Overactive bladder after hysterectomy

Incontinence After Hysterectomy

Q1. Is it possible for me to be suffering from urinary incontinence due to a recent total vaginal hysterectomy? Should I consult my ob-gyn, and what should I do about it?

— Terri, Ohio

Urinary incontinence after vaginal hysterectomy is not common but may develop because of several mechanisms. You should definitely seek medical care. One cause would be what is termed stress urinary incontinence, the leakage of urine when the bladder undergoes a physical stress, such as lifting, laughing, coughing, and sneezing. This may result from a weakening of the pelvic floor or loss of normal function of the sphincter (the muscle that keeps the urethra closed). Although this would be more common after radical hysterectomy for uterine cancer, it may theoretically occur after vaginal hysterectomy as well.

A second possibility is that the bladder is now overactive as a result of the surgery or changes in the pelvic floor musculature associated with hysterectomy. Urge incontinence causes leakage of urine without warning, associated with urgency and the inability to suppress such urges.

A third possibility, more serious in nature, but luckily much less common, would be a fistula that was inadvertently created during surgery. A fistula is a connection between the urethra or bladder and the vagina. Such a fistula could cause continual leakage of urine may be more difficult to resolve.

Luckily, all forms of incontinence are treatable, but there are very different approaches for each. Stress urinary incontinence can be improved with Kegel exercises, injection of collagen or other inert materials into the urethra, or surgical procedures called sling operations. Urge incontinence is usually treated with medications to reduce bladder overactivity. Surgery is rarely indicated unless there is significant bladder prolapse; that is, the bladder has dropped down into the vaginal region. Finally, fistulas infrequently close spontaneously and so typically need surgical correction, which can lead to very successful resolution of the problem.

Regardless of the cause, patients with urinary incontinence after vaginal hysterectomy should seek the attention of their gynecologist or another physician who specializes in the evaluation and treatment of incontinence.

Q2. I just read about bladder training. I always thought it was bad to hold your urine for any length of time and that the healthy thing to do was empty the bladder quickly to avoid infection. Is that wrong? Could bladder retraining help me deal with my urge incontinence?

— Lee, Connecticut

Bladder training is in fact an important tool in modifying urinary issues and dealing with urge urinary incontinence. Most bladders have a very large capacity and store urine at very low pressures. Therefore, holding on to urine and delaying your urge to urinate is unlikely to cause damage in the vast majority of patients. Certain individuals with underlying neurogenic (nerve-mediated) bladder problems, very small bladder capacities due to scarring, radiation, or surgery, and patients with surgically enlarged bladders may be at increased risk for upper-urinary-tract deterioration and kidney damage if the bladder is not emptied in a timely manner. However, these represent exceptional cases.

For most men and women with normal bladder capacity, the bladder can be trained to accept larger volumes of urine before responding to the urge to urinate. The bladder senses that it’s filling through a stretch receptor located just beneath the lining of the bladder wall. These signals are then transmitted to the spinal cord and up to the brain. In many patients with urge incontinence, the problem is a sensory issue in which the bladder becomes conditioned to respond inappropriately to these sensations of fullness. In other cases, the bladder muscle may become excessively reactive to normal stimuli. Either way, by delaying the urge to urinate repeatedly, in a systematic fashion, it is possible to reduce your frequent need to urinate as well as the urge-incontinence episodes.

The main focus of bladder training is a concept called timed-voiding. With timed-voiding (or urination), the individual initially selects an interval of time between bathroom visits that is easy to meet. A person who feels the need to urinate every two hours, for instance, might start with a voiding interval of one and a half hours. Thus, every hour and a half they would urinate whether they had the urge or not. Once the bladder becomes accustomed to this interval, the interval is then increased. Over a series of weeks, one can incrementally increase the interval of time between voids.

In the absence of any of the several significant underlying bladder disorders described above, you have a good chance to improve your urge incontinence through timed-voiding and bladder training. If these behavioral modifications alone are not successful, additional approaches could include Kegel exercises, pharmacologic treatment, and for severe cases, bladder injections with Botox or implantation of a nerve stimulator that modifies the sensory input from the bladder to the spinal cord. Kegel exercises, like bladder training, are a noninvasive method used to inhibit the urge to urinate. Although typically used for stress urinary incontinence after childbirth and after prostate-cancer surgery, the act of a Kegel exercise — in which the external sphincter muscle of the urethra is contracted repeatedly — may cause a reflex that inhibits the spinal signals responsible for urinating.

Q3. I have had incontinence for more than 25 years and had bladder repair surgery vaginally about 15 years ago that didn’t make any difference at all. Is there something else that will help this without the side effects of medication?

