Case of longitudinal vaginal septum with pelvic organ prolapse

Longitudinal vaginal septum is a rare mullerian anomaly and its association with pelvic organ prolapse (POP) is unusual. A case of longitudinal vaginal septum with stage IV POP in a 35-year-old multiparous woman is being reported. Examination revealed an incomplete longitudinal vaginal septum (9 × 6 × 2 cm) with stage IV POP. Vaginal hysterectomy with repair and reconstruction was done along with excision of the longitudinal vaginal septum which was technically challenging due to proximity to rectum. This is the only case report of stage IV pelvic organ prolapse associated with a thick longitudinal vaginal septum in a multiparous woman without any obstetric complications. Surgery required increased caution per operatively while dissecting the septum from the vaginal wall and the adjacent organs.     

Should Asymptomatic Anterior Pelvic Organ Prolapse Be Corrected to Treat Irritative Urinary Symptoms?

In clinical practice, women seen with pelvic organ prolapse (POP) often present with a variety of pelvic floor symptoms: urinary incontinence, irritative or overactive bladder symptoms, fecal urgency or incontinence, obstructive voiding, sexual disorders, pelvic and perineal pain, and vaginal bulging. Among these, the only symptom reliably associated with clinically relevant POP that will resolve following vaginal reconstructive surgery is the visualization and/or sensation of a vaginal bulge. Most other symptoms often attributed to POP at best have only weak correlations with worsening pelvic anatomical support. Specifically, with respect to the anterior and/or apical vaginal compartment, there does not appear to be a correlation between irritative overactive bladder symptoms and the presence or degree of anterior vaginal wall prolapse. Furthermore, no other symptoms, urinary or otherwise, are reliably influenced by correction of anatomical defects of pelvic support, especially in the otherwise asymptomatic patient with POP without vaginal bulge. A review of the recent literature underscores the realization that the relationship between pelvic floor symptoms and anatomy is incompletely and poorly understood. With this in mind, there does not seem to be any absolute justification for the surgical correction of otherwise asymptomatic pelvic support defects.     

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair

Introduction and hypothesis  This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP). Methods  This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh. Results  Mean postoperative value (±SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: −2.4 ± 1.1 (cm), −2.4 ± 0.9 (cm), and −7.7 ± 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05). Conclusions  Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.     

Prediction model and prognostic index to estimate clinically relevant pelvic organ prolapse in a general female population

Introduction and hypothesis  Estimation on prevalence and distribution of pelvic organ prolapse (POP) signs in a general female population is difficult. We therefore developed and validated a prediction model and prognostic instrument. Methods  Questionnaires were sent to a general female population (45–85 years). A random sample underwent vaginal examination for POP (POPQ). A prediction model was developed using multivariate analysis and validated in a subgroup of participants. Results  Positive questionnaire-response rate was 46.8% (1,397 of 2,979). From the questionnaire group, 649 women were vaginally examined (46.5%). Prevalence of clinically relevant POP was 21%. Multivariate analysis demonstrated significantly higher odds ratios on the report of vaginal bulging, parity ≥2 and a mother with POP. The receiver operating characteristic curve showed areas under the curve of 0.672 and 0.640. Conclusions  The prevalence of POP at or beyond the hymen could be estimated in a general female population using our prediction model with 17 questions and our POP score chart with eight questions.     

Urinary retention is uncommon after colpocleisis with concomitant mid-urethral sling

The purpose of this study was to evaluate the effect of colpocleisis and concomitant mid-urethral sling on voiding function. This is an IRB-approved, retrospective case series of women who underwent a colpocleisis with concomitant synthetic mid-urethral sling for treatment of stress urinary incontinence (SUI) between January 2005 and September 2007. Thirty-eight women with pelvic organ prolapse and SUI symptoms were included. Thirty percent had a post-void residual (PVR) greater than 100 ml preoperatively. PVRs were normal in all but two women after surgery. Median prolapse and urinary subscales of the pelvic floor distress inventory improved significantly after surgery [75 (50–100) vs. 0 (0–38), p < 0.0001 and 44 (8–100) vs. 0 (0–50), p < .0001, respectively]. Colpocleisis with concomitant mid-urethral sling improves urinary symptoms without causing significant urinary retention. This combination may be offered to elderly women with SUI who are undergoing colpocleisis regardless of preoperative PVR.     

