Urodynamics and Colpoplasty – How They Fit Together

Urodynamic testing is an important consideration any time a surgery is performed involving the lower urinary tract or pelvic organs in women. Colpoplasty, which is defined as plastic surgery involving the vagina, has the ability to change the way the urinary tract functions for women.

Additionally, colpoplasty may be performed during gender reassignment surgery, and urodynamic assessment can be required in order to verify whether the urinary tract functions in the proper manner. Ultimately, urodynamics and colpoplasty¹ go hand in hand. In this article, urodynamics, colpoplasty, and how they fit together will be discussed in depth.

What is Urodynamic Testing?

Urodynamics is a blanket term for a series of tests that assess the lower urinary tract. A number of issues which commonly affect women can be diagnosed via urodynamics. Typically, these tests are ordered before and after any type of surgery involving the pelvic organs or the urinary tract, as well as when a patient presents for certain urinary symptoms.

These complaints include pain in the pelvic region during urination or during sexual intercourse; fecal and urinary incontinence; changes in urinary function; or other similar symptoms. The types of urodynamic tests commonly performed include the following:

• Uroflowmetry is a test used to measure a patient’s natural urine flow rate, as well as urine volume. Here, the patient is asked to empty her bladder naturally while a flow rate meter records measurements. This test is routinely performed for all urodynamic assessments, and is useful when diagnosing slow urination or difficulty urinating. Additionally, uroflowmetry can determine how well a patient’s bladder and sphincter are functioning, and can be used to determine if obstructions are blocking the normal flow of urine.

• Pressure uroflowmetry is similar to uroflowmetry described above in that it also measures the rate of urination. However, bladder and rectal pressures are also simultaneously recorded during this assessment. Pressure uroflowmetry requires catheterization and is useful for diagnosing disorders that cause difficulty urinating. Common problems that are diagnosed with this test are bladder muscle weakness and bladder outlet obstruction.

• Post-void residual volume tests are used to measure the volume of urine that remains in the bladder after voiding. This test is important in the assessment of many urinary tract disorders. Here, the patient is asked to void her bladder naturally, and then a bladder scanner is used to noninvasively measure the amount of urine remaining in the bladder, or the patient is catheterized. Post-void residual volume assessments are primarily used to determine neurogenic bladder disorders as well as the cause of frequent urinary tract infections, renal insufficiency, bladder outlet obstruction, and detrusor underactivity.

• Multichannel cystometry is a type of pressure uroflowmetry test². Two pressure catheters are inserted, one in the bladder and one in the rectum, in order to measure associated pressures during both filling and emptying of the bladder. Assessments that are made include the presence of contractions in the bladder wall during filling or stress (i.e. coughing), urethra strength, detrusor under- or overactivity, and bladder outlet obstruction. This test is the gold standard for diagnosing stress urinary incontinence.

• Electromyography is a test that measures the electrical activity in the bladder neck. It can be performed during voiding to determine coordinated or uncoordinated voiding and the functioning of the detrusor muscle. For this measurement, electrodes are placed in the pubic area of the patient to test for electrical impulses from the muscles. Most commonly, electromyography is beneficial when testing for neurologic disorders that affect the communication between the brain and body.

• Urethral pressure profilometry measures strength of sphincter contractions. This test is used to further study urinary incontinence in women.

• Fluoroscopy (also known as video urodynamics) is a moving video x-ray of the bladder and bladder neck that is obtained while the patient is voiding her bladder. This test helps doctors provide a better view of what is happening in the lower urinary tract, such as bladder outlet obstruction or pelvic organ prolapse.

Ultimately, each of the tests described above is important for diagnosing various disorders of the lower urinary tract. These tests range from non- to minimally invasive and are performed as outpatient procedures. There is little pain or discomfort associated with each assessment, and few risks involved. Additionally, doctors are typically able to provide patients with immediate answers regarding their urinary symptoms.

What is Colpoplasty?

