Correlation between posterior vaginal wall defects assessed by clinical examination and by defecography

To estimate the accuracy of clinical examination and the indications for defecography in patients with primary posterior wall prolapse. Fifty-nine patients with primary pelvic organ prolapse were evaluated with a questionnaire, clinical examination and defecography. Defecography was used as reference standard. There was no relation between bowel complaints and posterior wall prolapse evaluated by clinical examination (p = 0.33), nor between bowel complaints and rectocele (p = 0.19) or enterocele (p = 0.99) assessed by defecography. The diagnostic accuracy of clinical examination in diagnosing rectocele was 0.42, sensitivity was 1.0 and specificity was 0.23. The diagnostic accuracy of clinical examination in diagnosing enterocele was 0.73, with a sensitivity of 0.07 and a specificity of 0.95. Clinical examination is not accurate to assess anatomic defects of the posterior vaginal wall. Defecography is recommended as a helpful diagnostic tool in the work-up of patients with posterior vaginal wall prolapse if surgical repair is considered.     

围手术期优质护理配合心理护理对子宫脱垂合并肠疝患者的效果观察

目的观察围手术期优质护理配合心理护理对子宫脱垂合并肠疝患者的应用效果。 方法选取2017年2月至2020年7月阜阳市妇女儿童医院收治的子宫脱垂合并肠疝患者60例作为研究对象,所有患者均接受阴式子宫切除术联合阴道前后壁修补术,随机分为2组,每组患者30例。对照组接受围手术期常规护理方案,观察组则在对照组的基础上接受围手术期优质护理配合心理护理方案。比较2组患者干预前后的子宫脱垂情况、与发病机制相关的氧化应激因子以及生活质量影响情况。 结果观察组优质护理干预后的子宫脱垂测量点表现优于对照组（P<0.05）;观察组干预后转化生长因子-β1、基质金属蛋白酶-2及基质金属蛋白酶组织抑制因子-2较对照组有改善（P<0.05）;观察组在干预后及出院3个月的生活质量评分优于对照组（P<0.05）。 结论给予子宫脱垂合并肠疝患者围手术期优质护理配合心理护理的应用具有显著的临床疗效,不仅有效改善患者的子宫脱垂情况及氧化应激水平,还可提高患者的生活质量。     

Laparoscopic hysteropexy in a patient with spina bifida and ventriculoperitoneal shunt

Laparoscopic repair of pelvic organ prolapse in patients with ventriculoperitoneal shunts has not been previously described. The optimum management of patients with ventriculoperitoneal shunts undergoing laparoscopy is uncertain. We describe the case of a 21-year-old female patient with spina bifida and ventriculoperitoneal shunt who underwent laparoscopic hysteropexy for severe pelvic organ prolapse. The implications of performing laparoscopy on patients with ventriculoperitoneal shunts are reviewed along with strategies to reduce potential intraoperative complications.     

超声评估盆腔器官脱垂的进展

超声可清晰显示盆底解剖结构、盆底重建术后网片位置及长度,且诊断重度盆腔器官脱垂与盆腔器官脱垂定量分度标准的一致性较好,可为评价盆底重建术的安全性及有效性提供影像学基础。本文对超声在盆腔器官脱垂诊断及盆底重建术术后疗效评价中的应用进展进行综述。     

Incontinence and voiding difficulties associated with prolapse

Purpose

Prolapse is the protrusion of a pelvic organ beyond its normal anatomical confines. It represents the failure of fibromuscular supports.

Materials and Methods

A MEDLINE search was done using the keywords cystocele, uterine prolapse, vault prolapse, enterocele or rectocele in combination with urinary incontinence. We reviewed 97 articles. From this material the definition, classification, incidence, symptoms and evaluation are described.

