Int Urogynecol J (2004) 15: 175–178 DOI 10.1007/s00192-004-1138-8

O R I GI N A L A R T IC L E

George Lazarou Æ Richard J. Scotti Æ Magdy S. Mikhail Huang Sue Zhou Æ Kenneth Powers

Pessary reduction and postoperative cure of retention in women with anterior vaginal wall prolapse

Received: 2 October 2003 / Accepted: 16 January 2004 / Published online: 14 February 2004
International Urogynecological Association 2004

Abstract This study aimed to determine whether preoperative pessary reduction of anterior vaginal wall prolapse in patients with elevated postvoid residual (PVR) volumes relieves urinary retention, and if reconstructive pelvic surgery in these patients cures urinary retention. The records of all women with symptomatic anterior vaginal wall and urinary retention (PVR ‡100 cc) who underwent evaluation and surgical repair of the anterior vaginal wall at our institution between 1996 and 1999 were retrospectively reviewed. All patients underwent a detailed urogynecologic and urodynamic evaluation and had a pessary trial prior to surgery. Cure of urinary retention was defined as PVR <100 cc at 3 months postoperatively. Sensitivity, specificity, positive and negative predictive values for pessary reduction testing were calculated. Twenty-four patients met the inclusion criteria. Two patients (8%) had stage 2, eleven (46%) stage 3, and eleven (46%) stage 4 anterior vaginal wall prolapse. Preoperatively, the use of pessary was associated with relief of urinary retention in 75% patients. In predicting postoperative cure of urinary retention,

G. Lazarou (&) Female Pelvic Medicine and Reconstructive Surgery, Jack D. Weiler Hospital, Albert Einstein College of Medicine, Montefiore Medical Center, Department of Obstetrics and Gynecology, 3332 Rochambeau Avenue, Bronx, NY 10467, USA E-mail: glazarou@montefiore.org Tel.: +1-718-9206311 Fax: +1-718-9206313 M. S. Mikhail Æ H. S. Zhou Æ K. Powers Æ G. Lazarou Department of Obstetrics & Gynecology and Women’s Health, Division of Female Pelvic Medicine and Reconstructive Surgery, Albert Einstein College of Medicine/Montefiore Medical Center Bronx, NY, USA R. J. Scotti Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charles R. Drew University of Medicine and Science/UCLA Medical School, LAC/King Drew Medical Center, Los Angeles, CA, USA

pessary testing had a sensitivity of 89%, specificity of 80%, positive predictive value of 94%, and negative predictive value of 67%. Nineteen of 24 patients had a PVR <100 cc postoperatively, indicating a 79% cure rate for urinary retention. In women with symptomatic anterior vaginal wall prolapse and urinary retention, use of a pessary is associated with relief of retention in the majority of patients. Furthermore, pessary reduction testing has good sensitivity, specificity, and positive predictive value for postoperative voiding function. Keywords Anterior vaginal wall prolapse Æ Pessary reduction Æ Urinary retention

Introduction The prevalence of bladder outlet obstruction in women is unknown and most probably has been underestimated [1]. Among the most common etiologies are previous anti-incontinence procedures and severe genital prolapse. Anterior vaginal wall prolapse is a common condition. As the prolapse becomes more advanced, it may be associated with elevated postvoid residual (PVR) volumes, voiding difficulty, recurrent urinary tract infections, symptoms of pelvic pressure and/or urinary incontinence. There is no real consensus regarding what amount of residual urine is considered elevated PVR. Most authorities consider volumes greater than 50– 100 cc to be abnormal. Urodynamic testing in patients with advanced anterior vaginal wall prolapse and elevated PVR usually reveals reduced maximum urine flow rates (Q max), suggestive of bladder outlet obstruction. Various investigators have evaluated the value of preoperative prolapse reduction testing. Romanzi et al. [2] utilized urodynamic testing, with prolapse reduction using a pessary, to determine symptomatic and occult conditions. Bump et al. [3] described urethral obstruction and masking of urinary incontinence in women with severe uterovaginal prolapse, while Richardson et al. [4]

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demonstrated increased urethral resistance, which was reversed by reducing the prolapse, in patients with severe degrees of uterovaginal prolapse. The objectives of this study were to determine 1) whether preoperative pessary reduction of anterior vaginal wall prolapse in patients with elevated PVR volumes could predict cure of urinary retention postoperatively, and 2) if reconstructive pelvic surgery in these patients cures urinary retention.

