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How Does Site of Pelvic Organ Prolapse Repair Affect Overactive Bladder Symptoms? Alexis A. Dieter, MD, Autumn L. Edenfield, MD, Alison C. Weidner, MD, and Nazema Y. Siddiqui, MD, MHSc
Objectives: To assess how site of pelvic organ prolapse repair affects overactive bladder (OAB) symptoms, we compared change in OAB symptoms in women undergoing isolated anterior/apical (AA) repair versus isolated posterior (P) repair. Methods: This is a retrospective cohort study of women with bothersome OAB undergoing either AA or P prolapse repair. The subjects completed the Pelvic Floor Distress Inventory short form and the Overactive Bladder Questionnaire (OAB-q) validated questionnaires preoperatively and 6 weeks postoperatively. Our primary outcome was OAB-q symptom severity (SS) change score (preoperative minus postoperative score) compared between the 2 groups. Results: Of 175 subjects, 133 (76%) underwent AA repair and 42 (24%) underwent P repair. Baseline OAB-q SS scores and baseline characteristics were similar except that the AA group had more severe baseline prolapse (median pelvic organ prolapse quantification stage 3 for AA [interquartile range, 2Y3] vs stage 2 for P [interquartile range, 1Y3]; PG0.01] and a higher rate of concomitant midurethral sling (57% in AA vs 31% in P; PG0.01). Overall OAB symptoms significantly improved within 6 weeks of surgery (PG0.01). The meanTSD OAB-q SS change score was higher in the AA repair group (26T24 in AA vs 13 T 28 in P; P=0.01), indicating greater improvement in OAB symptom severity after AA repair. In linear regression adjusting for age, body mass index, diabetes, stress urinary incontinence, pelvic organ prolapse quantification stage, anticholinergic use, and midurethral sling, this difference did not remain significant. Conclusions: Patients have significant improvement in OAB symptoms after POP repair. In adjusted analyses, there was no difference in improvement in OAB-q SS scores in the patients who had AAversus P repair. Key Words: overactive bladder, pelvic organ prolapse, OAB-q, quality of life (Female Pelvic Med Reconstr Surg 2014;20: 203Y207)
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veractive bladder (OAB) affects an estimated 38% of community-dwelling adult women, and, in the United States alone, treatment of OAB costs more than $65 billion dollars each year.1,2 Pelvic organ prolapse (POP) is also common, with a woman’s reported lifetime risk of undergoing surgery for POP repair ranging from 11% to 19%.3,4 Since OAB and POP are common conditions affecting similar populations of adult women, it is not surprising that OAB and POP often occur concomitantly in the same patient.5,6
From the Department of Obstetrics and Gynecology, Division of Urogynecology & Reconstructive Pelvic Surgery, Duke University Medical Center, Durham, NC. Reprints: Alexis A. Dieter, MD, Department of Obstetrics and Gynecology, Division of Urogynecology & Reconstructive Pelvic Surgery, Duke University Medical Center, 5324 McFarland Dr, Suite 310, Durham, NC 27707. E-mail: [email protected]. The authors have declared they have no conflicts of interest. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0000000000000087
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The relationship between OAB and POP is unclear. Research has shown that obstructive urinary symptoms increase with greater severity of prolapse.7 However, other urinary symptoms do not consistently correlate with anterior or apical compartment defects.7Y10 Recent studies investigating the effect of POP repair on OAB symptomatology have shown that, in most cases, patients experience an improvement in OAB symptoms when assessed several months to years after undergoing POP surgery.11Y18 Yet, it remains to be determined whether the repair of a specific compartment is associated with improvements in OAB or whether simply undergoing any prolapse repair leads to improved OAB symptoms. Therefore, our primary objective was to assess how the site of prolapse repair affects OAB symptoms in the postoperative period. We measured OAB symptoms, as assessed by the Overactive Bladder Questionnaire Symptom Severity (OAB-q SS) validated questionnaire, before and after surgery in patients undergoing prolapse repair to determine whether site of repair is associated with the margin of improvement in postoperative OAB symptoms.
MATERIALS AND METHODS We performed a retrospective cohort study of women with bothersome OAB who were undergoing prolapse repair in the Division of Urogynecology and Reconstructive Surgery at Duke University Medical Center from February 2011 through December 2012. Institutional review board (IRB) approval was obtained before study initiation (IRB no. Pro00043314). We compared 2 cohorts: (1) those undergoing isolated anterior/ apical (AA) prolapse repair; and (2) those undergoing isolated posterior (P) prolapse repair. For both cohorts, we included subjects undergoing prolapse repair with or without concomitant midurethral sling. Our principal interest was to examine the effect of anterior compartment repair (AA procedure) versus prolapse repair not involving the anterior compartment (isolated P repair). Thus, we excluded women undergoing AA and P repair (ie, repairs in all compartments). Patient responses to validated quality of life questionnaires were collected at the preoperative visit and 6 weeks postoperatively. Patients were approached by a research coordinator and asked to complete confidential questionnaires before their preoperative surgical workup visit and 6 weeks after surgery. Subjects were also contacted via e-mail through the Research Electronic Data Capture consortium19 and given the option to complete questionnaires electronically prior to office visits. All subjects scheduled for surgery were asked to complete the Pelvic Floor Distress Inventory short form (PFDI-20). The PFDI-20 assesses the presence of symptoms of lower urinary tract disorders, lower gastrointestinal tract disorders, and POP, and assesses the degree of bother and distress that is caused by those symptoms.20 This validated questionnaire has been shown to be responsive to change in women with pelvic floor disorders undergoing surgery.20 The PFDI-20 is comprised of a total of 20 questions divided into 3 scales (the Urinary Distress
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Inventory [UDI-6], the Pelvic Organ Prolapse Distress Inventory [POPDI-6], and the Colorectal-Anal Distress Inventory [CRADI-8]), with a summary score calculated as the sum of all 3 subscales with higher scores indicating greater distress. For our study, if a patient answered yes to question 16 of the PFDI-20 (‘‘Do you usually experience leakage associated with a feeling of urgency; that is, a strong sensation of needing to go to the bathroom?’’) at the preoperative visit and also indicated ‘‘moderate’’ or ‘‘quite a bit’’ degree of bother, she was prompted to complete the OAB-q short form at that visit and on all subsequent questionnaires. The OAB-q is used to assess the impact of OAB symptoms on the patient’s life21 and has been shown to be responsive to reductions in urinary urgency, frequency, and incontinence during anticholinergic therapy.22 The OAB-q short form questionnaire consists of 19 items divided into a 6-item SS scale and a 13-item health-related quality of life (HRQL) scale, with both scales ranging from 0 to 100. For the OAB-q SS scale, a higher score indicates