Nonsurgical management of pelvic organ prolapse

A feasibility study of three-dimensional ultrasound imaging of the vagina under distension

BACKGROUND

The distension properties of the vagina are critical to its function including support of surrounding organs, childbirth, and intercourse. It could be altered by many pathophysiological processes like pregnancy, radiotherapy, and reconstruction surgery. However, there are no clinically available diagnostic tools capable of quantifying the distension properties of the vagina.

PURPOSE

A proof-of-concept study was designed to assess the feasibility of a novel three-dimensional (3D) ultrasound imaging technique that allows quantitative evaluation of the vagina under distension.

METHODS

Patients with symptomatic pelvic organ prolapse (POP) were recruited for the study. An ultrathin, oversized bag was inserted into the vagina and filled with water using a modified urodynamics system. The instilled water volume and intravaginal pressure were continuously recorded. At maximum vaginal capacity, 3D transintroital ultrasound of the distended vagina and surrounding pelvic structures was performed. Exams were performed in duplicate for each patient, two hours apart (round A and round B). Following the development of a 3D surface model of the distended vagina from each scan, several measurements were obtained, including cross-sectional area, anteroposterior (AP) length and lateral width in the plane of minimum hiatal dimensions (PMHD), AP and lateral diameter at the pubic symphysis (PS) level, maximum and minimum diameter, and maximum vertical length. To assess repeatability between measurements in two rounds, the coefficient of variation (CV) and the intraclass correlation coefficient (ICC) were calculated for each measurement. Correlations between physical measurements including the pelvic organ prolapse quantification (POP-Q) system and vaginal diameter measurements, and obtained metrics were also assessed.

RESULTS

Sixteen patients with POP (average age 69 years) completed both rounds of imaging. There was sufficient echogenicity on 3D transintroital ultrasound of the distended vaginal wall to establish boundaries for 3D surface models of the vagina. Overall, all metrics had good or excellent reliability (ICC = 0.77-0.93, p < 0.05; CV = 3%-18%) except maximum diameter, which demonstrated only moderate reliability (ICC = 0.67, p = 0.092). Strong correlations were found between physical exam measurements including D point of POP-Q, introitus diameter and lateral diameter at apex, and maximum vaginal capacity, maximum vertical length, lateral diameter at PS, minimum diameter, and distended PMHD measurements. The results demonstrated that this system could generate 3D models of the shape of the distended vagina and provide multiple metrics that could be reliably calculated from automated analyses of the models.

CONCLUSIONS

A novel system for evaluation of the distension properties of the vagina was developed and preliminary evaluation was performed. This system may represent a technique for evaluation of the biomechanical and structural properties of the vagina.

Outcomes of pessary fitting trials for patients with stage IV pelvic organ prolapse: a prospective study

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the efficacy of pessaries in the treatment of stage IV pelvic organ prolapse (POP) and identify the influencing factors.

METHODS

One hundred and fifty-seven patients with stage IV symptomatic POP were admitted to the hospital for pessary fitting. A successful pessary fitting was defined as a patient fitted with a pessary at the initial fitting in whom use continued 2 weeks later. The rates of successful pessary fitting, patient satisfaction, remission of prolapse and urinary symptoms, and the occurrence of factors associated with successful pessary fitting were calculated and predictors of appropriate pessary type selection were analyzed.

RESULTS

A total of 130 patients with stage IV POP had a successful pessary fitting (82.8%). The satisfaction rate associated with the two types of pessaries was more than 90%. The success rate among patients undergoing a ring pessary fitting trial was 44.6%, and 84.3% of the patients were self-managed. Prolapse symptoms significantly improved in 90% of cases, and urinary symptoms improved in 58-93% of cases from baseline. The number of vaginal deliveries, history of hysterectomy and vaginal introitus/total vaginal length (TVL) ratio were independent risk factors associated with unsuccessful pessary fitting.

CONCLUSION

For patients with stage IV POP, the successful fitting rate is as high as 80% or more. More vaginal deliveries, a history of hysterectomy, and a larger vaginal introitus/TVL ratio (ratio  >0.6) were predictors of unsuccessful pessary fitting.

Adherence to support pessary in the treatment of pelvic organ prolapse: a retrospective study conducted among 1,371 women

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the adherence to pessary treatment in women with pelvic organ prolapse (POP) who were found eligible for this treatment by the urogynecologist, at the first visit at the Department of Gynecology and Obstetrics, Odense University Hospital.

METHODS

Data were extracted from the women's medical records. Frequency tabulations were performed to describe the women's reasons for pessary discontinuation by age group. Binominal logistic regression analysis was conducted to investigate how women's age, POP characteristics, urogynecological history, and their pessary experience and management were associated with continued pessary use.