Results

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence. A large cystocele may cause urethral kinking and overflow incontinence. Uterine descent can cause lower back and sacral pain. Enterocele may cause only vague symptoms of vaginal discomfort. A rectocele can lead to incomplete evacuation of stool. A thorough history and physical examination are the most important means of assessment. A voiding diary helps determine functional bladder capacity. Uroflow examination determines the average and maximum flow rates, and the shape of the curve can help identify Valsalva augmented voiding. Multichannel urodynamics or videourodynamics with prolapse reduced can be important. The advantages of dynamic magnetic resonance imaging include excellent depiction of the soft tissues and pelvic organs, and their fluid content during various degrees of pelvic strain. To our knowledge whether it is cost-effective in this manner has not been determined.

Conclusions

Correction of prolapse must aim to restore vaginal function and any concomitant urinary incontinence.     

女性盆底器官脱垂伴尿失禁患者的尿动力学特征

目的 探讨女性盆底器官脱垂伴尿失禁患者膀胱储尿期和排尿期的尿动力学参数变化. 方法对182例女性尿失禁和盆底器官脱垂患者进行尿动力学检查,其中尿失禁140例,尿失禁伴盆底器官脱垂42例.在统一标准下行尿动力学检查测定膀胱灌注量、排尿量、膀胱顺应性、最大尿流率、最大尿流率逼尿肌压、最小尿流率逼尿肌压、尿道阻力因子(URA)、膀胱梗阻指数(OBI)以及归-化逼尿肌收缩力,评价女性尿失禁患者盆底器官脱垂对膀胱储尿功能和排尿功能的影响. 结果 尿失禁组与尿失禁伴盆底器官脱垂组患者尿失禁病程[(58.1±75.4)与(41.9±55.4)个月]、膀胱灌注量[(295.3±95.8)与(276.5±80.8)ml]、膀胱顺应性[(77.7±122.1)与(51.5±61.9)ml/cm H2O]、最大尿流率[(15.8±12.5)与(14.7±13.9)ml/s]、最小尿流率逼尿肌压[(3.2±5.8)与(2.8±5.5)ml/cm H2O]、归-化逼尿肌收缩力[(7.5±12.8)与(8.2±13.8)cm H2O]相比差异均无统计学意义(P>0.05);而年龄[(58.7±12.2)与(67.1±8.3)岁]、排尿量[(269.2±145.2)与(248.9±135.1)ml]、最大尿流率逼尿肌压[(20.4±16.2)与(25.7±21.3)cm H2O]、URA[(11.3±9.5与(14.8±12.6)cm H2O]、OBI[(15.6±14.5)与(21.7±20.1)cm H2O]2组相比差异有统计学意义(P<0.05).结论高龄女性尿失禁患者更可能伴有盆底器官脱垂,而盆底器官脱垂对膀胱储尿功能无影响,但可影响排尿期相关参数,增加膀胱出口阻力和膀胱残余尿量.     

Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Restoration of apical vaginal support remains a challenging problem for the pelvic reconstructive surgeon. The transvaginal use of the uterosacral-cardinal ligament complex is gaining increasing popularity in the surgical treatment of uterovaginal and posthysterectomy vault prolapse. We describe an extraperitoneal surgical approach using this ligamentous complex to reattach the vaginal apex in women with posthysterectomy vault prolapse and report our surgical experience with this procedure in 123 women over 5 years. The relevant anatomy related to the procedure and risk of ureteric injury with uterosacral suspension is also reviewed. Extraperitoneal vault suspension can be combined with the use of polypropylene mesh if required. The extraperitoneal approach is an alternative procedure in women with vault prolapse with or without concomitant enterocele or where access to the Pouch of Douglas is difficult particularly after previous pelvic surgery. We believe this procedure to have less risk of ureteral injury than the intraperitoneal approach.     

