Free uroflowmetry for voiding dysfunction measurement in women with pelvic organ prolapse and urinary incontinence in primary care

Abstract

Voiding dysfunction might exist in women with POP, which can be determined by free uroflowmetry.1 Uroflowmetry in combination with PVR measurement could be used to evaluate the micturition process in women with POP in primary care. This evaluation could be useful in the diagnostic approach and decision-making process regarding referral of patients with POP and urinary symptoms from primary to secondary care. We aimed to investigate the prevalence of voiding dysfunction in women with POP in primary care and to explore potential predictors for the existence of voiding dysfunction. This was a cross-sectional study of 233 female patients aged ≥55 years, registered in 23 general practices in the northern part of the Netherlands between February 2008 and March 2011. Urinary symptoms were assessed by the Urinary Distress Inventory-6, POP by the POP-Q stage measurement, and voiding dysfunction by free uroflowmetry and PVR. Voiding dysfunction was defined as a urine flow below the 10th maximum flow rate centile of the Liverpool Nomograms or as a flow with a maximum flow rate ≤15 mL/s and/or a PVR ≥50 mL.1, 3 Women were included in the present study if they reported having urinary incontinence in a questionnaire, and POP was diagnosed during physical examination. Statistical analysis was carried out using Fisher's exact test, as well as univariate and multivariate logistic regression analyses. Overall, the included patients had a mean age 65 ± 8 years, median parity was two (range 2–3) and 4.7% had previous gynecological surgery (Table S1). A total of 91 (39.7%) patients had obstructive urinary symptoms according to the Urinary Distress Inventory-6. Gynecological examination showed that 40.8% of the participants had POP-Q stage I, 50.6% had stage II and 8.6% had stage III. No significant differences in urinary symptoms were observed between the POP-Q stages. The Liverpool Nomograms resulted in a higher percentage of interpretable uroflowmetry results than the flow parameters + PVR (95.5% vs 67.1%; P < 0.001). With the Liverpool Nomograms, significantly more cases of voiding dysfunction were found compared with the flow parameters + PVR (33.2% vs 24.8%; P < 0.001). In multivariate logistic analyses, with the Liverpool Nomograms, increasing age (OR 1.04, 95% CI 1.00–1.08) and posterior wall prolapse (OR 1.38, 95% CI 1.03–1.99) were predictors (Table 1). Increasing age (OR 1.08, 95% CI 1.02–1.14) and anterior wall prolapse (OR 1.79, 95% CI 1.01–2.81) as well as posterior wall prolapse (OR 1.88, 95% CI 1.10–3.08) were predictors for voiding dysfunction defined with flow parameters + PVR. The present study showed that free uroflowmetry can be carried out in primary care. First, we found 95% interpretable flows, which is rather high compared with the literature. Other researchers reported percentages between 64% and 89% of interpretable flows.2, 4 In addition, we found that increasing age, and prolapse of the anterior and posterior vaginal wall were risk factors for voiding dysfunction, which was in line with the current literature.1 To our knowledge, the exact prevalence of voiding dysfunction in women with POP is unknown. It is estimated to be between 18% and 39%.2, 5 In the study by Haylen et al., 39% of the women with symptoms of POP had voiding dysfunction according to free uroflowmetry parameters, but no vaginal examination was carried out to confirm POP.1 In the study by Serati et al., the prevalence of voiding dysfunction was 18% after full urodynamic studies and all women had POP by vaginal examination.5 As the present study results were closest to that found by Haylen et al., we suggested that free uroflowmetry could possibly overestimate the prevalence of voiding dysfunction. Evaluation of the micturition process in primary care could lead to a change of treatment. It has already been reported that urodynamic evaluations could influence the selection of patients who could benefit for surgical treatment of pelvic floor dysfunction in secondary care.6 There were several limitations in the present study, our data were collected only from women with POP as well as urinary symptoms, and the uroflowmetry results were not compared with a complete urodynamic study, the gold standard. Because only a limited number of women with POP-Q stage III and IV were included in the present study, statements about the correlation between prolapse stage and voiding dysfunction should be interpreted with caution. Our data showed that voiding dysfunction is a common symptom in women with POP in primary care. Increasing age and involvement of the anterior and posterior vaginal wall were predictive for the presence of voiding dysfunction, but POP-Q stage and the presence of urinary symptoms were not. A further study, designed by comparing the diagnostic approach of patients with and without uroflowmetry in primary care, is required to give an answer on the question of the value of uroflowmetry in the diagnostic approach and treatment for women with POP in primary care.7 None declared. Table S1 Characteristics of patients and urinary symptoms. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.