Functional and anatomic follow-up of enterocele repairs

OBJECTIVE: To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair. METHODS: Fifty-four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms. RESULTS: Fifty-four women had enterocele repairs as part of their surgery. Mean follow-up time was 16 months (range 6-29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty-three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow-up. CONCLUSION: Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.     

Risk factors for surgical failure after posterior intravaginal slingplasty: a case series

Objective

The goal of this study was to analyze the potential risk factors of surgical failure after posterior intravaginal slingplasty for uterine or vaginal vault prolapse.

Study design

Women with symptomatic uterine or vaginal vault prolapse that extended to or beyond the introitus were eligible for inclusion. Each woman underwent a detailed history taking and a vaginal examination for staging of pelvic organ prolapse before treatment. Follow-up evaluations were at 3, 6, 9, 12, 18, 24, and 30 months after the operation. Surgical failure is defined as the presence of symptomatic uterine or vaginal vault prolapse ≧stage 2 (higher than 0, at the hymen) after posterior intravaginal slingplasty.

Results

The surgical failure rate (8/61) following posterior intravaginal slingplasty was 13.1%. Using univariable logistic regression, C or D point stage IV before surgery was significantly associated with surgical failure of posterior intravaginal slingplasty for uterine or vaginal vault prolapse. Complications (11/61 = 18%) included vaginal erosion (9.8%), blood loss over 500 ml (4.9%), and perineal pain (3.3%).

Conclusion

Procidentia is a significant risk factor for surgical failure of posterior intravaginal slingplasty, and therefore this procedure should never be used alone in patients with complete uterine or vaginal vault prolapse.     

Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse

Objective

To determine whether the presence of obstructive defecatory symptoms is associated with the site and severity of pelvic organ prolapse. Methods: A cross-sectional study was performed of women with pelvic organ prolapse of grade 2 or greater who had completed a validated questionnaire that surveyed pelvic floor symptoms. Associations between patient characteristics, site and severity of prolapse, and obstructive bowel symptoms were investigated.

Results

Among 260 women with pelvic organ prolapse, women with posterior vaginal wall prolapse were more likely to report obstructive symptoms, such as incomplete emptying (41% vs 21%, P = 0.003), straining at defecation (39% vs 19%, P = 0.002), and splinting with defecation (36% vs 14%, P < 0.001) compared with women without posterior vaginal wall prolapse. There was no significant association between any bowel symptom and increasing severity of prolapse.

Conclusions

Obstructive bowel symptoms are significantly associated with the presence of posterior vaginal wall prolapse, but not with the severity of prolapse.     

The relationship of vaginal prolapse severity to symptoms and quality of life

OBJECTIVE: To assess the relationship and location of vaginal prolapse severity to symptoms and quality of life. DESIGN: A prospective observational study. SETTING: Urogynaecology Unit, Imperial College, St Mary's Hospital, London. POPULATION: Women with and without symptoms of vaginal prolapse. METHODS: All women completed a validated Prolapse Quality of Life (P-QOL) questionnaire. This included a urinary, bowel and sexual symptom questionnaire. All women were examined using the Pelvic Organ Prolapse Quantification system (POP-Q). POP-Q scores in those with and without prolapse symptoms were compared. Urinary and bowel symptoms and sexual function were compared and related to prolapse severity and location. MAIN OUTCOME MEASURES: POP-Q scores, P-QOL scores, urinary and bowel symptoms and sexual function. RESULTS: Three hundred and fifty-five women were recruited-233 symptomatic and 122 asymptomatic of prolapse. The median P-QOL domain scores ranged between 42-100 in symptomatic women and 0-25 in those who were asymptomatic. The stage of prolapse was significantly higher in those symptomatic of prolapse (P < 0.001) except for perineal body (PB) measurement. Urinary symptoms were not correlated with uterovaginal prolapse severity whereas bowel symptoms were strongly associated with posterior vaginal wall prolapse. Cervical descent was found to have a relationship with sexual dysfunction symptoms. CONCLUSIONS: Women who present with symptoms specific to pelvic organ prolapse demonstrate greater degrees of pelvic relaxation than women who present without symptoms. Prolapse severity and quality of life scores are significantly different in those women symptomatic of prolapse. There was a stronger relationship between posterior prolapse and bowel symptoms than anterior prolapse and urinary symptoms. Sexual dysfunction was related to cervical descent.     

