Diagnosis of cystocele – the correlation between clinical and radiological evaluation

In patients with genital prolapse involving several compartments simultaneously, radiologic investigation can be used to complement the clinical assessment. Contrast medium in the urinary bladder enables visualization of the bladder base at cystodefecoperitoneography (CDP). The aim of the present study was to evaluate the correlation between clinical examination using the Pelvic Organ Prolapse Quantification system (POP-Q) and CDP. Thirty-three women underwent clinical assessment and CDP. Statistical analysis using Pearsons correlation coefficient (r) demonstrated a wide variability between the current definition of cystocele at CDP and POP-Q (r=0.67). An attempt to provide an alternative definition of cystocele at CDP had a similar outcome (r=0.63). The present study demonstrates a moderate correlation between clinical and radiologic findings in patients with anterior vaginal wall prolapse. It does not support the use of bladder contrast at radiologic investigation in the routine preoperative assessment of patients with genital prolapse.Abbreviations CDP Cystodefecoperitoneography Editorial Comment: The authors attempt to correlate the visceral position of the bladder on fluoroscopy to the anterior vaginal wall measurements on POP-Q examination. Consistent with other published reports, they show only moderate statistical correlations. Clinically, the correlations are probably not useful. Thirty-eight percent of women with radiographic cystoceles had no clinically significant prolapse (stage III or IV). Based on their findings the authors conclude that the routine use of radiologic investigation might not be warranted in the preoperative assessment of women with pelvic organ prolapse. This must be interpreted with caution when generalizing their data to all women with prolapse. Only 17% of the women in this study had had prior pelvic surgery. The authors also do not address how cystodefecoperitoneography results affected the diagnosis of enterocele or rectocele. Other authors have shown a significant increase in enterocele diagnosis using cystodefecoperitoneography.     

Effect of anatomic urethral length on the correlation between the Q-tip test and descent at point Aa of the POP-Q system

The objective of this study is to evaluate the effect of anatomic urethral length on the relationship between descent at point Aa of the pelvic organ prolapse quantification (POP-Q) system and the Q-tip straining angle. The records of 323 patients who were evaluated for urinary incontinence were reviewed. Prolapse staging was performed using the POP-Q system. Urethrovesical junction hypermobility defined as a maximal straining angle ≥30° was assessed with the Q-tip test. Urethral length was measured with a urethral profilometer. A substantial correlation was found between descent at point Aa and the straining Q-tip angle (r = 0.65, p < 0.0001). There was no correlation between the anatomic urethral length and straining Q-tip angle (r = −0.01, p = 0.8). Urethral length does not affect the straining Q-tip angle. Point Aa is a strong predictor of an abnormal straining Q-tip angle in women with stage I anterior vaginal wall prolapse or greater.     

Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse?

Objective: To determine if women with anterior support stages 0 or I by pelvic organ prolapse quantification (POP-Q) system require Q-tip testing to assess urethral mobility. Methods: A prospective study of 134 women presenting for urogynecologic evaluation were examined and assigned stages of anterior wall support according to the POP-Q system. A Q-tip test was performed and urethral hypermobility was defined as a straining angle 30°. The Spearman correlation coefficient was used to assess degree of correlation between POP-Q point Aa position and Q-tip values. Results: The correlation coefficient between point Aa position and Q-tip angle was r=0.787 (P<0.001). Urethral hypermobility was noted in 91% of stage I and 100% of stage II–IV patients. The positive predictive value of Q-tip angle 30° in stage I–IV prolapse was 99%. Conclusion: The POP-Q system is highly predictive of straining urethral angle in all stages of prolapse.     

Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse?

