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.

     

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion

Introduction and hypothesis

Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs

Methods

A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.

Results

This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.

Conclusions

Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

     

Endoscopic lithotripsy and vaginal excision of a calcified bladder-mesh extrusion

Introduction and hypothesis

Synthetic meshes have proven to increase efficacy of pelvic organ prolapse (POP) repair, but associated complications are not rare. Bladder mesh extrusion is one of the most serious adverse events following POP surgery with mesh. The aim of this video was to describe endoscopic and vaginal approaches for treating a bladder-mesh extrusion.

Methods

A 52-year-old female patient with a history of vaginal POP surgery with mesh was referred for severe pelvic and perineal pain, dyspareunia, and dysuria. She was found to have a bladder calculus on a mesh extrusion. The calculus was removed by endoscopic lithotripsy before vaginal mesh excision was performed.

Conclusions

With the use of synthetic vaginal mesh, the incidence of bladder-mesh extrusion could increase. This didactic video will be helpful to surgeons required to manage such cases using a minimally invasive treatment.

     

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.

     

Association between vaginal bulge and anatomical pelvic organ prolapse during pregnancy and postpartum: an observational study

Introduction and hypothesis

Pelvic organ prolapse (POP) is defined as the coexistence of anatomical POP and relevant symptoms. Vaginal bulge is the symptom most closely associated with the anatomical condition in nonpregnant women. Even if childbearing is a major risk factor for the development of POP, there is scant knowledge on the prevalence of specific POP symptoms, and how these symptoms relate to anatomical POP during pregnancy and postpartum. The aim of this study was to explore whether vaginal bulge symptoms were associated with anatomical POP in pregnancy and postpartum, and to present the prevalence of vaginal bulge symptoms throughout this period.

Methods

A prospective observational study was carried out following 300 nulliparous pregnant women with repeat assessments from mid-pregnancy until 1 year postpartum. Symptoms of vaginal bulge defined as the sensation of a vaginal bulge inside and/or outside the vagina were assessed by electronic questionnaires. Anatomical POP defined as pelvic organ prolapse quantification system (POP-Q) stage ≥2 has been presented in a previous publication and showed a range of 1–9%. The association between the symptom vaginal bulge and anatomical POP at the various visits was analyzed using Fisher’s exact test.

Results

Prevalence of vaginal bulge ranged between 16 and 23%. At 6 weeks postpartum the symptom was associated with anatomical POP; otherwise, these two features were unrelated.

Conclusions

The symptom vaginal bulge was barely associated with anatomical POP, and cannot identify anatomical POP in pregnancy or postpartum.

     

Effectiveness of a continuous-use ring-shaped vaginal pessary without support for advanced pelvic organ prolapse in postmenopausal women

Introduction and hypothesis

There is considerable variation in the clinical management of pessaries. This study was aimed at exploring the efficacy of the continuous use of ring pessaries without support for the treatment of advanced pelvic organ prolapse (POP) in nonhysterectomized postmenopausal women.

Methods

We conducted this prospective study of fitted pessaries between January 2013 and June 2015 in the Department of Obstetrics and Gynecology at Macarena Hospital, Seville University, Spain. A total of 171 nonhysterectomized postmenopausal patients with symptomatic POP (stages III and IV) were counseled for two treatment options: either surgery or vaginal pessary. A total of 94 patients who agreed to use the vaginal ring pessary were included. A successful fitting was defined as the continued use of the device until the end of the study (a median 27-month follow-up). The data were analyzed with continuity correction tests, Mann–Whitney U tests, and Fisher’s exact test.

Results

Pessary use was continued by 80.8% of the patients. Most discontinuations (50.0%) occurred within the first week after device insertion. The adverse events rate was 31.6%, and all adverse events were Clavien–Dindo grade I. The complications were extrusion of the pessary (18.4%), bleeding or excoriation (10.5%), and pain or vaginal discharge (2.6%). No major complications occurred.

Conclusions

The ring pessary without support was successfully fitted in patients with advanced POP, resulting in a high success rate. There were few side effects and complications associated with continuous use of this pessary without periodic removal or replacement.

     

Age at hysterectomy as a predictor for subsequent pelvic organ prolapse repair

Introduction and hypothesis

The aim of this study was to investigate the association between patient age at the time of hysterectomy and subsequent pelvic organ prolapse (POP) surgery.