Relationship between Stress Urinary Incontinence and Pelvic Organ Prolapse

We investigated the objective coexisting rate of stress urinary incontinence and pelvic organ prolapse, and also compared the treatment outcomes in patients who had both conditions, treated by a corrective operation on the basis of a precise preoperative evaluation. We reviewed 97 cases who underwent urodynamic studies and evaluation of the prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system from among patients who were admitted for treatment of either stress urinary incontinence or pelvic organ prolapse. A Burch urethropexy, either alone or with a parvaginal repair, was done to correct the stress urinary incontinence, as well as additional operations to correct prolapse of stage II or more. The patients were evaluated postoperatively for the stress urinary incontinence and the degree of prolapse at every visit. Nineteen of 30 (63.3%) patients who were admitted with stress urinary incontinence had a coexisting pelvic organ prolapse, most often of the anterior wall. In 42 of 67 (62.7%) cases admitted with pelvic organ prolapse there was a coexisting stress urinary incontinence. A total of 61 patients who had both conditions were followed for 12 months postoperatively. The recurrence rate of stress urinary incontinence and prolapse (all of which were stage II) was 3.3% and 18.0%, respectively. It was noted that the greater the preoperative stage, the higher the recurrence rate (stage II 4.35%; stage III 25.0%; stage IV 33.6%). The coexisting rates of pelvic organ prolapse in patients having stress urinary incontinence, and stress urinary incontinence in patients having a pelvic organ prolapse, were both high. Therefore, when a preoperative evaluation that simultaneously considers both conditions and the correcting surgery is based on this evaluation, the recurrence rates of both conditions could be lowered.     

Symptomatic vaginal enterocele associated with malfunctioning ventriculoperitoneal shunt and cerebrospinal ascites

Abdominal pseudocyst formation is a rare adult complication associated with ventriculoperitoneal (VP) shunts. Presenting symptoms are primarily abdominal and include distention, pain and anorexia, and secondarily neurological with signs and symptoms of shunt malfunction. We describe a case of VP shunt-related pseudocyst formation presenting as symptomatic pelvic organ prolapse with stage 4 enterocele 4 years after VP shunt placement. The patient's vaginal enterocele enlarged and became more symptomatic as intra-abdominal cyst formation expanded. Symptomatic relief of pelvic floor symptomatology including resolution of exteriorized prolapse was established by conservative measures and eventual VP shunt revision and removal. VP shunt malfunction may present as symptomatic pelvic organ prolapse and may require shunt removal or revision for resolution of symptoms.     

Overt rectal prolapse following repair of stage IV vaginal vault prolapse

Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.     

Unusual site of graft erosion after abdominal sacrocervicopexy

Large fasciomuscular damage of the feminine pelvic floor resulting in pelvic organ prolapse constitutes a challenge for surgical reconstruction.Between 2005 and 2010, ten women aged 47–75 years were treated by abdominoperineal implantation of polypropylene mesh for modified sacral perineocolporectopexy and subsequently followed up. They were suffering from enterocele (9), genital prolapse (8), descending perineum (5), rectal prolapse (4), and rectocele (3). Five women were incontinent (mean Wexner 9) and six had incomplete rectal evacuation. Defecography revealed enterocele III? (5) and II? (4). Magnetic resonance (MR) diagnosed descending perineum in five patients (mean 3.8 cm).Permanent reconstruction of the pelvic floor and remission of organ prolapse was achieved at 12-months of follow-up in all except one patient. There were two small vaginal mesh erosions and one hematoma within the pelvic floor. Improvement at rectal emptying and anal incontinence (mean Wexner 4) were found.Modified sacral perineocolporectopexy is effective in the treatment of complex pelvic floor anatomical defects and organ prolapse. Improvements in rectal emptying, pelvic feeling of heaviness, and dyspareunia were achieved. The procedure was safe and characterized by good implant tolerance and a low rate of complications.     

