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Nocturia and pelvic organ prolapse: a common but under-explored association

By Prof. Antonella Giannantoni

Pelvic organ prolapse (POP) includes anterior vaginal prolapse (cystocele), posterior vaginal prolapse (rectocele), apical or uterine prolapse, enterocele and perineal descent. [1] POP has been reported to affect 50% of the parous women, and the lifetime risk of undergoing a single operation for prolapse by age 80 is approx. 11%. [2] As the population ages, it is estimated that the rate of women seeking treatment for POP will double. [3] Overactive bladder (OAB), defined as urgency with or without urgency incontinence, usually with frequency and nocturia, [4] is often observed in patients affected by POP. OAB symptoms increase with age in both sexes, with 21% of women older than 70 years being affected by the condition. 88% of women affected by POP present with OAB symptoms. [2] As POP and OAB are frequently observed in the old female population, an association of the two conditions in the same patient would be expected. The close relationship between OAB/LUTS and POP has rarely been explored, but it seems that having either incontinence or prolapse may be associated with an increased risk of developing the other condition. [5] Indeed, data from community-based hospital studies show that the prevalence of OAB symptoms is higher in patients affected by POP, although these studies do not allow the establishment of a causal relationship between the two conditions. From a pathophysiologic point of view, there are several theories to explain the relationship between OAB and POP. A supersensitivity to neurotransmitters (i.e. acetylcholine) and a higher irritability of the detrusor muscle due to partial denervation of the obstructed bladder as well as changes in spinal micturition reflexes after obstruction are usually considered as potential causative factors. [2] Indeed, several studies reported lower maximum flow rates during voiding and a higher prevalence of detrusor overactivity (DO) in patients with POP than in those without the condition, although the prevalence of DO does not increase with the severity of POP. Furthermore, data from the literature do not show a clear association between the prevalence of OAB/DO symptoms and both stage and type of the prolapsed compartment, although an improvement in OAB symptoms after treatment of POP can be observed in women with coexisting POP and OAB.

POP has also been shown to affect many aspects of a woman’s quality of life (QoL) including her social, psychological, physical, sexual, body image and overall wellbeing. A high prevalence of depression has been detected in women with POP. [6] Women seeking treatment for urogenital prolapse frequently present with nocturia, pelvic pain and bowel dysfunction perceived as their most bothersome symptoms. In a recent study, lower urinary tract symptoms (LUTS) associated with POP, and particularly nocturia, have been found to increase the likelihood of poor sleep quality. Poor sleep quality and sleep deprivation have a negative impact on mood, cognitive health, immune function and cardiovascular health. [5] In spite of these observations, presence of nocturia and assessment of the nocturia type in patients with POP, including its eventual resolution after POP treatment, have been rarely investigated.

Adjoussou et al. assessed functional symptoms related to POP and tested anatomo-functional associations in 374 patients aged 65 years. [7] They found that the incidence of nocturia, voiding difficulties and occult stress urinary incontinence was significantly higher in patients with stage 3–4 anterior vaginal prolapse, while patients with stage 3–4 rectocele suffered significantly more frequently of defecatory dysfunction. De Boar et al. investigated which factors predict the presence of OAB symptoms after surgery for POP and found that bothersome OAB symptoms decreased after POP intervention. [8] Frequency and urgency were more likely to improve or disappear as compared to urge incontinence and nocturia. According to the authors, the presence of nocturia may be more dependent on external factors such as poor sleep and nocturnal polyuria, which are both unlikely to be influenced by the presence of a vaginal prolapse, and probably more related to cardiac condition. [8] In a previous study examining the clinical and urodynamic characteristics of women with LUTS presenting various rates of cystocele, nocturia, urgency and urge incontinence were found to be significantly associated to functional bladder capacity. [9] In this study no relationship was demonstrated between the degree of cystocele and symptoms of the filling phase of the bladder on the one hand, and urodynamic evidence of DO and incontinence on the other hand.

Okui et al. analysed the changes in the OAB Symptom Score of women followed up for one year after anterior repair surgery using a polypropylene mesh. [10] The surgery was significantly effective in improving urgency, daytime frequency, incontinence, but no significant change in nocturia was observed 1 year after surgery. The authors do not give any explanation for this result.

From the sparse results of the literature about nocturia in women with POP and its resolution after surgery, it can be observed that the symptom affects a high proportion of women with POP, but does usually not improve or resolve after any surgical treatment. As the majority of women affected by POP are older, postmenopausal, parous as well as overweight and may present with several comorbidities linked to the elderly, it is possible to hypothesize a different etiology for their nocturia, which might be due not only to an obstructed bladder but perhaps also, and more often, to nocturnal polyuria.

Presence and types of nocturia in women with POP should be more adequately investigated and assessed in future studies, in order to really improve such a bothersome condition which affects, together with other LUTS, a number of females with urogenital prolapse.

References

  1. Payne C, Brown J, Castro-Diaz D et al. In Abrams P, Cardozo L, Khoury S, Wein A editors. Chapter 23: research in Incontinence. 4th International consultation on Incontinence. Paris, July, 5-8 2008. 4th Edition. Health Publication Ltd; 2009.

  2. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997; 89: 501-6.

  3. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: Current observations and future projections. Am J Obstet Gynecol. 2001; 184: 1496-501.

  4. Abrams P, Cardozo L, Fall et al. The standardisation of terminology of lower urinary tract function: Report from the standardisation sub-committee of the International Continence Society. Neurourol urodyn. 2002; 21: 167-78.

  5. Cartwright R, Kirby AC, Tikkinen KA et al. Systematic review and metaanalysis of genetic association studies of urinary symptoms and prolapse in women. Am J Obstet Gynecol. 2015; 212: 199-24.

  6. Ghetti C, Lee M, Oliphant S, et al. Sleep quality in women seeking care for pelvic organ prolapse. Maturitas. 2015; 80: 155-61.

  7. Adjoussou SA, Bohoussou E, Bastide S, et al. Functional symptoms and associations of women with genital prolapse. Prog Urol. 2014; 24: 511-7.

  8. 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: 1143-9.

  9. Adot Zurbano JM, Salinas Casado J, Dambros M, et al. Filling phase abnomalities and cistocele. Arch Esp Urol. 2005; 58: 309-15.

  10. 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: 226-31.

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