The Impact of Pelvic Organ Prolapse Surgery on Postoperative Urge Incontinence: A Secondary Analysis

INTRODUCTION: Pelvic organ prolapse (POP), a common disorder affecting millions of women in the U.S., is associated with multiple other genitourinary symptoms. Compared to women without POP, women with POP are six times more likely to report symptoms of overactive bladder (OAB), including urinary urgency, frequency, and urge urinary incontinence (UUI). Prior studies have demonstrated improvement in OAB symptoms following both conservative and surgical management of POP. Given prevalence as high as 70–88% of OAB symptoms among women with symptomatic POP, evaluating the effect of surgical prolapse repair on urgency symptoms is critical for guiding surgical counseling and postoperative expectations. OBJECTIVE: To evaluate changes in UUI symptoms in women undergoing apical and anterior wall repair for management of pelvic organ prolapse. METHODS: This study is a secondary analysis of all women participating in the SUPeR, OPTIMAL, and OPUS trials using data from the NIH Data and Specimen Hub (DASH) database. Differences in POP-Q measurements were evaluated from baseline to 12 months post-op. Changes in urge incontinence symptoms were determined by responses to the Pelvic Floor Distress Inventory (PFDI). Changes in overall urinary function were assessed using the Urogenital Distress Inventory (UDI) subscore of the PFDI and Urinary Impact Questionnaire (UIQ) subscore of the Pelvic Floor Impact Questionnaire. RESULTS: A total of 735 women were included for analysis across the three studies. 82.3% of the cohort underwent a native tissue repair, 13.6% a vaginal mesh-augmented repair, 69.1% an anterior repair, and 68.8% had a concomitant mid-urethral sling (MUS). Statistically significant differences in POP-Q measurements from baseline to 12 months post-op were seen for all points measured (p<0.001). Post-op improvement in UUI and bladder emptying was demonstrated with significant improvement in UDI and UIQ subscores (p<0.001). Subjects with preexisting UUI had greater improvements in UDI and UIQ subscores compared to those without preexisting UUI (p<0.001). Degree of improvement as measured by UDI and UIQ subscores varied by surgery type, although the greatest improvement was seen for the combination of either uterosacral ligament suspension or sacrospinous ligament fixation with an anterior repair and concomitant MUS. In general, undergoing an MUS (with or without anterior repair) resulted in greater improvement in UDI and UIQ subscores than receiving only an anterior repair alone (p<0.001). In evaluation of point-Ba of the POP-Q as a surrogate for anterior wall support and point-C as an indicator for apical support, there was no difference across the three trials with regards to change in Ba or C resulting in a clinically significant change in the UDI or UIQ subscores. There was no identifiable threshold at which a change in point-Ba or point-C resulted in a clinical difference in either subscore. However, improvements in difficult and incomplete bladder emptying were seen as the mean change in point Ba (i.e., distance of displacement proximally) approached 3.6 cm (p 0.003, 0.012, respectively). CONCLUSIONS: Pelvic organ prolapse surgery results in improvement in urinary symptoms including UUI with greatest improvements in women undergoing a combination of non-obliterative native tissue repair with anterior repair and concomitant mid-urethral sling (Tables 1 and 2).