Eyeball (Office) urodynamics: is there value to predict hidden (Occult) stress urinary incontinence with sims speculum reduction in patients with pelvic organ prolapse? – a retrospective descriptive study
Thesis (MMed)--Stellenbosch University, 2019.
Introduction: Occult stress urinary incontinence (OSUI) is an accepted predictor of postoperative stress urinary incontinence (POSUI) in stress continent women with pelvic organ prolapse (POP)(1). De novo stress urinary incontinence (SUI) occurs in 22% of women following POP surgery(2). This newly developed postoperative SUI leads to patient dissatisfaction after reconstructive surgery if the patient was not adequately counselled preoperatively. Currently there is no standardised reduction test for OSUI but in the literature different methods have been described(3). Aims and Objectives: The objective of this study is to determine sensitivity, specificity and predictive values of Sims speculum reduction of pelvic organ prolapse as a preoperative test to predict occult stress urinary incontinence with the help of eyeball/ office urodynamics (UDS). Methods: This is a retrospective study of 123 patients who have undergone POP surgery during a three year period from January 2014 until December 2016 in our institution. POP was assessed by history and the clinical POP-Q grading system. Routine preoperative UDS (eyeball or laboratory) with Sims speculum reduction of the prolapse in a sitting position were performed. To test for OSUI at maximum bladder capacity or to a maximum of 500ml, the Sims speculum was placed in the posterior fornix for the intact uterus or in the vault with a previous hysterectomy. Posterior compartment prolapse only on its own was excluded from routine UDS Frank or OSUI patients were counselled for either 1-step (combined POP surgery with anti-incontinence procedure) or 2-step surgery (POP surgery only). At the 6 week visit, postoperative SUI was checked by history, clinical examination and ICIQ-SF questionnaire. Retrospective data was available for at least 2 years postoperatively to determine SUI and reoperation rates. Statistical analysis was performed with SPSS version 25 software. Results: A total of 123 patients were entered with a mean age of 60.37 years, BMI 29.5kg/m2, and median parity of 3. 83.7% had grade 2 -3 anterior POP, while 3.3% had grade 4. UDS tests were performed in 95 of the 123 patients with POP. Of those, 66 received eyeball/office UDS and 29 laboratory UDS. In the eyeball UDS group, 18 patients had frank SUI, 17 with OSUI and 30 without OSUI. One had severe involuntary urine leakage and SUI could not be assessed. Of the 17 OSUI patients, 6 had 1-step surgery performed while 11 had 2-step surgery. Among the 14 OSUI patients that presented for 6 week follow up, postoperative SUI was clinically demonstrated in two cases, where one was from the 2-step surgery group and none required anti-incontinence surgery. Only 4 patients overall had bothersome postoperative SUI and 3 required mid urethral sling (MUS). The rate of secondary surgery for MUS insertion in the current study was low even for those patients who had frank SUI preoperatively and 2-step surgery (5.6%). The outcome for the Sims speculum reduction test for OSUI can be reported as follows: the sensitivity is 20%, the specificity is 78.12%, the positive predictive value is 12.5% and the negative predictive value is 86.21%. Overall, 31.7% of the patients had postoperative anterior compartment prolapse grade 2 and 1 (0.8%) patient with grade 3 anterior compartment prolapse. A total of 7 patients required reoperation for POP. The overall incidence of postoperative SUI in women with recurrence of anterior compartment prolapse was 15%, while the incidence was lower at 10% for women without recurrence of anterior POP. Conclusion: The Sims speculum reduction method with eyeball UDS in a sitting position has poorly predicted postoperative SUI, in OSUI patients diagnosed preoperatively. The limitation in our study is the retrospective design, small sample size, non-standardised cough stress test and recurrence of anterior compartment prolapse. The protective effect of anterior POP recurrence against POSUI as mentioned in Lensen’s study was not observed(2). Caution should be exercised before statistical conclusions can be made from current findings.
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