Contemporary understanding of the dynamic anatomy of pelvic floor support has lead us to new conservative surgery for the management uterine prolapse. The uterus itself does not play any role in the pathogenesis of uterine prolapse. Therefore, hysterectomy should not be the prime treatment, and fixing of the cervix to strong ligament such as sacrospinous ligament could give a more successful result and conservation of the uterus in young women. Other techniques, such as abdominal mesh hysteropexy or posterior intravaginal slingoplasty with conservation of the uterus, are alternative surgical options.
Definition
For the purpose of this review, a young woman is defined as a woman of reproductive age. Pelvic organ prolapse (POP) is common and seen in 50% of parous women. The annual aggregated rate of associated surgery is in the range of 10–30 per 10,000 women. It is estimated that women have an 11% life-time risk of undergoing surgery for POP. This rate is projected to increase over the next two to three decades.
Anatomical considerations
POP is usually caused by weakness of the pelvic diaphragm. Descent of the pelvic diaphragm places stress on the endopelvic connective tissue support system. Subsequent increases in intra-abdominal pressure result in prolapse. In most cases, labour and childbirth are thought to be the primary factors responsible for pelvic neuropathies and tissue damage that predispose to the development of POP. Certain connective tissue defects, congenital defects, and operative procedures also contribute to pelvic support defects.
DeLancey’s anatomical cadaver studies showed that pelvic organs are suspended by the pelvic ligament and supported by the levator ani muscle. Breaks in the connective tissue and neuromuscular damage affecting the pelvic floor muscle cause POP. Magnetic resonance imaging (MRI) and ultrasonography have begun to define the dynamics of the pelvic floor and document specific tissue lesions involved in this process.
Vaginal structure
The structures that support the vagina and the uterus are divided into three levels ( Table 1 ).
| Level | Structure | Function | Effect of damage |
|---|---|---|---|
| Level 1: suspension | Parametrium and paracolpium | Suspends uterus and upper vagina | Uterine prolapse or vault prolapse |
| Level 2: attachment | Pubocervical fascia | Supports bladder | Cystocele–urethrocele |
| Level 3: fusion | Rectovaginal fascia, levator ani and perineal body | Supports rectum and fixes vagina to adjacent structures | Rectocele, urethrocele or perineal deficiency |
Level 1 (suspension)
The upper part of the vagina and the cervix are suspended from above. The suspending structure that is attached to the uterus is called the parametrium and the structure attached to the vagina is known as the paracolpium. The parametrium is made up of what is clinically referred to as the cardinal and uterosacral ligaments, and continues down the vagina as the paracolpium. The upper portion of the paracolpium is responsible for suspending the apex of the vagina after hysterectomy.
Level 2 (attachment)
In the middle portion of the vagina, the paracolpium becomes shorter and is attached medially to the vaginal wall and laterally to the pelvic side walls.
Level 3 (fusion)
Fusion corresponds to the region of the vagina that extends 2–3 cm above the hymenal ring; the vagina is fused laterally to the levator muscle and posteriorly to the perineal body whereas anteriorly it blends with the urethra. The opening within the levator muscle through which the urethra and the vagina pass (and through which the prolapse occurs) is called the urogenital hiatus of the levator ani. The hiatus is bound anteriorly by the pubic bone, laterally by levator ani muscle, and posteriorly by the perineal body and external anal sphincter. It has been shown that increasing pelvic organ prolapse is associated with increased urogenital hiatus size. Furthermore, the hiatus was found to be larger after several failed repair operations than after successful surgery or a single failure.
Damage to the upper suspensory fibres of the parametrium and paracolpium causes a different type of prolapse from damage to the midlevel support of the vagina. Therefore, although the loss of the upper suspensory fibre of the paracolpium and the parametrium is responsible for the development of uterine prolapse and vault prolapse, the defects in the support provided by mid-level vaginal support (pubocervical and rectovaginal fasciae) result in a cystocele, rectocele, or both. The support under the urethra has special importance for urinary incontinence. These defects usually occur in varying combinations.
As these specific defects will lead to certain types of prolapse, specific surgical procedures will be needed. For example, if there is a defect at level 2 with detachment of the pubocervical fascia, it will result in the presence of a cystocele; it would be a mistake to believe that the attachment of the vaginal vault to the sacrospinous ligament would correct the anatomical defect of the anterior vaginal wall at level 2. On the other hand, if the parametrium or paracolpium is over-stretched, resulting in second-degree uterine prolapse or vault prolapse, anterior vaginal repair will not correct this type of prolapse and only suspension of the vagina vault will correct such a defect.
Vaginal axis
A study using MRI showed the function and actual shape of the levator ani. The levator ani muscle was dome-shaped at rest. During voluntary pelvic contractions, it straightened becoming more horizontal and, during bearing down, it descended becoming basin shape. This MRI study and others have shown the importance of the vaginal axis over the levator ani plate; in particular during increased intra-abdominal pressure. The tone of the levator muscle increases during increased intra-abdominal pressure and also the configuration of the muscle is altered; it is straightened and made more horizontal to support the vagina. Colpography has shown that the upper vagina lies on an almost horizontal axis towards the sacrum. Using vaginography, Funt et al. and Delancey have also confirmed an angulated shape of the normal upper vagina and that the angle between the upper and lower vaginal axis is about 130° ( Fig. 1 ). After hysterectomy, the upper third of the vagina is suspended by the vertical fibres of the paracolpium. However, if these fibres are damaged then vault prolapse might occur.