Colpoplasty, also called vaginoplasty, is plastic surgery of the vagina. There are numerous reasons for a patient to undergo colpoplasty, ranging from medically necessary to cosmetic. The term colpoplasty (or vaginoplasty) is a blanket term which describes any procedure involving vaginal reconstruction or repair.

Reasons for Colpoplasty

The reasons for colpoplasty are vast, and every scenario will not be discussed here. However, colpoplasty can be performed for the following reasons:

• After the removal of a growth or abscess from the vagina
• Reconstruction after radiological cancer treatment
• For correction of birth defects to the urethra, vagina, or rectum
• To correct a pelvic organ prolapse, particularly uterine or vaginal prolapse
• To repair the vagina after trauma, such as child birth
• To reduce the entrance size of the vagina
• To alter the physical appearance of the vagina
• To construct a vagina during gender reassignment surgery
• To repair a short urethra

Types of Colpoplasty

The methods used for vaginoplasty are as diverse as the reasons for having one performed. Furthermore, the method used has implications for the functioning of the lower urinary tract, as well as the vagina. The most common methods include:

• McIndoe Surgical Technique, where a vaginal canal is surgically created between the urinary bladder and urethra using a skin graft that has been wrapped around a mold and placed in the canal. This method is often used in instances of congenital absence of the vagina.
• Sigmoid colon vaginoplasty, where a 20 cm segment of the colon is removed from the sigmoid colon for the construction of a vaginal canal. This method is primarily used in gender reassignment surgery.
• Gender reassignment surgery can be performed using the sigmoid colon method described above, or by using penile-scrotal skin flaps or full/split-thickness skin grafts from other parts of the body.
• Elective vaginoplasty and labiaplasty are elective surgeries that are performed for cosmetic reasons, such as to reduce the size of the labia or to tighten the opening to the vagina.
• Balloon vaginoplasty is a method where a Foley catheter is inserted into the rectouterine pouch laproscopically and is gradually distended in order to create a neovagina.
• Vecchietti procedure is a technique used for treating muellerian agenesis, which is a congenital disorder that results in a missing uterus and vaginal hypoplasia. Here, a vagina is created whereby a plastic sphere is sutured against the vaginal area and the threads are drawn through the vaginal skin up through the navel. A traction device is used whereby the sphere is pulled up into the body by 1 cm daily in order to create a vagina that is approximately 7 cm deep and 7 cm wide over the course of 7 days.
• Urethro-vaginoplasty is the surgical repair of the torn wall of the internal urethral sphincter, as well as the closing of the rupture that weakened the sphincter. This surgery is used to address urinary incontinence and is performed by overlapping two anterior vaginal wall flaps.
• Burch Colposuspension is used to treat stress urinary incontinence. For this procedure, an incision is made above the pubic area to reveal the bladder neck. Then, four permanent sutures are placed on both sides of the bladder neck and attached to the Cooper’s Ligament. Scar tissue helps keep these sutures in place to provide permanent support in order to overcome stress urinary incontinence.

How Does Colpoplasty Affect the Urinary Tract?

The effect of colpoplasty on the urinary tract is dependent upon the reason for the surgery. In some instances, such as the Burch Repair or Urethro-vaginoplasty, these surgeries are performed in order to improve the functioning of the urinary system for greater comfort for the patient.

In other instances, entirely new “plumbing” must be created as a result of surgery in order for the urethra to function in an area that is appropriate for someone with a neovagina. For instance, in gender reassignment surgery urethral stricture can be a long term complication of a male-to-female transition, resulting in difficulty voiding. However, for surgeries such as the Burch Repair, this procedure is intended to improve the functioning of the urinary tract. Women who have developed stress urinary incontinence as a result of childbirth, injury, surgery, or lack of muscle tone are all candidates for this procedure.

How Urodynamics and Colpoplasty Fit Together

The role of urodynamics in colpoplasty is important. Any time pelvic organs are repaired or created, the functioning of the lower urinary tract must be ascertained.

While vaginoplasty is commonly used to repair issues with the urinary tract, it can also cause additional problems, such as worsened stress incontinence. Therefore, urodynamic assessment should be made before and after any type of colpoplasty is performed. Case studies including the role of urodynamics for various types of vaginoplasties are described here.

