Patients with severe pelvic organ prolapse (POP) often suffer from urinary disturbances, such as urinary frequency, urgency, incontinence and obstruction, which seriously affect their quality of life. Overseas studies have shown that vaginal closure has low risk, few complications, high success rate and low recurrence rate, and can effectively relieve the symptoms of urinary distress and significantly improve the quality of life of patients, and has become one of the common procedures for patients with severe POP who are old and frail, have more medical comorbidities and have difficulty in tolerating complex pelvic floor reconstruction surgery. There are few studies in China on the effects of vaginal closure on patients’ urinary disturbances. We investigated the urinary disturbance in 60 patients with severe POP who underwent vaginal closure from October 2005 to February 2010, and we report the following. Data and methods 1 Study subjects From October 2005 to February 2010, 63 patients with POP were treated with total or partial vaginal closure in the Department of Obstetrics and Gynecology of our hospital, except for 3 patients with senile dementia and mental disorders who were unable to complete the questionnaire. 60 patients had an average age of (73±5) years, an average body mass index (BMI) of (25±4) kg/m2, an average number of deliveries (3.5±2.2), and an average number of terminations. Of the 60 patients, 56 (93%) had more than one medical comorbidity, including 32 cases of hypertension, 23 cases of coronary artery disease and post-operative cardiac disease, 14 cases of diabetes mellitus, 9 cases of cerebrovascular disease, 4 cases of hematological disease, 2 cases of hyperthyroidism, and 1 case of post-operative breast cancer. All 60 cases were staged from stage III to IV by the POP quantitative grading (POP-Q) method, of which 50 cases (83%) were stage III and 10 cases (17%) were stage IV. According to the location of prolapse, there were 50 cases (83%) of uterine prolapse, 9 cases (15%) of vaginal vault prolapse, 1 case of cervical prolapse after subtotal resection, and 46 cases (77%) and 39 cases (65%) of anterior and posterior vaginal wall bulge, respectively. There were 25 cases (41%, 25/60) with urinary frequency, 22 cases (36%, 22/60) with urinary urgency, 20 cases (33%, 20/60) with stress urinary incontinence (SUI), 8 cases (13%, 8/60) with history of SUI before prolapse, 23 cases (38%, 23/60) with difficulty in urination, and 23 cases (38%, 23/60) with hand-assisted urination, The mean preoperative residual urine volume was (110±38) ml in the 23 cases with dyspareunia. 60 patients had no history of urinary incontinence surgery. All 60 patients had no surgical history of urinary incontinence. 2 Surgical methods: total or partial vaginal closure, anal levator + perineal body repair in cases with old perineal laceration, trans-obturator tension-free vaginal tape (TVT-O) in cases with SUI. The urinary disturbance scale (UDI-6) and pelvic organ prolapse disturbance scale (POPDI-6) of the classic POP symptom questionnaire PFDI-20 and the urinary impact questionnaire (UIQ-7) and pelvic organ prolapse impact questionnaire (POPIQ-7) of the pelvic floor impact questionnaire (PFIQ-7) of the quality of life questionnaire were used. The scoring scale for POPDI-6 and UDI-6 was 0 for no symptoms, 1 for symptomatic but no impact on quality of life, 2 for mild impact, 3 for moderate impact, and 4 for severe impact. The scores for each question were summed and divided by the corresponding number of questions × 25 for the respective scale score, which ranged from 0 to 100. The scoring scale of POPIQ-7 and UIQ-7: no impact on quality of life 0, mild impact 1, moderate impact 2, severe impact 3. The scores of each question were summed and divided by the corresponding number of questions × 100/3 for the respective subscale score, which ranged from 0 to 100. The higher the score, the greater the impact of urinary distress on patients’ quality of life. 4 Survey method The questionnaire was administered exclusively by non-surgical staff and completed together with the patient. The preoperative questionnaire was completed before the surgery was performed after admission to the hospital, and the postoperative questionnaire was completed at the 2-month, 6-month and 1-year postoperative outpatient follow-up visits. Those who could not come to the hospital for follow-up were followed up by telephone. All patients who completed the questionnaire were conscious and could answer the questions independently. 