Pelvic Organ Prolapse

Transcription

Clinical Expert Series
Editor’s Note: Continuing medical education credit is available online at
www.greenjournal.org.
Anne M. Weber,
MD, MS,
and Holly E. Richter,
PhD, MD
Abstract: Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse,
and enterocele, is a common group of clinical conditions affecting millions of American women.
This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its
pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of
disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with
severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial
and may operate under a “multiple-hit” process in which genetically susceptible women are
exposed to life events that ultimately result in the development of clinically important prolapse. The
evaluation of women with prolapse requires a comprehensive approach, with attention to function
in all pelvic compartments based on a detailed patient history, physical examination, and limited
testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often
challenging for the clinician to determine which symptoms are attributable to the prolapse itself and
will therefore improve or resolve once the prolapse is treated. When treatment is warranted based
on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical,
which includes pelvic floor muscle training and pessary use; and surgical, which can be
reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms
require additional management. Virtually all women with prolapse can be treated and their
symptoms improved, even if not completely resolved.
(Obstet Gynecol 2005;106:615–634)
CLINICAL IMPORTANCE
Because the prevalence of pelvic organ prolapse
increases with age, the changing demographics of the
world’s population will result in even more affected
women. Based on projections from the United States
Census Bureau, the number of American women
aged 65 years and over will double in the next 25
years, to more than 40 million women by 2030.1 By
one estimate, the demand for health care services
related to pelvic floor disorders will increase at twice
the rate of the population itself.2 The lifetime risk that
a woman in the United States will have surgery for
From the Department of Obstetrics, Gynecology, and Reproductive Sciences,
Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, University of
Alabama Hospital, University of Alabama at Birmingham School of Medicine,
Birmingham, Alabama.
Corresponding author: Anne M. Weber, MD, MS, Magee-Womens Hospital,
300 Halket Street, Pittsburgh, PA 15213; e-mail: [email protected].
© 2005 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/05
VOL. 106, NO. 3, SEPTEMBER 2005
prolapse or urinary incontinence is 11%, with up to
one third of surgeries representing repeat procedures.3 Although the overall rate of prolapse surgery
has dropped, this represents a substantial drop in the
rate of surgery for women less than 50 years old and
a moderate increase for women aged 50 years and
greater (Fig. 1).4 Perioperative death is uncommon (3
per 10,000 surgeries), although that figure underestimates mortality occurring outside of the index hospitalization for surgery. The direct cost of prolapse
surgery is greater than $1 billion per year.5
Surgically treated prolapse represents the severe
end of the clinical spectrum. Where is the cutoff
between early prolapse and “normal” pelvic support?
Two factors make this question difficult to answer.
Changes in vaginal anatomy are exceedingly common, especially in parous women; and beyond the
sensation of protruding tissue with advanced prolapse, symptoms of prolapse are notoriously nonspecific. Prolapse is commonly found on physical examination in women without pelvic symptoms.6,7 For the
vast majority of asymptomatic women with physical
OBSTETRICS & GYNECOLOGY
615
Fig. 1. Age-adjusted rates of prolapse procedures per 1,000
women from 1979 to 1997 in the United States, stratified by
patient age. Red line, all ages; blue line, women less than
50 years of age; green line, women 50 years or older.
Modified from Boyles SH, Weber AM, Meyn L. Procedures
for pelvic organ prolapse in the United States, 1979 –1997.
Am J Obstet Gynecol 2003;188:108 –15. Copyright 2003,
with permission from Elsevier.
Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.
findings of prolapse, no treatment is indicated. In
contrast to traditional concepts that predict inevitable
progression of prolapse with time, prolapse is a
dynamic condition; regression of prolapse occurs at
the same or higher rate as incidence.8 Factors related
to progression and remission need further study. This
review will outline our recommendations, combined
with an evidence-based approach when available, for
the evaluation and treatment of the postreproductive
woman with pelvic organ prolapse.
PATHOPHYSIOLOGY
A useful approach to understanding the pathophysiology of prolapse is to consider risk factors as predisposing, inciting, promoting, or decompensating
events (Table 1).9 Depending on the combination of
risk factors in an individual, prolapse may or may not
develop over her lifetime. As a hypothetical example,
imagine a woman who is genetically predisposed to
prolapse. She has a family history of prolapse, and
unknown to her, she carries a subclinical defect in
connective tissue remodeling. She experienced an
inciting event in the birth of her 9-pound postterm
son, with prolonged second stage followed by forceps
delivery over midline episiotomy that extended to
disrupt the anal sphincter. Over the next 10 years, she
gained 60 pounds. She has chronic excessive straining
at defecation. At menopause, she had a simple hysterectomy for atypical endometrial hyperplasia, with
no attention given to reattaching the uterosacral ligaments to the vaginal cuff. At age 55, she is diagnosed
with stage III vaginal prolapse.
Now let’s give this woman an identical twin sister,
who carries the same genetic predisposition but who
experiences different life events. She never experienced pregnancy or delivery. She maintained normal
weight and an active lifestyle. She never developed an
indication for hysterectomy. At age 55, her pelvic
support is excellent. Although hypothetical, these 2
cases emphasize the multifactorial nature of prolapse.
Risk factors have been and will continue to be
identified; with progress such as the Human Genome
Project, eventually we may be able to predict those at
highest risk of developing prolapse. Modifiable risk
factors can be altered to decrease the likelihood of
subsequent prolapse.
Risk factors for prolapse include increasing age,
higher gravidity and parity (especially the number of
vaginal births), and history of hysterectomy, especially hysterectomy for prolapse or other prolapse or
incontinence operations.3,6,7,10 Although increased
parity is a risk factor for prolapse, nulliparity does not
provide absolute protection against prolapse. In the
Women’s Health Initiative, almost one fifth of nulliparous women had some degree of prolapse.7 These
data should give pause to enthusiasts promoting cesarean delivery for all women to prevent prolapse.
Obesity is one of the few modifiable risk factors
identified so far.7,10 In the Women’s Health Initiative,
Table 1. Potential Risk Factors for Pelvic Organ Prolapse
Predispose
Incite
Genetic (congenital or hereditary)
Race: White ⬎ African-American
Gender: Female ⬎ Male
Pregnancy and delivery
Surgery such as hysterectomy
for prolapse
Myopathy
Neuropathy
Promote
Decompensate
Obesity
Smoking
Aging
Menopause
Pulmonary disease (chronic coughing)
Constipation (chronic straining)
Recreational or occupational activities
(frequent or heavy lifting)
Neuropathy
Myopathy
Debilitation
Medication
Adapted from Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am
1998;25:723–46. Copyright 1998, with permission from Elsevier.
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Weber and Richter
body mass index greater than 30 kg/m2 conferred a
40 –75% increased risk of prolapse.7
DIAGNOSTIC APPROACH
Symptoms
Symptoms are not specific to different compartments
of prolapse but may reflect the overall stage of
prolapse at its most advanced site.11 With descent of
the cervix into the vagina, women may find they can
no longer wear tampons. Women are usually not
aware of an actual protrusion while prolapse is above
the hymen, but they may have pelvic pressure or
heaviness. Although pelvic pain and low back pain
have classically been considered symptoms of prolapse, a recent study found pelvic pain was not
associated with prolapse, and women with more
advanced prolapse actually had less back pain than
women with mild prolapse.12
Women with prolapse often have urinary symptoms, although the mechanism responsible for these
symptoms can be markedly different. Some women
have stress incontinence symptoms due to urethral
incompetence, but many women, particularly those
with advanced anterior vaginal prolapse, are continent. In some women, this reflects normal urethral
sphincter competence despite lack of support. In
other cases, women with urethral incompetence are
continent only because the prolapse causes urethral
kinking and obstruction.13 This is called potential,
masked, latent, or occult stress incontinence because
women do not have symptoms of incontinence as
long as the prolapse is untreated. In one study,
urethral obstruction occurred in 58% of women with
grade 3 and 4 anterior vaginal prolapse, compared
with 4% in women with grade 1 and 2 prolapse.14 As
prolapse advances, women are less likely to have
stress incontinence and more likely to manually reduce prolapse to void. Women may have a remote
history of stress incontinence that resolved as the
prolapse became more advanced. Women with urethral obstruction commonly have voiding dysfunction, manifested by symptoms of urinary hesitancy,
frequency, or incomplete emptying.
