CHAPTER 10 Scott W. Smilen1,2Kimberley Ferrante1Dianne Glass1,2 and Dominique Malacarne1,2 Division of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, NY, USA Division of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Department of Urology, NYU Langone Medical Center, New York, NY, USA Pelvic organ prolapse is a benign, common condition that can significantly impact a woman’s life. Approximately 3% of women complain of feeling a vaginal protrusion while up to 50% of women will be found to have prolapse on examination [1]. Pelvic organ prolapse occurs in women across all age groups, with peak incidence in the 1970s [2]. Risk factors include age, parity, connective tissue disorders, menopause and conditions that increase abdominal pressure (e.g. obesity, chronic constipation) [3, 4]. Acceptable treatment options include observation (for women who are minimally symptomatic), surgery and non‐surgical treatments. In the United States, approximately 300 000 surgeries per year are performed for pelvic organ prolapse [5] and a woman has about a 6% lifetime risk of having surgery for prolapse [6]. We conducted a review of pelvic organ prolapse using evidence based medicine. Clinical questions relevant to the clinical scenario were developed using the evidence based medicine format, PICO (Population, Intervention, Comparison, and Outcomes). We searched the EMBASE, CINAHL, PubMed, Medline, and Cochrane Databases as well as performed a manual search of references for each question. In this review we will discuss pelvic organ prolapse interventions, including considerations for hysterectomy vs. uterine preservation, routes of surgery and use of native tissue vs. graft materials. Pelvic organ prolapse occurs because of weakness in the pelvic floor muscles and its supporting network of connective tissues and ligaments. Vaginal childbirth is a common inciting reason for this problem which is closely related to hernias. Some women with prolapse are asymptomatic, while others may see or feel pressure and/or protrusion, experience voiding, defecatory, or sexual dysfunction. Impairment in quality of life typically leads women to seek treatment for this problem. When the normal pelvic supportive structures are impaired, organs including the bladder, cervix/uterus, rectum, and peritoneum/intestines, may herniate into and distend the vaginal canal. The entities associated with these areas of prolapse can be called, respectively, cystocele, uterine prolapse, rectocele, and enterocele. Pelvic organ prolapse is considered to be a slowly progressive problem, although there are few studies evaluating its natural evolution. One study found that 78% of women had no change in their prolapse stage after 16 months of follow‐up [7]. Therefore, many women without significant bother may be observed. Those desiring treatment can utilize a vaginal insert device (pessary) or undergo surgery. There are many different considerations for women undergoing prolapse repair surgery, and operations should be tailored toward each patient’s anatomic abnormalities, considering their objectives, age, medical co‐morbidities, and surgeon experience. Vaginal pessaries are effective non‐surgical treatments for women with pelvic organ prolapse. Most women can be effectively fit with a pessary [8]. The risks from pessary use are very low relative to surgery, whereas the benefit may be relief of prolapse symptoms. There is also some data to suggest therapeutic effects of pessaries. Recent literature reports significant improvement in stage of disease after consistent pessary use for one year [9]. Additionally, there is data to support low likelihood of prolapse worsening during pessary use. Pessaries therefore should be considered for all women with prolapse [10]. There are many different types, sizes, and shapes of pessaries and the individual efficacies have not been extensively compared to each other. One randomized crossover trial aimed at comparing symptoms relief and change in life impact for women using the ring with support and Gelhorn pessaries revealed equivalence in clinical efficacy among the two devices [11]. Neither the optimal way to fit a pessary nor how best to manage it have been studied. It is generally recommended that women are taught to change the pessary themselves and to do so as frequently as they desire. Prolapse symptoms are usually worse during the day when patients are upright and improve at night with the supine position. Therefore, pessaries may remain out overnight with little adverse consequence. For patients unable to change their pessary, providers can do this at least every three months. When pessaries are retained over long periods of time, women will often develop manifestations of long‐term foreign body use, including inflammatory discharge, ulceration, and bleeding. Various creams and gels are often recommended for regular use to decrease the occurrence of these problems. None of these strategies have been adequately studied. The pathology of uterine prolapse is deficiency in the supporting structures for the uterus. These include Level I apical support, the uterosacral, and cardinal ligaments, as well as widening of the genital hiatus [12]. Since uterine descent is a result of these disruptions, the uterus in theory can be re‐attached to its ligamentous supports and not removed. A uterine suspension or hysteropexy procedure therefore may be utilized for these patients. Some women may prefer hysteropexy for reasons including: preservation of fertility, body image, or patient preference [13]. Alternatively, removal of the uterus (i.e. hysterectomy) will eliminate the risk for uterine cancer (as well as cervical cancer if the cervix is removed), eliminate menstrual bleeding and provide permanent contraception. Hysteropexy procedures may be performed vaginally, abdominally, or laparoscopically/robotically. When performed vaginally, the cervix, and upper vagina may be attached to the sacrospinous or uterosacral ligaments, typically done with sutures or graft material. Abdominal, laparoscopic or robotic routes may be utilized to shorten uterosacral ligaments and attach the cervix/upper vagina to the proximal segments of those ligaments. Alternatively, sacro‐hysteropexy may be performed by attaching a piece of mesh between the anterior longitudinal ligament at the sacral promontory and the cervix [14, 15]. There are no studies that have compared the various types of hysteropexy procedures. Overall, there is a paucity of literature comparing hysteropexy to hysterectomy, however there is some data to support similar results in durability when looking at these two techniques [16]. A recent multicenter randomized non‐inferiority trial looking at women with stage II prolapse or higher found that sacrospinus hysteropexy was non‐inferior for anatomical recurrence of the apical compartment, bothersome bulge symptoms and repeat surgery, when compared with vaginal hysterectomy [17]. However, in other reports, hysterectomy has been demonstrated to decrease the risk for recurrent prolapse when compared to hysteropexy in women with advanced (Stage III or IV) prolapse [16]. Colpocleisis, or vaginal closure, is another alternative to hysterectomy in women with prolapse. Patients undergoing this procedure must be thoroughly counseled regarding the irreversible loss of sexual function following colpocleisis. In such patients, this has been shown to be a very successful procedure, yielding high patient satisfaction [18]. Each mode of prolapse repair has varying degrees of efficacy. There are also multiple ways to define success when looking at the efficacy of prolapse operations. Some studies look at subjective outcome measures such as patient symptoms and quality of life questionnaires. Others look at objective measures such as anatomic recurrence. In fact, a 2009 paper by Barber et al. looked at 18 different definitions of success after abdominal sacrocolpopexy and found that success varied widely based on definition. They also found that the absence of bulge symptoms correlated strongly with a patient’s assessment of improvement. Prolapse past the hymen seems to be the point where women report more bulge symptoms. This study concluded that using the hymen as the “cut off point” for anatomic success seems to be reasonable [19, 20]. Although this recommendation was published in 2009, current reviews are limited to the definition of success used in the individual studies. One such review by Hill and Barber nicely summarizes success rates of apical prolapse repairs [21]. Vaginal operations include McCall culdoplasty, Iliococcygeus fixation, sacrospinous ligament fixation, uterosacral ligament suspension, and colpocleisis. Sacrocolpopexy is approached abdominally with an open, laparoscopic or robotic approach.
Pelvic floor prolapse/urinary incontinence
Background
Clinical questions
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