Review: Predicting and Managing Lower Urinary Tract Symptoms After Prolapse Surgery

Women who undergo surgical correction of pelvic organ prolapse can have persistent or new lower urinary tract symptoms (LUTS) afterward. A review published in Current Urology Reports by Urologist Elise J. B. De, MD, in the Department of Urology at Massachusetts General Hospital, and colleagues stresses the importance of trying to predict and counsel patients about these symptoms—and offers practical guidance for managing LUTS postoperatively.

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Preoperative Evaluation and Counseling

Patients who need prolapse repair should report their urinary symptoms preoperatively. Documentation assists with patient education and may also be useful for medico-legal protection. One clinically useful tool is the Overactive Bladder Questionnaire (OAB-Q).

For patients with symptoms of urgency and frequency, a one-week trial of a pessary is an inexpensive way to approximate postoperative results.

Clinicians should be vigilant in screening for:

• Voiding dysfunction
• Obstructing diverticulum
• Neurogenic bladder
• Tumor
• Kidney Stones

Pelvic floor muscle dysfunction should also be investigated and should be treated by a pelvic floor physical therapist prior to surgery.

The physical examination should include determining the degree of prolapse, such as according to the Pelvic Organ Prolapse Quantification System. The American Urological Association recommends that patients with stage II, III or IV prolapse should undergo preoperative urodynamic studies (UDS) with reduction of the prolapse to assess for associated LUTS, occult stress urinary incontinence and neurogenic bladder.

Patients with significant preoperative symptoms, history of neurologic disease, pelvic floor dysfunction, bladder neck obstruction or higher stages of anterior wall prolapse should be counseled that they are at higher risk of postoperative voiding dysfunction. Patients often cope better if they know in advance that postoperative treatment might be necessary.

Initial Postoperative Evaluation and Management

Too many women with postoperative LUTS receive little more than vague reassurance. Instead, initial steps should include:

1. Administering validated symptom questionnaires
2. Reviewing the preoperative workup and history
3. Screening for voiding or levator dysfunction
4. Questioning about behavioral factors (e.g., caffeine, irritating teas, volumes consumed)
5. Screening for neurologic disease

Measurement of postvoid residual (PVR) and urinalysis to check for infection are also mandatory. The exception is that if obstructive symptoms occur de novo and immediately after prolapse repair, especially with a concurrent sling, the surgery itself should be the primary suspect.

If the PVR and culture results are acceptable, management depends on the type of LUTS:

• Storage symptoms, such as increased daytime urinary frequency, nocturia, urgency and urinary incontinence: pelvic floor physical therapy, urge suppression behavioral therapy, anticholinergic medications, beta-3 agonists, sacral nerve stimulation or botulinum toxin

• Voiding symptoms, such as a slow stream, spraying, intermittent stream, hesitancy, straining to void and terminal dribble: pelvic floor physical therapy, alpha blockers or sacral nerve stimulation

Additional Postoperative Testing

If initial treatment is unsuccessful, if the PVR is high, if hematuria is present or if the patient has recurrent UTIs, the reviewers recommend UDS and cystoscopy. These can identify detrusor overactivity, small capacity or underactive bladder, obstruction, stone or a missed foreign body.

If UDS and cystoscopy are unrevealing, order pelvic imaging, which may reveal a tumor, urethral diverticulum or stone caught in the intramural ureter. Refer the patient for a neurologic examination if UDS identifies refractory detrusor overactivity or detrusor-sphincter dyssynergia.

If all of the above are ruled out, the patient should be evaluated for a decompensated bladder.

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Learn more about Mass General's Voiding Dysfunction and Incontinence Program

Refer a patient to the Department of Urology