Materials and methods We conducted a retrospective review of all patients who underwent reconstructive pelvic surgery at Montefiore Medical Center, Bronx, New York between 1996 and 1999. The Institutional Review Board exempted the study protocol. The inclusion criteria for this study were symptomatic anterior vaginal wall prolapse with preoperative presence of urinary retention [5] defined as PVR ‡100 cc, the absence of any neurological disorders and ability to use and retain a pessary without difficulty. All patients underwent a detailed urogynecologic history and physical examination including urethral axis determination by cotton swab (Q tip), site-specific prolapse grading by the International Continence Society (POPQ) [6] and New York Classification (NYC) [7] Systems, spontaneous uroflowmetry, PVR urine determination, urine analysis and urine culture. All studied patients with elevated PVR (‡100 ml) had repeated PVR determinations and confirmation of abnormally elevated residual volume at each voiding trial along with complex uroflowmetry. This is in keeping with clinical practice guidelines [8]. All patients had a pessary trial, with an appropriate size and type of pessary, prior to surgery. On follow-up, a PVR was obtained by straight catheterization shortly after spontaneous voiding. The PVR was measured and recorded. Multichannel urodynamic testing was performed in the sitting position using an Aquarius Urodynamics Monitor (Laborie, Inc., Burlington, VT). Resting and dynamic urethral closure profiles were obtained both with the prolapse extended and reduced. Complex uroflowmetry was performed at maximum cystometric capacity. All patients underwent site-specific pelvic reconstructive and/or incontinence surgery as appropriate. The choice of surgical incontinence procedure in patients with urethral hypermobility (>30 cotton swab test) was made on the basis of preoperative Q-tip testing, urethral resting closure pressure and Valsalva/cough leak point pressures. Patients with urethral hypermobility, urodynamic evidence of stress urinary incontinence (GSI) and maximal urethral closure pressure (MUCP) of £ 20 cmH2O, and/or leak point pressure (LPP) of £ 60 cmH2O were treated by suburethral sling procedure. The Burch procedure was performed for those patients with urethral hypermobility, urodynamic evidence of GSI and MUCP of >20 cmH2O, and/or LPP of >60 cmH2O. At the time of surgery a suprapubic catheter was placed in all patients and was discontinued when voiding resumed spontaneously and the PVR was <100 cc. At 3 months following surgery, all patients underwent a detailed sitespecific evaluation in the supine position during maximal Valsalva and empty bladder using the site-specific prolapse grading proposed by the International Continence Society (POPQ) [6] and New York Classification (NYC) [7] Systems, along with Q-tip testing, uroflowmetry and PVR measurement. Cure of urinary retention was defined as a PVR <100 cc at 3 months postoperatively. Data were analyzed using the paired t test and Fisher’s exact test where appropriate. Sensitivity, specificity, positive and negative predictive values for pessary reduction testing were also calculated.

patients were parous and all postmenopausal patients had been placed on hormone replacement therapy preoperatively. The mean age was 58.1 years (range 33–88). In accordance with the ICS and NYC classifications, two patients (8%) had stage 2, eleven (46%) stage 3, and eleven (46%) stage 4 anterior vaginal wall prolapse. Six patients (25%) had previous incontinence surgery and eight (33%) had prior hysterectomy. All patients were questioned regarding urinary symptoms. Nineteen out of 24 (79%) reported preoperative symptoms of urinary frequency, urgency or incomplete emptying that may accompany increased PVR volumes. The mean preoperative PVR volume of our cohort was abnormally elevated at 210 ml with abnormally low mean Q-max of 12.8 cc/s that normalized after pessary placement (75 ml) and after pelvic surgery (64 ml). The types and sizes of pessaries used to reduce the prolapse are provided in Table 1. However, more than half (13/24) of the patients required a Donut type of pessary to reduce the significant prolapse. Preoperatively, the use of pessary was associated with relief of urinary retention in 75% of patients (n=18/24). Nineteen of 24 patients with preoperative urinary retention had a PVR <100 ml postoperatively, indicating a 79% cure rate for urinary retention. Of the six patients who failed the preoperative pessary test, four underwent a suburethral sling procedure. Their mean PVR postoperatively was 210 cc. Four of the five patients with persistent elevated PVR volumes had failed the preoperative pessary test. All four patients underwent a suburethral sling procedure. The sensitivity, specificity, positive and negative predictive values of pessary reduction testing in predicting postoperative cure of urinary retention are shown in Table 2. At the 3-month follow-up, there were no reported anterior vaginal wall defects observed in our study group.

