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Lower Urinary Tract Symptoms, Quality of Life and Pelvic Organ Prolapse: Irritative Bladder and Obstructive Voiding Symptoms in Women Planning to Undergo Abdominal Sacrocolpopexy for Advanced Pelvic Organ Prolapse
Lower Urinary Tract Symptoms, Quality of Life and Pelvic Organ Prolapse: Irritative Bladder and Obstructive Voiding Symptoms in Women Planning to Undergo Abdominal Sacrocolpopexy for Advanced Pelvic Organ Prolapse Holly E. Richter,* Ingrid Nygaard, Kathryn L. Burgio,† Victoria L. Handa, Mary Pat FitzGerald, Patricia Wren, Halina Zyczynski, Paul Fine, Morton B. Brown and Anne M. Weber for the Pelvic Floor Disorders Network From the Department of Obstetrics and Gynecology (HER) and Division of Gerontology and Geriatric Medicine, Department of Medicine (KLB), University of Alabama at Birmingham and Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center (KLB), Birmingham, Alabama, University of Utah (IN), Salt Lake City, Utah, Johns Hopkins School of Medicine (VLH), Baltimore and National Institutes of Child Health and Human Development (AMW), Bethesda, Maryland, Department of Obstetrics and Gynecology, Loyola University (MPF), Chicago, Illinois, School of Health Sciences, Oakland University (PW), Rochester and Department of Biostatistics, University of Michigan (MBB), Ann Arbor, Michigan, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh, Magee-Womens Hospital (HZ), Pittsburgh, Pennsylvania, and Baylor College of Medicine (PF), Houston, Texas
Purpose: We compared lower urinary tract and voiding symptoms in women with and without symptoms of stress urinary incontinence who were planning to undergo abdominal sacrocolpopexy for pelvic organ prolapse. Materials and Methods: Subjects without stress urinary incontinence included 293 women in the Colpopexy and Urinary Reduction Efforts Trial. Subjects with stress urinary incontinence included 82 women who met trial inclusion criteria except for having stress urinary incontinence symptoms. We assessed symptoms and quality of life using validated measures. Results: After adjusting for age, race and site subjects with stress urinary incontinence had higher irritative and obstructive symptom subscale scores and reported greater symptom bother, greater impact of colorectal and prolapse symptoms, and poorer physical and mental health. Conclusions: Women with prolapse and stress urinary incontinence had more lower urinary tract symptoms and reported more functional impact. This is contrary to our hypothesis that women with prolapse and stress urinary incontinence would have fewer irritative, obstructive and voiding symptoms because of the relief valve effect of the less resistant urethra. Key Words: prolapse; urinary incontinence, stress; urinary tract; quality of life, questionnaires
riencing other lower urinary tract irritative and obstructive symptoms is unknown. One may hypothesize that women without primary SUI symptoms may be more obstructed and, therefore, have more complaints of voiding dysfunction and bladder storage symptoms. Given that stress incontinence is generally associated with lower urethral resistance, we hypothesized that women with POP plus SUI would be less likely to have symptoms associated with obstruction, such as urinary urgency, frequency and voiding dysfunction, compared to women without SUI who do not have this pressure release valve. In this crosssectional study we compared LUTS other than SUI and voiding symptoms in 2 groups of women with and without preoperative SUI symptoms planning to undergo abdominal sacrocolpopexy for POP. We also compared the groups on preoperative measures of symptom specific and general quality of life using validated questionnaires.
elvic organ prolapse often coexists with various LUTS, including SUI,1,2 irritative or storage symptoms, such as urinary urgency and frequency, nocturia, urge incontinence and voiding symptoms, such as incomplete emptying and difficult emptying.3–5 Advanced POP protects some women from experiencing SUI symptoms,6 presumably because of urethral kinking or compression from the bulge.7 However, 15% to 80% of women with significant POP may experience SUI after prolapse is reduced at stress or urodynamic testing.8 To our knowledge the degree to which SUI may protect women with advanced prolapse from expe-
P
Submitted for publication January 22, 2007. Study received approval from the Institutional Review Board at all clinical sites and the Data Coordinating Center. Supported by National Institute of Child Health and Human Development Grants U01 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269 and U10 HD41267, and National Institute of Diabetes, Digestive and Kidney Diseases Grant K24 DK068389. * Correspondence: Women’s Pelvic Medicine and Reconstructive Surgery, University of Alabama at Birmingham, 620 20th St. South, NHB 219, Birmingham, Alabama 35233 (telephone: 205-934-7874; FAX: 205-975-8893; e-mail: [email protected]). † Financial interest and/or other relationship with Pfizer.
0022-5347/07/1783-0965/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
MATERIALS AND METHODS Institutional Review Board approval was obtained at all clinical sites and the Data Coordinating Center. All subjects were women planning to undergo abdominal sacrocolpopexy
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for POP. All potential subjects underwent clinical evaluation for possible participation in the CARE Trial.9 For the purposes of the current analysis 2 groups of women were identified, including those with and without SUI symptoms. The diagnosis of SUI was symptom based and defined as an answer of sometimes or often to any of the first 6 questions of the MESA questionnaire, which is a validated instrument used to assess symptoms of stress and urge incontinence.10 Subjects without SUI included 293 of the 322 women in the CARE Trial9 who answered never or rarely to the first 6 questions of the MESA questionnaire,10 which are used to assess symptoms of stress incontinence. Subjects with subjective complaints of SUI included 82 women in an adjunct study of the Pelvic Floor Disorders Network looking at voiding symptoms and urodynamic studies, who were also planning to undergo abdominal sacrocolpopexy and who reported feeling a bulge. All subjects were evaluated in standardized fashion and differed only by answers to the MESA questionnaire. From the CARE cohort 21 women were excluded from this analysis because they did not report seeing or feeling a bulge, and another 8 were excluded because of incomplete or missing data. The 2 groups could have other bladder symptoms. All subjects were candidates for Burch colposuspension. All patients provided a detailed medical and surgical history, and underwent POP-Q examination and pelvic floor muscle strength assessment, as previously described.9 Irritative and obstructive bladder symptoms, and colorectal and POP symptoms were measured using PFDI subscales.11 PFDI assesses symptom distress in women with pelvic floor disorders and it has 3 scales, including UDI with 28 items, Colorectal-Anal Distress Inventory (17 items) and POP Distress Inventory (16 items). Each item includes a measure of bother for each symptom quantified as not at all, somewhat, moderately or quite a bit. For the purposes of these analyses bother was defined as an answer of moderately or quite a bit. Subjects also completed the Pelvic Floor Impact Questionnaire,11 which measures life or functional impact and also has 3 scales, including the Incontinence Impact Questionnaire, CRAIQ and POPIQ, each containing 31 items. The Medical Outcomes Study SF-36™12 was used to assess more general quality of life. Sexual function was measured using PISQ.13 The 2 cohorts were compared by the Mantel-Haenszel statistic adjusted for age, race, previous urinary incontinence surgery and site. The p value and OR with the 95% CI are presented. Data are shown as the mean ⫾ SD. RESULTS Table 1 lists subject characteristics. Subjects in this study were predominantly white and the groups did not differ significantly in regard to race. Subjects in the SUI group were younger than those without SUI (p ⫽ 0.0031) and had a higher body mass index (p ⫽ 0.0038) and higher medical comorbidity scores (p ⫽ 0.0015). More women in the SUI group had undergone surgical as well as nonsurgical treatment for urinary incontinence (p ⬍0.0001). On physical examination women with SUI had poorer pelvic muscle function than those without SUI but the groups did not differ significantly in regard to POP-Q stage (p ⫽ 0.0032 and 0.38, respectively).
