Management of genital prolapse

Two-dimensional biomechanical finite element modeling of the pelvic floor and prolapse

We developed the pelvic floor model in physiological and pathological states to understand the changes of biomechanical axis and support that may occur from the normal physiological state to the prolapse pathological state of the pelvic floor. Based on the physiological state model of the pelvic floor, we model the uterus to the pathological state position by balancing intra-abdominal pressure (IAP) and uterine pathological position load. Under combined impairments, we compared the patterns of changes in pelvic floor biomechanics that may be induced by different uterine morphological characteristic positions under different IAP. The orientation of the uterine orifice gradually changes from the sacrococcygeal direction to the vertical downward of vaginal orifice, and a large downward prolapse displacement occurs, and the posterior vaginal wall shows "kneeling" profile with posterior wall bulging prolapse. When the abdominal pressure value was 148.1 cmH₂O, the descent displacement of the cervix in the normal and pathological pelvic floor system was 11.94, 20, 21.83 and 19.06 mm in the healthy state, and 13.63, 21.67, 22.94 and 19.38 mm in the combined impairment, respectively. The above suggests a maximum cervical descent displacement of the uterus in the anomalous 90° position, with possible cervical-uterine prolapse as well as prolapse of the posterior vaginal wall. The combined forces of the pelvic floor point in the direction of vertical downward prolapse of the vaginal orifice, and the biomechanical support of the bladder and sacrococcygeal bone gradually diminishes, which may exacerbate the soft tissue impairments and biomechanical imbalances of the pelvic floor to occur of POP disease.

Uterine prolapse: impact of the condition and practical advice

Pelvic-organ prolapse is where organs such as the uterus move out of place; in some cases, they can protrude out of the body. It occurs when muscles extending from the pubic bone to the coccyx or the levator ani muscles become weak or are injured. Although it is not life-threatening, the condition can be life limiting, adversely affecting physiological processes, function and quality of life, with patients reporting years of pain, discomfort, humiliation and embarrassment. Uterine prolapse is often under-reported as women may feel resigned to a condition that is viewed as part of getting old or the menopause, or a consequence of childbirth; they may also feel embarrassed. Gynaecology has the fastest growing waiting lists of any NHS specialty, and women may wait a long time for treatment. This article focuses on uterine prolapse, management of symptoms from conservative self-help to surgical options, and includes a case study of a successful laparoscopic hysteropexy with bifurcated polypropylene mesh apical support procedure carried out by a skilled surgeon.

Relationship between high intra-abdominal pressure and compliance of the pelvic floor support system in women without pelvic organ prolapse: A finite element analysis

Previous studies mainly focused on the relationship between the size of the prolapse and injury to the supporting tissues, but the strain and stress distributions of the supporting tissues as well as high-risk areas of injury are still unknown. To further investigate the effect of supporting tissues on organs and the interactions between organs, this study focused on the relationship between high intra-abdominal pressure and the compliance of the pelvic floor support system in a normal woman without pelvic organ prolapse (POP), using a finite element model of the whole pelvic support system. A healthy female volunteer (55 years old) was scanned using magnetic resonance imaging (MRI) during rest and Valsalva maneuver. According to the pelvic structure contours traced by a gynecologist and anatomic details measured from dynamic MRI, a finite element model of the whole pelvic support system was established, including the uterus, vagina with cavity, cardinal and uterosacral ligaments, levator ani muscle, rectum, bladder, perineal body, pelvis, and obturator internus and coccygeal muscles. This model was imported into ANSYS software, and an implicit iterative method was employed to simulate the biomechanical response with increasing intra-abdominal pressure. Stress and strain distributions of the vaginal wall showed that the posterior wall was more stable than the anterior wall under high intra-abdominal pressure. Displacement at the top of the vagina was larger than that at the bottom, especially in the anterior–posterior direction. These results imply potential injury areas with high intra-abdominal pressure in non-prolapsed women, and provide insight into clinical managements for the prevention and surgical repair plans of POP.

The effect of pelvic floor muscle exercises applied during pregnancy on genito-pelvic pain level in postpartum period

INTRODUCTION AND HYPOTHESIS

The goal of the study is to determine the effect of pelvic floor muscle exercises on genito-pelvic pain levels during the postpartum period.

