Correlation of symptoms with location and severity of pelvic organ prolapse

OBJECTIVE: The purpose of this study was to compare the symptoms that are related to pelvic floor dysfunction with the location and severity of the coexisting prolapse. STUDY DESIGN: Two hundred thirty-seven consecutive patients with symptomatic pelvic organ prolapse came to Johns Hopkins Medicine during a 24-month period beginning in July 1998 and completed a symptom-specific Likert scale questionnaire that included standardized questions that were compiled from commonly used validated instruments. All questionnaires were completed by the patients before they were seen by a physician. Further evaluation included a standardized physical examination that included the International Continence Society's system for grading uterovaginal prolapse. Symptoms were categorized according to both severity and associated anatomic compartment. Symptoms that were related to urinary and anal incontinence and voiding, defecatory, sexual, and pelvic floor dysfunction were analyzed with respect to location and severity of pelvic organ prolapse with the use of the nonparametric correlation coefficient, Kendall's tau-b. RESULTS: The mean age of the women was 57.2 years (range, 23-93 years); 109 of the women (46%) had undergone hysterectomy. Overall, stage II was the most common pelvic organ prolapse (51%) that was encountered. In 77 patients (33%), anterior compartment pelvic organ prolapse predominated; 46 patients (19%) demonstrated posterior compartment prolapse, whereas 26 patients (11%) had apical prolapse. In 88 patients (37%), no single location was more severe than another. Voiding dysfunction that was characterized by urinary hesitancy, prolonged or intermittent flow, and a need to change position was associated with the increasing severity of anterior and apical pelvic organ prolapse. Pelvic pressure and discomfort along with visualization of prolapse were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Defecatory dysfunction characterized by incomplete evacuation and digital manipulation was associated with worsening posterior compartment pelvic organ prolapse. Impairment of sexual relations and duration of abstinence were strongly associated with worsening pelvic organ prolapse. An inverse correlation was observed between increasing severity of pelvic organ prolapse and urinary incontinence and enuresis. CONCLUSION: Women with pelvic organ prolapse experience symptoms that do not necessarily correlate with compartment-specific defects. Increasing severity of pelvic organ prolapse is weakly to moderately associated with several specific symptoms that are related to urinary incontinence and voiding, defecatory, and sexual dysfunction.     

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse

OBJECTIVE: To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure. METHODS: All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months. RESULTS: Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71-12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction. CONCLUSION: A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3.     

Prolapse severity, symptoms and impact on quality of life among women planning sacrocolpopexy.

OBJECTIVES: To explore the relationship between severity of pelvic organ prolapse (POP), symptoms of pelvic dysfunction and quality of life using validated measures. METHOD: Baseline data from 314 participants in the Colpopexy And Urinary Reduction Efforts (CARE) trial were analyzed. Pelvic symptoms and impact were assessed using the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). PFDI and PFIQ scores were compared by prolapse stage and history of incontinence or POP surgery. Regression analyses were performed to identify other predictors of symptoms and impact. RESULTS: Women were predominantly (90%) Caucasian and had mean age of 61 years. Women with stage II POP, especially those with prior surgery, reported more symptoms and impact than women with more advanced POP. There were no other significant predictors of symptoms or life impact. CONCLUSIONS: Women planning sacrocolpopexy with stage II prolapse and prior pelvic surgery reported more symptoms and quality of life impact than those with more advanced prolapse.     

Correlation of severity of pelvic organ prolapse with lower urinary tract symptoms

ObjectiveRelationships between pelvic organ prolapse (POP) staging and lower urinary tract symptoms (LUTS) are controversial. In this study, we evaluated correlations of POP staging with LUTS in different compartments.Materials and methodsFrom January 2016 to December 2017, 250 consecutive patients with urogynecologic complaints who were referred to our urodynamic unit were recruited into this study. Different stages of different compartments (anterior, central and posterior) of POPs according to IUGA and ICS terminology were re-grouped into four categories as stage 0, 1, 2, and 3 (including stage 4 because of a limited number of patients in stage 4). Pearson correlation coefficient and general linear regression were used for correlations of POP staging in different compartments and LUTS (stress urinary incontinence, overactive bladder and voiding symptoms) as well as their associated factors.ResultsOnly OAB had a moderate correlation with different compartments of POP (anterior vaginal wall: ?0.3116; cervix: ?0.2954 and posterior vaginal wall: ?0.3779; all p < 0.05). Stage 1 AVWP significantly increased (39.6%) the occurrence of OAB compared to no prolapse. Posterior compartment (stage 1–3) prolapse reduced the occurrence of OAB.ConclusionOnly stage 1 AVWP is associated with an increase in OAB, and posterior compartment prolapse may reduce the occurrence of OAB.     