Vaginal noise: prevalence, bother and risk factors in a general female population aged 45–85 years

Introduction and hypothesis  Vaginal noise (VN) is a symptom of pelvic floor (PF) dysfunction and has been described in a few studies. No other risk factors have been described besides parity and pelvic organ prolapse (POP). Underlying mechanisms of VN are unclear. Aims of this study were to describe prevalence, bother and relation between VN and PF (muscle)(dys)function. Methods  A cross-sectional study was performed on a general population of 2,921 women (aged 45–85 years). Questionnaires were filled in by 1,397 women, and 800 were selected at random to undergo vaginal examination for POP Quantification and PF muscle function assessment. Chi-square tests, Student's t test and multivariate logistic regression were performed (P < 0.05). Results  Response rate was 62.7%. Prevalence of VN was 12.8%; 72.1% reported only a little bother. Odds ratios for parity and solid stool were high. Conclusions  VN was strongly related to many symptoms of pelvic floor dysfunction, but it was only causing a little bother.     

Self-perceived natural history of pelvic organ prolapse described by women presenting for treatment

Introduction and hypothesis  This study aimed to describe the self-perceived natural history of pelvic organ prolapse (POP) in women seeking care. Methods  Women presenting to a university-based urogynecology clinic for POP (n = 107) completed a questionnaire including questions about how and when their prolapse was discovered. A urogynecologic examination including the pelvic organ prolapse quantification (POP-Q) was also performed. Results  Forty-eight percent of these women sought medical attention “immediately” after discovering a bulge. The median time to seek care was 4 months (range from 1 month to 45 years). Twenty-six percent associated their prolapse with a specific event (e.g., moving furniture or pushing a car). POP was self-discovered by 76% (81/107) of women. Self-discovered prolapses were larger than those diagnosed by physicians (Ba +1.3 vs 0.1 cm, P = .03, respectively). Conclusions  Women seek medical advice within months of discovering their prolapse. Self-discovery is associated with higher stage prolapse than prolapse diagnosed by health care providers.     

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6–12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.     

Transvaginal pelvic organ prolapse repair of anterior enterocele following cystectomy in females

This study aims to highlight pelvic organ prolapse (POP) in females following radical cystectomy and to describe our experiences with their management. This is a retrospective case series of five women who had symptomatic POP following radical cystectomy and ileal conduit urinary diversion. All patients presented with a midline anterior enterocele with atrophic ulcerated vaginal skin. One patient presented with small bowel evisceration and required an emergency surgical repair. The average time for presentation was 10.6 ± 6.5 months after cystectomy. In all cases, repair was done via a transvaginal approach. Three patients underwent fascial repair, one colpocleisis, and one bilateral iliococcygeal repair. In three cases, we had to use mesh for reinforcement. Two patients underwent ancillary procedures because of POP recurrence. Surgical repair of POP in women following radical cystectomy is challenging especially if vaginal length is to be maintained. Transvaginal repair is feasible and using synthetic mesh may be necessary.     

Biomechanical properties of vaginal tissue: preliminary results

The aim of this study is to characterise the biomechanical properties of vaginal tissue to develop an accurate cure of pelvic organ prolapse (POP). Prolapsed vaginal tissues were extracted during the prolapse cure of five patients (POP) and on five cadavers without noticed pelvic floor dysfunction (non-pelvic organ prolapse) with agreement of the ethics committee. Uni-axial tension was performed, and the results were analysed. Individual reproducibility of experimental results was good, and the results highlight the non-linear relationship between stress (force per unit of surface) and strain (l − l ₀ / l ₀) and very large deformation before rupture appearance. This experimental study has proven for the first time that the mechanical behaviour of vaginal tissue has to be defined as hyperelastic with a large deformation. This response has to be taken into account to develop accurate synthetic prostheses for POP cure and in the numerical simulation of the pelvic floor. The authors thank the Foundation for Medical Research for financing this study and the ethics committee for their approval.     

Comparative histological analysis of anterior vaginal wall in women with pelvic organ prolapse or control subjects. A pilot study

The purpose of this study was to compare smooth muscle content of anterior vaginal wall in women with pelvic organ prolapse (POP) and control subjects. Specimens were taken in the midline from the apex of anterior vaginal cuff from eleven women with POP and eight control subjects operated for hysterectomy without prolapse. Masson’s trichrome stain was used to determine the distribution of collagen in the extracellular matrix of the vaginal muscularis and to quantify the collagen in area of interest. Slides of alpha smooth muscle actin were detected using antibodies. Morphometric analysis was used to compare and to quantify the smooth muscle content of the vaginal muscularis. Fractional area of nonvascular vaginal smooth muscle of women with POP was significantly decreased in comparison to control subjects (41.9 vs 61.9%, p = 0.005). Fractional area of connective tissue was significantly increased (56.8 vs 35%, p = 0.004). Fractional area of blood vessels was similar (2.2 vs 3.4%, p = 0.20).     