RESULTS

This study included 1,371 women treated with support pessary. Of these, 850 women continued pessary treatment and 521 women underwent surgical treatment. A history of hysterectomy (OR: 0.68, 95% CI: 0.51-0.90, p = 0.008), urinary incontinence (OR: 0.71, 95% CI: 0.56-0.89, p = 0.003), and previous pessary use (OR: 0.75, 95% CI: 0.56-0.99, p = 0.047) were significant factors associated with discontinuation. Further, women aged 81-99 years were significantly more likely to continue pessary treatment (OR: 1.77, 95% CI: 1.15-2.74, p = 0.009). "POP surgery," "prolapse stage," and "prolapse predominant compartment" were not associated with discontinuation. Approximately 38% of women aged 26-54 years discontinued owing to personal preference.

CONCLUSIONS

Hysterectomy, incontinence, and previous pessary use are significant predictors of pessary discontinuation. Increasing age is significantly associated with pessary continuation.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Inequality in healthcare-seeking behavior among women with pelvic organ prolapse: a systematic review and narrative synthesis

INTRODUCTION

Pelvic organ prolapse (POP) affects women's quality of life in various aspects. However, evidence on the healthcare-seeking behavior of women with POP is limited. Therefore, this review aimed to identify and synthesize the existing evidence on the healthcare-seeking behavior among women with POP.

METHODS

This systematic review and narrative synthesis of the literature on healthcare-seeking behavior among women with POP was conducted from 20 June to 07 July 2022. The electronic databases PubMed, African Journals Online, Cumulative Index to Nursing and Allied Health Literature, African Index Medicus and Directory of Open Access Journal, and Google Scholar were searched for relevant literature published from 1996 to April 2022. The retrieved evidence was synthesized using a narrative synthesis approach. The characteristics of included studies and the level of healthcare-seeking behavior were summarized in a table and texts. Error bar was used to show the variability across different studies.

RESULTS

A total of 966 articles were retrieved of which only eight studies with 23,501 women (2,683 women with pelvic organ prolapse) were included in the synthesis. The level of healthcare-seeking behavior ranges from 21.3% in Pakistan to 73.4% in California, USA. The studies were conducted in four different populations, used both secondary and primary data, and were conducted in six different countries. The error bar shows variation in healthcare-seeking behavior.

CONCLUSIONS

The level of health-care seeking behavior among women with POP is low in low-income countries. There is substantial variability in the characteristics of the reviewed studies. We recommend a large-scale and robust study which will help to better understand the healthcare-seeking behavior among women with POP.

The added value of conventional defecography and MRI defecography in clinical decision making on treatment for posterior compartment prolapse

INTRODUCTION AND HYPOTHESIS

Conventional defecography and MRI defecography can be requested as an additional test for diagnosing and differentiating the type of posterior compartment prolapse and/or obstructive defecation disorders. The objective of this study was to determine the added value of conventional defecography, conventional defecography and MRI defecography for clinical decision-making on treatment for patients with posterior compartment prolapse.

METHODS

Four gynecologists were asked to fill in their treatment plan per patient for 32 cases for three different steps. Step 1 consisted of information on the anamnesis and physical examination (POP-Q). Step 2 consisted of Step 1, including conventional defecography (group A) or MRI defecography (group B). In Step 3, all gynecologists received the information on Step 1 including both conventional defecography and MRI defecography. Data analysis solely focused on the assessment of changes in the gynecological treatment plan of the posterior compartment.

RESULTS

After Step 2 a change in treatment plan occurred in 37% and 48% of the women in groups A and B, respectively. Accordingly, after Step 3 (including all imaging data), a change in treatment plan occurred in 19% and 52% of the women in groups A and B, respectively. A change within the surgery group (when a different type of surgery was selected) was seen for a total of 11 cases in group A and 20 in group B in all steps combined.

CONCLUSIONS

Both conventional defecography and MRI defecography had an large effect on the treatment plan for patients with posterior compartment prolapse. The dedicated added value of the imaging modality individually cannot be concluded yet.

Contemporary Use and Techniques of Laparoscopic Sacrocolpopexy With or Without Robotic Assistance for Pelvic Organ Prolapse

Laparoscopic sacrocolpopexy with or without robotic assistance is an effective approach for the treatment of any pelvic organ prolapse when apical involvement is present.