Uterine prolapse is therefore the result of a defect in level 1 support with the damage to cardinal and uterosacral ligaments. The uterus itself plays no role in uterine prolapse.
Anatomical considerations
POP is usually caused by weakness of the pelvic diaphragm. Descent of the pelvic diaphragm places stress on the endopelvic connective tissue support system. Subsequent increases in intra-abdominal pressure result in prolapse. In most cases, labour and childbirth are thought to be the primary factors responsible for pelvic neuropathies and tissue damage that predispose to the development of POP. Certain connective tissue defects, congenital defects, and operative procedures also contribute to pelvic support defects.
DeLancey’s anatomical cadaver studies showed that pelvic organs are suspended by the pelvic ligament and supported by the levator ani muscle. Breaks in the connective tissue and neuromuscular damage affecting the pelvic floor muscle cause POP. Magnetic resonance imaging (MRI) and ultrasonography have begun to define the dynamics of the pelvic floor and document specific tissue lesions involved in this process.
Vaginal structure
The structures that support the vagina and the uterus are divided into three levels ( Table 1 ).
| Level | Structure | Function | Effect of damage |
|---|---|---|---|
| Level 1: suspension | Parametrium and paracolpium | Suspends uterus and upper vagina | Uterine prolapse or vault prolapse |
| Level 2: attachment | Pubocervical fascia | Supports bladder | Cystocele–urethrocele |
| Level 3: fusion | Rectovaginal fascia, levator ani and perineal body | Supports rectum and fixes vagina to adjacent structures | Rectocele, urethrocele or perineal deficiency |
Level 1 (suspension)
The upper part of the vagina and the cervix are suspended from above. The suspending structure that is attached to the uterus is called the parametrium and the structure attached to the vagina is known as the paracolpium. The parametrium is made up of what is clinically referred to as the cardinal and uterosacral ligaments, and continues down the vagina as the paracolpium. The upper portion of the paracolpium is responsible for suspending the apex of the vagina after hysterectomy.
Level 2 (attachment)
In the middle portion of the vagina, the paracolpium becomes shorter and is attached medially to the vaginal wall and laterally to the pelvic side walls.
Level 3 (fusion)
Fusion corresponds to the region of the vagina that extends 2–3 cm above the hymenal ring; the vagina is fused laterally to the levator muscle and posteriorly to the perineal body whereas anteriorly it blends with the urethra. The opening within the levator muscle through which the urethra and the vagina pass (and through which the prolapse occurs) is called the urogenital hiatus of the levator ani. The hiatus is bound anteriorly by the pubic bone, laterally by levator ani muscle, and posteriorly by the perineal body and external anal sphincter. It has been shown that increasing pelvic organ prolapse is associated with increased urogenital hiatus size. Furthermore, the hiatus was found to be larger after several failed repair operations than after successful surgery or a single failure.
Damage to the upper suspensory fibres of the parametrium and paracolpium causes a different type of prolapse from damage to the midlevel support of the vagina. Therefore, although the loss of the upper suspensory fibre of the paracolpium and the parametrium is responsible for the development of uterine prolapse and vault prolapse, the defects in the support provided by mid-level vaginal support (pubocervical and rectovaginal fasciae) result in a cystocele, rectocele, or both. The support under the urethra has special importance for urinary incontinence. These defects usually occur in varying combinations.
As these specific defects will lead to certain types of prolapse, specific surgical procedures will be needed. For example, if there is a defect at level 2 with detachment of the pubocervical fascia, it will result in the presence of a cystocele; it would be a mistake to believe that the attachment of the vaginal vault to the sacrospinous ligament would correct the anatomical defect of the anterior vaginal wall at level 2. On the other hand, if the parametrium or paracolpium is over-stretched, resulting in second-degree uterine prolapse or vault prolapse, anterior vaginal repair will not correct this type of prolapse and only suspension of the vagina vault will correct such a defect.
Vaginal axis
A study using MRI showed the function and actual shape of the levator ani. The levator ani muscle was dome-shaped at rest. During voluntary pelvic contractions, it straightened becoming more horizontal and, during bearing down, it descended becoming basin shape. This MRI study and others have shown the importance of the vaginal axis over the levator ani plate; in particular during increased intra-abdominal pressure. The tone of the levator muscle increases during increased intra-abdominal pressure and also the configuration of the muscle is altered; it is straightened and made more horizontal to support the vagina. Colpography has shown that the upper vagina lies on an almost horizontal axis towards the sacrum. Using vaginography, Funt et al. and Delancey have also confirmed an angulated shape of the normal upper vagina and that the angle between the upper and lower vaginal axis is about 130° ( Fig. 1 ). After hysterectomy, the upper third of the vagina is suspended by the vertical fibres of the paracolpium. However, if these fibres are damaged then vault prolapse might occur.