worse severity of symptoms, whereas for the OAB-q HRQL scale, a higher score indicates better quality of life. Data regarding demographics, medical history, surgical history, preoperative pelvic organ prolapse quantification (POP-Q) and urodynamic study results, surgical procedures, and postoperative information including postoperative POP-Q and any complications were collected retrospectively from medical records. We defined AA repair to include anterior colporrhaphy and/or apical suspension including sacrocolpopexy with mesh (usually performed robotically), uterosacral ligament suspension, or sacrospinous ligament fixation. We defined P repair to include posterior colporrhaphy, perineorrhaphy, and/or perineoplasty. All P repairs and almost all anterior colporrhaphies were native tissue repairs, performed without vaginal synthetic mesh or biologic graft augmentation. One patient underwent anterior colporrhaphy and apical suspension with transvaginal mesh placement with the Uphold\ (Boston Scientific, Natick, Mass) mesh implant. Our primary outcome was OAB-q SS change score, calculated as preoperative OAB-q SS score minus postoperative OAB-q SS score, such that a positive change score of higher numeric value indicates improved severity of symptoms after surgery. In order to determine the percentage of patients with
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significantly improved OAB-q SS scores after surgery, we defined improvement to be a change score on the OAB-q SS of 10 or greater. This value is consistent with previous work revealing that the minimally important difference on the OAB-q SS is 10 or higher.23,24 We compared OAB-q SS change scores as well as percentage of patients with improvement between our 2 cohorts to determine whether isolated AA repair as compared with isolated P repair improves OAB symptoms. The OAB-q HRQL change scores and the UDI-6 change scores were examined as secondary outcomes. The OAB-q HRQL change score was calculated as preoperative OAB-q HRQL minus postoperative OAB-q HRQL, and a large negative OAB-q HRQL change score indicates improved postoperative quality of life. The UDI6 was calculated similarly, but a positive change score indicates improvement (decreased symptom bother). Categorical variables were analyzed using the W2 or the Fisher exact test; continuous variables were analyzed using the Student t test. Median POP-Q stage was analyzed via the MannWhitney U test. A P value of less than 0.05 defined statistical significance. Multivariate linear regression was performed to adjust for confounding variables, which were identified during bivariate analyses and univariate linear regression. All statistical analyses were performed using the Statistical Package for the Social Sciences version 20.0 (Chicago, Ill) and verified using SAS version 9.3 (SAS Institute, Cary, NC). Data are presented according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational studies.25
RESULTS There were a total of 175 subjects included in this study, with 133 (76%) undergoing AA repair and 42 (24%) undergoing P repair. Overall, baseline demographic characteristics, including baseline rates of stress urinary incontinence (SUI) assessed by affirmative response to PFDI-20 question 17 (‘‘Do you usually experience urine leakage related to coughing, sneezing or laughing?’’) and preoperative urodynamic studies, were similar between the 2 groups (Table 1). The AA group had significantly worse preoperative prolapse, with a median preoperative POP-Q stage of 3 versus a median preoperative POP-Q stage of 2 in the
TABLE 1. Baseline Characteristics
Age, y BMI, kg/m2 White race Obese (BMIQ30) Smoker Diabetes Postmenopausal Preoperative POP-Q stage SUI by PFDI-20 question 17 SUI by urodynamic studies Anticholinergic medication use
AA Cohort (n=133)
P Cohort (n=42)
P
63T12 29T6 115 (86) 50/132 (38) 17 (13) 26 (20) 116 (87) 3 (2Y3) 64/75 (48) 72/107 (54) 12 (9)
60T12 30T7 38 (90) 21 (50) 4 (10) 8 (19) 34 (81) 2 (1Y3) 31/38 (74) 17/25 (40) 3 (7)
0.11* 0.23* 0.49† 0.16† 0.57† 0.94† 0.31† G0.01§ 0.61† 0.95† 1.00‡
Data are presented as meanTSD, number (percentage), or median (interquartile range [25%Y75%]). Value in bold font is statistically significant. *P value from Student t test. †P value from Pearson W2. ‡P value from Fisher exact test. §P value from Mann-Whitney U test. BMI, body mass index.
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P group (PG0.01). There were no significant differences in intraoperative estimated blood loss or complications, but subjects in the AA group were more likely to undergo concomitant midurethral sling at the time of surgery (57% [n=76] in AA vs 31% [n=13] in P, PG0.01). The most common postoperative complication was urinary tract infection (17% [n=23] in AA vs 10% [n=4] in P, P=0.22), followed by urinary retention requiring catheterization (5 patients), and wound cellulitis (3 patients). Preoperative PFDI-20 scores indicated moderate symptom burden prior to surgery (Table 2). All validated questionnaire scores significantly improved after surgery (PG0.05 for all), reflecting decreased symptom burden and improved quality of life for the subjects by their 6-week postoperative visit (Table 2). When comparing scores between the 2 cohorts, the subjects in the AA group had lower PFDI-20 scores on preoperative assessment (meanTSD, 128T49 in AA vs 157T51 in P, PG0.01; Table 3). This difference is likely attributable to the finding that the AA group had significantly lower colorectal symptom bother, as assessed via the CRADI-8 scale at the time of preoperative assessment (meanTSD CRADI-8 score, 26T22 in AA vs 48T26 in P, P 90.01), but had similar preoperative UDI-6 and POPDI-6 scores. Preoperative OAB-q SS and OAB-q HRQL scores indicated similar severity of OAB symptom burden and similar quality of life impairments due to OAB symptoms. There were no significant differences in postoperative PFDI-20, UDI-6, POPDI-6, CRADI-8, OAB-q SS, or OAB-q HRQL scores between the 2 groups (Table 3). For our primary outcome, OAB-q SS change score was found to be significantly higher in the AA group compared with the P group, indicating a larger improvement in OAB symptom severity postoperatively in patients undergoing isolated AA repair as compared with patients undergoing isolated P repair (meanTSD OAB-q SS change score, 26T24 in AA vs 13T28 in P, P=0.01; Table 3). Using an OAB-q SS change score of 10 or greater to define improvement, we found that 79% (84/106) of the AA patients versus 61% (19/31) of the P patients (P=0.042) experienced improvement in OAB symptoms. However, in a linear regression analysis adjusting for age, body mass index, diabetes, SUI, preoperative POP-Q stage, anticholinergic medication use, and concomitant midurethral sling, OAB-q SS change score did not remain significantly different between the 2 groups (P=0.09). We also performed linear regression analysis of postoperative OAB-q SS scores with the same
TABLE 2. Quality of Life Questionnaire Scores for All Patients Questionnaire PFDI-20 Summary score UDI-6 POPDI-6 CRADI-8 OAB-q SS OAB-q HRQL
n 133 133 133 133 141 139
Preoperative Score 133T23 59T19 45T23 29T25 47T19 65T22
Postoperative Score 37T44 18T22 8T13 11T17 24T22 84T19
P G0.01 0.04 G0.01 G0.01 G0.01 G0.01
Data are presented as meanTSD. P values are calculated from Student t test. Symptom severity range is 0 to 100, with higher score indicating greater SS; HRQL range is 0 to 100, with higher score indicating better quality of life.