METHODS

The data of the study, which was carried out in a randomized controlled experimental design, were collected in the antenatal policlinic of a public hospital from June-December 2019. There were 60 pregnant women in the experimental and control groups. Pelvic floor muscle exercises were applied to the pregnant women in the experimental group from the 30th week of gestation to the 6th week postpartum. The control group was not given pelvic floor muscle exercise training, and only data collection forms were filled in. During the study, the Descriptive Form, Verbal Category Scale, Pelvic Floor Distress Inventory-20, and Labour and Postpartum Information Form were given to the pregnant women in both groups.

RESULTS

After pregnant women in the experimental group performed pelvic floor muscle exercises, pain levels were significantly lower than in the control group (p < 0.01). Pelvic Floor Distress Inventory-20 total score and sub-dimension scores of the experimental group were statistically significantly lower than in the control group (p < 0.01). In addition, a statistically significant difference was found (p < 0.01) in the postpartum 72 h findings of the experimental group in which pelvic floor muscle exercises were applied compared to the control group.

CONCLUSIONS

According to the result of the study, as the gestational weeks progress, the genito-pelvic pain increases. Pelvic floor muscle exercises applied during pregnancy prevent the development and progression of pelvic floor disorders in both the antenatal and postnatal periods.

TRIAL REGISTRATION

NCT05343520.

Gangrenous Small Bowel Due to Reposition of Procidentia in an Elderly Woman

Gynecologists are familiar with procidentia, a severe form of pelvic organ prolapse (POP) that includes herniation of the anterior, posterior, and apical compartments of the vagina, through the introitus. Usually, women with POP present with concerns of something coming out of the vagina, heaviness, discharge through the vagina, urinary complaints, and, rarely bowel, complaints. Intestinal obstruction secondary to procidentia is a rare complication and is seldom reported in the literature. We report one such case where an elderly woman presented with the primary concerns of constipation, retention of urine, and multiple episodes of vomiting. Clinical history revealed that herniated tissue protruding outside the vaginal introitus was reposited inside the vagina two days ago. Clinical examination and investigations were suggestive of intestinal obstruction, secondary to the reposition of procidentia. Exploratory laparotomy revealed gangrene of the terminal ileum. Right hemicolectomy with ileo-colic anastomosis was done, which saved the woman’s life. Reposition of the prolapsed uterus was thought to be the probable reason, leading to obstructed and gangrenous small bowel. As this case illustrates, the chronology of symptoms and signs and progression of disease should be appropriately interpreted to diagnose and manage such potentially life-threatening conditions.

Do patients discharged from the physiotherapy-led pelvic health clinic re-present to the urogynaecology service?

INTRODUCTION AND HYPOTHESIS

The physiotherapy-led pelvic health clinic (PLPHC) is an advanced practice clinic that manages women from the urogynaecology waitlist with pelvic organ prolapse (POP) and/or urinary incontinence (UI) at Gold Coast Health, Australia. This study was aimed at determining re-referral rates and reasons for re-presentation of women previously managed and discharged from the PLPHC. We hypothesised that there would be low representation rates for the same condition within 12 months of discharge.

METHODS

A retrospective audit was undertaken of all (n = 209) patients discharged between 1 January and 31 December 2017. Re-presentation rates and reasons for re-referral for women seen in the PLPHC and discharged without requiring urogynaecology medical specialist review were analysed and descriptive analysis performed.

RESULT

Of the 209 patients, 67 were referred to, or had, urogynaecology medical specialist review after their initial physiotherapy care and were removed from further analysis. Of the remaining 142 patients, who were initially managed by physiotherapy only, 10 (7.1%) women were re-referred to specialist medical outpatient gynaecology and urology out-patient departments, for management of a different diagnosis, and 10 (7.1%) for their original diagnoses, within 12 months of discharge. Of the latter, 1 patient required further physiotherapy and urogynaecologist management; 7 patients required ongoing pessary management; 1 patient continued with urologist medical management; and 1 failed to attend.

CONCLUSION

This study presents novel data on low re-presentation rates in the 12 months following discharge for patients with POP or UI managed in a PLPHC; and provides further support for advanced scope of practice physiotherapy gynaecological service models.

Surgical and quality of life outcomes after pelvic organ prolapse surgery in older postmenopausal women

Introduction

To evaluate the surgical outcome, and quality of life (QoL) 12-months after Le Fort colpocleisis (LFC), and sacrospinous fixation (SSF) in older postmenopausal women.

