Pelvic Organ Support and Prevalence by Pelvic Organ Prolapse-Quantification (POP-Q) in Korean Women

PURPOSE

We evaluated pelvic organ support and the prevalence of pelvic organ prolapse in Korean women using the Pelvic Organ Prolapse-Quantification system as the assessment tool.

MATERIALS AND METHODS

The study population consisted of 713 women 18 to 72 years old who were seen for annual Papanicolaou testing and pelvic examinations. Pregnant patients and patients who had delivered within the previous 6 weeks were not recruited. All pelvic examinations were performed by a single examiner. The patient was examined in the dorsal lithotomy position in a pelvic examination chair positioned at a 15-degree angle. All 9 measurements except total vaginal length were taken with the patient performing the maximal Valsalva maneuver.

RESULTS

Mean patient age was 41.6 years (range 18 to 72), mean weight +/- SD was 55.8 +/- 7.4 kg (range 40 to 83), mean height was 158.7 +/- 5.4 cm (range 138 to 177), mean body mass index was 22.3 +/- 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). Mean scores for the position of the cervix and posterior fornix, and total vaginal length were -5.0, -6.6 and 7.0 cm, respectively. In the 713 women with a uterus the incidence of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of pelvic organ prolapse quantification system stage was stages 0 to 4 in 68.3%, 19.9%, 11.2%, 0.6% and 0.0% of patients, respectively.

CONCLUSIONS

Vaginal size in Korean women differs from that in Western women. The prevalence of any degree of prolapse was approximately 31.7%. Korean women were at relatively higher risk for anterior and posterior vaginal prolapse than for uterine prolapse.

Magnetic resonance imaging of the levator ani in the squirrel monkey: a comparison of muscle volume between a cohort with pelvic organ prolapse and matched normals

OBJECTIVE

Magnetic resonance imaging was used to test whether squirrel monkeys with pelvic organ prolapse have reduced pelvic muscle volumes, compared with matched normals.

STUDY DESIGN

Levator ani and obturator internus volumes obtained from T1-weighted axial scans of matched groups were measured. Muscle volumes and weights were compared for animals necropsied after magnetic resonance imaging.

RESULTS

Two observers concurred on measures of levator ani and obturator internus (Kendal tau > or = 0.60 with P < .003). Levator ani volume was related to mass (R2 = 0.62, P = .0009). Animals with pelvic organ prolapse did not differ (P = .67, Wilks multivariate test) from those without pelvic organ prolapse in age, parity, and weight. Levator ani differed between groups (pelvic organ prolapse = 520 mm3 versus normals = 392 mm3, P = .015) and not sides (P = .80). The obturator internus did not differ between groups (P = .29) or sides (P = .72).

CONCLUSION

Magnetic resonance imaging demonstrates that levator ani volumes in parous squirrel monkeys with pelvic organ prolapse were not reduced, suggesting that prolapse is not related to pelvic muscle size reduction in this species.

Levator plate angle in women with pelvic organ prolapse compared to women with normal support using dynamic MR imaging

OBJECTIVE

The purpose of this study was to determine whether the levator plate is (1) horizontal in women with normal support, (2) different between women with and without prolapse, (3) related to levator hiatus and perineal body descent.

STUDY DESIGN

Cohorts of cases with prolapse at least 1 cm below the hymen and normal controls with all points 1 cm or more above the hymen were prospectively enrolled in a study of pelvic organ support to be of similar age, race, and parity. Subjects underwent supine midsagittal dynamic magnetic resonance imaging (MRI) during Valsalva. Levator plate angle (LPA) was measured relative to a horizontal reference line. Levator hiatus length (LH) and perineal body location (PB) were also measured. Student t tests and Pearson correlation coefficients (r) were performed.

RESULTS

Sixty-eight controls and 74 cases were analyzed. During Valsalva, controls had a mean LPA of 44.3 degrees . Cases, compared to controls, had 9.1 degrees (21%) more caudally directed LPA (53.4 degrees vs 44.3 degrees , P < .01), 15% larger LH length (7.8 cm vs 6.8 cm, P < .01), and 24% more caudal PB location (6.8 cm vs 5.5 cm, P < .01). Increases in LPA were correlated with increased LH length (r = 0.42, P < .0001) and PB location (r =.51, P < .0001).

CONCLUSION

The measured levator plate angle in women with normal support is 44.3 degrees . During Valsalva, women with prolapse have a modest (9.1 degrees) though statistically greater levator plate angle compared to controls. This larger angle showed moderate correlation with larger levator hiatus length and greater displacement of the perineal body in women with prolapse compared to controls.

Pelvic organ prolapse

Pelvic organ prolapse, a condition in which the ligaments and muscles that suspend the vagina within the pelvic cavity weaken or break, is a frequent cause of urinary and fecal incontinence. Stigma, embarrassment and the belief that pelvic organ prolapse is a natural part of aging prevents many women from seeking treatment. Medical imaging modalities such as defecography, dynamic magnetic resonance imaging and ultrasound help health care providers make effective treatment decisions.

The relationship between anterior and apical compartment support

OBJECTIVE

The purpose of this study was to determine whether the degree of anterior compartment (bladder) and apical compartment (cervix) prolapse are correlated, and whether 2 anterior compartment elements (urethra and bladder) are related at maximal Valsalva.