盆腔脏器脱垂患者阴道封闭术后生活质量调查分析

目的:评价阴道封闭手术对盆腔脏器脱垂患者生活质量的影响。方法:2003年3月至2009年5月北京大学人民医院妇产科为27例POP-Q分期Ⅱ～Ⅳ期的盆腔脏器脱垂患者实施了阴道封闭手术。患者填写术前及术后生活质量调查问卷。术后定期复查,判定主客观复发情况。结果:可进行生活质量评价的阴道封闭手术患者27例,均为联合盆腔缺陷。随访时间7～79个月,平均35.5个月,主观满意率96.3%,客观治愈率100%。术前及术后生活质量自评分有显著统计学差异(χ2=60,P<0.01)。术后患者性功能完全丧失,1例患者随访79个月,仍有下腹部及会阴部坠胀感。结论:老年女性特别是有合并症不能耐受较大手术的患者阴道封闭术疗效肯定,可显著改善患者术后生活质量,但术后患者完全失去性功能,且部分患者术后有下腹部及会阴部坠胀感,应引起重视。     

Combined tension-free vaginal tape and prolapse repair under local anaesthesia in patients with symptoms of both urinary incontinence and prolapse

OBJECTIVE: To study the combination of tension-free vaginal tape (TVT) and prolapse repair under local anaesthesia in patients suffering from stress incontinence and prolapse. STUDY DESIGN: The study was designed as a prospective, open, nonrandomized study. A standardized protocol was used for pre- and postoperative evaluation. Check-ups were performed after 2, 6, 12 and 24 months. The protocol included medical history, stress test (supine and standing position with a comfortably filled bladder), life quality assessment including a visual analogue scale, 24- to 48-hour pad test, and 48-hour micturition diary. PATIENTS: In total 32 patients participated. All suffered from urinary stress incontinence (grade 1-3) and prolapse (grade 1-3). 2 patients had previously undergone surgery 2 and 3 times, respectively, for urinary incontinence with methods other than TVT (traditional anti-incontinence surgery). 3 patients had a history of total hysterectomy. 1 patient had a large rectocele with urinary and faecal incontinence. Mean age was 54 (range 31-74) years, mean parity 2 (range 0-5), and mean duration of incontinence 13 (range 2-29) years. SURGICAL TECHNIQUE: TVT was carried out according to the standardized technique as originally described. The prolapse repair included anterior and/or posterior colporrhaphy. All operations could be performed under local anaesthesia. RESULTS: 30 of 32 patients (93%) were cured. One patient (3%) was considerably improved, and 1 patient (3%) was considered a failure. Mean urinary leakage in 24 h was 96 (range 12-355) g preoperatively, and postoperatively 2.7 (range 0-28) g. Mean intraoperative bleeding was 75 (range 25-300) ml. Mean residual urine preoperatively was 15 (range 0-85) ml, and postoperatively 7 (range 0-40) ml. The mean stay in hospital after surgery was 2 (range 1-5) days. No postoperative urinary retention, no defective healing, and no tape rejection occurred. There was one uneventful bladder perforation in a patient who had previously undergone traditional incontinence surgery. This patient left the hospital the day after surgery without postoperative catheterization. CONCLUSION: The study clearly demonstrates that TVT can be combined with prolapse surgery to effectively treat symptoms of prolapse and urinary stress incontinence.     

The use of pessaries in vaginal prolapse

Pessaries are frequently used in cases of vaginal prolapse. Many different type of pessaries have been used in the past and are still in use today. In general it is considered to be a safe and simple form of therapy but little is known on the success rate, the indications and the optimal management. We give an overview of the history, type, indications and complications of pessaries, and give guidelines for daily practice.     

Utero-vaginal prolapse due to portio vaginal fibroma

Utero-vaginal prolapse can be caused by traction on to the cervix by heavy myoma. Here we present a unique case of huge, compressed, pedunculated fibromyoma of the cervix, which led to cervical elongation and third-degree utero-vaginal prolapse.     

Anterior vaginal wall culdeplasty at vaginal hysterectomy to prevent posthysterectomy anterior vaginal wall prolapse

OBJECTIVE: The purpose of our study was to evaluate a surgical technique we have developed that, when used at vaginal hysterectomy, helps prevent posthysterectomy anterior vaginal segment (wall) prolapse. STUDY DESIGN: This modified surgical procedure was used in 966 consecutive vaginal hysterectomies performed from January 1989 through December 1994. Patients returned at 1, 3, and 12 months and annually thereafter for follow-up. The longest follow-up period to date is 5.5 years. RESULTS: Of the 925 patients in our study followed up for ≥1 year, 908 (98.1%) retained excellent anterior vaginal support. Symptomatic anterior vaginal segment prolapse occurred in 12 patients (1.3%), and asymptomatic prolapse, with the anterior vaginal wall descending less than halfway from the ischial spines to the hymen, occurred in 5 (0.5%). None of the 42 patients followed up for <1 year has had evidence of prolapse. CONCLUSION: This procedure is an acceptable method to help prevent posthysterectomy anterior vaginal segment prolapse. (Am J Obstet Gynecol 1996;174:1863-72.)     

