[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]

Management of female pelvic organ prolapse-Summary of the 2021 HAS guidelines

When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.

[Non-neurological overactive bladder and pelvic-perineal pathology in women]

INTRODUCTION

The aim was to synthesize current knowledge on overactive bladder (OAB) and female pelvic-perineal diseases.

METHOD

A systematic literature review based on PubMed, Embase and Google Scholar was conducted in April 2020.

RESULTS

Women with pelvic organ prolapse very often have OAB. Prolapse surgery should be considered if the prolapse is symptomatic and never be indicated in case of overactive bladder symptoms solely. In case of symptomatic prolapse and OAB, pessary and surgical treatments are effective on both pathologies up to 71 % of the cases. OAB may occur in parallel or as part of a menopausal genitourinary syndrome. In the latter case, only local estrogen therapy is effective. OAB may occur alongside stress urinary incontinence (SUI) or be integrated into mixed urinary incontinence. The initial treatment should be based on the most troublesome symptoms. In case of SUI, the outcome of surgical treatment on OAB remains uncertain. De novo, OAB follows prolapse or SUI surgery. It requires investigations to exclude urinary tract infection, bladder outlet obstruction or erosion. The treatment is the same as OAB.

CONCLUSION

The clinician's challenge is to draw a balance between the OAB and a pelvic-perineal pathology in order to adapt the treatment.

Genital prolapse: epidemiology, clinic and therapeutic at Saint Joseph Hospital of Kinshasa

The aim of the study was to describe the epidemiological, clinical and therapeutical profile of genital prolapse in the gynecology and obstetrics service of Saint Joseph Hospital of Kinshasa. This is a descriptive study carried out from medical files of patients who have suffered from genital prolapse in the gynecology and obstetrics service of Saint Joseph Hospital from January 1st, 2008 to December 31st, 2017. It is based on the no probabilistic sampling of suitability. We recorded 161 cases of genital prolapses upon 13957 patients. The genital prolapses frequency was 1.2% with an annual average of 16.1 cases (SD 10.1) per year. The symptomatology consisted of pelvic mass associated with urinary and digestives troubles (94.0%, n=140). The stage III of cysto-colpocele was the most frequent (56.0%, n=82). The vaginal hysterectomy associated to rectocele and cystocele cure was the most performed operation (52.0%, n=69). The recurrence rate was of 2.0% (3 out of 148 cases). The genital prolapse really exist in our milieu, its symptomatology is classical and its treatment is mostly surgical by vaginal access.

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.

RESULTS

Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

[Uterine preservation or not during prolapse surgery: Review of the literature]

OBJECTIVE

To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation.

MATERIAL AND METHODS

We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer.

RESULTS

Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR=2.21 [95% CI: 0.33-14.67]) or vaginal surgery (OR=1.07 [95% CI: 0.38-2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3-11).

CONCLUSION

In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.

Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies

BACKGROUND

Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject.

OBJECTIVE

This article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed.

METHODS

We performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date.

RESULTS

We selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it.

CONCLUSION

Pelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.

[Preoperative functional explorations of genital prolapse (urodynamics, dynamic MRI)]

The evaluation of genital prolapse is essentially clinical; however imaging tests such as dynamic MRI or urodynamic explorations may be useful in complex cases, especially before surgical management. Dynamic MRI allows morphological and dynamic analysis of pelvic floor and levator ani function. It can also detect post-obstetric injuries, although the long-term significance of these injuries remains to be discovered. Quantification of the severity of prolapse is possible with MRI; however, the correlation of these measures with clinical examination seems poor. Its interest lies mainly in the qualitative assessment of the three stages of prolapse and the detection of elytroceles, which can be difficult to clinical examination. Urodynamics provides useful information on vesico-sphincteric function, but none of these parameters seems to be decisive in the management of prolapse.

[Could we perform vaginal mesh surgery for treatment of pelvic organ prolapse in elderly women?]

INTRODUCTION

Prevalence of pelvic organ prolapse will increase with the aging of the population. Concerning the treatment of pelvic organ prolapse, transvaginal route is often preferred for elderly women. However few data are available concerning transvaginal mesh surgery in this population. The aim of this study was to compare efficiency and complications of transvaginal mesh surgery between women aged over 75 and younger women.

MATERIALS AND METHODS

A monocentric, retrospective study included all women who underwent anterior sacrospinous suspension with mesh for treatment of pelvic organ prolapse. The primary endpoint was anatomical success at the last follow-up, defined by a pelvic organ prolapse stage 0 or 1 of POP-Q classification. The secondary endpoints were rate of complications and urinary, colorectal and sexual functional results.

RESULTS

We included 329 patients, 69 were under 75 years old and 260 were aged over 75. The median of follow-up was 12 months (IQR: 6). The rate of anatomical success was significantly higher in patients aged over 75: 92% versus 85% in younger patients (P=0.02). However this difference was no more significant in multivariate analysis after inclusion of confusions factors (P=0.82). The rate of perioperative complications was low and similar in the 2 groups even in multivariate analysis.

CONCLUSION

Utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh seems to achieve at least similar results between women aged more than 75 years and younger women. There is no excess risk of complications in elderly women.

LEVEL OF EVIDENCE

4.