Mechanical properties of synthetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material?

The authors review the literature concerning all types of synthetics implants used in prolapse repair or the treatment of stress urinary incontinence, and analyze the mechanical properties of and the tolerance to the various products used. Various synthetic implants are also studied, including their advantages and disadvantages, as well as outcome following implantation and tolerance by the host, with respect to the type of product and the type of intervention. A review of current implant products demonstrated that the perfect product does not exist at present. The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity. Their properties of resistance are undisputed, but it remains to be shown whether they are well tolerated when inserted by the vaginal route. The technical modalities for their use are still under evaluation, which should enable a better identification of the respective indications for these products in prolapse repair and treatment of urinary incontinence by the vaginal route.

Predicting treatment choice for patients with pelvic organ prolapse

OBJECTIVE

To evaluate which clinical factors were predictive of treatment choice for patients with pelvic organ prolapse.

METHODS

One hundred fifty-two patients were enrolled in this cross-sectional study to collect clinical data on potential predictors of treatment choice. Continuous parametric, continuous nonparametric (ordinal), and categoric data were compared with chosen management plan (expectant, pessary, surgery) using analysis of variance, the Kruskal-Wallis test, and the chi(2) test for association, respectively. All significant predictors (P <.05) of treatment choice for pelvic organ prolapse identified during univariate analysis were entered into a backward elimination polytomous logistic regression analysis for predicting surgery versus pessary versus expectant management, with surgery as the reference group.

RESULTS

The probability of choosing expectant management rather than surgery 1). increases as the preoperative pelvic pain score increases (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.07, 2.40; P =.024) and 2). decreases as the prolapse severity increases (OR 0.46; 95% CI 0.29, 0.72; P =.001). The probability of choosing pessary rather than surgery 1). increases as age increases (OR 1.1; 95% CI 1.05, 1.16; P <.001), 2). decreases as the prolapse severity increases (OR 0.77; 95% CI 0.60, 0.99; P =.042), and 3). is less if the participant had prior prolapse surgery (OR 0.23; 95% CI 0.07, 0.76; P =.017).

CONCLUSION

Age, prior prolapse surgery, preoperative pelvic pain scores, and pelvic organ prolapse severity were independently associated with treatment choices in a predictable way and provide physicians with medical evidence necessary to support a patient's decision.

Case study: challenges of pessary management

Genital prolapse is the relaxation of the supporting structures of the pelvic floor. Significant morbidity can be associated if left untreated. Patients can elect to have surgical repair of their prolapse or use a pessary. The more significant the pelvic organ prolapse the more difficult it is to manage with pessary support. The case study in this article describes such a patient and the challenges we faced with managing her advanced genital prolapse.

Evidence-based practice in urogynaecology

Urogynaecology practice is rapidly progressing, with a trend towards minimally invasive techniques. This article attempts to cover the evidence behind the assessment and treatment of urinary and anal incontinence, and vaginal prolapse.

Entrapped vaginal pessary presented with frequency and urge incontinence

Pessaries remain helpful for patients with genital prolapse who refuse or are not able to have surgery due to medical complications. It is generally considered both conservative and safe to wear a vaginal pessary. Only a few cases of severe complications have been reported whereby most result from a neglected pessary. We present a patient with extreme frequency and urge incontinence with recovery following the removal of the entrapped pessary. An 82-year-old oriental female carrying a vaginal pessary for more than 10 years had suffered from intractable frequency and urge incontinence for 6 months. The urinary analysis and urodynamic studies showed no sign of lower urinary infection or outlet obstruction. Physical examination found a black ring pessary in the vagina which could not be mobilized due to its deep embedment. The lower urinary tract symptoms were recovered after surgical removal of the pessary. Complication of a vaginal pessary may be caused by an ignorant patient or doctor. Frequency and urge incontinence could be an early sign of a severe complication due to a neglected pessary.

Uterine cervical elongation and prolapse during pregnancy: an old unsolved problem

Prolapse with elongation of the cervix is a rare complication of pregnancy. Prolapse that existed before onset of pregnancy will usually resolve spontaneously by the end of the second trimester, without further complications. A pessary can be used to protect the cervix. Prolapse that develops during pregnancy is usually first noted in the third trimester, and management consists of bed rest in a slight Trendelenburg position. In these cases, pessaries will probably not remain in place or prevent preterm labor. Patient discomfort, urinary tract infection, acute urinary retention, premature labor, and prenatal loss are still major complications, and prolapse usually persists or recurs after labor. Treatment depends on the severity of the condition and the patient's preference.

