URODYNAMIC CHARACTERISTICS OF WOMEN WITH COMPLETE POSTHYSTERECTOMY VAGINAL VAULT PROLAPSE

Objectives. To review the symptoms and lower urinary tract function in women with posthysterectomy vaginal vault prolapse. Methods. A retros pective review was carried out of the urodynamic records of 19 women w ith posthysterectomy vaginal vault prolapse who had been evaluated in the Bladder Function Laboratory of the Department of Obstetrics and Gy necology at Duke University Medical Center. Results. A full urodynamic evaluation was carried out on 19 women who had had a hysterectomy and who had subsequently experienced complete prolapse of the vaginal vau lt. Vaginal eversion produced massive distortion of the lower urinary tract and was associated with complex symptoms. Among the cystometric findings in these patients was an early average first desire to void ( 94 mL) and a reduced average cystometric capacity (370 mL). Symptoms o f voiding difficulty were common. During noninstrumented uroflowmetry, the average peak and mean flow rates were reduced in these women (16. 5 mL/s and 8.1 mL/s, respectively), suggestive of functional obstructi on of the outlet due to the prolapse. Pressure-flow voiding studies sh owed a reduced peak flow rate (1 1 mL/s) with an increased detrusor pr essure at peak flow (50 cm H2O), also indicative of functional obstruc tion. All women underwent urethrocystoscopy, and no patient had a uret hral stricture or urethral stenosis. Although symptoms of urgency (79% ) and urge incontinence (63%) were common, detrusor instability was co nfirmed by urodynamic studies in only 3 women (16%), suggesting that u rge-related symptoms in these women may often be due to anatomic disto rtion of the lower urinary tract rather than to detrusor overactivity. ''Genuine'' stress incontinence was documented in only 2 women (11%) during cystometry; however, when these patients were examined with ful l bladders with their prolapses reduced and returned to a normal anato mic position with a single-bladed speculum, the physical sign of stres s incontinence was demonstrated in all 9 women (47%) who had a complai nt of stress incontinence. This suggests that massive vaginal prolapse may mask an incompetent continence mechanism, which may then be revea led after surgical repair of the prolapse. Conclusions. Women with pos thysterectomy vaginal vault prolapse present complicated reconstructiv e problems for the pelvic surgeon. The same pathophysiological process may produce both voiding dysfunction and stress incontinence. These p atients should be evaluated carefully before surgical repair is undert aken. Stress incontinence may not be demonstrated in these patients un less they are examined with a full bladder with their prolapse careful ly reduced to a normal anatomic position. Women who demonstrate stress incontinence with the vaginal prolapse reduced and the urethra suppor ted normally should be suspected of having ''type III'' incontinence ( demonstrable stress incontinence in the presence of normal urethral su pport). Women with these findings may require a suburethral sling proc edure if they are to remain continent after correction of posthysterec tomy vaginal vault eversion.