STUDY DESIGN

Women with a complete spectrum of pelvic support were recruited for a pelvic support study. Dynamic magnetic resonance scans were taken during Valsalva. A convenience sample of 153 women with a mean age of 53.3 +/- 12.5 (SD) years with a uterus in situ was studied. Anterior compartment status was assessed by the most caudal bladder point and the internal urinary meatus. The external cervical os was used to assess the apical compartment. The position of the bladder, urethra, and uterus were determined in 20 nulliparous women to determine their reference locations. The distances of each structure below the reference positions were calculated at maximum Valsalva.

RESULTS

Average distances of the bladder base, urethra, and uterus from the reference positions at maximal Valsalva were 4.1 +/- 2.4 cm, 3.1 +/- 1.3 cm, and 4.3 +/- 2.4 cm, respectively. The Pearson correlation coefficient of the relationship between the bladder base and uterine distances was r = 0.73 (r2 = 0.53). The Pearson correlation coefficient of the bladder distance and urethral distance was r = 0.82 (r2 = 0.67).

CONCLUSION

Half of the observed variation in anterior compartment support may be explained by apical support.

Changes in the extracellular matrix in the anterior vagina of women with or without prolapse

To investigate the changes in the connective tissues located in the upper portion of the anterior vaginal wall, which are associated with anterior vaginal wall prolapse, 23 women with anterior vaginal wall prolapse were included in the study group and 15 women with normal genital support served as control group. The anterior vaginal wall tissue samples were obtained for immunohistochemical staining of collagen (type I, III, IV, V, VI), elastin, and glycoproteins from the extracellular matrix (fibronectin, vitronectin, laminin). The number of capillaries per arteriole and mitochondria numbers per smooth muscle cell were evaluated for demonstrating whether the anatomical prolapse affect on blood supply to these tissues. Collagen III was significantly less in the anterior vaginal wall of patients with anterior vaginal wall prolapse. Quantitative immunoreactivity of collagen I and III had significant positive correlations with ageing.

Primary carcinoma of the rectovaginal septum diagnosed as uterine prolapse

BACKGROUND

Primary carcinoma of the rectovaginal septum is very rare. Most cases are associated with documented endometriosis, and patients will often present with vaginal or rectal bleeding.

CASE

A 47-year-old woman presented to the emergency department complaining of urinary symptoms and "something falling out of the vagina." She was diagnosed initially as having uterine prolapse. However, further investigations and surgery showed that she had a primary papillary serous carcinoma of the rectovaginal septum, and the carcinoma later metastasized to the lymph nodes. No evidence of endometriosis was found. Assessment and subsequent treatment of this aggressive tumour was likely delayed because of its initial benign presentation.

CONCLUSION

Our presentation of the case of a woman with primary carcinoma of the rectovaginal septum not associated with a focus of endometriosis shows that this rare aggressive cancer may present in a clinically benign fashion.

Anal incontinence in women with and those without pelvic floor disorders

OBJECTIVE

To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group.

METHODS

We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis.

RESULTS

Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002).

CONCLUSION

Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.

Surgery for vaginal prolapse: a review

This article reviews clinical trials of surgery for the repair of apical vaginal prolapse. The procedures include those from the abdominal, laparoscopic and transvaginal approach. When considering new surgical devices or procedures, it is essential to be aware of clinical data. The use of tension-free tape devices for apical support is promising, but a large trial is needed to demonstrate its efficacy and safety.

Tissue Fixation System posterior sling for repair of uterine/vault prolapse -- a preliminary report

AIMS

To assess the posterior Tissue Fixation System (TFS) sling for repair of uterine/vault prolapse.

PATIENTS AND METHODS

The TFS comprises of two small polypropylene soft tissue anchors connected to an adjustable polypropylene tape. The posterior TFS sling works much like a McCall procedure. The anchors are inserted just lateral to the uterosacral ligaments. Tightening the sling elevates the prolapsed uterus/vaginal vault. The study group comprised 67 patients who were assessed with a 24-h urinary diary, structured questionnaire, transperineal ultrasound, urodynamics, cough stress test, and 24-h pad test, pre and postoperatively.

RESULTS

Sixty-seven patients, mean age 65 years (35-87), mean weight 71 kg (38-117 kg), mean 1.6 previous pelvic operations, underwent posterior sling (level 1) repair for uterine/vault prolapse (fourth degree: n = 2; third degree: n = 17; second degree: n = 20; symptomatic first degree: n = 28). Level 2 (n = 18) and level 3 repairs (n = 18) were also performed as required. One patient was lost to the study. At mean 9 months' review (3-15 months), the prolapse repair had been successful in all but one patient. There were however, 14 de novo herniations postoperatively (20%), cystocoele 12, enterocoele 1, rectocoele 1. Operating time for the sling only was 5-10 min, and mean hospital stay was 1.5 days. Minimal analgesia was required.

CONCLUSIONS

The preliminary results indicate that the TFS posterior sling appears to work well in patients with uterine/vault prolapse. Longer term follow up and studies by other surgeons are required to fully evaluate this procedure.

The Manchester operation for uterine prolapse

OBJECTIVE

To evaluate the clinical characteristics, complications, and satisfaction scores of patients who underwent the Manchester operation.

METHODS

This retrospective observational study evaluated data from 204 women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004.

