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

Author Yvonne Ogrodzinski covers Pelvic Organ Prolapse & Stress Urinary Incontinence: Surgery vs Conservative Management on BackTable OBGYN

Yvonne Ogrodzinski • Aug 20, 2023 • 728 hits

Stress urinary incontinence and pelvic organ prolapse treatment can range from conservative management to surgical procedures. The conversation should center on shared decision making based on symptomatic presentation, patient lifestyle, and comorbidities. Management approaches based on durability of repair should be weighed against those that promote uterine conservation. OB/GYN Dr. Amy Park and Urologist Dr. Jose Silva discuss their approaches to management of stress urinary incontinence and pelvic organ prolapse.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

• Pelvic organ prolapse surgical treatment can be considered in patients with symptomatic presentation, however in asymptomatic patients, the benefits may not outweigh the risks of a procedure. Conservative treatment often involves physical therapy, although success is dependent upon patient adherence to exercises.

• Bulking agents for stress urinary incontinence provide immediate results for patients with active lifestyles or who otherwise want to avoid the OR and recovery time from a sling procedure. While not a permanent solution, agents like Bulkamid are easy to inject and have been shown to improve symptoms for up to seven years.

• Patients who are already undergoing pelvic organ prolapse treatment may benefit from concomitant treatment of stress urinary incontinence. Even those who do not experience preoperative urinary incontinence can benefit from a combined procedure due to the risk of developing postoperative stress urinary incontinence after prolapse repair.

• A vaginal approach to prolapse procedures is beneficial for patients with a uterus who have contraindications for mesh, or have a history of abdominal surgeries and other comorbidities.

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

Table of Contents

(1) Conservative Pelvic Organ Prolapse Treatment

(2) Bulking Agents for Stress Urinary Incontinence

(3) Surgical Management of Stress Urinary Incontinence & Pelvic Organ Prolapse

Conservative Pelvic Organ Prolapse Treatment

In managing a patient with stress urinary incontinence coupled with pelvic organ prolapse, the decision to address the prolapse should hinge on the patient's symptomatic experience, while also weighing the potential surgical risks. A patient who presents asymptomatically with pelvic organ prolapse may not experience sufficient benefit from surgical treatment to outweigh the risk of complications, such as dyspareunia. For those patients with minor pelvic floor disorders, pelvic floor exercises and physical therapy may provide sufficient management. Furthermore, if a pelvic organ prolapse is non-obstructive, Dr. Park views the prolapse as potentially enhancing sling function, given the compression provided by a hypermobile urethra. However, any symptomatic prolapse may be a reason to push for surgical repair to alleviate dysfunction.

[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.

Listen to the Full Podcast

Management of Female Stress Incontinence and Pelvic Organ Prolapse with Dr. Amy Park and Dr. Jose Silva on the BackTable OBGYN Podcast)
Ep 3 Management of Female Stress Incontinence and Pelvic Organ Prolapse with Dr. Amy Park and Dr. Jose Silva
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Bulking Agents for Stress Urinary Incontinence

Urethral bulking agent injections are used to treat stress urinary incontinence for patients who are otherwise not ideal candidates for sling procedures. While not a permanent solution, patients who have undergone radiation therapy, have a prior history of mesh erosion, or desire to preserve future fertility, can avoid the OR and still see improvement in symptoms. In comparing bulkamid vs sling, injections of bulking agents facilitate a quicker recovery time to daily activities compared to a sling procedure, making it a more suitable choice for patients leading active lifestyles. If a patient stops seeing improvement years after treatment, it is still possible to explore candidacy for a sling or even recommend additional urethral bulking agents.

[Jose Silva MD]
Amy, in terms of the SUI stress incontinence for sling procedures, when are you doing a sling procedure vs a bulking agent?

[Amy Park MD]
I think the bulking agents are good for patients who aren't really good candidates for sling. Cancer patients, post-radiation patients, patients who've had healing issues like mesh erosions from a prior sling, women who desire future fertility or have a fixed urethra, or patients who are too sick to go to the OR, I think it's a good medium-term option.

Basically, the data demonstrates from Europe, when they compare the Bulkamid urethral injections vs the sling, pretty good results up to seven years, and they were comparable. The sling actually has longer-term data up to 17 years. I always counsel patients that if they want a more permanent solution to the incontinence, that the sling would be a better option. But I have some patients who have too much going on. They're busy, they like the idea of doing an office procedure or something quick in the surgery center. That's my practice, but I'm curious to hear what you've been doing because I think with urology and urogynecology, sometimes we have a little bit different patient populations coming in.

[Jose Silva MD]
I think more or less the same thing that you just said. I definitely ask the patient if they want to continue being active because I do TVTs, I do the Advantage Fit, and I tell them that it's going to be three to four weeks of really nothing, no exercise. I know that might be challenging, but if they want something that they can go back to their regular life faster, then the bulking agent, I think you said the Bulkamid, I think it's a better option. Of course, if it doesn't work. You can bulk it again or put a sling. That's how I talk to the patient. Not sure if I'm doing the right thing.

[Amy Park MD]
No, it's totally true. The downtime is a huge issue for patients. Previously I was always hesitant to recommend urethral bulking agents because I just didn't feel like they worked very well. A lot of times I would talk the patients out of it, even though I did mention it as an option in my standard surgical counseling, but the Bulkamid is so much easier to inject and with longer lasting results. So I feel better about counseling because I think it's a more legitimate option.

[Jose Silva MD]
I didn't do any bulking agents before. I just started with the Bulkamid. Definitely, seven years of good results is better, I'm not going to be doing this every six months. That's why I did more slings. But now with Bulkamid maybe, I think it's taking away from the patients that did slings.

[Amy Park MD]
I still do a lot of slings, but I'm definitely doing more bulking agents than I ever did just because it's also easier to counsel patients about the fact that it's a hydrogel, it's 97% water, has 70% to 80% improvement for up to seven years. The prior ones that I used, I used Contigen, but having to do the skin testing for the bovine collagen reaction, allergic reaction, was a barrier.

I never found Coaptite to be that effective. When I would go back for repeat injections or placing a sling, the calcium hydroxyapatite material would often migrate or extrude. I think the Bulkamid probably does migrate a little bit. All of them do. It's just a lot easier to use and the patients have pretty good results immediately.

Surgical Management of Stress Urinary Incontinence & Pelvic Organ Prolapse

Patients experiencing both stress urinary incontinence and pelvic organ prolapse can simultaneously address both conditions through combined procedures. Even patients without preoperative stress incontinence who are undergoing prolapse repair may benefit from a simultaneous sling procedure, given the potential risk of postoperative stress urinary incontinence. For prolapse procedures, Dr. Park prefers a vaginal approach for patients with a history of abdominal surgery or other contraindications for mesh. The vaginal uterosacral ligament approach can also avoid deviation of the vagina and preserve natural access in patients with a uterus. A sacrospinous ligament fixation works for post-hysterectomy patients, but for the most durable repair on patients who have had recurrence, Dr. Park will utilize laparoscopic sacrocolpopexy for post-hysterectomy patients with anterior apical prolapse.

[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.

Podcast Contributors

Dr. Jose Silva discusses Management of Female Stress Incontinence and Pelvic Organ Prolapse on the BackTable 3 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Dr. Amy Park discusses Management of Female Stress Incontinence and Pelvic Organ Prolapse on the BackTable 3 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Cite This Podcast

BackTable, LLC (Producer). (2022, November 14). Ep. 3 – Management of Female Stress Incontinence and Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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