— Mary, California

There may be. You are one of the 12 million adults in theUnited States who suffer from urinary incontinence, which is most prevalent in women over 50 years old. It is often due to the weakening of the pelvic muscles that support your bladder, which can result from childbirth, as well as from the decreased hormone levels that occur during menopause. Because there are different types of incontinence, it’s important to figure out what kind (or kinds) you have.

  • Stress incontinence. You leak due to sudden pressure on your lower stomach muscles, such as when you sneeze, cough, laugh, or exercise.
  • Urge incontinence. You can’t get to the bathroom quickly enough. (This is most common in elderly people and could signal a kidney or bladder infection.)
  • Overflow incontinence. You constantly drip due to an overfilled bladder, or you feel like you can’t completely empty your bladder. (This typically happens in men when something blocks the flow, e.g., an enlarged prostate gland or tumor. Certain medications and diabetes can also exacerbate the problem.)
  • Functional incontinence. You have normal control over your bladder but something else prevents you from getting to the bathroom in time, e.g., arthritis or injury.
  • Mixed incontinence.You suffer from a combination of both stress incontinence and urge incontinence.

There are certain factors that raise your risk of becoming incontinent, such as age, the way you delivered your children (forceps or multiple birth boost your odds), obesity, diabetes, excess alcohol or caffeine consumption, medications that increase urine production, and smoking, which causes excessive coughing. Treatment is usually composed of exercises to strengthen the pelvic muscles and/or medication or surgery, depending on the underlying cause. In your case, since your surgery didn’t help, my advice is to concentrate on pelvic exercises that strengthen the muscles that hold up your bladder. There are physical therapists that specialize in this type of treatment — but before you start, be sure your condition is really due to weak muscles. If you haven’t already had one, a simple but complete urological exam (preferably performed by a doctor that specializes in treating female incontinence) will determine the type you have and the best treatment for your condition. Your doctor may prescribe medications to decrease bladder emptying or suggest you wear a pessary, a diaphragm-like device that’s placed in the vagina to elevate the bladder. Other potentially helpful devices include vaginal weighted cones, which you insert into your vagina and use your pelvic floor muscles to hold in place; or a bladder neck support or urethral plug, both of which are used during physical activity to prevent leakage.

Remember, you’re not alone, and there have been many advances in treating incontinence since you had your surgery. In addition to a urologist, I suggest you contact the National Association for Continence (NAFC) at www.nafc.org for information about joining a support group for those who share this challenging ailment.

Learn more in the Everyday Health Incontinence and Overactive Bladder Center.

Suture found in bladder after hysterectomy

Suture found in bladder after hysterectomy

A 40-year-old woman underwent a hysterectomy due to dysmenorrhea. Despite the presence of blood in the catheter bag after the procedure, the surgeon did not consult a urologist or perform a cystoscopy. Later, when the patient reported urinary retention, urinary leakage, and dyspareunia, a urologist performed a cystoscopy and discovered a suture in the bladder wall and a vesicovaginal fistula.

PATIENTS’ CLAIM:

During the procedure, the gynecologic surgeon inadvertently placed a suture in the bladder wall. The presence of blood in the Foley catheter required an immediate urology consult and cystoscopy, during which the presence of the errant suture would have been discovered. Repair surgery then would have prevented subsequent injuries.

PHYSICIANS’ DEFENSE:

The surgeon used reasonable judgment, as there were explanations for the blood in the catheter due to a difficult catheter placement and lysis of bladder adhesions.

VERDICT:

A Michigan defense verdict was returned.

Related article:
How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy

Bowel injury during tubal ligation

A 40-year-old woman underwent laparoscopic tubal ligation using cauterization at an outpatient surgery center. Two hours after the procedure, her BP began to drop. She was promptly transferred to a hospital and underwent emergency surgery that revealed a bowel injury. Part of the patient’s small intestine was resected.

The gynecologic surgeon committed a medical error when she injured the bowel during trocar insertion.

DEFENDANTS’ DEFENSE:

The bowel injury was a known complication of the surgery.

A Louisiana defense verdict was returned.

Related article:
How to avoid major vessel injury during gynecologic laparoscopy

Colon injured twice: $1M settlement

A 59-year-old woman underwent laparoscopic total hysterectomy and salpingectomy. Her history included an umbilical hernia repair.

Two days after surgery, the patient experienced abdominal pain, chills, abdominal distention, and a foul-smelling discharge from her umbilical suture site. She went to the emergency department where a computed tomography scan revealed 2 injuries in the bowel. Emergency laparotomy included transverse colon resection and right colon colostomy with Hartmann’s pouch. She wore an ostomy bag for 8 months. She developed an infection because of the colostomy and also required operations to resolve a bowel obstruction and repair incisional hernias.

The gynecologic surgeon was negligent when performing the surgery. When he inserted the Veress needle and trocar through the patient’s umbilicus, the transverse colon was injured twice with a 3-cm anterior tear and a 1-cm posterior laceration. The injuries were not discovered during the procedure. He should have been more careful knowing that she had undergone prior umbilical hernia surgery.

