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

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

Evaluation of confounding factors interfering with sexual function in women with minimal pelvic organ prolapse

Objective

To evaluate the effects of confounding factors on sexual function in women with minimal pelvic organ prolapse (POP).

Methods

A cross-sectional study was conducted at a cervical cancer screening center in Turkey between December 1, 2012, and March 31, 2013. Symptom-free women with stage I or II POP were enrolled to evaluate the association between sexual function and sociodemographic variables, POP, POP-related quality of life, stress incontinence, and overactive bladder.

Results

Of 243 volunteers (mean age 46.0 ± 9.1 years), 188 (77.4%) had a low Female Sexual Function Index score. Women with better sexual function tended to be younger, have a higher salary, not be in the menopause, and have no chronic illness (P < 0.05 for all). There was no difference between the groups in terms of POP Quantification measurements (P > 0.05), apart from transvaginal length (P = 0.011). Overactive bladder was more common (P = 0.005) and more severe (P = 0.002) in women with sexual dysfunction, and their POP-related quality of life was worse (P < 0.05). In a linear regression analysis, high salary had a positive effect and overactive bladder had a negative effect on sexual function.

Conclusion

Sexual dysfunction is highly prevalent in women with minimal POP. Overactive bladder and low income are the major factors adversely affecting sexual function.     

Laparoscopic surgical repair of pelvic organ prolapse and female stress urinary incontinence

Pelvic organ prolapse (POP) occurs in a relatively big population of women which is continuously increasing and is associated with a variety of urinary bowel and sexual symptoms. As this problem magnifies, the need for surgical repair is increasing relatively. The main goals of surgical repair for POP include: no anatomic prolapse, no functional symptoms, patient satisfaction and avoidance of complications, goals that cannot always be fully achieved. The decision for the type of surgery depends of various factors such as patient characteristics and prolapsed compartment but also by the surgeon expertise. The laparoscopic approach is already the gold standard procedure for many urologic procedures and can also be used for the treatment of POP and stress urinary incontinence. Herein, we review the literature about the available data concerning laparoscopic surgery techniques for treating POP.     

Surgical repair of pelvic organ prolapse and follow-up: An institutional multi-center experience

AIM: To investigate the effects of the Elevate Anterior and Posterior transvaginal mesh procedure on 30 patients affected by pelvic organ prolapse (POP) at 12 mo follow-up. METHODS: Between September 2011 and September 2012, a prospective multicenter observational study enrolled 30 consecutive patients with POP-Q ≥ stage II. After a preoperative evaluation, patients underwent prolapse repair utilizing the Elevate Anterior and Posterior Prolapse Repair System (American Medical Systems, Minnetonka, MN, United States). Operative technique was standardized and performed by the same surgical team under spinal or general anesthesia. Patients were evaluated postoperatively at 1, 3, 6 and 12 mo. RESULTS: All 30 patients completed the 12 mo follow-up. The mean age was 65.3 years (range 49-81 years) and average hospital stay was 4.5 d. The mean operative time was 65 min (range 40-120 min). Related adverse events reported were mesh extrusions (6.7%) and post void residual urine volume (13.3%). There were no visceral injuries, no infection of the mesh, and no symptoms of recurrent prolapse. All quality-of-life scores significantly improved from baseline. CONCLUSION: One year’s follow-up of our 30 patients confirms the safety and the efficacy of the Elevate Anterior and Posterior transvaginal mesh procedure for POP treatment. Our final results are comforting but longer term follow-up is ongoing.     

Reutilization of the Prolift mark system for the simultaneous correction of prolapse and incontinence in patients with pelvic organ prolapse and stress urinary incontinence

Objective

The reutilization of the Prolift™ system with the simultaneous creation of a midurethral sling from the same set was described.

Study design

The technique was applied in 23 patients with pelvic organ prolapse (POP) and clinically evident or occult stress urinary incontinence (SUI).

Results

Correction of POP was achieved in 21 out of 23 (91.3%) patients, and complete continence after the surgery in 20 out of 23 (86.9%). There was a significant improvement in voiding symptoms without deterioration of voiding function. Morbidity of the surgery was not different from that with Prolift™ alone.

Conclusion

Modification of the method with creation of a suburethral sling from the same set is more economically viable without compromising either pelvic organ support or continence.     

Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse

OBJECTIVE: Our purpose was to estimate, in women after 2 months of pessary use, patient satisfaction and the percentage of prolapse and urinary symptoms that improve or worsen. STUDY DESIGN: In a prospective study, 100 consecutive women with symptomatic pelvic organ prolapse were fitted with a pessary, and 73 women had a successful 2-week pessary fitting trial. Prolapse and urinary symptoms were assessed at baseline and at 2 months. Patient satisfaction was assessed at 2 months. Risk factors for patient dissatisfaction were assessed. RESULTS: Nearly all prolapse symptoms resolved from baseline to 2 months, respectively: bulge (90% to 3%; P<.001), pressure (49% to 3%; P<.001), discharge (12% to 0%; P=.003), and splinting (14% to 0%; P=.001). Among women with concurrent urinary symptoms at baseline, stress incontinence improved in 45%, urge incontinence improved in 46%, and voiding difficulty improved in 53%, after 2 months. However, among women without urinary symptoms at baseline, occult (de novo) stress incontinence occurred in 21%, de novo urge incontinence occurred in 6%, and de novo voiding difficulty occurred in 4%. At 2 months, 92% of the women were satisfied with their pessary. Six women (8%) were dissatisfied and discontinued use of the pessary. Dissatisfaction was associated with occult stress incontinence (odds ratio, 17.1; 95% CI, 1.9, 206; P=.004). CONCLUSION: After 2 months, 92% of women with a successful pessary fitting trial were satisfied. Nearly all prolapse symptoms resolved after 2 months; 50% of urinary symptoms improved, but occult stress incontinence was a common side effect.     

The effect of physical activity on pelvic organ prolapse

Objective  The objective of this study was to determine whether pelvic organ prolapse increases after physical activity.
Design  Prospective observational study.
Setting  St Mary's Hospital, Manchester, UK.
Sample  Women undergoing surgery for pelvic organ prolapse.
Methods  Fifty-four women were recruited to the study. Symptoms and POPQ findings were assessed after a period of prescribed activity and overnight bedrest.
Main outcome measures  Primary outcome was an increase in Pelvic Organ Prolapse Quantification (POPQ) measurements with activity. Secondary outcomes were association of symptoms or quality-of-life scores (Pelvic Floor Distress Inventory [PFDI] and Pelvic Floor Impact Questionnaire [PFIQ]) with an increase in POPQ measurements.
Results  There was a significant increase in POPQ stage and five vaginal parameters (Aa, Ba, C, Ap and Bp) with physical activity ( P < 0.001). Reported symptoms, higher PFDI and PFIQ scores and higher individual symptom bother scores were not more common in the women with greater pelvic organ descent (measured by the POPQ system) following physical activity.
Conclusions  Greater pelvic organ prolapse was found on POPQ examination following physical activity, but this was not associated with worsening of symptoms and greater impairment of quality of life.     

Evaluating the efficacy of the single-incision uphold system for pelvic organ prolapse repair

Objective

The aim of this study was to assess the efficacy and clinical outcomes of pelvic floor reconstruction with transvaginal mesh of the Uphold? Vaginal Support System (Boston Scientific Corporation).

Role of MR imaging in surgical planning and prediction of successful surgical repair of pelvic organ prolapse

ObjectiveTo determine the role of magnetic resonance imaging (MRI) in surgical planning for females with pelvic organ prolapsed (POP) and to determine the clinical utility of MR imaging in predicting successful surgical repair.MethodsFifteen patients with different varieties of pelvic floor dysfunction and 15 nulliparous females as control subjects were studied by magnetic resonance imaging (static and dynamic). Intraoperative findings related to POP were correlated to MRI findings. In the symptomatic patients, magnetic resonance imaging was repeated within 6–12 months after surgery.ResultsPreoperative MRI and operative findings showed a significant correlation in all types of prolapse, except rectocele. On the other hand preoperative pelvic examination and operative findings were significantly correlated for cystocele, rectocele and vaginal cuff prolapse (r = 0.75, P < 0.008). Preoperative magnetic resonance imaging added information that changed the management in 40% of symptomatic women. Postoperative magnetic resonance imaging showed normal pelvic floor in asymptomatic patients (n = 13). Abnormal imaging findings were found in patients with persistent postoperative or de novo complaints (n = 2).ConclusionMagnetic resonance imaging can accurately localize pelvic floor defects, evaluate success or failure of surgical procedures, predict the need for more extensive reconstruction, and identify complications.     

