The value of the vaginal pack test in large cystoceles

To detect possible stress urinary incontinence associated with but masked by large cystoceles protruding through the vaginal orifice, a vaginal pack test was done in conjunction with video fluoro-urodynamic studies. Sixteen female patients with large cystoceles did not demonstrate stress urinary incontinence on clinical examination and were included in this study. Additionally, 10 healthy female volunteers underwent the same test to study the effect of a vaginal pack on urethral dynamics. The vaginal pack revealed the presence of stress urinary incontinence in 11 patients (69%): 3 (19%) with type II (vesicourethral hypermobility) and 8 (50%) with type III (internal sphincteric deficiency). After insertion of the vaginal pack, urodynamic studies showed that the closing proximal urethral pressure in patients with stress urinary incontinence was significantly lower than in continent patients (p < 0.05). No significant change in urethral pressures was noted in volunteer subjects after vaginal pack insertion. Fluoroscopy showed kinking of the posterior urethra and enlargement of the most dependent portion of the cystocele, that is the lower half of the hourglass image. Our study suggests that the mechanisms of continence in these patients are multifactorial, including urethral kinking, urethral compression and pressure dissipation. The vaginal pack test is easy to perform, increases visualization of the vesicourethral unit when used with fluoroscopy, and can aid in the selection of patients who would benefit from anti-incontinence surgery and/or cystocele repair.