The past 4 years have been consequential in the world of surgery to correct pelvic organ prolapse. In 2018, results of a large, multicenter randomized trial demonstrated very disappointing cure rates of traditional native tissue repairs at 5 years or more. In 2019, a vaginal mesh hysteropexy kit was removed from the market by the U.S. Food and Drug Administration only to subsequently demonstrate it provided better cure rates and similar risk profile to vaginal hysterectomy plus native tissue repair in its own 5-year study published in 2021. Meanwhile, the use and techniques of laparoscopic sacrocolpopexy with or without robotic assistance have evolved such that it is commonly adapted to treat all support defects for patients with uterovaginal or posthysterectomy prolapse. This article is intended to provide an overview of the contemporary use and techniques of laparoscopic sacrocolpopexy based on the evidence and our clinical experience.

Factors associated with unsuccessful pessary fitting and reasons for discontinuation in Korean women with pelvic organ prolapse

Objective

To identify the factors associated with unsuccessful pessary fitting and reasons for pessary discontinuation in Korean women with pelvic organ prolapse (POP).

Methods

The medical records of 234 patients who underwent pessary fitting for the management of symptomatic POP were retrospectively reviewed. A ring pessary with or without support was used. Successful pessary fitting was defined as the ability to wear a pessary for 2 weeks without any discomfort. Factors associated with unsuccessful pessary fitting were determined using a multivariable logistic regression analysis. A Kaplan-Meier survival curve was obtained to examine the probability of continuing pessary use over the follow-up period. The reasons for the discontinuation of pessary were identified.

Results

Two-hundred-and-twenty-five women were included in the analysis. The rate of unsuccessful pessary fitting was 40%. Prior hysterectomy (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.81–9.42) and POP quantification stage III–IV (OR, 2.49; 95% CI, 1.28–4.85) were independent risk factors for unsuccessful pessary fitting. Among the patients with successful pessary fitting, the median time to discontinuation of pessary use was 4 years. The most common causes of discontinued use were vaginal erosion (45.3%) and urinary incontinence (26.5%).

Conclusion

Patients with a history of hysterectomy and advanced-stage POP are at risk for an unsuccessful fitting of the ring pessary. Vaginal erosion is the main reason for discontinued use among patients with successful pessary fitting.

Effect of vaginal estrogen in postmenopausal women using vaginal pessary for pelvic organ prolapse treatment: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Evidence and recommendations for the use of intravaginal estrogen for prevention of bacterial vaginosis and pessary-related complications are limited and controversial. We hypothesized that adding intravaginal estrogen to pessary use would decrease the incidence of bacterial vaginosis and other pessary-related complications.

METHODS

A single-center, open-label, randomized, parallel study was conducted between April 2018 and August 2020. Participants were randomized to either receive intravaginal estriol 0.03 mg plus Lactobacillus acidophilus 100 million viable cell vaginal tablets or have no treatment. The Amsel criteria, normal flora index, visual analog scale, Thai version of the ICIQ-VS (International Consultation on Incontinence Questionnaire-Vaginal symptoms) questionnaire, vaginal abrasions and vaginal bleeding were evaluated at entry and at 2- and 14-week follow-up.

RESULTS

Seventy-eight women were included and randomized to two groups (39 women per group). At 2-week follow-up, one participant in the intervention group and two participants in the control group were diagnosed with bacterial vaginosis (2.7% vs. 5.7%, p = 0.609). At 14-week follow-up, two participants in the intervention group and two participants in the control group were diagnosed with bacterial vaginosis (5.7% vs. 6.2%, p = 0.926). Normal flora index was significantly different at 2-week follow-up [8 (6.3) vs. 5 (6.0), p = 0.032]. There was no significant difference in the visual analog scale, Thai version of the ICIQ-VS, vaginal abrasions and vaginal bleeding between the 2- and 14-week follow-ups.

CONCLUSIONS

This study shows no benefit of intravaginal estrogen in reducing bacterial vaginosis, vaginal abrasions, vaginal bleeding and pain in postmenopausal women using a vaginal pessary for pelvic organ prolapse treatment.

Vaginal pessary treatment in women with symptomatic pelvic organ prolapse: a long-term prospective study

OBJECTIVE

To evaluate the 5-year pessary continuation rate and identify clinical risk factors associated with discontinuation in patients with symptomatic pelvic organ prolapse (POP).

METHODS

In this prospective observational study, 312 women with symptomatic POP received pessary treatment between November 2013 and July 2015 in Peking Union Medical College Hospital, China, a tertiary referral center. Patients were initially fitted with a ring pessary with support. Those who failed were fitted with a Gellhorn pessary. A successful pessary fitting was defined as a patient who was fitted and continued to use the pessary 2 weeks later. Patients with successful pessary fitting were followed for 5 years. Data analysis was performed with t tests, nonparametric tests, chi-square tests, and logistic regression.

