Women with genital prolapse but without urinary incontinence are at risk to develop incontinence after vaginal prolapse repair. Combining the latter with anti-incontinence surgery will reduce the first but may lead to overtreatment. Only repairing the prolapse may lead to undertreatment. We tried to find out if a vaginal pessary is helpful in making the decision whether anti-incontinence surgery should be added to prolapse surgery?

Retrospective database review of women with symptomatic genital prolapse but without bothersome urinary stress incontinence between that were seen between 1.1.2008 and 31.12.2017. Pre-operatively all women had an annular vaginal pessary inserted in order to detect occult urinary stress incontinence. If the pessary revealed a bothersome stress incontinence, the woman was offered a concomitant mid-urethral sling. The primary outcome at follow-up was the ‘de novo’ urinary stress incontinence.

In total 220 women were included. Prolapse of the anterior compartment was most commonly found (96%), followed by the posterior compartment prolapse (84%) and by apical prolapse (72%). This corroborates with what is found in the literature. The pessary stress urinary incontinence test was negative in 132 (60%) patients and not-bothersome positive in 20 (9%) patients. The pessary revealed bothersome stress incontinence in 68 (31%) women. They were proposed to undergo a sling procedure at the time of prolapse repair; 65/68 (96%) women agreed to do so. All women were seen two months postoperatively. At that time, bothersome urinary stress incontinence was present in 21 women: 12/132 (9%) of these women had been continent with the pessary pre-operatively; 7/20 (35%) had shown non-bothersome incontinence before surgery and 2 out of the 3 women, already bothersome incontinent with the pessary before surgery but not wanting to undergo the sling procedure, remained incontinent. Women who showed non-bothersome incontinence with the pessary were more prone to develop bothersome incontinence (35%) post-operatively compared to those who were pre-operatively continent with the pessary (9%). However, this difference did not reach statistical significance. The number needed to treat the women showing no or with ‘non-bothersome’ incontinence (N=152) with a mid-urethral sling (N=19) was eight (8). If we take into consideration only those women who were continent after a pessary test (N=132) before surgery, then the number needed to treat was eleven (11). Post-operative complications were scanty but more common, although not to a significant degree, with combination surgery:13/65 (20%) in the latter group and 19/155 (12%) in the prolapse surgery group. Urgency symptoms at the post-operative visit were more frequently encountered in those women who underwent a concomitant mid-urethral sling but this difference did not reach statistical significance. The lack of significances in the aforementioned complications and symptoms could mean that our study is underpowered.

This study is an attempt to find out whether a pessary can be used to find out who will benefit from a concomitant mid-urethral sling intervention at the same time as anti-prolapse surgery. To our knowledge, this is the first time that a difference is made between ‘bothersome’ and ‘not-bothersome’ incontinence to determine who will need an additional mid-urethral sling. It is possible that some of the preoperative incontinent women, who underwent a mid-urethral sling, might have been overtreated. Indeed, an important shortcoming is that we do not know how many stress incontinent women after pessary insertion would not have been incontinent after having just undergone a prolapse procedure. The ultimate way to elucidate this is the randomized controlled trial were preop incontinent women should be allocated at random to yes or no mid-urethral sling at the same time as anti-prolapse surgery.

. In women with symptomatic pelvic organ prolapse, a vaginal pessary test before surgery is a useful tool to reveal underlying troublesome post-operative stress incontinence. By doing so, overtreatment was importantly reduced and undertreatment was kept within acceptable limits.