Material and methods

Eighty-six (86) post-menopausal women were included in this study (38 in the LFC group and 48 in the SSF group). Pelvic organ prolapse quantification (POP-Q) was used to evaluate the participants’ pelvic organ prolapse (POP) pre-operatively and post-operatively (PO). The Arabic version of the WHOQoL-BREF Inventory was used to evaluate the participants’ QoL preoperatively and post-operatively. The surgical outcome and QoL 12-months after LFC and SSF were analysed to evaluate the surgical outcome, as well as QoL 12 months after LFC and SSF.

Results

The pre-operative Aa, Ba, D, Ap, and Bp values of POP-Q significantly improved 12 months PO in the LFC group (p1 = 0.004, 0.0006, 0.02, 0.004, and 0.0001; respectively), and in the SSF group (p1 = 0.003, 0.0003, 0.003, 0.0005, and 0.01, respectively). Eighty (93.02%) of the studied women had no prolapse at 12-month PO follow-up. The 12-month PO psychological and social health domains were significantly higher in the SSF group compared to the LFC group (p2 = 0.04, and 0.02, respectively). In addition, the 12-month PO general health satisfaction and total QoL scores were significantly higher in the SSF group compared to the LFC group (p2 = 0.03 and 0.01, respectively).

Conclusions

LFC can be considered a good surgical procedure with minimal or neglectable complications for POP in older postmenopausal women with multiple co-morbidities. The psychological and social health domains, general health satisfaction, and total QoL score were significantly higher in the SSF group compared to LFC group 12 months PO.

Conservative Management of Pelvic Organ Prolapse: Indian Contribution

Pelvic organ prolapse (POP) is a very common condition which can greatly impact a woman's quality of life. Treatment options are individualized and typically involve a combination of physiotherapy, pessary insertion and surgical treatments. It is well known that nulliparous prolapse in India constitutes 1.5-2% of genital prolapse, while the incidence is even higher (5-8%) for young women who have delivered one or two children, thus making it one of the highest rates in the world. This has necessitated the development of numerous conservative surgical treatment options for POP, which allows women to retain their sexual and reproductive function and therefore allows for subsequent pregnancies. With the controversy surrounding the use of mesh, a variety of surgical treatment options should be considered. Such alternative treatments include the use of surgical sling procedures, which have been used widely in Indian practice for the treatment of POP for over 60 years. This review outlines some of the well-established conservative treatment options for POP. It also highlights the unique contribution of Indian Obstetricians in the development of these conservative surgical treatment options, from prominent Indian Gynecologists including Dr VN Shirodkar, Dr BN Purandare, VN Purandare, RP Soonawala, Brigadier SD Khanna and Dr RM Nadkarni.

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.

Total colpocleisis technique in huge neglected ulcerated uterovaginal prolapse

INTRODUCTION AND HYPOTHESIS

We present a video describing the technical considerations for performing a total colpocleisis in the management of significant, neglected, ulcerated, and symptomatic complete uterovaginal prolapse.

METHODS

A 79-year-old debilitated woman presented with a large, ulcerated pelvic bulge. A previous attempt at pessary treatment failed because of a disproportion of the pessary with the prolapse size. She had a history of liver insufficiency and hypertension. Obliterative colpocleisis surgery was selected because the healing of a large ulcerated vagina was not likely within a short timeframe. Sharp dissection with scissors and de-epithelialisation of the remaining non-eroded vaginal mucosa with the friction of a sharp-edged surgical knife were performed. Closely located purse strings were used to obliterate potential spaces. Two mirror image triangles in the anterior and posterior vaginal walls were removed. After the formation of a new perineal body, the diamond-shaped vaginal incision was closed vertically to narrow introitus.

RESULTS

The patient was discharged on the first postoperative day and an uncomplicated postoperative course ensued. At the 4-week follow-up, there was no evidence of infection, recurrent prolapse, de novo stress incontinence, or voiding with difficulty.

CONCLUSIONS

Total colpocleisis is an excellent surgical option in women with multiple, large cervicovaginal ulcers and multiple comorbidities with no desire for penetrative vaginal function.

Predictors of successful ring pessary use in women with pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management.