RESULTS

Mean age was 34.68+/-4.24 years and parity 2.47+/-0.96; 85.8% of the patients were premenopausal; 176 patients (86.28%) had grade 3 and 28 (13.72%) had grade 2 uterine prolapse; 95.1% of the patients had associated cystoceles and 51.3% had associated rectoceles; and 81.4% had urinary incontinence. Regarding early postoperative complications, 27 patients (13.23%) had febrile morbidity; retroperitoneal hematoma occurred in 1 patient (0.49%); urinary retention occurred in 45 patients (22.05%), and cervical stenosis occurred in 23 patients (11.27%). At 1 year, 1 patient had undergone abdominal hysterectomy because of unsuccessful cervical dilatation; and a mean of 3.6 years following the operation, 8 patients (3.9%) had undergone the tension-free vaginal tape procedure plus a vaginal hysterectomy for recurrent stress urinary incontinence and uterine prolapse. The mean satisfaction/acceptance score for the operation was 8.52+/-2.13 (range, 2-10).

CONCLUSION

A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus.

The use of graft materials in vaginal pelvic floor surgery

OBJECTIVE

To review recent literature on graft materials used in vaginal pelvic floor surgery.

METHODS

A Pubmed-search ("anterior vaginal wall" or "cystocele"), ("posterior vaginal wall" or "rectocele") and ("vaginal vault" or "pelvic prolapse") and ("mesh" or "erosion" or "graft" or "synthetic") from 1995 to 2005 was performed; recent reviews [Birch C. The use of prosthetics in pelvic reconstructive surgery. Best Pract Res Clin Obstet Gynaecol 2005;19:979-91 [1]; Maher C, Baessler K. Surgical management of anterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct 2005 (May 25) [Electronic Publication] [2]; Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:84-8 [3]; Altman D, Mellgren A, Zetterstrom J. Rectocele repair using biomaterial augmentation: current documentation and clinical experience. Obstet Gynecol Surv 2005;60:753-60 [4] were added.

RESULT

There are few prospective randomized trials that prove the benefit of implanting grafts in vaginal pelvic floor surgery. Many articles are retrospective case series with small sample sizes or incomplete outcome variables. Serious complications such as erosions are often not mentioned. Inconsistent or unclear criteria for anatomic cure make it difficult to compare outcomes. Quality of life issues such as dyspareunia, urinary or bowel symptoms are often ignored.

CONCLUSION

Due to a lack of well-designed prospective randomized trials, recommendations for using graft materials in vaginal reconstructive surgery cannot be made. At this time, grafts should have limited use in a carefully selected patient population.

Static and dynamic MRI features of the levator ani and correlation with severity of genital prolapse

BACKGROUND

To describe the static and dynamic MRI features of the levator ani, and evaluate whether they are associated with the MRI evaluation of the severity of genital prolapse.

METHODS

Static and dynamic MRI of 40 patients, referred for evaluation prior to genital prolapse surgery, were reviewed retrospectively. Prolapse severity was evaluated on MRI at maximal straining by descent of the bladder neck under the pubococcygeal line for the anterior compartment, by descent of the uterine cervix under the pubococcygeal line for the middle compartment, and by anterior bulging of the rectum for the posterior compartment. For evaluation of the levator ani, the following parameters were recorded: (1) at rest: thinning or defects in both puborectalis and iliococcygeus muscles, (2) at rest and at straining: urogenital hiatus length and width, M line, iliococcygeal and levator plate angles. The levator ani features were tested for potential associations with the MRI evaluation of prolapse severity.

RESULTS

Bladder neck descent at straining was correlated with the levator plate angle at rest (p=0.001), and with the hiatus length at rest (p=0.02), and at straining (p=0.008). Uterine cervix descent at straining was correlated with the hiatus length (p=0.0005), and width (p=0.014) at straining, M line (p=0.002) and levator plate angle (p=0.007) at straining, whereas anterior rectal bulging at straining was paradoxically inversely correlated with the hiatus width at rest (p = 0.04).

CONCLUSION

In a population of women with genital prolapse, MRI evaluation of the levator ani was associated with MRI evaluation of the severity of genital prolapse.

Vaginal vault prolapse: identification and surgical options

Reconstructive surgeons should be familiar with the identification and treatment of vaginal vault prolapse. Most utilized techniques can be effective in terms of suspension of the vaginal apex. New technology has allowed for the performance of vaginal-approach techniques with increasingly physiologic anatomic and functional outcomes (Figure 8).

PET-CT-Untersuchungen der Halterung und Kontinenz der Beckenorgane

Like all other organs in the chest or abdominal cavities, pelvic organs are not suspended by specialized ligaments such as those in the skeletomuscular system. In spite of this, the organs of the pelvis remain well suspended within their cavity even during evacuation. This support system for these organs consists of inconspicuous smooth muscle elements scattered throughout pelvic structural fat tissue and fascial structures, in particular Denonvilliers' fascia. We used PET-CT studies to identify spontaneous muscle activity in the pelvis, which is strongest at Denonvilliers' fascia. We were able to correlate continence function, filling, and evacuation of pelvic organs with this spontaneous muscle activity that leads to stiffening and relaxation of the muscular walls of these organs. During the course of different disease processes such as visceral prolapse, these pelvic support structures are prone to fail gradually. Surgical interventions should take the pelvic support system into account to avoid therapeutic errors.

