Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures

To compare the difference in abdominal leak point pressures (ALPPs) between patients with large cystoceles and severe vaginal vault prolapse and to assess the frequency of occult stress urinary incontinence (SUI) in these groups.

A total of 24 adult female patients with pelvic prolapse underwent prospective fluorourodynamic testing to determine the change in ALPP with and without reduction of the pelvic prolapse. Twelve patients had grade III-IV vaginal vault prolapse and 12 had large cystoceles without vault prolapse. ALPP testing was performed with the prolapse unreduced and then reduced using gauze packing and a vaginal speculum.

In patients with vault prolapse, the frequency of occult SUI was 50% (6 of 12) and the mean decrease in ALPP was 59 cm H(2)O after prolapse reduction. In the patients with cystocele, all patients had overt SUI, and the mean change in ALPP was 11 cm H(2)O after prolapse reduction. A component of intrinsic sphincter deficiency was identified in 9 (75%) of 12 women with vault prolapse after reduction, and 8 (66%) of 12 women with no vault prolapse had a component of intrinsic sphincter deficiency before reduction, with an additional 2 (17%) of 12 patients after reduction.

There is a high incidence of occult SUI in patients with vault prolapse and the ALPP after reduction is decreased to a much greater degree in patients with vaginal vault prolapse than in patients with cystocele alone. By reducing the pelvic prolapse during urodynamic testing, an accurate ALPP can be obtained, allowing the appropriate incontinence procedure to be performed.