Living with pelvic organ prolapse: voices of women from Amhara region,Ethiopia

Introduction

The objective of the study was to explore how women with symptomatic pelvic organ prolapse in a low-income setting explain, experience, and handle the potential practical and social consequences of the condition.

Methods

An explorative qualitative design was employed using in-depth interviews in the data collection. A total of 24 women with different degrees of symptomatic pelvic organ prolapse were included; 18 were recruited at the hospital and 6 from the community. Fieldwork was carried out in the Amhara region of northwest Ethiopia in 2011 and 2015.

Results

The informants held that the pelvic organ prolapse was caused by physical strain on their body, such as childbirth, food scarcity or hard physical work, particularly during pregnancy and shortly after delivery. Severe difficulties and pain while carrying out daily chores were common among the women. The informants used a variety of strategies to manage their work while striving to avoid disclosure of their condition. Disclosure was related to embarrassment and fear of discrimination from people living close to them, including the fear of being expelled from the household. Most of the informants, however, experienced substantial support from relatives, friends, and at times also from their husband, after disclosing their condition.

Conclusions

The study highlights how symptomatic pelvic organ prolapse may severely affect women’s lives in a low-income setting. The condition is perceived to be both caused by and aggravated by the heavy physical burdens of daily work.

     

Mental health screening in women with severe pelvic organ prolapse,chronic fourth-degree obstetric tear and genital tract fistula in western Uganda

Introduction and hypothesis

High levels of mental health dysfunction have been identified in women with genital tract fistula. The aim of this study was to use the General Health Questionnaire-28 (GHQ-28) to screen women in western Uganda with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula for risk of mental health dysfunction.

Methods

Women undergoing surgery for severe pelvic organ prolapse, chronic fourth-degree obstetric tear, and genital tract fistula were interviewed using the GHQ-28 to screen for the risk of mental health dysfunction.

Results

A total of 125 women completed the GHQ-28, including 22 with pelvic organ prolapse, 47 with fourth-degree obstetric tear, 21 with genital tract fistula, and 35 controls. Nearly all women with these serious gynaecological conditions were positive for the risk of mental health dysfunction. In the domain assessing symptoms of severe depression, women with fourth-degree obstetric tear and genital tract fistula scored higher than women with pelvic organ prolapse.

Conclusions

A significant risk of mental health dysfunction was identified in women with severe pelvic organ prolapse and chronic fourth-degree obstetric tear. These rates are similar to the high rates of mental health dysfunction in women with genital tract fistula. Identification and management of mental health dysfunction in women with these conditions should be a priority.

     

Transvaginal mesh: a historical review and update of the current state of affairs in the United States

Introduction

Transvaginal mesh usage has been at the forefront of popular media and academic debate for the past 10 years. Several US Food and Drug Administration (FDA) communications, society statements, and research articles have been written in an attempt to define and articulate the classification system, safety data, and efficacy of this approach to transvaginal surgery. In this review, we explore the history of transvaginal mesh surgery for pelvic organ prolapse (POP), review FDA and society statements, and research current practice in the United States.

Methods

We searched the English language literature using PubMed for articles related to safety and monitoring of transvaginal mesh and reviewed all FDA publication and notices and gynecology and urogynecology society statements on its use in the United States. We then reviewed 22 articles and grouped them into several sections.

Results

Mesh used to augment transvaginal repair of POP was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several FDA notifications and warnings. The type of mesh used, reporting and classifications systems, and provider usage has varied widely over time.

Conclusion

We present a historical review of transvaginal mesh use for pelvic organ prolapse in the United States from 2005 to 2016. There continues to be heated debate among practitioners about balancing the efficacy of mesh use to decrease recurrent prolapse and complications. Research into safety and efficacy, along with tighter FDA regulations, is ongoing.

     

Trends in prolapse surgery in England

Introduction and hypothesis

Women have a lifetime risk of undergoing pelvic organ prolapse (POP) surgery of 11–19%. Traditional native tissue repairs are associated with reoperation rates of approximately 11% after 20 years. Surgery with mesh augmentation was introduced to improve anatomic outcomes. However, the use of synthetic meshes in urogynaecological procedures has been scrutinised by the US Food and Drug Administration (FDA) and by the European Commission (SCENIHR). We aimed to review trends in pelvic organ prolapse (POP) surgery in England.

Methods

Data were collected from the national hospital episode statistics database. Procedure and interventions-4 character tables were used to quantify POP operations. Annual reports from 2005 to 2016 were considered.

