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.