Introduction• Lower urinary tract symptoms (LUTS)before POP surgery• LUTS after POP surgery epidemiology evaluation int...
LUTS before POPsurgery• Up to 63% with bulge symptoms• Up to 73% with UI• Up to 86% urgency or frequency• Up to 62% voidin...
OABand QoL
Urinary Distress Inventory (UDI)(ext. version)
Pelvic FloorDistress Inventory (PFDI)
PFDI
Incontinence Impact Questionnaire (IIQ)(ext. Version)
Incontinence Impact Questionnaire (IIQ)(short version)
Pelvic FloorImpact Questionnaire (PFIQ)
OABand POP• OAB & POP are both commonconditions• POP is not a causative factor of OABbut is a coincidental finding…• ...bu...
OABand POP• Relative Risk (RR) of OAB in women withPOP is 2.1-5.8• Conflicting data about relationshipbetween stage/compar...
Effect of POPsurgery on OAB
Effect of POPsurgery on OAB
Effect of POPsurgery on OAB
OABafterPOPsurgery without SUIsurgeryDifferent risk patterns for different OABsymptoms:• Post-op frequency and urgency les...
Effect of POPsurgery on OAB
OABafterPOPsurgery without SUIsurgery
OABafterPOPsurgery without SUIsurgery“It is the chang e in opening pressure ratherthan the baseline value which is of impo...
OABafterPOPsurgery without SUIsurgeryEvidence emerging by studies with UD:• Improvement of the flow rate and fall of theop...
Effect of POPsurgery on DO
Effect of POPsurgery on DO• Most studies showed an improvementafter POP surgery but the effect is not ofthe same magnitude...
Effect of POPsurgery on OAB
OABafterPOPsurgery with SUIsurgeryControversial findings !!• Preoperative DO as predictor for persistenceof OAB complaints...
De novo OABafterPOPsurgery• Prevalence: 5-22 %• Older age, BMI and SUI surgery were riskfactors for de novo OAB and UUI• A...
Effect of POPsurgery on voiding• Placement of vaginal ring pessary led to anormal free-flow rate in 94% of women withgrade...
Effect of POPsurgery on voiding• It has been hypothesized that women withsignificant POP, particularly of the anteriorvagi...
Effect of POPsurgery on voiding• Distinction between detrusor underactivityand bladder outlet obstruction in women isvery ...
Effect of POPsurgery on voiding• The cause of this obstruction or outletresistance is not fully understood• Mechanical ure...
Effect of POPsurgery on voiding• Women with proven voiding dysfunction onfree flowmetry were more likely to have acystocel...
Effect of POPsurgery on voiding• An enterocele was consistently associatedwith low flow rate, indicating that repair ofpos...
Effect of POPsurgery on voiding• Hence voiding dysfunction is not only relatedto the anterior vaginal wall prolapse and re...
Occult stress urinary incontinence(OSUI) and POP• OSUI prior POP surgery: 5-30%• Due to the lack of randomised controlledt...
Occult stress urinary incontinence(OSUI) and POP• “. . . in wo m e n with O SIand PO P, a clinicianwo uld have to inse rt ...
De novo SUI afterPOPsurgery
De novo SUI afterPOPsurgery
De novo SUI afterPOPsurgeryICI
De novo SUI afterPOPsurgery
Valutazione e interpretaz delle alterazioni minzionali dopo chirurgia del prolasso_Curti
Valutazione e interpretaz delle alterazioni minzionali dopo chirurgia del prolasso_Curti
Valutazione e interpretaz delle alterazioni minzionali dopo chirurgia del prolasso_Curti
Valutazione e interpretaz delle alterazioni minzionali dopo chirurgia del prolasso_Curti
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Valutazione e interpretaz delle alterazioni minzionali dopo chirurgia del prolasso_Curti

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Dr. Curti Corso GLUP TV - 22-23 marzo 2013

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Valutazione e interpretaz delle alterazioni minzionali dopo chirurgia del prolasso_Curti