Posterior vaginal wall defects and their relation to measures of pelvic floor neuromuscular function and posterior compartment symptoms

OBJECTIVE: The purpose of this study was to describe the pelvic floor neuromuscular function and posterior compartment symptoms in patients with posterior vaginal wall prolapse. STUDY DESIGN: Two hundred twenty-seven women who were referred to a urogynecology and urology clinic were enrolled prospectively. Each patient completed a health history questionnaire and standardized physical examination that specifically graded uterovaginal prolapse according to the pelvic organ prolapse quantification system. RESULTS: Sixty-nine women had a pelvic organ prolapse quantification system point (most dependent portion of the posterior vaginal wall during straining as measured from the hymeneal ring) of < or =-1. Older age, a history of hysterectomy, a genital hiatus of >3 cm (48% vs 24%; P =.002), and perineal descent of > or =2 cm (14% vs 5%; P =.042) were significantly more common in women with posterior vaginal prolapse. When women with posterior prolapse and symptomatic complaints were compared with asymptomatic women with prolapse, a perineal descent of > or =2 cm (21% vs 0%; P =.004) was significantly more common in the symptomatic group. CONCLUSION: Pelvic floor neuromuscular function should be related to posterior vaginal prolapse and symptoms; however, only perineal descent appears associated strongly with both symptoms and prolapse in this population.     

Vaginal wall descensus and pelvic floor symptoms in older women

OBJECTIVE: To understand the clinical significance of early pelvic organ prolapse in older women, we studied associations between vaginal descensus and pelvic floor symptoms. METHODS: In this cross-sectional study, 270 women enrolled at one site of the Women's Health Initiative clinical trial completed a questionnaire modified from the Pelvic Floor Distress Inventory on pelvic floor symptoms and underwent a Pelvic Organ Prolapse Quantification (POP-Q) examination. We tested associations between symptoms (individual and grouped) with anterior, posterior, uterine, and maximum vaginal descensus. RESULTS: Mean age was 68 years. Ninety-six percent had POP-Q stages I or II. Only obstructive urinary symptoms and feeling a bulge were associated with vaginal descensus. Obstructive urinary symptom scores increased as anterior (P = .04), posterior (P < .01), and maximal (P = .01) vaginal descensus increased. Urinary incontinence or bowel symptoms were not associated with descensus of any vaginal compartment. 'See or feel a bulge,' reported by 11 women (4%), was associated with descensus in all compartments (P < or = .04 for all) and with prolapse at or beyond the hymen (P < .001). This symptom was specific (100%), but not sensitive (16%) for prolapse, defined as descensus at or beyond the hymen. CONCLUSION: Vaginal support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge. However, symptoms are not useful in discriminating between women with and without milder vaginal wall descensus. Based on these results, we suggest that other etiologies for bothersome bladder or bowel complaints be considered before performing surgery for early pelvic organ prolapse.     

改良的经后路阴道壁悬吊术在盆底重建中的应用

目的 探讨应用改良的经后路阴道壁悬吊(PVWH)术治疗盆腔器官脱垂,同时保留子宫,及进行盆底重建的可行性和有效性。方法对32例有不同缺陷的盆腔器官膨出患者进行改良的PVWH术。应用聚丙烯网片悬吊双侧骶棘韧带,将脱垂的子宫复位;经阴道放置悬吊带,以加固子宫骶骨韧带;在应用聚丙烯网片形成新的阴道直肠筋膜的同时,加固肛提肌板,完成中后盆底重建。根据国际尿控协会制定的盆腔器官脱垂定量(POP-Q)分度法,评价手术效果。结果改良的PVWH术的手术时间平均为55min,出血量平均为150ml。根据POP-Q分度法,32例患者的子宫脱垂全部得到纠正;平均随访7个月,均未出现阴道扭曲、缩短,无性生活障碍。除1例患者出现宫颈延长外,其余无复发;各种症状改善率≥50％。结论改良的．PVWH术,对子宫脱垂患者在保留子宫的同时行中后盆底重建的短期疗效稳定,长期疗效尚有待进一步观察。     