Incidence rate and risk factors for vaginal vault prolapse repair after hysterectomy

Our objective was to estimate the incidence and identify the risk factors for vaginal vault prolapse repair after hysterectomy. We conducted a case control study among 6,214 women who underwent hysterectomy from 1982 to 2002. Cases (n = 32) were women who required vaginal vault suspension following the hysterectomy through December 2005. Controls (n = 236) were women, randomly selected from the same cohort, who did not require pelvic organ prolapse surgery. The incidence of vaginal vault prolapse repair was 0.36 per 1,000 women-years. The cumulative incidence was 0.5%. Risk factors included preoperative prolapse (odds ratio (OR) 6.6; 95% confidence interval (CI) 1.5–28.4) and sexual activity (OR 1.3; 95% CI 1.0–1.5). Vaginal hysterectomy was not a risk factor when preoperative prolapse was taken into account (OR 0.9; 95% CI 0.5–1.8).Vaginal vault prolapse repair after hysterectomy is an infrequent event and is due to preexisting weakness of pelvic tissues.     

A case of a large rectovaginal mass presenting as posterior vaginal wall prolapse

A 66-year-old female presented with symptoms suggestive of pelvic organ prolapse, history of fibroid uterus, and rectal pressure. Pelvic examination revealed a large pelvic mass filling the posterior cul-de-sac, occupying the rectovaginal septum, and compressing the rectum. There was a stage II pelvic organ prolapse of the posterior vaginal wall with distal vaginal wall extending to the hymen during valsalva. A CT scan confirmed the large pelvic mass distinct from the uterus measuring 9.4 × 9.8 × 6.2 cm. Colorectal workup revealed adenocarcinoma of colon on screening colonoscopy with biopsies. Patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, colon resection, and abdominal resection of the pelvic mass in the rectovaginal septum and inferior to the uterus. The patient did not require any concomitant pelvic reconstruction and the posterior vaginal wall prolapse resolved after resecting the pelvic mass.     

Complications from vaginally placed mesh in pelvic reconstructive surgery

Introduction and hypothesis  We describe complications associated with the use of transvaginal mesh for treatment of pelvic organ prolapse. Methods  We retrospectively identified patients referred to our institution from January 2003 through September 2007 who had complications after vaginal placement of mesh. Results  We identified 21 patients with a mean (SD) age of 61 (11) years. Types of mesh used included mesh kits (n = 9, 43%), nontrocar mesh augmentation (n = 5, 24%), IVS Tunneller (n = 4, 19%), and unspecified (n = 3, 14%). Eleven patients (52%) underwent more than one procedure before referral. Only three patients were referred by the original treating surgeon. Complications included mesh erosions in 12 women, dyspareunia in ten, and recurrent prolapse in nine. Sixteen patients (76%) were managed surgically. Follow-up survey among sexually active patients showed 50% with persistent dyspareunia. Conclusions  Use of vaginal mesh for pelvic reconstruction can produce complications. Multiple interventions may be necessary, and bothersome symptoms may persist. Presented at the 34th Scientific Meeting of the Society of Gynecologic Surgeons, Savannah, GA, USA, April 14–16, 2008 Mayo Clinic does not endorse the products mentioned in this article.     

Does COLIA1 SP1-binding site polymorphism predispose women to pelvic organ prolapse?

Introduction and hypothesis  COLIA1 polymorphism is associated with increased risk for stress urinary incontinence. We hypothesize that a similar association exists with pelvic organ prolapse (POP). Methods  Patients with advanced prolapse and healthy controls were evaluated by interview, validated questionnaires, and pelvic examination. DNA was extracted from peripheral blood, and polymerase chain reaction was performed to determine the presence or absence of the polymorphism. Power calculation indicated the need for 36 patients in each arm. Results  The prevalence of the polymorphic heterozygous genotype (GT) in the study and control groups was 33.3% and 19.4%, respectively, leading to an odds ratio of 1.75. This difference, however, did not reach statistical significance (p = 0.27). Conclusions  The COLIA1 polymorphism was not significantly associated with increased risk for POP.     