Classification and evaluation of prolapse

Pelvic organ prolapse is prevalent among older women. Milder stages of prolapse, cranial to the hymen, are common and usually symptomless. A specific symptom is a bulge outside the vagina. Functional symptoms from the bladder, bowel and sexual life frequently coexist without a known cause/effect relationship to prolapse. Prolapse should be measured by the validated internationally approved pelvic organ prolapse quantification (POPQ) system that can measure prolapse in the three compartments and three levels of the vagina. We should work on a common classification system and agreement in which symptoms should be recorded as related to prolapse and expected to improve by prolapse surgery.

Associated pelvic organ prolapse in women with stress urinary incontinence: when to operate?

PURPOSE OF REVIEW

This review discusses recently published data concerning the indications for pelvic organ prolapse (POP) surgery in women who present with stress urinary incontinence (SUI).

RECENT FINDINGS

POP can functionally mask SUI. Surgery for POP may unmask occult SUI in many women. Clinically continent women undergoing POP surgery are at risk for developing symptomatic SUI postoperatively. Preoperative identification of occult (and overt) SUI will facilitate the use of an appropriate prophylactic anti-incontinence procedure at the time of prolapse repair. Numerous studies on the preoperative prediction of SUI following repair of POP have been conducted in an effort to determine whether concomitant prophylactic measures should be taken at the time of POP repair to prevent the postoperative unmasking of SUI in women who do not have SUI preoperatively (with or without prolapse reduction). Although the literary evidence available is not sufficient for POP with occult SUI, there is some information available to guide clinicians in deciding when to perform concurrent POP surgery in women who are undergoing primary surgery for SUI.

SUMMARY

The intended goal of surgical correction of SUI and POP is durable restoration of normal anatomy and function, with symptomatic relief and avoidance of morbidity. Recommendations regarding when to surgically intervene for POP in women who present with SUI are based on the available literature although contemporary studies are few and include small numbers of patients with no controls. Long-term, randomized, controlled prospective studies of large numbers of patients are indicated.

Abdominal sacral colpopexy: an independent prospective long-term follow-up study

AIMS

The aim of the study was to provide a long-term follow up of subjective and objective outcomes following sacral colpopexy.

METHODS

A cohort of 148 women who had undergone sacral colpopexy in a tertiary unit between 1998 and 2001 were contacted for follow-up. Women were questioned about current symptoms including patient determined subjective measures and the Baden-Walker site specific examination for vaginal prolapse was performed.

RESULTS

Ninety-three women were able to be contacted for review. Of these, 64 were available for clinical examination and a further 29 were available for telephone interview. Of those women examined 62 had good vault support. Therefore, recurrent vault prolapse was uncommon at 3%. Recurrent prolapse was present in other vaginal compartments in 40.6% of women. Subjectively 78% of women felt that their prolapse symptoms had resolved and 65% had a visual analogue score (VAS) >or= 80, indicating satisfaction with the surgery. Stress urinary incontinence symptoms decreased at this long-term review, however, 24% of women required further incontinence surgery.

CONCLUSIONS

Abdominal sacral colpopexy is an effective technique for the management of vaginal vault prolapse, with a two-year successful outcome in excess of 90%. Further study is required to investigate recurrent prolapse in other vaginal compartments and the functional aspects following surgery.

How to approach common urogynaecological problems?

Urogynaecology is dedicated to the treatment of women with pelvic floor dysfunction such as urinary orfecal incontinence and prolapse (bulging or falling) of the vagina, bladder and/or the uterus. Pelvic organ prolapse simply means displacement from the normal position. On average, 11% of women will undergo surgery for this condition. Pelvic organ prolapse quantification system (POP-Q) is an objective, site-specific system for describing the anatomic position that can be used to determine the stage of the prolapse. Urinary incontinence (leakage of urine) is a very common condition affecting at least 10-20% of women under age 65 and up to 56% of women over the age of 65. The most common subtypes of urinary incontinence are (1) stress urinary incontinence (SUI) ; (2) urge urinary incontinence (UUI) ; and (3) mixed urinary incontinence (MUI). Patients presenting with symptoms of pelvic organ prolapse or incontinence should undergo a thorough medical evaluation consisting of a targeted history (include bladder diary or voiding diary), physical examination, urinalysis and urine culture, and postvoid residual volume (PVRV) by pelvic ultrasound. Treatment options for patients with pelvic organ prolapse and urinary incontinence are nonsurgical (lifestyle interventions, pelvic floor muscle rehabilitation, and pessary placement) and surgical management.

[Case management of pelvic floor disorders]

Pelvic floor disorders can involve all three parts of the pelvic floor, and must be managed holistically. They are often associated with one another, because they all involve an imbalance between counterbalancing forces, namely abdominal pressure on the one hand and mooring forces on the other hand. The mooring forces consist of 1) the visceral ligaments, which are fibrous cellular condensations around vessels and nerves, connecting the pelvic wall to the organs; 2) the endopelvic fascia; and 3) the pelvic muscles, including the levator ani. The physical examination must be both functional and anatomical, in order to detect obvious and occult disorders of the three parts of the pelvic floor. When physical examination is inadequate, standard radiography or MRI may be used. Radiographic explorations include colpocystography and defecography. The first is carried out in the standing position with a "blocked" perineum, and the second is performed in the defecation position with a "relaxed" perineum. Treatment must take into account dysfunctions, incontinence, and ptosis of the three parts. The author discusses the various examinations and treatments (by the abdominal or vaginal approach), based on published data and personal experience. The choice of treatment always depends on the patient's age, anatomical defects and functional disorders, and the surgeon's expertise