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TABLE 3. Quality of Life Questionnaire Scores by Cohort Questionnaire PFDI-20 Preoperative summary score UDI-6 POPDI-6 CRADI-8 Postoperative summary score* UDI-6* POPDI-6* CRADI-8* UDI-6 change score* OAB-q SS Preoperative score† Postoperative score‡ Change score‡ OAB-q HRQL Preoperative score§ Postoperative score|| Change score||
AA Cohort (n=133)
P Cohort (n=42)
P
128T49
157T51
G0.01
59T21 43T23 26T22 34T43
61T18 48T25 48T26 46T47
0.61 0.25 G0.01 0.19
17T21 7T12 11T17 41T26
25T24 12T14 10T13 36T25
0.07 0.06 0.73 0.34
48T19 23T21 26T24
43T20 29T25 13T28
0.15 0.15 0.01
64T23 86T18 j21T24
63T23 80T19 j16T24
0.81 0.15 0.34
Data are presented as meanTSD. P values are calculated from Student t test. *n=103 for AA, n=30 for P. †n=129 for AA. ‡n=112 for AA, n=32 for P. §n=128 for AA. ||n=111 for AA, n=32 for P. Symptom severity range is 0 to 100, with higher score indicating greater SS; HRQL range is 0 to 100, with higher score indicating better quality of life.
variables listed above but also adding preoperative OAB-q SS score as a variable, and the outcome was the same. Our secondary outcomes of OAB-q HRQL change score and UDI-6 change score were not significantly different between the groups (Table 3). Both groups had negative OAB-q HRQL change scores, indicating similar improvements in quality of life postoperatively for the patients undergoing isolated AA repair and isolated P repair. Linear regression analyses confirmed these findings, even when adjusting for preoperative OAB-q HRQL along with the other variables listed above.
DISCUSSION Overactive bladder and POP are prevalent conditions that commonly coexist.5 Our data confirm that women with OAB who undergo surgery for POP repair experience decreased severity of symptoms and improved quality of life. We have shown that this improvement occurs in the acute postoperative period. Additionally, women with OAB who undergo AA repair with or without concomitant midurethral sling were found to have a more significant improvement than the women undergoing P repair with or without concomitant midurethral sling; however, this difference did not persist in adjusted analyses. Overactive bladder is a condition defined by a patient’s symptoms. Previous studies have shown that symptoms may not correlate with objective measures of bladder function, and www.fpmrs.net
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thus, it is important to assess symptom burden when evaluating patients with OAB.26Y28 The OAB-q has been proven to accurately assess OAB-specific symptoms and OAB HRQL, and it has been shown to be responsive to therapeutic intervention.22 We used a standardized, robust database with patient responses to the PFDI-20 (which incorporates the UDI-6) and the OAB-q, which are validated questionnaires commonly used by clinicians and researchers to assess patient-reported conditionspecific symptoms and HRQL.27,28 Previous studies have used variable methods to assess OAB symptoms, and most did not use the validated and OAB-specific OAB-q questionnaire. Concomitant use of both the UDI-6 and the OAB-q allowed us to compare both baseline and change scores in those questionnaires. The only significant difference in baseline scores between the 2 groups was a higher CRADI-8 score in the P group. This higher CRADI-8 score reflects greater colorectal symptom bother in patients undergoing P repair. We did not find a significant correlation between prolapse severity and OAB-q subscale change scores. de Boer et al6 found that symptomatic prolapse was an independent risk factor of OAB symptoms but did not have physical examination data to correlate with prolapse stage or compartment. Gutman et al10 examined severity of prolapse and pelvic floor symptoms at baseline and were unable to identify a threshold of prolapse severity that predicted symptoms other than bulging/protrusion. A more recent study by Miranne et al17 examining how prolapse severity affected OAB symptoms after prolapse repair found that severity of preoperative prolapse did not significantly change improvement in UDI-6 scores at 12 months postoperatively. However, in adjusted analyses, women with more severe prolapse (stage 3Y4) had lower odds of experiencing improvement in frequency or urge incontinence as compared with women with stage 1 to 2 prolapse. Miranne and colleagues17 did not include patients undergoing concomitant sling surgery and did not account for anticholinergic use, which may explain the variation in results. In contrast, Fletcher et al13 found no significant correlation between more severe anterior prolapse and persistent urge incontinence after prolapse repair. Our results support the findings of Gutman et al10 and Fletcher et al13 because the severity of prolapse did not correlate with severity of OAB symptoms. More investigation is needed to clarify the relationship between prolapse severity and OAB symptomatology. The improvement in OAB symptoms experienced by our patients is clinically significant. Studies examining the minimally important difference on the OAB-q have suggested a change of at least 10 points or higher as the clinically relevant threshold for both subscales.23,24 Both the AA group and the P group had more than a 10-point improvement in OAB-q SS and OAB-q HRQL (Table 2). Interestingly, while the AA group had a significantly higher OAB-q SS change score in bivariate analysis (indicating a more significant improvement in OAB symptoms after surgery), this difference did not persist in adjusted analyses. The UDI-6 also showed clinically significant improvement in the postoperative period, with mean improvement in both groups of greater than 35 points.24 Studies examining the specific site of prolapse repair and the effect on OAB symptoms are limited. de Boer et al11 examined risk factors of OAB after prolapse surgery, and in their findings stated that urinary urge incontinence decreased more in anterior compartment repair compared with repair in other compartments. However, the authors acknowledge that their findings were limited by the fact that the majority of subjects underwent surgery in more than one compartment and they did not analyze isolated compartmental repairs. In our study, we have examined isolated AA repair as compared with
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isolated P repair in order to reduce confounding factors. Our results lead us to conclude that either type of prolapse repair will lead to improvement in OAB symptoms. Although this is encouraging for patients with OAB who are planning to undergo POP repair, the mechanisms behind this improvement are unclear, and further research is needed to gain a more detailed understanding of the pathophysiology behind how prolapse repair in any compartment leads to improvements in lower urinary tract symptoms. Strengths of this study are the well-characterized study population, excellent follow-up, and utilization of validated patient-reported questionnaires. We obtained detailed data on perioperative characteristics, including use of anticholinergic medication, from medical records. We used validated questionnaires that have been rigorously tested. Previous studies have shown improvement in OAB symptoms following prolapse surgery at follow-up of several months to years.11Y18,29Y32 We used a shorter period of observation to assess whether patients experience this improvement in the acute postoperative period. In doing so, we are able to attribute the improvement in OAB SS to undergoing prolapse repair since there are fewer temporal factors involved. Additionally, we also show that the improvement in OAB symptoms occurs relatively quickly after surgery, which is an interesting and novel result. The limitations of our study include the retrospective design and potential recall and selection bias. Although this study is retrospective, patients did complete the validated questionnaires in a prospective fashion so as to limit recall bias. All subjects were asked to complete the questionnaires voluntarily, and, although most of our patients agreed to do so, there was a small population that declined and, thus, these patients are not reflected in our study. The acute time period of observation, while enabling us to directly attribute change to surgery, prevents us from determining OAB symptoms more than 6 weeks after surgery. Notably, the patients undergoing AA repair had a higher rate of concomitant midurethral sling. We accounted for this difference by including midurethral sling as a covariate in our linear regression analysis. Interestingly, when adjusting for this variable, any differences in change scores that we initially saw were no longer significant. An important consideration is the inclusion of patients undergoing concomitant midurethral sling in the study population. By including patients undergoing midurethral sling, our results are probably more applicable to the general population of women with OAB who undergo POP repair as midurethral sling surgery is commonly performed at the time of prolapse repair. Our finding that concomitant sling did not significantly affect OAB symptoms in the postoperative period reflects the findings of previous studies conducted in patients undergoing prolapse repair with or without concomitant sling.11,14,16,30 In conclusion, this study shows that patients undergoing prolapse repair experience clinically significant improvements in OAB symptoms and related quality of life, as assessed via the OAB-q SS and the OAB-q HRQL. This improvement occurs within the first 6 weeks after surgery. Patients with OAB undergoing AA repair have similar improvements as compared to patients with OAB undergoing P repair, regardless of whether they undergo concomitant midurethral sling surgery. REFERENCES 1. Anger JT, Saigal CS, Litwin MS. The prevalence of urinary incontinence among community dwelling adult women: results from the National Health and Nutrition Examination Survey. J Urol 2006;175:601Y604.
