Clinical and Urodynamic Predictors of Urinary Urgency Improvement After Cystocele Repair

Article information

Int Neurourol J. 2026;30(2):163-171

Publication date (electronic) : 2026 June 30

doi : https://doi.org/10.5213/inj.2652102.051

Ju Hun Ahn, Joon Chul Kim, Jin Bong Choi, Jun Sung Koh, Young Kyu Han, Seong Joo Yang, Kang Jun Cho

Department of Urology, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Corresponding author: Kang Jun Cho Department of Urology, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 327 Sosa-ro, Wonmi-gu, Bucheon 14647, Korea Email: gift99@catholic.ac.kr

Received 2026 April 10; Accepted 2026 May 19.

Abstract

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition among women, especially as they age and have more children. Large population-based studies show that anterior compartment prolapse, including cystocele, is one of the most prevalent forms of POP [1]. The lifetime risk of undergoing surgical treatment for either POP or stress urinary incontinence (SUI) is estimated to be around 20% [2]. Cystocele often changes the geometry of the bladder outlet and weakens normal pelvic floor support, lead-ing to the frequent coexistence of lower urinary tract symptoms (LUTS), especially overactive bladder (OAB) symptoms, with this anatomical defect. In women with pelvic floor disorders, the pathophysiology of OAB is complex and multifactorial. Proposed mechanisms include detrusor overactivity (DO), altered urothelial signaling, and dysregulation of the neural pathways involved in bladder sensation and contraction [3]. Bladder outlet obstruction (BOO) associated with cystocele may exacerbate these mechanisms by increasing afferent sensitivity or causing changes in the urothelial proteome, which can promote urgency or urge urinary incontinence (UUI) [4].

Surgical correction of POP can restore bladder outlet dynamics, and some patients report improvement in urgency symptoms after surgery. However, clinical outcomes vary widely. Studies assessing postoperative changes in OAB have found significant differences in symptom improvement among individuals. Various patient-related and prolapse-related factors have been investigated to explain this variability. Prolapse severity has been identified as one factor potentially influencing postoperative OAB outcomes following reconstructive surgery [5]. Additionally, studies on mesh-based POP repair have identified specific preoperative clinical and urodynamic characteristics that may correlate with postoperative improvement in urgency symptoms [6]. Despite these observations, evidence regarding the predictive value of preoperative urodynamic parameters remains inconclusive. Wolter et al. [7] found that preoperative urodynamic findings did not consistently predict postoperative urgency in women with mixed urinary incontinence and cystocele. Conversely, other studies have suggested potential predictive associations with bladder dynamics or symptom profiles; however, these findings have not been consistently replicated across various populations [8].

Current evidence indicates that the improvement of postoperative urgency following cystocele repair is influenced by a complex interplay of anatomical, functional, and symptomspecific factors. However, reliable and broadly applicable predictors are still limited. Therefore, identifying preoperative factors linked to urgency improvement is crucial for enhancing patient counseling and postoperative management.

This study aims to investigate the preoperative clinical characteristics and urodynamic factors associated with postoperative urgency improvement in women undergoing surgical correction for cystocele. By clarifying these associations, we hope to enable more accurate patient stratification, support perioperative decision-making, and facilitate early targeted interventions for patients at high risk of experiencing persistent urgency.

MATERIALS AND METHODS

This retrospective review examined patients who underwent surgical treatment for cystocele and had preoperative urgency scores of 3 or higher on a 5-point urinary sensation scale between September 2010 and June 2025. Urinary urgency was assessed using a 5-point urinary sensation scale, a single-item patient-reported measure of urgency severity. This approach is consistent with regulatory recommendations, including those from the European Medicines Agency, which emphasize the use of patient-reported outcomes for the assessment of urinary symptoms. The scale ranges from 1 to 5, with higher scores indicating greater urgency severity: 1=no urgency (“I felt no need to empty my bladder but did so for other reasons”); 2=mild urgency (“I could postpone voiding as long as necessary without fear of leakage”); 3=moderate urgency (“I could postpone voiding for a short time without fear of leakage”); 4=severe urgency (“I could not postpone voiding and had to rush to the toilet to avoid leakage”); and 5=urgency urinary incontinence (“I leaked before reaching the toilet”). This grading system has been used in prior clinical studies evaluating LUTS and OAB, including trials of combination therapy with antimuscarinics and α-blockers [9]. Patients with moderate to severe postoperative complications affecting lower urinary tract function, suspected neurogenic causes for urgency, urinary tract infections, bladder stones, bladder cancer, a history of pelvic radiation therapy, or those who received anticholinergics for urgency within 3 months after surgery were excluded from the study. Patients were not given anticholinergics prior to surgery. Surgical repairs for cystocele, including transvaginal mesh surgery and robotic-assisted laparoscopic sacrocolpopexy, were performed by 1 of 2 experienced urologists (JCK, KJC). This study received approval from the ethics committee and the institutional review board (IRB) at Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea (IRB #2025-2977-0001).

