Pelvic Organ Prolapse & Stress Urinary Incontinence: Surgery vs Conservative Management

[Jose Silva MD]
For patients that have stress, or any type of incontinence, and when you do the pelvic exam, they don't have symptoms of prolapse, but there's a little bit of prolapse there, let's say POP 0 or -1, that is not going outside the vaginal area. When do you decide to treat the prolapse as well when you're treating the incontinence?

[Amy Park MD]
That's a really good question. There was a study looking at this ancillary data with some of the NIH-funded studies on prolapse and incontinence. Basically for those patients who have stage 2 prolapse, which is right around the hymen, and some of them are symptomatic and some of them aren’t, there's not really a big progression in the prolapse. My take is there are some sequelae to treating prolapse surgically. It's rare, but I don't want to risk dyspareunia number one. Number two, you really can't improve on no symptoms. I tend to not treat asymptomatic prolapse unless they for some reason have something else that's pushing me. Like they have abnormal uterine bleeding, and I might as well do a hysterectomy at the same time, and then I'll do a prolapse repair. Or if they have some incomplete bladder emptying, and it's like prolapse related voiding dysfunction. Otherwise I don't treat asymptomatic prolapse.

[Jose Silva MD]
Sometimes I see sling patients that have seen other urologists and they already have the workup, and they scale it directly to me for surgery. When I'm there, I see a little bit of prolapse. I don't know if it is the prolapse or-- I don't do the sling. For now, I haven't had any problems, but I always have the doubt whether they needed more treatment. At least, for now, it hasn't happened but I’m always curious when you actually treat the prolapse.

[Amy Park MD]
Yes. I think that that was definitely more of a question before, that I had. You see it coming down a little bit, and you're like, "Oh, should I just deal with it at the time of surgery?" Honestly, the slings work better in the setting of urethra hypermobility. If you really push it back, they don't actually work as well because the mechanism of the sling is really it backs up against, which the urethra can compress with a hypermobility. I actually think the sling may work a little bit better if they have a little bit of prolapse, but you don't want it to be obstructive. That's the thing that people worry about, is when it gets to that point where you wonder, "If it comes out some more, is it going to be a problem for their emptying?" That's when I think you just have to judge and see. But a lot of people with advanced prolapse still are able to empty completely.

[Jose Silva MD]
Okay. In terms of pelvic floor exercises, let's say a patient with stress incontinence, but also symptomatic prolapse. Do pelvic floor exercises do anything or do you really just need to treat the prolapse and the incontinence?

[Amy Park MD]
I think pelvic floor PT is very good at addressing urge incontinence, levator spasm, and pelvic pain. I think it's imperative to have a partnership with pelvic floor physical therapists. The caveat to pelvic floor PT for addressing urge is that patients have to keep up with the exercises. The physical therapists are also very good at addressing the underlying causes for levator spasm and pelvic pain, like underlying back pain and hip pain. It's less good at effectively treating SUI and prolapse.

There's a couple different techniques that the PTs will teach patients for stress incontinence, like something called the knack, where the patients can kegel, cross their legs and turn their bodies to the side, and it helps pull up their pelvic floor. It doesn't completely stop the leakage, but it decreases the amount of leakage that they experience with coughing, sneezing, and Valsalva.

Then for prolapse, I counsel patients that the PT isn't going to magically retract the prolapse back up, but it will help in most of those cases where the leading edge of prolapse is right at the hymenal threshold, which is where patients become symptomatic. So they don't really feel it as much anymore. I've also encountered several patients that have strengthened their pelvic floor through performing core-centric exercises, like karate or Pilates or barre, and have experienced treatment. Weight loss also improves pelvic floor disorders.

[Jose Silva MD]
So for prolapse and incontinence, are you doing combined procedures or do you prefer to treat one first and then see how that person does?

[Amy Park MD]
If the patient doesn't desire surgical management, they can be fitted with an incontinence dish or ring with support and knob that reduces the prolapse and addresses the incontinence as well, by providing support to the bladder neck.