Defecatory symptoms such as excessive straining,
incomplete rectal emptying, or the need for perineal
or vaginal pressure to accomplish defecation should
be sought in all women with prolapse. In addition, the
influence of prolapse on sexual functioning should be
addressed in women of all ages.15 Some women with
prolapse avoid vaginal intercourse out of concern or
embarrassment. Other women experience urinary or
fecal incontinence (or the fear of incontinence) that
interferes with sexual activity. Assessing sexual function is particularly important before and after surgery,
so that any potentially adverse effects can be recognized and addressed.16
Physical Examination
Physical examination focuses on the pelvic examination, beginning with a careful inspection of the vulva
and vagina to identify erosions, ulcerations, or other
lesions. Suspicious lesions should be biopsied immediately. Benign-appearing ulcers should be closely
observed and biopsied if they do not resolve with
treatment.
The extent of prolapse should be systematically
assessed. With advanced prolapse, determining the
extent of prolapse and its constituents (anterior and
posterior vagina; cervix or vaginal apex) is usually not
difficult. Paradoxically, with less advanced prolapse,
it can be more difficult to identify its components,
particularly by inspection alone. The use of vaginal
speculums (eg, the posterior blade of a Graves speculum) or retractors is very helpful in determining what
vaginal sites are affected by prolapse. An unidentified
vaginal bulge (Fig. 2) can be clearly identified as the
vaginal apex, once the anterior and posterior vagina
are retracted (Fig. 3). Similarly, anterior vaginal prolapse can be seen more clearly after retracting the
posterior vagina. At times, posterior vaginal prolapse
Fig. 2. Stage II prolapse. By inspection, it is not possible to
determine which components of the vagina (anterior, apical, posterior) are affected by prolapse. Reprinted from
Weber AM, Brubaker L, Schaffer J, Toglia MR. Office
urogynecology: practical pathways in obstetrics & gynecology. 1st ed. New York (NY): McGraw-Hill; 2004. Reproduced with permission of The McGraw-Hill Companies.
Weber and Richter
617
Fig. 3. Stage II prolapse of the vaginal apex (the same
patient as in Fig. 2). With retraction of the anterior and
posterior vagina, it is now clear that this prolapse affects the
vaginal apex, possibly with an enterocele. Reprinted from
Fig. 4. Diagrammatic representation of the pelvic organ
prolapse quantitation system for staging prolapse by physical examination findings, showing the 6 sites (points Aa
and Ba anteriorly, points Ap and Bp posteriorly, point C for
the cervix or apex, and point D for the cul-de-sac), genital
hiatus (gh), perineal body (pb), and total vaginal length (tvl)
used for pelvic organ prolapse quantitation. Modified from
Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO,
Klarskov P, et al. The standardization of terminology of
female pelvic organ prolapse and pelvic floor dysfunction.
Am J Obstet Gynecol 1996;175:10 –7. Copyright 1996,
with permission from Elsevier.
(rectocele) will be easily identified by vaginal examination. At other times, rectovaginal examination is
invaluable in distinguishing between posterior vaginal
prolapse alone, high apical prolapse (possible enterocele), or a combination of these.
Although many systems for staging prolapse have
been described, the standard is the system approved
by the International Continence Society, the Pelvic
Organ Prolapse Quantification system.17 This system
measures 9 locations on the vagina and vulva in
centimeters relative to the hymen. These 9 locations
are used to assign a stage (from 0 to IV) of prolapse at
its most advanced site (Fig. 4). The pelvic organ
prolapse quantification system is probably more detailed than necessary for clinical care, but clinicians
should be familiar with it because most studies now
use the Pelvic Organ Prolapse Quantification system
to report research results. Its 2 most important advantages over previous grading systems are 1) the standardized technique with quantitative measurements at
straining relative to a constant landmark, the hymen,
and 2) prolapse assessment at multiple vaginal sites
(not just the most advanced). In lieu of using the full
pelvic organ prolapse quantification system of 9 measurements, clinicians are encouraged to record at least
3 measurements: the most advanced extent of prolapse in centimeters relative to the hymen that affects
the anterior vagina, the cervix or vaginal apex, and
the posterior vagina.
The maximal extent of prolapse is demonstrated
with a standing straining examination when the bladder is empty.18 Standing examinations are not always
practical, and small differences may not be clinically
meaningful. However, if the initial examination does
not reproduce the patient’s symptoms or description
of her prolapse, a standing straining examination
should be performed. Assessing paravaginal or lateral
anterior vaginal support is not included in the pelvic
organ prolapse quantification system. Indeed,
whether examination can reliably differentiate specific defects of anterior vaginal support has been
questioned.19 Until the existence of specific defects is
confirmed and better systems of measurement developed, prolapse assessment relative to the hymen
seems to be the most reliable way to describe prolapse.
Pelvic muscle function should be assessed in all
women.20 After the bimanual examination while the
patient is in lithotomy position, the examiner can
palpate the pelvic muscles a few centimeters inside
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the hymen, along the pelvic sidewalls at the 4 and 8
o’clock positions. Baseline muscle tone and increased
tone with voluntary contraction should be assessed,
along with the strength, duration, and symmetry of
contraction. This serves as a baseline measure for
comparison with subsequent examinations. It also
identifies women who may benefit from focused
intervention to strengthen the pelvic muscles. If a
woman has no awareness of her pelvic muscles and
cannot perform a voluntary contraction, one would
expect little or no benefit from an unsupervised
program of pelvic muscle exercise. She will need to
be taught to locate and contract her pelvic muscles by
an experienced clinician, whether a physical therapist, nurse or nurse practitioner, or physician.
In addition, resting tone and voluntary contraction of the anal sphincters should be assessed during
rectovaginal examination. With normal resting tone
of the anal sphincters, the examiner will feel the ring
of muscle snugly around the examining finger; during
voluntary contraction, the ring of muscle should
tighten circumferentially. Abnormalities should be
noted, such as low resting tone (looseness of the ring
of muscle), weak or absent voluntary contraction, anal
sphincter defect (usually at the 12 o’clock position, as
a result of obstetric injury), hemorrhoids, or rectal
prolapse.
Testing
Bladder Testing
At a minimum, for all patients with prolapse, 3 pieces
of information should be obtained: 1) screening for
urinary tract infection; 2) postvoid residual urine
volume; and 3) presence or absence of bladder sensation (by voided volume with sensation of fullness,
by voiding diary, or by bladder filling). Although
there is no consensus on a postvoid residual cutoff
that is “normal” versus “abnormal,” less is better as an
indicator of efficient bladder emptying. Provided the
initial voided volume was more than 150 mL,
postvoid residual volume less than 100 mL indicates
acceptable bladder emptying. Postvoid residual volume over 100 mL indicates impaired bladder emptying, which may or may not be caused by prolapse.
Women with prolapse and urinary incontinence
should have stress testing performed with the prolapse reduced because this will mimic bladder and
urethral function when the prolapse is treated. Prolapse reduction with bladder testing has not been
standardized. Different techniques include using the
posterior blade of a speculum, ring forceps, pessary,
vaginal packing, or large cotton swabs. Regardless of
technique, avoid overcorrection of anterior vaginal
prolapse and ensure that the urethra is not obstructed
with prolapse reduction to avoid falsely negative
stress testing. In the setting of a positive reduction
stress test, we recommend that an incontinence procedure should be performed at the time of prolapse
surgery. However, little evidence is available from
controlled trials for patients with and those without
preoperative symptoms of stress incontinence combined with prolapse warranting surgery. We need to
counsel patients extensively about the risks and benefits of performing or withholding an incontinence
procedure in this clinical situation. When an incontinence procedure is added to prolapse repair, at worst,
the patient may receive overtreatment and risk voiding dysfunction. Conversely, when the incontinence
procedure is not performed at the same time as the
prolapse repair, the patient may need a second surgery to treat new (unmasked) or persistent stress
incontinence. With effective minimally invasive procedures that can be performed with local anesthesia,
this situation is less problematic than in the recent
past. The key is open communication with the patient
about her options and expected outcomes, so that she
can participate in making an informed decision.
Imaging
Imaging is not usually necessary in women with
prolapse unless the information obtained would be
critical in formulating recommendations for management. Imaging tests in women with prolapse, such as
magnetic resonance imaging21 and cystoproctography,22 are primarily for research at this point; they are
not recommended routinely for clinical care.
