Status Plus

abstract

404 - THE RING THAT CAN CONCEAL AND REVEAL AT THE SAME TIME

404

THE RING THAT CAN CONCEAL AND REVEALAT THE SAME TIME

G. ARAKLITIS1, J. E.HUNTER 1, G. THIAGAMOORTHY 1, A. M. RANTELL 1,E. SOLOMON 2, D. ROBINSON 1, L. CARDOZO 1;
1King's Coll. Hosp., London, United Kingdom, 2Guysand St Thomas' NHS Trust, London, United Kingdom.

Introduction: Women withurogenital prolapse may suffer from concomitant lower urinary tractsymptoms (1). This may lead to kinking or compression of the urethra,which can cause bladder outlet obstruction or conceal sphincterincompetence (1). Prolapse management in the form of either surgeryor a pessary may improve prolapse symptoms and help any voidingdifficulties but can un-mask stress urinary incontinence (SUI). Formost women this can be an unwelcome surprise. Therefore predictingthose women who may develop SUI can help with appropriate counselingand consent. Reducing the prolapse at pre-operative urodynamics witha pessary can identify occult urodynamic stress incontinence(OUSI).
Objective: To determine the accuracy ofpre-operative urodynamics with reduction of the prolapse using a ringpessary in predicting post-operative SUI. We also compared voidingparameters of those with voiding difficulties and how they changewith insertion of the pessary.
Methods: This was aretrospective cohort study of consecutive women who attended oururodynamics clinic between 2008-2016. All women underwent assessmentincluding history, physical examination using the pelvic organprolapse quantification (POP-Q) classification, urinalysis,uroflowmetry, videocystourethrography, pressure flow studies and postvoid residual check. Urodynamics were performed by trained doctorsand specialist nurses in keeping with Good Urodynamic Practice. Thosewith significant prolapse who did not leak when asked to cough toassess SUI, had a pessary inserted to reduce the prolapse (“ringtest”). They were asked to cough again to look for OUSI.Post-operative SUI was assessed in the follow up clinic. Whenassessing those with voiding difficulties, we included those whovoided more than 100mls with a residual of more than 100mls aturoflowmetry. We excluded those who had previous continenceprocedures.
Results: Of 1355 patients, 46 patientsfulfilled the inclusion criteria for this study. They had a medianage of 65 years, median parity of 2 and median ordinal POP-Q score of2. Twenty percent had previous hysterectomy and 13% had previouspelvic floor repairs. Forty-six percent had complained of SUIpre-operatively and 24% complained post-operatively. Table 1summarises our results. The “ring test” had a sensitivity of 64%and a specificity of 80%. Its positive predictive value (PPV) was 50%with a negative predictive value (NPV) of 88%. Only three patientshad post-operative urodynamics, of whom all had OUSI pre-operativelyand all three had post-operative urodynamic stress incontinence.Twelve patients had voiding difficulties at uroflowmetry. The meanvoid was 333mls with a mean residual of 173mls. The “ring test”reduced the residual in 92% of patients, with 58% achieving aresidual less than 100mls. The Qmax increased in only 17% (mean4.5ml/sec) whilst it reduced in 83% (mean 6.6ml/sec).
Conclusions:This study shows that the “ring test” is a good tool inpredicting those who will not develop post-operative SUI. Our NPV of88% was less than previous studies, 98% (1) and 96% (2), even thoughthey had similar number of patients. This may be explained byinadequate prolapse reduction, which may not have revealed OUSI. Somefeel that diagnosing OUSI allows the surgeon to consider concomitantprophylactic continence surgery. Our results found a PPV of 50%whilst other studies showed it to be 40% (1) and 62% (2). Wetherefore believe that the PPV of the “ring test” is too low toadvice continence surgery and expose patients to unnecessary risks.If SUI is a problem post-operatively, then a patient can be offered amid-urethral tape, which is a minimally invasive day-case procedure.Though our numbers are small, prolapse correction with a pessaryimproved post-void residuals in 92%, but interestingly only 17% hadan improved Qmax. Again this may be explained by using a temporarypessary which may have not been the optimal size and therefore notfully alleviate the obstruction. One study found reducing theprolapse in predicting post-operative urinary retention cure, had aPPV of 94% (3). This study confirms that the “ring test” canaccurately predict patients who may develop SUI and help withcounseling and consent. Though we showed an improvement in post voidresiduals, larger numbers would be needed to comment on improvementin bladder outlet obstruction.
References:

  1. InternationalUrogynaecology Journal (2011); 22:171-175

  2. InternationalUrogynaecology Journal (2009); 20:1301-1306

  3. InternationalUrogynaecology Journal (2004); 15:175-178


Table1. How well the ring pessary predicts post-operative SUI

Postoperative SUI

RingPessary

OUSI+

OUSI-

Positive

7

4

Negative

7

28