This document discusses occult stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP). [1] Between 36-80% of women with POP have occult SUI that is only revealed when the prolapse is reduced. [2] There is no standardized method for diagnosing occult SUI. Methods to reduce the prolapse include pessaries, vaginal packs, and speculums. Cough tests during filling cystometry can identify urine leakage indicative of SUI. [3] Treatment options include postponing or performing concomitant anti-incontinence surgery with POP repair. More studies are needed to determine best practices for diagnosing and treating occult SUI.

1. IRCCS Ospedale San Raffaele Milano
Università Vita-Salute San Raffaele
PROLASSO ED INCONTINENZA ASSOCIATI:
COSA E COME FARE
STEFANO SALVATORE

2. SUI E POP 1-
 40% of women with POP report SUI symptoms
Grody
 Occult SUI ranges from 36% to 80%
Bergman/Richardson
 11-22% preoperatively continent women developed
SUI after POP repair
Stanton/ Borstad and Rud

3. SUI E POP 2-
CONCOMITANT SUI
GENITAL
PROLAPSE OCCULT SUI

4. Latent (Occult) urinary stress
incontinence
What is it?
How and when to diagnose?
If, when and how to treat?

5. OCCULT SUI -DEFINITION-

6. External O
Urethral C
urethral E
kinking
compressi C T
on U I
Increased L O
intra-urethral T L
pressure
O
S G
U Y
I
Occult SUI

7. OCCULT SUI -HOW TO DIAGNOSE?-

8.  In women presenting with POP w/o SUI the rate of urodynamic
stress incontinence detection is lower with pessary than with
speculum prolapse reduction (LE1)
 The pessary test has also been suggested to predict the result
of POP surgery on urinary symptoms. In this indication the
predictive value of the pessary test remains unclear (LE3), and
it is not recommended to use it routinely (Grade C)
 Different methods for POP reduction:
 Large swab placed at the apex
 Posterior blade of a bivalve
speculum
 Sims speculum
 Vaginal pessary

9. OCCULT SUI -HOW TO
DIAGNOSE?-
Pessary test procedure:
 Pessary placed at maximum cystometric capacity or at
400mls (whatever reached first)
 Patients were asked to cough repeatedly for 5-6 times

10. OCCULT SUI -HOW TO
DIAGNOSE?-
VAGINAL
PACK
Pessaries have a tendency to fall out in the
absence of the uterus and it is difficult to know
whether the prolapse is adequately reduced and
whether urethral obstruction has occured -> use
of vaginal pack
Gallentine

11. OCCULT SUI -DIAGNOSIS-
 Filling cystometry at 400-500 ml CC
 Cough test at CC in sitting position repeated 3
times before flowmetry
 Loss of urine after 1 cough -> severe IUS
Loss of urine after 3 cough -> moderate IUS
Loss of urine after 5 cough -> mild IUS

12. OCCULT SUI -DIAGNOSIS-
 Prolapse reduced by pessary
 In case of pessary loss -> use of vaginal
pack

13. VAGINAL VAULT PROLAPSE AND
OCCULT SUI
 Patients with vault prolapse have high incidence of
uccult SUI
 The change in ALPP is much higher than in patients
with vault prolapse than in patients with moderate
grade cystoceles and rectoceles

14. POSTERIOR VAGINAL DEFECTS AND
OCCULT SUI
Pessary test procedure:
 A posterior blade of a Pederson speculum was used
 Bladder filled up to 300 mls
 Patients performed three separate sets of Valsalva
maneuvers, and urine leakage was noted
Results:
 12 (54%) of 22 women revealed occult SUI

15. OCCULT SUI -HOW TO TREAT-

16. 322 women randomized
 157 underwent abdominal sacrocolpopexy with Burch
colposuspension (Burch group)
 165 underwent only abdominal sacrocolopexy (controls)
RESULTS:
23.8% Burch group vs 44.1% controls had stress incontinence after
surgery
CONCLUSIONS:
Burch colposuspension singnificantly reduced post-operative
symptoms of
stress incontinence

17. OCCULT SUI -HOW TO TREAT-
Abdominal POP
POP repair
repair + Burch
alone
colposuspension
Incontinence
rate 54.2% 39.1%
after surgery
CONCLUSIONS: Burch colposuspension does not provide any
benefity in POP repair in patients with urinary incontinence

18. OCCULT SUI -HOW TO TREAT-
Anterior plication of
Objective rate Subjective rate
endopelvic fascia
+ TVT 92% 96%
- TVT 56% 64%

19. OCCULT SUI -HOW TO TREAT-
UROLOGY 76: 1358–1363, 2010
117 women with POP and occult SUI who had
concomitant prolapse repair and TVT-O
RESULTS:
 Subjective cure rate: 97.8%
 Objective cure rate: 86%

20. UROLOGY 76: 1358–1363, 2010
Comparison of subjective cure rate between anti-incontinence
procedures
 TVT-O 97.8%
 TVT
98%
 Burch 96%
 Pubovaginal sling
95%

21. OCCULT SUI -POSSIBLE
SOLUTIONS-
 Perform anti-incontinence surgery in ALL patients
undergoing POP surgery
 Perform anti-incontinence surgery in NO patients
undergoing POP surgery
 Perform anti-incontinence surgery in SOME patients
undergoing POP surgery based on some set of clinical
predictors (i.e. presence of symptons of SUI, clinical
observation of SUI on stress testing or occult SUI on
stress testing with prolapse reduction)

22. MORE STUDIES ARE NEEDED…

23. PATIENT INFORMATION
 Risk of develop postoperative SUI
 Need of preoperative urodynamic evaluation to
reveal occult SUI
 Decide for prophylactic anti-incontinence
precedure in case of occult SUI
 Decide the more effective and safer anti-
incontinence procedure

24. CONCLUSIONS
 Standardized defintion by ICS/IUGA since 2010
 No standardized method for prolapse reduction and evaluation of
occult SUI
 Treatment choice include postponed or concomitant anti-
incontinence procedure with prolapse repair
 Overall success rate on a short, medium and long term basis
should be part of preoperative counseling as well as LUT
functional effects
Latent (Occult) urinary stress incontinence. What is it? How and
when to diagnose? If, when and how to treat?

25. GRAZIE!