Anterior compartment prolapse with occult stress incontinence and chronic cough
Fatima is 58, para 4, BMI 31, a secondary-school teacher, with a two-year history of a dragging sensation and a lump at the introitus that worsens through the day. She denies urinary leakage. Pelvic Organ Prolapse Quantification: Aa +2, Ba +3, C −2, D −4, Bp −2, Ap −2, total vaginal length 8 cm; on Valsalva the anterior wall descends beyond the hymen. She has COPD, continues to smoke 15 cigarettes daily and has a chronic cough. On examination, after the prolapse is reduced with a Sims speculum, she leaks urine on coughing. Post-void residual is 40 mL and urinalysis is negative. She is not sexually active and has no plans to be. She asks whether she needs 'the mesh', and whether the womb must be removed.
1. How do you interpret the examination, and how would you confirm and quantify the occult stress incontinence before planning surgery?
Read the worked answer
Interpretation: stage 3 anterior compartment prolapse (Ba +3, beyond the hymen) with the uterus well supported (C −2) and a normal posterior compartment. The leakage on coughing only after reduction is occult - or unmasked - stress incontinence: the prolapse has been obstructing the urethra and hiding the symptom. Post-void residual of 40 mL is normal, and negative urinalysis excludes infection as a cause of leakage.
Confirmation before operating:
- Repeat the cough stress test with a comfortably full bladder (about 250–300 mL), in the standing position, with and without reduction, and consider a pad test to quantify loss.
- Ask specifically about urgency, frequency and nocturia - mixed symptoms are common and change counselling. If there is significant urgency, or if she has failed previous continence surgery, arrange urodynamics to look for detrusor overactivity and intrinsic sphincter deficiency.
- Urodynamics is not mandatory before primary prolapse surgery, but here the decision to add a continence procedure hinges on demonstrable leakage, so objective confirmation is worth the effort and protects you medico-legally.
- Explain that if the prolapse alone is repaired, she has a roughly 40–50% chance of troublesome postoperative stress incontinence, and that this is the reason for the test.
2. Compare the surgical options for the anterior compartment, and discuss whether to perform a concomitant continence procedure and whether the uterus should be removed.
Read the worked answer
Prolapse repair:
- Native-tissue anterior colporrhaphy is first-line. It avoids mesh complications; recurrence is higher than with mesh but re-operation rates at 5 years are similar in randomised data.
- Transvaginal mesh is restricted in most health systems to recurrent or high-risk cases and often to research or specialist centres, because of erosion, pain and dyspareunia. It is not a first operation in a 58-year-old with comorbidity.
- Colpocleisis is the most durable, lowest-morbidity option in a woman who accepts that vaginal intercourse will no longer be possible. She says she is not sexually active, but this must be discussed explicitly and documented, including the possibility of regret.
- The uterus does not need removing for anterior prolapse; options include sacrospinous hysteropexy or vaginal hysterectomy with repair. Preserving the uterus shortens surgery in a woman with COPD.
Concomitant continence procedure: the CARE trial randomised women with occult stress incontinence undergoing prolapse repair to Burch colposuspension or not, and found markedly less postoperative stress incontinence with the Burch (roughly 24% versus 45%), at the cost of more urinary tract infections and voiding difficulty. A retropubic midurethral sling is the modern equivalent. Given demonstrable leakage and a desire to avoid a second operation, offering a sling at the time of repair is reasonable - with explicit counselling about obstruction, tape complications and the alternative of deferring and treating later.
3. She asks whether she could avoid surgery. Outline your conservative and risk-reduction plan and the factors that would make you advise against immediate surgery.
Read the worked answer
A pessary trial is a legitimate first-line option and should be offered.
- A ring pessary (with a Gellhorn or cube as alternatives) can control symptoms for years; fit it, teach self-management, use vaginal oestrogen if atrophic, and review at 1–4 weeks for expulsion, erosion or discharge. Many women choose this over surgery once they understand the recurrence rate.
- Add pelvic floor muscle training with a specialist physiotherapist: it improves symptoms and bladder function, though it rarely reduces prolapse stage.
- Weight loss, treatment of constipation, and - crucially - optimising her COPD and stopping smoking. A chronic cough is the strongest predictor of recurrence after repair, and continuing to smoke raises anaesthetic, wound and respiratory complication rates. Refer to smoking cessation and respiratory review, and defer elective surgery until the cough is controlled, typically 4–6 weeks after cessation.
Features that would make me advise against immediate surgery: an unprepared airway and uncontrolled cough, uncorrected anaemia, inability to stop smoking before a general anaesthetic, urinary infection, or a patient whose symptoms are only mildly bothersome. Since she teaches and stands all day, she should know that recurrence after native-tissue repair in a woman with chronic cough may be 20–30%.
Document the discussion of pessary, surgery, colpocleisis and doing nothing, so that whichever she chooses is an informed one.