Table 1 Type and size of pessary used for prolapse reduction Pessary type and size

% (n)

Donut #5 Donut #4 Donut #3 Ring without support #3 Ring with support #3 Gellhorn #3

16 (4) 21 (5) 16 (4) 8 (2) 16 (4) 21 (5)

Table 2 Preoperative prolapse reduction testing and cure of urinary retention Preoperative prolapse reduction

Postoperative cure % (n)

Persistent retention % (n)

Results

Yes No

89.5 (17) 10.5 (2)

20.0 (1) 80.0 (4)

Twenty-four patients met the inclusion criteria. All patients complained of a ‘‘bulge’’ in the vagina. All

Sensitivity = 89% (17/19), specificity = 80% (4/5), positive predictive value = 94% (17/18), negative predictive value = 67% (4/6). P =0.0065, Fisher’s Exact Test

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Preoperative multichannel urodynamic testing revealed eight patients (33%) with genuine stress incontinence, six of whom had intrinsic sphincter deficiency, four (17%) with detrusor instability, six (25%) with mixed incontinence, and six (25%) with no urinary incontinence. Table 3 shows concurrent surgical procedures performed for correction of prolapse and incontinence. Procedures to correct genuine stress incontinence (GSI) were performed in 14 (58%) of the patients. Of these six patients who underwent a sling procedure for the treatment of intrinsic sphincter deficiency, four (67%) had persistent retention postoperatively and only two (33%) had passed the preoperative pessary test. The effect of pessary use and surgical repair on voided volumes, PVR, Q max, and changes in the Q-tip test are shown in Table 4. There were significant preoperative increases in Q max (p =0.04), voided volume (p =0.04), and significant decrease in PVR (p =0.01) with the prolapse reduced compared to prolapse extended. There were no statistically significant differences in Q max (p =0.32), voided volume (p =0.48), or PVR (p =0.40) preoperatively, with the prolapse reduced, compared to postoperatively. The mean voided volumes, PVR, and Q max in patients with persistent urinary retention (n=6) compared to those with relief of urinary retention (n=18) after pessary support are shown in Table 5. Of 24 patients, five had persistent urinary retention at 3 months postoperatively. There were no significant differences in age, parity, degree of prolapse, Q-tip test, Table 3 Concurrent surgical procedures for correction of prolapse and urinary incontinence (patients may have undergone more than one procedure) Procedures

% (N)

TAH/BSO TVH McCall culdoplasty Sacrospinous ligament fixation Colpocleisis Burch urethropexy Paravaginal repair Suburethral sling Anterior colporrhaphy Posterior colporrhaphy

29 (7) 21 (5) 21 (5) 21 (5) 4 (1) 33 (8) 33 (8) 25 (6) 21 (5) 17 (4)

TAH total abdominal hysterectomy, BSO bilateral salpingooophorectomy, TVH total vaginal hysterectomy

Table 4 Preoperative and postoperative comparison of voided volumes, PVR, Q max, and Q-tip test

Table 5 Mean voided volumes, PVR, Q max in patients with persistent urinary retention (N=6) compared with those with relief of urinary retention (N=18) after pessary support

Voided volume (cc) PVR (cc) Q max (cc/s)

N=6

N=18

225.6 211.7 16.2

238.8 29.2 31.3

Q max or PVR ( p >0.05) between patients with or without retention postoperatively. However, the type of incontinence surgery significantly influenced postoperative voiding function. Those patients undergoing a sling procedure were four times more likely to have postoperative urinary retention than those who underwent a Burch urethropexy (50 vs. 12.5%; Fisher’s Exact test, p <0.02).

Discussion Urinary retention from bladder outlet obstruction in women presents both diagnostic and therapeutic challenges to gynecologists. Our findings demonstrate that the use of pessary in women with symptomatic anterior vaginal wall prolapse and urinary retention is associated with relief of retention in the majority of patients. Furthermore, prolapse reduction testing using the pessary as a predictor for postoperative cure of urinary retention had good sensitivity, specificity and positive predictive value in patients with symptomatic anterior vaginal wall prolapse who underwent reconstructive pelvic surgery. Additionally, the type of surgery used to treat GSI influenced voiding function postoperatively. Previous studies of urodynamic parameters as predictors of postoperative urinary retention have yielded conflicting results. Bhatia and Bergman [9] predicted which women undergoing incontinence surgery were at increased risk of postoperative voiding dysfunction using urodynamic parameters. In contrast, the data of Kobac et al. [10] does not support the value of preoperative pressure flow voiding studies in predicting postoperative voiding function, but concluded that time to adequate voiding after bladder neck suspension is influenced by the type of surgical procedure. Fitzgerald et al. [11] demonstrated that preoperative voiding pressure studies were poor predictors of postoperative voiding in patients with advanced pelvic organ prolapse