Methods

We gathered data on all benign hysterectomies and POP surgeries performed in Denmark on Danish women from 1977 to 2009 from the Danish National Patient Registry. The cohort consisted of 154,882 hysterectomized women, who were followed up for up to 32 years. Survival analysis for each age group at hysterectomy was performed using Kaplan–Meier product limit methods.

Results

For all hysterectomized women, we found that low age at hysterectomy yielded a lower risk of subsequent POP surgery than did hysterectomy at an older age. This difference diminished after stratification by indication; all non-POP hysterectomies had a low cumulative incidence at 8–11 % at the end of the follow-up period. For all women hysterectomized, the predominant compartment for POP surgery was the posterior. Women hysterectomized when aged over 66 years had a higher proportion of POP surgery in the apical compartment than in the other age groups (p?=?0.000).

Conclusion

Our findings indicate that age at hysterectomy only marginally influences the risk of subsequent POP surgery for women hysterectomized for indications other than POP. If POP is the indication for hysterectomy, the risk of undergoing subsequent POP surgery increases substantially.

     

The Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: a matched historical cohort study

Introduction and hypothesis

This study compares vaginal hysterectomy with uterosacral ligament suspension (VH) with the Manchester-Fothergill procedure (MP) for treating pelvic organ prolapse (POP) in the apical compartment.

Methods

Our matched historical cohort study is based on data from four Danish databases and the corresponding electronic medical records. Patients with POP surgically treated with VH (n?=?295) or the MP (n?=?295) in between 2010 and 2014 were matched for age and preoperative POP stage in the apical compartment. The main outcome was recurrent or de novo POP in any compartment. Secondary outcomes were recurrent or de novo POP in each compartment and complications.

Results

The risk of recurrent or de novo POP in any compartment was higher after VH (18.3%) compared with the MP (7.8%) (Hazard ratio, HR?=?2.5, 95% confidence interval (CI): 1.3–4.8). Recurrence in the apical compartment occurred in 5.1% after VH vs. 0.3% after the MP (hazard ratio (HR)?=?10.0, 95% confidence interval (CI) 1.3–78.1). In the anterior compartment, rates of recurrent or de novo POP were 11.2% after VH vs. 4.1% after the MP (HR?=?3.5, 95% CI 1.4–8.7) and in the posterior compartment 12.9% vs. 4.7% (HR?=?2.6, 95% CI 1.3–5.4), respectively. There were more perioperative complications (2.7 vs. 0%, p?=?0.007) and postoperative intra-abdominal bleeding (2 vs. 0%, p?=?0.03) after VH.

Conclusions

This study shows that the MP is superior to VH; if there is no other indication for hysterectomy, the MP should be preferred to VH for surgical treatment of POP in the apical compartment.

     

Pelvic organ prolapse surgery following hysterectomy with benign indication: a national cohort study in Taiwan

Introduction and hypothesis

Hysterectomy and pelvic organ prolapse (POP) surgeries are two of the most common gynecologic surgeries conducted for benign conditions. This nationwide retrospective cohort study explored the risk of subsequent POP surgery following hysterectomy without simultaneous POP surgery.

Methods

This study identified 7298 patients who underwent hysterectomy between January 1, 2000, and December 31, 2012, from the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed comprising 29,192 age-matched patients who had not undergone hysterectomy. All hysterectomy and control patients were followed until they required POP surgery, withdrew from the NHI system, died, or December 31, 2012. Patients were excluded if they underwent POP surgery before or at the time of hysterectomy.

Results

The adjusted hazard ratio (aHR) of subsequent POP surgery in subjects with hysterectomy was higher [2.60, 95% confidence interval (CI) 1.79–3.78] than that of controls during the follow-up period. Compared with patients who had not undergone hysterectomy, the highest risks of subsequent POP surgery was noted in those who had undergone vaginal hysterectomy (VH; HR 6.29, 95% CI 1.54–25.79) followed by those who underwent laparoscopy-assisted VH (LAVH; HR 3.77, 95% CI 2.43–5.85).

Conclusions

Hysterectomy may increase the risk of subsequent POP surgery, and various hysterectomy techniques, particularly VH and LAVH, may increase the risk of subsequent POP surgery.

     

Incidence of pelvic organ prolapse repair subsequent to hysterectomy: a comparison between radical hysterectomy and total abdominal hysterectomy

Introduction and hypothesis

The aim of this study was to compare the incidence of subsequent pelvic organ prolapse (POP) repair in women following radical hysterectomy versus total abdominal hysterectomy.

