Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment

INTRODUCTION — Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) coexist in up to 80 percent of women with pelvic floor dysfunction [1]. While these conditions are often concurrent, one may be mild or asymptomatic, which makes selection of the optimal surgical procedure(s) challenging. Prolapse repair can unmask urinary incontinence in previously continent women or worsen existing SUI symptoms [2].

Combined surgical treatment for POP and SUI will be reviewed here. Other approaches to surgical and medical treatment of these conditions and other types of urinary incontinence are discussed separately.

●(See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)

●(See "Female urinary incontinence: Evaluation".)

●(See "Female stress urinary incontinence: Choosing a primary surgical procedure".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

TERMINOLOGY

●Stress urinary incontinence (SUI) – Leakage of urine with increased intraabdominal pressure (eg, cough, physical activity). (See "Female urinary incontinence: Evaluation", section on 'Clinical tests'.)

●Occult SUI – In women without symptoms of SUI, occult SUI describes the finding of SUI that is apparent only during clinical or urodynamic urinary function testing when the prolapse is reduced (ie, stress testing with reduction of prolapsed structures). Occult stress incontinence is also referred to as latent, hidden, iatrogenic, or potential. (See 'Occult SUI' below.)

There are inconsistent definitions of occult SUI in the medical literature. While some authors use the term to describe only incontinence that has been demonstrated on urinary function testing (as in this topic review), others use the term occult incontinence to highlight the possibility that SUI will occur after prolapse repair.

●De novo urinary incontinence – This term is used to describe urinary incontinence that is newly symptomatic, typically after surgery, in a previously continent patient. The type of new incontinence should be specified (eg, stress, urge). As an example, a patient with urgency incontinence and no SUI before surgery may have persistent urgency incontinence and de novo stress incontinence after surgery.

●Prolapse reduction testing – Support of prolapse to approximate normal pelvic support during pelvic examination or clinical or urodynamic urinary function testing. This is performed in combination with a urinary stress test (cough test) to test for occult SUI. (See 'Detection and risk calculation' below.)

SURGICAL ISSUES FOR CONSIDERATION

Concurrent or staged procedures for POP and SUI — Prolapse repair can unmask SUI in previously asymptomatic women or worsen existing SUI symptoms [2]. Deciding whether to perform concurrent surgical procedures to treat both prolapse and SUI or a single procedure that addresses only one condition requires balancing the risks of incomplete treatment and potential need for additional future surgery with the risks of exposing the patient to unnecessary surgery and potential complications, particularly for asymptomatic patients [3]. This decision becomes further involved when results from the preoperative evaluation are ambiguous (eg, prolapse noted on examination in a patient with no prolapse-related symptoms or a patient with advanced prolapse with no leakage on prolapse reduction testing). Shared decision making is performed to incorporate the patient's goals and preferences rather than simply focusing on anatomic correction [4,5]. One tool that can help guide the discussion is an incontinence risk calculator for women considering POP surgery available through the American Urogynecologic Society [6].

With the use of the midurethral sling as our primary SUI procedure, based on the low number of subsequent SUI procedures needed following prolapse repair and the similar efficacies of the SUI repairs themselves regardless of timing [7-9], we offer options and generally counsel women that a staged approach is a reasonable option for those who wish to avoid the additional surgical risks of incontinence surgery (eg, bladder perforation, urinary tract infection, major bleeding, and urinary retention). For women who prioritize a lower risk of postoperative SUI and/or desire a single operative experience, as well as accept the increased surgical risks of a dual procedure, we counsel that concurrent procedures for SUI and POP are reasonable.

Our approach is informed by the following data:

●In a 2012 multicenter trial of 327 women with anterior POP (stage 2 or higher) but without symptoms of stress incontinence, the 3- and 12-month rates of postoperative SUI were nearly double for women randomly assigned to prolapse repair alone compared with women undergoing prolapse repair and concurrent tension-free vaginal tape (TVT; 3 months: 49 versus 24 percent; 12 months: 43 versus 27 percent) [8]. However, less than 10 percent of the women from this trial who did not initially receive a TVT elected to have a staged TVT, which suggests a low rate of residual bothersome SUI after repair of prolapse alone. A subsequent smaller trial including 80 women noted similar findings [9].

●In a 2010 multicenter trial of 181 women with POP and SUI who were assigned to undergo prolapse repair with either concurrent or staged (three months after prolapse repair) TVT, the SUI cure and complication rates were similar between groups (SUI cure rates of 95 versus 89 percent and complication rates of 18 versus 13 percent, respectively) [7]. Of note, in the staged group, TVT was ultimately performed on only about half of the women (56 percent) who had confirmed SUI at three months after prolapse repair. Among the women in the staged group who did not undergo TVT, one-year outcomes were as follows: 27 percent were still continent, and 15 percent had some SUI but declined TVT.

●Earlier observational comparative studies reported no significant differences in SUI cure rates among women who underwent midurethral sling placement alone compared with sling placement combined with vaginal surgery (hysterectomy or prolapse repair) [10-12]. In a prospective cohort study, women who underwent prolapse repair concurrently with midurethral sling placement, compared with those who planned a staged procedure, had no significant differences in SUI symptoms (22 versus 21 percent), change in severity of SUI, or satisfaction (8.8 versus 9.2 on a 10-point scale) at one-year follow-up [13]. Of note, only 33 percent of the women in the planned staged group underwent sling placement within the study period.