The case was settled before the trial began.

A $1 million Virginia settlement was reached.

Chronic pain after sling procedure: $2M verdict

A 63-year-old woman reported urinary incontinence to her gynecologist, who performed a transobturator midurethral sling procedure. After surgery, the patient experienced pelvic pain, urinary urgency, intermittent incontinence, and dyspareunia. She returned to the gynecologist twice. He performed a cystoscopy after the second visit but found nothing wrong.

The patient sought a second opinion. A gynecologic surgeon found a large mass in the patient’s bladder consisting of a crystallized piece of tape that had been used to secure the sling supporting the bladder. The mass was removed and the patient reported that, although surgery alleviated many symptoms, she was not pain-free.

The gynecologist negligently inserted the end of the sling through one wall of her bladder and failed to detect the malpositioning during surgery or later. He failed to diagnose and treat bladder stones that resulted from the sling’s malpositioning. He failed to perform a cystoscopy when she first reported symptoms and improperly performed cystoscopy at the second visit.

There was no negligence on the part of the gynecologist. The patient did not report ongoing symptoms until 1 year after sling insertion.

A $2 million Pennsylvania verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected] Please include your name and the city and state in which you practice.

Bladder Control Issues and Hysterectomy

Tori Hudson, N.D., Medical Director for Women’s Health Clinic Center, Author Women’s Encyclopedia of Natural Medicine

One of the most common problems I see in my women’s health practice is bladder control issues and occasional urinary incontinence. In fact, nearly 40% of all women will be affected by occasional urinary incontinence at some point in their lives. While there are numerous causes, such as menopause, vaginal delivery, constipation and medications, the relationship of hysterectomy to bladder control issues hasn’t got a lot of attention.

We need a structurally sound bladder, bladder neck, urethra (where the urine exits), surrounding muscles, nerves and supporting tissue, in order to have normal bladder function. Hysterectomy can possibly negatively alter that supporting structure and impact on bladder control.

There are different kinds of hysterectomies that may have different impacts on bladder control. It doesn’t seem to matter if the hysterectomy is done through the vagina (vaginal hysterectomy) or through the abdomen (abdominal hysterectomy). The main concern is what was removed during the surgical procedure.

If the hysterectomy procedure removes the whole uterus, it could also remove some of the structures that are required to provide pelvic support for bladder control. If the hysterectomy removes not only the whole uterus, but also both ovaries, then the procedure will cause not only the structural damage mentioned above, but also cause the dramatic decrease of hormone levels. Both the damage of pelvic supporting structure and lowered hormone levels can contribute to bladder control issues.

Whenever possible, a hysterectomy that spares ovaries and the bottom part of the uterus (called a supra-cervical hysterectomy) is preferred. This type of procedure can avoid the drastic changes in hormone levels to assure a close to normal menopause process, protect the tone of the pelvic floor and maintain bladder control, as well as the integrity and sensation of the vagina.

If you already had occasional urinary incontinence before your hysterectomy, you may experience increasedloss of bladder control issues for the first two years after the hysterectomy. Therefore it becomes even more important for you to discuss with your surgeon about having a supra-cervical hysterectomy as well as keeping your ovaries, if you have a medical condition that warrants a hysterectomy.

As a ND, I always prefer the natural treatment first – “Do no harm” is the guiding principle for naturopathic medicine. When it comes to natural treatments for loss of bladder control with or without hysterectomy, I’ve been using a Chinese herbal formula, Better Woman, for my patients for more than two years now. I have found that most women experience significant improvement in their urinary leakage well within two months. I also recommend Kegel exercises to enhance the tone of the pelvic floor, and sometimes some special pelvic floor rehabilitation techniques with women’s heath physical therapies.

J Urol May 2002; 167:2088-92.

Lancet 2007 Oct 27; 370:1494.

Note: This is the Abstract of the original article, edited to comform to the dietary supplement regulations.

Removal Of Uterus Increases Risk Of Urinary Incontinence

Hysterectomy is the most common gynaecological abdominal operation in the world. It is normally performed as a cure for benign medical problems in order to improve life quality for the patients. However, the long-term effects are largely unknown, and it has long been suspected that the operation increases the risk of developing urinary incontinence, in many respects a very disabling condition that affects hundreds of thousands of women in Sweden.

Researchers at Karolinska Institutet have now shown that women who have had a hysterectomy are more than twice as likely to undergo surgery for urinary incontinence as women with intact uteri.

“It’s important that gynaecologists take this into account ahead of a hysterectomy, and the patients should themselves be aware of the greater risk the operation entails, particularly if they belong to a high-risk group,” says Daniel Altman, gynaecologist and one of the researchers behind the study.