RESULTS

In total, 265 patients (84.9%) had successful pessary fitting. After 5 years, 180 of 239 patients continued pessary use (75.3% continuation rate), with 26 lost to follow-up. The discontinuation rates decreased over time, from 8.7% at 1 year to 2.7% at 5 years. Total vaginal length < 7.5 cm (TVL, OR = 2.7, 95% CI 1.3-5.7, P = 0.007), improvement in Urinary Impact Questionnaire-7 scores < 50% at 3 months (OR = 2.1, 95% CI 1.1-4.2, P = 0.025), and incapability of self-care (OR = 2.6, 95% CI 1.3-5.1, P = 0.008) were potential discontinuation risk factors.

CONCLUSION

Three-quarters of patients with symptomatic POP had successful pessary treatment at 5-year follow-up. TVL < 7.5 cm, poor urinary symptom relief at 3 months, and incapability of self-care were potential discontinuation risk factors.

Pelvic floor muscle training in the treatment of pelvic organ prolapse: A meta-analysis of randomized controlled trials

BACKGROUND

We aimed to assess the overall effect of pelvic muscle training (PFMT) on patients with pelvic organ prolapse (POP) based on eligible randomized controlled trials (RCT).

METHODS

We searched the following databases, such as PubMed, Cochrane, and Embase, to identify eligible RCT based on the index words updated to December 2018. We also searched the publications related to the present study. Odds rations (OR), and mean difference (MD) along with 95% confidence interval (95% CI) were used to analyze the main outcomes.

RESULTS

In this meta-analysis, 15 RCTs were included with a total of 1309 patients in the PFMT group and a total of 1275 patients in the control group. The overall results showed no significant difference in the incidence of add 2 POP-Q stages (RR: 0.55, 95%CI: 0.19-1.63), add 1 POP-Q stages (RR: 1.04, 95%CI: 0.69-1.57), no POP-Q stages change (RR: 0.94, 95%CI: 0.81-1.09), reduce 2 POP-Q stages (RR: 1.72, 95%CI: 0.79-3.76), self-reported same symptom change (RR: 0.70, 95%CI: 0.45-1.09), and self-reported worse symptom change (RR: 0.67, 95%CI: 0.22-2.03) between the 2groups. Besides, the incidence of reduce 1 POP-Q stages was significantly higher in the PFMT group than that of the control group (RR: 1.80, 95%CI: 1.20-2.69), and the PFMT significantly changed the self-reported symptoms with better outcomes when compared with the control group (RR: 2.90, 95%CI: 1.72-4.89). However, after the therapy, the PFMT group decreased the POP-SS (SMD: -0.24, 95%CI: -0.71-0.22), POPDI-6 (SMD: -0.14, 95%CI: -0.43-0.15), CRADI-8 (SMD: -0.03, 95%CI: -0.16-0.11), and UDI-6 (SMD: -0.17, 95%CI: -0.43-0.10) versus the control group, but without statistical significance.

CONCLUSION

PMFT showed better effect in reducing 1 POP-Q stages, changing the self-reported symptoms with better outcomes, decreasing the score of POP-SS, POPDI-6, CRADI-8, and UDI-6 in women with POP versus the control group. However, more high-quality multicenter RCTs with a larger sample size are needed to confirm the present conclusions.

Factors associated with pessary fitting in women with symptomatic pelvic organ prolapse: A large prospective cohort study

AIM

To identify factors associated with unsuccessful pessary fitting in a large cohort of patients with symptomatic pelvic organ prolapse (POP).

METHODS

This prospective observational study included 611 consecutive women with symptomatic POP in a tertiary-care hospital. Patients were initially fitted with a ring pessary with support. Those who failed were fitted with a Gellhorn pessary. A successful pessary fitting was defined as a patient who was fitted or refitted with a pessary and continued to use it 2 weeks later. Parametric and nonparametric tests were used for the data analysis.

RESULTS

A total of 524 patients had successful pessary fittings (85.8% success rate). The success rate of the ring pessary with support was 57.9%, of the Gellhorn pessary was 69.1%. Stage IV prolapse (odds ratio [OR], 2.12), posterior compartment prolapse (OR, 1.92), genital hiatus (OR, 1.41), and vaginal introitus (OR, 1.40) were independent predictors of unsuccessful ring with support pessary fitting. Vaginal length (OR, 0.74/0.60 for ring with support/Gellhorn) and history of POP reconstructive surgery (OR, 2.50/2.58 for ring with support/Gellhorn) were independent predictors of both ring with support and Gellhorn pessary fitting.