Data from the United States National Inpatient sample reported that, for apical prolapse repair procedures, the rate of concurrent continence surgery increased from 38 percent in 2001 to 47 percent in 2009 [14].

Vaginal, minimally invasive abdominal, or open abdominal surgical routes — For women with both SUI and POP, surgical treatment can be performed entirely vaginally, entirely abdominally (including open, laparoscopic, and robotic techniques), or with a combination of both. After performing shared decision making with the patient, we generally choose the surgical route that is most appropriate to treat the anatomic site(s) of prolapse (ie, anterior, apical, posterior), with the goal of avoiding incisions in two sites, if possible.

●All vaginal – All-vaginal surgery typically includes whichever POP procedures are necessary to address the affected compartments (anterior, apical, and posterior) and a suburethral sling (generally a midurethral sling). Advantages of the all-vaginal approach include ease of recovery associated with minimally invasive surgery, fewer complications compared with the abdominal route, and ability to perform multisite vaginal repair using native tissue (ie, no foreign body). However, for women with vault prolapse, transvaginal surgery is associated with lower rates of anatomic success. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Abdominal versus vaginal approach' and "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Vaginal approach'.)

●Minimally invasive abdominal prolapse and vaginal incontinence procedures – A dual abdominal/vaginal approach takes advantage of the benefits of both techniques with the disadvantage of requiring two surgical routes and thus increasing complication risk. In particular, for women with apical prolapse and SUI, a sacrocolpopexy (laparoscopic or robotic) and midurethral sling combine two minimally invasive procedures with high efficacy, although both abdominal and vaginal incisions are required. In a planned secondary analysis of a trial comparing Burch urethropexy and midurethral sling in women undergoing sacrocolpopexy, women in the midurethral sling group reported higher rates of stress-specific continence at two years of follow-up (70 versus 45 percent) [15]. (See 'Minimally invasive (laparoscopy or robot-assisted)' below.)

●All abdominal – For women with apical prolapse and SUI, an all-abdominal approach typically includes a sacrocolpopexy and Burch colposuspension. Both laparoscopic and robot-assisted abdominal sacrocolpopexy provide the ease of recovery of minimally invasive surgery (compared with open abdominal surgery) and result in a more durable prolapse repair compared with transvaginal apical suspension techniques. However, because of the increased technical difficulty of laparoscopic or robotic Burch procedures compared with transvaginal midurethral sling procedures, most surgeons perform a transvaginal midurethral sling procedure at the time of sacrocolpopexy for the treatment of SUI, as discussed below [15]. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Benefits of abdominal repair' and "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Abdominal approach'.)

Additional factors that influence selection of the surgical route include:

●Patient preference.

●Medical history – Comorbidities, prior surgeries.

●Procedure efficacy – This depends upon both the procedure and surgeon's experience [16].

PREOPERATIVE EVALUATION

General evaluation — Women who are considering pelvic reconstructive surgery for POP or SUI should have a comprehensive evaluation to guide surgical planning. All patients benefit from medical optimization, surgical counseling, procedure consent, and plans for thromboprophylaxis and prevention of surgical site infection. (See "Urogynecologic surgery: Perioperative care issues", section on 'Preoperative'.)

Preoperative evaluation typically includes:

●Medical history and symptoms related to POP and SUI (a voiding diary may be useful).

●Pelvic examination with objective quantification of prolapse.

●Clinical or urodynamic urinary stress testing with and without reduction of prolapse. In continent women, testing with prolapse reduction is recommended. (See 'Detection and risk calculation' below.)

●Assessment of patient goals and quality of life.

The complete diagnostic and preoperative evaluations unique to women with POP or SUI are discussed in detail separately:

●(See "Pelvic organ prolapse in women: Diagnostic evaluation".)

●(See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure".)

Informed consent and patient goals — In addition to general surgical risks and consent related to surgical materials specific to planned surgery, women planning pelvic floor reconstructive surgery should be counseled about the potential for incomplete resolution of symptoms or postoperative development or new symptoms of SUI, urinary retention, or urgency incontinence.

Discussing patient goals and setting expectations can also help both the patient and surgeon measure surgical success. Achievement of patient goals, including symptom resolution, or improvement in lifestyle, activity, or sexual function, correlates with postoperative satisfaction [4,5]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Establishing patient goals'.)

Identification of special populations

●Women with high surgical risk – Depending on the degree of surgical risk, women with SUI and POP can be treated using conservative measures (eg, pessary, pelvic floor exercises); however, surgery may be an option for some. Colpocleisis (surgical obliteration of the vaginal lumen) is the procedure of choice in women at high surgical risk who are not planning further sexual intercourse and desire surgical treatment. This procedure involves minimal surgical risk and can be combined safely and effectively with a midurethral sling procedure for treatment of symptomatic SUI or occult SUI. Assessment of the postvoid residual is recommended prior to surgery. In this group, special consideration should be given to performing SUI and POP procedures concurrently, as opposed to staged, in order to avoid two separate surgical events, assuming the patient does not have voiding dysfunction [17-19]. (See "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)".)

