You had the prolapse surgery but now you have to worry about leaking while exercising or laughing.

There’s nothing worse than fixing one problem and having that fix create a new problem.  This can happen in all different areas of our lives- parenting, relationships, home repairs.  It always seems to happen when I am watching one of those HDTV home renovation shows-ripping out the drywall reveals the inferior structural support.  It is the law of unintended consequences.  That can happen in prolapse surgeries too.  Sometimes women wil leak after a prolapse repair.

Why might you leak after a prolapse repair?

Prolapse, especially cystoceles, causes trouble emptying the bladder and causes overactive bladder symptoms.  Correcting the prolapse corrects these bladder symptoms, and makes it easier for you to empty.  But easier emptying can mechanically lead to stress incontinence symptoms.  That means that women who have never leaked, may leak with exercise or laughing after a prolapse repair.  Trading a prolapse for leaking is not what women want.

There are different ways to address this increase in leaking after a prolapse repair.  To pick the best approach, you need to consider your risk factors, your current bladder symptoms, your desires, and your surgeon’s clinical opinion.  Here are the different approaches:

Ways to approach potential leaking before a prolapse repair

1. Interval approach- This means that you know you might leak after surgery and you are going to wait and assess this after surgery. If you do leak, you know what the next steps will be and the time frame.  This might include physical therapy, an office bulking procedure, or an outpatient incontinence sling.
2. Testing-This mean you are going to do some bladder testing prior to surgery to try to determine if you will leak when the prolapse is gone. This test is called a CMG or urodynamics and will be done with the prolapse held up.
3. Prophylactic- There have been studies done that support doing an incontinence surgery at the time of a prolapse repair in woman who don’t leak. These studies have created “risk calculators.”  These calculators factor in your personal risk factors like age, weight and number of vaginal deliveries, to give you an idea of your risk of leaking after surgery.  Interested in this approach?  You can see the risk calculator here (https://riskcalc.org/FemalePelvicMedicineandReconstructiveSurgery/)

There isn’t one perfect answer here.  I often think that picking the approach is a personality test.  Some women will pick the interval approach because they want to do the least amount of surgery possible.  Some women can’t stand the idea of leaking, not even for a short amount of time.  They will often pick a prophylactic sling.  The important thing is to have the conversation and to know your next steps.  Unexpected leaking after a prolapse repair is an unpleasant surprise.  This is a important part of making an informed surgical decision.

Brubaker et al NEJM 2006

Wei et al NEJM 2012

Jelosvsek et al Obstet Gynecol 2014