Posterior intravaginal slingplasty with preservation of the uterus: a modified surgical technique in a young myelomeningocele patient

We report a case of uterine prolapse in a young woman, treated by posterior intravaginal slingplasty with preservation of the uterus as a feasible and safe surgical procedure. Posterior intravaginal slingplasty is commonly used to correct vaginal vault prolapse, but may be a valuable alternative to correct uterine prolapse. We compare this technique to other techniques to correct uterine prolapse.     

Combined anterior vaginal wall mesh with sacrospinous ligament fixation or with posterior intravaginal slingplasty for uterovaginal or vaginal vault prolapse

Objective

To evaluate outcomes of anterior vaginal wall mesh augmentation with concomitant sacrospinous ligament fixation (SSLF) or with concomitant posterior intravaginal slingplasty (IVS) for uterovaginal or vaginal vault prolapse.

Study design

Women with symptomatic uterovaginal or vaginal vault prolapse were randomly allocated to SSLF or IVS. All underwent concomitant anterior repair augmented with self-tailored multifilament polypropylene and polyglactin composite mesh. Before and 2, 12, 24 and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of pelvic organ prolapse at stage II or beyond (−1 cm or greater) at any site of the vaginal wall. Secondary outcomes included perioperative and postoperative complications, symptom resolution, reoperation and mesh exposure.

Results

Twenty-two women were recruited from March 2003 to December 2005. At 3-year follow-up3 (2 posterior and 1 apical) out of 14 (21%) in the IVS group had anatomic recurrences of pelvic organ prolapse, and 1 anterior out of 8 (13%) in the SSLF group. Severe operative complications or reoperations did not occur. The proportions of symptomatic patients, including those with dyspareunia, did not differ between the groups. Erosion of the anterior multifilament mesh was found in 2 out of 22 cases (9%; 95% CI 3-28%).

Conclusion

At 3-year follow-up anterior repair reinforced with a composite mesh with concomitant sacrospinous ligament fixation or with concomitant posterior intravaginal slingplasty allowed feasible support in patients with severe pelvic organ prolapse.     

AAGL Practice Report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy

Pelvic organ prolapse may adversely impact physical, sexual and emotional health. Women with symptomatic prolapse often experience altered bladder and bowel function, increased pelvic pressure, diminution of sexual satisfaction, and altered body image. With increasing vaginal descent, various bladder, bowel, and prolapse symptoms are increased. Approximately 200,000 women undergo inpatient procedures for prolapse in the United States each year, with regional and racial differences in rates of surgery reported. The demand for health care services related to pelvic floor disorders will increase at twice the rate of the population itself.     

Vaginal descent and pelvic floor symptoms in postmenopausal women: a longitudinal study

OBJECTIVE: To determine whether vaginal descent changes are associated with pelvic floor symptoms in postmenopausal women. METHODS: This 4-year prospective study included 260 postmenopausal women with an intact uterus enrolled at one Women's Health Initiative (WHI) clinical trial site. All completed at least two annual pelvic organ prolapse quantification (POP-Q) examinations and symptom questionnaires (30 bladder, bowel, and prolapse symptom items, modified from the Pelvic Floor Distress Inventory). Symptoms were grouped, and group scores categorized into two or three evenly distributed levels. Year 4 data collection was incomplete because the overall WHI study halted. Generalized logistic linear models and generalized estimating equation methods were used to measure associations between vaginal descent and a symptom or symptom score, controlling for time, age, and body mass index (BMI). RESULTS: Mean age was 68+/-5 years, BMI 30+/-6 kg/m(2), and median parity 4. Ninety-five percent of women had POP-Q stages I-II prolapse. Increasing maximal vaginal descent was associated with "see/feel a bulge" and "sensation of protrusion or bulging," and with obstructive bladder, prolapse, and obstructive bowel scores. Increasing apical descent (POP-Q point C) was associated with "see/feel a bulge," increasing anterior descent (POP-Q point Ba) with bladder pain and obstructive bladder scores, and increasing posterior descent (POP-Q point Bp) with the bowel incontinence score. CONCLUSION: Although previous work showed that most pelvic floor symptoms correlated poorly with levels of early prolapse, longitudinal analysis suggests that vaginal descent progression over time is positively associated with various bladder, bowel, and prolapse symptoms in postmenopausal women with stages I-II prolapse. LEVEL OF EVIDENCE: II.     

