This study aims to determine the impact on the quality of life of women undergoing pelvic organ prolapse (POP) surgery who obtained a positive result in Urodynamics (UD) for mild occult stress urinary incontinence (SUI) or at maximum cystometric capacity. To identify the proportion of women who had clinical SUI disappearance after POP surgery and the proportion of women who developed clinical SUI, after POP surgery without added anti-incontinence technique, in those who obtained a diagnosis of mild SUI in pre-surgical UD. 
To perform an objective self-evaluation and self-criticism about the therapeutic attitude recommended and applied to patients treated in the pelvic floor unit. This descriptive study will allow us to generate working hypotheses for other cohort studies that will allow us to compare conservative vs. surgical treatment in terms of patient satisfaction and control of urinary incontinence symptoms.

A retrospective observational study was conducted in a group of patients evaluated by Urodynamics in the Pelvic Floor Unit (to rule out occult stress urinary incontinence (SUI) due to pelvic organ prolapse (POP)) and candidates for prolapse-reducing surgery, during the time period January 1st 2020 to December 31 at 2021 and who underwent prolapse corrective surgery without anti-incontinence technique including: vaginal hysterectomy and/or anterior colpoplasty (with own tissues or with anterior mesh), subtotal hysterectomy (STH) associated with cervicopexy (CP) by laparoscopy and colposacropexy (CSP).The occurrence of de novo SUI and the disappearance of clinical SUI at three, six and twelve months after surgery were assessed through physical examination in the specialized pelvic floor consultation and the application of the ICIQ. A database was created in the SPSS program through a search of the hospital's clinical records, taking into account the inclusion and exclusion criteria. Inclusion criteria: women diagnosed with symptomatic POP, and candidates for POP surgery, with Urodynamics performed in that period of time. The diagnosis made in the specialized pelvic floor consultation (SPFC) was reviewed with the clinical history, the pre-treatment ICIQ, the result of the Urodynamics study, the type of surgery performed and those patients with 12-month follow-up after surgery and who were discharged from the Pelvic Floor Unit were included. Those who did not follow up for 12 months were excluded.

Fifty-three patients were included in the study. The most frequently diagnosed type of POP was anterior compartment prolapse (cystocele) associated with apical (uterine) prolapse in 36 patients (63.92%). Only 1 (1.88%) patient presented exclusively dome prolapse and likewise only one (1.88%) patient presented posterior compartment prolapse (rectocele). Eleven patients (20.75%) had posterior compartment prolapse associated with uterine prolapse and/or cystocele. 

Seventeen patients (32.07%) had SUI clinically at the time of the first SPFC. Of these patients, 5.88% had posterior compartment prolapse, 5.88% had cystocele-type POP associated with rectocele; 23.53% had POP in all three compartments; six patients (35.29%) had apical compartment POP associated with anterior compartment; finally, only 14.28% had apical compartment POP and 17.65% had POP with anterior compartment involvement. 


Among the results observed in the UDs performed, 62.26% of the UDs ruled out occult SUI due to POP. In this subgroup, seven patients showed clinical SUI. 

We observed 20 results that were interpreted as positive for occult SUI by POP.  Seventeen results (32.07%) of UD were oriented as mild or weak positive occult SUI because they appeared at maximum cystometric capacity and for which the addition of an anti-incontinence technique to POP corrective surgery is not recommended as a matter of course.  Within this subgroup, only seven patients (41.48%) 
manifested SUI clinically. Three positive UD results were observed for pure SUI occult by prolapse and these patients reported symptoms at the previous UD visit.

Among the patients who referred SUI at the anamnesis prior to UD, 58.82% had a positive result for occult SUI on testing and 41.18% had a result that ruled out occult SUI on DU. Of the thirty-six patients who did not manifest SUI, 27.28% had a weak positive result/maximal cystometric capacity for occult SUI, while 72.22% had occult SUI ruled out by the test. 

The most frequent type of surgery was vaginal hysterectomy associated with repair of the anterior compartment (anterior colpoplasty) that included pexy with the patient's own tissues or with an anterior mesh, with a total of 29 interventions. Two subtotal hysterectomies associated with laparoscopic cervicopexy and 1 laparoscopic colposacropexy were performed. 

A total of fifty (96.34%) patients had no UI at twelve months post-treatment. Of the seventeen patients who had SUI before surgery, only two (11.76%) continued to have UI at 12 months post-surgery. 

At the end of the study period, 100% of the patients had a negative ICIQ. Only three patients had UI at 12 months: two of them already had UI in the anamnesis and had a weak positive result in the UD prior to surgery too. Of the seventeen patients who were diagnosed with a weak positive or mild SUI on UD, 88.24% had no UI at the end of the observation and were discharged satisfactorily.

The urodynamics study is an effective and necessary diagnostic test to rule out occult SUI in patients with POP (1) in the decision-making process when proposing surgical treatment in this type of patient. In the experience followed in these two years, a good clinical correlation was observed in the management of pure occult SUI due to POP, diagnosed by DU. 

In those cases in which a weak positive result or mild SUI was obtained and in which it was decided not to add an anti-incontinence technique to the POP corrective surgery, the patients presented very satisfactory post-treatment clinical SUI cure percentages (88.24% without UI at 12 months post-treatment). In the present study the UD exhibited a high specificity to rule out SUI hidden by prolapse (72.22%) similar to that reported in the literature, in contrast to what was expected, the sensitivity did not exceed 60%.

Urodynamics remains a necessary and efficient diagnostic test in the process of planning the surgical strategy in patients with POP (2). 
Those patients who refer SUI before undergoing an urodynamic study may benefit from prolapse corrective surgery without the need to add an anti-incontinence technique if the UD result is weakly positive. A study including a much larger number of patients is needed and a longer follow-up (2 to 5 years) of these patients would be necessary to assess whether the efficacy of corrective surgery is maintained in the long term.
Arguably, prolapse corrective surgery can improve the quality of life of patients with overt or occult SUI due to prolapse without the addition of an anti-incontinence technique, even in those patients with a mild SUI result on urodynamic testing, but a second comparative study will be necessary to test this hypothesis.

Italian national big data on urodynamics: Relationship between clinical and urodynamics diagnosis Emanuele Rubilotta i, Francesco Ditonno i, Matteo Balzarro i, Marilena Gubbiotti ii, Enrico Ammirati
International Continence Society Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study Peter F.W.M Rosier1* | Werner Schaefer2 | Gunnar Lose3 | Howard B. Goldman4 | Michael Guralnick5 | Sharon Eustice6 | Tamara Dickinson7 | Hashim Hashim8
Surgery for women with pelvic organ prolapse with or without stress urinary incontinence (Review). Baessler K, Christmann-Schmid C, Maher C, Haya N, Crawford TJ, Brown J