Uterine prolapse is therefore the result of a defect in level 1 support with the damage to cardinal and uterosacral ligaments. The uterus itself plays no role in uterine prolapse.
Management of uterine prolapse in young women
Conservative management or conservation of the uterus during surgical management in young women of reproductive age could be essential in many situations.
Vagianl pessaries
For women who have medical conditions that make them unsuitable for anesthetics or who are planning a pregnancy, vaginal pessaries are useful as a temporary measure while waiting for surgical correction. Otherwise, vaginal pessaries are unacceptable as a long-term treatment strategy, particularly in sexually active women.
Pelvic floor exercise (pelvic floor muscle training)
In a recent Cochrane review, three relevant trials were identified. The largest of these considered the effect of pelvic floor muscle training in preventing anterior prolapse from worsening, but had limitations affecting the generalisability and rigor of the findings. The trial focused on anterior prolapse only in a group that included both symptomatic and non-symptomatic women. The outcome for those randomised women who had no prolapse at the outset was not reported. Prolapse severity was measured in a crude and non-standardised fashion, and measurement of other important outcomes (e.g. prolapse symptoms) was not attempted. Denominators and numerators were not clearly reported, and analyses did not take into account clustering effects. For these reasons, the conclusion that the pelvic floor muscle programme was effective for severe prolapse should be treated sceptically. Women from the same post-code area (i.e. within a cluster) had more similarities than those from a different area. That is, women within a cluster cannot be treated as independent, and analysis of the data should reflect this.
A feasibility study randomised 47 women with grade one or two prolapse (any type) to pelvic floor muscle training or control, and found suggestions of better outcomes (improvement in prolapse reported by women and decreased prolapse severity) in the intervention group. The sample size was small, however, and the findings need to be confirmed in a larger trial.
The third trial evaluated peri-operative physiotherapy for women undergoing surgery for prolapse, incontinence, or both. The investigators reported that urinary symptoms, pelvic floor muscle function, and quality of life had improved more in the treatment group than in the control group. The data were reported in such a way that they could not be used in the analysis. The trial was small and no prolapse-specific outcome measures were used.
Few data are available from randomized-controlled trials to inform the comparisons specified in this review. A large, rigorous trial of pelvic floor muscle training is needed in women with confirmed prolapse, using standardised measures of prolapse symptoms and objective severity.
Vaginal hysterectomy
“ Because the pathologic descent of the uterus is the result of genital prolapse, hysterectomy should not be the prime objective of surgery for genital prolapse…….For the patient who wishes to retain her uterus, the surgeon may elect to perform colpopexy without hysterectomy” (Nichols )
Vaginal hysterectomy has traditionally been considered an integral step in the repair of uterine prolpase owing to the perceived advantage that hysterectomy facilitates pelvic floor repair and improves results.
In recent years, a shift in our understanding of the dynamics of pelvic organ support, and the need to reduce surgical morbidity in an ageing population, have led researchers to question the role of vaginal hysterectomy in uterovaginal prolapse repair. In addition, an increasing number of women are declining hysterectomy because of delayed childbearing, the perception that the uterus is necessary for sexual satisfaction, and the desire to avoid major surgery. In addition, two major disadvantages are associated with vaginal hysterectomy One is the high risk of subsequent vault prolapsed, and the other is that the vagina is usually left unduly shortened, thus predisposing to dyspareunia.
Cervical and uterine suspension
Several techniques have been reported with good success rates. These include vaginal sacrospinous cervico-colpopexy, vaginal posterior intravaginal slingplasty, abdominal or laparoscopic sacrocolpopexy and posterior mesh repair. The sacrospinous ligament suspension of the uterus is called sacrospinous cervico-colpopexy, or sacrospinous hysteropexy. It is also known as sacrospinous fixation (SSF) of the uterus, and this term will be used here.
SSF is the operation of choice for the management of uterovaginal prolapse at Benenden Hospital, UK. We must, however, stress that the other techniques are equally good techniques for the treatment of uterine prolapsed, albeit with varying results.
Traditional surgical management
A wide variety of surgical treatments are available for managing uterine prolapse, including open or laparoscopic abdominal sacral colpopexy, vaginal sacrospinous colpopexy, vaginal or abdominal hysterectomy, high levator myorrhaphy, uterosacral ligament vault suspension, vaginal Mayo McCall repair. This indicates lack of consensus on optimal treatment. Published guidelines are based on studies of mixed type and quality. Provided that sufficient numbers of trials of adequate quality have been conducted, the most reliable evidence will come from randomised-controlled trials.
In a recently published Cochrane review, 15 randomised-controlled trials of different surgical approaches to the management of uterine prolapse were compared. The investigators concluded that, generally, the effect of surgery on associated pelvic floor symptoms (including bladder, bowel and sexual function), quality of life, cost, and patient satisfaction were poorly reported.
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