This study aims to evaluate the changes of overactive bladder symptoms to anterior vaginal wall prolapse repair. Ninety-three consecutive women with symptomatic anterior vaginal wall prolapse ≥ stage II and coexistent overactive bladder symptoms were prospectively studied using a urinalysis, urodynamics, King’s Health Questionnaire (KHQ), Prolapse Quality of Life (P-QOL) questionnaire and pelvic organ prolapse quantification (POP-Q) system before and 1 year after surgery. All women underwent a standard fascial anterior repair. Postoperatively, urinary frequency, urgency and urge incontinence disappeared in 60, 70 and 82% of women respectively (p value < 0.001). The vaginal examination findings as well as the quality of life of the women assessed using KHQ and P-QOL significantly improved after surgery (p value < 0.001). This study has demonstrated that anterior vaginal repair does produce significant improvement in overactive bladder symptoms. A larger longer-term study is required to assess if these changes persist over time.     

Assessment of sexual function in women with pelvic floor dysfunction

Forty-seven women participated in a pilot study for a multi-centre randomized controlled trial of the effectiveness of pelvic floor muscle training (PFMT) for women with prolapse. Women with symptomatic stage I or II prolapse [measured by Pelvic Organ Prolapse Quantification (POP-Q)] were randomized to a 16-week physiotherapy intervention (PFMT and lifestyle advice; n = 23) or a control group receiving a lifestyle advice sheet (n = 24). Symptom severity and quality of life were measured via postal questionnaires. Blinded POP-Q was performed at baseline and follow-up. Intervention women had significantly greater improvement than controls in prolapse symptoms (mean score decrease 3.5 versus 0.1, p = 0.021), were significantly more likely to have an improved prolapse stage (45% versus 0%, p = 0.038) and were significantly more likely to say their prolapse was better (63% versus 24%, p = 0.012). The data support the feasibility of a substantive trial of PFMT for prolapse. A multi-centre trial is underway.     

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.     

Pelvic organ prolapse quantification in women referred with overactive bladder

Introduction and hypothesis

A study was carried out to investigate the relationship of anterior vaginal wall descent or prolapse to overactive bladder and its potential mechanisms, advancing the management of overactive bladder (OAB).

Methods

Two hundred twenty-six consecutive women with OAB symptoms were prospectively studied using OAB questionnaire (OAB-q) and pelvic organ prolapse quantification (POP-Q). According to POP-Q staging, they were divided into three groups: stages 0, I, and II. For statistical analysis, a one-way ANOVA was used to test for significant differences with Student–Newman–Keuls post hoc analysis for continuous variables (OAB-q symptom severity, health-related quality of life total scores, and age) and chi-squared test for discrete variable (number of menopausal women).

Results

Twenty-two women (9.73%) did not show any prolapse on examination; 204 (90.26%) had anterior vaginal wall descent or prolapse. The outcome statistics denoted that the difference in OAB-q scores among three groups has statistical significance (P?<?0.05). Anterior vaginal wall descent or prolapse may have associations with OAB.

Conclusions

Anterior vaginal wall descent or prolapse may have associations with OAB and is directly correlated to OAB severity.     

Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography

The aim of the present study was to compare clinical and radiological findings when assessing posterior vaginal wall prolapse. Defecography can be used to complement the clinical evaluation in patients with posterior vaginal wall prolapse. Further development of the defecography technique, using contrast medium in the urinary bladder and intraperitoneally, have resulted in cystodefecoperitoneography (CDP). Thirty-eight women underwent clinical examination using the pelvic organ prolapse quantification system (POP-Q) followed by CDP. All patients answered a standardized bowel function questionnaire. Statistical analysis measuring correlation between POP-Q and CDP using Pearson's correlation coefficient (r) and Spearman's rank order correlation coefficient (rs) demonstrated a poor to moderate correlation, r=0.49 and rs=0.55. Although there was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001), severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging. Vaginal topography and POP-Q staging predict neither radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological evaluation may therefore be a useful complement in selected patients.     