Results

The total number of POP procedures increased from 2005, reaching a peak in 2014 (N?=?29,228). With regard to vaginal prolapse, native tissue repairs represented more than 90% of the procedures, whereas surgical meshes were considered in a few selected cases. The number of sacrospinous ligament fixations (SSLFs) grew more than 3 times over the years, whereas sacrocolpopexy remained stable. To treat vault prolapse, transvaginal surgical meshes have been progressively abandoned. We also noted a steady increase in uterine-sparing, and obliterative procedures.

Conclusions

Following FDA and SCENIHR warnings, a positive trend for meshes has only been seen in uterine-sparing surgery. Native tissue repairs constitute the vast majority of POP operations. SSLFs have been increasingly performed to achieve apical support. Urogynaecologists’ training should take into account shifts in surgical practice.

     

The effect of pelvic organ prolapse repair on vaginal sensation

Introduction and hypothesis

The objective was to evaluate vaginal and clitoral sensation before and after robotic sacrocolpopexy for the repair of pelvic organ prolapse.

Methods

Twenty-two women, mean age 63 years (range 41–77), were admitted for robotic sacrocolpopexy repair of pelvic organ prolapse; 4 were lost to follow-up. Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina (anterior and posterior areas) and clitoris 1 day before and a mean of 12?±?4 months following surgery. Student’s paired t test was used to compare sensory thresholds before and after surgery.

Results

For the 18 women who completed follow-up, sensitivity was significantly higher after surgery (sensory threshold decreased) at the clitoral and vaginal regions, to cold and warm stimuli. In contrast, the vaginal and clitoral vibratory sensory thresholds did not change significantly following surgery.

Conclusion

The repair of pelvic organ prolapse by robotic sacrocolpopexy could potentially play a role in restoring clitoral and vaginal wall sensation. The effects of these sensory changes on sexual function and the quality of sexual life need further investigation.

     

Failure of Expectations in Vaginal Surgery: Lack of Appropriate Consent,Goals and Expectations of Surgery

Introduction and Background

Vaginal surgery for the treatment of urinary stress incontinence (USI) and pelvic organ prolapse (POP) using a synthetic polypropylene mesh is going through a time of unprecedented turmoil and debate. This review focuses on vaginal surgery for vaginal prolapse and looks at the current scientific literature on issues surrounding surgery including consent and expectations.

Safety and Effectiveness of Surgical Options

Synthetic mesh has been used both abdominally and vaginally to improve the effectiveness of POP surgery. The relatively high incidence of mesh complications particularly with vaginal surgery has lead to repeat surgery, disappointment and litigation in some women. The benefits and risks of the various POP procedures are reviewed including native tissue repair, uterine conservation and obliterative vaginal surgery.

Conclusion

Women with symptomatic pelvic organ prolapse and their doctors have many treatment options. The benefits and risks should be discussed as part of shared decision making.

     

Sacrocolpopexy: Surgical Technique,Outcomes, and Complications

Purpose of Review

Pelvic organ prolapse is a non-life-threatening condition that has a wide variety of symptoms. Sacrocolpopexy has been the “gold standard” for management of apical pelvic organ prolapse with reported high success rates for anatomic correction. Herein, we review the surgical procedure, anatomic, and functional outcomes, as well as the intraoperative and postoperative complications.

Recent Findings

Findings suggest that the ASC has an acceptably low overall complication rate comparable between open and minimally invasive approach. Mesh extrusion and anatomic failure have been shown to increase over time.

Summary

Patient education and counseling are important preoperatively. It is important to discuss with the patient risks of the surgical procedure, specifically mesh-related extrusion, longer term anatomic recurrence rates, rates of functional improvement, or worsening of bladder and bowel symptoms, as well as rates of dyspareunia.

     

LeFort colpocleisis: a step-by-step simulation video for Female Pelvic Surgeons

Introduction and hypothesis

LeFort colpocleisis is a minimally invasive surgical option for patients with pelvic organ prolapse who no longer desire sexual activity. Pelvic surgeons have limited exposure to this procedure during their training, and are therefore less likely to offer this procedure to their patients.

Methods

We use a split screen live action surgery, side by side with a low cost 3D model of a prolapse to describe a LeFort colpocleisis step by step.

Results

This video is an easily reproducible guide to the steps and surgical techniques necessary to successfully perform a LeFort colpocleisis. The simulation model can be used to educate and train those performing female pelvic surgery.

Conclusion

Pelvic surgeons should be able to offer LeFort colpocleisis to their patients. This video may be used to facilitate the understanding and reproducibility of the procedure.