●Women planning future pregnancy – In general, women planning future pregnancy should not undergo pelvic floor reconstructive surgery. Pelvic support may be disrupted during the process of pregnancy and delivery, which can necessitate further surgery after delivery. Conservative measures are appropriate treatment for these patients. In rare cases, women with severe symptoms that are refractory to conservative treatment will undergo surgery even though they may be considering future pregnancy. (See "Vaginal pessaries: Indications, devices, and approach to selection" and "Female urinary incontinence: Treatment".)

●Women at risk for occult SUI – Women with advanced POP (pelvic organ prolapse quantitation system [POP-Q] stage II to IV) are at particular risk for occult SUI [1]. For these women, the occult SUI may become apparent only when the prolapse has been corrected. We evaluate all women with prolapse but no SUI symptoms for the presence of occult SUI, although the predictive value of such testing is limited. (See 'Symptomatic POP without symptomatic SUI' below and 'Occult SUI' below.)

APPROACH BASED ON PATIENT PRESENTATION — POP and SUI may present in isolation or concurrently in a variety of combinations. As examples, women with advanced prolapse may have occult SUI, and women with SUI may have pelvic support defects that are asymptomatic. The combination of symptoms and findings on preoperative evaluation guide the choice of procedure(s) for treatment. Choosing a procedure that addresses POP, SUI, or both is discussed here (algorithm 1).

Symptomatic POP and symptomatic SUI — For women with symptoms of both POP and SUI, we recommend concurrent prolapse repair and continence procedure rather than POP repair alone (algorithm 1). Cumulative data from trials, prospective observational studies, and retrospective reviews of women with both symptomatic POP and SUI report significantly lower rates of postoperative SUI in women who undergo both POP repair and a continence procedure compared with those who undergo POP repair alone (residual incontinence rates of 0 to 54 versus 28 to 84 percent, respectively) (algorithm 2) [7,15,20-32]. However, differing assessments of the data exist. A meta-analysis that separately evaluated a subset of trials concluded that, for POP surgery in women with SUI, a concomitant midurethral sling probably reduced postoperative subjective SUI rates in women undergoing vaginal repair (risk ratio [RR] 0.30, 95% CI 0.19-0.48, 319 women, two trials) and probably decreased the need for future continence surgery (RR 0.04, 95% CI 0.00-0.74, 134 women, one trial), but also noted that vaginal repair with concurrent versus staged midurethral sling did not result in differing postoperative SUI rates between the groups (RR 0.45, 95% CI 0.12-1.37, 140 women, one trial) [33]. The meta-analysis concluded that a midurethral sling probably reduced rates of postoperative SUI and should be discussed but that a staged approach was also reasonable.

One limitation of concurrent treatment for SUI at the time of POP repair is there is no single procedure that adequately treats both POP and SUI [20]. Selection of a primary procedure for treatment of SUI is discussed in detail separately. (See "Female stress urinary incontinence: Choosing a primary surgical procedure".)

Symptomatic POP without symptomatic SUI

Comparison of surgical strategies — The management of women with symptomatic POP, but no SUI symptoms, is controversial. Continent women with stage I POP who are planning prolapse repair are unlikely to have urethral obstruction and resultant occult SUI and thus are unlikely to benefit from a concurrent continence procedure. This may include women having hysterectomy for an indication other than prolapse (ie, cervical dysplasia, menorrhagia) who also happen to have apical descent greater than half the total vaginal length and would benefit from an apical suspension, or the rare case of isolated uterine prolapse, which is symptomatic and bothersome at stage I but without anterior vaginal wall prolapse. These women generally do not require concurrent continence surgery. We generally do not perform a concurrent continence procedure on these women but do counsel them regarding the potential need for a staged intervention should postoperative incontinence develop.

With increasing prolapse severity, however, there is a high likelihood that they will develop SUI postoperatively, and thus the additional risks of continence surgery are more likely to be outweighed by the benefits. Further confounding the decision is a lack of a highly accurate diagnostic test for occult SUI. (See 'Predictive value' below.)

There are three possible strategies for addressing potential SUI at the time of stage II or greater POP treatment in women without SUI symptoms:

●Universal – Concurrent surgeries are performed for POP and SUI, regardless of preoperative prolapse reduction and urinary stress testing, if performed. This approach recognizes the limited value of prolapse reduction stress testing and minimizes the number of trips to the operating room for a patient. The major disadvantage is that some women will undergo surgery, and attendant surgical risk, that was unnecessary. (See 'Predictive value' below.)

●Selective – Preoperative prolapse reduction and urinary stress testing is performed. If occult SUI is detected, a continence procedure is performed at the time of POP repair (concurrent procedures). If occult SUI is not detected, POP repair alone is performed, and an SUI procedure is performed at a future date, if needed (staged procedures). This approach attempts to harness the predictive value of the preoperative reduction stress test to treat the women at greatest risk of postoperative SUI and minimize unnecessary surgery for those women at lower risk. (See 'Detection and risk calculation' below.)

●Staged – In the staged approach, POP repair alone is performed without a concurrent SUI procedure. Preoperative prolapse reduction and urinary stress testing are not required prior to prolapse repair. A subsequent continence procedure is performed only if the patient develops SUI symptoms and desires surgical treatment. This approach generally appeals to women who place a high priority on avoiding an unnecessary procedure. However, this approach also requires two different surgical events, and some women may elect to endure SUI symptoms rather than have a second surgery.