THERAPEUTIC APPROACH
Management for prolapse includes observation, pelvic floor rehabilitation, pessary use, and surgery.
Unfortunately, there is little evidence-based information with which to counsel our patients. There is a
dearth of rigorously conducted trials that compare
management approaches.23–25 In most cases, clinicians
must rely on their best judgment and the patient’s
preferences to select a management plan.
Indications for Treatment
Choice of treatment for prolapse usually depends on
symptom severity and severity of prolapse, in line
with the patient’s general health and activity. Importantly, the correlation between many pelvic symptoms and the extent of prolapse is weak.26,27 Symptoms associated with stage I or stage II prolapse
require careful evaluation, especially if surgery is
being considered.28 Many women with stress urinary
incontinence have stage I or II prolapse, although
stress incontinence is not a symptom of prolapse; it is
simply a coincident symptom. Factors that determine
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how clinicians make recommendations and how patients make decisions have not been well studied.
Patient and clinician goals of treatment may differ
considerably and lead to dissatisfaction if expectations
(that may be unrealistic) are not met. In symptomatic
women choosing treatment, patients were more likely
to choose surgery, compared with expectant management or pessary use, with more advanced prolapse,
with increasing age, and with prior prolapse surgery.28
Observation
Observation is appropriate for women whose symptoms are not sufficiently bothersome to warrant active
intervention. When first learning of prolapse, many
women require only information and reassurance that
treatment is available when and if they become
symptomatic. As outlined in the section “Diagnostic
Approach,” a careful evaluation will serve as a baseline with which subsequent examinations can be
compared. For an otherwise healthy woman, repeat
assessment can be conveniently performed at her
yearly health maintenance visit. The patient should
be instructed to call for an interval visit if she experiences any symptoms that concern her. She can be
counseled that acute changes rarely occur in the
setting of early prolapse. There is virtually no indication for treatment, particularly surgery, for women
with asymptomatic prolapse “before the problem gets
any worse.” The old adage “You can’t make an
asymptomatic patient better; you can only make her
worse” was never more true than it is for prolapse.
Occasionally, a patient will present with advanced prolapse, yet she will say that she is asymptomatic. Is observation still appropriate? An important consideration is her efficiency of bladder
emptying. If she has partial urinary retention, she is at
risk for persistent or recurrent urinary tract infections
and possibly urosepsis, depending on her overall
medical status. The exposed vaginal epithelium is at
risk for erosion, which rarely can become secondarily
infected and serve as a source for sepsis. Even more
rare is the risk of evisceration, an event of high
morbidity and mortality. After considering these risks
and discussing them with the patient (and family
members, as appropriate), if she still prefers observation, we recommend close follow-up, such as every 3
months, to reassess potential risks and the decision for
observation versus active management.
Nonsurgical Management
Nonsurgical management of prolapse includes adjunct therapy to address concomitant symptoms, pelvic floor muscle training, and pessaries. Ideally, nonsurgical management will decrease the frequency and
severity of symptoms, delay or avoid surgery, and
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potentially prevent worsening the prolapse. We recommend nonsurgical management if observation is
not (or is no longer) suitable, when surgery presents
higher-than-average risks, or in women who do not
want surgery. Pessaries may also be used before
prolapse surgery to estimate whether symptom relief
will be obtained with surgery. This strategy is particularly useful in patients whose symptoms do not
match their physical findings (such as severe symptoms with mild prolapse) or in patients with nonspecific symptoms, such as back pain, that are not
definitely caused by prolapse. We recommend discussing nonsurgical management with most, if not all,
women before surgery. In addition, some components of nonsurgical management can be effectively
added to surgery to maximize outcomes.
Adjunct Therapy
Adjunct therapy addresses symptoms of urinary, defecatory, and sexual dysfunction as appropriate to
each individual. As one example of a commonly
encountered clinical problem, patients will often
present with defecatory symptoms, such as excessive
straining at stool and a feeling of incomplete evacuation, and physical examination reveals stage II or
early stage III posterior vaginal prolapse (rectocele). It
is usually not possible to determine whether the
symptoms predated the physical findings, or vice
versa. In fact, from a clinical standpoint, it is probably
irrelevant. First and foremost, the patient’s symptoms
need to be addressed. The patient should have a
thorough evaluation from the gastrointestinal (GI)
perspective, either by referral or by the interested
obstetrician-gynecologist. Age-appropriate screening
for colorectal cancer should be obtained. Begin with a
focused diet history (including fiber and fluid intake),
exercise history, review of medications for GI adverse
effects, and bowel history, including frequency and
consistency of bowel movements. Physical examination should focus on anorectal examination, prolapse
staging (if present), and pelvic muscle assessment.
Provided no GI pathology is diagnosed, we recommend treatment to regulate her bowel habit and
prevent straining. Based on the patient’s history, she
should alter her fluid and fiber intake (to a total of
6 – 8 glasses of fluid and at least 20 grams of fiber per
day) and her exercise level. She should arrange a
regular schedule to allow time for defecation after
meals. Add osmotic (eg, polyethylene glycol) or cathartic laxatives (eg, bisacodyl), as necessary. In selected cases, use suppositories or enemas on a daily or
as-needed basis. For women who contract (instead of
relax) their pelvic muscles at attempted defecation,
consider adding biofeedback.29 If her symptoms are
relieved, we recommend no further treatment. MonOBSTETRICS & GYNECOLOGY
itor her posterior vaginal prolapse at regular intervals,
such as annually. However, if the patient experiences
no relief from her defecatory symptoms despite an
adequate trial (eg, the above changes for a month with
escalating doses of cathartic laxatives), we recommend a gastroenterology consultation.
If the patient is still bothered by protrusion of
prolapse after resolution of her defecatory symptoms,
we recommend that surgery be considered. The clinician and patient should clearly understand the goal
of surgery, ie, to reduce the bulge in the posterior
vagina. It is important to note that if this patient’s
condition was approached in the opposite order (rectocele surgery first, treatment of her defecatory symptoms later), it is likely that she would not have a
satisfactory outcome. Counsel the patient to resume
her individualized bowel regimen after surgery, including fiber and fluids, with adjustments as necessary
during recovery with its reduced activity level, possible dietary changes, and use of constipating medications. Advise the patient to use laxatives early to avoid
constipation and impaction. We recommend bisacodyl, 5-mg tablets, to be taken as soon after surgery as
liquids are tolerated, increased by 2 tablets each night
until a bowel movement occurs (usually the following
morning). Instruct the patient to repeat this process as
needed until her regular bowel habit is restored.
Adjunct therapy often includes advice on lifestyle
alterations, weight loss, and a general exercise program. Although data are lacking to support these
recommendations specifically for prolapse, many fit
into general guidelines for a healthy lifestyle.
Pelvic Floor Muscle Training
Pelvic floor muscle training is designed to increase the
strength and endurance of the pelvic muscles, thereby
improving support to the pelvic organs. Although no
direct evidence proves that pelvic floor muscle training prevents or treats prolapse, it is effective for
urinary and fecal incontinence and may be beneficial
for prolapse.30 In our experience, pelvic muscle
strengthening often relieves symptoms of pelvic pressure that commonly accompany prolapse. Although it
seems unlikely that advanced prolapse will resolve
with pelvic floor muscle training, women may still
experience a beneficial effect on their symptoms.
Therefore, we do not use any cutoff as to extent of
prolapse in recommending or not recommending
pelvic floor muscle training. With virtually no adverse
effects, its only negative is the cost of providing
instruction and follow-up for patients and the investment that patients must make, as in any exercise
program, for its potential success.
Most women recognize what “Kegel” exercises
are; some have performed them on their own. But few
women perform pelvic floor muscle exercises correctly or with the necessary intensity (frequency,
duration) to obtain maximum benefit. In our experience, having the patient work with an experienced
physical therapist or dedicated nurse practitioner
gives her the best chance of achieving benefit, usually
starting with a program of up to 2 visits per week for
8 –12 weeks, with ongoing maintenance exercises
after that. A detailed discussion of pelvic floor muscle
training is beyond the scope of this article, but it is
probably underused as a nonsurgical therapy for
prolapse, either alone or in combination with pessary
use and other adjunct therapies. Interested readers are
referred to recent review articles31–33 for more details.
Professional organizations (such as the American
Physical Therapy Association, www.apta.org, under
Women’s Health) can often assist in locating practitioners in your geographic area.