The surgical management of vaginal vault prolapse.

OBJECTIVE--A review of the results of surgery for vaginal vault prolapse following hysterectomy. DESIGN--A retrospective review of all patients treated surgically for vaginal vault prolapse between 1981 and 1990 in one hospital. SETTING--St George's Hospital, London. SUBJECTS--28 women. INTERVENTIONS--The 28 patients underwent 33 operations, either a colposacropexy (23 procedures) or a Zacharin procedure (10 procedures). Of the 28 women 25 were seen in the gynaecological clinic within the last year. MAIN OUTCOME MEASURES--Pre- and post-operative data and any interim prolapse surgery was recorded. Success of the procedure in terms of cure, urinary complications, infection and sexual function. RESULTS--The mean follow-up time was 17.1 months for the colposacropexy and 33 months for the Zacharin. The cure rate for colposacropexy was 91% and that for the Zacharin procedure was 70%. The two commonest complications were development of a voiding difficulty and infection. Three women developed voiding difficulty following the Zacharin and one following colposacropexy. Two women following colposacropexy required removal of the Mersilene mesh due to a persistent discharging sinus. CONCLUSION--The colposacropexy had a better success rate and, as it is a simpler operation to perform, has become the operation of choice in this unit. It is, however, associated with a risk of infection which can necessitate removal of the supporting mesh.     

The effect of prolapse surgery on vaginal sensibility

IntroductionProlapse surgery has been shown to have major impact on sexual function. Since prolapse surgery not only influences psychological factors but might also influence physiological conditions such as vaginal innervation, there is a need for objective outcome measurements to better understand the effects of prolapse surgery on sexual function.AimsTo assess the effects of prolapse surgery with or without stress incontinence surgery on vaginal sensibility and to assess the relationship between vaginal wall sensibility and sexual well‐being.MethodsThis study was performed parallel to a randomized controlled trial comparing vaginal and abdominal prolapse surgery with or without incontinence surgery in women with uterine prolapse stage 2 or more.Main Outcome MeasuresVaginal wall sensibility was defined as mean sensation threshold to electrical stimulation of the vaginal wall at four standardized places, measured before and 6 months after surgery. Higher sensation thresholds postsurgery relative to presurgery indicate diminished vaginal wall sensibility. Sexual function was assessed at the same time points using a questionnaire.ResultsData on vaginal wall sensibility were obtained from 65 patients. The sensibility of the distal posterior (P = 0.02) and distal anterior (P = 0.10) vaginal wall decreased after vaginal surgery compared to abdominal surgery. Abdominal prolapse surgery with incontinence surgery decreased sensibility of the distal part of the anterior vaginal wall significantly more than abdominal prolapse surgery only (P = 0.01). Before surgery, vaginal wall sensibility was lower in women who reported vaginal dryness or anorgasmia. The presence of genital pain was associated with higher vaginal wall sensibility. Postoperative vaginal wall sensibility was similar in women with and without sexual problems.ConclusionVaginal prolapse surgery as well as abdominal prolapse surgery with additional incontinence surgery resulted in decreased vaginal wall sensibility. This pilot study shows no influence of the decreased vaginal wall sensibility on sexual well‐being. Larger studies are needed to better understand the association between changes in vaginal wall sensibility and changes in sexual well‐being. Lakeman MME, van der Vaart CH, Laan E, and Roovers J‐PWR. The effect of prolapse surgery on vaginal sensibility..     

Endoscopic suspension of vaginal prolapse

A new alternative for the surgical treatment of vaginal prolapse is presented in which the prolapse vagina is brought towards the abdominal wall using an extraperitoneal abdomino perineal approach with endoscopic control. The technique consists of a small suprapubic transverse incision to expose the abdominis rectus muscle aponeurosis. A Stamey needle is passed retropubically to the vagina and the extremity of a helicoidal suture previously made in the vaginal wall is introduced in the eye of the needle. It is then withdrawn to bring the thread to the suprapubic region. The maneuver is repeated on the other side and the threads are tied up over the aponeurosis of the rectus abdominis muscles, bringing the vagina to its original position. Endoscopic control is important to avoid bladder perforation.