CONCLUSIONS

Stage IV prolapse, posterior compartment prolapse, large genital hiatus, and wide vaginal introitus were risk factors for unsuccessful fitting of ring pessary with support. Short vaginal length and a history of POP reconstructive surgery were risk factors for unsuccessful fitting of both pessaries.

Factors associated with unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: Systematic review and metanalysis

AIMS

To identify the factors associated with unsuccessful pessary fitting and reasons for discontinuation for women with symptomatic pelvic organ prolapse (POP).

METHODS

This systematic review is registered at the PROSPERO database. We have included all studies, regardless of the study design whose primary outcomes were factors associated with unsuccessful pessary fitting and discontinuation for symptomatic POP women. Exclusion criteria were case series, literature reviews, other forms of conservative treatment. Data selection/extraction was performed by two investigators. For pessary fitting, a meta-analysis was performed for at least two studies pooled in a forest plot. The risk of bias was classified by the ROBINS-I and ROB-2 classification.

RESULTS

From 409 studies retrieved after data search, only twenty-one articles remained for final analysis (18 cohort studies, 1 cross-sectional study, and 2 RCTs). Meta-analysis was performed in nine studies for pessary fitting and the associated factors were: higher body mass index (BMI) (MD = 0.688 [0.233-1.143]; P = .03; i² = 0%), previous reconstructive surgery (OR = 1.705 [1.016-2.860]; P = .043; i² = 69%) and advanced POP (OR = 4.2 [2.9-6.1]; P < .05; i² = 92%). Older age, larger total vaginal length (TVL), and genital hiatus and previous hysterectomy were not associated factors. Regarding discontinuation, thirteen reasons were quoted, and the most frequent were: the desire for surgical treatment (111/3.601), pessary extrusion (385/3.601), and pain/discomfort (163/3.601).

CONCLUSION

Obese, previously reconstructive pelvic surgery, advanced prolapse are at risk for unsuccessful pessary fitting. Pain is the most quoted reason for discontinuation. These pooled data may help clinicians to identify patients that may not succeed in their attempt for pessary treatment.

First-line treatment of pelvic organ prolapse and discontinuation of pessary treatment

INTRODUCTION

The primary objective of this study was to investigate the percentages of women choosing watchful waiting, pessary use or surgery as first-line treatment of pelvic organ prolapse (POP). Second, the rate and cause of discontinuation of pessary use were investigated.

METHODS

A retrospective chart review was conducted on 794 patients referred with POP at a Danish tertiary center for urogynecology at Aalborg University Hospital between 1 January 2014 and 31 December 2015. The following data were registered: age, BMI, previous use of a pessary, total number of births, vaginal births, cesarean sections, previous hysterectomy, prolapse surgery and incontinence surgery, smoking, menopause, sexual status and POP-Q stage in the three vaginal compartments. Pessary treatments were evaluated after 3 months. Additional visits, reason for discontinuation and secondary treatment were noted.

RESULTS

First-line treatment was surgery in 50%, watchful waiting in 33% and pessary use in 17% of patients. Characteristics associated with choosing surgery instead of a pessary were age < 65 years, previous prolapse surgery, prolapse in the anterior or posterior compartment, and POP-Q stage > 2. Characteristics associated with choosing watchful waiting instead of a pessary were age < 65 years and prolapse in the posterior compartment. A total of 33% discontinued pessary treatment within the first 3 months. Discontinuation was associated with age < 65 years, previous hysterectomy and pelvic surgery, and additional visits. Expulsion of the pessary and pain/discomfort were the main causes of discontinuation.

CONCLUSION

This study showed that 50% of patients referred with POP were treated with conservative treatment (watchful waiting and pessary) and thus more women could probably be treated in primary care.

Timing of Office-Based Pessary Care: A Randomized Controlled Trial

OBJECTIVE

To evaluate the influence of pessary visit intervals on development of vaginal epithelial abnormalities.

METHODS

We conducted a randomized, noninferiority trial of office-based pessary care. Eligible participants were adult women wearing a ring, Gellhorn, or incontinence dish pessary to treat pelvic organ prolapse or incontinence or both. Patients were randomized 1:1 to routine pessary care (office visits every 12 weeks, "routine" arm) or to extended pessary care (office visits every 24 weeks, "extended" arm). The primary study outcome was rate of vaginal epithelial abnormalities (epithelial break or erosion) at the final study visit (48 weeks). The predetermined noninferiority margin was 7.5%.