Pessaries
As for all types of nonsurgical management of prolapse, we recommend pessaries to decrease symptom
frequency and severity, delay or avoid surgery, and
potentially prevent worsening of prolapse. The most
important relative contraindication for pessary use
occurs when the patient cannot comply with followup. Particularly concerning is the setting of dementia
or other medical or social conditions that may result
in pessary neglect, with the resultant risk of the most
serious complications of pessaries, rectovaginal or
vesicovaginal fistulae. The clinician providing the
pessary must ensure that appropriate follow-up care is
provided, especially because the woman may transition from her own home to an assisted living or skilled
nursing facility.
Another relative contraindication to pessary use
is persistent vaginal erosions. Some women with
advanced prolapse will have extensive vaginal erosions at initial evaluation. If immediate surgery is not
planned, an attempt to heal the erosions will usually
require pessary use. Erosions with advanced prolapse
will almost always persist if the prolapse remains
unreduced, the vagina being unable to heal under the
continuous pressure of gravity and friction on the
woman’s underclothes. A different situation occurs
when a woman develops persistent vaginal erosions in
the setting of longstanding pessary use. This may
indicate that local estrogen should be added or increased, that a smaller pessary may now be necessary,
or, rarely, that a vaginal neoplasm has developed.
Pessary use must be discontinued occasionally for
persistent vaginal erosions.
Pessary use for prolapse is widespread in the
clinical practices of gynecologists34 and urogynecologists35 in the United States. The most commonly used
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pessaries are ring (with or without support), doughnut,
and Gellhorn pessaries, although there are many
other types (Fig. 5). Up to three quarters of women
with prolapse can be successfully fitted with a pessary.
Although many clinicians have biases about who can
and who cannot be fitted with pessaries, few characteristics have been identified consistently in research.
Unsuccessful fitting is associated with short vaginal
length (less than 7 cm) and wide introitus (4 fingerbreadths).36 However, this should not preclude fitting
attempts in women with those characteristics, because
some women can still be successfully fitted. After 2
months, 92% of women who were successfully fitted
were satisfied, with resolution of nearly all prolapse
symptoms.37 Urinary symptoms improved in about
half the women, but stress incontinence occurred as a
new symptom in about one fifth.37 Women who are
sexually active accept pessary use, with 60% continuing long-term use (up to 2.5 years).38
Pessaries can be separated into 2 broad categories: support and space-filling.39 The ring pessary
(with diaphragm) and other support pessaries are
commonly recommended for stage II and early stage
III prolapse, whereas the space-filling pessaries such
as the Gellhorn are usually used for more advanced
prolapse. Most pessaries are silicone, plastic, or medical grade rubber. Silicone has many advantages: it is
nonallergenic, does not absorb odors or secretions, is
resistant to repeat cleaning, and is pliable and soft.
Before using a pessary that contains rubber, be sure
that the patient does not have a latex allergy.
If some perineal support is preserved, a ring
pessary (without support when the cervix is present,
with support after hysterectomy) is a good first choice.
Many clinicians start with size 4 and then move to a
larger or smaller pessary, depending on fit. The ring
pessary is designed to sit with one end in the posterior
vaginal fornix and the other end behind the symphysis pubis (Fig. 6). A well-fitted pessary should fill the
vagina from side to side, with the clinician’s finger
able to easily pass between the pessary and the pelvic
sidewall. When the pessary is properly placed in the
upper vagina, the patient should be unaware of its
presence. The patient should be asked to stand and
move about to see if the pessary remains in place. If
the patient becomes aware of the pessary at the
introitus, the next larger size should be tried. If the
patient is aware of tightness, pressure, or any other
discomfort, fitting with the next smaller size pessary
should be attempted. It sometimes occurs that one
size is too large and the next smaller size fails to
adequately hold the prolapse in place. In that case, a
different type of pessary can be chosen. In some
women, such as those who have had previous vaginal
surgery, an oval pessary may fit when a ring does not.
Gellhorn pessaries are useful for women with
more advanced prolapse and less perineal support
because they sometimes stay in place when ring
pessaries do not. Gellhorn pessaries are sized based
Fig. 5. A variety of pessaries.
Fig. 6. Ring pessary without support in place; patient with
cervix and uterus. Note that the pessary rests at the level of
the bladder neck anteriorly and behind the cervix posteriorly. Reprinted from Weber AM, Brubaker L, Schaffer J,
Toglia MR. Office urogynecology: practical pathways in
obstetrics & gynecology. 1st ed. New York (NY): McGrawHill; 2004. Reproduced with permission of The McGrawHill Companies.
622
Weber and Richter
on the diameter of the disk. The stem and knob differ
only slightly in different brands of pessaries, some
with a string attached to the stem to aid in removal.
The Gellhorn is fitted so that the disk is centered in
the upper vagina and the stem points downward
behind the perineal body (Figure 7). As with the ring
pessary, when well fitted, the disk should fill the upper
vagina yet still allow the examiner’s finger to pass
easily between the disk and the pelvic sidewall. For
removal, it is necessary to insert an examining finger
behind the disk to break the suction between the disk
and the vagina, and then gently maneuver the disk
out. If removal is difficult in a Gellhorn without a
string, it is sometimes helpful to pull on the stem using
a tenaculum or ring forceps to help in bringing the
pessary closer to reach behind the disk to break the
suction.
When initiating pessary use, ideally the physician
can teach the patient to remove and replace the
pessary herself. This will put control of the pessary in
the patient’s hands, allowing her to use it as needed.
Ring pessaries are usually easy for patients to remove
and replace, especially for women who have used
diaphragms in the past. Gellhorn pessaries are more
challenging for patients to handle, but some women
will find it possible. The goal of changing the pessary
at frequent intervals is to prevent vaginal irritation
that leads to discharge, infection, and erosion.
Fig. 7. Gellhorn pessary in place; patient with cervix and
uterus. Note that the disk of the Gellhorn pessary rests at the
level of the bladder neck anteriorly, and behind the cervix
posteriorly (similar to the position of a ring pessary) and that
the knob rests behind the perineal body. Reprinted from
Women can remove the pessary at bedtime and
replace it in the morning. If daily changing is too
bothersome, a schedule of weekly or twice-weekly
removal can be used. In this setting, after an early
follow-up visit (such as 2– 4 weeks later) to assess
whether the pessary is adequately relieving the patient’s symptoms and to review pessary maintenance,
women can be returned to annual care unless new
symptoms develop in the meantime.
Some patients will not be able or willing to
manage pessary care themselves and thus require
more frequent office visits. After an early follow-up
visit to check the pessary’s effectiveness at relieving
symptoms, office care can be arranged, usually at
intervals of 3 months. At these visits, the pessary is
removed, rinsed, and replaced after carefully inspecting the vagina for irritation or erosions. Vaginal
discharge is commonly present, but unless the patient
expresses bother, treatment is not required. In some
practice settings, visits related to pessary maintenance
can be efficiently accomplished by a nurse practitioner, physician’s assistant, or other staff. The patient
should be counseled to call if vaginal odor, discharge,
or bleeding occurs because these symptoms warrant
investigation for infection or erosion.
Vaginal estrogen is commonly employed with
pessaries, although this should be individualized to
each patient. Some patients will have sufficient endogenous estrogen that atrophy does not occur and
pessary use does not cause irritation. Some women
use nonhormonal lubricants effectively with pessaries.
However, in women with vaginal atrophy at pessary
initiation, local estrogen is important to prevent vaginal erosions, even if women are already taking
systemic estrogen. Vaginal estrogen can be used in
any form: cream, tablets, or sustained-release ring
(Estring silicone ring with slow-release estradiol; Pharmacia & Upjohn, Kalamazoo, MI). It is particularly
convenient to use Estring in women with a Gellhorn
pessary; the Estring is placed behind the Gellhorn
and is changed during office visits at 3-month intervals.
Pessary use in some previously continent women
will reveal or unmask latent stress incontinence. In
selected cases, periurethral injection of bulking agents
(such as collagen) can be used to treat the stress
incontinence while pessary use is maintained for
prolapse treatment.40 However, in most situations,
pessary use will be discontinued and plans made to
proceed with surgery.