Urethral Stricture

Transgendered patients who undergo a male to female transition commonly experience urethral stricture. In fact, 18.3% of women⁴ who have undergone this procedure have reported difficulties urinating. Urodynamics play a significant role post-operatively after gender reassignment surgery to ensure that the lower urinary tract is functioning properly, particularly when the urethra has been shortened during this reassignment. Over time, the urethra can narrow, causing urethral meatal stenosis, which results in difficulty voiding. Urodynamic tests such as uroflowmetry are used to diagnose this issue.

Urinary Incontinence following Gender Reassignment

While urethral stricture is one common complication following male to female gender reassignment surgery, the development of stress urinary incontinence is another. In this case study⁵, meatal stenosis (partially caused by excess erectile tissue) in addition to stress incontinence were reported in the five - nine years following gender reassignment surgery for one woman.

To diagnose the problem, video urodynamics were used. This procedure indicated a partially open bladder neck at rest and prolapse of the posterior wall of the neovagina. Cough induced detrusor overactivity was also reported as a result of urodynamic testing. To remedy the problem, a second colpoplasty surgery was performed, where a pubo-vaginal sling was incorporated using the autologous rectus sheath for support.

Follow-up urodynamic assessments showed that the patient’s flow rate was satisfactory and there was minimal post-void residual urine. The stress incontinence was no longer an issue, although occasional urge incontinence was reported. Additional urodynamic testing was not performed, as there were no symptoms that warranted these tests. Overall, without the use of urodynamic assessment, diagnosing this patient’s problems would have been difficult.

Pelvic Organ Prolapse and Transvaginal Mesh

A common cause of stress urinary incontinence is pelvic organ prolapse. Treatment for this disorder, which can occur with any of the pelvic organs, commonly involves anterior or posterior colpoplasty in addition to transvaginal mesh support¹. According to the American Urological Association’s guidelines, anytime surgery is to be performed in the pelvic region on an incontinent individual, a full urodynamic assessment should be performed. These tests, particularly multichannel cystometry, are important for making the most informed decision regarding treatment. In addition, the same urodynamic tests should be performed post-operatively to identify whether the treatment was effective. In some instances, symptoms become worse, which should be noted by the physician.

MRKH Syndrome

Mayer–Rokitansky–Kuester–Hauser syndrome is a congenital deformity that affects 1 in 4,000 live births throughout the world. This disorder causes malformation of female genitalia. The disorder affects each woman to a varying degree; however, in many cases women have no vagina. In this instance, colpoplasty is required. Urodynamics plays two roles here.

In the initial diagnosis of the disorder, urodynamic assessment is necessary in order to determine whether the lower urinary tract is otherwise functioning at full capacity. Additionally, following surgery (most commonly the Vechietti procedure), it is necessary to determine whether vaginal lengthening impaired the function of the bladder.

In one such study, 19 women⁶ underwent urodynamic assessment before and after the Vechietti procedure was performed. Prior to surgery, 53% of women were found to have urinary symptoms. Following surgery, there was no change in reported symptoms, other than altered bladder capacity and increased urine frequency.

Urethro-vaginoplasty

Urethro-vaginoplasty is a type of colpoplasty procedure intended to repair the urethra after damage sustained from trauma, such as child birth. This procedure is performed for the management of stress urinary incontinence, detrusor overactivity, anterior vaginal wall descent, and mixed-type urinary incontinence. As such, urodynamic assessment is important pre-operatively in order to fully diagnose the disorder before surgical treatment can be ordered.

The most important diagnostic tests are cystometry, urethral pressure profilometry, stress cysto-urethral pressure profilometry, and leak-point pressure tests. Post-operatively these same procedures are performed in order to assess the outcome of the surgery. Ideally, there should be no urine leakage as a result of stress, increased urethral closure pressure, increased bladder capacity, significantly reduced detrusor contractions during bladder filling, and an elevation of abdominal leak-point pressure. Additionally, post-void residual urine volume should be less than 50 mL. For urethra-vaginoplasty, urodynamic assessment is crucial for determining surgical outcomes.