RESULTS

From January 2015 through June 2017, inclusive, 448 patients were screened and 130 were randomized, 64 to the routine arm and 66 to the extended arm. Baseline characteristics of the study arms were similar with the exception of pessary type, with ring pessary more common in the routine arm and Gellhorn pessary more common in the extended arm (P=.02). The rate of epithelial abnormalities at the final study visit (48 weeks) was 7.4% in the routine arm and 1.7% in the extended arm (difference, -5.7 percentage points; 95% CI -7.4 to -4), which met the criterion for noninferiority. Rates of all types of epithelial abnormalities did not differ between arms at any time point. Increasing duration of pessary use (P=.003) and history of prior epithelial abnormalities were associated with development of epithelial abnormalities (P=.01). Other than epithelial abnormalities, no adverse events related to pessary use occurred in either arm.

CONCLUSION

In women who receive office-based pessary care and are using a ring, Gellhorn, or incontinence dish pessary, routine follow-up every 24 weeks is noninferior to every 12 weeks based on incidence of vaginal epithelial abnormalities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02371083.

Traditional Chinese medicine decreases the obstructive uropathy risk in uterovaginal prolapse: A nationwide population-based study

Traditional Chinese medicine (TCM) is a popular treatment for voiding dysfunction in Eastern countries. However, no previous studies have investigated the effects of TCM on preventing obstructive uropathy in uterovaginal prolapse women. We conducted a large-scale nationwide population-based cohort study to investigate the relationship between TCM and obstructive uropathy in uterovaginal prolapse women. This is a retrospective cohort study with the Taiwan National Health Insurance Research Database (NHIRD). The study population was newly diagnosed uterovaginal prolapse patients between 1997 and 2010 year. Among patients, 762 uterovaginal prolapse patients in this cohort. Significant adjusted HRs of urine retention or hydronephrosis in Cox proportional hazard models were uterovaginal prolapse (hazard ratio [HR]: 1.74, 95% confidence intervals [CI]: 1.43-2.14), age 40 to 64 years (1.51, 1.01-2.27), ≥60 years (3.52, 2.32-5.34), DM (1.52, 1.23-1.89), hypertension (1.38, 1.13-1.7), constipation (1.35, 1.05-1.75), urinary tract calculi (1.54, 1.06-2.23), and TCM users (0.34, 0.28-0.41). The Kaplan-Meier analysis showed a higher incidence rate of urine retention or hydronephrosis in the uterovaginal prolapse cohort compared with that of the without uterovaginal prolapse cohort. The results of this nationwide population-based study support a relationship between TCM and a reduced risk of obstructive uropathy in uterovaginal prolapse women.

The Novel and Minimally Invasive Treatment Modalities for Female Pelvic Floor Muscle Dysfunction; Beyond the Traditional

Pelvic floor dysfunction is a clinical entity that is prevalent among female patients. Determining the exact underlying cause of pelvic floor dysfunction is difficult, and surgical intervention for this clinical entity may be challenging. Pelvic floor dysfunction can affect the quality of life of the patient by causing stress urinary incontinence, pelvic organ prolapse, or both. Well-defined surgical treatment options, minimally invasive approaches, and novel techniques for the treatment of pelvic floor dysfunction have been recently introduced. Here, we evaluated the management options available for patients with stress urinary incontinence and pelvic organ prolapse. We searched Medline and EMBASE databases for relevant articles by using the keywords “pelvic floor dysfunction,” “minimally invasive procedures,” “stress urinary incontinence,” “pelvic organ prolapse,” and “novel techniques”. Traditional treatment options for stress urinary incontinence and pelvic organ prolapse are beyond the scope of our review. Laparoscopic and robotic surgical treatments for pelvic floor dysfunction continue to evolve and develop. These minimally invasive techniques will soon replace open procedures. Alternative novel treatment modalities have also been developed from novel human-compatible materials and are emerging as successful treatments for stress urinary incontinence. The development of these various treatment options has implications for future surgical practice in the field of uro-gynecology.

Nonsurgical Treatment Options for Women With Pelvic Organ Prolapse

Pelvic organ prolapse is a medical condition that can cause pelvic discomfort as well as urinary and bowel complications. Approximately 25% of women in the United States and roughly 50% of women worldwide develop this condition. Although pelvic organ prolapse is usually a non-life-threatening condition, it can result in decreased self-confidence and negative body image. Physical and emotional sequelae can limit physical activity, and decreased productivity could be a consequence. Evidence from the literature indicates that pessary use and pelvic floor muscle training are effective options when conservative treatment is desired. Additional research is necessary to determine long-term outcomes in women who choose nonsurgical treatments. Nonsurgical options are important for women for whom surgery is contraindicated or not preferred.