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2. Ganz ML, Smalarz AM, Krupski TL, et al. Economic costs of overactive bladder in the United States. Urology 2010;75:526Y532, 532 e1Y18. 3. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501Y506. 4. Smith FJ, Holman CD, Moorin RE, et al. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 2010;116:1096Y1100. 5. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311Y1316. 6. de Boer TA, Slieker-ten Hove MC, Burger CW, et al. The prevalence and risk factors of overactive bladder symptoms and its relation to pelvic organ prolapse symptoms in a general female population. Int Urogynecol J 2011;22:569Y575. 7. Bradley CS, Nygaard IE. Vaginal wall descensus and pelvic floor symptoms in older women. Obstet Gynecol 2005;106:759Y766. 8. Ellerkmann RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332Y1337; discussion 1337Y1338. 9. Ghetti C, Gregory WT, Edwards SR, et al. Pelvic organ descent and symptoms of pelvic floor disorders. Am J Obstet Gynecol 2005;193:53Y57. 10. Gutman RE, Ford DE, Quiroz LH, et al. Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms? Am J Obstet Gynecol 2008;199:683.e1Y683.e7. 11. de Boer TA, Kluivers KB, Withagen MI, et al. Predictive factors for overactive bladder symptoms after pelvic organ prolapse surgery. Int Urogynecol J 2010;21:1143Y1149. 12. Digesu GA, Salvatore S, Chaliha C, et al. Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse? Int Urogynecol J Pelvic Floor Dysfunct 2007;18:1439Y1443. 13. Fletcher SG, Haverkorn RM, Yan J, et al. Demographic and urodynamic factors associated with persistent OAB after anterior compartment prolapse repair. Neurourol Urodyn 2010;29:1414Y1418. 14. Foster RT Sr, Barber MD, Parasio MF, et al. A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse. Am J Obstet Gynecol 2007;197:82.e1Y82.e4. 15. Lin SN, Klapper AS, Wong P, et al. Quality of life after treatment with midurethral sling and concomitant prolapse repair in patients with mixed versus stress urinary incontinence. Neurourol Urodyn 2011;30:1507Y1511. 16. Long CY, Hsu CS, Wu MP, et al. Predictors of improved overactive bladder symptoms after transvaginal mesh repair for the treatment of pelvic organ prolapse: predictors of improved OAB after POP repair. Int Urogynecol J 2011;22:535Y542.
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17. Miranne JM, Lopes V, Carberry CL, et al. The effect of pelvic organ prolapse severity on improvement in overactive bladder symptoms after pelvic reconstructive surgery. Int Urogynecol J 2013;24:1303Y1308. 18. Wolter CE, Kaufman MR, Duffy JW, et al. Mixed incontinence and cystocele: postoperative urge symptoms are not predicted by preoperative urodynamics. Int Urogynecol J 2011;22:321Y325. 19. Available at: http://www.project-redcap.org/. Accessed July 31, 2013. 20. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 2005;193:103Y113. 21. Coyne K, Revicki D, Hunt T, et al. Psychometric validation of an overactive bladder symptom and health-related quality of life questionnaire: the OAB-q. Qual Life Res 2002;11:563Y574. 22. Coyne KS, Matza LS, Thompson CL. The responsiveness of the Overactive Bladder Questionnaire (OAB-q). Qual Life Res 2005;14:849Y855. 23. Coyne KS, Matza LS, Thompson CL, et al. Determining the importance of change in the Overactive Bladder Questionnaire. J Urol 2006;176:627Y632; discussion 632. 24. Dyer KY, Xu Y, Brubaker L, et al. Minimum important difference for validated instruments in women with urge incontinence. Neurourol Urodyn 2011;30:1319Y1324. 25. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453Y1457. 26. Abrams P, Artibani W, Gajewski JB, et al. Assessment of treatment outcomes in patients with overactive bladder: importance of objective and subjective measures. Urology 2006;68:17Y28. 27. Brubaker L, Chapple C, Coyne KS, et al. Patient-reported outcomes in overactive bladder: importance for determining clinical effectiveness of treatment. Urology 2006;68:3Y8. 28. Coyne KS, Tubaro A, Brubaker L, et al. Development and validation of patient-reported outcomes measures for overactive bladder: a review of concepts. Urology 2006;68:9Y16. 29. El-Azab AS, Abd-Elsayed AA, Imam HM. Patient reported and anatomical outcomes after surgery for pelvic organ prolapse. Neurourol Urodyn 2009;28:219Y224. 30. Lleberia J, Pubill J, Mestre M, et al. Surgical treatment of mixed urinary incontinence: effect of anterior colpoplasty. Int Urogynecol J 2011;22:1025Y1030. 31. Nguyen JK, Bhatia NN. Resolution of motor urge incontinence after surgical repair of pelvic organ prolapse. J Urol 2001;166:2263Y2266. 32. Okui N, Okui M, Horie S. Improvements in overactive bladder syndrome after polypropylene mesh surgery for cystocele. Aust N Z J Obstet Gynaecol 2009;49:226Y231.