In some patients with long-term pessary use, it is
necessary to switch to smaller pessaries over time. A
recent study has provided evidence that supports
clinical observations of improved prolapse status with
pessary use in some patients. In 19 women with
Weber and Richter
623
pessary use for at least 1 year, no woman had worse
prolapse and 4 women (21.1%, 95% confidence interval 0.2– 43.7%) improved.41
Surgical Management
The primary aim of surgery is to relieve or improve
prolapse symptoms and, if possible, symptoms associated with the lower urinary and gastrointestinal
tracts. In some women, this means an attempt to
restore normal vaginal anatomy and maintain or
improve sexual function. In others, an obliterative
approach is more appropriate and still yields the
desired result of symptom relief.
Approach
Approaches to prolapse surgery include vaginal, abdominal, and laparoscopic routes or a combination of
approaches.42– 44 Depending on the extent and location of prolapse, surgery usually involves a combination of repairs addressing the anterior vagina, vaginal
apex, posterior vagina, and perineum; concomitant
surgery may be planned for the bladder neck or anal
sphincters. Procedures for posterior vaginal prolapse
most commonly use a transvaginal approach, or less
commonly, a transanal approach. Apical and anterior
vaginal prolapse can be approached by either vaginal
or abdominal routes. There is clear benefit when
comparing the vaginal approach with the abdominal
approach (ie, laparotomy), from the perspective of
complications and short-term effects on recovery. By
avoiding laparotomy, the vaginal approach results in
fewer wound complications, less postoperative pain,
shorter hospital stay, and less cost than abdominal
surgery.42,43 Whether prolapse repaired abdominally
is more effective or durable than vaginally repaired
prolapse is controversial; the evidence supporting
both sides of this argument will be reviewed in a later
section. Adding to the debate is the potential benefit
of the laparoscopic approach compared with the
abdominal or vaginal route for prolapse surgery.45 In
laparoscopic surgery for stress incontinence, the perceived cost advantage of reduced hospital time is
often offset and even exceeded by increased operative
time and expense of laparoscopic instruments.46
There are no comparable data for prolapse operations.
Surgical route is chosen based on the type and
severity of prolapse, the surgeon’s training and experience, the patient’s preference, and the expected or
desired surgical outcome. Procedures for prolapse can
be broadly categorized into 3 groups: 1) restorative,
which use the patient’s endogenous support structures; 2) compensatory, which attempt to replace
deficient support with some type of graft, including
synthetic, allogenic, xenogenic, or autologous materi624
Weber and Richter
als; and 3) obliterative, which close the vagina. These
groupings are somewhat arbitrary and not entirely
exclusive. Grafts may be used to reinforce repairs,
such as colporrhaphy, or to replace support that is
deficient or lacking. For example, graft use in abdominal sacral colpopexy substitutes for the connective
tissue attachments (DeLancey’s level I) that would
normally support the vaginal apex.47 In addition to
the primary goal of relieving symptoms related to
prolapse, urinary, defecatory, and sexual function
must be considered as well in choosing the appropriate prolapse procedures. The types of procedures will
be briefly reviewed. Detailed discussion of technique
is beyond the scope of this article and interested
readers are referred to surgical atlases, videos, and
textbooks.
Prolapse Procedures
Anterior Vaginal Repair
Recurrent anterior vaginal prolapse continues to be
the Achilles’ heel of reconstructive pelvic surgery.
Anterior vaginal prolapse has traditionally been repaired with anterior colporrhaphy, where the vaginal
epithelium is separated from the underlying fibromuscular connective tissue, followed by midline plication
of the vaginal muscularis with a series of interrupted
stitches, usually of absorbable suture, excision of
excess epithelium, and closure.48 Variations include
placing graft material on top of or instead of the
midline plication. The results of 2 randomized trials
suggest modest improvement in success, adding 12–
18% to the “cure” rates after 1 year, when polyglactin
mesh (Vicryl; Ethicon, Somerville, NJ) was placed
over the midline plication compared with standard
repair.49,50 Until there is evidence showing long-term
benefit from the use of graft material with anterior
colporrhaphy, we recommend the use of delayed
absorbable sutures such as Vicryl or No. 1 polydioxanone (PDS; Ethicon, Somerville, NJ), with midline
plication.
Richardson reintroduced the concept of paravaginal repair, which reattaches the anterior lateral vaginal sulcus to the obturator internus muscle and fascia
at the level of the arcus tendineus fascia pelvis (“white
line”), usually performed as a bilateral procedure, via
transvaginal or retropubic (abdominal or laparoscopic) access.51,52 With advanced anterior vaginal
prolapse, midline excision of redundant tissue may be
necessary in addition to paravaginal repair. The anterior vaginal apex can be supported by placing
stitches to the level of the ischial spine on each side,
although this procedure should not be used as the sole
treatment for vaginal vault prolapse. The long-term
effectiveness of paravaginal repair is unknown. Furthermore, performance of the vaginal paravaginal
repair requires specific expertise to perform correctly.
There are no randomized trials that compare outcomes after anterior colporrhaphy versus paravaginal
repair.
When prolapse repair is approached vaginally,
we recommend anterior colporrhaphy when indicated for anterior vaginal prolapse. If the surgeon has
the clinical experience and expertise and feels that
lateral detachment is causing the anterior vaginal
prolapse, a vaginal paravaginal repair is performed,
but robust apical vaginal support should also be
present or added with a specific apical suspension.
When abdominal sacral colpopexy for prolapse repair is planned, retropubic paravaginal repair can be
performed when the surgeon judges that support of
the anterior vagina would be insufficient without it. In
our experience, this happens infrequently. We recommend that retropubic paravaginal repair be added to
Burch colposuspension when necessary to provide
additional support to the mid-vagina (DeLancey level
II).47
Posterior Vaginal Repair
Traditional posterior colporrhaphy involves separation of the vaginal epithelium from the underlying
fibromuscular connective tissue (which includes the
rectovaginal septum, in between the vaginal muscularis and the rectovaginal adventitia), followed by
midline plication with interrupted stitches, excision of
excess epithelium, and closure.53 As with anterior
colporrhaphy, variations include placing graft material on top of or instead of the midline plication.
Other procedures can be combined with posterior
colporrhaphy, such as levator ani plication and perineorrhaphy, although the indications for these additions are controversial.
Dyspareunia after posterior repair has been
blamed on levator ani plication if a band or narrowing
is formed inside the vagina.54 Narrowing can also
occur with overzealous perineorrhaphy or combinations of procedures that alter normal vaginal contours.
For example, the vaginal configuration is altered by
the Burch procedure, where the upward displacement
of the anterior vaginal tube creates a transverse ridge
in the posterior vagina. A similar vaginal configuration may be created by other incontinence procedures
that elevate the anterior vagina. Dyspareunia is especially likely to occur when Burch is combined with
posterior repair, when the altered vaginal contour and
posterior transverse ridge is overlaid with the plication of the posterior repair. Despite careful attention
to ensure adequate introital caliber after posterior
repair, 38% of women after Burch and posterior
repair had persistent dyspareunia 1 year or more after
surgery.16
According to Richardson, isolated defects of the
rectovaginal “fascia” (layers that include the vaginal
muscularis, rectovaginal septum, and adventitia) occur in some women with posterior vaginal prolapse.55
The site-specific repair is approached by dissecting
the vaginal epithelium from the underlying layers to
expose the defect and close it with interrupted stitches
of usually absorbable suture, followed by closing the
vaginal epithelium. Initial retrospective56 and prospective57 uncontrolled case series reported shortterm results similar to or better than posterior colporrhaphy. However, with longer follow-up, one series
has reported recurrent prolapse after site-specific repair at higher rates than after traditional posterior
colporrhaphy.58 No randomized clinical trials exist
comparing these techniques.
We recommend reattachment of the rectovaginal
connective tissue to the perineal body in all repairs
when separation is identified. Until data demonstrate
superior or equivalent long-term outcomes with sitespecific defect repairs, we recommend traditional
posterior colporrhaphy, with careful attention to prevent narrowing of the vagina or introitus, when
indicated to relieve symptomatic posterior vaginal
prolapse. Lateral rectovaginal connective tissue is
plicated in the midline using a delayed absorbable
suture, such as Vicryl or PDS, taking care not to
create strictures in the vagina with initiation of the
plication too far laterally. A finger in the rectum helps
identify the integrity of the supportive layer formed
with plication.
In many cases, mild-to-moderate posterior vaginal prolapse is identified as one component of prolapse in women with more advanced apical or anterior prolapse. In those situations, clinicians and
patients must carefully weigh the risks (particularly of
dyspareunia) and benefits in deciding whether to
repair otherwise asymptomatic posterior vaginal prolapse. Although traditional teaching has held that all
“defects” should be repaired at one surgical setting,
this may be the exception, where the patient is better
served in avoiding or delaying surgery of the posterior
vagina until specific symptoms need to be addressed.
