Prolapse surgery and stress urinary incontinence

Approximately 50% of women with prolapse extending to the vaginal entrance have coexistent leakage with coughing, sneezing and exercise. Interestingly, this number decreases to about one third of women having stress urinary incontinence with large prolapse extending outside the vagina. This is likely to be due to the prolapse kinking the urethra and preventing leakage. As seen in the flow diagram below having continence surgery at the time of prolapse surgery reduces the risk of postoperative incontinence from 56% ( POP surgery alone) to 10% (POP +continence surgery)

In women without stress urinary incontinence prior to prolapse surgery post- surgical correction of the prolapse as many as 30% may unfortunately develop stress urinary incontinence postoperatively which is referred to as occult stress urinary incontinence (OSUI). To help identify those at risk of OSUI pre-operatively gynaecologist reduce the prolapse and with the bladder moderately full test for urinary leakage with coughing or sneezing. If positive this is called a positive occult stress urinary incontinence test. Please see our video on how to test for occult stress urinary incontinence.

Women with occult stress urinary incontinence have a 56% chance of developing SUI post POP surgery alone and this risk is reduced to 16% if POP + continence surgery is performed. Women without occult stress urinary incontinence should have prolapse surgery without continence surgery.

The data supporting these recommendations is reproduced below from the Surgical management of prolapse committee in the 2017 International Collaboration on Incontinence.

This data resulted in the committee on the surgical management of prolapse (ICI 2017) developing this guideline in relation to the need for continence surgery being performed at the time of prolapse surgery.

Do I need continence surgery at the time of prolapse surgery?