Two trials, one using all vaginal surgery and one using all open abdominal surgery, assessed the residual SUI rates among women who were randomly assigned to universal or no SUI procedure at the time of surgical POP repair.

●All vaginal surgery – In the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial, 337 women with stage II to IV prolapse but without SUI symptoms were assigned to undergo transvaginal prolapse repair (including apical suspension, anterior repair, colpocleisis) with either universal retropubic midurethral sling (tension-free vaginal tape [TVT]) or sham bilateral suprapubic incisions [8]. For this all-vaginal approach, the rates of postoperative SUI were lower in the sling group compared with the sham group at both 3 and 12 months of follow-up (24 versus 49 percent and 27 versus 43 percent, respectively). For women whose preoperative testing indicated no occult SUI, 38 percent developed postoperative SUI at three months if concurrent continence surgery was not performed compared with a 21 percent residual SUI rate for women who underwent TVT insertion. For women whose preoperative testing indicated occult SUI, 72 percent developed postoperative SUI at three months if concurrent continence surgery was not performed compared with a 30 percent residual SUI rate for women who underwent TVT insertion.

While the degree of benefit in preventing de novo SUI was similar to that reported in the CARE trial, the complication rates were higher in women who underwent a TVT procedure compared with those who did not (bladder perforation: 7 versus 0 percent, urinary tract infection [UTI]: 31 versus 18 percent, major bleeding complications: 3 versus 0 percent, and urinary retention at six weeks: 4 versus 0 percent, respectively).

●All open abdominal surgery – In the Colpopexy and Urinary Reduction Efforts (CARE) trial, 322 women with stage II to IV prolapse but without SUI symptoms were assigned to undergo open sacrocolpopexy with or without Burch colposuspension [2,34-36]. For this all-abdominal surgical approach, the rates of postoperative SUI were lower in the universal Burch versus no Burch groups at 3 and 24 months of follow-up (24 versus 44 percent and 32 versus 45 percent, respectively) [2,36]. For women whose preoperative testing indicated no occult SUI, 39 percent developed postoperative SUI if concurrent continence surgery was not performed compared with a 20 percent residual SUI rate for women who underwent concurrent Burch colposuspension. For women whose preoperative testing indicated occult SUI, 60 percent developed postoperative SUI if concurrent continence surgery was not performed compared with a 37 percent residual SUI rate for women who underwent concurrent Burch colposuspension. A detailed discussion of the data from the CARE trial is presented below. (See 'Open abdominal (laparotomy)' below.)

Our approach by surgical route — Our approach to continent women with stage II prolapse or greater planning POP repair depends upon whether or not they were found to have occult SUI on preoperative prolapse reduction and urinary stress testing (ie, selective approach) (algorithm 1). (See 'Comparison of surgical strategies' above.)

Discussions of the advantages and risks of abdominal and vaginal prolapse repair as well as selection of a primary incontinence procedure are presented separately.

●(See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

●(See "Female stress urinary incontinence: Choosing a primary surgical procedure".)

Vaginal — For women with POP but no symptoms of SUI who are planning all-vaginal surgery, the best approach to management (universal, selective, or staged surgical treatment of SUI) is unclear and a shared decision-making process with the patient is necessary. Patient counseling should include the potential benefits of the prophylactic continence surgery (based upon the results of preoperative prolapse reduction and urinary stress testing), potential complications (including surgical complications, UTIs, dysfunctional voiding, and mesh-related complications, if used), and patient goals and preferences (algorithm 1).

Selective approach — While the final surgical decision is based upon the patient's preferences, given the available evidence (algorithm 2) and clinical considerations, we take a selective approach to the treatment of potential SUI in women undergoing vaginal surgery and base the surgical treatment (concurrent or staged SUI surgery) on the results of the evaluation for occult SUI. Our rationale is based upon the following data:

●In the OPUS trial, as discussed above, the women undergoing a prophylactic midurethral sling procedure benefited from prophylactic SUI surgery, and the degree of benefit was similar to that of women who underwent all abdominal surgery with a prophylactic Burch urethropexy procedure in the CARE trial (in both studies, postoperative SUI rates of approximately 24 percent [treated] versus 44 to 49 percent [untreated] at three months of follow-up) [2,8,34-36]. (See 'Comparison of surgical strategies' above.)

●However, in the OPUS trial, the addition of a prophylactic midurethral sling increased the risk of complications while the rates of adverse events were similar between the Burch and no-Burch groups in the CARE trial [2,8]. Although complications such as bladder perforation or UTI typically do not add significant postoperative morbidity and resolve either with intraoperative treatment or short-term use of a bladder catheter or antibiotic therapy, some women will have persistent voiding dysfunction following midurethral sling surgery. Such persistent voiding dysfunction can require prolonged catheterization and potentially a subsequent surgical procedure (typically urethrolysis). The rate of urethrolysis in the OPUS trial (2.4 percent) was consistent with the rate of post-sling persistent voiding dysfunction reported in other studies (0.6 to 2.0 percent) [8,37,38]. The approximately 2 percent rate of urethrolysis is an important consideration since one of the principal benefits of prophylactic continence surgery is avoiding the need for a subsequent surgery. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Voiding dysfunction'.)