Enrolled patients were divided into 2 groups based on urgency symptoms 3 months after surgery: improved and nonimproved urgency. Improved urgency was defined as a reduction of 2 or more points on the 5-point urinary sensation scale, reflecting a meaningful change in urgency severity. Preoperative clinical factors and urodynamic factors were compared between the 2 groups. The preoperative clinical factors included age, body mass index (BMI), presence of diabetes, vaginal parity, history of hysterectomy, cystocele severity, UUI, SUI, and International Prostate Symptom Score (IPSS). Cystocele severity was assessed using the Pelvic Organ Prolapse Quantification system and categorized into stage ≤3 and stage 4.

Urodynamic factors obtained from the urodynamic study (UDS), conducted in accordance with the Good Urodynamic Practice standards recommended by the International Continence Society [10], included the following: maximum flow rate (Qmax), postvoid residual urine volume (PVR), maximal cystometric capacity, detrusor pressure at maximum flow rate (PdetQmax), maximal urethral closure pressure, DO, BOO, bladder sensitivity index, and bladder compliance.

DO was defined as either spontaneous or provoked involuntary detrusor contractions accompanied by urgency during the filling phase of baseline cystometry [11]. BOO was defined as a Qmax <15 mL/sec and PdetQmax >20 cm H2O in a pressureflow study [12].

The bladder sensitivity index was calculated as the ratio of maximal bladder volume to the bladder volume at the first desire to void [13]. To evaluate both the changes in urgency and the overall alterations in lower urinary tract function after cystocele repair, we compared preoperative and postoperative IPSS, Qmax, and PVR. Additionally, we analyzed changes in these parameters separately within the improved and unimproved urgency groups.

RESULTS

A total of 137 women were analyzed, with 98 (71.5%) experiencing postoperative improvement in urinary urgency, while 39 (28.5%) did not. Table 1 presents a comparison of baseline clinical and urodynamic characteristics between the improved and nonimproved groups. There were no significant differences in age, BMI, the presence of diabetes, or history of previous hysterectomy between the 2 groups. However, vaginal parity was significantly lower in the improved group compared to the nonimproved group (P=0.026). Additionally, the prevalence of preoperative UUI was significantly higher in the improved group (62.2%) than in the nonimproved group (30.8%, P=0.001).

Table 1.

Comparison of baseline clinical characteristics and urodynamic parameters according to urgency improvement

In terms of urodynamic parameters, the improved group exhibited a significantly higher PdetQmax (22.9) than the nonimproved group (18.0, P=0.004). Consequently, the proportion of patients diagnosed with BOO was also significantly higher in the improved group (43.9%) compared to the nonimproved group (20.5%, P=0.011).

The multivariate logistic regression analysis identified preoperative UUI, PdetQmax, and vaginal parity as independent factors associated with the improvement of urgency symptoms following cystocele repair (Table 2).

Table 2.

Factors associated with postoperative urgency improvement in multiple logistic regression analysis

Comparing pre- and postoperative Qmax and PVR revealed that while Qmax did not show significant change, PVR decreased significantly after surgery in both the improved and nonimproved groups (Fig. 1).

Fig. 1.

Changes in Qmax and PVR before and after cystocele repair, stratified by urgency outcome. Patients were classified into an urgency- improved group and a nonimproved group based on postoperative urgency status. (A) Qmax in the urgency-improved group, (B) Qmax in the nonimproved group, (C) PVR in the urgency-improved group, and (D) PVR in the nonimproved group are presented at baseline and postoperatively. Data are shown as box-and-whisker plots, in which the boxes represent the interquartile range, the horizontal line indicates the median, and the whiskers represent the minimum and maximum values. P-values for within-group comparisons were calculated using the Wilcoxon signed-rank test and are displayed on the graph. Qmax, maximum flow rate; PVR, postvoid residual volume.