Posterior pelvic floor compartment disorders

Posterior pelvic floor compartment disorders generally refer to functional anorectal disturbances that by definition are symptom-based rather than anatomical defect-based and have a significant impact on quality of life. Symptoms attributed to the posterior compartment are often non-specific and associated with structural, neuromuscular and functional defects giving rise to symptoms of prolapse, pelvic pressure, faecal incontinence, stool trapping and constipation. They may range from mild to incapacitating and occur in varying combinations. While symptoms of constipation and incontinence may conceptually represent the opposing extremes of normal anorectal function, the dynamic interrelationships between the different pathophysiological mechanisms involved in the development of these disorders suggest a more complex explanation. Faecal continence and defecation are dependent on several neurological and anatomical factors that involve coordinated physiological processes, including intestinal transit and absorption, colonic transit, rectal compliance, anorectal sensation and continence mechanism. However, it is well recognized that pelvic floor symptoms originating from one compartment do not imply absent pathology in another compartment. Furthermore, symptoms associated with one disorder (such as constipation related to functional obstructed defecation) can be causative in the sequential development of other pelvic floor disorders, such as a urogenital prolapse syndrome, that may further exacerbate symptoms. In addition, it has been found that treatment that corrects one problem may improve, worsen or even predispose to other symptoms from another compartment. Consequently, while the concept of global pelvic floor dysfunction has emerged, the traditional single speciality referral and evaluation of pelvic floor problems continues to foster potentially segregated management strategies that can overlook the relevance of concomitant symptomatology. The evaluation and treatment of posterior pelvic compartment disorders needs to assume an individualized but multidisciplinary therapeutic approach. Given the variation in surgical approaches described to correct anatomical integrity of posterior pelvic compartment deficits, the consensus on optimal management has yet to be achieved. Therefore, it is critical that outcome measures following surgery are clearly defined. Treatment is to a great extent dictated to by functional severity and the impact that symptoms have on quality of life. Long-term follow-up should ensure that the potential for complications is minimized and satisfactory bowel, bladder and sexual function is maintained.

Pelvic Organ Prolapse

Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, and enterocele, is a common group of clinical conditions affecting millions of American women. This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse. The evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often challenging for the clinician to determine which symptoms are attributable to the prolapse itself and will therefore improve or resolve once the prolapse is treated. When treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; and surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms require additional management. Virtually all women with prolapse can be treated and their symptoms improved, even if not completely resolved.

Long-term results with tension-free vaginal tape on mixed and stress urinary incontinence

OBJECTIVE

To compare outcome of the tension-free vaginal tape (TVT) procedure in women with urinary mixed and stress incontinence.

METHODS

A mailed questionnaire was answered by 760 of 970 women who had undergone TVT surgery 2-8 years ago (78% response rate). Seventeen women had unclassified incontinence, and 51 women who developed de novo urgency were excluded, giving 580 (83.8%) with stress incontinence and 112 (16.2%) women with mixed incontinence eligible for analysis. Demographic, reproductive factors, and medical history were obtained. The questionnaire included detailed questions about urinary symptoms. Analysis of outcome was done for cohorts by number of years since the operation.

RESULTS

The women with stress incontinence had a persistent cure rate of 85% from 2 to 8 years after the TVT procedure. The women with mixed incontinence had a persistent cure rate of 60% up to 4 years postoperatively, but the cure rate then steadily declined to 30% from 4 to 8 years after surgery. The increased rate of incontinence was due to urgency symptoms.

CONCLUSION

The results of this study indicate that initial good cure rates of TVT for mixed incontinence do not persist after 4 years.

LEVEL OF EVIDENCE

III.

Incarceration of a retroflexed, gravid uterus from severe uterine prolapse: a case report

BACKGROUND

Acute urinary retention as a result of incarceration of a retroflexed, gravid uterus is a known phenomenon. However, prolapse as a risk factor has not been previously described.

CASE

A 40-year-old woman, gravida 4, para 2, with an intrauterine gestation of 19 weeks presented to the emergency room complaining of inability to void for the previous 12 hours and difficulty voiding and constipation for the previous 6 weeks. She had a history significant for stage III uterine prolapse in early pregnancy. Foley catheterization yielded 800 mL of urine, and an examination revealed a retroflexed uterus. The cervix was displaced anteriorly behind the pubic symphysis. Ultrasound confirmed these findings and the presence of a viable gestation. The uterus was successfully manually displaced under epidural anesthesia. The patient was able to void without difficulty after uterine displacement.

CONCLUSION

Incarceration of a retroflexed uterus should be considered in the differential diagnosis in any woman who presents with voiding difficulty in the late first or second trimester. Uterine prolapse is a risk factor for incarceration of a retroflexed uterus. Epidural anesthesia should be considered for a patient if manual uterine displacement cannot be performed successfully without anesthesia.

Life-threatening reaction to indigo carmine--a sulfa allergy?

Indigo carmine is commonly used during cystoscopy when evaluating for lower urinary tract safety after gynecologic surgery. We report a case of severe hypotension and bradycardia following intravenous indigo carmine injection in a patient with known sulfa allergy.