The effect of prolapse repair on sexual function in women

IntroductionSexual dysfunction is common in women with pelvic organ prolapse (POP). Treatment of symptomatic prolapse often requires surgery. The outcome of prolapse symptoms following surgery is well studied and reported, but evidence on outcomes of sexual function following pelvic reconstructive surgeries is limited.AimThe objective of this study was to assess the impact of different forms of surgery for POP on sexual function using prospectively collected data.MethodsIn this ethically approved project, data were collected prospectively for women undergoing prolapse repair between 2008 and 2010 and were stratified into four groups: “posterior repair,”“anterior repair,”“anterior repair with vaginal hysterectomy,” and “combined anterior and posterior repair.” The electronic personal assessment questionnaire‐pelvic floor (ePAQ‐PF) was used to assess symptoms. The sexual dimension of ePAQ‐PF computes domain scores for sexual dysfunction secondary to vaginal symptoms and dyspareunia on a scale of 0–100 (0 = best possible and 100 = worst possible health status). ePAQ‐PF was completed in 123 sexually active women both pre‐ and 3–6 month postoperatively. Results were analyzed using SPSS (SPSS Inc., Chicago, IL, USA). Pre‐ and postoperative scores for each domain were compared in all groups (Student's t‐test). Individual symptoms in these domains were compared using Wilcoxon signed‐rank test.Main Outcome MeasuresChange in sexual symptoms and dyspareunia following prolapse surgery in each group.ResultsWomen undergoing anterior repair or anterior repair and vaginal hysterectomy reported significant improvement in sexual symptoms and dyspareunia. Women undergoing a posterior repair in isolation had improved sexual function following surgery though improvement in dyspareunia was not significant. Women undergoing combined anterior and posterior repair had the least improvement in sexual function.ConclusionsSexual function improves in women following pelvic reconstructive surgery, but the improvement is more substantial following anterior repair either alone or in combination with a vaginal hysterectomy when compared with posterior repair. Dua A, Jha S, Farkas A, and Radley S. The effect of prolapse repair on sexual function in women. J Sex Med 2012;9:1459–1465.     

Long term review of laparoscopic sacrocolpopexy

OBJECTIVE: Assessment of long term outcome following laparoscopic sacrocolpopexy. DESIGN: Retrospective follow up study using standardised examination with pelvic organ prolapse quantification system (POP-Q) and questionnaires. SETTING: A tertiary urogynaecology unit in the North West of England. POPULATION: One hundred and forty consecutive cases who had a laparoscopic sacrocolpopexy at St Mary's Hospital, Manchester, between 1993 and 1999. METHODS: Women completed questionnaires and were examined in gynaecology clinic or sent postal questionnaires if unable to attend the clinic. MAIN OUTCOME MEASURES: Adequacy of vault support and recurrent vaginal prolapse assessed by POP-Q score. Assessment of prolapse, urinary and bowel symptoms and sexual function using questionnaires. RESULTS: One hundred and three women were contacted after a median of 66 months. Sixty-six women were examined and a further 37 women filled in questionnaires only. Recurrent vault prolapse occurred in 4 of the 66 women who were examined. Prolapse had recurred or persisted in 21 of 66 women, with equal numbers of anterior and posterior vaginal wall prolapse. Overall, 81/102 (79%) said that their symptoms of prolapse were 'cured' or 'improved'; 39/103 (38%) still had symptoms of prolapse. For every two women who were cured of their urinary or bowel symptoms, one woman developed worse symptoms. CONCLUSIONS: Among the 66 women available for examination laparoscopic sacrocolpopexy provided good long term support of the vault in 92%. Forty-two percent of these women had recurrent vaginal wall prolapse. Despite this, 79% of women felt that their symptoms of prolapse were cured or improved following surgery.     