Burch Repair

A Burch Repair is a common colpoplasty procedure that is performed for women with stress urinary incontinence. As in the case of urethro-vaginoplasty, urodynamic assessment is crucial for both diagnostic and post-operative assessment. In one study⁷, multichannel urodynamic tests were performed prior to and one year following Laproscopic Burch Repair for genuine stress incontinence. Frequent urodynamic assessments are important following this colpoplastic procedure, as 18% of patients develop pelvic organ prolapse within the first 5 years following Burch repair.

The urodynamic tests performed included the keeping of a urinary journal, a cough stress test, and a multichannel urodynamic assessment. In this study, the urodynamic assessments revealed that 4 of 41 women had recurrent genuine stress incontinence, while one woman had developed a grade 1 cystocele. Here, urodynamic testing is a crucial component for diagnosing lower urinary tract symptoms both pre- and post-operatively.

Final Thoughts

Ultimately, urodynamics and colpoplasty go hand in hand, as vaginal reconstructive surgery is used to either repair disorders of the lower urinary tract, or to create a vagina while possibly disrupting bladder and urethral functioning in the process. Urodynamic assessments are the golden standard in diagnosing urinary disorders, and the tests available are powerful in their diagnostic abilities.

Additionally, colpoplasty covers a wide range of women and disorders, from medically necessary to fully elective. Whether vaginoplasty is performed for the repair of an ongoing disorder, to create a neovagina, or for vanity reasons, urodynamic assessment is warranted both pre- and post-operatively for diagnosis and continuing care. As per the American Urology Association guidelines, urodynamic assessment is indeed necessary whenever a surgical procedure involving the pelvic organs is performed, particularly when the primary function is to treat urological symptoms.

References

1. Kanasaki, H., Oride, A., Mitsuo, T., & Miyazaki, K. (2014). Occurrence of Pre- and Postoperative Stress Urinary Incontinence in 105 Patients Who Underwent Tension-Free Vaginal Mesh Surgery for Pelvic Organ Prolapse: A Retrospective Study. ISRN Obstetrics and Gynecology, 2014, 1-5. doi:10.1155/2014/643495 Link
2. Nitti, V. W. (2005). Pressure Flow Urodynamic Studies: The Gold Standard for Diagnosing Bladder Outlet Obstruction. Reviews in Urology, 7(Suppl 6), S14–S21. Link
3. Duckett, J. R., & Tamilselvi, A. (2005). Urogynaecology: Effect of tension-free vaginal tape in women with a urodynamic diagnosis of idiopathic detrusor overactivity and stress incontinence. BJOG: An International Journal of Obstetrics & Gynaecology, 113(1), 30-33. doi:10.1111/j.1471-0528.2005.00810.x Link
4. Lin, Y., Lin, W., & Hsu, J. (2013). Urethral stricture in male-to-female transsexual patients—Report of two cases. Formosan Journal of Surgery, 46(5), 173-175. doi:10.1016/j.fjs.2013.07.001 Link
5. Dangle, P. P., & Harrison, S. C. W. (2007). Stress urinary incontinence after male to female gender reassignment surgery: Successful use of a pubo-vaginal sling. Indian Journal of Urology : IJU : Journal of the Urological Society of India, 23(3), 311–313. http://doi.org/10.4103/0970-1591.33731 Link
6. Michala, L., Strawbridge, L., Bikoo, M., Cutner, A. S., & Creighton, S. M. (2012). Lower urinary tract symptoms in women with vaginal agenesis. International Urogynecology Journal, 24(3), 425-429. doi:10.1007/s00192-012-1870-4 Link
7. Ross, J. (1996). Multichannel urodynamics for laparoscopic Burch and pelvic vault repairs. The Journal of the American Association of Gynecologic Laparoscopists, 3(4). doi:10.1016/s1074-3804(96)80283-0 Link