(Poster 74) Intra-op Crede vs Preoperative Reduction Stress Test to Predict De Novo SUI

Objectives: To evaluate the feasibility of a randomized study comparing intraoperative Crede maneuver (M1) and preoperative prolapse reduction stress test (M2) in predicting postoperative de novo stress urinary incontinence (PONSUI) in women undergoing pelvic organ prolapse (POP) surgery. We assessed subjective PONSUI rates at 6 months and assessed each maneuver’s utility in guiding incontinence treatment. Secondary aims included comparing objective PONSUI (office cough stress test with full bladder), urinary symptoms, complications, and M1/M2 discordance.

Methods: Women without baseline SUI undergoing POP surgery were randomized 1:1 to two groups. All participants underwent both intraoperative Crede maneuver (M1) and preoperative prolapse reduction stress test (M2) with full bladder (250-350mL). In Group A, a positive M1 prompted concomitant incontinence treatment, while in Group B, incontinence treatment was based on M2 results. Concomitant incontinence treatment could be urethral bulking or retropubic mid-urethral sling (MUS), based on shared decision-making between participants and surgeons. Some participants opted for staged treatment and were not randomized but were followed for outcomes. Data is presented as mean (standard deviation) and N (%). McNemar test was performed to test the M1/M2 discordance rate, and Fisher exact tested the association between Crede result and PONSUI.

Results: Twenty-seven participants were included and followed for a mean of 6 months. The study was stopped before achieving the desired sample size goal of 110 women due to slow recruitment. Mean age was 66.1 (9.6) years old. At baseline, 16/21 (76%) reported severely bothersome pelvic floor symptoms, and 3 (14%) reported moderately bothersome symptoms (PGI-S).
Intraoperative Crede manoeuver was positive in 15 cases (55.6%) and preoperative prolapse reduction stress test was positive in 1 case (3.7%), with 51.9% discordance of results (p < 0.001). Nine women chose not to be randomized (declined concomitant SUI intervention regardless of test results), whereas 18 were randomized. Nine were randomized to the Crede manoeuver, out of which 4 were positive and treated intraoperatively with 1 urethral bulking and 3 MUS. Nine were randomized to preoperative reduction test, out of which 1 was positive and treated intraoperatively with urethral bulking.
Overall, 9/27 (33%) reported subjective PONSUI at the last postoperative visit, including 4 (44%) in the Crede group, 3 (33%) in the preoperative group and 2 (22%) in the no-randomization group. Rate of positive Crede among those with subjective SUI at last postoperative visit was 44.4% vs. 61.1% for those without SUI (p-value=0.448). Objective PONSUI was positive in only 1/27 (3.7%) at the last postoperative visit

Conclusions: Neither the intraoperative Crede nor the preoperative reduction cough stress test were significantly associated with the risk of PONSUI after POP surgery. More studies are needed to develop predictive tests to predict and strategies to prevent PONSUI.