Abdominal sacral colpoperineopexy: A new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse

OBJECTIVE: Our purpose was to assess a modification of abdominal sacral colpopexy in 19 patients. STUDY DESIGN: The rectovaginal space was dissected to the superior aspect of the posterior vaginal fascia still contiguous with the perineal body. Mersilene (Ethicon, Somerville, N.J.) mesh was sutured to this fascia and along the entire posterior vaginal wall. Patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles are reported. Outcome measures included bowel symptoms and pelvic organ prolapse staging. Defecography was performed in three patients. Wilcoxon signed rank analysis was used for comparison of prolapse measures. RESULTS: Mean follow-up was 11 weeks. Bowel symptoms improved in 8 of 11 women. No subjects had greater than stage II prolapse postoperatively and median improvement in stage was 3 (range 2 to 4). The mean decrease in the genital hiatus measurement was 3.13 ± 1.25 (range 2 to 6) cm. Postoperative defecography documented correction of rectoceles and enteroceles and improvement in perineal descent with straining. CONCLUSIONS: Abdominal sacral colpoperineopexy is effective surgery for vaginal vault prolapse associated with perineal descent and posterior vaginal defects.(Am J Obstet Gynecol 1997;177:55)     

Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse

OBJECTIVE: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. STUDY DESIGN: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. RESULTS: After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. CONCLUSION: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.     

Vaginal surgical approach to vaginal vault prolapse: considerations of anatomic correction and safety

PURPOSE OF REVIEW: Pelvic organ prolapse is a common problem in women and often requires surgical management. Vaginal vault prolapse requires significant expertise. The pelvic reconstructive surgeon should be familiar with various methods of repair, including the vaginal approach, in order to provide appropriate individualized patient care. The safety of procedures should be balanced against the need for anatomic correction. RECENT FINDINGS: Vaginal surgical approaches such as sacrospinous suspension, although shown in the past to have slightly less success than abdominal approaches such as sacral colpopexy, continue to have good safety and efficacy profiles, and may be used in appropriately selected patients. Randomized clinical trials are still required to compare different vaginal procedures such as sacrospinous and uterosacral ligament suspension. A new minimally invasive transperineal approach, posterior intravaginal slingplasty, requires further evaluation before being used in routine clinical practice. SUMMARY: Posthysterectomy prolapse of the apical vaginal compartment frequently requires a surgical solution. This may be approached via the abdominal, vaginal or combined route. A vaginal approach, being less invasive, may be the safer option if carefully performed. The gynecologic surgeon must balance the advantages of anatomic correction (e.g. with sacrospinous vault suspension) against the advantages of a potentially safer yet less anatomically correct procedure (e.g. colpocleisis). The surgical approach must be individualized for every patient.     

Morphometric properties of the posterior vaginal wall in women with pelvic organ prolapse

OBJECTIVE: Our purpose was to analyze the morphometric properties of the posterior vaginal wall and compare the smooth muscle distribution in the posterior vaginal muscularis in women with and without pelvic organ prolapse. STUDY DESIGN: Specimens were taken from the apex of the posterior vaginal wall after hysterectomy from 15 women with pelvic organ prolapse and from 8 healthy control subjects. Smooth muscle cells of the posterior vaginal wall were identified by immunohistochemistry with antibodies to smooth muscle alpha-actin. Morphometric analysis was performed on histologic cross-sections of the posterior vaginal wall to determine the fractional area of nonvascular smooth muscle in the muscularis. The innervation pattern of the vaginal wall was determined by use of S100 immunostaining. Statistical comparisons between two groups were conducted by a Student t test. Comparisons between multiple groups were conducted with a one-way analysis of variance followed by a post-hoc Student-Neuman-Keuls test. RESULTS: The fractional area of nonvascular vaginal smooth muscle in the muscularis of women with posterior wall prolapse was significantly decreased compared with that of healthy control subjects. Nerve bundles were located in the deep vaginal muscularis and adventitia of the posterior vaginal wall. In women with posterior wall prolapse, nerve bundles were smaller and fewer in number. CONCLUSION: Morphologic features of the posterior vaginal wall are significantly altered in women with posterior wall prolapse compared with asymptomatic control subjects.     

