The effect of genital prolapse on voiding.

PURPOSE: We determined whether genital prolapse causes obstruction that may be relieved by a vaginal pessary as well as the degree to which voiding difficulty, urethral hypermobility, bladder outlet obstruction, occult stress incontinence, detrusor instability and impaired detrusor contractility are associated with prolapse.

MATERIALS AND METHODS: We prospectively evaluated 60 women with a mean age of 52 years who had genital prolapse, including 35 (58%) with grade 1 or 2 and 25 (42%) with grade 3 or 4 cystocele, using pressure-flow video urodynamics and cotton swab testing. Leak point pressure and uroflowmetry were repeated in patients with severe prolapse after insertion of a ring pessary.

RESULTS: Urethral hypermobility (p<0.05) and symptoms of voiding difficulty (p<0.01) were more common in women with grade 3 or 4 cystocele. Urodynamics revealed bladder outlet obstruction in 2 patients (4%) with grade 1 or 2 cystocele and 18 (58%) with grade 3 or 4 cystocele (p<0.001). After vaginal pessary placement bladder outlet obstruction reverted to normal free flow in 17 women (94%) with grade 3 or 4 cystocele. Seven women (20%) with grade 1 or 2 cystocele versus 13 (52%) with grade 3 or 4 cystocele had detrusor instability (p<0.05). Impaired detrusor contractility was noted in each group (p>0.05). In patients with stress incontinence intrinsic sphincter deficiency did not correlate with the degree of prolapse and urethral hypermobility did not correlate with leak point pressure.

CONCLUSIONS: Lower urinary tract symptoms are common in women with genital prolapse. Voiding difficulty, bladder outlet obstruction and occult stress incontinence may coexist and they are associated with prolapse. Detrusor instability and urethral hypermobility also correlate with the degree of prolapse but impaired detrusor contractility and intrinsic sphincter deficiency do not. In women with severe prolapse ring pessary reduction of prolapse during urodynamics is useful to determine symptomatic and occult conditions.