Pelvic organ prolapse (POP) with concomitant stress urinary incontinence (SUI) is a challenging task for the clinician; some advocate for the one-step approach where POP and incontinence surgeries are performed simultaneously, whilst others choose the two-step approach; POP surgery first and, if necessary, incontinence surgery is performed at a later stage. However, other types of urinary incontinence (UI), than SUI, may bother women with POP. We wished to investigate how primary POP surgery alone affects symptoms of UI, in women with POP and concomitant UI (including but not limited to SUI). We also sought to find any predicting parameters of postoperative urinary continence.

In Denmark, all urogynecological procedures performed must be registered in the Danish Urogynecological Database, which ensures high validity (1). We performed a database study, using data from the Danish Urogynecological Database, from the years 2013-2016. We included women with POP and concomitant UI who underwent primary POP surgery without concomitant incontinence surgery. The women were excluded if they had any history of POP surgery, incontinence surgery, or previous hysterectomy. In Denmark, women fill out the International Consultation on Incontinence Questionnaire – Urinary Incontinence – short form (ICIQ-UI-sf) before POP surgery, and approximately three months after POP surgery. Data from departments with a minimum 75% response rate in the ICIQ-UI-sf (pre- and postoperatively) were included in our study. Women were categorized with either stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI), based on their preoperative ICIQ-UI-sf. Postoperatively, the women were again categorized using their postoperative ICIQ-UI-sf, with urinary continence as an additional group. 
We performed multivariate logistic regression analyses for each preoperative UI group, including the parameters preoperative POP stage, compartment (anterior, posterior or anterior and posterior), preoperative ICIQ-UI-sf total score (1-7, 8-14 or 15-21), age and BMI. P-values <0.05 were considered statistically significant.

We included 1657 women. The women had a mean age of 61.9 years with a median BMI of 25.8. In their preoperative assessments, most of the women had either POP-Q stage 2 (51%) or 3 (46%). Before POP surgery, we found SUI in 32% of the women, 28% had UUI, and 41% had MUI. In 70% of the women, POP surgery was performed in the anterior compartment, 19% in the posterior compartment, and 11 % had POP surgery in the anterior and posterior compartments combined. We found that after surgery, significantly more women with preoperative UUI were continent (60%) compared to women with preoperative SUI (52%) and MUI (38%) (p<0,0001). 
Table 3 shows the odds of achieving urinary continence after primary POP surgery, based on the preoperative POP-Q stage, the involved compartment, preoperative ICIQ-UI-sf total score, women’s age and BMI. The table separates between women with preoperative SUI, UUI and MUI.

We included 1657 women. The women had a mean age of 61.9 years with a median BMI of 25.8. In their preoperative assessments, most of the women had either POP-Q stage 2 (51%) or 3 (46%). Before POP surgery, we found SUI in 32% of the women, 28% had UUI, and 41% had MUI. In 70% of the women, POP surgery was performed in the anterior compartment, 19% in the posterior compartment, and 11 % had POP surgery in the anterior and posterior compartments combined. We found that after surgery, significantly more women with preoperative UUI were continent (60%) compared to women with preoperative SUI (52%) and MUI (38%) (p<0,0001). 
Table 3 shows the odds of achieving urinary continence after primary POP surgery, based on the preoperative POP-Q stage, the involved compartment, preoperative ICIQ-UI-sf total score, women’s age and BMI. The table separates between women with preoperative SUI, UUI and MUI.

POP surgery has a positive effect on symptoms of UI, especially in women with UUI, where those with POP in the anterior compartment have the best outcome. Therefore, it can be argued that one should wait for the effect of POP surgery, before deciding on whether or not a patient should undergo surgery, or receive treatment, for UI.

Guldberg R, Brostrøm S, Hansen JK, Kærlev L, Gradel KO, Nørgård BM, et al. The Danish Urogynaecological Database: establishment, completeness and validity. Int Urogynecology J. 2013 Jun 1;24(6):983–90.