Three (Unhappy) Musketeers – Prolapse, Bladder Outlet Obstruction and Overactive Bladder

Pelvic organ prolapse, difficult urination, frequency, urgency and overactive bladder – for some women, it’s all related.

(C) Lauri Romanzi 2010

Pelvic organ prolapse and overactive bladder. de Boer TA, et al. Neurourol Urodyn. 2010;29(1):30-9.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Medical research comes in several forms. This particular study gathered all the research already published on the topic, pooling all the data in one big group for re-analysis. Called meta-analysis, studies that pool data from other studies advance medical science by reviewing smaller clinical trials to figure out if the findings have anything in common that might thereby be considered “true”.

courtesy womensvoicesforchange.org

Look at this picture – what a mess. There’s no way bladders caught in the clutches of severe pelvic organ prolapse can function properly. The urethra, a 2-3 inch straw-shaped tube that allows urine to pass out of the bladder, is often kinked or compressed by the prolapse. The muscles in the bladder wall, normally located above the urethra, are now below the urethra, forced to fight the mighty forces of gravity and the kinked or compressed urethra, in order to empty, and as a result, the emptying is often incomplete. So the bladder fills up more quickly, starting a whole cascade of symptoms, enough to make any bladder crazy.

Not emptying fully, the bladder fills more quickly. Result? Frequency. And a propensity to bladder infections from all that stagnant urine. You used to urinate a few times a day without much thought, but now bladder management is a part-time job. Urine flow is very slow, dribbling, and sometimes stop – and – start.  This condition is called bladder outlet obstruction.

Contracting extra-hard in this upside down position in order to bypass gravity and urethral obstruction from all that kinking or compression, the bladder starts to misfire, suddenly contracting without any warning of fullness, as if it can’t make up it’s mind. Result? Urgency, that horrible sensation of needing to get to the bathroom RIGHT NOW and wondering if you’re going to make it in time. Or not making it in time, literally peeing in your pants on your mad dash to the water closet (urge incontinence). This condition is called overactive bladder.

courtesy "Plumbing and Renovations"

The common findings in the studies included in this meta-analysis showed that any method of successfully managing the prolapse, be it pessary or surgery, allowed the bladder to return to normal function. Anything that un-kinks the urethra, re-positions the bladder so that it’s on top of, instead of underneath, the urethra, and repositions all the pelvic organs to their normal location will normalize bladder function in most cases. Why is this an important finding? Because it helps doctors understand that, in a woman with prolapse and bladder problems, just fixing the prolapse ought to fix the bladder problems, without overactive bladder medications or the need for constant antibiotics to fight all those urinary tract infections.

Here is a synopsis of the data (aka abstract) of this study:

Abstract

AIMS: In this review we try to shed light on the following questions: *How frequently are symptoms of overactive bladder (OAB) and is detrusor overactivity (DO) present in patients with pelvic organ prolapse (POP) and is there a difference from women without POP? *Does the presence of OAB symptoms depend on the prolapsed compartment and/or stage of the prolapse? *What is the possible pathophysiology of OAB in POP? *Do OAB symptoms and DO change after conservative or surgical treatment of POP? METHODS: We searched on Medline and Embase for relevant studies. We only included studies in which actual data about OAB symptoms were available. All data for prolapse surgery were without the results of concomitant stress urinary incontinence (SUI) surgery. RESULTS: Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP. No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms. All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms. It is unclear what predicts whether OAB symptoms disappear or not. When there is concomitant DO and POP, following POP surgery DO disappear in a proportion of the patients. Bladder outlet obstruction is likely to be the most important mechanism by which POP induces OAB symptoms and DO signs. However, several other mechanisms might also play a role. CONCLUSIONS: There are strong indications that there is a causal relationship between OAB and POP