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How Does Site of Pelvic Organ Prolapse Repair Affect Overactive Bladder Symptoms? Alexis A. Dieter, MD, Autumn L. Edenfield, MD, Alison C. Weidner, MD, and Nazema Y. Siddiqui, MD, MHSc
Objectives: To assess how site of pelvic organ prolapse repair affects overactive bladder (OAB) symptoms, we compared change in OAB symptoms in women undergoing isolated anterior/apical (AA) repair versus isolated posterior (P) repair. Methods: This is a retrospective cohort study of women with bothersome OAB undergoing either AA or P prolapse repair. The subjects completed the Pelvic Floor Distress Inventory short form and the Overactive Bladder Questionnaire (OAB-q) validated questionnaires preoperatively and 6 weeks postoperatively. Our primary outcome was OAB-q symptom severity (SS) change score (preoperative minus postoperative score) compared between the 2 groups. Results: Of 175 subjects, 133 (76%) underwent AA repair and 42 (24%) underwent P repair. Baseline OAB-q SS scores and baseline characteristics were similar except that the AA group had more severe baseline prolapse (median pelvic organ prolapse quantification stage 3 for AA [interquartile range, 2Y3] vs stage 2 for P [interquartile range, 1Y3]; PG0.01] and a higher rate of concomitant midurethral sling (57% in AA vs 31% in P; PG0.01). Overall OAB symptoms significantly improved within 6 weeks of surgery (PG0.01). The meanTSD OAB-q SS change score was higher in the AA repair group (26T24 in AA vs 13 T 28 in P; P=0.01), indicating greater improvement in OAB symptom severity after AA repair. In linear regression adjusting for age, body mass index, diabetes, stress urinary incontinence, pelvic organ prolapse quantification stage, anticholinergic use, and midurethral sling, this difference did not remain significant. Conclusions: Patients have significant improvement in OAB symptoms after POP repair. In adjusted analyses, there was no difference in improvement in OAB-q SS scores in the patients who had AAversus P repair. Key Words: overactive bladder, pelvic organ prolapse, OAB-q, quality of life (Female Pelvic Med Reconstr Surg 2014;20: 203Y207)
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veractive bladder (OAB) affects an estimated 38% of community-dwelling adult women, and, in the United States alone, treatment of OAB costs more than $65 billion dollars each year.1,2 Pelvic organ prolapse (POP) is also common, with a woman’s reported lifetime risk of undergoing surgery for POP repair ranging from 11% to 19%.3,4 Since OAB and POP are common conditions affecting similar populations of adult women, it is not surprising that OAB and POP often occur concomitantly in the same patient.5,6
From the Department of Obstetrics and Gynecology, Division of Urogynecology & Reconstructive Pelvic Surgery, Duke University Medical Center, Durham, NC. Reprints: Alexis A. Dieter, MD, Department of Obstetrics and Gynecology, Division of Urogynecology & Reconstructive Pelvic Surgery, Duke University Medical Center, 5324 McFarland Dr, Suite 310, Durham, NC 27707. E-mail: [email protected]. The authors have declared they have no conflicts of interest. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0000000000000087
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The relationship between OAB and POP is unclear. Research has shown that obstructive urinary symptoms increase with greater severity of prolapse.7 However, other urinary symptoms do not consistently correlate with anterior or apical compartment defects.7Y10 Recent studies investigating the effect of POP repair on OAB symptomatology have shown that, in most cases, patients experience an improvement in OAB symptoms when assessed several months to years after undergoing POP surgery.11Y18 Yet, it remains to be determined whether the repair of a specific compartment is associated with improvements in OAB or whether simply undergoing any prolapse repair leads to improved OAB symptoms. Therefore, our primary objective was to assess how the site of prolapse repair affects OAB symptoms in the postoperative period. We measured OAB symptoms, as assessed by the Overactive Bladder Questionnaire Symptom Severity (OAB-q SS) validated questionnaire, before and after surgery in patients undergoing prolapse repair to determine whether site of repair is associated with the margin of improvement in postoperative OAB symptoms.
MATERIALS AND METHODS We performed a retrospective cohort study of women with bothersome OAB who were undergoing prolapse repair in the Division of Urogynecology and Reconstructive Surgery at Duke University Medical Center from February 2011 through December 2012. Institutional review board (IRB) approval was obtained before study initiation (IRB no. Pro00043314). We compared 2 cohorts: (1) those undergoing isolated anterior/ apical (AA) prolapse repair; and (2) those undergoing isolated posterior (P) prolapse repair. For both cohorts, we included subjects undergoing prolapse repair with or without concomitant midurethral sling. Our principal interest was to examine the effect of anterior compartment repair (AA procedure) versus prolapse repair not involving the anterior compartment (isolated P repair). Thus, we excluded women undergoing AA and P repair (ie, repairs in all compartments). Patient responses to validated quality of life questionnaires were collected at the preoperative visit and 6 weeks postoperatively. Patients were approached by a research coordinator and asked to complete confidential questionnaires before their preoperative surgical workup visit and 6 weeks after surgery. Subjects were also contacted via e-mail through the Research Electronic Data Capture consortium19 and given the option to complete questionnaires electronically prior to office visits. All subjects scheduled for surgery were asked to complete the Pelvic Floor Distress Inventory short form (PFDI-20). The PFDI-20 assesses the presence of symptoms of lower urinary tract disorders, lower gastrointestinal tract disorders, and POP, and assesses the degree of bother and distress that is caused by those symptoms.20 This validated questionnaire has been shown to be responsive to change in women with pelvic floor disorders undergoing surgery.20 The PFDI-20 is comprised of a total of 20 questions divided into 3 scales (the Urinary Distress
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Inventory [UDI-6], the Pelvic Organ Prolapse Distress Inventory [POPDI-6], and the Colorectal-Anal Distress Inventory [CRADI-8]), with a summary score calculated as the sum of all 3 subscales with higher scores indicating greater distress. For our study, if a patient answered yes to question 16 of the PFDI-20 (‘‘Do you usually experience leakage associated with a feeling of urgency; that is, a strong sensation of needing to go to the bathroom?’’) at the preoperative visit and also indicated ‘‘moderate’’ or ‘‘quite a bit’’ degree of bother, she was prompted to complete the OAB-q short form at that visit and on all subsequent questionnaires. The OAB-q is used to assess the impact of OAB symptoms on the patient’s life21 and has been shown to be responsive to reductions in urinary urgency, frequency, and incontinence during anticholinergic therapy.22 The OAB-q short form questionnaire consists of 19 items divided into a 6-item SS scale and a 13-item health-related quality of life (HRQL) scale, with both scales ranging from 0 to 100. For the OAB-q SS scale, a higher score indicates