"Eyeball" POP-Q examination: shortcut or valid assessment tool?

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Transperineal pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repair

OBJECTIVE

To compare the outcomes of transvaginal mesh (TVM) and native-tissue repair (NTR) for the repair of anterior compartment prolapse.

METHODS

This retrospective study involved 90 patients with anterior compartment prolapse who underwent pelvic organ prolapse surgery between January 2018 and October 2020. A TVM was used to treat 53 patients and 37 underwent NTR. All patients underwent a standardized interview, clinical examination, and four-dimensional pelvic floor ultrasound (PFUS) before and after the surgery. The primary outcome was anatomic recurrence evaluated by ultrasonic parameters. The secondary outcomes were subjective recurrence and complications.

RESULTS

Subjective recurrence was 9.43% (5/53) for TVM and 16.22% (6/37) for NTR (P = .522). Significant recurrence of prolapse on ultrasound occurred in five patients (9.43%) after TVM and 12 (32.43%) after NTR; there was a significant difference between the TVM and NTR groups (P = .006). In the TVM group, the mesh was visible on ultrasound in each patient. The mesh exposure rate was 1.89% (1/53). The postoperative hiatal area reduction in the TVM group, compared with the NTR group, was statistically significant (5.55 ± 4.71 cm² vs 3.09 ± 5.61 cm² , P = .027). The incidence of de novo stress urinary incontinence was higher in the TVM group (20.75% vs 2.70%, P = .03). After surgery, there were significant differences between the two groups based on bladder descent (12.02 ± 8.64 mm vs 22.41 ± 13.95 mm, P = .000) and urethral rotation angle (25.26 ± 13.92° vs 40.27 ± 23.72°, P = .001).

CONCLUSION

PFUS is effective for evaluating postoperative outcomes. TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.

The importance of using 3D ultrasound during pelvic organ prolapse surgery in relation to pre- and post-operative quality of life questionnaires

AIM

The main aim of this study is to evaluate the interest of three-dimensional ultrasound perineal in the measurement of the levator hiatus area as an objective reflection of the surgical correction of pelvic organ prolapse (POP). Our hypothesis is that POP surgery decreases the size of the levator hiatus area.

MATERIALS AND METHODS

A longitudinal and prospective study was conducted between April and July 2017 in the Department of Gynaecology & Obstetrics at University Hospital of Angers. Surgery was performed either by laparoscopy (sacrocolpopexy) or vaginal surgery (with or without the use of mesh). All patients were handed an information letter and signed an informed consent before being included in the study. A questionnaire was fullfilled before and one month after surgery. A clinical evaluation using the simplified POP-Q classification and a perineal 3D ultrasound were carried out before and after surgery by the same professional. The levator hiatus area was assessed before and after surgery in order to evaluate the impact of surgery on the levator hiatus area. Simplified POP-Q measurements and responses to PFDI-20 and PFDI-7 questionnaires were also collected.

RESULTS

A total of 18 patients were included in the study and four were excluded. Seven underwent laparoscopic surgery and seven underwent vaginal surgery. The levator hiatus area decreased substantially from 20.87 to 16.55cm² on mean (p=0.0001) at rest. Regarding patient satisfaction, the PFDI-20 score improved after surgery from 89.36 to 37.87 on mean (p=0.006), but the PFIQ-7 score did not reveal any significant changes (p=0.096). For the clinical examination, we used the simplified POP-Q with Ba measurement from 2.3 to -1.92cm (p=0.005) or Bp from -1.5 to -2.46cm, which is not a significant change (p=0.14). Points C (or D in cases with a history of hysterectomy) changed from -3.1 to -6.15cm (p=0.03).

CONCLUSION

The levator hiatus area seems to decrease after POP surgery. 3D ultrasound seems a new and complementary procedure that allowed to evaluate objectively the levator hiatus area and thus the clinical findings of the surgery.

Emerging concepts for pelvic organ prolapse surgery: What is cure?

The objective of this review is to discuss emerging concepts in pelvic organ prolapse, in particular, "What is cure?" In a post-trial data analysis of the CARE (Colpopexy and Urinary Reduction Efforts) trial, treatment success varied tremendously depending on the definition used (19.2%-97.2%). Definitions that included the absence of vaginal bulge symptoms had the strongest relationships with the patients' assessment of overall improvement and treatment success. As demonstrated by this study, there are several challenges in defining cure in prolapse surgery. Additionally, the symptoms of prolapse are variable. The degree of prolapse does not correlate directly with symptoms. There are many surgical approaches to pelvic organ prolapse. Multiple ways to quantify prolapse are used. There is a lack of standardized definition of cure. The data on prolapse surgery outcomes are heterogeneous. The goal of surgical repair is to return the pelvic organs to their original anatomic positions. Ideally, we have four main goals: no anatomic prolapse, no functional symptoms, patient satisfaction, and the avoidance of complications. The impact of transvaginal mesh requires thoughtful investigation. The driving force should be patient symptoms in defining cure of prolapse.