Methods

From the Danish National Patient Registry, we collected data on all radical hysterectomies, all total abdominal hysterectomies, and all POP operations performed in Denmark from 1 January 1977 to 31 December 2009. We excluded patients with prior POP repair, POP diagnosis, or concomitant POP repair at hysterectomy. We analyzed the incidence of POP surgery using Kaplan–Meier curves and hazard ratio (HR).

Results

In all, 5279 women underwent radical hysterectomy, and 63 of these underwent subsequent POP surgery. In the same period, 149,920 women underwent total abdominal hysterectomy, and 6107 of these had POP surgery subsequent to the hysterectomy. The cumulative incidence of POP surgery was significantly lower for radical hysterectomy than for abdominal hysterectomy—3.4 % and 9.5 %, respectively, at the end of the study period, yielding a crude HR of 0.36 and an adjusted HR of 0.40 in favor of the radical hysterectomy. The distribution of POP operations in the defined compartments was the same for the two types of hysterectomy.

Conclusions

This study found a significantly lower incidence of subsequent POP operations among women who undergo radical hysterectomy than total abdominal hysterectomy.

     

Oestrogen-soaked vaginal packing for decubitus ulcer in advanced pelvic organ prolapse: a case series

Introduction

Cervicovaginal decubitus ulceration is a well-known complication of advanced pelvic organ prolapse (POP). There is no consensus for its management. This case series describes the outcome of using repeated vaginal packs soaked with oestrogen cream to reduce POP and promote decubitus ulcer healing. We aimed to investigate the speed of ulcer healing and endometrial safety with this regimen.

Methods

This was a retrospective study of patients with stage 3 or 4 POP and intact uterus with decubitus ulcer who were planned for surgery that included hysterectomy after ulcer healing. Vaginal packs are replaced at least biweekly—or more frequently if extruded—until ulcer resolution.

Results

Thirteen patients were studied. Mean age was 69?±?6 years and mean duration of menopause was 19?±?6 years. Nine patients had a single ulcer and four had multiple ulcers. Mean ulcer diameter was 2.8?±?1.5 cm and mean duration for ulcer healing was 26?±?14 days. Hysterectomy and pelvic floor reconstruction was performed a median of 5 (range 0–153) days after ulcer healing was first noted. Histopathological examination of the endometrium following hysterectomy showed three specimens with endocervical hyperplasia; one had concurrent proliferative endometrium, two had simple endometrial hyperplasia and another two had proliferative endometrium.

Conclusion

Oestrogen-soaked vaginal packing is a viable option for managing a decubitus ulcer in advanced POP. We document a measurable impact on the endometrium with this short-term preoperative regimen. Further research is needed to evaluate its efficacy in promoting ulcer healing and endometrial safety.

     

Neuromodulation for Chronic Pelvic Pain

Purpose of Review

Chronic pelvic pain is a heterogeneous condition that often requires multiple physician visits and various treatments prior to achieving an acceptable management strategy. Neuromodulation has been used to treat chronic pelvic pain that has failed other therapies.

Recent Findings

Numerous modalities of neuromodulation have been used to alleviate chronic pelvic pain with promising results.

Summary

Numerous modalities of neuromodulation have demonstrated efficacy in the management of pelvic pain. Further investigation is needed to elucidate the most effective treatment modality and to identify the patients who would benefit most from this therapy.

     

Physical activity and pelvic floor muscle training in patients with pelvic organ prolapse: a pilot study

Introduction and hypothesis

The details of the physical activity in patients with mild to moderate pelvic organ prolapse (Pmoderate pelvic organ prolapse (POP) remain under-studied. The purpose of the present study was to investigate objective physical activity levels and the changes in pelvic floor muscle(PFM) strength, symptoms and quality of life (QOL) between before and after PFM training (PFMT) in patients with POP.

Methods

In a prospective pilot study, 29 patients with stage II or III POP completed approximately 16 weeks of PFMT. A reliable activity monitor was used to measure physical activity parameters including step counts, activity and total calories expended, and duration at each intensity level. Maximum vaginal squeeze pressure, POP symptoms and QOL were assessed. Changes in these outcome measures were compared before and after PFMT.