Impacto de la suspensión de la cúpula vaginal al ligamento sacroespinoso sobre el compartimiento anterior

ObjectivesA prospective study was conducted to assess the efficacy of sacrospinous vaginal vault fixation and its impact on the anterior compartment. The Pelvic Organ Prolapse Quantification (POP-Q) system was used to quantify pelvic organ prolapse in the apical and anterior vaginal compartments.MethodsFifty-eight patients underwent a procedure to correct apical prolapse from March 2003 to February 2006. Mean preoperative and postoperative POP-Q scores were respectively: Aa (+0.74; -1.45); Ba (+3.17; -1.36); C (+3.41; -7.71) (p<0.001).ResultsCure rate was 93.1%. Preoperative and postoperative evaluation of the anterior vaginal compartment was respectively: stage 1 (5.2%; 48.3%), stage 2 (6.9%; 34.5%), stage 3 (74.1%; 5.2%), and stage 4 (13.8%; 0%). De novo cystocele occurred in 87.9% of cases. An improvement was seen in lower urinary tract symptoms of urgency, nocturia, and urge incontinence.ConclusionsSacrospinous vaginal vault suspension is effective for the treatment of apical prolapse and leads to formation of cystocele in most cases     

Validation of the pelvic organ prolapse quantification (POP-Q) system in left lateral position

Introduction and hypothesis  The purpose of this study is to examine the inter-observer reliability of the pelvic organ prolapse quantification (POP-Q) system in left lateral position. Methods  Women attending urogynaecology outpatient clinics were examined in the left lateral position using a digital examination and POP-Q. This was repeated separately by a second blinded clinician. The inter-observer agreement was calculated using the Cohen’s kappa coefficient. The POP-Q examination was then performed with a woman lying in dorsal lithotomy position. The POP-Q findings in the two positions were compared. Results  Two hundred and eighteen women were recruited. The digital examination had a moderate inter-observer reliability with a kappa value of 0.54. The POP-Q showed a high degree of reliability (0.88). There was a high degree of correlation between the POP-Q findings in left lateral and lithotomy position (rho > 0.95, p < 0.001). Conclusion  The POP-Q in the left lateral position is reliable, easy to perform, acceptable for patients, and is not a time-consuming examination.     

Does bladder neck descent increase with age?

It is assumed that pelvic organ descent and prolapse increase with age. Epidemiological studies support this assumption. We aimed to define the relationship between age and bladder neck descent (BND) in a retrospective observational study on 790 women referred for evaluation of pelvic floor disorders. Bladder neck descent, cystocele descent and urethral rotation were evaluated on maximal Valsalva manoeuvre, using trans-labial ultrasound. There was a weak negative correlation between bladder neck descent on Valsalva and age (r = −0.154, p < 0.001), which was absent in nulliparous women (n = 107) and stronger (r = −0.213, p < 0.001) in parous women (n = 683). This relationship was evident from the age of 50 years onwards and may be explained by increased tissue stiffness after menopause. The difference observed between parous and nulliparous women is intriguing and raises the issue of obstetric confounders such as historical changes in the likelihood of significant pelvic floor trauma.     

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.     

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.     

Accuracy of assessing Pelvic Organ Prolapse Quantification points using dynamic 2D transperineal ultrasound in women with pelvic organ prolapse

Introduction and hypothesis

We determined the relationship between clinical assessment of female pelvic organ prolapse (POP) using the validated Pelvic Organ Prolapse Quantification (POP-Q) and dynamic 2D transperineal ultrasound (TPUS).

Methods

Women attending the urogynecology clinics between July and October 2009 were recruited. Prolapse was assessed using the POP-Q. Points Ba, Bp and C (anterior, posterior and middle compartments, respectively) were measured. TPUS was performed at maximum Valsalva by another clinician. As the TPUS probe compresses the prolapse that extends beyond the hymen, these women were excluded. A reference line was drawn parallel to the inferoposterior margin of the pubic symphysis, perpendicular to which the leading edge of descent was measured. The offset measured from the curved array of the probe to the reference line was added to the prolapse quantification on ultrasound (US) scan to make it objectively comparable with the POP-Q reference of the hymen. Points Ba, Bp and C on POP-Q were then compared with points of maximum descent achieved on TPUS.