AIM

To determine any association between history, clinical and four-dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success.

MATERIALS AND METHODS

From November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success.

RESULTS

Of 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty-eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty- Two (50%) were still using the pessary at a three-month follow-up. Predictors associated with failure included being pre-menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre-menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis.

CONCLUSIONS

A history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.

Success rates and outcomes of laparoscopic mesh sacrohysteropexy

BACKGROUND

Uterovaginal prolapse is a prevalent gynaecological issue, which can have a negative impact on the quality of life of women. Hysterectomy and vaginal repair are conventional treatments to address apical prolapse; however, women are increasingly requesting uterine-preserving alternatives.

AIMS

This study aimed to evaluate the impact of laparoscopic mesh sacrohysteropexy on symptomatic prolapse from an Australian experience.

MATERIALS AND METHODS

This retrospective cohort study presents outcomes of 157 patients who underwent laparoscopic mesh sacrohysteropexy at a private practice in South Australia during 2007-2017. Primary outcome is the success rate according to the pelvic organ prolapse quantification (POP-Q) system. Secondary measures included complication rates and patients identified as having Stages III-IV prolapse and their outcomes.

RESULTS

The median age was 58 years (27-86 years), median parity was 2 (0-6), and median body mass index was 26.8 (23-29.9). One hundred and thirty-four women had a laparoscopic hysteropexy and concurrent vaginal prolapse repair and four women had an isolated laparoscopic hysteropexy. The mean pre-operative point C was 0.60. The mean change from pre-operative point C to post-operative point C was 7.6 cm (P < 0.01). Of the 136 patients (98.6%) seen at post-operative 4-6 weeks, all had Stage 0 POP-Q scores. Prolapse recurrence was observed in 22 patients, while 116 patients remained cured at their last follow-up. Prolapse recurrence was associated with anterior vaginal mesh, previous prolapse surgery, pre-operative Stage III-IV disease and number of vaginal deliveries.

CONCLUSIONS

Laparoscopic mesh sacrohysteropexy is an effective and safe procedure with a high success rate comparable to available international data.

Le Fort partial colpocleisis as an effective treatment option for advanced apical prolapse in elderly women

OBJECTIVE

The aim of this study was to evaluate the outcomes of women with advanced apical prolapse who were treated with the obliterative LeFort partial colpocleisis (LFC) procedure.

MATERIALS AND METHODS

We reviewed the medical records of patients who underwent LFC for advanced apical prolapse. We collected data for baseline patient characteristics, co-morbidities, severity of prolapse, operating time, intraoperative injuries, and postoperative complications. Subjective postoperative outcomes and patient satisfaction levels were also assessed.

RESULTS

Ninety-five patients underwent LFC during the study period. Median age of patients at operation was 76.0years. Mean operation time was 121.5 ± 31.9 min. Mean postoperative hospital stay was 3.5 ± 1.6 days. Postoperative complications, which were virtually all urinary symptoms, were present in 29.8% of patients, and 89.3% of patients have been in spontaneous remission. There was one case with perineal wound infection, one case of prolapse recurrence, and one case of de novo rectal prolapse after LFC. The objective success rate of the LFC procedure for all patients was 98.9% (94/95). Most (96%) patients were satisfied with the LFC results and pleased with the improvement in body image.

CONCLUSION

The obliterative LFC procedure had a high success rate and was associated with minimal adverse events for the elderly patients with advanced apical prolapse. This procedure should be considered as a treatment option for the advanced apical prolapse in selected elderly women who do not want to conserve vaginal intercourse, as it offers improvement in quality of life and is associated with a low regret rate.

Person-Centered Care for Patients with Pessaries

Pelvic organ prolapse is a common condition affecting women of any age but more likely to occur in the aging woman. Prolapse has a significant impact on quality of life, sexuality, and body image. Vaginal support pessaries have been used since ancient times and are a safe and effective nonsurgical treatment option. Fitting a pessary results in immediate symptom improvement. A comprehensive evaluation for pessary fitting is time intensive but necessary. Nurse providers perform direct pessary care and have a role in caring for women with prolapse expanding access to care. Caregiver and family involvement is important for pessary care and follow-up.

[The gynecological pessary: Is it really a device of another age, a fig leaf?]