Pelvic organ descent and symptoms of pelvic floor disorders

OBJECTIVE

This study evaluates the relationship between symptoms of pelvic floor disorders, and measurement of pelvic organ prolapse.

STUDY DESIGN

This retrospective cross-sectional study assessed prolapse in 905 women in an academic urogynecologic practice using the Pelvic Organ Prolapse Quantification exam. Symptoms were assessed with a Likert symptom questionnaire and the Urogenital Distress Inventory. Relationships between symptoms and prolapse were analyzed using Spearman's correlation.

RESULTS

Symptoms of "bulging" correlated moderately to the greatest extent of prolapse (r=0.4, P<.001). Frequency of bother progressively increases when the leading edge descends from -3 and 0. Between +1 and +5, 90% of women report bother. Symptoms typically attributed to anterior or posterior wall prolapse did not correlate with descent of the respective compartment.

CONCLUSION

"Bulging" is the principle symptom that correlates with prolapse severity. We found no discrete anatomic position that discriminates between prolapse as a disease state and normal anatomic variation.

Vaginal thickness, cross-sectional area, and perimeter in women with and those without prolapse

OBJECTIVE

Use axial magnetic resonance imaging to test the null hypothesis that no difference exists in apparent vaginal thickness between women with and those without prolapse.

METHODS

Magnetic resonance imaging studies of 24 patients with prolapse at least 2 cm beyond the introitus were selected from an ongoing study comparing women with prolapse with normal control subjects. The magnetic resonance scans of 24 women with prolapse (cases) and 24 women without prolapse (controls) were selected from those of women of similar age, race, and parity. The magnetic resonance files were imported into an experimental modeling program, and 3-dimensional models of each vagina were created. The minimum transverse plane cross-sectional area, mid-sagittal plane diameter, and transverse plane perimeter of each vaginal model were calculated.

RESULTS

Neither the mean age (cases 58.6 years +/- standard deviation [SD] 14.4 versus controls 59.4 years +/- SD 13.2) nor the mean body mass index (cases 24.1 kg/m(2)+/- SD 3.3, controls 25.7 kg/m(2)+/- SD 3.7) differed significantly between groups. Minimum mid-sagittal vaginal diameters did not differ between groups. Patients with prolapse had larger minimum vaginal cross-sectional areas than controls (5.71 cm(2)+/- standard error of the mean [SEM] 0.25 versus 4.76 cm(2)+/- SEM 0.20, respectively; P = .005). The perimeter of the vagina was also larger in the prolapse group (11.10 cm +/- SEM 0.24) compared with controls (9.96 cm +/- SEM 0.22) P = .001. Subgroup analysis of patients with endogenous or exogenous estrogen showed prolapse patients had larger vaginal cross-sectional area (P = .030); in patients without estrogen group differences were not significant (P = .099).

CONCLUSION

Vaginal thickness is similar in women with and those without pelvic organ prolapse. The vaginal perimeter and cross-sectional areas are 11% and 20% larger in prolapse patients, respectively. Estrogen status did not affect differences found between groups.

Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging

BACKGROUND

Paravaginal defects are often assumed to be the underlying anatomical abnormality in anterior compartment descent. Neither clinical examination nor ultrasound assessment are generally accepted diagnostic modalities.

AIMS

To compare clinical examination and translabial 3D ultrasound in the detection of such defects.

METHODS

Fifty-nine women without previous prolapse or incontinence surgery were seen prospectively. Clinical and ultrasound assessments were carried out in blinded fashion. 3D translabial ultrasound was undertaken after voiding and supine. Volumes were acquired at rest, on Valsalva and on levator contraction. Loss of paravaginal support ('tenting') in the axial plane was taken to signify paravaginal defects.

RESULTS

Paravaginal defects were reported clinically in 14 cases on the left (24%), 19 times on the right (32%). Two 3D ultrasound examinations did not yield satisfactory volumes, leaving 57 for analysis. Neither midsagittal nor coronal views yielded data that correlated with clinical assessments. In the axial plane there was absence of tenting at rest in 32/57 (57%) patients, but this did not correlate with clinical findings. Loss of tenting on Valsalva was observed less often (21/57, 37%) and was weakly associated with clinically observed lateral defects (P = 0.036).

CONCLUSIONS

Pelvic floor ultrasound in midsagittal, axial or coronal planes does not correlate well with clinical assessment for paravaginal defects. This could be due to poor clinical assessment technique or limitations of the ultrasound method. On the other hand, paravaginal defects may be uncommon or clinically irrelevant. On present knowledge, the paravaginal defect has to be regarded as an unproven concept.

The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment

Each year, pelvic floor dysfunction affects between 300,000 and 400,000 American women so severely that they require surgery. Approximately 30% of the operations performed are re-operations. The high prevalence of this problem indicates the need for preventive strategies, and the common occurrence of re-operation indicates the need for treatment improvement. Efforts at prevention and treatment improvement will only be possible if research clarifies causative mechanisms and scientifically valid studies discover why operations fail. By reaching a goal of 25% prevention we could save 90,000 women from experiencing pelvic floor dysfunction and with 25% treatment improvement we could avoid 30,000 women from needing a second operation. To achieve these goals we must discover specific events or behaviors in a woman's life that lead to these problems and that are amenable to preventive strategies. In addition, we must define specific biologic and behavioral factors that explain why certain women have recurrence after surgery. Because the pelvic organ support system is comprised of muscles, ligaments, and nerves arranged in a complex tension-based apparatus, the basic nature of this work must include biomechanical analyses of the overall mechanism and targeted research into the biology of muscle, ligament, nerve, and their complex interactions in normal pelvic floor function and in symptomatic patient. Each of these scientific disciplines is well developed so that engaging scientists in the effort to move forward will bring predictably important results. With an integrated approach to this problem over the next 20 years, it should be possible to achieve these goals and reduce the suffering for more than 100,000 afflicted women.