Some Characteristics of Vaginal Prolapse in Nepali Buffaloes

Prolapse of vagina is one of the important maternal abnormalities during pregnancy in cattle and buffaloes. A field investigation was carried out on 26 Murrah graded buffaloes to study clinical characteristics of vaginal prolapse in buffaloes in Nepal. Fifty-seven percent of the 26 buffaloes with vaginal prolapse were either heifers or in first lactation. Sixty-five percent of the cases were in seventh month of pregnancy or later. About three quarters of the cases occurred between June and October. Twelve cases (63%) of the 19 animals excluding 7 heifers had a history of vaginal prolapse in previous gestations. A half of the buffaloes were showing prolapse of the vagina even when they were in standing position and showing moderate or vigorous straining. After the conventional treatments, twenty-three buffaloes retained the replaced vagina and calved normally. One animal aborted although the vagina was retained. Two buffaloes had severest degree of vaginal prolapse complicated with edema, injury and cyanosis, and they did not respond to the treatment. The two buffaloes had frequently recurrent prolapse and subsequently died. Early detection and prompt treatment may be imperative to control the vaginal prolapse in buffaloes.

Bilateral hydroureter and hydronephrosis causing renal failure due to a procidentia uteri: a case report

We report a case of complete uterine prolapse that resulted in bilateral hydroureter, hydronephrosis, and renal dysfunction. The nonoperative reduction of the prolapse with a vaginal pessary reversed the obstructive uropathy and ameliorated renal function. The lower urinary tract should be imaged in patients with complete uterine prolapse. If present, obstructive uropathy should be relieved by the reduction of the prolapse before irreversible renal damage occurs.

The demographics of pelvic floor disorders: current observations and future projections

OBJECTIVE

Our aim was to assess current demand for care of pelvic floor disorders and create projections for future demand for care. We also sought to better understand the characteristics of women seeking care.

STUDY DESIGN

Current demand for care was calculated by comparing those women seeking care through the female pelvic floor disorders clinic with those women of the same age range at risk within an integrated health care delivery program. Patients underwent complete urogynecologic evaluation including cystometry. Women seeking care were compared with regard to age, distribution of conditions (pelvic organ prolapse, stress conditions, urge conditions), and probability of undergoing surgery. Modeling the study population by use of data from the US Census Bureau, which projects population changes over the next 30 years, created predictions of future demand.

RESULTS

Data were available on 2070 consecutive patients with an age range of 30 to 89 years normally distributed around a median age of 61.5 years drawn from an at-risk population of 149,000 women aged 30 to 89 years. Older women generated more consults per 1000 woman years than did the younger cohorts (1.7 vs 18.6 consults per 1000 woman years for those 30-39 years old vs those 70-79 years old; P <.05). Estimates of growth in demand at 30 years indicate a 45% increase in demand while net growth of the same population segment should be 22%. Stress conditions were more common among younger women and urge conditions were more common among older women. Pelvic organ prolapse was equally distributed throughout the age ranges.

CONCLUSIONS

Over the next 30 years, growth in demand for services to care for female pelvic floor disorders will increase at twice the rate of growth of the same population. Demand for care for pelvic floor disorders comes from a wide age range of women, although mature age groups generate 10 times the number of consults per 1000 woman years as do their younger counterparts. Age plays a major role in the distribution of conditions with which patients present. These findings have broad implications for those responsible for administering programs to care for women, allocating research funds in women's health and geriatrics, and training physicians to meet this rapidly escalating demand.

Assessing and treating pelvic organ prolapse

At least half of all women who have given birth experience pelvic organ prolapse, a condition where pelvic organs protrude through the vagina. Because of the presentation of the different aspects of prolapse, treatment had become compartmentalized in line with pelvic involvement, with urologists, gynecologists, colorectal surgeons, and gastroenterologists each addressing their field of expertise. In addition, urinary or fecal incontinence, urinary retention, and urinary tract infections often are associated with pelvic organ prolapse. Both pelvic organ prolapse and incontinence have a significant impact on the quality of life. New training programs in urogynecology and reconstructive pelvic surgery are producing clinicians who are better equipped to treat pelvic organ prolapse, as well as related urinary and fecal incontinence. This article provides an overview of the various aspects of pelvic organ prolapse for all clinicians involved in assessment, treatment, and potential prevention of this condition.

Gynecologists' patterns of prescribing pessaries

OBJECTIVE

To determine how gynecologists in the United States prescribe pessaries.

STUDY DESIGN

A 34-question (long) survey was sent to 2,000 gynecologists. Those who did not respond were then sent a five-question (short) survey.