Results

The step counts per day (mean ± SD) of women with POP was 7,272.9 ± 3,091.7 before PFMT and 7,553.4 ± 2,831.0 after PFMT. There was no significant change between before and PFMT. PFM strength was significantly increased after PFMT. POP-related symptoms including stress urinary incontinence, frequency, postmicturition dribble and interference with emptying the bowels were significantly improved. The QOL scores for general health, physical limitations, emotion, and severity measures were significantly improved after PFMT.

Conclusions

Although PFMT changed PFM strength symptoms, and QOL, there were no changes for any physical activity parameters before and after PFMT. This is probably because the physical activity levels in patients with mild to moderate POP were almost same as in age-matched healthy women.

     

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.

     

Is levator hiatus distension associated with peripheral ligamentous laxity during pregnancy?

Introduction and hypothesis

The impact of pregnancy on pelvic floor disorders remains poorly understood. During pregnancy, an increase in ligamentous laxity and pelvic organ mobility is often reported. Our main objective was to investigate a possible association between peripheral ligamentous laxity and levator hiatus (LH) distension during pregnancy.

Methods

This was a prospective longitudinal study of 26 pregnant women followed up from the first to the third trimester. We collected the following information: occurrence of pelvic organ prolapse (POP) symptoms (score higher than 0 for the POP section of the Pelvic Floor Distress Inventory 20 questions score), 4D perineal ultrasound scan results with LH distension assessment and measurement of metacarpophalangeal joint mobility (MCP laxity). The association between MCP laxity and LH distension was estimated by mixed multilevel linear regression. The associations between MCP laxity and categorical parameters were estimated in a multivariate analysis using a generalized estimating equation model.

Results

MCP laxity and LH distension were correlated with a correlation coefficient of 0.26 (p?=?0.02), and 6.8% of the LH distension variance was explained by MCP laxity. In the multivariate analysis, MCP laxity was associated with POP symptoms with an odds ratio at 1.05 (95% CI 1.01–1.11) for an increase of 1° in MCP laxity.

Conclusion

LH distension and peripheral ligamentous laxity are significantly associated during pregnancy. However, the relationship is weak, and the results need to be confirmed in larger populations and with more specific techniques such as elastography to directly assess the elastic properties of the pelvic floor muscles.

     

Conservative management of pelvic abscess following sacrocolpopexy: a report of three cases and review of the literature

Introduction and hypothesis

After sacrocolpopexy, intra-abdominal pelvic abscesses are often managed with intravenous antibiotics, excision of the mesh involved, and debridement of compromised tissue.

Methods and results

Three cases of successful management of pelvic abscesses after sacrocolpopexy using long-term antibiotics and percutaneous drainage of intra-abdominal abscesses without removing the mesh are presented.

Conclusions

In selected patients who have undergone sacrocolpopexy, with careful counseling, conservative management of pelvic abscesses with percutaneous drainage and long-term antibiotic treatment without the surgical excision of the mesh may play a role.

     

The UK National Prolapse Survey: 10 years on

Introduction and hypothesis

To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey.

Methods

An online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures.

Results

Of 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment.

Conclusion

Basic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

     

Prevalence of obstetric fistula and symptomatic pelvic organ prolapse in rural Ethiopia

Introduction and objective

Little is known about the extent to which women in low- and middle-income countries suffer with urological and urogynaecological complications of childbirth. This study measured the prevalence of obstetric fistula and symptomatic pelvic organ prolapse (POP) in east and north Ethiopia.

Methods

We randomly selected 23,023 women of reproductive age (15–49 years) from 113 villages in East Harraghe, South Gondar and West Gojjam, Ethiopia. Trained local health workers administered a validated face-to-face survey and a team of researchers verified data by readministering a random selection (5 %) of the survey. All suspected fistulae were followed up to confirm a clinical diagnosis.

Results

Mean age was 29.5 [standard deviation (SD) 8.05] years. Only 22 % of women were knowledgeable about the symptoms of fistula. The prevalence of all obstetric fistulae was 6:10,000 reproductive-aged women [95 % confidence interval (CI) 3–8], of untreated fistula 2:10,000 (95 % CI 0–4) and of symptomatic POP 100:10,000 (95 % CI 86–114).

Conclusion

The prevalence of obstetric fistula in these rural zones of Ethiopia is relatively low and reflects a substantial reduction from previous reports. Significant numbers of women suffer with symptomatic POP, for which surgical and nonsurgical treatments would be beneficial.

Brief summary

Obstetric fistula in north and east Ethiopia is relatively low; however, the many women with symptomatic pelvic organ prolapse could benefit from treatment.