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