5 Statistical methods SPSS 10.0 software was used for statistical analysis. t-test or rank sum test was used for quantitative data, and Pearson c2 test was used for categorical data. p < 0.05 was considered statistically significant. Results 1 Surgery Among the 60 patients, 45 (75%) had total vaginal closure, 15 (25%) had partial vaginal closure, and 20 (33%) had TVT-O, and there were no surgical side injuries. The postoperative morbidity rate was 5% (3/60), including 2 cases of urinary tract infection and 1 case of bacteraemia. 4 cases had residual urine >100 ml after removal of urinary catheter, which was intermittently opened for 3-7 d by indwelling urinary catheter, and normalized after oral administration of bromipyridamole and terazosin tablets. 2 The follow-up rates at 2 months, 6 months and 1 year after surgery were 93% (56/60), 88% (53/60) and 87% (52/60), respectively, with one case dying of heart disease at 8 months after surgery. All follow-up patients had a postoperative POP-Q stage ≤ stage I. There was no clinical recurrence in any of the cases, and the objective success rate was 100%. The mean residual urine volume of the 23 patients with preoperative dyspareunia was reduced to 12 ml after removal of the catheter, and the patients’ dyspareunia, hand-assisted voiding and dysuria were completely relieved 2 months after surgery, while the urinary frequency, urgency and SUI were significantly but not completely relieved (Table 1); the POPDI-6, UDI-6, POPIQ-7 and UIQ-7 scores were significantly reduced (Table 2), indicating that the vaginal The patients’ urinary distress symptoms were significantly relieved and their quality of life was significantly improved after the closure. Among the 20 patients who had TVT-O, one case had mild SUI at 2 months postoperatively; eight cases who did not have TVT-O because of preoperative transient SUI had mild SUI in two cases at 2 months postoperatively; the symptoms of SUI in these three cases did not worsen until 1 year postoperatively, and they were not operated again because of mild symptoms and low impact on quality of life. Table 1 Changes in symptoms of urinary distress before and after vaginal closure surgery (n, %) Tab 1 Bothersome urinary symptoms at baseline, 2 months, 6 months and 1 year after surgery Urinary symptoms Baseline (n = 60) 2 2 months postoperation (n=56) 6 months postoperation (n=53) 12 months postoperation (n=52) Frequency Urgency SUI Strainning to void Manual assistance Incomplete emptying 25 (41) 22 (36) 28 (47) 23 (38) 23 (38) 37 (62) 3 (5) a 2 (4) a 3 (5) a 0 (0) a 0 (0) a 0 (0) a 0 (0) a 3 (6) a 2 (4) a 3 (6) a 0 (0) a 0 (0) a 0 (0) a 0 (0) a 3 (6) a 2 (4) a 3 (6) a 0 (0)a 0(0)a 0(0)a aP < 0.01, vs preoperation Table 2 Comparison of patients' voiding distress symptoms and quality of life scores before and after surgery (`x±s ) Tab 2 Questionnaires scores related to bothersome urinary symptoms and quality of life at baseline,2 months,6 months and 1 year after surgery Questionnaires Baseline (n=60) 2 months postoperation (n=56) 6 months Postoperation (n = 53) 12 months postoperation (n = 52) POPDI-6 UDI-6 POPIQ-7 UIQ-7 34.97±16.72 28.89±19.60 41.39±17.31 32.38±19.11 3.61±3.94a 6.93± 7.85a 3.15±3.66a 10.21±14.45a 0.63±2.21a 6.06±6.54a 0.18±1.32a 8.88±12.65a 0.48±1.96a 5.95±6.53a 0.18±1.31a 8.81±12.54a aP = 0.0000, vs preoperation Discussion Many women with POP have varying degrees of urinary distress symptoms, such as voiding obstruction (difficulty in urination, feeling of incomplete urination, need for hand-assisted voiding), urinary incontinence, urinary frequency, and urinary urgency, which seriously affect the quality of life of patients.POP is one of the most relevant causes of voiding obstruction symptoms. According to statistics, up to 50% of patients with severe POP have voiding obstruction, 21% require hand-assisted voiding, and 30% of patients with POP have urodynamic examinations suggesting bladder outlet obstruction. This is mainly due to a decrease in the posterior angle of the vesicourethra and consequent outflow tract obstruction when the degree of bladder distention increases. The fact that the residual urine in these patients mostly returns to normal after surgery also indicates a close relationship. In our