TABLE 1. Cohort characteristics Stress Continent
Stress Incontinent
No. subjects Mean ⫾ SD age No. race (%): White Black Other No. Hispanic (%) No. Pop-Q stage (%): 2 3 4
293 61.6 ⫾ 10.2
82 56.6 ⫾ 14.1
273 (93.2) 14 (4.8) 6 (2.0) 9 (3.1)
78 (95.1) 2 (2.4) 2 (2.4) 3 (3.7)
35 (11.9) 201 (68.6) 57 (19.5)
15 (18.5) 56 (69.1) 10 (12.3)
Total Mean ⫾ SD body mass index Mean ⫾ SD No. previous vaginal births Mean ⫾ SD comorbid scoring No. nonsurgical treatment (%) No. surgery (%): For incontinence For POP Mean ⫾ SD Brink score
293 27.2 ⫾ 4.6
81 29.0 ⫾ 6.9
3.0 ⫾ 1.5
2.9 ⫾ 1.5
0.61
3.9 ⫾ 3.0
4.9 ⫾ 3.9
0.0015
37 (12.9)
42 (53.2)
⬍0.0001
20 (6.8) 116 (39.7) 7.9 ⫾ 2.1
22 (27.2) 32 (40.0) 7.3 ⫾ 2.7
⬍0.0001 0.87 0.0032
Characteristic
p Value 0.0031 0.31
0.67 0.38
0.0038
PFDI urinary irritative and obstructive subscale scores were significantly different between participants with and without SUI. Those with SUI scored significantly higher, reflecting greater symptom severity, on the irritative symptom subscale than subjects without SUI (p ⬍0.0001) and more reported bothersome symptoms (80.3% vs 46.8%, p ⬍0.0001, table 2). Women with SUI also had higher scores on the obstructive symptom subscale (p ⫽ 0.0001). Although obstructive voiding symptoms were more often reported by women with SUI, post-void residual volumes were not higher than those of women without SUI (65.7 ⫾ 71.5 vs 86.9 ⫾ 107.2 ml, p ⫽ 0.31). When comparing the groups in regard to individual UDI symptom categories, more women with SUI reported bother (moderately or quite a bit) for each category, except dysuria (table 2). For example, more women with SUI reported bothersome voiding symptoms (72.4% vs 48.8%, p ⫽ 0.0009). In addition, more women with SUI reported bother associated with enuresis (7.9% vs 0.3%, p ⫽ 0.002), amount of leakage (61.8% vs 10.2%, p ⬍0.0001) and incontinence with sex (19.7% vs 2.0%, p ⬍0.0001). When comparing Pelvic Floor Impact Questionnaire scores, we found that subjects with SUI reported significantly greater functional impact on daily activities due to urinary symptoms (urinary incontinence quantification score p ⬍0.0001), colorectal symptoms (CRAIQ score p ⬍0.0001) and POP symptoms (POPIQ score p ⬍0.0001, table 3). Analysis was repeated, including history of stress incontinence surgery as a covariate, which did not significantly change the results. In addition to reporting greater pelvic floor symptom specific impact, subjects with SUI reported more problems in overall quality of life. In terms of general health women with SUI had poorer physical and mental health (p ⫽ 0.0032 and ⬍0.0001, respectively), as measured by those 2 SF-36 component summary scores, an indication of greater impact on overall quality of life (table 4). Finally, in sexually active women in each group PISQ scores were lower, reflecting
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TABLE 2. Irritative and obstructive symptoms, and bother
No. subjects Mean ⫾ SD UDI subscale: Irritative Obstructive No. symptom bother categories (%):* Irritative Nocturia Enuresis Dysuria Filling Voiding
Stress Continent
Stress Incontinent
p Value
296
82
19.8 ⫾ 16.1 36.1 ⫾ 20.4
42.6 ⫾ 23.5 47.0 ⫾ 24.6
⬍0.0001 0.0001
137 (46.8) 91 (31.1) 1 (0.3) 35 (11.9) 48 (16.4) 143 (48.8)
61 (80.3) 42 (55.3) 6 (7.9) 15 (19.7) 27 (35.5) 55 (72.4)
⬍0.0001 0.0002 0.0020 0.28 0.0005 0.0009
OR (95% CI)
0.22 (0.11–0.42) 0.35 (0.20–0.62) 0.05 (0.00–0.55) 0.67 (0.32–1.40) 0.34 (0.18–0.64) 0.36 (0.20–0.66)
* A response of yes and then a response of moderately or quite a bit to the bother component of any question asking, “Do you usually experience or feel “frequent urination,” “a strong feeling of urgency to empty your bladder,” “urine leakage associated with a feeling of urgency, that is a strong sensation of needing to go to the bathroom,” “urine leakage when you go from sitting to standing” (irritative), “awaken during your normal sleeping hours to urinate” (nocturia), “bedwetting” (enuresis), “pain or burning when urinating,” “pain in the middle of your lower abdomen as your bladder fills” (dysuria), “pressure in the middle of your lower abdomen as your bladder fills” (filling) or “difficulty emptying your bladder,” “a feeling of incomplete bladder emptying,” “that you have an unusually weak stream or that you take too long to empty your bladder,” “when you urinate, does your stream usually start and stop and start again,” “have to assume an unusual position or change positions to start or complete urination,” “have to push up on a bulge in the vaginal area with your fingers to start or complete urination,” “have to push on your lower abdomen to start or complete urination” or “dribble urine as you stand up or begin to walk immediately after you have finished urinating” (voiding).