●In the OPUS trial, for women who received universal midurethral sling procedures for potential SUI, the number needed to treat in order to prevent one case of postoperative urinary incontinence at 12 months was 6.3, although there was modest evidence to suggest that patients with a positive prolapse reduction stress test before surgery received more benefit than those with a negative test [8]. By using a selective approach and performing continence surgery only in women with a positive prolapse reduction stress test, the number needed to treat in order to prevent one case of urinary incontinence at three months dropped to 2.4.

Approach based on occult SUI results — For women who agree with selective treatment of symptomatic POP in the absence of SUI symptoms, we perform preoperative evaluation for occult SUI and then take the following approaches (see 'Detection and risk calculation' below):

●For women planning vaginal repair of stage II or greater POP with positive preoperative testing for occult SUI, we suggest concurrent procedures for prolapse and SUI rather than prolapse repair alone. (See 'Detection and risk calculation' below.)

Many experts consider women with confirmed occult SUI to be similar to women who present with SUI symptoms and advise a combined procedure for prolapse and SUI. Women with a positive preoperative prolapse reduction stress test are at the highest risk of postoperative SUI (average across studies of 54 percent (algorithm 2)). In the OPUS trial, there was modest evidence to suggest that patients with a positive prolapse reduction stress test before surgery received more benefit than those with a negative test [8]. The overall positive predictive value of the preoperative prolapse reduction stress for postoperative SUI based upon multiple studies is 51 percent (algorithm 2), and it was 72 percent in the OPUS trial [8,9,21,25,39-43]. Separately, a meta-analysis of five trials evaluating women with SUI reported that rates of subjective postoperative SUI were lower in women receiving concurrent midurethral sling procedures (relative risk [RR] 0.38, 95% CI 0.26-0.55, 369 women, five trials) [33]. Based on these data, the meta-analysis reported that if the baseline risk of postoperative urinary incontinence was 34 percent following repair of prolapse only, the risk of SUI with a concurrent midurethral sling decreased to 10 to 22 percent. The need for further continence surgery was not reported. While we suggest concurrent procedures, staged POP repair and continence surgery is a reasonable option for women who place a high priority on avoiding a potentially unnecessary procedure, voiding dysfunction, or midurethral mesh-related complications and are willing to accept an increased risk of postoperative SUI.

●For women planning vaginal repair of stage II or greater POP with negative preoperative testing for occult SUI, we suggest prolapse repair alone with subsequent SUI surgery only if symptoms develop (staged approach) rather than a combined procedure for prolapse and SUI (concurrent approach). While concurrent continence surgery in the OPUS trial in this patient population resulted in an absolute risk reduction for postoperative urinary incontinence of 17 percent, women who underwent TVT sling procedures also had increased sling-related complications and associated morbidity as well as other complications (ie, UTI) [8]. Similarly, a meta-analysis of one trial reported that, for continent women undergoing vaginal prolapse repair, addition of a midurethral sling did not significantly change postoperative SUI rates (RR 0.69, 95% CI 0.47-1.00, 220 women, one trial). Based on these data, the risk of postoperative SUI without concurrent surgery would be 40 percent, and the risk with concurrent surgery would range from 19 to 40 percent.

If a staged approach is used, a patient with stage II or greater POP without symptoms of SUI would only undergo surgery for POP with no concurrent continence procedure. The staged procedure typically takes place within one year of the original prolapse repair, and it is performed only if the patient develops symptoms of bothersome SUI requiring correction. The advantage of this approach is that unnecessary procedures are avoided. The OPUS trial demonstrated that, for women who underwent only vaginal POP repair, 49 percent developed SUI, but only 5 percent had a sling procedure in the first year [8]. Compared with a concurrent approach, the staged approach resulted in a 95 percent reduction in the number of slings placed.

However, for women who place a high value on avoiding postoperative SUI and are willing to accept an increased risk of perioperative complications and voiding dysfunction, concurrent POP repair and continence surgery is a reasonable option despite negative preoperative testing for occult SUI. This approach acknowledges both patient-important outcomes (avoiding SUI) and the limited predictive value of negative testing for occult SUI. (See 'Predictive value' below.)

Minimally invasive (laparoscopy or robot-assisted) — For women without SUI symptoms who are planning a minimally invasive sacrocolpopexy (MISC) for symptomatic prolapse, the optimal approach to incontinence surgery (universal, selective, or staged) is not known. While the final surgical decision is based upon the patient's preferences, given the available evidence (algorithm 2) and clinical considerations, we advise a selective approach for the treatment of potential SUI in women undergoing MISC and base the surgical treatment (concurrent or staged SUI surgery) on the results of the evaluation for occult SUI. Thus, for women planning MISC for POP and with identified occult SUI, we suggest concurrent surgical treatment of SUI. In our practice, we prefer transvaginal midurethral sling procedures rather than a laparoscopic Burch procedure. However, the benefits of midurethral slings, including shorter operative time, avoidance of an open abdominal incision, and technical ease (compared with open or laparoscopic Burch procedures), must be weighed against the risks of mesh-related complications and need for subsequent surgery for an individual woman. For women planning MISC for POP but without occult SUI, we generally suggest prolapse repair only and offer staged correction of SUI should it develop.