     

Informed consent checklists for midurethral slings: a common-sense approach

Introduction and Hypothesis

Following the US Food and Drug Administration’s (FDA’s) warning about the use of transvaginal mesh to treat pelvic organ prolapse (POP) and the use of single-incision slings to treat incontinence, the number of lawsuits for medical negligence regarding the use of any polypropylene mesh in the vagina has increased tremendously.

Methods

This same FDA document did not question the use of polypropylene midurethral slings and polypropylene for sacrocolpopexies. Surprisingly, despite all the evidence and recommendations from respected international scientific societies, we are constantly being called upon by our patients to defend the use of midurethral slings. The most common reasons for the new rash of medicolegal proceedings involving midurethral slings has to do with “breach of duties” resulting from undisclosed postoperative complications on the consent form and/or the lack of information in the medical records confirming that all possible alternative treatment options were presented to and discussed with the patient.

Results

One response to these lawsuits involves the addition of preoperative checklists when performing informed consent with patients electing surgical correction of stress urinary incontinence (SUI).

Conclusions

This clinical opinion provides an expert clinician’s perspectives and legal point of view on this controversial topic and discusses the role of a preoperative checklist supplementary to the standard informed consent form.

     

Female pelvic organ prolapse using pessaries: systematic review

Introduction and hypothesis

The purpose of this systematic review is to assess the impact of pessary use on the quality of life of women with pelvic organ prolapse, and to determine the satisfaction rate and rationale for discontinuation.

Methods

This review is recorded in the PROSPERO database under number CRD42015023384. The criteria for inclusion were observational study; cross section; cohort study; randomized controlled trial; study published in English, Portuguese, and Spanish; and study whose participants are women with female pelvic organ prolapse treated using a pessary. We did not include limitations on the year of publication. The criteria for exclusion included studies that did not include the topic, bibliographic or systematic reviews and articles that did not use validated questionnaires. The MeSH terms were “Pelvic Organ Prolapse AND Pessaries AND Quality of Life” OR “Pessary AND Quality of Life” OR “Pessaries”.

Results

We found 89 articles. After the final analyses, seven articles were included. All articles associated pessary use with improved quality of life, and all used only validated questionnaires. Over half of the women continued using the pessary during the follow-up with acceptable levels of satisfaction. The main rationales for discontinuation were discomfort, pain in the area, and expulsion of the device.

Conclusion

This systematic review demonstrates that the pessary can produce a positive effect on women’s quality of life and can significantly improve sexual function and body perception.

     

Total colpocleisis: technical considerations

Introduction

We present a video describing the technical considerations for performing a total colpocleisis in the management of symptomatic post-hysterectomy pelvic organ prolapse.

Methods

A 76-year old female presented with pelvic pressure and the presence of a palpable vaginal bulge. She had significant bother and had previously failed use of a pessary. She wasnot sexually active, with no plans for future sexual activity. Her medical history was significant for coronary artery disease with prior myocardial infarction. She had high-grade vaginal vault prolapse, without occult incontinence. After discussing observation, pessaries, restorative and obliterative procedures, she elected to undergo colpocleisis. Following hydrodissection with lidocaine with epinephrine, a quadrant-based dissection was performed to remove the vaginal epithelium circumferentially. Following this, serial purse string sutures were used to reduce the prolapse, with meticulous hemostasis. The vaginal epithelium was then closed transversely. Next, a perineorrhaphy was performed. The midline was plicated and the perineal body reconstructed.

Results

The patient had an uncomplicated postoperative course. At six-week follow-up she had no evidence of recurrent prolapse and was voiding without difficulty.

Conclusions

Colpocleisis can provide excellent anatomic and subjective outcomes. Our goal is to highlight pertinent technical considerations in order to optimize patient outcomes.

     

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

Aim

We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.

Material and methods

We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.

Conclusion

This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

     

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion

Introduction and hypothesis

This committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management.

Method

A working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee.

Results

There is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited.

Conclusion

The assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.

     

Assessing the use of the IUGA/ICS classification system for prosthesis/graft complications in publications from 2011 to 2015

Introduction and hypothesis

Complications of pelvic organ prolapse and urinary incontinence surgery have gained increasing attention from both lay media and medical societies. The International Urogynecological Association and International Continence Society proposed the category–time–site system to classify complications in 2011. Our objective is to assess the usage of the category–time–site system in the literature.