RESULTS

Nine hundred forty-seven (47.3%) long and short questionnaires were returned. Eighty-six percent of gynecologists prescribe pessaries. Most received minimal or no training in pessaries in their residencies. The most common pessaries used were the ring and doughnut. Uterine prolapse was treated most often with the Gellhorn and doughnut pessaries. The cube and Gellhorn pessaries were thought to be the most effective for vaginal vault prolapse. The Gehrung and ring pessaries were thought to be most effective for correction of cystocele. However, the ring pessary was considered the easiest to use. Follow-up visits were most often performed at one week, one month and then every three months. Estrogen was used in most cases.

CONCLUSION

Most gynecologists prescribe pessaries. The ring pessary is used most often and is deemed the easiest to use. Pessaries are thought to work for all pelvic organ prolapse defects but are thought to be less effective for posterior defects. Follow-up of patients differs from manufacturers' recommendations.

Non-surgical treatment of uterovaginal prolapse using double vaginal rings

A new technique of using double vaginal ring pessaries to treat uterovaginal prolapse in a group of elderly women is described. Eighteen women with a mean age of 82 years and advanced Stage III or IV uterovaginal prolapse had double vaginal rings inserted. All of them previously had used single vaginal ring pessaries or had undergone pelvic floor repair surgery. Double ring pessaries were successful in 13 of the 18 women. They are a useful treatment of advanced prolapse in women unsuitable for surgery.

Horseshoe-shaped marlex mesh for the treatment of pelvic floor prolapse

OBJECTIVE

Pelvic prolapse results from weakness or damage to the normal pelvic-support systems. The main support for the pelvic viscera is provided by the pelvic fascia, which is naturally reinforced by urethra-pelvic ligaments, cardinal ligaments and uterosacral ligaments. A polypropylene mesh (Marlex-Bard) was used as a genitourinary and rectal support in order to substitute the damaged pelvic fascia.

METHODS

Sixteen consecutive females suffering from severe genitourinary prolapse entered the study. Using the HWS (Baden-Walker) classification 10 patients presented a grade-IV and 6 patients a grade-III cystocele, 7 patients a grade-III and 1 a grade-IV rectocele. Hysterocele of grade IV was present in 2 patients and in 5 patients grade III. No enterocele was present at the pre-operative visit. Twelve patients suffered from stress incontinence; one had obstructive urinary symptoms with postvoiding residual urine of >200 ml. All patients underwent urodynamic tests and pre-operative cystography. The primary aim was prolapse reduction and continence. The operation, under general anesthesia, consisted of insertion and fixation of a horseshoe-shaped Marlex mesh between pubis and sacrum to close the area between the pelvic viscera and inferior pelvic hiatus. Three patients underwent hysterectomy.

RESULTS AND CONCLUSIONS

The follow-up ranged between 12 and 29 months. In 15 patients the prolapse was completely resolved and 13 were dry at follow-up. One patient presented a complete recurrence at the 3-month follow-up. Nine cases of pre-operative constipation were recovered after surgery. This technique seems to give promising results in the repair of genitourinary prolapse and stress incontinence.

Pessary placement and management

Female pelvic organ prolapse is a common and aggravating condition that few women openly discuss. Fortunately, nonsurgical and surgical treatment options exist for this condition. Nonsurgical treatments include pessaries, which are used to reduce prolapse. The type of pessary depends on the direction and extent or grade of the protruding organ. The use of vaginal pessaries for urinary stress continence is a relatively new treatment option. Proper fit that is determined by trial is essential for effectiveness. Nurses at all levels now need to be familiar with the use of the vaginal pessary for pelvic organ prolapse and urinary stress incontinence. Nurses' roles regarding pessary use need to be clearly defined. Continence nurses should be familiar with the indications for pessary use, the types available for incontinence, and patient education regarding pessary care. Home health and long-term care nurses are frequently asked to periodically remove and insert pessaries. Skills and tips for making removal and insertion as easy as possible need to be disseminated. Advance practice nurses need skills for assessment of prolapse, fitting, and current outpatient pessary care routines. Increasing nurses' understanding of and comfort with pessary use might make a significant difference in the treatment of pelvic organ prolapse and urinary stress incontinence.

Urinary retention resulting from incarceration of a retroverted, gravid uterus

Urinary retention resulting from urethral obstruction by a retroverted, gravid uterus is an uncommon disorder that is reported only once in the Emergency Medicine literature. Yet these patients may present in extreme distress and precipitate considerable confusion regarding the cause of and solution to this problem. No study evaluating outcome, risk of complications, or therapy exists. We present two cases that clarify diagnostic and therapeutic controversies and provide a better understanding of what is known about the pathophysiology and treatment alternatives.