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 > or =30 degrees. 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 > or =30 degrees in stage I-IV prolapse was 99%.

CONCLUSION

The POP-Q system is highly predictive of straining urethral angle in all stages of prolapse.

A short-form questionnaire identified genital organ prolapse

OBJECTIVE

We constructed a simple questionnaire that, with a minimum of questions, could accurately and reliably identify women with genital organ prolapse.

STUDY DESIGN AND SETTING

Two hundred women with confirmed genital organ prolapse and 199 outpatients with various gynecologic symptoms but no objective prolapse answered 13 questions perceived to be valuable for the diagnosis. With stepwise backward logistic regression, the discriminatory ability of a successively abbreviated set of questions was assessed. The resulting short questionnaire was tested in a new population-based sample of 282 women participating in a screening survey.

RESULTS

A final five-item questionnaire retained 94% of the predictive value of all 13 questions and had 92.5% sensitivity and 94.5% specificity in the first group of women. When the questionnaire was used in the subsequent population-based survey, the sensitivity and specificity values were 66.5% and 94.2%, respectively. Most missed cases had stage I prolapse.

CONCLUSION

Although the sensitivity of the test was moderate, the specificity, and hence the ability to rule in cases, was satisfactory. The test is suitable for case finding in epidemiologic studies.

Sacrocolpopexy for vault prolapse and rectocele: do concomitant Burch colposuspension and perineal mesh detachment affect the outcome?

OBJECTIVE

This study compares the effect of abdominal sacrocolpopexy with posterior Teflon mesh interposition with and without concomitant Burch colposuspension on the posterior compartment.

STUDY DESIGN

This retrospective review includes 49 consecutive women who underwent sacrocolpopexy for vault or uterine prolapse stage 2 or higher and rectocele; 25 of them had a concomitant Burch colposuspension for urodynamic stress incontinence. Postoperative bladder, bowel and sexual function and recurrent pelvic organ prolapse was assessed at > or =12 months.

RESULTS

There was no recurrent vault prolapse. Rectoceles (stage 2) recurred in 5 women (21%) without and in 8 women (36%) with Burch colposuspension ( P > .05). The mesh became detached by >2 cm from its perineal position in 30% of the cases, which was associated with excessive defecation straining ( P = .04). Rectocele stages significantly correlated with mesh detachment ( P > .001) but not with obstructed defecation ( P > .05).

CONCLUSION

Sacrocolpopexy was effective if the mesh did not become detached from its perineal position. Concomitant Burch colposuspension did not seem to affect the posterior compartment adversely in this small case series.

Evaluation of Aa point and cotton-tipped swab test as predictors of urodynamic stress incontinence

OBJECTIVE

To compare the predictive abilities of the Aa point of the pelvic organ prolapse quantification examination and the cotton-tipped swab test straining angle to diagnose urodynamic stress incontinence.

METHODS

A case-control study was conducted between June 1997 and February 2003. Cases were defined as patients with urodynamic stress incontinence (n = 352). Controls were patients who also underwent urodynamic testing but who did not have a diagnosis of urodynamic stress incontinence (n = 245). Independent variables were defined as Aa point, Aa point of 0 or greater, straining cotton-tipped swab angle, and straining cotton-tipped swab angle of 30 degrees or greater. Logistic regression estimated the odds ratio of stress incontinence in women based on Aa values and cotton-tipped swab straining angle measurements, controlling for other variables commonly associated with stress incontinence.

RESULTS

The mean (+/- standard deviation) age of the cases was 55.9 +/- 13.4 and of controls was 55.3 +/- 14.8, (P = .6). The median parity of the cases was 2 (range 0-10) and of controls, 2 (range 0-9) (P = .7). The Aa point was not associated with a diagnosis of stress incontinence (odds ratio 1.01, 95% confidence interval (CI) 0.83-1.23). The adjusted odds ratios of having an Aa value of 0 or greater was 0.49 (95% CI 0.26-0.92), and of having a cotton-tipped swab angle of 30 degrees or greater was 3.1 (95% CI 1.09-5.07), in a model that adjusted for age, parity, race, and postmenopausal and hormonal replacement status.

CONCLUSION

Aa point is not associated with a diagnosis of stress incontinence. However, a cotton-tipped swab angle of 30 degrees or greater is positively associated with stress incontinence.

The role of the nurse in the use of vaginal pessaries to treat pelvic organ prolapse and/or urinary incontinence: a literature review

The available literature between 1990 and 2004 was reviewed to determine if the nurse's role in the use of vaginal pessaries to treat pelvic organ prolapse and/or urinary incontinence is well defined. Forty-five articles were reviewed, including one written by a physician's assistant, two written by both a physician and a registered nurse, seven written by registered nurses, 34 written by physicians, and one unpublished manuscript. Nurses could make a valuable contribution to the bank of information available on the use of vaginal pessaries to treat stress urinary incontinence and pelvic organ prolapse.