The highest likelihood of incontinence surgery was noted within five years of the removal of the uterus, but the higher risk remains throughout the patients’ lives. The risk increased most for women who had a hysterectomy before their menopause or after having undergone several deliveries.

The study was based on analyses of patient registers for the years 1973 to 2003, and incorporated over 165,000 women who have had hysterectomies and almost 479,000 women who have not.

Reference: Daniel Altman, Fredrik Granath, Sven Cnattingius och Christian Falconer, Hysterectomy and risk of stress urinary incontinence surgery: nationwide cohort study, The Lancet, 27 oktober 2007, ref 370: 1494-1499.

Does hysterectomy raise the risk of stress-incontinence surgery?

Yes. This population-based cohort study from Sweden found that hysterectomy for benign indications by itself doubles the risk of future surgery for urinary stress incontinence, regardless of hysterectomy technique. The risk of stress-incontinence surgery varied with the length of follow-up, with the highest overall risk observed within 5 years of hysterectomy and the lowest risk after 10 years or more (2.7 versus 2.1).

EXPERT COMMENTARY

Urologists, among others, have long suspected that hysterectomy is somehow implicated in the development of stress incontinence, a point of view that has met with considerable resistance from gynecologists. Now comes this carefully designed study by Altman and colleagues, which lends considerable support to this belief.

Strengths of the study include use of Swedish health registry

The study design used by the authors is impressive. Because Sweden (unlike the United States) has a national health-care system with an integrated national database, the authors were able to select more than 165,000 women from the Swedish health registry who had undergone hysterectomy (the “exposed” cohort) and compare them with almost 480,000 women who had not had a hysterectomy (three controls for every exposed case), matching them by year of birth and county of residence. Because of the integrated nature of the Swedish health registry, they were able to follow these women for 30 years and link their medical records to subsequent surgical procedures for urinary stress incontinence.

The authors eliminated from consideration any patient whose surgery had been done for malignancy. Because patients undergoing hysterectomy for pelvic organ prolapse might well be predisposed to develop stress incontinence in later life, the authors considered as a separate subset those women whose hysterectomy was done for prolapse or who had an associated procedure performed for prolapse at the same time.

As might be expected, women who underwent hysterectomy for prolapse had the highest risk of undergoing stress-incontinence surgery within 5 years of the removal of their uterus.

Vaginal delivery magnified the impact of hysterectomy

Altman and colleagues also considered the impact of vaginal delivery on subsequent surgery for stress incontinence, finding an additive effect. There was a “dose-response” increase in risk related to the number of vaginal births. Women who had four vaginal deliveries had a sixfold increase in the risk of stress incontinence surgery, and women who had four vaginal deliveries plus a hysterectomy had a 16-fold increase in the risk of stress-incontinence surgery.

Were some women predisposed to elective surgery?

Because surgery for urinary stress incontinence is an elective procedure to improve quality of life, the argument could be made that the women who chose this form of therapy had a lower threshold for elective surgery. The authors attempted to control for this by analyzing the likelihood of undergoing osteotomy of the great toe (hallux valgus surgery) and varicose vein stripping. They found no meaningful association between these elective operations and hysterectomy or stress-incontinence surgery.

“Escalator effect” may be involved

An important question that this study is unable to answer concerns the “escalator effect.” Because urinary stress incontinence is highly prevalent, it affects many women who also have other, more pressing gynecologic complaints. We do not know how many women had stress incontinence that was much less troubling than, say, leiomyomata or dysfunctional uterine bleeding and who, after these problems were solved by hysterectomy, then had their attention increasingly focused on this new complaint, which then moved higher up their list of concerns as other problems were treated.

The authors also acknowledge that other behavioral and lifestyle factors that are probably associated with stress incontinence, such as smoking, strenuous work, and elevated body mass index, were not accounted for in their study.

Should this study alter clinical practice?

Women undergoing hysterectomy should probably be informed that the operation may increase the likelihood of their undergoing surgery for stress incontinence later in life. In some cases, this information may lead women to reconsider the need for elective hysterectomy, but a possible future risk of undergoing a generally safe and effective operation for stress incontinence is unlikely to be determinative for most women who are contemplating surgery for other debilitating gynecologic conditions that can be treated permanently and effectively by hysterectomy.

Hysterectomy – abdominal – discharge

Plan to have someone drive you home from the hospital after your surgery. DO NOT drive yourself home.

You should be able to do most of your regular activities in 6 to 8 weeks. Before then:

  • DO NOT lift anything heavier than a gallon (4 liters) of milk. If you have children, DO NOT lift them.
  • Short walks are ok. Light housework is ok. Slowly increase how much you do.
  • Ask your provider when you can go up and down stairs. It will depend on the type of incision you had.
  • Avoid all heavy activity until you have checked with your provider. This includes strenuous household chores, jogging, weightlifting, other exercise and activities that make you breathe hard or strain. DO NOT do sit-ups.
  • DO NOT drive a car for 2 to 3 weeks, especially if you are taking narcotic pain medicine. It is OK to ride in a car. Although long trips in cars, trains or airplanes are not recommended during the first month after your surgery.