Pelvic organ prolapse: the impact on quality of life and psychological well-being

The aim of this work is to propose a brief comment about the impact of pelvic organ prolapse on the quality of life and the psychological well-being of the affected women.

Sacrospinous Ligament Fixation Under Local Anesthesia in Elderly Patients at High Risk of General Anesthesia

Introduction and Hypothesis: Sacrospinous ligament fixation(SSLF) is a commonly used surgical procedure in pelvic organ prolapse due to high treatment success rates. Many intraoperative and postoperative anesthesia-related obstacles may be encountered by the elderly population. Local anesthesia alone or with intravenous sedation may provide simple, cheap, and safe anesthesia. For elderly patients at high risk for general anesthesia according to the American Society of Anesthesiologists(ASA), it is better to operate through the vaginal route under local anesthesia. To perform minimal invasive SSLF surgery, the Pelvic Floor Repair Tissue Fixing Anchor, which is a target-specific system, can be used. In this prospective observational study, evaluation was made of elderly patients who underwent SSLF under local anesthesia. Materials and Methods: The study included 11 patients evaluated as high risk for general and regional anesthesia who underwent SSLF under local anesthesia as pelvic organ prolapse surgery. All operations were performed by a single experienced surgeon using 1% lidocaine infiltration and the Pelvic Floor Repair Tissue Fixing Anchor system. Results: The mean age of the patients was 69.6 years. Stage IV prolapse was determined in 7 (63.6%) patients, 4 (36.3%) had a history of hysterectomy, 5 (45.4%) were classified as ASA 3, and 6 (54.6%) as ASA 4. No complications occurred and patients were followed up for 24 months. In two patients, recurrence of POP was observed at postoperative 8 and 10 months, respectively. Conclusions: The results of this study demonstrated the surgical and anesthetic safety of SSLF under local anesthesia for pelvic organ prolapse in elderly patients.

Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists

Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder.

Spontaneous Preterm Birth in Multiples

The number of multiple gestations has increased over the last several decades and preterm birth is one of the leading causes of perinatal morbidity and mortality for these pregnancies. While screening and treatment strategies have achieved moderate success in singleton gestations, screening strategies are less effective in multiple gestations. In addition, to date no intervention aimed at preventing preterm birth has been conclusively shown to either prolong gestation or improve neonatal outcomes for multiple gestations. As in singleton gestations, cervical length is one of the strongest predictors of preterm birth. While not conclusive, emerging data suggest that vaginal progesterone or cervical pessary may be able to prevent preterm birth in twin gestations with a short cervix.

Non-surgical interventions for pelvic organ prolapse in rural Nepal: a prospective monitoring and evaluation study

Objectives

Pelvic organ prolapse (POP) is a major cause of morbidity in Nepal, particularly affecting women in the rural communities. Women with POP in Nepal may suffer from symptoms for decades. At present, the Government of Nepal advocates surgical intervention but access to surgical care is inadequate. This report evaluated the feasibility of a non-surgical public health programme in rural Nepal, and describes risk factors associated with POP in this setting.

Design

Prospective monitoring and evaluation study of a new public health programme.

Setting

Baglung district, rural Nepal.

Participants

Women with gynaecological symptoms of POP.

Main outcome measures

Risk factors for disease progression were assessed using Fisher’s exact test, Pearson’s χ²-test and logistic regression analysis.

Results

Of the 74 women included in this analysis, 70.8% were diagnosed with stage 2 POP or greater. The majority of women did not have any further children following the onset of POP symptoms (63.5%). Duration of symptoms ranged from 2 months to 60 years, with 73.4% of women suffering for over 5 years and 28.4% suffering for over 20 years. Univariate analyses identified age at screening, age at onset of symptoms, the duration of symptoms and an associated rectocele as factors associated with increasing POP severity (p < 0.05). Kegel exercises were taught to 25 (33.8%) women with POP and ring pessaries were offered to 47 (63.5%) women with POP.

Conclusions

Non-surgical interventions may provide an opportunity to address the significant burden of POP in rural Nepal.

The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Our objective was to assess the effectiveness of pelvic floor muscle training (PFMT) as a treatment for women with pelvic organ prolapse (POP) or as an adjunct to prolapse surgery.