Methods

We conducted a systematic review and identified records using PubMed search terms “mesh” and “prolapse or incontinence” and “complication or excision” (February 2011 to December 2015) to select publications following the introduction of category–time–site system. Relevant publications were included and reviewed for study design, initial procedure, number of patients assigned codes, number of unique codes applied, purpose of assigning codes, and duration of clinical follow-up.

Results

Of 167 eligible records, 23 (14 %) used the system, 137 (82 %) used no system, and 7 (4 %) used another system. They included three study designs: randomized control trials, case reports, and case series. Given the very limited amount of data, no statistical tests were performed, but trends were noted.

Conclusions

Fourteen percent of the reports in the literature describing complications related to prosthesis/graft use in pelvic surgery utilize the category–time–site system. The system’s limited and inconsistent use hinders the ability to draw conclusions useful for clinical practice. Effort should be directed toward improving appropriate usage or revising the system to increase its exposure in related publications. An improved system will better prepare pelvic surgeons for assessing future generations of prostheses/grafts.

     

Interethnic variation in pelvic floor morphology in women with symptomatic pelvic organ prolapse

Introduction and hypothesis

There is a lack of epidemiological studies evaluating female pelvic organ prolapse in developing countries. Current studies have largely focused on women of white ethnicity. This study was designed to determine interethnic variation in pelvic floor functional anatomy, namely, levator hiatal distensibility and pelvic organ descent, in women with symptomatic pelvic organ prolapse in a multi-ethnic South African population.

Methods

This prospective observational study included 258 consecutive women referred for pelvic organ prolapse assessment and management at a tertiary urogynaecological clinic. After a detailed history and clinical examination, including POPQ assessment, patients underwent a 4D transperineal ultrasound. Offline analysis was performed using 4D View software. Main outcome measures included levator muscle distensibility, pelvic organ descent, and levator ani defects (avulsion).

Results

Mean age was 60.6 (range, 25–91) years, mean BMI 29.83 (range, 18–53). Points Ba and C were lower and the genital hiatus more distensible in black women (all p < 0.05). They were found to have greater hiatal area (p = 0.017 at rest, p = 0.006 on Valsalva) compared with South Asians and whites and showed greater pelvic organ mobility (all p < 0.05) than Caucasians on ultrasound. Levator defects were found in 32.2% (n = 83) of patients and most were bilateral (48.2%, n = 40), with significant interethnic differences (p = 0.014).

Conclusion

There was significant variation in clinical prolapse stage, levator distensibility, and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (p = 0.014).

     

Pelvic Organ Prolapse and Pregnancy in the Female Bladder Exstrophy Patient

Purpose of Review

Classic bladder exstrophy (BE) remains one of the most demanding reconstructive challenges encountered in urology. In female BE patients, the long-term sequela of both primary and revision genitoplasty, as well as intrinsic pelvic floor deficits, predispose adult women to significant issues with sexual function, pelvic organ prolapse (POP), and complexities with reproductive health.

Recent Findings

Contemporary data suggest 30–50% of women with BE develop prolapse at a mean age of 16 years. Most women will require revision genitoplasty for successful sexual function, although in some series over 40% report dyspareunia. Current management for pregnancy includes elective cesarean section with involvement of high-risk obstetrics and urologic surgery.

Summary

This review encapsulates contemporary concepts of etiology, prevalence, and management of POP and pregnancy in the adult female BE patient.

     

In vivo response to polypropylene following implantation in animal models: a review of biocompatibility

Introduction and hypothesis

Polypropylene is a material that is commonly used to treat pelvic floor conditions such as pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Owing to the nature of complications experienced by some patients implanted with either incontinence or prolapse meshes, the biocompatibility of polypropylene has recently been questioned. This literature review considers the in vivo response to polypropylene following implantation in animal models. The specific areas explored in this review are material selection, impact of anatomical location, and the structure, weight and size of polypropylene mesh types.

Methods

All relevant abstracts from original articles investigating the host response of mesh in vivo were reviewed. Papers were obtained and categorised into various mesh material types: polypropylene, polypropylene composites, and other synthetic and biologically derived mesh.

Results

Polypropylene mesh fared well in comparison with other material types in terms of host response. It was found that a lightweight, large-pore mesh is the most appropriate structure.

Conclusion

The evidence reviewed shows that polypropylene evokes a less inflammatory or similar host response when compared with other materials used in mesh devices.

     

Sacrospinous hysteropexy: review and meta-analysis of outcomes

Introduction

Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery.

Methods

Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration’s Review Manager software to perform meta-analysis of randomized controlled studies and observational studies.

Results

Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n?=?651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76–5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41–2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy.

Conclusion

Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.