DO NOT have sexual intercourse until you have had a checkup after surgery.

  • Ask when you will be healed enough to resume normal sexual activity. This takes at least 6 to 12 weeks for most people.
  • DO NOT put anything into your vagina for 6 weeks after your surgery. This includes douching and tampons. DO NOT take a bath or swim. Showering is OK.

To manage your pain:

  • You will get a prescription for pain medicines to use at home.
  • If you are taking pain pills 3 or 4 times a day, try taking them at the same times each day for 3 to 4 days. They may work better this way.
  • Try getting up and moving around if you are having some pain in your belly.
  • Press a pillow over your incision when you cough or sneeze to ease discomfort and protect your incision.
  • In the first couple of days, an ice pack may help relieve some of your pain at the site of surgery.

Make sure your home is safe as you are recovering. Having a friend or family member provide groceries, food, and housework for you during the first month is highly recommended.

Hysterectomy

Common Myths

Before the operation friends may warn that you might get fat, grow facial hair, become depressed, and find it difficult to make love properly again.

These common myths about hysterectomy are simply not true. However, women sometimes feel a great sense of loss when their womb is removed.

A proper understanding of why the hysterectomy is necessary may help.

Don’t be afraid to ask about alternatives to hysterectomy such as endometrial ablation or a Mirena coil and don’t agree to the operation until you are sure it is really necessary.

How will I feel after the operation?

After the operation you may have an intravenous drip for fluids or sometimes blood. You may also have a catheter to drain urine.

If your operation is performed through an abdominal incision, the wound will be held together with clips or stitches. The internal stitches used in vaginal hysterectomy will dissolve naturally. The wound will heal in a week or so but internal surgery will take longer. This is why the recovery period can take up to twelve weeks.

Recovery

The day after your hysterectomy you will be encouraged to stand and have a short walk. You should be allowed home from hospital after 5 days if you have had an abdominal hysterectomy or after 72 hours if you have had a vaginal hysterectomy. While recuperating at home, you will be advised to rest and avoid lifting heavy weights. You should be able to drive a car or go swimming about six weeks after the operation. By the fifth or sixth week you should be starting to get back to normal. You should gradually increase your activity much like an athlete recovering from an injury. It should be possible to return to work soon after the post-operative check up, six to eight weeks after leaving hospital. It is usual to feel unexpectedly tired in the second month after the operation, but this does not last. Some women can take up to 12 months before they are feeling 100% better.

Many women feel vague abdominal sensations, described as being like “pinging elastic” for some time after a hysterectomy. Again, this is perfectly normal. You may have a pale brown vaginal discharge for a few weeks. This is nothing to worry about unless the discharge becomes heavy, smelly or itchy, which may indicate an infection.

There is no reason why you should gain weight after a hysterectomy.

Gentle sexual intercourse should be possible by about the sixth week after the operation. Some women feel more relaxed about lovemaking once the fears of pregnancy or unpleasant symptoms have gone. Others might feel the point of sex has been removed, and experience a psychological loss of libido. If problems remain after several months, psychosexual counselling may help you achieve a relationship that’s as good as or even better than before.

We know that the ovaries, even after the menopause, continue to secrete androgen, and these hormones are very important in maintaining libido in women. Removing the ovaries during a hysterectomy denies a woman, whatever her age, this sexual stimulant. However, if testosterone therapy is taken after the operation some women notice that their sex drive returns to what is normal for them.

A few women will feel depressed and lethargic after a hysterectomy. They may need a period of time to mourn the loss of their womb. Sometimes it is difficult for friends and family, or even your partner, to understand a woman’s feelings about the operation. It is important to talk to your partner about your feelings and accept help and support from elsewhere if necessary.

Stress Incontinence Common

About 600,000 women in the U.S. have hysterectomies each year, and the vast majority of the procedures are done for conditions such as irregular heavy menstrual bleeding and uterine prolapse.

Far more women — as many as 45% by some estimates — suffer from some degree of stress incontinence, defined as involuntary urine loss associated with activities such as laughing, coughing, sneezing, and exercise.

“We know that there are many, many women with this problem who are never treated,” Altman says. “That is why it is important to look for better ways to prevent it.”

Using data from a nationwide Swedish hospital discharge registry, Altman and colleagues were able to follow 165,260 women who had hysterectomies and 479,506 similarly aged women who did not have hysterectomies for three decades to determine if they later had surgery to relieve stress incontinence.

Women who had hysterectomies were 2.4 times more likely to have a subsequent surgery for incontinence, regardless of the type of hysterectomy procedure they had undergone. The greatest risk of incontinence was within five years of the first surgical procedure.