poorer sexual function in those with vs without SUI (p ⫽ 0.033). DISCUSSION While much has been written about lower urinary tract function in women without prolapse, less is known about lower urinary tract function in women with prolapse. We describe voiding and other lower urinary tract symptoms in women planning surgery for POP. In this sample of women with and without SUI symptoms presenting for sacrocolpopexy we found that women with prolapse and SUI had more irritative and obstructive voiding symptoms, greater bother and more functional impact from such symptoms on daily activities than women with prolapse without SUI symptoms. This study tested and ultimately failed to support our hypothesis that women with prolapse and without SUI would have greater irritative, obstructive and voiding symptoms than women with prolapse and SUI because of the obstructive effect of prolapse and increased urethral resistance. Instead, the fact that women with prolapse and SUI had markedly worse overall bladder function suggests that SUI may be a marker of pelvic floor disorder severity. A combination of POP and SUI may represent a more advanced end of the spectrum of the same process as the more ubiquitous mild pelvic floor disorder. Despite the increasing reported prevalence of SUI with age,14 these women with POP and SUI were younger and more likely to have undergone SUI surgery. We hypothesize that women with the 2 conditions
may have experienced more of a pelvic floor insult during childbirth or sustained damage from other etiological events and the severity of these insults led not only to SUI and POP, but also to other bladder symptoms. Alternatively rather than having similar origins, it is possible that the mechanism that causes SUI leads to bladder dysfunction. For example, urine present in the proximal urethra because of a weak urethral sphincter may stimulate reflex detrusor contractions, causing urinary frequency and urgency.8,15 Women with POP and SUI had more irritative and obstructive bladder symptoms. Not surprisingly they also had poorer quality of life and sexual function than women with POP alone. Our findings echo those of a smaller study in which 58 women with advanced POP were grouped into categories of stress continence or incontinence according to their responses on the Bristol Female Lower Urinary Tract Symptoms Questionnaires.16 Women with SUI symptoms were more likely to report urinary frequency, urgency and nocturia than those without such symptoms. The findings are also in agreement with a population based study showing that LUTS are common in women with POP and, indeed, they are common in older women in general. Of 4,000 Danish women 28% had at least 1 bothersome lower urinary tract symptom, excluding SUI.17 Of 110 women with at least grade 2 prolapse 21% to 45% reported urge incontinence, urgency, frequency and emptying difficulties at least weekly.18 Unfortunately these symptoms were not stratified by SUI, which is present in a quarter of these women. Similarly of 60 women, including 68% with SUI symptoms, almost half had urgency, frequency and nocturia.19
TABLE 3. Pelvic Floor Impact subscale scores Characteristic No. subjects Urinary Impact Questionnaire: Social Travel Emotional Physical CRAIQ POPIQ
Mean ⫾ SD Stress Continent
Mean ⫾ SD Stress Incontinent
p Value
296 147.2 ⫾ 50.3
82 213.4 ⫾ 76.3
⬍0.0001
32.0 ⫾ 11.3 39.2 ⫾ 16.9 35.9 ⫾ 12.6 40.6 ⫾ 17.7 129.3 ⫾ 50.3 145.5 ⫾ 57.3
48.8 ⫾ 19.6 56.1 ⫾ 21.0 50.5 ⫾ 19.2 57.6 ⫾ 23.9 175.9 ⫾ 85.1 192.6 ⫾ 84.3
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001
TABLE 4. Global and sexual quality of life outcomes Parameter SF-36 component summary score: Physical Mental PISQ (No. sexually active women only)
Mean ⫾ SD Stress Continent
Mean ⫾ SD Stress Incontinent
p Value
45.1 ⫾ 9.7 52.0 ⫾ 9.0 70.3 ⫾ 15.0 (149)
42.0 ⫾ 8.8 45.2 ⫾ 12.4 63.9 ⫾ 14.6 (38)
0.0032 ⬍0.0001 0.033
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Women with advanced POP report increased voiding dysfunction symptoms.4,20 This was also true in our population, although women with SUI were 50% more likely to have bothersome voiding symptoms than women without SUI (72% vs 49%). In general women with advanced prolapse are less likely to have SUI than women with early prolapse.5 Because we specifically focused on women planning to undergo surgery for prolapse, there was no difference in prolapse severity between women with and without SUI. Our findings should not be construed as being generalizable to the population of women with prolapse not seeking surgery. It is possible that the women in this study who complained of stress incontinence had a lower threshold for reporting symptoms than women without stress incontinence. That would be a potential explanation of the higher prevalence of other pelvic floor symptoms in this population. Many factors influence selfreporting of incontinence symptoms and we cannot exclude with certainty that our results are not explained by unmeasured differences between these groups.
Abbreviations and Acronyms CARE CRAIQ LUTS MESA
PFDI ⫽ PISQ ⫽ POP POPIQ POP-Q SUI UDI
1.
CONCLUSIONS
APPENDIX Pelvic Floor Disorders Network Members: Dr. Holly E. Richter (Principal Investigator), Kathryn L. Burgio (Co-Principal Investigator), Dr. Patricia Goode, Dr. R. Edward Varner, Dr. Mark Lockhart (Co-Investigators) and Velria Willis (Research Coordinator), University of Alabama at Birmingham; Dr. Paul M. Fine (Principal Investigator), Dr. Rodney A. Appell (Co-Principal Investigator), Dr. Peter K. Thompson, Dr. Peter M. Lotze (Co-Investigators) and Naomi Frierson (Research Coordinator), Baylor College of Medicine; Dr. Ingrid Nygaard (Principal Investigator), Dr. Karl Kreder, Dr. Catherine S. Bradley, Dr. Satish Rao (Co-Investigators), Debra Brandt and Denise Haury (Research Coordinators), University of Iowa; Dr. Geoffrey Cundiff (Principal Investigator), Dr. Victoria Handa, Dr. Jamie Wright, Dr. Robert Gutman (Co-Investigators) and Mary Elizabeth Sauter (Research Coordinator), The Johns Hopkins Medical Institutes; Dr. Linda Brubaker (Principal Investigator), Dr. Mary Pat FitzGerald (Co-Principal Investigator), Dr. Kimberly Kenton (Co-Investigator), Dorothea Koch and Charity Ball (Research Coordinators), Loyola University, Chicago; Morton B. Brown (Principal Investigator), Dr. John T. Wei (Co-Principal Investigator), Beverly Marchant (Project Manager), Dr. John O. L. DeLancey, Nancy K. Janz, Dean G. Smith, Patricia A. Wren (Co-Investigators), James Imus (Statistician) and Yang Wang Casher (Database Programmer), University of Michigan; Dr. Anthony G. Visco (Principal Investigator), Dr. AnnaMarie Connolly, Dr. John Lavelle, Dr. Ellen C. Wells, William Whitehead, Dr. Julia Fielding (Co-Investigators), Mary J. Loomis and Anita K. Murphy (Research Coordinators), University of North Carolina at Chapel Hill; Dr. Halina Zyczynski (Principal Investigator), Diane Borello-France, Dr. Wendy Leng, Dr. Pamela A. Moalli, Dr. Chiara Ghetti (Co-Investigators) and Judy A. Gruss (Research Coordinator), University of Pittsburgh/ Magee-Womens Hospitals; Dr. Robert Park (Steering Committee Chairman); and Dr. Anne M. Weber (Project Scientist), National Institute of Child Health and Human Development.