The significance of pelvic floor support on the pelvic floor muscle functions of women with lower urinary tract symptoms

ObjectiveTo explore the significance of pelvic organ prolapse (POP) on pelvic floor muscle (PFM) function among women with lower urinary tract symptoms (LUTS).Materials and methodsFour-dimensional ultrasound data of 577 women with LUTS were retrospectively analyzed. The bladder neck and genital hiatus were assessed during resting, coughing, and squeezing. The bladder neck location, genitohiatal size, and genitohiatal location were evaluated with bladder neck distance (BNd) and bladder neck angle (BNa), genitohiatal dimension (GHd) and genitohiatal area (GHAR), and genitohiatal angle (GHa), respectively.ResultsCompared with women without POP (n = 306), women with POP (n = 271) exhibited higher rates of levator complete avulsion (6.5% vs. 40.2%, P < 0.001), shorter BNd (2.84 ± 1.56 cm vs. 2.45 ± 0.45 cm, P = 0.018), larger BNa (92 ± 15° vs. 101 ± 21°, P < 0.001), longer GHd (5.25 ± 0.72 cm vs. 5.60 ± 0.87 cm, P < 0.001), larger GHa (141 ± 10° vs. 145 ± 9°, P = 0.004), and larger GHAR (20.0 ± 4.7 cm² vs. 24.2 ± 5.6 cm², P < 0.001) during resting. Fewer women with POP were able to maintain stable bladder neck location (79.5% vs. 65.5%, P < 0.001), genitohiatal size (60.7% vs. 51.9%, P = 0.042), and genitohiatal location (61.6% vs. 52.8%, P = 0.044) following coughing. Fewer women with POP were capable of squeezing (77.8% vs. 58.3%, P < 0.001).ConclusionAmong women with LUTS, the presence of POP is associated with weaker resting, involuntary, and voluntary PFM functions.     

Adoption of the pelvic organ prolapse quantification system in peer-reviewed literature

OBJECTIVE: The purpose of this study was to examine the method of describing pelvic organ prolapse in the peer-reviewed literature since the introduction of the Pelvic Organ Prolapse Quantification System (POPQ). STUDY DESIGN: Representative US and international gynecology and urology journals were selected for review. All prolapse or urinary incontinence articles published in these journals from January to December of 1999 (period 1) and July 2001 to June 2002 (period 2) were hand searched by two independent reviewers. Systems for grading the severity of pelvic organ prolapse were separated into the following categories: POPQ, Baden-Walker system, Beecham system, grade without reference, or nonstandardized system. Chi-square and Fisher exact tests were used for statistical analysis. RESULTS: A prolapse staging system was not referenced, or a nonstandardized staging system was used in 54.8% of studies. Overall, the POPQ system was the most common system used (22.6%), followed by the Baden-Walker system (19.8%). There was a statistically significant increase in the use of POPQ from period 1 (13.3%) to period 2 (28%) (P=.03). Articles published in gynecology journals were more likely to use the POPQ system than those published in urology journals (29% vs. 14%, P=.009). CONCLUSION: POPQ was the most common system used; however, the staging system was not cited or a nonstandardized staging system was used in more than half of studies.     

改良盆底重建术与传统手术治疗盆腔器官脱垂的随访评价

目的:评价经阴道全子宫切除术加改良盆底重建术和经阴道全子宫切除术加阴道前后壁修补术治疗盆腔脏器脱垂的治疗效果。方法:对2007年4月至2011年4月盆腔脏器脱垂Ⅱ～Ⅳ度102例患者进行术后3个月、6个月、12个月、36个月随访,其中经阴道子宫切除术加改良盆底重建术(重建组)65例,经阴道子宫切除术加阴道前后壁修补术(传统组)37例。采用POP-Q分度法,Ⅱ度及Ⅱ度以上判定为复发。结果:重建组2例(3.08%)复发,传统组6例(16.21%)复发,两组复发率差异有统计学意义(P<0.05);重建组复发患者均合并网片侵蚀、外露,剪除外露网片并局部雌激素治疗后放置子宫托,目前疗效满意;传统组复发患者分别行子宫托治疗、改良盆底重建术、Prolift盆底重建术、阴道封闭术,目前疗效满意;重建组35例术后恢复性生活,传统组25例术后恢复性生活,性功能问卷评分均较术前下降(P<0.05),但两组术后性功能评分无显著差异(P>0.05)。结论:改良盆底重建术作为一种新术式,能更好地修补缺陷、实现结构重建和组织替代,其复发率低,尤其是对于Ⅲ～Ⅳ度脱垂患者较传统手术更具优势。术后复发患者首选子宫托治疗,传统组可行网片再次手术治疗,阴道封闭术为最后的选择方法。     

Vaginal prolapse repair using the Prolift kit: a registry of 100 successive cases

Objectives

To evaluate anatomical, functional outcomes and complications inherent to the treatment of pelvic organ prolapse by implantation of polypropylene mesh, using the Prolift™ kit.