LOX family enzymes expression in vaginal tissue of premenopausal women with severe pelvic organ prolapse

Introduction and Hypothesis  

The extracellular matrix proteins collagen and elastin provide tissue strength and resilience, whereas lysyl oxidase enzymes play a major role in their stabilization. This study examines the expression and tissue localization of lysyl oxidase family proteins in the anterior vaginal wall of premenopausal women with advanced pelvic organ prolapse (POP, n = 15) and asymptomatic controls (n = 11). All women were in the proliferative phase of menstrual cycle.     

The development of pelvic organ prolapse after colposuspension: a prospective, long-term follow-up study on the prevalence and predisposing factors

The objectives of this prospective study were to determine the prevalence of pelvic organ prolapse (POP) after colposuspension and to investigate possible preoperative and operative risk factors. Seventy-seven women who underwent colposuspension between 1996 and 1997 were investigated. POP was assessed before colposuspension using the pelvic organ prolapse quantification system (POPQ). Women were reassessed at one and seven to eight years (or when referred with symptomatic POP). By seven to eight years, of the 77 women, 29 (38%) had developed symptomatic prolapse, 29 (38%) had asymptomatic prolapse, 7 (9%) had no symptoms and no prolapse, and 12 (15%) could not be assessed. POP at one year was significantly associated with the presence of posterior vaginal descent before colposuspension (odds ratio 3.07, 95% CI 1.10–8.60, p=0.03). No variable reached statistical significance by eight years postcolposuspension. In conclusion, this is the first study to assess POP prospectively using a validated method before and after colposuspension. The results add support to the view that there is an association between colposuspension and the development of symptomatic POP (requiring surgery).     

Biomechanical properties of prolapsed vaginal tissue in pre- and postmenopausal women

The aim of this study was to explore the relationship between biomechanical properties and the occurrence of pelvic organ prolapse (POP) through analysis on biomechanical properties of vaginal tissue. The biopsy specimens were obtained from 43 patients undergoing transvaginal hysterectomy, who were assigned into premenopausal POP, postmenopausal POP, premenopausal control and postmenopausal control groups. Tissue specimens were biomechanically assessed by a purpose-built tissue puller system, and stress–strain curves were digitally recorded. The Young’s modulus, Poisson’s ratio, maximum elongation, maximum fracture of vaginal tissue were 9.45 ± 0.70, 0.43 ± 0.01, 1.50 ± 0.02, 0.60 ± 0.02 in premenopausal POP group; 12.10 ± 1.10, 0.39 ± 0.01, 1.14 ± 0.05, 0.27 ± 0.03 in postmenopausal POP group; 6.65 ± 1.48, 0.46 ± 0.01, 1.68 ± 0.11, 0.79 ± 0.05 in premenopausal control group and 10.26 ± 1.10, 0.42 ± 0.01, 1.37 ± 0.04, 0.42 ± 0.03 in postmenopausal control group. There was significant difference in biomechanical properties between premenopausal POP group and premenopausal control group (p < 0.01). There was significant difference in biomechanical properties between postmenopausal POP group and postmenopausal control group (p < 0.01). Biomechanical properties in POP group were significantly lower than that in control group, suggesting that degeneration of biomechanical properties in pelvic support construction might lead to the occurrence of POP. Grant Fujian Science & Technology Bureau Foundation No. 2000I1003.     

Fibulin-5 expression is decreased in women with anterior vaginal wall prolapse

The aim of this study was to compare fibulin-5 expression in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in a standardized fashion from women with (n = 12) or without (n = 10) anterior vaginal wall prolapse. Quantitative real-time polymerase chain reaction was performed to measure mRNA levels of fibulin-5 (FIB-5). FIB-5 protein expression was assessed by immunohistochemistry. There were no significant differences in demographic data between the two groups. FIB-5 mRNA expression was significantly decreased in women with anterior vaginal wall prolapse compared to women without prolapse [(FIB-5 mean ± SD mRNA expression in relative units) 0.01 ± 0.01 vs. 0.09 ± 0.14, P = 0.04]. Fibulin-5 staining intensity was diminished in women with prolapse compared to women without prolapse [intensity score, median (range), 1 (1–2) vs. 3 (2–3), P = 0.04]. Fibulin-5 expression is decreased in vaginal biopsies from women with prolapse. Changes in fibulin expression may play a role in the development of pelvic organ prolapse.