Abstract
BACKGROUND: Pelvic organ prolapse (POP) is common in women and frequently associated with stress urinary incontinence (SUI). SUI may be present following prolapse reduction (occult SUI) and may develop after surgery for POP (new-onset SUI). OBJECTIVES: To determine the impact of surgery for symptomatic POP, with or without concomitant or delayed two-stage continence procedures, to treat or prevent SUI, on postoperative bladder function. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, two trials registries, journals and conference proceedings (searched 29 April 2024, updated 23 July 2025), and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) including surgical interventions for POP with or without continence procedures in continent or incontinent women. Our primary outcome was subjective postoperative SUI. Secondary outcomes included POP on examination, overactive bladder, further continence surgery, and voiding dysfunction. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. We assessed evidence certainty using GRADE. MAIN RESULTS: We included 22 RCTs with 3095 women. Evidence certainty ranged from low to moderate. Limitations were risk of bias (especially blinding of outcome assessors), indirectness, and imprecision associated with low event rates and small samples. POP surgery in women with SUI Vaginal POP surgery with versus without midurethral sling: a concomitant midurethral sling may decrease SUI, (risk ratio (RR) 0.30, 95% confidence interval (CI) 0.19 to 0.48; 2 studies, 319 women), and rates of further continence surgery (RR 0.04, 95% CI 0.00 to 0.74; 1 study, 134 women), both low-certainty evidence. This suggests that if the risk of SUI with POP surgery alone is 39%, the risk with midurethral sling is between 8% and 19%. Vaginal POP surgery with concomitant versus delayed midurethral sling: low-certainty evidence suggested little or no difference in SUI (RR 0.41, 95% CI 0.12 to 1.37; 1 study, 140 women). Vaginal transobturator mesh versus vaginal POP surgery with midurethral sling: evidence from one study with 84 women suggested little or no difference in SUI (RR 1.47, 95% CI 0.51 to 4.26); POP (RR 6.29, 95% CI 0.79 to 50.03); new-onset overactive bladder (RR not estimable); and voiding dysfunction (RR 3.14, 95% CI 0.13 to 75.02), low-certainty evidence. Abdominal sacrocolpopexy with versus without Burch colposuspension: an additional Burch colposuspension may have little or no effect on SUI after five years (RR 1.17, 95% CI 0.60 to 2.26; 45 women), or on overactive bladder (RR 0.85, 95%CI 0.61 to 1.18), new-onset overactive bladder (RR 1.92, 95% CI 0.19 to 19.73) or voiding dysfunction (RR 0.96, 95%CI 0.06 to 14.43) all after one year (1 study, 47 women, all low-certainty evidence). Abdominal sacrocolpopexy with concomitant midurethral sling or Burch colposuspension: midurethral sling may decrease SUI at two years (RR 0.54, 95% CI 0.34 to 0.86; 113 women) but not POP (RR 1.85, 95%CI 0.18 to 19.62; 79 women), overactive bladder (RR 1.18, 95% CI 0.71 to 1.94; 44 women), new-onset overactive bladder (RR 0.59, 95% CI 0.06 to 6.09; 48 women), or voiding dysfunction (RR 1.23, 95% CI 0.52 to 2.90; 92 women), low-certainty evidence from one study. This suggests that if the risk of SUI with Burch is 55%, the risk with midurethral sling is between 19% and 48%. POP surgery in women with occult SUI Vaginal POP surgery with versus without midurethral sling: probably decreases SUI (RR 0.38, 95% CI 0.26 to 0.55; 5 studies, 369 women) and further continence surgery rates (RR 0.15, 95% CI 0.04 to 0.53; 4 studies, 279 women) both moderate-certainty evidence. This suggests that if the risk with POP surgery alone is 34%, the risk with concomitant midurethral sling is between 10% and 22%. Low-certainty evidence suggests little or no difference in POP (RR 0.86, 95% CI 0.34 to 2.19; 1 study, 50 women), overactive bladder (RR 0.75, 95% CI 0.52 to 1.07; 1 study, 43 women), new-onset overactive bladder (RR 2.11, 95% CI 0.73 to 6.11; 2 studies, 75 women) or voiding dysfunction (RR 1.00, 95% CI 0.15 to 6.55; 1 study, 50 women). POP surgery in stress urinary continent women Vaginal POP surgery with versus without concomitant midurethral sling: there is probably no difference in SUI between groups (RR 0.69, 95% CI 0.47 to 1.00; 1 study, 220 women; moderate-certainty evidence). This suggests that if the risk with POP surgery alone is 40%, the risk with concomitant midurethral sling is between 19% and 40%. Abdominal sacrocolpopexy with versus without Burch colposuspension: there may be little or no effect on SUI after two years (RR 0.72, 95% CI 0.53 to 0.99; I² = 75%; 2 studies, 364 women; low-certainty evidence). This suggests that if the risk with sacrocolpopexy alone is 36%, the risk with concomitant Burch colposuspension is between 19% and 36%. Low-certainty evidence from one study suggests there may be little or no difference in POP (RR 0.98, 95% CI 0.74 to 1.30, 250 women), new-onset overactive bladder (RR 1.41, 95%CI 0.25 to 7.91, 66 women) and voiding dysfunction (RR 8.49, 95% CI 0.48 to 151.59, 66 women). Vaginal transobturator mesh repair versus native tissue repair: low-certainty evidence suggests that transobturator mesh repair may increase SUI at 3-7 years (RR 1.77, 95% CI 1.08 to 2.91; 3 studies, 417 women) but may decrease POP (RR 0.40, 95% CI 0.31 to 0.52 ; 3 studies, 458 women). There may be little or no difference in voiding dysfunction at 12 months (RR 1.65, 95% CI 0.22 to 12.10; 2 studies, 125 women). AUTHORS' CONCLUSIONS: In women with POP and symptomatic or occult SUI, a concomitant midurethral sling probably reduces SUI, but adverse effects remain unclear. It is also feasible to postpone the midurethral sling and perform a continence procedure only if required. In continent women, a Burch colposuspension during abdominal POP surgery reduced new-onset SUI rates in one underpowered study, but another RCT reported conflicting results. Adding a midurethral sling during vaginal POP repair might prevent new-onset SUI. An anterior native tissue repair might be better than vaginal transobturator mesh for preventing new SUI; however, POP recurrence may be more common with native tissue repair.