OBJECTIVES

The use of pessary to put back up prolapsed organs to their normal position dates back prior to several millennia. This work aims to discuss its place in our clinical practice through an updated bibliographic review and emphasizes a hands-on approach to pessary fitting and management in terms of indication, pessary type selection, device' size, insertion, removal, follow-up visits and care.

METHODS

A review of the literature, in the light of the latest publications and recommendations of French and international learned societies, as well as our own experience, were analyzed.

RESULTS

This device appears to be as effective as surgical management to relieve symptoms related to urogenital prolapse and restore body image. It can be used temporarily, awaiting a surgical solution or as a therapeutic test (mimicking the effect of a surgical procedure to predict its functional outcome or identifying a masked urinary incontinence). It can also represent an alternative to surgery (patient choice, women who wish to complete childbearing or who are unsuitable for surgery because of medical comorbidities) and thus can be used in first intention. However, despite its moderate cost and its harmlessness, this device remains somewhat little known as regards the practical modalities of its use, which, moreover, appear not consensual.

CONCLUSION

A guide intended for the attention of the patients as well as a film relating to the practical modalities of the device' use were elaborated to improve the knowledge of both professionals and users in order to optimize and secure the care pathway.

Effects of Surgical Anatomical Correction of Pelvic Anterior Compartment Defect on Lower Urinary Tract Symptoms

OBJECTIVE

To evaluate the effects of surgical anatomical correction on lower urinary tract symptoms (LUTS) in patients with a pelvic anterior compartment defect (PACD).

METHODS

This prospective study was carried out on 30 women who had stage II-IV PACD. The women were questioned regarding LUTS symptoms such as urgency, urge incontinence, frequency, hesitancy, abnormal emptying, nocturia and dysuria pre and postoperatively. After a 7-month follow up, the comparison of LUTS symptoms with respect to their healing, existence or de novo appearance was performed using the McNemar and Bowner and Wilcoxon signed-rank tests.

RESULTS

For the repair of ACD, 15, 8 and 7 women were operated on using site-specific surgery, transvaginal mesh placement and anterior colporrhaphy, respectively. Surgery has significantly improved the LUTS: urgency (100 vs 26.7%, urge incontinence (70 vs 16.7%), frequency (76.7 vs 13.3%), abnormal emptying (56.7 vs 10%), hesitancy (30 vs 6.7%), nocturia (83.3 vs 60%) and dysuria (30 vs 6.7%). The differences were statistically significant (P < 0.05).

CONCLUSIONS

The correctional surgery on anterior compartment defects not only maintains the anatomy but also significantly heals the LUTS.

Management of Overactive Bladder in the Face of High Grade Prolapse

Patients with pelvic organ prolapse (POP) may present with a large combination of symptoms including overactive bladder (OAB) symptoms such as urgency, frequency, and urgency incontinence. The explanation as to why these symptoms are more prevalent in POP patients is not clearly understood, but there seems to be an overall agreement that prolapse-induced bladder outlet obstruction (BOO) may trigger bladder changes resulting in OAB symptoms. Presuming this to be true, many of the studies managing OAB in POP patients have focused on the surgical management of prolapse and its aftermath, which in many of the patients leads to improvement of OAB symptoms. This review presents the most recent studies and evidence looking at management of OAB in the face of POP and seeks to evaluate if there is any association between prolapse severity and OAB symptoms.

Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Abnormalities of common collagen proteins have been noted in individuals affected by POP and JHM, suggesting a common aetiology. We assessed strength, consistency and potential for bias in pooled associations of the relationship between JHM and POP.

METHODS

We searched MEDLINE, EMBASE and CINAHL, as well as International Continence Society (ICS) and International Urogynaecologic Association (IUGA) annual meeting abstracts, including reference lists, without language restrictions. We included case-control and cohort studies and applied strict criteria for choosing eligible studies. Methodologically trained reviewers independently screened abstracts and full texts to confirm eligibility. We extracted data on study and patient characteristics, clinical assessment tools, and methodology. We assessed comparability and representativeness of source populations, confidence in the assessment of JHM and POP and adjustment for confounding and missing data. Meta-analysis was performed using a random effects model.

