ICS 1999, Denver
Informally discussed posters
Urodynamics
Prolapse reduction testing in patients with grades I and II anterior wall prolapse

R.J. Scotti, K. Powers, G. Lazarou, T.W. Chu, W.M. Greston
Albert Einstein College of Medicine/Montefiori Medical Center, Bronx, New York, USA

Aims of Study: (1) To determine if patients with grades I and II of anterior vaginal wall prolapse are at risk for genuine stress or potential incontinence and (2) to compare these to a group of patients with grades III and IV prolapse [1-5].

Methods: 36 patients with anterior wall descent between 2 cm below the ischial spines and the hymen but not protruding beyond the hymen (ICS grades I-II) were evaluated in our unit with their prolapse extended and manually reduced. A group of 24 patients with grades III and IV were used for comparison. All patients underwent urinanalysis, urine culture and sensitivity, detailed history, detailed urogynecologic exam including urethral axis deternimation by Q-tip test, post void residual urine volume determination, site specific assessment by International Continence Society (POPQ) [6] and New York Classification [7] Systems, and multichannel urodynamics including urethral pressure profiles (UPP) and cough UPP and leak point pressures (LPP) with prolapse reduced and extended. The presence of genuine stress incontinence (GSI) and potential incontinence (GSI only with prolapse reduced) were documented. Statistical tests (Mann Whitney and chi square) were used where appropriate.

Results: Of the 36 patients with grades I-II prolapse, 6 patients (16%) demonstrated potential incontinence; 19 (53%) had GSI (frank incontinence); 11 showed no evidence of frank incontinence or potential incontinence. In the grades III-IV group, 6 of the 24 women (25%) had potential incontinence, and 6 (25%) demonstrated GSI.

Conclusions: (1) Patients with lesser grades I-II prolapse of the anterior vaginal wall are at risk for potential incontinence (1d5%) as are patients with grades III and IV (25%), (2) the grades I-II group was more likely to have genuine stress incontinence (53%) than patients with grades II-IV prolapse (25%) p<.001, (3) there was a significant difference in the incidence of potential and GSI frank incontinence in the grades I-II group compared to the grades III-IV groups (p<.01).

It is therefore our recommendation that all patients contemplating a surgical repair with any degree of anterior wall prolapse should be evaluated urodynamically during prolapse reduction for appropriate triage and treatment.

References

1. Scotti R.J., Henderson M.G. The prolapse reduction test for potential incontinence in women with severe eversion of the anterior vaginal wall. Abstracts of the Twentieth Scientific Meeting of the Society of Gynecologic Surgeons, Nashville, TN, March 1994.
2. Bump R.C., Fantl J.A., Hurt W.G. The mechanism of urinary continence in women with severe uterovaginal prolapse: Results of barrier studies. Obstet Gynecol 1988; 72: 291-5
3. Bergman A. Predicting postoperative urinary incontinence development in women undergoing operations for genitourinary, prolapse. Am J Obstet Gynecol 1988; 158:1171-5.
4. Borstad E., Rud. T. The risk of developing urinary stress incontinence after vaginal repair in continent women. Acta Obstet Gynecol Scand 1989; 68: 545-91.
5. Fianu S., Kjaeldgaard A., Larsson B. Pre-operative screening for latent stress incontinence in women with cystocele. Neurourol Urodyn 1985; 4: 3-7.
6. Committee on Standardization of Terminology. The standardization of terminology of lower urinary tract function. Glasgow: The International Continence Society, 1984.
7. Scotti R.J., Flora R.F., Greston W.M., Budnick L., Hutchinson-Colas J. Characterizing and reporting pelvic floor defects: The revised New York classification system. Int Urogynecol J (in press).