Materials and methods

Single-center observational study of 100 successive patients enrolled in a registry, who underwent Prolift™ prolapse repair. Data on prior treatments, associated procedures and per- and post-operative complications were collected and the patients were seen after 2, 6 and 12 months. Anatomical outcomes were assessed using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system. Function was assessed in terms of urinary and digestive problems, and impact on sex life. Failure was defined as relapse of POP-Q Grade 2 or more.

Results

Of the 100 patients, 32 had an anterior, 14 a posterior, 54 a total Prolift™; 53 had concomitant urinary incontinence surgery. At 6 and 12 months respectively, 8% and 12% of the patients were lost to follow-up. Mean operating time was 39.8 min. With respect to peri-operative complications, there was no bladder or rectal damage but three patients experienced bleeding (≥300 ml) without needing transfusion. POP-Q Grades before surgery were: Grades III-IV cystocele in 65.7% of the anterior Prolift™ patients; Grades II-III rectocele in the posterior; and 77.8% of total were Grade III and 11.1% Grade IV.The incidence of recurrence was 3.6% at Month 6 and 10.2% at Month 12. Significant (p < 0.05) improvements were seen in median scores for the various POP-Q items. With respect to functional problems, stress urinary incontinence was cured in 92% of the patients but 7.7% reported new-onset urinary incontinence after one year. One case of vaginal exposure after one year was observed and major or symptomatic mesh retraction was observed in 8%. New-onset dyspareunia was reported by 11.1% of the patients.

Conclusions

These results confirm the feasibility of using the Prolift™ kit in the repair of prolapse via a vaginal approach and the low per- and post-operative morbidity associated with that technique. Nevertheless, longer-term evaluation is required to confirm the results.     

Collagen content of nonsupport tissue in pelvic organ prolapse and stress urinary incontinence

OBJECTIVE: Reduction in the collagen content of the pelvic floor tissue of the patients with pelvic organ prolapse and/or stress urinary incontinence has been documented previously. However, this is less clear for nonsupport tissue. We aimed to compare the collagen content of the uterine cervix, a nonsupport tissue, of women who had pelvic organ prolapse with and without stress urinary incontinence against those without these problems. STUDY DESIGN: Cervical collagen content was compared between 14 women who had pelvic organ prolapse with and without stress urinary incontinence and 17 controls without these conditions. Specimens were obtained after surgery for benign gynecologic conditions. RESULTS: Groups were similar with respect to age, parity, body mass index, and tobacco use. Women who had pelvic organ prolapse with and without stress urinary incontinence possessed significantly less collagen compared with the controls (8.10%+/-3.43% vs 12.35%+/-4.72%, P=.0104). Furthermore age, parity, body mass index, or tobacco use had no significant relationship to collagen content. CONCLUSION: Cervical collagen content is significantly decreased in women who have pelvic organ prolapse with and without stress urinary incontinence regardless of age, parity, body mass index, or tobacco use.     

Efficacy and safety of anterior vaginal prolapse treatment using single incision repair system: Multicentric study

ObjectiveUp to 80% of all POP surgical procedures are due to anterior vaginal wall prolapse.The aim of this study is to evaluate the efficacy and safety of transvaginal anterior mesh for POP surgical repair.Materials and methods153 consecutive patients with symptomatic or recurrent anterior vaginal prolapse undergoing surgical single-incision mesh (Calistar S) were prospectively enrolled in the study. Preoperative evaluation was performed collecting urogynecological history and performing a clinical exam, 3-day voiding diary and urodynamic testing. All incontinent patients completed the International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF). Operative time, blood loss, perioperative and postoperative complications were prospectively recorded. Postoperative follow-up was scheduled at 1, 6, and 12 months with a urogynecological interview and examination.Success rate was assessed at 1, 6 and 12 months postoperatively.ResultsThe median follow-up was 16.4 months. None of patients had intraoperative complications. Eight patients (5%) required surgical intervention for complications (5 patients (3%) for haematoma and 3 (2%) for vaginal erosion). At 12 months of follow up 130 out of 140 patients (93%) gained the subjective cure criterion, while 129 out of 140 patients (92%) obtained the objective cure criterion. Eleven (7.8%) patients experienced stage 2 or higher prolapse recurrence and three of them with a stage ≥3 underwent reintervention. No significant differences were recorded in primary outcome at 1, 6 or 12 months postoperatively.ConclusionsAnterior compartment prolapse repair by Calistar S (single-incision vaginal mesh) is an effective and safe procedure without significant complications.     