  1. 1. Introduction• Lower urinary tract symptoms (LUTS)before POP surgery• LUTS after POP surgery epidemiology evaluation interpretation
  2. 2. LUTS before POPsurgery• Up to 63% with bulge symptoms• Up to 73% with UI• Up to 86% urgency or frequency• Up to 62% voiding dysfunction
  3. 3. OABand QoL
  4. 4. Urinary Distress Inventory (UDI)(ext. version)
  5. 5. Pelvic FloorDistress Inventory (PFDI)
  6. 6. PFDI
  7. 7. Incontinence Impact Questionnaire (IIQ)(ext. Version)
  8. 8. Incontinence Impact Questionnaire (IIQ)(short version)
  9. 9. Pelvic FloorImpact Questionnaire (PFIQ)
  10. 10. OABand POP• OAB & POP are both commonconditions• POP is not a causative factor of OABbut is a coincidental finding…• ...but there is a causal link
  11. 11. OABand POP• Relative Risk (RR) of OAB in women withPOP is 2.1-5.8• Conflicting data about relationshipbetween stage/compartment POP and OABsymptoms• In all studies there was an improvement inOAB after POP surgery (up to 69%)• Thus the strong link between POP andOAB seems quite compelling
  12. 12. Effect of POPsurgery on OAB
  13. 13. Effect of POPsurgery on OAB
  14. 14. Effect of POPsurgery on OAB
  15. 15. OABafterPOPsurgery without SUIsurgeryDifferent risk patterns for different OABsymptoms:• Post-op frequency and urgency less commonin women with higher pre-op POP-Q stages• Use of vaginal mesh material had a favorableeffect on urgency• Previous hysterectomy predictor forbothersome post-op urgencyEvidence emerging by studies without UD:
  16. 16. Effect of POPsurgery on OAB
  17. 17. OABafterPOPsurgery without SUIsurgery
  18. 18. OABafterPOPsurgery without SUIsurgery“It is the chang e in opening pressure ratherthan the baseline value which is of importancein symptom resolution”
  19. 19. OABafterPOPsurgery without SUIsurgeryEvidence emerging by studies with UD:• Improvement of the flow rate and fall of theopening pressure related to improvement• Relationship between preoperative DO(OR0.2) and bladder trabeculation (OR 6.1) andimprovement of UUI after surgery• Higher preoperative detrusor pressure wasassociated with persistence of symptoms
  20. 20. Effect of POPsurgery on DO
  21. 21. Effect of POPsurgery on DO• Most studies showed an improvementafter POP surgery but the effect is not ofthe same magnitude as for OAB symptoms(RR>1)
  22. 22. Effect of POPsurgery on OAB
  23. 23. OABafterPOPsurgery with SUIsurgeryControversial findings !!• Preoperative DO as predictor for persistenceof OAB complaints after surgery• Preoperative DO as predictor of improvement
  24. 24. De novo OABafterPOPsurgery• Prevalence: 5-22 %• Older age, BMI and SUI surgery were riskfactors for de novo OAB and UUI• After correction for age and BMI, onlyconcomitant SUI surgery was predictor for denovo OAB and UUI
  25. 25. Effect of POPsurgery on voiding• Placement of vaginal ring pessary led to anormal free-flow rate in 94% of women withgrade 3 or 4 cystocele• Vaginal ring pessary mimics the surgicalcorrection of prolapse and improve voidingby relieving urethral kinking caused bycystocele
  26. 26. Effect of POPsurgery on voiding• It has been hypothesized that women withsignificant POP, particularly of the anteriorvaginal wall, may have impaired bladderemptying owing to a “kink” in the normalurethral mechanism• Because of this, these women may alsohave voiding dysfunction
  27. 27. Effect of POPsurgery on voiding• Distinction between detrusor underactivityand bladder outlet obstruction in women isvery difficult:Cystometry and pressure flow studyCystometry and pressure flow study• not well validated methods to evaluate detrusorcontractility• controversial urodynamic definition of obstructiion• useful relationship pressure/flow for the diagnosisof obstruction (high Pdet/low Qmax)• nomograms validated only in male patients
  28. 28. Effect of POPsurgery on voiding• The cause of this obstruction or outletresistance is not fully understood• Mechanical urethral kinking• Urethral and/or bladder neck compressionby the cystocele• Alteration of urethral innervation affectingurethral relaxation, detrusor contraction andefficient bladder emptying
  29. 29. Effect of POPsurgery on voiding• Women with proven voiding dysfunction onfree flowmetry were more likely to have acystocele and an intact retrovesical angle onultrasound
  30. 30. Effect of POPsurgery on voiding• An enterocele was consistently associatedwith low flow rate, indicating that repair ofposterior vaginal wall may solve voidingdysfunction
  31. 31. Effect of POPsurgery on voiding• Hence voiding dysfunction is not only relatedto the anterior vaginal wall prolapse and repairof other prolapsed compartment may alsoresult in resolution of voiding dysfunction andpossibly OAB• The ultrasound appearance of the bladderneck and retrovesical angle may be moreimportant in function than the stage of prolapseseen clinically• The use of ultrasound to assess the bladderand voiding function is worthy of moreresearch
  32. 32. Occult stress urinary incontinence(OSUI) and POP• OSUI prior POP surgery: 5-30%• Due to the lack of randomised controlledtrials there are not clearly defined treatmentstrategies for POP and OSUI• Positive association between OSUI and postoperative SUI (15% subjective SUI)• However OSUI does not adequately identifyindividual women in need of prophylactic anti-incontinence surgery undergoing POP repair
  33. 33. Occult stress urinary incontinence(OSUI) and POP• “. . . in wo m e n with O SIand PO P, a clinicianwo uld have to inse rt 1 0 TVT to pre ve nt 1wo m an fro m re q uiring a sling 2-4 ye ars po st-o pe rative ly”
  34. 34. De novo SUI afterPOPsurgery
  35. 35. De novo SUI afterPOPsurgery
  36. 36. De novo SUI afterPOPsurgeryICI
  37. 37. De novo SUI afterPOPsurgery

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