Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse

Purpose: We determined the indications for anti-incontinence surgery in con tinent women undergoing surgical repair of severe urogenital prolapse. Materials and Methods: We prospectively evaluated 24 continent women referr ed for evaluation of severe urogenital prolapse. All patients underwent a m eticulous clinical evaluation, including a complete history and physical ex amination, urinary questionnaire, voiding diary, pad test, cotton swab test , video urodynamics and cystoscopy. The urodynamic evaluation was repeated with prolapse repositioning by a fitted vaginal pessary. Surgical intervent ion was tailored according to urodynamic findings. Results: Reduction of prolpase with a pessary unmasked sphincteric incontin ence in 14 women (58%). Ten women with no urodynamic evidence of sphincteri c incontinence underwent anterior colporrhaphy and no additional anti-incon tinence procedure was performed. Mean followup was 44 months (range 12 to 9 6). None had postoperative stress incontinence but 1 (10%) had a recurrent grade 2 cystocele, The 14 remaining women with sphincteric incontinence aft er prolapse reduction underwent anterior colporrhaphy with a pubovaginal sl ing procedure. Mean followup in these cases was 47 months (range 12 to 108) . In 2 patients (14%) stress incontinence developed postoperatively and 1 ( 7%) had a recurrent grade 3 cystocele, The incidence of urge incontinence d id not appear to be significantly influenced by either surgical interventio n. Overall 12 patients had preoperative urge incontinence, of whom 9 (75%) had persistent urge incontinence postoperatively. In another woman new onse t urge incontinence developed. Conclusions: Preoperative urodynamic evaluation with and without prolapse r eduction is essential for making the correct diagnosis of masked stress inc ontinence in women with urogenital prolapse. The decision to perform a conc omitant prophylactic anti-incontinence procedure should be tailored to indi vidual urodynamic findings. Larger series and longer followup are needed to establish the most effective preventive procedure for this troublesome cli nical problem.