In this way, many women will avoid dyspareunia for
the few women who will ultimately require a separate
posterior repair.
Perineorrhaphy should be performed with any
repair where there is separation of the perineal muscles. This also facilitates the natural posterior deflection of the vagina in the pelvis. After dissection to free
the ends of the superficial perineal and bulbocavernosus muscles, they are reapproximated in the midline
without tension. Levator ani plication is associated
with postoperative dyspareunia, and we recommend
that this not be performed in sexually active women.
Weber and Richter
625
In non–sexually active women, levator ani plication
can be performed to reinforce the repair and intentionally narrow the mid and lower vagina; high
perineorrhaphy can be added to further close the
introitus.
Vaginal Apical Repair
Apical vaginal prolapse includes uterine prolapse
with or without enterocele and vaginal vault prolapse,
typically with enterocele. Some cases of uterine prolapse present with marked elongation of the cervix as
well. In other cases, despite what appears to be
normal uterine support, the elongated cervix protrudes to or past the hymen. This occurs particularly
when the uterus is restricted to the abdomen, as in
uterine enlargement greater than the equivalent of
12–14 weeks of gestation. The standard treatment for
symptomatic uterine prolapse is hysterectomy with
procedure(s) to suspend the vaginal apex, address
enterocele when indicated, repair coexisting anterior
and posterior vaginal prolapse, and perform antiincontinence procedures as needed. It is particularly
important to emphasize that, when hysterectomy is
performed for prolapse, hysterectomy alone (or hysterectomy with colporrhaphy) is inadequate; a specific vaginal vault suspension procedure must be
performed in addition to hysterectomy.
Enterocele Repair. Enterocele repair is usually
performed in the setting of concomitant procedures
for prolapse, in which case the approach is based on
the combination of procedures required. Whether by
vaginal, abdominal, or laparoscopic access, enterocele repair is traditionally performed by sharply dissecting the peritoneal sac from the rectum and bladder. A purse-string suture can be used to close the
peritoneum as high (cephalad) as possible. Whether
excision of the peritoneum itself is necessary has not
been determined. In addition to closing the enterocele sac, we recommend approximation of the anterior to the posterior fibromuscular connective tissue
of the vagina. Suspension of the vaginal apex is almost
always necessary, except in rare cases when the
enterocele occurs in the presence of adequate apical
support.
Sacrospinous Ligament Suspension. Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous
component of the coccygeus muscle.59 Initially described as a unilateral procedure, later series reported
bilateral fixation. Access is traditionally extraperitoneal via the posterior vagina, although variations have
been described using the anterior vagina or even
laparoscopic access. Although initial case series reported high success rates for correcting apical prolapse,60 subsequent reports described high rates of
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Weber and Richter
anterior vaginal prolapse, attributed to the exaggerated posterior deflection of the vaginal axis with
sacrospinous ligament fixation.61 However, whether
this is unique to sacrospinous ligament fixation or
simply represents the predilection of anterior support
to fail remains unknown. When a decision has been
made to perform this procedure, we recommend the
use of delayed absorbable suture material such as
PDS.
Iliococcygeal Vaginal Suspension. Iliococcygeal vaginal suspension involves attachment of the
vaginal apex to the iliococcygeus muscle and fascia,
usually bilaterally.62 The extraperitoneal dissection to
the area of the ischial spine is approached from a
midline posterior vaginal incision. Using the ischial
spine as the landmark for identifying the sacrospinous
ligament medially and posteriorly and the iliococcygeus fascia anteriorly and caudad, a No. 1 polydioxanone (PDS) suture is placed and attached to the
vaginal apex with a pulley stitch. We perform the
procedure bilaterally. Compared with other vaginal
suspension procedures, the iliococcygeal suspension
has the fewest case series in the literature,62– 65 but cure
rates appear comparable to the sacrospinous suspension technique.65 We consider the iliococcygeal approach to apical suspension mainly to avoid peritoneal entry or as a fall-back procedure when
uterosacral ligament suspension was planned but peritoneal entry is not feasible. In addition, iliococcygeal
suspension works well in the case of a foreshortened
vagina when a vaginal approach is planned.
Uterosacral Ligament Suspension. Originally
described by McCall in 1938,66 surgical variations of
the uterosacral ligament suspension can be used
prophylactically at hysterectomy or therapeutically
for vaginal apical suspension.67 Once access to the
posterior cul-de-sac has been attained, the uterosacral
ligament remnant can be found with the use of Allis
clamps placed at the posterior medial aspect of the
ischial spine. Up to 3 sutures are placed in each
ligament and incorporated into the anterior and posterior fibromuscular layer of the vagina as well as the
vaginal epithelium (Fig. 8).67 Some surgeons approximate the ligaments in the midline, as described by
McCall, to close the cul-de-sac with the intention of
treating or preventing enterocele formation. We recommend this in the presence of an unduly enlarged or
redundant cul-de-sac. However, we usually prefer to
suspend the right and left vaginal apex to the ipsilateral uterosacral ligament, leaving the cul-de-sac open
to avoid impinging on the rectum and adversely
affecting bowel function. If permanent sutures are
used, the knots should be tied to the peritoneal side of
the repair. Absorbable sutures can be tied in the
Fig. 8. A modification of the high
uterosacral vaginal suspension described by Shull, whereby single
monofilament permanent sutures
are placed through the residual
uterosacral remnants cephalad to
and at the same posterior level of
the ischial spines, then secured in
locking fashion to the paravaginal
connective tissue of the anterior
and posterior vaginal cuff. After
the beginning of closure from
each lateral angle, the suspension
suture is tied to “pulley” the vaginal apex to a more physiologic
position.
Weber. Pelvic Organ Prolapse.
Obstet Gynecol 2005.
vaginal lumen with the expectation that they will
dissolve over time.
Comparison of Vaginal Approaches to Apical Repair
In a review by Sze and Karram42 of vaginal surgeries
for apical prolapse, recurrent prolapse was reported
in 8 –18%, with variable follow-up in mostly retrospective case series. Until controlled trials are available, clinicians should counsel patients that the vaginal approaches to apical suspension are probably
similar in outcomes related to prolapse repair. In
choosing which procedure to recommend for individual patients, clinicians should consider their own
training and experience, as well as technical aspects
and risks of complications specific to each procedure.
Sacrospinous ligament suspension may leave the
anterior vagina at greater risk for subsequent failure,61
because of the pronounced posterior deviation of the
vaginal axis, although the risk of recurrent anterior
vaginal prolapse seems high regardless of which vaginal
suspension procedure is used. Because the procedure
is extraperitoneal, there should be little if any risk of
ureteral injury; rectal injury is a rare complication of
posterior dissection. Because sutures are passed
through the sacrospinous ligament, risks unique to
this procedure include pudendal or inferior gluteal
vessel injury with intraoperative hemorrhage, or sciatic or pudendal nerve injury, manifested as severe
buttocks pain (that may radiate down the back of the
thigh) postoperatively. The pain may resolve spontaneously when absorbable sutures are used, but suture
removal may be necessary for permanent sutures.
The sacrospinous ligament may be atrophied and less
surgically useful in patients of advanced age and
debility. In addition, sacrospinous ligament suspension may be more difficult to teach, a factor to
consider for those involved in resident education.
The iliococcygeal suspension is a straightforward
procedure to learn and teach. It carries virtually no
risk of ureteral or small bowel injury, and in contrast
to sacrospinous ligament fixation, there are no vital
structures nearby at risk for surgical injury. In addition, the iliococcygeus muscle and fascia are uniformly present regardless of patient age, prolapse
status, or general debility. Some surgeons are concerned that the iliococcygeal suspension leaves the
vagina shorter than other procedures, although this
has not been described in the literature. It is possible
that the iliococcygeal suspension has been underused
as a vaginal apical suspension procedure.
