Fix Prolapse First
Overactive bladder guidelines call for following hierarchical treatment of patients, with correction of prolapse the next step for patients who fail modifiable and medical interventions.
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Many patients have overactive bladder, and it is imperative to manage any modifiable factors as part of first-line management as stated in the initial and most recent updates to the OAB guidelines. Second-line OAB therapies consist of medical management for symptoms not well controlled enough with fluid, behavioral and pelvic exercise management. While there are several medications for OAB, there are limited data to suggest one treatment is superior to the others. Furthermore, although data are limited, many patients are under treated or remain dissatisfied with medical therapy for OAB.
As one progresses to third-line therapeutic options, one should consider any other available treatment options as all of the third-line options carry along with them chronicity of therapy. In other words, there is a lifelong type of maintenance with each of them. If the patient with OAB has treatable prolapse that is of a moderate grade or worse, there is justification for considering treating vaginal prolapse in lieu of progressing to third-line therapies.
The patient with simultaneous prolapse and OAB may have resultant OAB symptoms due to one or more of the three factors of bladder outlet obstruction, bladder stretching or the open urethra. Of these factors, the bladder outlet obstruction theory is most agreed upon. In the patient with OAB with prolapse, this is analogous to a male patient with benign prostatic hyperplasia and predominant irritative voiding symptoms.
If standard first-line therapies do not work, most would consider outlet reduction surgery, provided there was evidence of bladder outlet obstruction on preoperative testing. While preoperative urodynamics does not have as much prognostic value in the female with prolapse and OAB, there are data to show patients with OAB and prolapse have higher voiding pressures, lower flow rates and a higher prevalence of detrusor overactivity.1 In addition, these tend to improve with correction of the prolapse (including the OAB).
Therapeutic interventions in this patient population may be trialed initially with a pessary to demonstrate improvement in OAB symptoms. This represents a simple and useful intervention as it is relatively noninvasive. If prolapse reduction results in OAB improvement, then one may opt to continue with the pessary (if the patient is satisfied with this modality) or proceed to surgery. Four series have examined this patient population and pessary placement has improved OAB symptoms (measured by validated questionnaires) in all the trials with an overall relative risk greater than 1.5.
If a patient improves with a pessary and desires prolapse surgery or opts to proceed directly to surgery, improvement in OAB symptoms has been shown in virtually all of the trials in this patient population.1 Again, this may be due to the reduction in bladder outlet obstruction as flow rates have been shown to improve simultaneous to a reduction in urodynamic detrusor overactivity. This “unkinking” of the bladder neck likely leads to less bladder work, more efficient emptying and resolution of OAB symptoms.
When determining whether to take the patient with prolapse and OAB–in whom medical therapy has failed–to prolapse repair or third-line therapies, the final consideration is the risks of third-line treatments. While prolapse surgery certainly has risks, third-line therapies may worsen some bladder issues.
Percutaneous tibial nerve stimulation (PTNS) has limited refractory data and requires lifelong therapy. Therefore, it has a limited basis compared with a possible single outpatient surgical procedure for prolapse. Sacral neuromodulation (SNM) may improve emptying and OAB. However, one must consider that SNM is really indicated for non-obstructive retention symptoms, and most patients with prolapse already have obstructive-type emptying dysfunction and carry post-void residuals.
Lastly, onabotulinumtoxinA injections may be an option, but with dose-dependent retention risks and the requirement for repeated injections in an already at-risk population with empting dysfunction due to the prolapse, this choice is challenged.
In summary, patients with moderate (stage 2 or greater) prolapse and refractory OAB symptoms should clearly undergo first- and second-line therapies, as per the OAB guidelines. If and when these interventions fail, correction of the prolapse represents the most fruitful and straightforward next step to help these patients.
Presented at this year’s American Urological Association (AUA) meeting in New Orleans, Louisiana.
This article originally appeared in AUA News: Volume 20, Issue 9 and is reprinted with permission.
Dr. Vasavada is Urologic Director for the Center for Female Urology and Reconstructive Pelvic Surgery within the Glickman Urological Institute. For more information contact Dr. Vasavada at firstname.lastname@example.org.