worse severity of symptoms, whereas for the OAB-q HRQL scale, a higher score indicates better quality of life. Data regarding demographics, medical history, surgical history, preoperative pelvic organ prolapse quantification (POP-Q) and urodynamic study results, surgical procedures, and postoperative information including postoperative POP-Q and any complications were collected retrospectively from medical records. We defined AA repair to include anterior colporrhaphy and/or apical suspension including sacrocolpopexy with mesh (usually performed robotically), uterosacral ligament suspension, or sacrospinous ligament fixation. We defined P repair to include posterior colporrhaphy, perineorrhaphy, and/or perineoplasty. All P repairs and almost all anterior colporrhaphies were native tissue repairs, performed without vaginal synthetic mesh or biologic graft augmentation. One patient underwent anterior colporrhaphy and apical suspension with transvaginal mesh placement with the Uphold\ (Boston Scientific, Natick, Mass) mesh implant. Our primary outcome was OAB-q SS change score, calculated as preoperative OAB-q SS score minus postoperative OAB-q SS score, such that a positive change score of higher numeric value indicates improved severity of symptoms after surgery. In order to determine the percentage of patients with
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significantly improved OAB-q SS scores after surgery, we defined improvement to be a change score on the OAB-q SS of 10 or greater. This value is consistent with previous work revealing that the minimally important difference on the OAB-q SS is 10 or higher.23,24 We compared OAB-q SS change scores as well as percentage of patients with improvement between our 2 cohorts to determine whether isolated AA repair as compared with isolated P repair improves OAB symptoms. The OAB-q HRQL change scores and the UDI-6 change scores were examined as secondary outcomes. The OAB-q HRQL change score was calculated as preoperative OAB-q HRQL minus postoperative OAB-q HRQL, and a large negative OAB-q HRQL change score indicates improved postoperative quality of life. The UDI6 was calculated similarly, but a positive change score indicates improvement (decreased symptom bother). Categorical variables were analyzed using the W2 or the Fisher exact test; continuous variables were analyzed using the Student t test. Median POP-Q stage was analyzed via the MannWhitney U test. A P value of less than 0.05 defined statistical significance. Multivariate linear regression was performed to adjust for confounding variables, which were identified during bivariate analyses and univariate linear regression. All statistical analyses were performed using the Statistical Package for the Social Sciences version 20.0 (Chicago, Ill) and verified using SAS version 9.3 (SAS Institute, Cary, NC). Data are presented according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational studies.25
RESULTS There were a total of 175 subjects included in this study, with 133 (76%) undergoing AA repair and 42 (24%) undergoing P repair. Overall, baseline demographic characteristics, including baseline rates of stress urinary incontinence (SUI) assessed by affirmative response to PFDI-20 question 17 (‘‘Do you usually experience urine leakage related to coughing, sneezing or laughing?’’) and preoperative urodynamic studies, were similar between the 2 groups (Table 1). The AA group had significantly worse preoperative prolapse, with a median preoperative POP-Q stage of 3 versus a median preoperative POP-Q stage of 2 in the
TABLE 1. Baseline Characteristics
Age, y BMI, kg/m2 White race Obese (BMIQ30) Smoker Diabetes Postmenopausal Preoperative POP-Q stage SUI by PFDI-20 question 17 SUI by urodynamic studies Anticholinergic medication use
AA Cohort (n=133)
P Cohort (n=42)
P
63T12 29T6 115 (86) 50/132 (38) 17 (13) 26 (20) 116 (87) 3 (2Y3) 64/75 (48) 72/107 (54) 12 (9)
60T12 30T7 38 (90) 21 (50) 4 (10) 8 (19) 34 (81) 2 (1Y3) 31/38 (74) 17/25 (40) 3 (7)
0.11* 0.23* 0.49† 0.16† 0.57† 0.94† 0.31† G0.01§ 0.61† 0.95† 1.00‡
Data are presented as meanTSD, number (percentage), or median (interquartile range [25%Y75%]). Value in bold font is statistically significant. *P value from Student t test. †P value from Pearson W2. ‡P value from Fisher exact test. §P value from Mann-Whitney U test. BMI, body mass index.
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P group (PG0.01). There were no significant differences in intraoperative estimated blood loss or complications, but subjects in the AA group were more likely to undergo concomitant midurethral sling at the time of surgery (57% [n=76] in AA vs 31% [n=13] in P, PG0.01). The most common postoperative complication was urinary tract infection (17% [n=23] in AA vs 10% [n=4] in P, P=0.22), followed by urinary retention requiring catheterization (5 patients), and wound cellulitis (3 patients). Preoperative PFDI-20 scores indicated moderate symptom burden prior to surgery (Table 2). All validated questionnaire scores significantly improved after surgery (PG0.05 for all), reflecting decreased symptom burden and improved quality of life for the subjects by their 6-week postoperative visit (Table 2). When comparing scores between the 2 cohorts, the subjects in the AA group had lower PFDI-20 scores on preoperative assessment (meanTSD, 128T49 in AA vs 157T51 in P, PG0.01; Table 3). This difference is likely attributable to the finding that the AA group had significantly lower colorectal symptom bother, as assessed via the CRADI-8 scale at the time of preoperative assessment (meanTSD CRADI-8 score, 26T22 in AA vs 48T26 in P, P 90.01), but had similar preoperative UDI-6 and POPDI-6 scores. Preoperative OAB-q SS and OAB-q HRQL scores indicated similar severity of OAB symptom burden and similar quality of life impairments due to OAB symptoms. There were no significant differences in postoperative PFDI-20, UDI-6, POPDI-6, CRADI-8, OAB-q SS, or OAB-q HRQL scores between the 2 groups (Table 3). For our primary outcome, OAB-q SS change score was found to be significantly higher in the AA group compared with the P group, indicating a larger improvement in OAB symptom severity postoperatively in patients undergoing isolated AA repair as compared with patients undergoing isolated P repair (meanTSD OAB-q SS change score, 26T24 in AA vs 13T28 in P, P=0.01; Table 3). Using an OAB-q SS change score of 10 or greater to define improvement, we found that 79% (84/106) of the AA patients versus 61% (19/31) of the P patients (P=0.042) experienced improvement in OAB symptoms. However, in a linear regression analysis adjusting for age, body mass index, diabetes, SUI, preoperative POP-Q stage, anticholinergic medication use, and concomitant midurethral sling, OAB-q SS change score did not remain significantly different between the 2 groups (P=0.09). We also performed linear regression analysis of postoperative OAB-q SS scores with the same
TABLE 2. Quality of Life Questionnaire Scores for All Patients Questionnaire PFDI-20 Summary score UDI-6 POPDI-6 CRADI-8 OAB-q SS OAB-q HRQL
n 133 133 133 133 141 139
Preoperative Score 133T23 59T19 45T23 29T25 47T19 65T22
Postoperative Score 37T44 18T22 8T13 11T17 24T22 84T19
P G0.01 0.04 G0.01 G0.01 G0.01 G0.01
Data are presented as meanTSD. P values are calculated from Student t test. Symptom severity range is 0 to 100, with higher score indicating greater SS; HRQL range is 0 to 100, with higher score indicating better quality of life.
