H.C. Hari, T. Tan, R. Ng, L.C. Lee, C. Chong, L. Lee
KK Women's & Children's Hospital, Singapore

Aims of Study:

1. To find out the incidence of stress urinary incontinence in women with severe genito-urinary prolapse.
2. To ascertain the need of urodynamics test in these women.
3. To determine the value of the ring pessary test in the investigations of these women.

Methods: A prospective non-randomised study from 1 November 1996 to 31 December 1998. All women were seen at Urogynaecology Clinic for either one the following conditions: (a) Second degree uterine descent; (b) Second degree vault descent and/or (c) grade 3 or 4 cystourethrocele. Detailed history was taken and thorough physical and vaginal examinations were performed. Urinalysis, modified ICS 1-hour pad test, stress incontinence sheet test, filling and voiding cystometry with and without ring pessary were carried out in all the women.

Results: 189 women were selected for the study. The mean age was 58.2 years od (range: 34-86). The mean pessay size used was 69 (range: 53-95). 71% of the women was menopausal. Only 10% of the menopausal women was on hormone replacement therapy. Average number of vaginal deliveries was 4.3 (range: 0-13).

107 women (57%) had history of stress incontinence, 88 women (47%) had urgency and 70 women (37%) had urge incontinence. 28 women (15%) had demonstrable stress incontinence. 29 women (15%) had positive ICS 1-hour pad test and 63 women (33%) had positive incontinence sheet test.

The clinical diagnosis was based on history, clinical signs and stress tests. 20 women (15%) had overactive bladder (OB) alone, 33 women (17%) had stress urinary incontinence (SUI) alone and 74 women (39%) had mixed OB + SUI. Only 53 women (28%) had no urinary symptoms. Total number of women with SUI were 107 (56%).

Only 61 women (32%) had similar clinical and urodynamics diagnosis. 14 women (8%) had undiagnosed GSI and 20 women (11%) had undiagnosed OB.

With ring pessary test, 18 women (10%) had hidden GSI. Total number of women with GSI diagnosed by urodynamics with or without ring pessary was 75 (40%)

Conclusion: We come to the following conclusions:

1. Urinary incontinence indeed is very common in women with severe genitourinary prolapse, with 56% of them had SUI symptoms an 54% had OB symptoms. 40% had urodynamics diagnosed GSI.
2. Urodynamics test is essential for accurate diagnosis as only 32% of them had similar clinical and urodynamics diagnosis.
3. Ring pessary test is crucial for the detection of the hidden GSI, which was 10% in the study.

Hence, vaginal hysterectomy and pelvic floor repair alone obviously cannot hold water anymore for women with severe genitourinary prolapse. With accurate diagnosis preoperatively, incontinence surgery can be discussed and planned to prevent future urinary incontinence.