BACKGROUND

EPIDEMIOLOGY OF INCONTINENCE AND PELVICORGAN PROLAPSE: A SYSTEMATIC REVIEW OF PREVALENCE OF SUI AND OCCULT UI IN WOMEN WITH PELVIC ORGAN PROLAPSE

OTHER KEY FINDINGS

Niamh-Maire McLennan 1

Cathryn Glazener 2

• Median estimate of clinically overt SUI 33% (13 studies)• Median estimate of occult SUI 42% (23 studies)• Wide variation in prevalence of SUI (9 to 80%); occult SUI (5 to 83%)• 28 were hospital-based observational studies; only 3 evaluated the

general population• The 3 studies conducted in the general population included 877 women:

the prevalence of overt SUI ranged from 29% to 44%(median 40%)

AIMS OF STUDY

Table 1- Prevalence of SUI in women with POP (median)

1 Medical Student, University of Aberdeen, Aberdeen, UK2Health Services Research Unit, University of Aberdeen, Aberdeen, UK

Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI)• Stress urinary incontinence is a frequent complaint in women with pelvic

organ prolapse• A recent, large systematic review 1 of the epidemiology of POP and

incontinence identified the prevalence of POP (5 to 10% with symptom ofbulge,1 40% based on examination 2) and, separately, the prevalence ofSUI (25 to 45% 1)

• But there was no information about the number of women with POP whoalso have SUI (overt or occult)

• Occult SUI is masked by the prolapse but revealed when the prolapse isreduced (replaced temporarily or by surgery)

• Preoperative urodynamic testing with and without prolapse reduction maybe offered in an attempt to detect women who might be at risk but it isunclear whether this is a reliable diagnostic test3

• Currently urodynamic studies are not carried out routinely on all womenundergoing prolapse repair in the UK unless they also have symptoms orsigns of SUI

• It may be important to identify women with occult SUI since thisknowledge might alter the surgical management of women with POP

• Crucial to introducing such a diagnostic service would be an estimation of the number of women who might benefit from assessment of occult SUI and therefore its treatment or prevention

Mechanism of link between POP and SUILoss of support of the anterior vaginal wall and pubocervical fascia can leadto urethral hypermobility (descent of the urethra below the pelvic floor)resulting in SUI and/or cystocele formation (thus kinking the urethra),which may mask the SUI until the cystocele is ‘unkinked’

RESULTS: Prisma study flow diagram

294 studies identified through database searching

291 studies after duplicates removed

291 studies screened

36 studies included in the review

255 studies excluded for:-Not reporting outcome data of interest -Not in women with POP

N of studies

N of women

SUI SUI(range)

SUI(IQR)

13 1554 33% 9 to 80% 27 to 55%

Table 2 - Prevalence of occult SUI in women with POP (median)

N of studies

N of women

Occult SUI Occult SUI(range)

Occult SUI(IQR)

23 1307 42% 5 to 83% 25 to 62%

Website: http://www.abdn.ac.uk/hsru

DISCUSSION

STUDY DESIGN AND METHODS

REFERENCES, CONTACT DETAILS AND ACKNOWLEDGEMENTS

1. To identify the prevalence of patient-reported symptoms or clinical signsof stress urinary incontinence in women with pelvic organ prolapse

2. To identify the prevalence of occult urinary incontinence in women withpelvic organ prolapse

• Literature review to determine the prevalence of SUI and occult SUI inwomen with prolapse

• MEDLINE search (December 2010) to identify epidemiological studies• Subject specific MeSH terms: urinary incontinence; pelvic organ prolapse;

cystocoele; vault prolapse; enterocele and uterine prolapse.• Definitions of overt SUI and occult SUI: as defined by study authors• Inclusion criteria for studies:women with POP (stage 2 or greater);which also reported the prevalence and type of incontinence;in both community and secondary care (hospital)

• Exclusion criterion for studies:studies whose aim was to identify the prevalence of POP in womenwho all had SUI

• Screening: one author (NMM), checked by second author (CG)• Analysis:data collated and stored in Microsoft Excel;analysis by calculation of the percentage of women with each conditionof interest in each study;summarised and presented as the median, range and inter quartilerange of those percentages

(median 40%)• In the 9 studies in hospitalised women or women seen in outpatient

clinics, the median prevalence was 32% (range 9% to 80%)

CONTACT DETAILS: Ms Niamh-Maire McLennan, c/o Health Services Research Unit, University of Aberdeen, UK AB25 2ZDACKNOWLEDGEMENTS: June Cody, Sheila Wallace, Bronwyn Davidson, Jonathan Cook and James N’Dow for support and help

AIMS OF STUDY

1. It was not possible to provide an accurate estimate of the prevalence ofconcomitant POP and SUI, or occult UI, due to wide variation in theestimates obtained and the high risk of potential biases, resulting in lowgeneralisability

2. A well designed observational study is needed to identify the scale of theproblem both in the general community and women referred forhospital/specialist management

1. Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U and Thom D. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Incontinence: 4thInternational Consultation on Incontinence, Paris, France: Health Publication Ltd, 2009, p. 35-112

2. Hendrix S, Clark A, Nygaard S et al. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186:1160-783. Visco AG, Brubaker L, Nygaard I et al. The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: the Colpopexy and Urinary Reduction

Efforts (CARE) randomized surgical trial. International Urogynecology Journal. 2008;19(5):607-14

CONCLUSIONS

• The majority of studies (23/26) were in women referred for hospital/specialist management of prolapse (32% SUI). This may have introducedselection bias

• The estimate for the prevalence of SUI in women with prolapse in thegeneral population (40%) could have been biased by low response ratesachieved in the studies

• The wide range in the prevalence rate of SUI and occult SUI suggestsbias which could have resulted from variety in: Definitions: (before 2001, SUI definition incorporated objective

demonstration of urine loss as a core component whereas currentlySUI is accepted as ‘any involuntary loss of urine’

Detection: subjective assessment (using questionnaires and visualanalogy scales) and objective assessment (using urodynamic studiesor stress tests) were used in different studies