group, 41% of patients had difficulty in urination and 39% had hand-assisted urination, which is higher than the results in the literature. This may be related to the fact that most of the patients in our group (77%) had severe POP and bulging bladder. Foreign studies have shown that vaginal closure can relieve most of the preoperative dyspareunia and residual urine in patients with severe POP, with a relief rate of 36%-89%. The results of our study also showed that the patients' postoperative voiding obstruction symptoms were completely relieved, indicating that vaginal closure can indeed effectively restore the posterior angle of the vesicourethra and eliminate bladder outlet obstruction, thus improving voiding obstruction symptoms. Urinary frequency and urgency is another common symptom in patients with severe POP, mostly caused by the instability of the bladder forceps due to bladder outlet obstruction caused by POP. According to statistics, the proportion of frequent and urgent urination in POP population is about 45% and 44%, and some literature reports that the proportion of urgent urination can be as high as 68%. In our group, the preoperative rates of urinary frequency and urgency were 41% and 36%, respectively, which were slightly lower than the results in the literature. Overseas studies have shown that vaginal closure surgery can effectively improve the symptoms of urinary frequency and urgency, and the incidence of symptoms of instability of the detrusor muscle decreased from 65% before surgery to 15% at 1 year after surgery. The results of this study also showed that urinary frequency and urgency were significantly relieved after surgery, which was apparently related to the effective release of bladder outlet obstruction by vaginal closure. However, in addition to the bladder outlet obstruction, estrogen deficiency and aging of the bladder forceps may also be responsible for the symptoms of forceps instability in patients with severe POP. The symptoms of urinary frequency and urgency in our patients were mostly relieved after the disappearance of dyspareunia but not completely disappeared may be related to this. SUI is not only a common symptom in POP patients before surgery, but also a more common problem after vaginal closure, which can also have a negative impact on the quality of life of patients. The literature reports that the incidence of SUI in the POP population is about 27%-59%, which is significantly higher than in the general population, and that new-onset postoperative incontinence can be as high as 11%. There are two main causes of new-onset SUI: one is the re-expression of the original SUI when the bladder bulge is corrected, i.e., occult incontinence; the other is the increase in the posterior angle of the vesicourethra due to intraoperative pulling down of the urethra, which can be prevented by avoiding separation of the anterior vaginal wall mucosa too close to the urethral orifice during surgery. However, there is no effective prediction or solution for the former. The predictive value of performing clinical and urodynamic examinations to screen for occult SUI after resetting the prolapse is also only 59%. In order to prevent postoperative SUI, some investigators have suggested that vaginal closure should always be accompanied by an anti-SUI procedure, but there is still a 14%-25% incidence of SUI after surgery. In a study by Fitzgerald et al, 14% of patients who underwent vaginal closure with an autologous fascial sling had postoperative urinary retention and required surgical removal of the sling. In the present study, four patients with TVT-O had transient urinary retention after surgery, but all of them were managed or resolved, and none of them required removal of the sling. Nevertheless, caution should be exercised when adding anti-continence surgery to these patients, and there is no Class I level clinical evidence that concomitant anti-continence surgery during vaginal closure can prevent the development of postoperative SUI. For those who develop SUI even after anti-incontinence surgery, some scholars suggest trying autologous fascial slings and paraurethral collagen injections, but their exact effects still need to be further confirmed clinically. In conclusion, vaginal closure surgery can effectively relieve the symptoms of urinary distress and significantly improve the quality of life of patients with POP.