⫽ ⫽ ⫽ ⫽ ⫽
Colpopexy and Urinary Reduction Efforts Colorectal-Anal Impact Questionnaire lower urinary tract symptoms Medical, Epidemiologic and Social Aspects of Aging Pelvic Floor Distress Inventory POP/Urinary Incontinence Sexual Function Questionnaire pelvic organ prolapse POP Impact Questionnaire POP Quantification stress urinary incontinence Urogenital Distress Inventory
REFERENCES
2.
Clinicians should be aware that women presenting for prolapse surgery who have symptomatic SUI are likely to have a host of other obstructive and irritative urinary symptoms as well as colorectal and prolapse symptoms. They are also likely to have poorer overall quality of life and sexual function. Further research is needed to determine the effect of prolapse and incontinence surgery on overall bladder function and quality of life in women with the 2 conditions preoperatively. Given that stress incontinence may be a marker for pelvic floor disease severity, future studies assessing surgical outcomes should perhaps stratify for this important predictor.
⫽ ⫽ ⫽ ⫽
3.
4. 5.
6.
7. 8.
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Bergman A, Koonings PP and Ballard CA: Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988; 158: 1171. Gallentine ML and Cespedes RD: Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures. Urology 2001; 57: 40. Gardy M, Kozminski M, DeLancey J, Elkins T and McGuire EJ: Stress incontinence and cystoceles. J Urol 1991; 145: 1211. Romanzi LJ, Chaikin DC and Blaivas JG: The effect of genital prolapse on voiding. J Urol 1999; 161: 581. Burrows LJ, Meyn LA, Walters MD and Weber AM: Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 2004; 104: 982. Veronikis DK, Nichols DH and Wakamatsu MM: The incidence of low-pressure urethra as a function of prolapse-reducing technique in patients with massive pelvic organ prolapse (maximum descent at all vaginal sites). Am J Obstet Gynecol 1997; 177: 1305. Marinkovic SP and Stanton SL: Incontinence and voiding difficulties associated with prolapse. J Urol 2004; 171: 1021. Rosenzweig BA, Pushkin S, Blumenfeld D and Bhatia NN: Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol 1992; 79: 539. Brubaker L, Cundiff GW, Fine P, Nygaard I, Richter HE, Visco AG et al: Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006; 354: 1557. Herzog AR, Diokno AC, Brown MB, Normolle DP and Brock BM: Two-year incidence, remission, and change patterns of urinary incontinence in noninstitutionalized adults. J Gerontol 1990; 45: M67. Barber MD, Kuchibhatla MN, Pieper CF and Bump RC: Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol 2001; 185: 1388. Ware JE Jr and Gandek B: Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA). J Clin Epidemiol 1998; 51: 903. Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S and Qualls C: A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ12). Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 164. Hunskaar S, Burgio K, Clark A, Lapitan MC, Nelson K, Sillen U et al: Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Incontinence. Edited by P Abrams, L Cardozo, S Khoury
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and A Wein. Plymouth, United Kingdom: Health Publications Ltd 2005; vol I, p 255. Ostergard DR: The neurological control of micturition and integral voiding reflexes. Obstet Gynecol Surv 1979; 34: 417. Long CY, Hsu SC, Wu TP, Sun DJ, Su JH and Tsai EM: Urodynamic comparison of continent and incontinent women with severe uterovaginal prolapse. J Reprod Med 2004; 49: 33. Moller LA, Lose G and Jorgensen T: The prevalence and bothersomeness of urinary tract symptoms in women 40 – 60 years of age. Acta Obstet Gynecol Scand 2000; 79: 298. Mouritsen L and Larsen JP: Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 122. Yalcin OT, Yildrim A and Hassa H: The effects of severe cystocele on urogynecologic symptoms and findings. Acta Obstet Gynecol Scand 2001; 80: 423. Chaikin DC and Blaivis JG: Voiding dysfunction: definitions. Curr Opin Urol 2001; 11: 395.
EDITORIAL COMMENT In this study the authors of the CARE trial report the incidence of obstructive and irritative voiding symptoms in women planning to undergo sacrocolpopexy. They found that women with prolapse reporting SUI on questionnaire were more likely to report LUTS than those without SUI. The authors had hypothesized the reverse, that is those without SUI would have more obstruction due to prolapse and, therefore, have greater bother associated with LUTS. This hypothesis is based partially on the finding that in women without prolapse pressure flow findings are less obstructive in those with urodynamically proven SUI.1 It is not clear that in women with prolapse the symptom SUI alone is associated with decreased outlet resistance. This study certainly questions the relationship of SUI symptoms and chronic outlet resistance in women with prolapse, if not the
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relatively accepted relationship between increased outlet resistance and LUTS or perhaps the 2 conditions. One must also keep in mind that women with SUI reported only the symptom and SUI was not demonstrated objectively. It was these women who were more likely to report irritative and obstructive voiding symptoms. As the authors point out, it is distinctly possible that this group of women may be more likely to report urinary symptoms overall, a finding unrelated to the prolapse condition. Furthermore, it is not clear that the proportion of women who might have been found to have SUI on objective testing would have had more LUTS than those with SUI by symptom alone. Arguably it remains imperative to demonstrate SUI objectively when considering vaginal surgery for prolapse since it has not been established that the role of a prophylactic SUI procedure for the vaginal repair of prolapse can be assumed based on the results of the CARE trial (reference 9 in article). Presumably the risk of an inappropriate sling procedure at vaginal prolapse repair would exceed that of a Burch procedure done at sacrocolpopexy. To their credit the authors do not over speculate on their findings. Studies such as this continue to help us better understand urinary symptoms in our patients with prolapse. An analysis of LUTS outcomes in patients with and without SUI symptoms would allow us to better counsel our patients as we prepare them for surgery. Gary E. Lemack Department of Urology University of Texas Southwestern Medical Center Dallas, Texas 1.
