Relative Risk (RR) of OAB in women with
POP is 2.1-5.8
• Conflicting data about relationship
between stage/compartment POP and OAB
symptoms
• In all studies there was an improvement in
OAB after POP surgery (up to 69%)
• Thus the strong link between POP and
OAB seems quite compelling
18. OABafterPOPsurgery without SUI
surgery
Different risk patterns for different OAB
symptoms:
• Post-op frequency and urgency less common
in women with higher pre-op POP-Q stages
• Use of vaginal mesh material had a favorable
effect on urgency
• Previous hysterectomy predictor for
bothersome post-op urgency
Evidence emerging by studies without UD:
22. OABafterPOPsurgery without SUI
surgery
Evidence emerging by studies with UD:
• Improvement of the flow rate and fall of the
opening pressure related to improvement
• Relationship between preoperative DO(OR
0.2) and bladder trabeculation (OR 6.1) and
improvement of UUI after surgery
• Higher preoperative detrusor pressure was
associated with persistence of symptoms
24. Effect of POPsurgery on DO
• Most studies showed an improvement
after POP surgery but the effect is not of
the same magnitude as for OAB symptoms
(RR>1)
27. De novo OABafterPOPsurgery
• Prevalence: 5-22 %
• Older age, BMI and SUI surgery were risk
factors for de novo OAB and UUI
• After correction for age and BMI, only
concomitant SUI surgery was predictor for de
novo OAB and UUI
28. Effect of POPsurgery on voiding
• Placement of vaginal ring pessary led to a
normal free-flow rate in 94% of women with
grade 3 or 4 cystocele
• Vaginal ring pessary mimics the surgical
correction of prolapse and improve voiding
by relieving urethral kinking caused by
cystocele
29. Effect of POPsurgery on voiding
• It has been hypothesized that women with
significant POP, particularly of the anterior
vaginal wall, may have impaired bladder
emptying owing to a “kink” in the normal
urethral mechanism
• Because of this, these women may also
have voiding dysfunction
30. Effect of POPsurgery on voiding
• Distinction between detrusor underactivity
and bladder outlet obstruction in women is
very difficult:
Cystometry and pressure flow studyCystometry and pressure flow study
• not well validated methods to evaluate detrusor
contractility
• controversial urodynamic definition of obstructiion
• useful relationship pressure/flow for the diagnosis
of obstruction (high Pdet/low Qmax)
• nomograms validated only in male patients
31. Effect of POPsurgery on voiding
• The cause of this obstruction or outlet
resistance is not fully understood
• Mechanical urethral kinking
• Urethral and/or bladder neck compression
by the cystocele
• Alteration of urethral innervation affecting
urethral relaxation, detrusor contraction and
efficient bladder emptying
32. Effect of POPsurgery on voiding
• Women with proven voiding dysfunction on
free flowmetry were more likely to have a
cystocele and an intact retrovesical angle on
ultrasound
33. Effect of POPsurgery on voiding
• An enterocele was consistently associated
with low flow rate, indicating that repair of
posterior vaginal wall may solve voiding
dysfunction
34. Effect of POPsurgery on voiding
• Hence voiding dysfunction is not only related
to the anterior vaginal wall prolapse and repair
of other prolapsed compartment may also
result in resolution of voiding dysfunction and
possibly OAB
• The ultrasound appearance of the bladder
neck and retrovesical angle may be more
important in function than the stage of prolapse
seen clinically
• The use of ultrasound to assess the bladder
and voiding function is worthy of more
research
35. Occult stress urinary incontinence
(OSUI) and POP
• OSUI prior POP surgery: 5-30%
• Due to the lack of randomised controlled
trials there are not clearly defined treatment
strategies for POP and OSUI
• Positive association between OSUI and post
operative SUI (15% subjective SUI)
• However OSUI does not adequately identify
individual women in need of prophylactic anti-
incontinence surgery undergoing POP repair
36. Occult stress urinary incontinence
(OSUI) and POP
• “. . . in wo m e n with O SIand PO P, a clinician
wo uld have to inse rt 1 0 TVT to pre ve nt 1
wo m an fro m re q uiring a sling 2-4 ye ars po st-
o pe rative ly”