超声评估盆腔脏器脱垂患者盆底结构的研究进展

目的盆腔器官脱垂(POP)显著影响女性生活质量。本文对比三维超声新技术与其他成像技术,对经二维、三维超声成像技术获取的信息及超声观察POP患者的盆底结构的研究进展进行综述。     

Enterocele manifesting as recurrent anterior rectal prolapse: A case report

Introduction and importanceAn enterocele is a true herniation of small bowel through the rectovaginal septum, most commonly occurring transvaginally. Although the prevalence of enterocele is not as low as previously thought, enteroceles manifesting transrectally or with rectal prolapse are exceedingly rare and without established surgical guidance.Case presentationA medically complex, oxygen-dependent patient presented with full fecal incontinence and transrectal enterocele associated with recurrent anterior rectal prolapse. This was diagnosed via defecography and repaired under regional anesthesia through an open transabdominal approach of posterior cul-de-sac obliteration, uterosacral ligament vaginal vault suspension and simplified ventral suture rectopexy. Surgical planning was determined through a multidisciplinary care-conference, with preference for an approach with minimal respiratory compromise and repair durability. Short-term, this patient has complete resolution of bulge symptoms, and improved fecal continence.Clinical discussionIn addition to history and examination, dynamic imaging of the pelvic floor, specifically defecography, is particularly useful in identifying enteroceles that present as a component of pelvic organ or anorectal prolapse. As there are no established standard surgical treatment approaches for these rare conditions, surgeons must consider several points prior to proceeding: the repair of the defect, the symptoms the repair targets, and repair durability.ConclusionsComplete assessment and specialist consultation should be pursued prior to surgical repair for anorectal pathology. For this patient, an open transabdominal native tissue repair under regional anesthesia was successful, emphasizing that approaches to surgical correction of such rare presentations must be individualized.     

Robotic-assisted pelvic organ prolapse surgery

Background This study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system. Methods During a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed. Results All but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45–280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results. Conclusion Our experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.     

Pelvic organ prolapse after uterine artery embolization for uterine myoma

Uterine artery embolization (UAE) is gaining popularity as a treatment modality in patients with symptomatic uterine fibroids who do not desire fertility. Complications of this procedure can be serious and disabling. A 50-year-old woman presented with stage II uterovaginal prolapse after UAE for symptomatic uterine fibroids. Pelvic organ prolapse developed 16 months after the initial procedure. Surgical correction was performed. This is the first case report of pelvic organ prolapse after UAE. Normal prior gynecological examinations, and absence of pelvic pressure symptoms, indicate that pelvic organ prolapse had occurred subsequent to UAE.     

Obstructed Defecation Caused by a Cystourethrocele and Mobile Posterior Vaginal Wall: A Case Report

Obstructed defecation may be caused by a rectocele and/or enterocele. Rectal wall procidentia may be due to an enterocele bulging into the rectum. Another cause of rectal procidentia resulting in obstructed defecation is presented. A 65-year-old woman complained of vaginal prolapse and incomplete bowel emptying. Pelvic examination revealed that a stage III anterior vaginal wall prolapse caused a mobile posterior vaginal wall to prolapse into the anal canal, resulting in rectal procidentia and subsequently in obstructed defecation. Careful assessment of all pelvic floor compartments is important to identify the cause of obstructed defecation, particularly in the absence of a rectocele.     

Pessary use in advanced pelvic organ prolapse

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patients discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.     

改良全盆底重建手术治疗女性盆腔器官脱垂35例疗效观察

目的评价改良盆底重建术治疗盆腔脏器脱垂的临床效果。方法盆腔脏器脱垂定量(POP-Q)分度为Ⅲ～Ⅳ度35例患者行改良盆底重建术,观察手术时间、术中出血量、住院时间等围手术期指标,以POP-Q分度为客观疗效评价指标,以临床症状消失为主观治愈指标。术后定期随访,观察疗效。结果手术平均时间(55士20.2)min、术中平均出血(100±40.2)ml,术后住院平均(4.5±1.5)d,术后随访3～18个月、中位随访时间6个月,客观治愈率94%(33/35),主观有效率91%(32/35)。术后仅1例发生网片侵蚀,3例发生排尿困难,2例发生性交痛,2例发生急迫性尿失禁。结论改良盆底重建术是治疗盆腔脏器脱垂的有效术式,保留子宫同时加强盆底组织,手术简单、安全、微创、经济,远期疗效有待进一步观察。     

Apical vault repair, the cornerstone or pelvic vault reconstruction

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.