Lemack GE, Baseman, AG and Zimmern PE: Voiding dynamics in women: a comparison of pressure-flow studies between asymptomatic and incontinent women. Urology 2002; 59: 42.
Purpose: We compared lower urinary tract and voiding symptoms in women with and without symptoms of stress urinary incontinence who were planning to undergo abdominal sacrocolpopexy for pelvic organ prolapse. Materials and Methods: Subjects without stress urinary incontinence included 293 women in the Colpopexy and Urinary Reduction Efforts Trial. Subjects with stress urinary incontinence included 82 women who met trial inclusion criteria except for having stress urinary incontinence symptoms. We assessed symptoms and quality of life using validated measures. Results: After adjusting for age, race and site subjects with stress urinary incontinence had higher irritative and obstructive symptom subscale scores and reported greater symptom bother, greater impact of colorectal and prolapse symptoms, and poorer physical and mental health. Conclusions: Women with prolapse and stress urinary incontinence had more lower urinary tract symptoms and reported more functional impact. This is contrary to our hypothesis that women with prolapse and stress urinary incontinence would have fewer irritative, obstructive and voiding symptoms because of the relief valve effect of the less resistant urethra. Key Words: prolapse; urinary incontinence, stress; urinary tract; quality of life, questionnaires
riencing other lower urinary tract irritative and obstructive symptoms is unknown. One may hypothesize that women without primary SUI symptoms may be more obstructed and, therefore, have more complaints of voiding dysfunction and bladder storage symptoms. Given that stress incontinence is generally associated with lower urethral resistance, we hypothesized that women with POP plus SUI would be less likely to have symptoms associated with obstruction, such as urinary urgency, frequency and voiding dysfunction, compared to women without SUI who do not have this pressure release valve. In this crosssectional study we compared LUTS other than SUI and voiding symptoms in 2 groups of women with and without preoperative SUI symptoms planning to undergo abdominal sacrocolpopexy for POP. We also compared the groups on preoperative measures of symptom specific and general quality of life using validated questionnaires.
elvic organ prolapse often coexists with various LUTS, including SUI,1,2 irritative or storage symptoms, such as urinary urgency and frequency, nocturia, urge incontinence and voiding symptoms, such as incomplete emptying and difficult emptying.3–5 Advanced POP protects some women from experiencing SUI symptoms,6 presumably because of urethral kinking or compression from the bulge.7 However, 15% to 80% of women with significant POP may experience SUI after prolapse is reduced at stress or urodynamic testing.8 To our knowledge the degree to which SUI may protect women with advanced prolapse from expe-
P
Submitted for publication January 22, 2007. Study received approval from the Institutional Review Board at all clinical sites and the Data Coordinating Center. Supported by National Institute of Child Health and Human Development Grants U01 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269 and U10 HD41267, and National Institute of Diabetes, Digestive and Kidney Diseases Grant K24 DK068389. * Correspondence: Women’s Pelvic Medicine and Reconstructive Surgery, University of Alabama at Birmingham, 620 20th St. South, NHB 219, Birmingham, Alabama 35233 (telephone: 205-934-7874; FAX: 205-975-8893; e-mail: [email protected]). † Financial interest and/or other relationship with Pfizer.
0022-5347/07/1783-0965/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
MATERIALS AND METHODS Institutional Review Board approval was obtained at all clinical sites and the Data Coordinating Center. All subjects were women planning to undergo abdominal sacrocolpopexy
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Vol. 178, 965-969, September 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.05.045
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for POP. All potential subjects underwent clinical evaluation for possible participation in the CARE Trial.9 For the purposes of the current analysis 2 groups of women were identified, including those with and without SUI symptoms. The diagnosis of SUI was symptom based and defined as an answer of sometimes or often to any of the first 6 questions of the MESA questionnaire, which is a validated instrument used to assess symptoms of stress and urge incontinence.10 Subjects without SUI included 293 of the 322 women in the CARE Trial9 who answered never or rarely to the first 6 questions of the MESA questionnaire,10 which are used to assess symptoms of stress incontinence. Subjects with subjective complaints of SUI included 82 women in an adjunct study of the Pelvic Floor Disorders Network looking at voiding symptoms and urodynamic studies, who were also planning to undergo abdominal sacrocolpopexy and who reported feeling a bulge. All subjects were evaluated in standardized fashion and differed only by answers to the MESA questionnaire. From the CARE cohort 21 women were excluded from this analysis because they did not report seeing or feeling a bulge, and another 8 were excluded because of incomplete or missing data. The 2 groups could have other bladder symptoms. All subjects were candidates for Burch colposuspension. All patients provided a detailed medical and surgical history, and underwent POP-Q examination and pelvic floor muscle strength assessment, as previously described.9 Irritative and obstructive bladder symptoms, and colorectal and POP symptoms were measured using PFDI subscales.11 PFDI assesses symptom distress in women with pelvic floor disorders and it has 3 scales, including UDI with 28 items, Colorectal-Anal Distress Inventory (17 items) and POP Distress Inventory (16 items). Each item includes a measure of bother for each symptom quantified as not at all, somewhat, moderately or quite a bit. For the purposes of these analyses bother was defined as an answer of moderately or quite a bit. Subjects also completed the Pelvic Floor Impact Questionnaire,11 which measures life or functional impact and also has 3 scales, including the Incontinence Impact Questionnaire, CRAIQ and POPIQ, each containing 31 items. The Medical Outcomes Study SF-36™12 was used to assess more general quality of life. Sexual function was measured using PISQ.13 The 2 cohorts were compared by the Mantel-Haenszel statistic adjusted for age, race, previous urinary incontinence surgery and site. The p value and OR with the 95% CI are presented. Data are shown as the mean ⫾ SD. RESULTS Table 1 lists subject characteristics. Subjects in this study were predominantly white and the groups did not differ significantly in regard to race. Subjects in the SUI group were younger than those without SUI (p ⫽ 0.0031) and had a higher body mass index (p ⫽ 0.0038) and higher medical comorbidity scores (p ⫽ 0.0015). More women in the SUI group had undergone surgical as well as nonsurgical treatment for urinary incontinence (p ⬍0.0001). On physical examination women with SUI had poorer pelvic muscle function than those without SUI but the groups did not differ significantly in regard to POP-Q stage (p ⫽ 0.0032 and 0.38, respectively).