METHODS

Relevant literature sources were searched using databases including PubMed, Ovid, Web of Science, Scopus, ClinicalTrials.gov, EBSCO, CINAHL, the Cochrane Central Register of Controlled Trials, CNKI, VIP, Wanfang, and CBM until 5 July 2015. Eligible studies were restricted to randomized controlled trials (RCT). The available data were pooled using Review Manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

In total, 13 studies with 2,340 patients were included. Our results indicated women receiving PFMT gained a greater improvement than controls in prolapse symptom score [mean difference (MD) -3.07, 95 % confidence interval (CI) -3.91 to -2.23] and POP stages [risk ratio (RR) 1.70, 95 % CI 1.19-2.44]. The number of women who said their prolapse was getting better was higher (RR 5.48, 95 % CI 2.19-13.72) and other discomfort syndromes, such as vaginal, bladder, and rectum, were lower in the PFMT groups than in controls. Meanwhile, women after PFMT had greater improvement in muscle strength and endurance but did not show a significant difference for further treatment needs. In addition, the results evaluating PFMT as an adjunct to prolapse surgery were inconclusive because of the variability in methods of measuring outcome.

CONCLUSIONS

Our meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity.

Pelvic organ prolapse: an overview

Pelvic organ prolapse is a common gynecologic complaint in which the vaginal walls are weakened, resulting in descent of pelvic organs through the vagina. Prolapse may be asymptomatic or associated with pelvic pressure and difficulties with urination and defecation, but usually is not responsible for pelvic or lower abdominal pain. Treatment options include conservative measures such as a pessary or pelvic floor physical therapy, or surgical correction. Patients should be reassured that prolapse typically is not an emergency or life-threatening condition.

Cervical pessaries for prevention of spontaneous preterm birth: past, present and future

This Review describes the rationale for the use of cervical pessaries to prevent spontaneous preterm birth and their gradual introduction into clinical practice, discusses technical aspects of the more commonly used designs and provides guidance for their use and future evaluation. Possible advantages of cervical pessaries include the easy, 'one-off' application, good side-effect profile, good patient tolerance and relatively low cost compared with current alternatives. Use of transvaginal sonography to assess cervical length in the second trimester allows much better selection of patients who may benefit from the use of a cervical pessary, but future clinical trials are needed to establish clearly the role of pessaries as a preterm birth prevention strategy worldwide.

Porcine dermis compared with polypropylene mesh for laparoscopic sacrocolpopexy: a randomized controlled trial

OBJECTIVE

To compare the surgical outcomes 12 months after laparoscopic sacrocolpopexy performed with porcine dermis and the current gold standard of polypropylene mesh.

METHODS

Patients scheduled for laparoscopic sacrocolpopexy were eligible for this randomized controlled trial. Both our clinical research nurse and the patients were blinded as to which material was used. Our primary end point was objective anatomic cure defined as no pelvic organ prolapse quantification (POP-Q) points Stage 2 or greater at any postoperative interval. Our sample size calculation called for 57 patients in each group to achieve 90% power to detect a 23% difference in objective anatomic cure at 12 months (α=0.05). Our secondary end point was clinical cure. Any patient with a POP-Q point greater than zero, or Point C less than or equal to -5, or any complaints of prolapse symptoms whatsoever on Pelvic Floor Distress Inventory-20 or Pelvic Floor Impact Questionnaire, Short Form 7, or reoperation for prolapse were considered "clinical failures"; the rest were "clinical cures." Statistical comparisons were performed using the χ or independent samples t test as appropriate.

RESULTS

As expected, there were no preoperative differences between the porcine (n=57) and mesh (n=58) groups. The 12-month objective anatomic cure rates for the porcine and mesh groups were 80.7% and 86.2%, respectively (P=.24), and the "clinical cure" rates for the porcine and mesh groups were 84.2% and 89.7%, respectively (P=.96). Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire, Short Form 7 score improvements were significant for both groups with no differences found between groups. There were no major operative complications.

CONCLUSIONS

There were similar outcomes in subjective or objective results 12 months after laparoscopic sacrocolpopexy performed with either porcine dermis or polypropylene mesh.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00564083.

LEVEL OF EVIDENCE

I.

Geriatric gynecology

Most postmenopausal vaginal bleeding is benign; however, it merits diagnostic evaluation by transvaginal ultrasound or endometrial biopsy after emergency department evaluation. Patients and physicians may treat menopausal symptoms with hormone replacement therapy or other agents, such as venlafaxine or gabapentin. Hormone replacement therapy, when initiated close to the start of menopause and continued at the lowest possible dose for the shortest possible duration, carries less risk than previously believed. Pelvic organ prolapse affects millions of women and may contribute to poor body image and difficulty with urinary, gastrointestinal, and sexual function. Treatment options include Kegel exercises, pessaries, and surgery.