Women who had more than one vaginal birth were also at increased risk.

Assessment of Overactive Bladder after Laparoscopic Lateral Suspension for Pelvic Organ Prolapse

Abstract

Background. Pelvic organ prolapses (POP) and overactive bladder (OAB) may coexist and both negatively impact quality of life in women. The correlation between POP and OAB remains unclear, but these patients may have the OAB resolution after the surgical treatment of POP. Aim of our study was to assess the anatomical results and the effect on OAB symptoms in women who underwent laparoscopic lateral suspension for POP. Materials and Methods. This prospective study included all women with apical POP who underwent surgical repair with laparoscopic uterine lateral suspension from January 2016 to December 2017. The baseline and the 1-year follow-up included post-void residual measurement, urinalysis, vaginal examination, OAB symptoms evaluation, and administration of questionnaires (PFDI-20, UDI 6). Results. 64 women underwent laparoscopic lateral suspension for uterine prolapse and 78.1% had concomitant anterior vaginal wall defect. At 1-year follow-up the anatomic success rates were 84.4% for the apical and 76.2% for the anterior compartment. The comparison between OAB symptoms before and after the surgical procedure showed the resolution of OAB in 76% of the women, while de novo OAB was present in 2.6%. With the questionnaires 95.3% (61/64) of our patients were satisfied after the POP repair. We documented a trend in ameliorating of OAB regardless of the POP-Q stage. However, the Pearson test showed this correlation as statistically significant only in women with anterior vaginal wall defect stage III and apical stage II. No patient had vaginal exposure of the polypropylene mesh. Conclusion. Our data show how laparoscopic lateral suspension is an effective procedure for apical and anterior vaginal wall defects. This study provides further evidence for the concept that OAB in women with POP >II stage improves after a successful POP surgery. These women may benefit from a resolution of OAB and POP symptoms with the improvement of patient’s quality of life.

1. Introduction

Pelvic organ prolapses (POP) are one of the most common indications to surgery due to their detrimental effect on the quality of life . Overactive bladder (OAB) is also a disturbing common condition defined as the urinary urgency, usually accompanied by increased urinary frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology .

POP and OAB symptoms are frequently encountered in the same patient . The correlation between POP and OAB remains unclear. A potential cause of OAB may result from mechanical bladder outlet obstruction (BOO) . In Urology it is well-known how in males the benign prostatic hyperplasia may create a chronic bladder obstruction resulting in OAB symptoms . With a similar mechanism a POP may have an obstructive action on the female urethra creating the base to develop OAB symptoms. Indeed, patients may present a spectrum of voiding complaints and symptoms of both OAB and BOO. POP repair usually resolves the mechanical BOO but the effect on OAB symptoms may be unpredictable . However, despite these hypotheses, the relationship between POP and OAB is not clear. If there is a causal relationship it could be anticipated that OAB symptoms would improve after successful treatment of POP . Therefore, POP surgery may cure or improve OAB, or it can result in de novo OAB .

Focusing on the upper vaginal compartment prolapses, the vaginal vault prolapse, or the uterine prolapse, several authors reported the effect of the different surgical techniques on OAB. In one RCT, Halaska et al. reported new OAB symptoms after vaginal vault repair with sacrospinous fixation or transvaginal mesh ranging from 9% to 21% . Maher et al. reported de novo OAB after sacrospinous fixation and sacrocolpopexy, respectively, at 20.6% and 33.3% . The first aim of this study was to assess the anatomical results and the effect on OAB symptoms in a cohort of women who underwent laparoscopic lateral suspension for POP.

2. Material and Methods

The study was approved by the Ethics Committee on Clinical Studies of Pomeranian Medical University. This prospective study included all women consecutively referred to our Department from January 2016 to December 2017, with symptomatic apical prolapse who underwent primary surgical repair with laparoscopic uterine lateral suspension.

Objective evaluations were performed with the International Pelvic Organ Prolapse Staging System (POP-Q), and the prolapse was assessed by maximum Valsalva effort in the seated semi-lithotomy position. Subjective assessment was achieved by the Pelvic Floor Distress Inventory Questionnaire (PFDI-20) and Urogenital Distress Inventory 6 (UDI 6).

We offered all patients comprehensive preoperative patient-centered counselling providing them with information and allowing them to participate in the decision-making process as reported in the recent literature . Exclusion criteria were post-void residual volume, posterior vaginal wall defects, previous prolapse or incontinence surgeries, previous hysterectomy, neurological conditions, uncontrolled diabetes, and bladder pain syndrome. Stress urinary incontinence was not an exclusion criterion, but patients were informed that only surgical repair of POP would be done.