TABLE 1. Cohort characteristics Stress Continent
Stress Incontinent
No. subjects Mean ⫾ SD age No. race (%): White Black Other No. Hispanic (%) No. Pop-Q stage (%): 2 3 4
293 61.6 ⫾ 10.2
82 56.6 ⫾ 14.1
273 (93.2) 14 (4.8) 6 (2.0) 9 (3.1)
78 (95.1) 2 (2.4) 2 (2.4) 3 (3.7)
35 (11.9) 201 (68.6) 57 (19.5)
15 (18.5) 56 (69.1) 10 (12.3)
Total Mean ⫾ SD body mass index Mean ⫾ SD No. previous vaginal births Mean ⫾ SD comorbid scoring No. nonsurgical treatment (%) No. surgery (%): For incontinence For POP Mean ⫾ SD Brink score
293 27.2 ⫾ 4.6
81 29.0 ⫾ 6.9
3.0 ⫾ 1.5
2.9 ⫾ 1.5
0.61
3.9 ⫾ 3.0
4.9 ⫾ 3.9
0.0015
37 (12.9)
42 (53.2)
⬍0.0001
20 (6.8) 116 (39.7) 7.9 ⫾ 2.1
22 (27.2) 32 (40.0) 7.3 ⫾ 2.7
⬍0.0001 0.87 0.0032
Characteristic
p Value 0.0031 0.31
0.67 0.38
0.0038
PFDI urinary irritative and obstructive subscale scores were significantly different between participants with and without SUI. Those with SUI scored significantly higher, reflecting greater symptom severity, on the irritative symptom subscale than subjects without SUI (p ⬍0.0001) and more reported bothersome symptoms (80.3% vs 46.8%, p ⬍0.0001, table 2). Women with SUI also had higher scores on the obstructive symptom subscale (p ⫽ 0.0001). Although obstructive voiding symptoms were more often reported by women with SUI, post-void residual volumes were not higher than those of women without SUI (65.7 ⫾ 71.5 vs 86.9 ⫾ 107.2 ml, p ⫽ 0.31). When comparing the groups in regard to individual UDI symptom categories, more women with SUI reported bother (moderately or quite a bit) for each category, except dysuria (table 2). For example, more women with SUI reported bothersome voiding symptoms (72.4% vs 48.8%, p ⫽ 0.0009). In addition, more women with SUI reported bother associated with enuresis (7.9% vs 0.3%, p ⫽ 0.002), amount of leakage (61.8% vs 10.2%, p ⬍0.0001) and incontinence with sex (19.7% vs 2.0%, p ⬍0.0001). When comparing Pelvic Floor Impact Questionnaire scores, we found that subjects with SUI reported significantly greater functional impact on daily activities due to urinary symptoms (urinary incontinence quantification score p ⬍0.0001), colorectal symptoms (CRAIQ score p ⬍0.0001) and POP symptoms (POPIQ score p ⬍0.0001, table 3). Analysis was repeated, including history of stress incontinence surgery as a covariate, which did not significantly change the results. In addition to reporting greater pelvic floor symptom specific impact, subjects with SUI reported more problems in overall quality of life. In terms of general health women with SUI had poorer physical and mental health (p ⫽ 0.0032 and ⬍0.0001, respectively), as measured by those 2 SF-36 component summary scores, an indication of greater impact on overall quality of life (table 4). Finally, in sexually active women in each group PISQ scores were lower, reflecting
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TABLE 2. Irritative and obstructive symptoms, and bother
No. subjects Mean ⫾ SD UDI subscale: Irritative Obstructive No. symptom bother categories (%):* Irritative Nocturia Enuresis Dysuria Filling Voiding
Stress Continent
Stress Incontinent
p Value
296
82
19.8 ⫾ 16.1 36.1 ⫾ 20.4
42.6 ⫾ 23.5 47.0 ⫾ 24.6
⬍0.0001 0.0001
137 (46.8) 91 (31.1) 1 (0.3) 35 (11.9) 48 (16.4) 143 (48.8)
61 (80.3) 42 (55.3) 6 (7.9) 15 (19.7) 27 (35.5) 55 (72.4)
⬍0.0001 0.0002 0.0020 0.28 0.0005 0.0009
OR (95% CI)
0.22 (0.11–0.42) 0.35 (0.20–0.62) 0.05 (0.00–0.55) 0.67 (0.32–1.40) 0.34 (0.18–0.64) 0.36 (0.20–0.66)
* A response of yes and then a response of moderately or quite a bit to the bother component of any question asking, “Do you usually experience or feel “frequent urination,” “a strong feeling of urgency to empty your bladder,” “urine leakage associated with a feeling of urgency, that is a strong sensation of needing to go to the bathroom,” “urine leakage when you go from sitting to standing” (irritative), “awaken during your normal sleeping hours to urinate” (nocturia), “bedwetting” (enuresis), “pain or burning when urinating,” “pain in the middle of your lower abdomen as your bladder fills” (dysuria), “pressure in the middle of your lower abdomen as your bladder fills” (filling) or “difficulty emptying your bladder,” “a feeling of incomplete bladder emptying,” “that you have an unusually weak stream or that you take too long to empty your bladder,” “when you urinate, does your stream usually start and stop and start again,” “have to assume an unusual position or change positions to start or complete urination,” “have to push up on a bulge in the vaginal area with your fingers to start or complete urination,” “have to push on your lower abdomen to start or complete urination” or “dribble urine as you stand up or begin to walk immediately after you have finished urinating” (voiding).