Magnetic resonance imaging of uterine version in a multiethnic, nulliparous, healthy female population

OBJECTIVE

To determine measurement and topography of uterine position in asymptomatic women with different ethnicity.

STUDY DESIGN

The angle and direction of uterine version were measured using magnetic resonance imaging in nulliparous, young volunteers from 5 ethnic groups (Emiratis, other Arabs, Indians/Pakistanis, Filipinos and Europeans/ Caucasians; N=55) and compared using Europeans/Caucasians as the reference group.

RESULTS

The uterus was anteverted on the vagina in 46 (83.6%) and retroverted in 9 (16.4%) women, with no significant difference between Europeans/Caucasians and non-Caucasians. The angle of uterine version was significantly less (i.e., the cervix was more anteverted or retroverted on the vagina) in Europeans/Caucasians as compared to other women (p=0.002), particularly Indians/Pakistanis (p < 0.00001).

CONCLUSION

The degree of uterine version is different in healthy, nulliparous European/Caucasian and non-Caucasian women.

Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse

OBJECTIVE

To study the ongoing results of the repair of anterior vaginal wall prolapse reinforced with tension-free polypropylene mesh (GyneMesh, Gynecare, Ethicon, Issy-Les-Moulineaux, France).

STUDY DESIGN

A case series of 87 consecutive women with anterior vaginal wall prolapse who underwent a transvaginal procedure using polypropylene mesh between October 1999 and August 2002. The mean age (+/-SD) was 62.4+/-13.4 years. Before the operation, patients underwent physical examination staging of the prolapse with the International Pelvic Organ Prolapse staging system. Thirteen women had stage 2 anterior vaginal wall prolapse (14.9%), 59 had stage 3 (67.9%), and 15 had stage 4 (17.3%). The polypropylene mesh was placed from the retropubic space to the inferior part of the bladder in a tension-freefashion. Patients were followed for 9-43 months, with a median follow-up (+/-SD) of 24+/-9.6 months. We defined "cure" as satisfactory (stage 1) or optimal (stage 0) outcome for point Ba in the staging system.

RESULTS

Eighty-four patients returned for follow-up (96.6%). At follow-up, 77 women were cured (91.6%), 5 women had asymptomatic stage 2 anterior vaginal wall prolapse, and 2 had a recurrent stage 3 (2.4%). There were no postoperative infections. There were a total of 7 vaginal erosions of the mesh (8.3%); 4 necessitated a second procedure for partial excision of the mesh.

CONCLUSION

Vaginal repair of anterior vaginal wall prolapse reinforced with tension-free polypropylene mesh is effective and relatively safe. Vaginal erosion occurred in 8.3% of the study population but was easily manageable, with no sequelae.

A new vaginal speculum for pelvic organ prolapse quantification (POPQ)

The purposes of this study were to introduce a new vaginal speculum, describe the technique of using the new speculum in identifying and measuring the severity of pelvic organ prolapse (POP), and present results of a pilot study comparing the new speculum to the conventional instruments used in performing POP quantification (POPQ). The new speculum has retractable upper and lower blades marked in centimeters. POPQ was performed with one instrument using the new speculum and multiple instruments performing the conventional technique. Twenty-two patients underwent POPQ-11 using the new speculum and 11 using conventional instruments. The duration of the procedure and the level of discomfort were assessed. The POPQ method using the new speculum is described. Preliminary experience with the new speculum showed that the length of examination is significantly shorter (p<0.001) and the comfort level is better than with the conventional technique (p=0.088). A new vaginal speculum with adjustable blades simplifies POPQ. Preliminary testing suggests potential savings in procedure time and reduction in patient discomfort.

Severity of pelvic organ prolapse associated with measurements of pelvic floor function

This study tested the hypothesis that clinical measurements of the superficial perineum and of pelvic floor muscle (PFM) function correlate with the severity of pelvic organ prolapse. This retrospective cross-sectional study assessed 1037 women in an academic urogynecologic practice. Greatest descent of prolapse, by the Pelvic Organ Prolapse Quantification system, was correlated with two assessments of levator function--the Oxford grading scale and levator hiatus (LH) size measured by digital examination. Correlations were calculated using Pearson's correlation for continuous variables and Kendall's tau-b. Severity of prolapse correlated moderately with genital hiatus (GH) (r = 0.5, p<0.0001) and with LH (transverse r = 0.4, p < 0.0001; longitudinal r = 0.5, p < 0.0001), but weakly with the Oxford grading scale (r = -0.16, p < 0.0001). LH correlated with GH (r = 0.5, p < 0.0001) but not with perineal body (r = 0.06, p = 0.06). Both GH and LH size are associated with the severity of prolapse. LH size correlates more strongly to prolapse severity than assessment of PFM function by the Oxford grading scale.

Uterine prolapse in a young nulligravida with scleroderma and premature ovarian failure

We report a case of pelvic organ prolapse quantification (POPQ) stage III uterine prolapse in a 25-year-old nulligravida. Premature ovarian failure was diagnosed after 1 year of amenorrhea. Localized scleroderma was noticed on her thigh and lower back. We discuss the possible role of scleroderma and ovarian failure on the occurrence of uterine prolapse in light of the literature.