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TABLE 3. Quality of Life Questionnaire Scores by Cohort Questionnaire PFDI-20 Preoperative summary score UDI-6 POPDI-6 CRADI-8 Postoperative summary score* UDI-6* POPDI-6* CRADI-8* UDI-6 change score* OAB-q SS Preoperative score† Postoperative score‡ Change score‡ OAB-q HRQL Preoperative score§ Postoperative score|| Change score||
AA Cohort (n=133)
P Cohort (n=42)
P
128T49
157T51
G0.01
59T21 43T23 26T22 34T43
61T18 48T25 48T26 46T47
0.61 0.25 G0.01 0.19
17T21 7T12 11T17 41T26
25T24 12T14 10T13 36T25
0.07 0.06 0.73 0.34
48T19 23T21 26T24
43T20 29T25 13T28
0.15 0.15 0.01
64T23 86T18 j21T24
63T23 80T19 j16T24
0.81 0.15 0.34
Data are presented as meanTSD. P values are calculated from Student t test. *n=103 for AA, n=30 for P. †n=129 for AA. ‡n=112 for AA, n=32 for P. §n=128 for AA. ||n=111 for AA, n=32 for P. Symptom severity range is 0 to 100, with higher score indicating greater SS; HRQL range is 0 to 100, with higher score indicating better quality of life.
variables listed above but also adding preoperative OAB-q SS score as a variable, and the outcome was the same. Our secondary outcomes of OAB-q HRQL change score and UDI-6 change score were not significantly different between the groups (Table 3). Both groups had negative OAB-q HRQL change scores, indicating similar improvements in quality of life postoperatively for the patients undergoing isolated AA repair and isolated P repair. Linear regression analyses confirmed these findings, even when adjusting for preoperative OAB-q HRQL along with the other variables listed above.
DISCUSSION Overactive bladder and POP are prevalent conditions that commonly coexist.5 Our data confirm that women with OAB who undergo surgery for POP repair experience decreased severity of symptoms and improved quality of life. We have shown that this improvement occurs in the acute postoperative period. Additionally, women with OAB who undergo AA repair with or without concomitant midurethral sling were found to have a more significant improvement than the women undergoing P repair with or without concomitant midurethral sling; however, this difference did not persist in adjusted analyses. Overactive bladder is a condition defined by a patient’s symptoms. Previous studies have shown that symptoms may not correlate with objective measures of bladder function, and www.fpmrs.net
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thus, it is important to assess symptom burden when evaluating patients with OAB.26Y28 The OAB-q has been proven to accurately assess OAB-specific symptoms and OAB HRQL, and it has been shown to be responsive to therapeutic intervention.22 We used a standardized, robust database with patient responses to the PFDI-20 (which incorporates the UDI-6) and the OAB-q, which are validated questionnaires commonly used by clinicians and researchers to assess patient-reported conditionspecific symptoms and HRQL.27,28 Previous studies have used variable methods to assess OAB symptoms, and most did not use the validated and OAB-specific OAB-q questionnaire. Concomitant use of both the UDI-6 and the OAB-q allowed us to compare both baseline and change scores in those questionnaires. The only significant difference in baseline scores between the 2 groups was a higher CRADI-8 score in the P group. This higher CRADI-8 score reflects greater colorectal symptom bother in patients undergoing P repair. We did not find a significant correlation between prolapse severity and OAB-q subscale change scores. de Boer et al6 found that symptomatic prolapse was an independent risk factor of OAB symptoms but did not have physical examination data to correlate with prolapse stage or compartment. Gutman et al10 examined severity of prolapse and pelvic floor symptoms at baseline and were unable to identify a threshold of prolapse severity that predicted symptoms other than bulging/protrusion. A more recent study by Miranne et al17 examining how prolapse severity affected OAB symptoms after prolapse repair found that severity of preoperative prolapse did not significantly change improvement in UDI-6 scores at 12 months postoperatively. However, in adjusted analyses, women with more severe prolapse (stage 3Y4) had lower odds of experiencing improvement in frequency or urge incontinence as compared with women with stage 1 to 2 prolapse. Miranne and colleagues17 did not include patients undergoing concomitant sling surgery and did not account for anticholinergic use, which may explain the variation in results. In contrast, Fletcher et al13 found no significant correlation between more severe anterior prolapse and persistent urge incontinence after prolapse repair. Our results support the findings of Gutman et al10 and Fletcher et al13 because the severity of prolapse did not correlate with severity of OAB symptoms. More investigation is needed to clarify the relationship between prolapse severity and OAB symptomatology. The improvement in OAB symptoms experienced by our patients is clinically significant. Studies examining the minimally important difference on the OAB-q have suggested a change of at least 10 points or higher as the clinically relevant threshold for both subscales.23,24 Both the AA group and the P group had more than a 10-point improvement in OAB-q SS and OAB-q HRQL (Table 2). Interestingly, while the AA group had a significantly higher OAB-q SS change score in bivariate analysis (indicating a more significant improvement in OAB symptoms after surgery), this difference did not persist in adjusted analyses. The UDI-6 also showed clinically significant improvement in the postoperative period, with mean improvement in both groups of greater than 35 points.24 Studies examining the specific site of prolapse repair and the effect on OAB symptoms are limited. de Boer et al11 examined risk factors of OAB after prolapse surgery, and in their findings stated that urinary urge incontinence decreased more in anterior compartment repair compared with repair in other compartments. However, the authors acknowledge that their findings were limited by the fact that the majority of subjects underwent surgery in more than one compartment and they did not analyze isolated compartmental repairs. In our study, we have examined isolated AA repair as compared with
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isolated P repair in order to reduce confounding factors. Our results lead us to conclude that either type of prolapse repair will lead to improvement in OAB symptoms. Although this is encouraging for patients with OAB who are planning to undergo POP repair, the mechanisms behind this improvement are unclear, and further research is needed to gain a more detailed understanding of the pathophysiology behind how prolapse repair in any compartment leads to improvements in lower urinary tract symptoms. Strengths of this study are the well-characterized study population, excellent follow-up, and utilization of validated patient-reported questionnaires. We obtained detailed data on perioperative characteristics, including use of anticholinergic medication, from medical records. We used validated questionnaires that have been rigorously tested. Previous studies have shown improvement in OAB symptoms following prolapse surgery at follow-up of several months to years.11Y18,29Y32 We used a shorter period of observation to assess whether patients experience this improvement in the acute postoperative period. In doing so, we are able to attribute the improvement in OAB SS to undergoing prolapse repair since there are fewer temporal factors involved. Additionally, we also show that the improvement in OAB symptoms occurs relatively quickly after surgery, which is an interesting and novel result. The limitations of our study include the retrospective design and potential recall and selection bias. Although this study is retrospective, patients did complete the validated questionnaires in a prospective fashion so as to limit recall bias. All subjects were asked to complete the questionnaires voluntarily, and, although most of our patients agreed to do so, there was a small population that declined and, thus, these patients are not reflected in our study. The acute time period of observation, while enabling us to directly attribute change to surgery, prevents us from determining OAB symptoms more than 6 weeks after surgery. Notably, the patients undergoing AA repair had a higher rate of concomitant midurethral sling. We accounted for this difference by including midurethral sling as a covariate in our linear regression analysis. Interestingly, when adjusting for this variable, any differences in change scores that we initially saw were no longer significant. An important consideration is the inclusion of patients undergoing concomitant midurethral sling in the study population. By including patients undergoing midurethral sling, our results are probably more applicable to the general population of women with OAB who undergo POP repair as midurethral sling surgery is commonly performed at the time of prolapse repair. Our finding that concomitant sling did not significantly affect OAB symptoms in the postoperative period reflects the findings of previous studies conducted in patients undergoing prolapse repair with or without concomitant sling.11,14,16,30 In conclusion, this study shows that patients undergoing prolapse repair experience clinically significant improvements in OAB symptoms and related quality of life, as assessed via the OAB-q SS and the OAB-q HRQL. This improvement occurs within the first 6 weeks after surgery. Patients with OAB undergoing AA repair have similar improvements as compared to patients with OAB undergoing P repair, regardless of whether they undergo concomitant midurethral sling surgery. REFERENCES 1. Anger JT, Saigal CS, Litwin MS. The prevalence of urinary incontinence among community dwelling adult women: results from the National Health and Nutrition Examination Survey. J Urol 2006;175:601Y604.