poorer sexual function in those with vs without SUI (p ⫽ 0.033). DISCUSSION While much has been written about lower urinary tract function in women without prolapse, less is known about lower urinary tract function in women with prolapse. We describe voiding and other lower urinary tract symptoms in women planning surgery for POP. In this sample of women with and without SUI symptoms presenting for sacrocolpopexy we found that women with prolapse and SUI had more irritative and obstructive voiding symptoms, greater bother and more functional impact from such symptoms on daily activities than women with prolapse without SUI symptoms. This study tested and ultimately failed to support our hypothesis that women with prolapse and without SUI would have greater irritative, obstructive and voiding symptoms than women with prolapse and SUI because of the obstructive effect of prolapse and increased urethral resistance. Instead, the fact that women with prolapse and SUI had markedly worse overall bladder function suggests that SUI may be a marker of pelvic floor disorder severity. A combination of POP and SUI may represent a more advanced end of the spectrum of the same process as the more ubiquitous mild pelvic floor disorder. Despite the increasing reported prevalence of SUI with age,14 these women with POP and SUI were younger and more likely to have undergone SUI surgery. We hypothesize that women with the 2 conditions
may have experienced more of a pelvic floor insult during childbirth or sustained damage from other etiological events and the severity of these insults led not only to SUI and POP, but also to other bladder symptoms. Alternatively rather than having similar origins, it is possible that the mechanism that causes SUI leads to bladder dysfunction. For example, urine present in the proximal urethra because of a weak urethral sphincter may stimulate reflex detrusor contractions, causing urinary frequency and urgency.8,15 Women with POP and SUI had more irritative and obstructive bladder symptoms. Not surprisingly they also had poorer quality of life and sexual function than women with POP alone. Our findings echo those of a smaller study in which 58 women with advanced POP were grouped into categories of stress continence or incontinence according to their responses on the Bristol Female Lower Urinary Tract Symptoms Questionnaires.16 Women with SUI symptoms were more likely to report urinary frequency, urgency and nocturia than those without such symptoms. The findings are also in agreement with a population based study showing that LUTS are common in women with POP and, indeed, they are common in older women in general. Of 4,000 Danish women 28% had at least 1 bothersome lower urinary tract symptom, excluding SUI.17 Of 110 women with at least grade 2 prolapse 21% to 45% reported urge incontinence, urgency, frequency and emptying difficulties at least weekly.18 Unfortunately these symptoms were not stratified by SUI, which is present in a quarter of these women. Similarly of 60 women, including 68% with SUI symptoms, almost half had urgency, frequency and nocturia.19
TABLE 3. Pelvic Floor Impact subscale scores Characteristic No. subjects Urinary Impact Questionnaire: Social Travel Emotional Physical CRAIQ POPIQ
Mean ⫾ SD Stress Continent
Mean ⫾ SD Stress Incontinent
p Value
296 147.2 ⫾ 50.3
82 213.4 ⫾ 76.3
⬍0.0001
32.0 ⫾ 11.3 39.2 ⫾ 16.9 35.9 ⫾ 12.6 40.6 ⫾ 17.7 129.3 ⫾ 50.3 145.5 ⫾ 57.3
48.8 ⫾ 19.6 56.1 ⫾ 21.0 50.5 ⫾ 19.2 57.6 ⫾ 23.9 175.9 ⫾ 85.1 192.6 ⫾ 84.3
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001
TABLE 4. Global and sexual quality of life outcomes Parameter SF-36 component summary score: Physical Mental PISQ (No. sexually active women only)
Mean ⫾ SD Stress Continent
Mean ⫾ SD Stress Incontinent
p Value
45.1 ⫾ 9.7 52.0 ⫾ 9.0 70.3 ⫾ 15.0 (149)
42.0 ⫾ 8.8 45.2 ⫾ 12.4 63.9 ⫾ 14.6 (38)
0.0032 ⬍0.0001 0.033
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Women with advanced POP report increased voiding dysfunction symptoms.4,20 This was also true in our population, although women with SUI were 50% more likely to have bothersome voiding symptoms than women without SUI (72% vs 49%). In general women with advanced prolapse are less likely to have SUI than women with early prolapse.5 Because we specifically focused on women planning to undergo surgery for prolapse, there was no difference in prolapse severity between women with and without SUI. Our findings should not be construed as being generalizable to the population of women with prolapse not seeking surgery. It is possible that the women in this study who complained of stress incontinence had a lower threshold for reporting symptoms than women without stress incontinence. That would be a potential explanation of the higher prevalence of other pelvic floor symptoms in this population. Many factors influence selfreporting of incontinence symptoms and we cannot exclude with certainty that our results are not explained by unmeasured differences between these groups.
Abbreviations and Acronyms CARE CRAIQ LUTS MESA
PFDI ⫽ PISQ ⫽ POP POPIQ POP-Q SUI UDI
1.
CONCLUSIONS
APPENDIX Pelvic Floor Disorders Network Members: Dr. Holly E. Richter (Principal Investigator), Kathryn L. Burgio (Co-Principal Investigator), Dr. Patricia Goode, Dr. R. Edward Varner, Dr. Mark Lockhart (Co-Investigators) and Velria Willis (Research Coordinator), University of Alabama at Birmingham; Dr. Paul M. Fine (Principal Investigator), Dr. Rodney A. Appell (Co-Principal Investigator), Dr. Peter K. Thompson, Dr. Peter M. Lotze (Co-Investigators) and Naomi Frierson (Research Coordinator), Baylor College of Medicine; Dr. Ingrid Nygaard (Principal Investigator), Dr. Karl Kreder, Dr. Catherine S. Bradley, Dr. Satish Rao (Co-Investigators), Debra Brandt and Denise Haury (Research Coordinators), University of Iowa; Dr. Geoffrey Cundiff (Principal Investigator), Dr. Victoria Handa, Dr. Jamie Wright, Dr. Robert Gutman (Co-Investigators) and Mary Elizabeth Sauter (Research Coordinator), The Johns Hopkins Medical Institutes; Dr. Linda Brubaker (Principal Investigator), Dr. Mary Pat FitzGerald (Co-Principal Investigator), Dr. Kimberly Kenton (Co-Investigator), Dorothea Koch and Charity Ball (Research Coordinators), Loyola University, Chicago; Morton B. Brown (Principal Investigator), Dr. John T. Wei (Co-Principal Investigator), Beverly Marchant (Project Manager), Dr. John O. L. DeLancey, Nancy K. Janz, Dean G. Smith, Patricia A. Wren (Co-Investigators), James Imus (Statistician) and Yang Wang Casher (Database Programmer), University of Michigan; Dr. Anthony G. Visco (Principal Investigator), Dr. AnnaMarie Connolly, Dr. John Lavelle, Dr. Ellen C. Wells, William Whitehead, Dr. Julia Fielding (Co-Investigators), Mary J. Loomis and Anita K. Murphy (Research Coordinators), University of North Carolina at Chapel Hill; Dr. Halina Zyczynski (Principal Investigator), Diane Borello-France, Dr. Wendy Leng, Dr. Pamela A. Moalli, Dr. Chiara Ghetti (Co-Investigators) and Judy A. Gruss (Research Coordinator), University of Pittsburgh/ Magee-Womens Hospitals; Dr. Robert Park (Steering Committee Chairman); and Dr. Anne M. Weber (Project Scientist), National Institute of Child Health and Human Development.