Preoperative (n=24)

Urine volume Voided volume (cc) PVR (cc) Q max (cc/s) Urethral axis deviation

Postoperative (n=24)

Prolapse extended

Prolapse reduced

Mean ± SD (range) 160.5±129.2 (8–438) 209.6±112.2 (100–450) 12.8±6.6 (2–19) 60.4±16.7 (20–90)

Mean ± SD (range) 235.5±165.3 (25–750) 74.8±89.0 (3–300) 27.5±10.6 (16–38) -

Mean ± SD (range) 227.8±165.3 (25–750) 64.0±82.7 (0–300) 18.2±8.6 (5–27) 6.3±8.3 (0–30)

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and elevated PVR. Nonetheless, most of their patients had normalization of PVR after surgery. We recognize the limitations of our study. First, this was a retrospective review with a relatively small sample size; larger prospective studies are needed to confirm our preliminary findings. Second, various types and sizes of pessaries were used to reduce the prolapse; however, this is consistent with clinical practice where trial and error is the rule for adequate sizing and comfort. Third, concomitant incontinence procedures were performed in addition to pelvic reconstructive surgery that may have contributed to urinary retention postoperatively. Fourth, postoperative urinary retention may reflect a preexisting voiding dysfunction not relieved by pelvic prolapse repair. Despite these and other limitations, the results of our study may be clinically useful. Preoperative pessary reduction testing correlated well with the resolution of urinary retention postoperatively, and may be a potential screening tool for predicting postoperative voiding function. Lastly, preoperative counseling of patients regarding the risk of postoperative urinary retention is important, particularly for those who may develop prolonged retention requiring long-term catheterization. Our present findings on the potential value of preoperative pessary reduction testing may be useful to the informed consent process in patients undergoing reconstructive pelvic surgery for anterior vaginal wall prolapse and urinary retention. Acknowledgments We wish to thank Wilma Greston for her assistance with manuscript preparation.

References 1. Patel R, Nitti V (2001) Bladder outlet obstruction in women: prevalence, recognition, and management. Curr Urol Rep 2:379–387 2. Romanzi LJ, Chaikin DC, Blaivas JG (1999) The effect of genital prolapse on voiding. J Urol 166:581–586 3. Bump RC, Fantl JA, Hurt WG (1988) The mechanisms of urinary continence in women with severe uterovaginal prolapse: results of barrier studies. Obstet Gynecol 72:291–295

4. Richardson DA, Bent AE, Ostergard DR (1983) The effect of uterovaginal prolapse on urethrovesical pressure dynamics. Am J Obstet Gynecol 146:901–905 5. MacMillan JB, Drutz H (2002) Postoperative voiding dysfunction. In: Drutz H, Hershom S, Diamant NE (eds) Female pelvic medicine and reconstructive pelvic surgery. Springer, London, pp 497–512 6. Bump RC, Mattiason A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Smith ARB (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17 7. Scotti RJ, Flora RF, Greston WM, Budnick L, HutchinsonColas J (2000) Characterizing and reporting pelvic floor defects: the Revised New York Classification system. Int Urogynecol J 11:48–60 8. Urinary Incontinence Guideline Panel (1992) Urinary Incontinence in adults: clinical practice guideline. Department of Health and Human Services, Rockville, MD. AHCPR Publication No. 92–0038 9. Bhatia N, Bergman A (1984) Urodynamic predictability of voiding following incontinence surgery. Obstet Gynecol 63:85– 91 10. Kobak WH, Walters MD, Piedmonte MR (2001) Determinants of voiding after three types of incontinence surgery: a multivariable analysis. Obstet Gynecol 97:86–91 11. Fitzgerald MP, Kulkarni N, Fenner D (2000) Postoperative resolution of urinary retention in patients with advanced pelvic organ prolapse. Am J Obstet Gynecol 183:1361–1363

Editorial comment The authors attempt to address an interesting question, whether preoperative reduction of anterior vaginal wall prolapse with a pessary is predictive of improved bladder emptying following surgical correction of the prolapse. In their small retrospective study they found that a successful pessary ‘‘test of cure’’ was predictive of resolution of urinary retention following surgery with a positive predictive value of 94%. Interestingly, neither the type of pessary nor the type of surgery seemed to influence these results. In addition, the authors noted a higher rate of continued urinary retention in patients who had undergone a sling for correction of their urinary incontinence. This study supports the use of a pessary ‘‘test of cure’’ for urinary retention in the face of anterior vaginal wall prolapse prior to surgical correction of such prolapse