All surgical procedures were performed by a senior skilled surgeon (WB). Prophylactic antibiotics were routinely administered intravenously before surgery with 1 g cefazolin i.v. All patients were given low-molecular-weight heparin prophylaxis.

Follow-up was scheduled 12 months after the surgery and performed by a skilled urogynecologist (EM). Objective cure was defined in case of POP-Q sites Ba, C, and Bp as less than -1 cm stage at any point in time of follow-up. Pelvic floor disorders, lower urinary tract symptoms, and digestive symptoms were detailedly recorded. Tract urinary infection was excluded by urinalysis, and trans-vaginal ultrasonography was performed to assess the post-void residual urine evaluation.

OAB was assessed by response to (i) UDI 6 item number 1, (ii) UDI6 item number 2, and (iii) the interview at the follow-up. De novo SUI was assessed by UDI 6 item 3, and stress test.

The use of drugs affecting OAB was investigated and recorded.

Data were entered into the database by one author (EM) and double-checked by another author (AS). Complications were reported according to Clavien-Dindo classification (reference).

2.1. Surgical Technique

All women underwent laparoscopic supracervical hysterectomy. A T-shaped polypropylene mesh was used for the lateral suspension. The body of mesh was fixed to the uterine cervix and to the upper part of the anterior vaginal wall. The arms were introduced retroperitoneally towards lateral abdominal walls, alongside round ligaments. After the prolapse reduction using a posterior blade of speculum placed in the anterior vaginal fornix the mesh was tension-free suspended.

2.2. Statistical Evaluation

Data analysis was performed using the Student t-test, Pearson’s correlation, and Gretl Software ver. 2017a. P value less than 0.001 was considered statistically significant.

3. Results

Sixty-four women who had uterine prolapse were consecutively included in the study, 78.1% of these (50/64) had a concomitant anterior vaginal wall defect, and no patient was lost at the follow-up. Demographic characteristics of the population are reported in Table 1.

Table 1 Patients’ characteristics.

A mild SUI was present in 21.8% of the population. These women reported the use of no more than one small pad/day.

All surgical procedures were done under general anesthesia. In 2/64 women (3.1%) there was a bladder injury that was resolved intraoperatively by suturing and leaving the urinary catheter for 7 days, rated grade 1 on the Clavien-Dindo classification. Operating time varied between 90 and 260 minutes depending on the number of surgical steps. No associated surgical procedure was done, and no blood transfusion was required. Patients were discharged from the hospital after 4-5 days. No woman had post-void residual requiring clean intermittent catheterization, or indwelling catheter at the discharge from the hospital. Postsurgical pain control was obtained with paracetamol, and no patient required more than 2 days of therapy.

At one-year follow-up the anatomic success rates were 84.4% (54/64) for the apical compartment, and 76.2% (32/42) for the anterior compartment. De novo posterior vaginal wall defect was present in 4.7% (3/64) of the population: one patient developed an enterocele in (1.6%), and two a rectocele (3.1%) (Table 5). The comparison between objective evaluation before and after the surgical procedure is reported in Table 2, whereas symptoms before and after surgery are listed in Table 3.

Table 2 Objective assessment: preoperative and the follow-up. Table 3 Symptoms before surgery, and at the 12-month follow-up.

With the questionnaires 95.3% (61/64) of our patients were satisfied after the POP repair also in case of POP recurrence due to its lower stage at the POP-Q, and 4.7% (3/64) were dissatisfied with the procedure due to a POP recurrence stage like it was before the surgical treatment.

Subjective evaluation showed how 76% of the patients with preoperative OAB had the resolution of symptoms, while de novo OAB was present in 2.6% (Table 4). No patient was under therapy for OAB. To make a correlation between the different stages of POP and OAB, we divided the population into three groups: (i) Group 1 was composed of 11 women with anterior vaginal wall and cervix defect, both stage II; (ii) Group 2 was composed of 31 women with anterior vaginal wall defect stage III and cervix defect stage II; (iii) Group 3 was composed of 22 women with anterior vaginal wall and cervix defect, both stage III. This subanalysis documented a trend in ameliorating of OAB regardless of the POP-Q stage. However, the Pearson correlation showed this correlation as statistically significant only in women of Group II due to the low sample size of Groups I and III (Figure 1). No patient had vaginal exposure of the polypropylene mesh, or complained of urinary tract infections.

n %
Overactive bladder symptoms
 Resolution 19/25 76.0
 Persistence 6/25 24.0
 De novo 1/39 2.6
Stress urinary incontinence
 Resolution 9/14 64.3
 Persistence 5/14 35.7
 De novo 2/50 4.0

Table 4 Overactive bladder symptoms, and stress urinary incontinence at the 12-month follow-up.