There are clinical advantages to performing a single procedure, but there is a lack of evidence to support the universal approach to treat both symptomatic POP and potential SUI in the MISC population. The incidence of postoperative de novo SUI following MISC for POP repair has not been thoroughly evaluated. In two different small, single-institution studies of women who underwent MISC without concurrent midurethral sling, the overall postoperative de novo SUI rate ranged from 24 to 27 percent [44,45]. However, in both studies, preoperative testing for occult SUI was not performed. In a different prospective study of 75 women with POP and demonstrated SUI or occult SUI, 13 women underwent MISC and midurethral sling while 62 women had MISC alone [46]. Although these women had demonstrated incontinence, of the women who underwent MISC only, 31 percent (19/62) had persistent SUI, but only 11 percent (7/62) underwent midurethral sling as a staged procedure. The authors concluded that unnecessary surgery could reasonably be avoided by a two-step approach [46].

Patients undergoing MISC represent a unique population; data from women undergoing transvaginal POP and midurethral sling procedures cannot simply be applied to women undergoing MISC with midurethral sling. The abdominal sacrocolpopexy procedure alters the axis of the vagina differently than a transvaginal prolapse repair, which potentially changes the dynamics between the anterior vaginal wall and the urethrovesical junction and could result in potentially different incidences of de novo SUI.

Open abdominal (laparotomy) — For women with POP in whom an open abdominal sacrocolpopexy (ASC) is planned, we take a selective approach to SUI and surgically treat only those women with demonstrated occult SUI (algorithm 1) [2,35,36]. While the authors do not recommend open abdominal procedures as the preferred route for treatment, it is sometimes necessary. For women with demonstrated occult SUI, we suggest a concurrent SUI procedure, but a staged approach is also reasonable. Although the Burch procedure for SUI has been the standard in the past, transvaginal midurethral sling procedures have become the preferred technique because of their ease of insertion and established long-term success. Clinicians who prefer a Burch colposuspension may still do so. While we generally do not suggest incontinence procedures for women without occult SUI, women who wish to minimize the risk of postoperative de novo SUI and are willing to accept the additional surgical risk of an incontinence procedure may reasonably do so.

Our approach takes into account the conflicting data regarding role of incontinence surgery in women planning an open ASC. Studies from the CARE trial reported that the addition of Burch colposuspension at the time of open ASC reduced postoperative de novo SUI for women with either positive or negative prolapse reduction testing without an increase in adverse events [2,34-36]. However, a meta-analysis of two trials concluded that there was no clear difference in postoperative SUI rates for continent women (ie, no occult SUI) undergoing open ASC, with or without Burch colposuspension (RR 1.31, 95% CI 0.19-9.01, 379 women) [33]. The meta-analysis acknowledged the CARE trial but assessed it as being underpowered and noted the second included trial provided conflicting results. Limitations of the meta-analysis include that it addressed only one subpopulation (continent women), did not account for benefit of reduced morbidity with single surgery, and did not include the potential surgical and mesh-related risks from a future staged midurethral sling procedure. In reality, minimally invasive (ie, laparoscopic or robot-assisted) ASC has become the preferred approach for ASC, and midurethral incontinence slings have generally replaced Burch colposuspension. (See 'Minimally invasive (laparoscopy or robot-assisted)' above.)

SUI with asymptomatic POP — Approximately 40 percent of women are found to have stage II or greater prolapse at annual gynecologic examination; however, symptoms related to prolapse often do not correspond with anatomical findings [47-50]. Thus, women who present with symptoms of SUI only, but have POP on examination, present a treatment dilemma. The issue is whether repair of asymptomatic prolapse provides a woman with a long-term benefit (eg, prevention of subsequent symptoms or surgery) or if it only increases the risk of perioperative complications. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

Given the available data and clinical considerations, we take the following approach for women with symptomatic SUI and asymptomatic POP:

●For women with asymptomatic stage I prolapse, we advise NOT repairing prolapse at the time of continence surgery. Since prolapse has not been proven to be progressive and stage I prolapse is almost never symptomatic, repair in these women appears to be unnecessary.

●For women with asymptomatic stage II or greater prolapse, we perform shared decision making with the patient. We explore her treatment goals and discuss the advantages/disadvantage of concurrent versus subsequent surgery. (See 'Informed consent and patient goals' above.)

An important question is whether prolapse in these women will worsen and/or become symptomatic with age or after menopause. Surprisingly, the natural history of prolapse does not follow a progressive course in all women. Data suggest that the course is progressive until menopause, after which the degree of prolapse may follow a course of alternating progression and regression [51-53]. Women with ongoing risk factors for POP are likely to have progression. These include increasing parity, hysterectomy, obesity, and chronic constipation. For obese women, weight loss does not appear to result in regression [54]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Risk factors'.)

Although natural regression of prolapse may occur, combined surgical treatment for SUI and POP appears to reduce the risk of subsequent surgery. This was illustrated in a retrospective study of insurance claims by over 1000 women who underwent a sling procedure for SUI [16]. Compared with women who did not undergo concurrent prolapse repair, women who had a concurrent repair were significantly less likely to have subsequent surgery for SUI or prolapse within one year of the initial surgery (SUI: 5 versus 10 percent; POP: 14 versus 22 percent) [16]. However, women who had a combined SUI and POP repair were also significantly more likely to have postoperative urethral obstruction (9 versus 6 percent). This study was limited by the lack of data on the stage of prolapse and whether symptoms were present, thus making it uncertain whether the results apply to asymptomatic women.