⫽ ⫽ ⫽ ⫽ ⫽
Colpopexy and Urinary Reduction Efforts Colorectal-Anal Impact Questionnaire lower urinary tract symptoms Medical, Epidemiologic and Social Aspects of Aging Pelvic Floor Distress Inventory POP/Urinary Incontinence Sexual Function Questionnaire pelvic organ prolapse POP Impact Questionnaire POP Quantification stress urinary incontinence Urogenital Distress Inventory
REFERENCES
2.
Clinicians should be aware that women presenting for prolapse surgery who have symptomatic SUI are likely to have a host of other obstructive and irritative urinary symptoms as well as colorectal and prolapse symptoms. They are also likely to have poorer overall quality of life and sexual function. Further research is needed to determine the effect of prolapse and incontinence surgery on overall bladder function and quality of life in women with the 2 conditions preoperatively. Given that stress incontinence may be a marker for pelvic floor disease severity, future studies assessing surgical outcomes should perhaps stratify for this important predictor.
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Bergman A, Koonings PP and Ballard CA: Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988; 158: 1171. Gallentine ML and Cespedes RD: Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures. Urology 2001; 57: 40. Gardy M, Kozminski M, DeLancey J, Elkins T and McGuire EJ: Stress incontinence and cystoceles. J Urol 1991; 145: 1211. Romanzi LJ, Chaikin DC and Blaivas JG: The effect of genital prolapse on voiding. J Urol 1999; 161: 581. Burrows LJ, Meyn LA, Walters MD and Weber AM: Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 2004; 104: 982. Veronikis DK, Nichols DH and Wakamatsu MM: The incidence of low-pressure urethra as a function of prolapse-reducing technique in patients with massive pelvic organ prolapse (maximum descent at all vaginal sites). Am J Obstet Gynecol 1997; 177: 1305. Marinkovic SP and Stanton SL: Incontinence and voiding difficulties associated with prolapse. J Urol 2004; 171: 1021. Rosenzweig BA, Pushkin S, Blumenfeld D and Bhatia NN: Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol 1992; 79: 539. Brubaker L, Cundiff GW, Fine P, Nygaard I, Richter HE, Visco AG et al: Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006; 354: 1557. Herzog AR, Diokno AC, Brown MB, Normolle DP and Brock BM: Two-year incidence, remission, and change patterns of urinary incontinence in noninstitutionalized adults. J Gerontol 1990; 45: M67. Barber MD, Kuchibhatla MN, Pieper CF and Bump RC: Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol 2001; 185: 1388. Ware JE Jr and Gandek B: Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA). J Clin Epidemiol 1998; 51: 903. Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S and Qualls C: A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ12). Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 164. Hunskaar S, Burgio K, Clark A, Lapitan MC, Nelson K, Sillen U et al: Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Incontinence. Edited by P Abrams, L Cardozo, S Khoury
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and A Wein. Plymouth, United Kingdom: Health Publications Ltd 2005; vol I, p 255. Ostergard DR: The neurological control of micturition and integral voiding reflexes. Obstet Gynecol Surv 1979; 34: 417. Long CY, Hsu SC, Wu TP, Sun DJ, Su JH and Tsai EM: Urodynamic comparison of continent and incontinent women with severe uterovaginal prolapse. J Reprod Med 2004; 49: 33. Moller LA, Lose G and Jorgensen T: The prevalence and bothersomeness of urinary tract symptoms in women 40 – 60 years of age. Acta Obstet Gynecol Scand 2000; 79: 298. Mouritsen L and Larsen JP: Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 122. Yalcin OT, Yildrim A and Hassa H: The effects of severe cystocele on urogynecologic symptoms and findings. Acta Obstet Gynecol Scand 2001; 80: 423. Chaikin DC and Blaivis JG: Voiding dysfunction: definitions. Curr Opin Urol 2001; 11: 395.
EDITORIAL COMMENT In this study the authors of the CARE trial report the incidence of obstructive and irritative voiding symptoms in women planning to undergo sacrocolpopexy. They found that women with prolapse reporting SUI on questionnaire were more likely to report LUTS than those without SUI. The authors had hypothesized the reverse, that is those without SUI would have more obstruction due to prolapse and, therefore, have greater bother associated with LUTS. This hypothesis is based partially on the finding that in women without prolapse pressure flow findings are less obstructive in those with urodynamically proven SUI.1 It is not clear that in women with prolapse the symptom SUI alone is associated with decreased outlet resistance. This study certainly questions the relationship of SUI symptoms and chronic outlet resistance in women with prolapse, if not the
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relatively accepted relationship between increased outlet resistance and LUTS or perhaps the 2 conditions. One must also keep in mind that women with SUI reported only the symptom and SUI was not demonstrated objectively. It was these women who were more likely to report irritative and obstructive voiding symptoms. As the authors point out, it is distinctly possible that this group of women may be more likely to report urinary symptoms overall, a finding unrelated to the prolapse condition. Furthermore, it is not clear that the proportion of women who might have been found to have SUI on objective testing would have had more LUTS than those with SUI by symptom alone. Arguably it remains imperative to demonstrate SUI objectively when considering vaginal surgery for prolapse since it has not been established that the role of a prophylactic SUI procedure for the vaginal repair of prolapse can be assumed based on the results of the CARE trial (reference 9 in article). Presumably the risk of an inappropriate sling procedure at vaginal prolapse repair would exceed that of a Burch procedure done at sacrocolpopexy. To their credit the authors do not over speculate on their findings. Studies such as this continue to help us better understand urinary symptoms in our patients with prolapse. An analysis of LUTS outcomes in patients with and without SUI symptoms would allow us to better counsel our patients as we prepare them for surgery. Gary E. Lemack Department of Urology University of Texas Southwestern Medical Center Dallas, Texas 1.
Lemack GE, Baseman, AG and Zimmern PE: Voiding dynamics in women: a comparison of pressure-flow studies between asymptomatic and incontinent women. Urology 2002; 59: 42.