Bilateral iliococcygeal fixation for vaginal vault prolapse and enterocele repair using a new suturing device--the digital needle driver

The objective of our study was to evaluate the surgical feasibility, efficacy and safety of the digital needle driver (DND 202), a modified, flexible surgical device, during iliococcygeal fixation (ICF) for vaginal vault prolapse and enterocele repair. A prospective longitudinal study was carried out among 21 consecutive patients who underwent bilateral iliococcygeal fixation at St George's Hospital, London. All patients filled a comprehensive questionnaire for pre- and post-operative prolapse, urinary, bowel and sexual symptoms and underwent pre- and post-operative site-specific vaginal examination, following the standardized International Continence Society scoring for prolapse, pre-operative urodynamic studies and analysis of the surgical results. The outcome measures were the feasibility of the procedure, the time needed, intra- and post-operative complications, short-term post-operative prolapse-associated symptoms and pelvic organ prolapse quantification. The mean age of the patients was 65 [5] years and the mean body mass index (kg/m(2)) was 23 [2.7]. In addition to ICF, 8 patients underwent vaginal hysterectomy, 18 had posterior repairs, 7 had anterior repairs and 6 had TVT. The mean time for ICF was 20 [11] minutes, the mean blood loss per surgical procedure was 264 [225] mL and the mean hospitalization time was 4.6 [1.2] days. Postoperatively, one patient had mesh erosion. At short-term post-operative evaluation none of the patient had prolapse symptoms. There was a statistically significant improvement in all stages of the apical and posterior walls prolapse (p < 0.001). The mean total vaginal length was significantly shorter postoperatively (7.8 [1.0] cm vs 6.6 [1.4] cm, p < 0.001). Thus, we can conclude that the use of DND device may facilitate the vaginal approach for vaginal vault prolapse and enterocele repair.     

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse

OBJECTIVE: To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure. METHODS: All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months. RESULTS: Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71-12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction. CONCLUSION: A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3.     

Transvaginal repair of anterior and posterior compartment prolapse with Atrium polypropylene mesh

OBJECTIVE: To determine the efficacy and safety of a new technique using Atrium polypropylene mesh (Atrium, Hudson, New Hampshire, USA) as an overlay graft for repair of large or recurrent anterior and posterior compartment prolapse. DESIGN: A retrospective review of women who had vaginal prolapse surgery with Atrium mesh reinforcement. SETTING: Tertiary referral urogynaecology unit in Australia. POPULATION: Forty-seven women where mesh was placed under the bladder base with lateral extensions onto the pelvic sidewall, 33 women where a Y-shaped mesh was placed from the sacrospinous ligaments to the perineal body and 17 women who had mesh placement in both compartments. METHODS: Women were assessed by site-specific vaginal examination pre-operatively and post-operatively at six weeks, six months and two years. MAIN OUTCOME MEASURES: All complications. Rate of recurrent prolapse assessed by the Baden-Walker halfway classification system. RESULTS: Mean follow up was 29 months (range 6 to 52). Four of 64 women with anterior mesh placement (6%) developed a grade 2 asymptomatic cystocele. Five women (5%) required further surgery for recurrent prolapse at a non-mesh site. Erosion occurred in nine women (9%). Three healed after intravaginal oestrogen cream, five after excision of exposed mesh and vaginal closure and one woman also had surgical closure of a rectovaginal fistula. The risk of mesh erosion decreased over the study period. Urinary, coital and bowel symptoms were significantly improved following surgery. CONCLUSIONS: This technique shows promise in correcting pelvic organ prolapse. Vaginal mesh erosion is the most common complication and is related to surgical experience.