If the patient desires surgical management and has preoperative stress incontinence, then I counsel them that I can address both conditions at the same time. Because some patients may be wary or hesitant to have mesh placed, then I engage in shared decision making and give them the option of preoperative urodynamics and concomitant sling at the time of prolapse repair, or proceed with a staged approach forgo the preoperative urodynamics with interval sling placement if they become more bothered after prolapse repair. Occasionally, patients will not demonstrate stress incontinence on preoperative dynamics. I will counsel them on performing a concomitant sling anyway since the data are supportive of that approach in terms of patient satisfaction and also because as we all know, urodynamics are an imperfect test. If the patient does not have preoperative SUI, then they still have a fairly high risk of developing de novo SUI postoperatively in the range of 40% to 50%.

I offer patients the same choices in terms of preop urodynamics and concomitant sling if it's positive for stress incontinence or the staged interval sling approach. Even though prolapse repair does not address incontinence per se, studies have shown that when you address anterior wall prolapse, urinary urgency does improve. Prolapse repair definitely helps with prolapse-related voiding dysfunction. I think the real danger area is for advanced prolapse that has caused long-standing bladder outlet obstruction, detrusor hypertrophy and underactivity, and then the patient has SUI. I would tread cautiously in that patient and possibly consider a bulking agent or a very loose sling.

[Jose Silva MD]
Exactly. That's what I was going to mention, at least the very loose sling because the first time that I had to cut a sling was a combined procedure. The GYN did the AP repair and I did the sling. I left it like I always do. And that patient, they were in retention and then I was talking to a friend of mine, like "Yeah, you need to leave it much looser because when they do, they close the AP repair, the defect, it tends to tighten it up." When you say looser, how do you create that? Do you leave something between the urethra and the sling to get that amount of looseness?

[Amy Park MD]
Yes, I use curved mayos underneath the mid urethra, and then I just make sure that I can just easily pass it between the mesh and the urethra. There was a Canadian RCT looking at mesh sling tensioning techniques and either using an instrument. I can't remember exactly what they used. It was either a curved mayos, or maybe it was a right angle or something. Then the other arm was using a Babcock. I think the Babcock had a higher mesh erosion rates, which makes sense because it’s a little bit of a knuckle of the sling that you leave out. I just have always used the mayo scissors underneath and then just making sure that it can pass easily.

[Jose Silva MD]
I use essentially a female urethra dilator. I leave a 10 FR, very small. I just put it there. I used to have the right angle, but just trying to keep it systematic and doing the same thing over and being able to make sure there’s space. So I changed to the 10 FR. What type of prolapse procedures do you do?

[Amy Park MD]
I do the vaginal approach as well as the laparoscopic approach. My go-to is the vaginal hysterectomy, bilateral salpingectomy, uterosacral ligament suspension, anterior-posterior repair for those women who still have the uterus. For select patients, you can talk about a hysteropexy with uterine conservation if they don't have a history of abnormal Paps or cervical elongation or enlarged uterus with fibroids. I'll perform the vaginal uterosacral ligament suspension intraperitoneally. Sometimes, occasionally I will perform a sacrospinous ligament hysteropexy.

The advantage to the uterosacral ligament approach is that it preserves a natural access of the vagina, whereas the sacrospinous ligament fixation stays extraperitoneal, it deviates the vaginal access laterally and can cause buttock pain for up to six weeks. For post-hysterectomy patients, I'll offer either sacrospinous ligament fixation or laparoscopic sacrocolpopexy. For the high posterior prolapse, I actually think the sacrospinous ligament fixation works great.

My approach is to take a diamond from the top and then just measure with Allis’s, make sure that it goes up to the sacrospinous ligament, and then shorten the vagina to where it doesn't just right on the sacrospinous ligament because I think it's the length that's very important there. For the predominant anterior apical prolapse, I prefer laparoscopic sacrocolpopexy.

That being said, I'll steer the patients towards the vaginal approach if they've had a lot of abdominal surgeries, they have a large hernia repair with mesh, history of small bowel obstruction, contraindications to steep trendelenburg like a severe pulmonary disease, contraindications to mesh like wound healing issues or significant comorbidities that preclude longer OR times associated with sacrocolpopexy.

I usually counsel patients that prolapse repairs are like any other reconstructive surgery in the body like an ACL tear or facelift or knee, hip replacements. The natural history of the disease is that the connective tissue will weaken. Therefore, I usually reserve laparoscopic sacrocolpopexy for those patients who are post-hysterectomy with anterior apical prolapse who have had a recurrence or want the most durable repair. I do perform primary sacrocolpopexy with concomitant hysterectomy or sacrohysteropexy in those patients who are young, like less than 40, who desire the most durable repair. But that's not my usual go-to.