Additional surgical procedures increase operative time and may increase the risk of perioperative complications [2,55]. In the study described above, concurrent surgery for SUI and POP was associated with an increase in postoperative urethral obstruction. However, it is controversial whether combined procedures lead to an increase in obstructive urinary symptoms [16,17,55-58]. There are no high quality studies of combined surgery for women with SUI and mild or asymptomatic prolapse.

OCCULT SUI

Mechanism — Occult SUI occurs because, in women with significant anterior or apical prolapse (usually prolapse past the vaginal introitus), the bladder neck is displaced posteriorly, and the urethra is relatively kinked, resulting in some degree of urethral obstruction. The urethral kinking then becomes the mechanism of continence (figure 1) [59]. When the prolapsed structures are replaced (approximating normal anatomy) during prolapse reduction testing in women with urethral obstruction due to advanced POP, the urethra is unblocked, and SUI often becomes evident when a urinary stress test is performed (ie, occult SUI). By contrast, women with stage I POP are unlikely to have urethral kinking and resultant occult SUI [47-50].

Detection and risk calculation — In our practice, we perform prolapse reduction testing to assess for occult SUI in all women planning pelvic floor reconstructive surgery. Medical history can also suggest the presence of occult SUI. A preoperative incontinence risk calculator has been developed, but supporting data are limited. Further study is needed to identify other methods that accurately detect occult SUI.

●History – Clues in the history that suggest occult SUI include incontinence that improved or resolved as prolapse worsened; the need to manually replace the prolapsed structures into the vagina to void; or worsening or development of SUI with use of a pessary [47].

●Prolapse reduction urinary stress test – The purpose of prolapse reduction testing is to simulate the patient's vaginal architecture before and after surgical repair. Prolapse reduction will often decrease a previously elevated postvoid residual and unmask SUI. If testing is performed in the setting of a urodynamic study, maximal urethral closure pressure will be decreased when the prolapse is reduced, but other filling or pressure flow parameters will not be altered [59].

Prolapse reduction testing is generally performed with the patient standing, although women who are unable to stand can undergo testing in the dorsal lithotomy position. The most common tools used to reduce prolapse include examiner's fingers, large cotton swab (ie, Scopette), single speculum blade, ring forceps, or pessary [41,60]. However, pessary stress testing may be less effective at detecting SUI than other methods because it may also cause urethral compression. We insert one or two large cotton swabs into the vagina to reduce the prolapse. These long swabs are well tolerated by patients and long enough to approximate a surgical suspension of the vaginal apex. When elevating the prolapsed structures, we take care to avoid obstructing the urethra or placing the anterior vaginal wall under excessive tension, both of which could mask incontinence. Some data suggest that the bladder should be filled to at least 300 mL; in one study, occult SUI identified with use of a bladder volume of 300 mL was more likely than 100 mL to be associated with postoperative SUI [61]. Once the patient's bladder has approximately 300 mL and the prolapse is reduced, we ask the patient to cough or generate intraabdominal pressure (ie, strain). The examiner then observes if the patient remains continent or loses urine during the stress provocation.

●Incontinence risk calculator – An incontinence risk calculator has been developed to predict postoperative SUI in stress-continent women who are planning prolapse repair surgery [62]. Using data regarding the rate of postoperative SUI from a prospective trial, the calculator had a concordance score of 0.72 compared with a score of 0.62 for prediction by a group of 22 expert urogynecologic surgeons and 0.51 for a preoperative prolapse reduction urinary stress test. The exact role of the incontinence risk calculator in the management of patients remains controversial because there are few published data confirming its validity and a large retrospective study of 500 women found that its discriminative ability was moderate with a planned sling but did not discriminate when a sling was not planned [63].

Predictive value — Although we perform prolapse reduction testing to identify occult SUI, the predictive value of such testing is limited. When preoperative prolapse reduction stress testing is performed in women with POP but no SUI symptoms, individual studies report occult SUI in 30 to 80 percent of women with symptomatic and/or advanced POP (algorithm 2) [7,20-26,39-41,64-79]. When the study results are combined, the overall rates are:

●In asymptomatic women who have positive preoperative prolapse reduction testing (ie, positive for occult SUI), the mean rates of postoperative SUI are 51 percent without an incontinence procedure and 11 percent with an incontinence procedure.

●In asymptomatic women who have negative prolapse reduction testing, the rates of postoperative SUI are 17 percent without an incontinence procedure and 18 percent with an incontinence procedure.

Prolapse reduction stress testing appears to have a similar predictive value for the development of postoperative SUI whether done as part of a clinical assessment or as part of formal urodynamic testing [8,41].

RESOURCES FOR PATIENTS AND CLINICIANS

●The International Urogynecology Association (IUGA) provides more than 30 patient information leaflets in multiple languages without charge.

●The American Urogynecology Society (AUGS) provides patient services, patient fact sheets, and clinical guidance documents that discuss best practice and position statements, all without charge.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary incontinence in adults" and "Society guideline links: Incontinence surgery in women" and "Society guideline links: Pelvic organ prolapse" and "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

●Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) coexist in up to 80 percent of women with pelvic floor symptoms. (See 'Introduction' above.)