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2. Ganz ML, Smalarz AM, Krupski TL, et al. Economic costs of overactive bladder in the United States. Urology 2010;75:526Y532, 532 e1Y18. 3. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501Y506. 4. Smith FJ, Holman CD, Moorin RE, et al. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 2010;116:1096Y1100. 5. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311Y1316. 6. de Boer TA, Slieker-ten Hove MC, Burger CW, et al. The prevalence and risk factors of overactive bladder symptoms and its relation to pelvic organ prolapse symptoms in a general female population. Int Urogynecol J 2011;22:569Y575. 7. Bradley CS, Nygaard IE. Vaginal wall descensus and pelvic floor symptoms in older women. Obstet Gynecol 2005;106:759Y766. 8. Ellerkmann RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332Y1337; discussion 1337Y1338. 9. Ghetti C, Gregory WT, Edwards SR, et al. Pelvic organ descent and symptoms of pelvic floor disorders. Am J Obstet Gynecol 2005;193:53Y57. 10. Gutman RE, Ford DE, Quiroz LH, et al. Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms? Am J Obstet Gynecol 2008;199:683.e1Y683.e7. 11. de Boer TA, Kluivers KB, Withagen MI, et al. Predictive factors for overactive bladder symptoms after pelvic organ prolapse surgery. Int Urogynecol J 2010;21:1143Y1149. 12. Digesu GA, Salvatore S, Chaliha C, et al. Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse? Int Urogynecol J Pelvic Floor Dysfunct 2007;18:1439Y1443. 13. Fletcher SG, Haverkorn RM, Yan J, et al. Demographic and urodynamic factors associated with persistent OAB after anterior compartment prolapse repair. Neurourol Urodyn 2010;29:1414Y1418. 14. Foster RT Sr, Barber MD, Parasio MF, et al. A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse. Am J Obstet Gynecol 2007;197:82.e1Y82.e4. 15. Lin SN, Klapper AS, Wong P, et al. Quality of life after treatment with midurethral sling and concomitant prolapse repair in patients with mixed versus stress urinary incontinence. Neurourol Urodyn 2011;30:1507Y1511. 16. Long CY, Hsu CS, Wu MP, et al. Predictors of improved overactive bladder symptoms after transvaginal mesh repair for the treatment of pelvic organ prolapse: predictors of improved OAB after POP repair. Int Urogynecol J 2011;22:535Y542.
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17. Miranne JM, Lopes V, Carberry CL, et al. The effect of pelvic organ prolapse severity on improvement in overactive bladder symptoms after pelvic reconstructive surgery. Int Urogynecol J 2013;24:1303Y1308. 18. Wolter CE, Kaufman MR, Duffy JW, et al. Mixed incontinence and cystocele: postoperative urge symptoms are not predicted by preoperative urodynamics. Int Urogynecol J 2011;22:321Y325. 19. Available at: http://www.project-redcap.org/. Accessed July 31, 2013. 20. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 2005;193:103Y113. 21. Coyne K, Revicki D, Hunt T, et al. Psychometric validation of an overactive bladder symptom and health-related quality of life questionnaire: the OAB-q. Qual Life Res 2002;11:563Y574. 22. Coyne KS, Matza LS, Thompson CL. The responsiveness of the Overactive Bladder Questionnaire (OAB-q). Qual Life Res 2005;14:849Y855. 23. Coyne KS, Matza LS, Thompson CL, et al. Determining the importance of change in the Overactive Bladder Questionnaire. J Urol 2006;176:627Y632; discussion 632. 24. Dyer KY, Xu Y, Brubaker L, et al. Minimum important difference for validated instruments in women with urge incontinence. Neurourol Urodyn 2011;30:1319Y1324. 25. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453Y1457. 26. Abrams P, Artibani W, Gajewski JB, et al. Assessment of treatment outcomes in patients with overactive bladder: importance of objective and subjective measures. Urology 2006;68:17Y28. 27. Brubaker L, Chapple C, Coyne KS, et al. Patient-reported outcomes in overactive bladder: importance for determining clinical effectiveness of treatment. Urology 2006;68:3Y8. 28. Coyne KS, Tubaro A, Brubaker L, et al. Development and validation of patient-reported outcomes measures for overactive bladder: a review of concepts. Urology 2006;68:9Y16. 29. El-Azab AS, Abd-Elsayed AA, Imam HM. Patient reported and anatomical outcomes after surgery for pelvic organ prolapse. Neurourol Urodyn 2009;28:219Y224. 30. Lleberia J, Pubill J, Mestre M, et al. Surgical treatment of mixed urinary incontinence: effect of anterior colpoplasty. Int Urogynecol J 2011;22:1025Y1030. 31. Nguyen JK, Bhatia NN. Resolution of motor urge incontinence after surgical repair of pelvic organ prolapse. J Urol 2001;166:2263Y2266. 32. Okui N, Okui M, Horie S. Improvements in overactive bladder syndrome after polypropylene mesh surgery for cystocele. Aust N Z J Obstet Gynaecol 2009;49:226Y231.
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