The total IPSS improved significantly in both groups, with the improved group showing enhancement in all subscores, while the nonimproved group demonstrated improvement in all subscores except for the storage subscore (Fig. 2).

Fig. 2.

Changes in the IPSS and QoL before and after cystocele repair, stratified by urgency outcome. Patients were classified into an urgency-improved group and a nonimproved group according to postoperative urgency status. (A) IPSS total score, (B) IPSS voiding subscore, (C) IPSS storage subscore, and (D) IPSS-related QoL score are shown for each group at baseline and postoperatively. Data are presented as box-and-whisker plots, in which the boxes represent the interquartile range, the horizontal line indicates the median, and the whiskers represent the minimum and maximum values. Within-group comparisons between baseline and postoperative values were conducted using the Wilcoxon signed-rank test, and exact P-values are displayed in the figure. IPSS, International Prostate Symptom Score; QoL, quality of life.

DISCUSSION

The present study investigated the predictive value of preoperative clinical and urodynamic factors on the improvement of urinary urgency following cystocele repair. Our principal finding is that 71.5% of women experienced significant improvement in urgency symptoms after surgical correction of cystocele. This improvement rate aligns with previous reports indicating that 61% to 88% of women experience significant improvement in urgency and other OAB symptoms after POP repair [14, 15]. We found that preoperative UUI, higher PdetQmax, and lower vaginal parity were independent predictors of improvement in postoperative urgency.

A key finding of this study is the positive predictive value of PdetQmax and BOO. Since PdetQmax is influenced by both detrusor-generated pressure and outlet resistance, it represents the interplay between detrusor contractility and bladder outlet conditions rather than just one physiological aspect [16]. In our cohort, the improved group exhibited significantly higher preoperative PdetQmax and a greater prevalence of BOO compared to the nonimproved group. This supports the “obstruction-induced overactivity” hypothesis, which suggests that cystocele causes mechanical kinking or compression of the urethra, leading to compensatory DO [17, 18]. An alternative explanation for higher PdetQmax could be differences in PVR; however, in our cohort, PVR was not significantly different between groups. Therefore, the association between higher PdetQmax and urgency improvement is more likely to reflect the contribution of BOO. Surgical correction effectively restores bladder outlet geometry, relieves obstruction, and resolves secondary urgency. In contrast, the group with persistent urgency demonstrated significantly lower PdetQmax, indicating impaired detrusor contractility. Although PdetQmax cannot independently quantify the severity of detrusor underactivity (DU), it is widely recognized as a clinically relevant surrogate for detrusor contractility [16]. Patients with DU or impaired contractility may experience urgency due to intrinsic bladder dysfunction rather than solely mechanical outlet obstruction. Clinical and experimental studies indicate that chronic bladder remodeling— such as partial denervation, altered afferent signaling, and unregulated autonomous bladder micromotions—can lead to nonvoiding contractions and sensations of urgency during bladder filling [19, 20]. Consequently, patients with reduced detrusor contractility may experience less improvement in urgency following anatomical correction of a cystocele. While we acknowledge that the proposed mechanisms are partially speculative without postoperative UDS data, our findings suggest that preoperative UDS are useful not only for diagnosing BOO but also for identifying patients with sufficient bladder contractility who are most likely to benefit from POP surgery.

Interestingly, our study found that patients with UUI experienced better postoperative outcomes than those without UUI. While some previous literature has indicated that mixed incontinence or UUI is linked to persistent postoperative symptoms, our findings suggest a different trend [8, 21]. A recent secondary analysis of POP surgery found that women with pre-existing UUI experienced greater postoperative improvement in their UUI symptoms. This suggests that baseline UUI may not always predict poorer outcomes; in fact, it can sometimes be linked to a greater degree of symptom improvement [22]. One possible explanation is that UUI occurring alongside significant cystocele may, at least in part, be driven by urgency resulting from mechanical distortion of the bladder outlet or bladder base. In this case, restoring pelvic anatomy through prolapse repair could normalize bladder geometry and reduce urgency-related urinary leakage. In contrast, urgency without incontinence may indicate sensory urgency or idiopathic OAB, which is less influenced by anatomical distortion and may be less responsive to prolapse correction [3, 23].

