Can uterine prolapse cause urge incontinence?

Can Uterine Prolapse Cause Urge Incontinence?

Yes, uterine prolapse can cause urge incontinence through multiple mechanisms, including bladder outlet obstruction, altered bladder sensation, and associated pelvic floor dysfunction.

Relationship Between Pelvic Organ Prolapse and Urinary Symptoms

Pelvic organ prolapse (POP) and urinary symptoms frequently coexist. The relationship between uterine prolapse and urinary symptoms is complex and involves several mechanisms:

Mechanisms of Urge Incontinence in Uterine Prolapse

1. Bladder Outlet Obstruction

   • Advanced uterine prolapse can cause mechanical obstruction of the urethra 1
   • This obstruction can lead to detrusor overactivity and urgency symptoms

2. Altered Bladder Sensation

   • Prolapse can affect the urothelium (bladder lining), which plays an important role as a sensor controlling bladder function 2
   • This can lead to increased sensitivity and urgency signals

3. Associated Pelvic Floor Dysfunction

   • Pelvic floor weakness that causes prolapse often affects urethral support and bladder function simultaneously
   • Mixed urinary incontinence is common in women with prolapse 3

Clinical Evidence

• Up to 60% of women presenting with pelvic organ prolapse are also diagnosed with some form of urinary incontinence 4
• In a study of women with mixed urinary incontinence, 80% had pelvic organ prolapse, compared to 46.9% with urge incontinence alone 3
• The American Urological Association guidelines note that urgency symptoms can be related to anatomical instability at the bladder outlet, which occurs in prolapse 5

Diagnostic Considerations

When evaluating a patient with uterine prolapse and urge incontinence symptoms:

1. Perform stress testing with prolapse reduction

   • This is recommended by AUA/SUFU guidelines for women with high-grade POP 2
   • Helps distinguish between occult stress incontinence and true urge incontinence

2. Consider urodynamic testing

   • Multichannel urodynamic studies can help determine if altered compliance, detrusor overactivity, or other urodynamic abnormalities are present 2
   • This is particularly important before invasive treatments

3. Document urgency symptoms

   • Use voiding diaries to quantify frequency and timing of urgency episodes 5
   • Differentiate urgency from other lower urinary tract symptoms

Treatment Implications

The treatment approach for urge incontinence associated with uterine prolapse should address both conditions:

1. Conservative Management

   • Pelvic floor physiotherapy (evidence level 1) 6
   • Pessary use (evidence level 2) 6
   • Local estrogen therapy for postmenopausal women

2. Pharmacological Options

   • Anticholinergic and β-sympathomimetic drugs for overactive bladder symptoms 6
   • These may be less effective if mechanical obstruction is the primary cause

3. Surgical Considerations

   • Correction of the prolapse may resolve urge incontinence in some cases
   • However, be aware that occult stress incontinence may become apparent after prolapse correction 7
   • Consider concurrent anti-incontinence procedures during prolapse repair in selected cases

Important Clinical Caveat

When treating a patient with both uterine prolapse and urge incontinence, it's crucial to understand that:

• Correction of prolapse may unmask stress incontinence that was previously "hidden" by the prolapse 1, 7
• Existing urge incontinence may resolve in approximately 45% of patients after prolapse correction 7
• However, 9.5% of women without preoperative urge incontinence may develop de novo urge symptoms after prolapse repair 7

Understanding these relationships is essential when planning treatment for women with uterine prolapse and urinary symptoms to optimize outcomes and minimize post-treatment complications.