Joint Plan for Continence and Prolapse?


SAN FRANCISCO — Risk-benefit ratios, the possibility of voiding dysfunction, the choice of prolapse procedure, and the woman's own priorities are among the factors that need to be considered when deciding whether to combine continence and prolapse procedures, Dr. Linda Brubaker said at a conference sponsored by the Society of Gynecologic Surgeons.

Dr. Brubaker was principal investigator in the Colpopexy and Urinary Reduction Efforts (CARE) trial. The results showed that combining the Burch colposuspension procedure with abdominal sacrocolpopexy significantly reduced the incidence of stress incontinence (N. Engl. J. Med. 2006;354:1557–66).

The trial randomized 157 women to both procedures and 165 to sacrocolpopexy alone. Three months after surgery, stress urinary incontinence was diagnosed in 44% of women who did not have the Burch procedure vs. 24% of women who did. Urge incontinence and serious adverse events were also reduced in the Burch group, but the difference did not reach statistical significance.

Dr. Brubaker, director of the division of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., emphasized that the trial does not apply to all patients. It enrolled only women who were asymptomatic at baseline.

“If you don't put a Burch in, at least a third of your women are going to have stress incontinence, but people who leak are going to leak regardless of the Burch,” commented Dr. Brubaker, professor of obstetrics and gynecology and of urogynecology and urology.

About 75% of all women with advanced prolapse have stress incontinence, you will learn if you carefully question, she said. The accuracy of diagnostic tests is limited, however, and she dismissed as largely ineffective most methods of predicting which patients will develop a problem after surgery.

Widely used terminology can be problematic as well, according to Dr. Brubaker. Patients can be said to have “potential stress incontinence” prior to surgery if they have no symptoms. Once they undergo urodynamic testing, however, either they have urodynamic stress incontinence or they do not. “The terms are not used in the same way,” she emphasized.

Another consideration is that the precise relationship between prolapse and symptoms is not clear, she said, warning that the chance of surgeon error increases with the extent of the prolapse. Overtreatment could lead to retention, she warned, and undertreatment could lead to incontinence.

“There is a delicate balance between voiding dysfunction and incontinence,” she added, discussing her decision not to do a continence procedure in a frail, elderly patient scheduled for colpocleisis. “It is better to err on the incontinence side. When both are present, undertreat the incontinence.”

Dr. Brubaker recommended doing a continence assessment that includes a preoperative evaluation of urinary symptoms, sexual function, and constipation in all patients. The assessment should also entail a discussion of each person's goals and expectations going into surgery. Sometimes you have to make a trade-off with patients who have prolapse, she said, so understanding goals is important.

About 75% of all women with advanced prolapse have stress incontinence. DR. BRUBAKER

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