●Prolapse repair can unmask SUI in previously asymptomatic women (ie, occult SUI) or worsen existing SUI symptoms. Deciding whether to perform concurrent surgical procedures to treat both prolapse and SUI or a single procedure that addresses only one condition requires balancing the risks of incomplete treatment and potential need for additional future surgery with the risks of exposing the patient to unnecessary surgery and potential complications, particularly for asymptomatic patients. (See 'Concurrent or staged procedures for POP and SUI' above.)

●For women with symptoms of both POP and SUI, we recommend a concurrent prolapse repair and continence procedure rather than a staged approach (Grade 1B). (See 'Symptomatic POP and symptomatic SUI' above.)

●The management of women with symptomatic POP, but no SUI symptoms, is controversial. To reduce the risk of de novo postoperative SUI in women with POP but no SUI symptoms, clinicians must weigh the advantages and disadvantages of universal (ie, concurrent), selective, or staged surgery for potential SUI at the time of POP repair. Our approach to continent women with prolapse who are planning POP repair depends upon the degree of prolapse, planned surgical route, and whether or not the patient is found to have occult SUI on preoperative prolapse reduction with urinary stress testing (algorithm 1). (See 'Comparison of surgical strategies' above.)

●Continent women with stage I POP who are planning prolapse repair are unlikely to have urethral obstruction with resultant occult SUI and thus are unlikely to benefit from a concurrent continence procedure. This may include women having hysterectomy for an indication other than prolapse (ie, cervical dysplasia, menorrhagia) who also happen to have apical descent greater than half the total vaginal length and would benefit from an apical suspension, or the rare case of isolated uterine prolapse, which is symptomatic and bothersome at stage I but without anterior vaginal wall prolapse. We generally do not perform a concurrent continence procedure on these women but do counsel them regarding the potential need for a staged intervention should postoperative incontinence develop. (See 'Comparison of surgical strategies' above.)

●For continent women with stage II or greater POP who are planning either abdominal or vaginal prolapse repair, we take a selective approach to the surgical treatment of SUI and incorporate the results of occult SUI testing into the shared decision-making process. (See 'Open abdominal (laparotomy)' above.)

•For continent women with stage II prolapse or greater who are planning vaginal prolapse repair:

-For women with stage II or greater POP who are undergoing vaginal surgery and who have positive preoperative testing for occult SUI, or have a high probability of postoperative stress incontinence using the continence calculator, we suggest a concurrent POP repair and continence procedure rather than prolapse repair alone (Grade 2B). However, POP repair with staged continence surgery is a reasonable option for women who place a high priority on avoiding a potentially unnecessary procedure, voiding dysfunction, or rare midurethral mesh-related complications and are willing to accept an increased risk of postoperative SUI. (See 'Vaginal' above.)

-For women with stage II or greater POP who are undergoing vaginal surgery and who have negative preoperative testing for occult SUI, or have a low probability of postoperative stress incontinence using the continence calculator, we suggest prolapse repair alone rather than a combined procedure for prolapse and SUI (Grade 2C). However, concurrent POP repair and continence surgery is a reasonable option for women who place a high priority on avoiding postoperative urinary incontinence and are willing to accept an increased risk of perioperative complications and voiding dysfunction. (See 'Vaginal' above.)

•For continent women with stage II or greater POP planning an abdominal POP repair (either open or minimally invasive approach):

-For women with demonstrated occult SUI undergoing abdominal POP repair, we suggest a concurrent SUI procedure (Grade 2B), although a staged approach is also reasonable. To treat SUI, we use the evidence-based approach of the transvaginal midurethral sling procedures rather than a laparoscopic Burch procedure. The benefits of midurethral slings, including shorter operative time, avoidance of an open abdominal incision, and technical ease (compared with open or laparoscopic Burch procedures), must be weighed against the risks of rare mesh-related complications and need for subsequent surgery for an individual woman. Clinicians who prefer a Burch colposuspension may still reasonably do so. (See 'Open abdominal (laparotomy)' above.)

-For women without demonstrated occult SUI undergoing abdominal POP repair, we suggest prolapse repair alone (Grade 2C). However, women who wish to minimize the risk of postoperative de novo SUI and are willing to accept the additional surgical risk of an incontinence procedure may reasonably do so. (See 'Open abdominal (laparotomy)' above and 'Minimally invasive (laparoscopy or robot-assisted)' above.)

●Women with SUI and asymptomatic prolapse generally do not undergo prolapse repair, particularly for stage 0 to I prolapse, unless they require an apical suspension for apical descent greater than halfway down the vagina. For women with stage II prolapse or greater, the approach is individualized according to patient treatment goals and the risks of subsequent surgery. (See 'SUI with asymptomatic POP' above.)

●Occult SUI occurs because, in women with significant prolapse, the bladder neck is displaced posteriorly and the urethra is kinked, resulting in relative urethral obstruction. The kinking then becomes the mechanism of continence; in the absence of prolapse, incontinence can develop (occult SUI). Preoperative prolapse reduction testing has a positive predictive value above 50 percent for postoperative SUI in otherwise asymptomatic women with POP. A continence calculator has also been developed, but supporting data are limited. (See 'Occult SUI' above.)