%
Total recurrences 8 12.5
Anterior vaginal wall recurrences 2 3.1
Apical recurrences 3 4.7
Enterocele recurrence 1 1.6
Posterior vaginal wall recurrences 2 3,1
Need for reoperation 7 10.9

Table 5 Recurrences and reoperation rates.
Figure 1

Subdivision of the cohort in three groups according to POP stage and correlation between stages and overactive bladder symptoms before surgery and at the 1-year follow-up. AVW, anterior vaginal wall; C, cervix; II, II°stage POP-Q; III, III°stage POP-Q.

Table 5 reports the recurrence and reoperation rates. In this table the two women with postoperatively recurrent cystoceles had a predominant anterior vaginal wall prolapsed (Ba>C) as compared to those with uterine prolapse only (C>Ba).

The analysis of validated questionnaires showed the improvement of symptoms and quality of life as reported in Table 6 and represented in Figure 2.

Table 6 Subjective changes measured by validated questionnaires before and after the surgical treatment.
Figure 2

Representation of change before and after surgical treatment at the questionnaires. PFDI20, Pelvic Floor Distress Inventory, POPDI6, Pelvic Organ Prolapse Distress Inventory, CRADI6, Colorectal-anal distress inventory, UDI6, Urinary Distress Inventory.

4. Discussion

In our study data show how laparoscopic lateral suspension with mesh is a feasible and safe technique with good anatomic results at one-year follow-up. Moreover, we documented a strong coexistence of OAB among patients with anterior vaginal wall defect and/or apical >2 stage II POP-Q. Before the surgical POP repair 39.1% of the women had OAB with 60.9% reporting urinary frequency ≥8/day, and 43.7% of nocturia. In the current literature the higher incidence of OAB in women with POP is well-known varying between 37 and 50% . This provides some epidemiological evidence for the concept that anatomic defect may entail OAB symptoms . Interestingly the prevalence of OAB was greater in women with higher stage POP-Q, but its cure was statistically significant only in anterior vaginal wall stage III and cervix stage II POP. Liedl et al. identified the higher prevalence of OAB in stage 2 POP than those in stages III-IV . Our data showed similar results with a trend of improvement in all the stages of POP but achieving a significant improvement after POP treatment only in anterior vaginal wall stage III and cervix II. These findings confirm also what was reported by Petros who recognized OAB symptoms in Half Way System classification low grade POP and the cure of OAB after POP surgical treatment .

Our results support the conclusions of previous studies, which determined that OAB may improve, and even resolve, after successful POP surgery . OAB and symptomatic POP negatively impact the quality of life of women. However, these patients with the surgical treatment of POP seem also to have the resolution of OAB. The finding of our investigation is that adequate pelvic floor surgery can resolve OAB.

Considering stress urinary incontinence we documented a 64.3% of resolution probably due to the pre-op mild SUI requiring no more than one small pad/day in the patients who used it. The data of persistent SUI in 1/3 of the patients suggest that a concomitant SUI procedure should be proposed after appropriate counselling. Surprisingly an accurate physical examination did not eliminate the appearance of occult stress urinary incontinence (de novo SUI). The use of an accurate counselling was extremely useful and probably helped to improve the approval of the surgical procedure.

A first limitation of our study was dividing the population into 3 groups to correlate the different POP stages with OAB; we did not gain a sample size, in Groups 1 and 3, able to establish the statistically significant improvement. However, the trends are all in the ameliorating direction and bigger numbers would confirm this data.

A second potential limitation is the 1-year follow-up that would have been better if it had been longer. Nevertheless, it should be considered that 12 months is more than enough time to evaluate the evolution of OAB in patients surgically treated for POP, and it is a sufficient time to evaluate anatomical POP results. Moreover, with a follow-up of 1-year we were able not to lose patients.

Women with POP complain of a vaginal bulge or pressure, but they often report other coexisting pelvic symptoms that affect urinary function. The absence of a bulge during a postoperative pelvic examination does not accurately reflect postoperative patient satisfaction, and the presence of an asymptomatic POP recurrence without bladder symptoms does not necessarily correlate to an unsatisfied patient. For these reasons symptoms affecting bladder function, like OAB, should be investigated before and after the surgical POP repair.

Our study suggests that the surgical treatment of apical descensus and cystocele by laparoscopic lateral suspension resulted in the significant improvement in prolapse, OAB symptoms, and patients’ quality of life.

5. Conclusion

Our data show how laparoscopic lateral suspension is an effective procedure for apical and anterior vaginal wall defects. This study provides further evidence for the concept that OAB in women with POP >II stage significantly improves after a successful POP surgery. These women may benefit from a resolution of OAB and POP symptoms with the improvement of patient’s quality of life.

Data Availability

The data used to support the findings of this study are included within the article.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Acknowledgments

We would like to thank Grzegorz Bugaj and Agata Bugaj for their valuable contributions to this project: Grzegorz Bugaj for his methodological advice and Agata Bugaj for data processing.

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