Pelvic organ prolapse (POP) affects 40-50% of parous women and frequently coexists with overactive bladder (OAB) symptoms. Proposed pathophysiological mechanisms include mechanical bladder outlet obstruction, anatomical distortion compromising pelvic innervation, and detrusor dysfunction. This systematic review and meta-analysis aimed to: (1) quantify the rate of OAB resolution following prolapse surgery; (2) compare outcomes across surgical techniques and approaches; (3) evaluate the incidence of de novo OAB; and (4) identify independent predictive factors of symptom resolution.

A systematic search was conducted across MEDLINE, Embase, Scopus, and Cochrane CENTRAL through December 2024. Eligible studies enrolled women with symptomatic POP-Q stage II or greater prolapse. Data extraction was independently performed by three reviewers. Pooled estimates were generated using random-effects meta-analyses with Freeman-Tukey double arcsine transformation to stabilize variance. Methodological quality was assessed using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies; evidence certainty was graded according to GRADE criteria. Pre-specified subgroup analyses were performed by surgical approach (vaginal, laparoscopic/robotic, abdominal), use of mesh augmentation, anatomical compartment repaired, study design, and duration of follow-up.

Twenty-four studies were included (8 randomized controlled trials, 16 observational studies), encompassing 7,739 women of whom 7,095 completed follow-up. Studies were published between 2003 and 2025; sample sizes ranged from 43 to 2,569 participants (median 126). Mean patient age ranged from 53.3 to 76.0 years, BMI from 22.98 to 29.8 kg/m2, and parity from 2 to 5. The majority (68%) presented with POP-Q stage III-IV prolapse. Median follow-up was 12 months (range 1.5-75 months). The overall OAB resolution rate was 58.0% (95% CI: 55.9-60.1%), with substantial heterogeneity (I2=83.0%, tau2=0.031, Q=66.34, p<0.001). No significant differences were observed between the vaginal approach (69.4%, 95% CI: 56.8-63.9%), laparoscopic/robotic approach (58.7%, 95% CI: 53.2-64.0%), and abdominal approach (54.2%, 95% CI: 46.1-62.1%; p=0.62). Mesh-augmented and native tissue repairs yielded comparable outcomes (61.3% vs 58.2%, p=0.48; RR 1.05, 95% CI: 0.91-1.22). Compartment-stratified analysis revealed significantly higher resolution rates for anterior/apical repairs (75.8%, 95% CI: 73.2-78.3%) compared to isolated posterior repairs (28.3%, 95% CI: 20.1-37.9%; p<0.001) and multi-compartment procedures (57.1%, 95% CI: 51.4-62.7%). This stratification substantially reduced heterogeneity (I2=42.3%). Six studies reported de novo OAB incidence ranging from 0 to 14.3%. Multivariate meta-regression accounted for 68% of variance (R2=0.68), with anatomical compartment as the sole significant independent predictor (p<0.001).

Anatomical compartment emerged as the strongest independent predictor of OAB resolution following prolapse surgery. The superior outcomes observed after anterior and apical compartment repair support a mechanistic role for urethral kinking, trigonal distortion, and nerve stretching secondary to bladder base descent in the pathogenesis of prolapse-associated OAB. The absence of significant differences by surgical approach or mesh use suggests that anatomical correction per se, rather than the technique employed, drives symptom improvement.

Pelvic organ prolapse surgery resolves overactive bladder symptoms in approximately 58% of patients. Anterior and apical compartment repair is associated with significantly superior OAB resolution compared to posterior repair, independent of surgical approach or use of mesh augmentation. These findings support an anatomically directed approach to surgical planning in women presenting with concurrent prolapse and overactive bladder, with anterior/apical correction prioritized to maximize symptom benefit.