Results

One hundred and fifty-eight women had a POP-Q and TPUS; 20 scans (12.6 %) were not analysable, and 41 women had prolapse beyond the hymen. Ninety-seven women were thus analysed. The correlation between 2D TPUS (with/without the addition of the offset) and POP-Q was statistically significant (p value <0.0001) for all three compartments. The proportion of correct predictions was 59.6 %, 61.5 % and 32.6 % for bladder, bowel and middle-compartment prolapse, respectively.

Conclusion

These findings suggest that the accuracy of pelvic floor US staging is limited and that clinical assessment remains the gold standard.

     

Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes

Our aim was to study the anatomic recurrence rates and quality of life outcomes of patients who had undergone either anterior colporrhaphy (AC) or anterior colporrhaphy and vaginal paravaginal repair (AC + VPVR) as part of surgery for pelvic organ prolapse. Chart reviews were used to identify anatomic prolapse recurrence. Phone interviews assessed quality of life outcomes [Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ)] outcomes. There was a trend towards longer time to anatomic recurrence (any compartment ≥grade 2) in the AC group compared with the AC + VPVR group (median 24 vs 13 months, p=0.069). If only patients who had undergone previous surgery were compared, time to anatomic recurrence appeared significantly longer in the AC group (median 41 vs 12 months, p=0.022). There were 55% of women in the AC group and 46% of women in the AC + VPVR group who reported significant bladder or bulge symptoms based on responses to the phone-administered UDI and IIQ (p=0.89). Our retrospective study did not suggest that adding VPVR was superior in terms of anatomic or quality of life outcomes. Prospective assessment of the role of VPVR in the treatment of pelvic organ prolapse is needed.     

Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results,quality of life and perioperative outcome—a prospective study with 101 cases

Our prospective study evaluates laparoscopic sacrocolpopexy for vaginal vault prolapse focusing on perioperative data, objective anatomical results using the pelvic organ prolapse quantification (POP-Q) system and postoperative quality of life using the Kings Health questionnaire. One hundred one patients completed the study. Fifty five had laparoscopic supracervical hysterectomy and sacrocolpopexy for uterine prolapse and 46 had laparoscopic sacrocolpopexy for post-hysterectomy prolapse. Median follow-up was 12 months. The subjective cure rate was 93% the objective cure rate (no prolapse in any compartment) according to the International Continence Society classification of prolapse was 98%. The main site of objective recurrence (6%) was the anterior compartment. No apical recurrences and no vaginal mesh erosion occurred. Postoperatively overall quality of life and sexual quality showed significant improvement with less than 1% de-novo dyspareunia. The procedure is recommended for experienced laparoscopic surgeons because of severe intraoperative complications like bladder or rectal injuries.     

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).     

Vaginal smooth muscle cell apoptosis is increased in women with pelvic organ prolapse

To compare the smooth muscle content and apoptosis of the vagina in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in women with (n = 6) or without (n = 6) anterior vaginal wall prolapse undergoing hysterectomy. Smooth muscle of the vagina was studied by immunohistochemistry. Digital image analysis was used to determine the fractional area of smooth muscle in the histologic cross-sections. Apoptosis was assessed by TUNEL assay. The fractional area of non-vascular smooth muscle in the vagina of women with anterior vaginal wall prolapse was significantly decreased compared to women without prolapse (0.36 ± 0.12 vs. 0.16 ± 0.12 P = 0.021) and the apoptotic index was significantly higher compared to women without prolapse (0.04 ± 0.01 vs. 0.02 ± 0.03, P = 0.041). The fraction of smooth muscle in the vagina is significantly decreased and the rate of apoptosis is higher in women with anterior vaginal wall prolapse compared to women without prolapse.     

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.