Vaginal parity was found to negatively predict improvements in urgency, with higher parity linked to worse postoperative outcomes. This aligns with the established understanding of obstetric pelvic floor injury, as repeated vaginal deliveries can lead to cumulative damage to the pelvic floor muscles, connective tissue support, and pudendal nerve innervation [24, 25]. Injuries such as levator ani trauma and pelvic neuropathy can cause ongoing neuromuscular dysfunction in the lower urinary tract. Even if the anatomical defect of a cystocele is successfully repaired, the underlying neuromuscular issues may persist, leading to continued urgency symptoms. As a result, while pro-lapse repair primarily addresses the structural aspects of pelvic floor dysfunction, it may not resolve the neuromuscular injuries associated with childbirth. Our findings suggest that urgency symptoms in multiparous women may reflect a non-mechanical or neuromuscular phenotype of OAB that does not improve with anatomical correction alone. This underscores the need for thorough preoperative counseling, especially for multiparous patients, about the possibility of ongoing urgency symptoms despite successful prolapse repair. Furthermore, inclusion of cystocele severity in the multivariable model did not materially alter the results, suggesting that prolapse severity itself did not substantially influence these associations.

Our study demonstrated a significant reduction in PVR volume in all patients after surgery, indicating improved bladder emptying following cystocele repair. However, we did not observe a significant change in Qmax. This may reflect the complex factors influencing Qmax, which is determined by both outlet resistance and detrusor contractility. Thus, while anatomical correction of the cystocele may enhance bladder emptying efficiency, it does not necessarily lead to a measurable change in Qmax. Regarding subjective symptoms, the total IPSS improved significantly in both the improved urgency group and the nonimproved group. In the improved group, both voiding and storage subscores showed improvement, while only the voiding subscore improved in the nonimproved group. These findings suggest that cystocele repair effectively addresses the mechanical aspects of voiding dysfunction, but urgency symptoms may persist in some patients due to mechanisms unrelated to outlet obstruction.

Despite these findings, several limitations must be acknowledged. First, this study was retrospective and conducted at a single center with a relatively small sample size, which may limit the generalizability of the results. Second, the surgical approaches varied, as both transvaginal mesh surgery and robotic sacrocolpopexy were included. The number of patients undergoing robotic sacrocolpopexy was relatively small, which limited the feasibility of performing a meaningful comparative or adjusted analysis based on surgical approach. Although both procedures aim to restore pelvic anatomy, differences in surgical technique may influence postoperative bladder function. Therefore, the inclusion of mixed surgical approaches may have introduced potential confounding. This should be considered when interpreting the results, and the impact of surgical technique on urgency outcomes warrants further investigation in larger, more balanced cohorts. Third, symptom outcomes were assessed only 3 months after surgery. While this timeframe likely reflects the early functional impact of anatomical restoration, longer follow-up studies are needed to assess the durability of urgency improvement and the potential influence of prolapse recurrence. Fourth, the study population was restricted to patients with preoperative urgency, which limits the generalizability of our findings. As a result, this study does not represent the full population undergoing cystocele repair and cannot evaluate the incidence of de novo urgency or the full spectrum of postoperative symptom trajectories, including resolution, persistence, or new onset. In addition, the reported rate of urgency improvement should be interpreted with caution, as it applies only to a selected symptomatic subgroup and may overestimate the perceived benefit when generalized to all surgical candidates. Fifth, IPSS was used to assess LUTS in women. Although it has been applied in female populations and is a simple, widely used instrument, it was originally developed for male patients; therefore, the results should be interpreted with caution. Finally, postoperative urodynamic studies were not performed. Therefore, the proposed mechanisms underlying urgency improvement, such as relief of BOO or changes in detrusor function, remain speculative. The associations observed between preoperative urodynamic parameters and postoperative outcomes should be interpreted cautiously, and causal inferences cannot be established.

Surgical repair of cystocele effectively resolves urinary urgency in many patients, especially those with preoperative BOO and preserved detrusor contractility. Significant predictors of postoperative urgency improvement include preoperative UUI, higher PdetQmax, and lower parity. These findings indicate that urgency in many patients with cystocele may be closely related to mechanical obstruction and altered bladder emptying associated with POP. However, urgency did not improve in all patients, underscoring the multifactorial nature of urgency in this population. Both clinical characteristics and urodynamic parameters may help identify patients with cystocele and preoperative urgency who are more likely to experience improvement in urgency after anatomical correction. These factors may also assist in preoperative counseling regarding the possibility of persistent urgency despite successful cystocele repair. These findings reflect short-term outcomes following cystocele repair.

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