Uterosacral ligament suspension traditionally
requires peritoneal entry, which may be challenging in posthysterectomy prolapse, especially in the
setting of bowel adhesions, engendering the rare
occurrence of bowel injury. Bowel packing may
delay the return of bowel function in occasional
patients. Uterosacral ligament suspension carries a
risk of ureteral injury (usually kinking due to medial
displacement or suture ligation that impedes urinary
flow, rather than transection) as high as 11%.68 As
long as ureteral injury is recognized and addressed
intraoperatively, most patients will not incur morbidity. However, if ureteral injury is not identified at the
index surgery and recognition is delayed, a second
surgery is usually necessary and subsequent morbidWeber and Richter
627
ity can be severe, at worst irretrievable loss of kidney
function on the affected side. Cystoscopy should
always be performed after the uterosacral sutures are
tied to confirm ureteral patency. Some surgeons
question whether the uterosacral ligaments are appropriate sources of support in women with advanced
prolapse, although other surgeons maintain that the
ligaments can virtually always be identified as surgically
useful structures. No trials compare outcomes after
different procedures for vaginal apical suspension.
Abdominal Apical Repair
Abdominal Sacral Colpopexy. Abdominal sacral
colpopexy uses graft material attached to the anterior
and posterior vaginal apex and suspended to the
anterior longitudinal ligament of the sacrum for repair
of apical prolapse.69 Surgical variations are legion,
including graft configurations on the vagina, the extent to which the anterior and posterior vagina are
attached to the graft, different graft and suture materials, peritoneal closure over the graft, and obliteration of the cul-de-sac for treatment or prevention of
enterocele. In case series, cure rates range from 78%
to 100% for apical prolapse. When cure is defined as
no postoperative prolapse, the range widens, from
56% to 100%, although subsequent anterior or posterior vaginal prolapse has not been as consistently
reported as apical prolapse.70
We recommend the use of 2 permanent sutures in
the anterior sacral ligament. The peritoneum overlying the vaginal apex is removed and polypropylene
mesh, fashioned in a Y configuration, is affixed to the
vaginal apex posteriorly from the rectovaginal junction to the bladder reflection anteriorly. No overt
tension is placed on the vagina while attaching the
third arm of the mesh to the anterior sacral ligament.
We reperitonealize over the mesh. In the setting of a
deep cul-de-sac, we place Halban culdoplasty sutures
with No. 1 polydioxanone (PDS). We perform cystoscopy at the end of the procedure.
When abdominal sacral colpopexy is planned for
apical prolapse and concomitant high rectocele is
present, some advocate extending the graft down the
posterior vagina to address this.69 Cundiff et al71
described the technique of sacral colpoperineopexy
to reconstruct the normal vaginal suspensory ligaments and “fascial sheet” that runs from the sacrum to
the perineal body. Because mesh erosion occurred
frequently when the vagina was opened (16% for
vaginally placed sutures and 40% for vaginally placed
mesh72), we recommend avoiding opening the vagina
whenever possible.
Complications associated with to abdominal sacral colpopexy fall into 3 major categories: 1) intraoperative hemorrhage, 2) laparotomy, and 3) graft
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Weber and Richter
infection or erosion. Intraoperative hemorrhage that
occurs when lacerated sacral veins retract into the
sacrum can be difficult to control. The consequences
can be as severe as intraoperative death from exsanguination. Complications due to laparotomy are usually related to adhesions and small bowel obstruction.
Although the risk seems highest in the immediate
postoperative period, the risk is lifelong. Synthetic
graft material holds the highest risk of infection or
erosion, although these complications have been reported with all types of graft material. As with small
bowel obstruction, mesh erosion or infection has been
reported years after the index surgery. Although
mesh erosion can usually be successfully treated with
a relatively minor excision of the exposed mesh,
occasionally the entire graft must be removed, with
high levels of surgical morbidity.
Laparoscopic Approach to Apical Prolapse
Repair. Virtually all procedures for apical prolapse
repair have been approached by the laparoscopic
route, although it is sacral colpopexy that seems most
likely to offer patient benefit, provided effectiveness is
equivalent.73 The potential applicability of these procedures is limited by the relatively high level of
technical skill required for advanced laparoscopic
techniques.
Comparison of Abdominal and Vaginal Approaches
to Apical Repair
Few randomized trials compare abdominal and vaginal approaches for the treatment of apical prolapse
(Table 2).74 –77 Success rates appear to favor the abdominal approach to apical vaginal prolapse. Randomized trials are important to compare outcomes in
an unbiased rigorous fashion, but the data obtained
may not always be generalizable. In the Benson
study,74 the external validity is reduced because needle urethropexy is no longer regarded as effective
treatment for stress incontinence. In the trial by
Roovers et al76 the 2 treatment groups were unequal
as to the performance of hysterectomy. Again, use of
the needle suspension technique for subjects with
urinary incontinence predisposed to increased failure.
In the trial of Maher et al,77 the colposuspension for
stress incontinence in the sacrospinous group may
have protected the anterior vaginal compartment. In
addition, open colposuspension combined with a
vaginal approach for prolapse would be less generalizable today with the increased use of midurethral
sling procedures. Furthermore, history of previous
hysterectomy type was not equal between groups,
introducing bias, and the vaginal group had more loss
to follow-up.
Despite the shortcomings of uncontrolled series
and the few randomized trials, clinicians can be
Weber and Richter
629
82/95
Mean 22 months
vaginal, 24
months
abdominal
(range 6–60
months)
12 months
Mean 2.1 years,
(range 1–5.2
years)
118/138
82
Mean 2.5 years,
(range 1–5.5
years)
Follow-up
80/88
N
Subjective: 94% (43/46)
abdominal, 91% (39/
43) vaginal, P ⫽ .19;
satisfaction 85% (39/
46) abdominal, 81%
(35/43) vaginal, P ⫽
.78; objective: 76%
(35/46) abdominal,
69% (29/42) vaginal,
P ⫽ .46.
Scores on 3/6 domains
significantly higher in
abdominal group vs
vaginal group; no
difference PE
80.3% (53.66) vaginal
group; 94.2% (49/52)
abdominal group
(P ⫽ .029)
Physical 29% vaginal
group; 58% abdominal
group; satisfaction
33% vaginal group,
16% abdominal group
Success Rate
Objective: no prolapse
greater than or equal
to grade 2 at any
vaginal site;
subjective: no
symptoms of
prolapse, satisfaction
Based on Dutch UDI
scores 6 domains
Apex above levator
plate, no protrusion
beyond hymen
(standing physical
examination);
satisfaction
No protrusion vaginal
wall greater than
stage II
Criteria for Success
Rate
Reoperation in 9/41 patients
abdominal group. At one
year: 5% vaginal and
abdominal group stage II
vault prolapse; 39% vaginal
group, 36% abdominal
group min stage II
cystoceles; 15% vaginal
group, 5% abdominal group
at least stage II rectoceles.
Abdominal group increased
subsequent surgery
Cumulative anterior vaginal
wall and apex: 13% (6/46)
abdominal group, 45% (19/
42) vaginal group, P ⫽ .01;
cumulative posterior wall:
33% (15/46) abdominal, 19%
(8/42) vaginal, P ⫽ .22
Incontinence: 2 ASC, none
SSS
Majority failure in vaginal
group anterior compartment
Development Other
Prolapse/ Incontinence
Significant difference in
operating time,
P ⫽ .01; return to
activities of daily
living, P ⫽ .01
10.6% vs 7.7%, SSS vs
ASC, respectively,
requiring reoperation
(P ⫽ .75).
Dyspareunia: ASC 1;
SSS 7, apareunia:
ASC 0, SSS 4.
No significant
differences
No significant
differences; more
severe in abdominal
group
Complications
SSS, sacrospinous suspension; VPV, vaginal paravaginal repair; ASC, abdominal sacral colpopexy; APV, anterior paravaginal repair; TVH, total vaginal hysterectomy; US, uterosacral; UDI,
Urogenital Distress Inventory; A/P, anterior and posterior colporrhaphy; PE, physical examination.