Risk factors of surgical failure following transvaginal mesh repair for the treatment of pelvic organ prolapse

Objective

To identify the factors associated with pelvic organ prolapse (POP) recurrence after transvaginal mesh (TVM) repair.

Study design

One hundred and thirteen women with symptomatic POP stage II to IV were scheduled for TVM procedures. All subjects underwent urinalyses and pelvic examination using the POP quantification (POP-Q) staging system before and after surgery.

Results

Seven (6.2%) of 113 women reported POP recurrence after a mean follow-up time of 30 months. We performed a univariate analysis of patients’ characteristics to identify the predictors of surgical failure after TVM. There was no difference between two groups as to body mass index, POP stage, mesh type, and preoperative urinary symptoms and urodynamic parameters (P > 0.05). However, we found that uterine prolapse (P = 0.016) and surgical experience (P = 0.043) were two significant predictors of surgical failure. Multivariate logistic regression showed similar results.

Conclusion

Advanced uterine prolapse and lack of surgical experience were two significant predictors of failure following TVM. POP recurrence after mesh repair appears to be unlikely beyond the learning curve.     

Estrogen levels and estrogen receptors in patients with stress urinary incontinence and pelvic organ prolapse.

OBJECTIVES: To investigate the histologic characteristics of tissues presumed to be the cause of urinary stress incontinence and pelvic organ prolapse. METHODS: Cardinal ligament and uterosacral ligament samples were obtained from 73 women undergoing hysterectomy. The evaluation of estrogen receptors (ERs) by immunohistochemical staining was semi-quantitative. Serum estrogen was determined by ELISA. Statistical analyses were performed by the independent-sample t-test and one-way ANOVA. RESULTS: Serum estradiol levels and ER values in the premenopausal women with pelvic organ prolapse were significantly lower than in the control group (P<0.01). A positive correlation was found between ERs and the number of postmenopausal years (P<0.01). ER values were similar in the cardinal and uterosacral ligaments. CONCLUSIONS: Serum estrogen levels and ER values are significantly lower in the uterine ligaments of premenopausal women with pelvic organ prolapse, and there was a positive correlation between ER values in the uterine ligaments and the duration of postmenopausal years. Serum estrogen levels and ER values were similar in the cardinal ligament and the uterosacral ligament.     

Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system

OBJECTIVE: Our purpose was to determine the intraobserver and interobserver reliability of site-specific measurements and stages with the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society 1994 draft prolapse terminology document. STUDY DESIGN: Women who completed informed consent procedures underwent pelvic examinations by two investigators, each blinded to the results of the other's examination. The reproducibility of the nine site-specific measurements and the summary stage and substage were analyzed with Spearman's correlation coefficient (r_s) and Kendel τ B Correlation Coefficient (τ_b), respectively. Similar analyses were performed on supine and upright examinations performed at two different times by one examiner. RESULTS: Experienced examiners averaged 2.05 minutes per examination and new examiners averaged 3.73 minutes. In the study of interobserver reliability, 48 subjects, mean age 61 ± 14 years, parity 3 ± 2, weight 74 ± 31 kg, comprised the study population. Correlations for each of the nine measurements were substantial and highly significant (r_s 0.817, 0.895, 0.522, 0.767, 0.746, 0.747, 0.913, 0.514, and 0.488, p = 0.0008 to <0.0001). Staging and substaging were highly reproducible (τ_b 0.702 and 0.652). In no subject did the stage vary by more than one; in 69% stages were identical. In the study of intraobserver reliability, for 25 subjects correlations for each of the nine measurements were equally strong (r_s 0.780, 0.934, 0.765, 0.759, 0.859, 0.826, 0.812, 0.659, 0.431). Measurements from the upright examinations reflected greater prolapse. Staging and substaging were highly reproducible (τ_b 0.712 and 0.712). In no subject did the stage vary by more than one; in 64% stages were identical. All stage discrepancies represented an increase in the upright position. CONCLUSIONS: There is good reproducibility of measures with the proposed system. The data suggest that the reliability is independent of examiner experience. Patient position is likely important in maximizing the severity of the prolapse. (Am J Obstet Gynecol 1996;175:1467-71.)