Maher et al, 200477
ASC vs unilateral SSS;
women with stress
incontinence stratified
between groups: Burch
colposuspension
Roovers et al, 200476
(Only women with uterine
prolapse)
TVH, possible A/P repair, US
vaginal vault suspension,
possible needle
urethropexy versus
sacrocolpopexy, uterine
preservation, culdoplasty,
possible Burch
colposuspension
Benson et al, 199674
Bilateral SSS, VPV, versus,
ASC, APV Incontinence
procedure: Abdominal:
retropubic urethropexy
Vagina: needle urethropexy
Lo and Wang, 199875
ASC vs unilateral SSS (No
incontinence procedure)
Study
Table 2. Randomized Trials for the Management of Apical Vaginal Prolapse
guided by the literature and their own clinical experience in offering abdominal versus vaginal surgery to
patients with apical prolapse. It seems likely that
abdominal sacral colpopexy is more durable in providing apical support, but at the cost of increased
complications, both immediate and long term. Therefore, patients for abdominal sacral colpopexy should
be those most likely to benefit from its durability and
at lowest risk for complications or those most likely to
recover from complications that might occur. Age is
often used as an important determining factor; for
example, we usually recommend abdominal sacral
colpopexy to younger women with prolapse for 2
reasons. Younger women benefit more from durability, with the reduced chance they will need prolapse
surgery in the future. Younger women are also likely
to be more active and subject their prolapse repair to
greater stress than older women who may be more
sedentary. Women who develop prolapse requiring
surgery at a young age may be intrinsically at higher
risk for prolapse recurrence.78 Therefore, they may
have better outcomes with abdominal sacral colpopexy that provides extrinsic apical support through
synthetic graft material, compared with vaginal apical
repairs that rely on the patient’s own tissues for
support. (Vaginal colporrhaphies augmented with
grafts would not and should not be expected to have
any effect on apical support unless the graft is incorporated into the uterosacral ligaments. No data exist
regarding outcomes in this clinical situation.)
We do not use an upper age limit for recommending abdominal sacral colpopexy. For older
women who are medically healthy and physically
active, an abdominal approach to apical repair may
be appropriate with careful counseling. Chronological
age is not always the most important determinant of
benefit versus risk. Health status, ie, the presence of
comorbid conditions, is often a better predictor of risk
than age. A clinical dilemma often arises as a woman
with prolapse ages—when is the best time to intervene
surgically, if ever? Say a woman has chosen pessary
management for her prolapse and this has worked
well for her from ages 65 to 70. But now her cognitive
function is declining and she may not be able to
provide ongoing care for her pessary as she has in the
past. Or she has developed hypertension, and although it is well controlled currently, she worries that
her risk of surgery will increase with time. Perhaps her
prolapse is progressing despite pessary use, and only
a cube pessary effectively relieves her symptoms now.
It seems likely that there is a window of time, in
choosing between nonsurgical and surgical management of prolapse as a woman ages, that favors surgery. In cases such as these, we recommend vaginal
apical repairs or colpocleisis, when minimizing mor630
Weber and Richter
bidity, rather than enhancing durability, is the most
important goal.
These are not absolute indications for the different apical procedures and every woman’s management should be individualized, based in large part on
her own preferences once she has been informed of
the choices. Ideally, surgeons would be equally skilled
and experienced in both abdominal and vaginal
approaches to apical prolapse to provide care that is
truly individualized, rather than emphasizing one
approach to the exclusion of the other.
Colpocleisis
Reconstructive procedures may last several hours and
are associated with potentially higher blood loss and
increasing morbidity with longer anesthesia. For older
patients who do not desire vaginal function, colpocleisis may be an appropriate choice.79 Many variations
exist, from partial colpocleisis (where some portion of
the vaginal epithelium is left, providing drainage
tracts for cervical or other upper genital discharge) to
total colpectomy (where all the vaginal epithelium is
removed from the hymen posteriorly to within 0.5–
2.0 cm of the external urethral meatus anteriorly). If
hysterectomy is performed, blood loss is greater and
operative time is longer than procedures without
hysterectomy.80 The technique often includes a levator plication and high perineorrhaphy to reinforce
posterior support and reduce the genital hiatus, with
the goal of reducing the chance of recurrent prolapse.
Case series have reported success rates ranging from
91% to 100%, although the patient population, by its
nature of relatively short life expectancy and limited
activity level, is probably at low risk for recurrence.
We typically perform a partial LeForte-type colpocleisis with the use of delayed absorbable suture. This
leaves the potential for egress of blood associated with
the procedure and cervicovaginal secretions postoperatively. We recommend levator plication using
permanent sutures and high perineorrhaphy to further reinforce vaginal closure.
The prevention or treatment of stress incontinence in the context of colpocleisis is problematic.
Some surgeons treat stress incontinence with sling
procedures, although elderly patients are at high risk
for postoperative urinary retention requiring sling
takedown.81 Other surgeons minimize the risk of
retention by performing suburethral Kelly plication to
provide differential support to the urethra and then
treat persistent or recurrent postoperative stress incontinence with periurethral injection. The impact of
colpocleisis on bowel function is unknown, as well as
its overall impact on quality of life. The issue of regret
after colpocleisis has not been well studied.82 A cohort
study is currently underway through the Pelvic Floor
Disorders Network to collect data prospectively on
incontinence, other pelvic symptoms, and life impact
after colpocleisis.
Diagnosis and Treatment of Stress Incontinence
with Pelvic Organ Prolapse
In patients with stress incontinence symptoms confirmed by stress testing, it seems straightforward to
recommend anti-incontinence surgery in the setting
of prolapse repair. However, as discussed previously,
how to treat the finding of latent stress incontinence in
symptomatically continent women with prolapse is
less clear. Positive stress testing with prolapse reduction is not the equivalent of confirming stress incontinence in a symptomatic woman. The false positive
rate of such testing is unknown. Postoperative stress
incontinence develops in up to one quarter of previously stress-continent women who did not receive a
continence procedure with prolapse repair.82,83 However, concern has been raised that “prophylactic”
continence procedures in women with latent stress
incontinence may represent overtreatment and result
in new voiding dysfunction, including urgency, urge
incontinence, and urinary retention.84 Nevertheless,
some studies report that patients benefit when antiincontinence procedures are added to prolapse repair
to treat latent incontinence, with low rates of both
stress incontinence (8 –10% at one year) and new urge
incontinence (8 –16%).85– 87 Tension-free vaginal tape
procedure is more effective in preventing stress incontinence than suburethral plication.87
The Pelvic Floor Disorders Network is currently
conducting a randomized trial88 for symptomatically
stress-continent women with advanced prolapse who
are undergoing abdominal sacral colpopexy, with
randomization to the addition of Burch colposuspension versus no Burch. The objectives are to determine
whether a trade-off exists in reducing stress incontinence versus worsening voiding dysfunction, and
whether preoperative prolapse reduction testing accurately predicts who benefits from the Burch procedure. Enrollment in the trial was halted early (at
approximately 350 subjects) based on interim results
showing less stress incontinence in the Burch group,
with no significant difference in voiding dysfunction,
at 3 months after surgery. The data will be analyzed to
determine whether the results of prolapse reduction
testing (or any aspect of urodynamic testing, the
results of which were masked to the surgeons) predicted outcomes. Follow-up is planned for at least 2
years after surgery.
Adjunctive Materials
The use of adjunctive materials in prolapse surgery is
an attempt to improve outcomes obtained by using
the patient’s own tissue. Surgeons, frustrated by recurrent prolapse, actively seek means to reduce the risk
of recurrence, but in their enthusiasm, they may
misjudge the risk presented by new materials that
have not been well studied in the vaginal environment. Currently, the most common prolapse procedures using adjunctive materials are abdominal sacral
colpopexy and anterior and posterior vaginal repairs.
The ideal adjunctive material should be biocompatible yet inert, nonallergenic and noninflammatory,
noninfectious, resistant to mechanical stress or shrinkage, and conveniently available. Several reviews have
evaluated the various types of synthetic and biologic
materials used in prolapse surgery,89 –90 although their
widespread use has leapfrogged ahead of scientific
evidence of their safety and effectiveness.91 The impact of adjunctive materials on sexual function and
long-term outcomes is unknown. Different grafts have
different complication rates, depending on where and
how they are used. Unlike graft material used in
abdominal sacral colpopexy, typical graft use in vaginal repairs involves a much greater area of contact
between the graft and the vagina after the vaginal wall
has been split by surgical dissection. It is critically
important for surgeons to discuss the use of adjunctive
materials with their patients before surgery so patients
are well-informed of the unknown risks and benefits
and can participate in the decision to use such materials. It cannot be assumed that graft use is automatically the same or better than existing procedures.
The likelihood that outcomes will actually be worse
must be considered by the clinician and the patient
considering the use of graft materials. Until we have
evidence that graft materials are beneficial, we recommend that their use be restricted to subjects in research protocols. This will ensure that evidence supporting or refuting their use actually becomes
available over the next several years.
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Pelvic Organ Prolapse

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