RESULTS

We retrieved 39 full texts, of which 14 were used in the meta-analysis. Overall pooled odds ratio (OR) was 2.37 [95 % confidence interval (CI) 1.54-3.64, I(2) = 77.0 %]. We identified no significant factors in meta-regression, and there was no evidence of publication bias; six studies were at high risk of bias with frequent differences in sampling frames, limited validity for clinical assessments and failure to match for important prognostic variables.

CONCLUSIONS

We found a strong association between POP and JHM, with an effect size that is clinically relevant. Our findings are limited by high heterogeneity and the potential for residual confounding factors. JHM is an important early indicator for POP risk, and future longitudinal studies should explore the shared aetiology.

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.

One-year prospective comparison of vaginal pessaries and surgery for pelvic organ prolapse using the validated ICIQ-VS and ICIQ-UI (SF) questionnaires

INTRODUCTION AND HYPOTHESIS

Vaginal pessaries, pelvic floor exercises and surgery are treatment options for women with symptomatic pelvic organ prolapse (POP). The aim of this study was to compare the outcomes of pessaries and surgery in women with symptomatic POP using the validated International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) and Urinary Incontinence (ICIQ-UI) Short Form (SF).

METHODS

Women attending the Urogynecology clinics with symptomatic POP were recruited. All women were treated using either a vaginal pessary or surgery. Outcomes were evaluated and then compared at 1 year using the validated ICIQ-VS and ICIQ-UI (SF) questionnaires.

RESULTS

A total of 287 women with symptomatic prolapse were recruited. 269 women completed the questionnaires at baseline and 183 at 1 year. At 1 year, improvement was noted in quality of life (QOL), frequency of urinary leak and vaginal symptoms in both groups except for the symptom of vaginal soreness in the pessary group and the symptom of a tight vagina in the surgery group. However, both these symptoms were not bothersome. Women who underwent surgery demonstrated an improvement in faecal evacuation and sex life. There was an overall statistically significant improvement in vaginal, sex, QOL and urinary symptom scores in both groups. No statistically significant difference was noted between the surgery and the pessary groups.

CONCLUSIONS

Using validated questionnaires 1 year after treatment, women with symptomatic POP report improvement in vaginal, bowel, urinary and quality of life scores when treated with either pessary use or surgery. No statistically significant difference was noted in the two groups.

Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care

OBJECTIVE

To compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years and over with symptomatic mild pelvic organ prolapse.

DESIGN

Randomised controlled trial.

SETTING

Dutch primary care.

PARTICIPANTS

Women aged 55 years or over with symptomatic mild prolapse (leading edge above the hymen) were identified by screening. Exclusion criteria were current prolapse treatment or treatment in the previous year, malignancy of pelvic organs, current treatment for another gynaecological disorder, severe/terminal illness, impaired mobility, cognitive impairment, and insufficient command of the Dutch language.

INTERVENTIONS

Pelvic floor muscle training versus watchful waiting.

MAIN OUTCOME MEASURES

The primary outcome was change in bladder, bowel, and pelvic floor symptoms measured with the Pelvic Floor Distress Inventory-20 (PFDI-20), three months after the start of treatment. Secondary outcomes were changes in condition specific and general quality of life, sexual function, degree of prolapse, pelvic floor muscle function, and patients' perceived change in symptoms.

RESULTS

Of the 287 women who were randomised to pelvic floor muscle training (n=145) or watchful waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) points more on the PFDI-20 than did participants in the watchful waiting group (P=0.005). Of women in the pelvic floor muscle training group, 57% (82/145) reported an improvement in overall symptoms from the start of the study compared with 13% (18/142) in the watchful waiting group (P<0.001). Other secondary outcomes showed no significant difference between the groups.

CONCLUSIONS

Although pelvic floor muscle training led to a significantly greater improvement in PFDI-20 score, the difference between the groups was below the presumed level of clinical relevance (15 points). Nevertheless, 57% of the participants in the intervention group reported an improvement of overall symptoms. More studies are needed to identify factors related to success of pelvic floor muscle training and to investigate long term effects.Trial registration Dutch Trial Register (www.trialregister.nl) identifier: NTR2047.

Female patient-specific finite element modeling of pelvic organ prolapse (POP)

Pelvic organ prolapse (POP) occurs only in women and becomes more common as women age. However, the surgical practices remain poorly evaluated. The realization of a simulator of the dynamic behavior of the pelvic organs is then identified as a need. It allows the surgeon to estimate the functional impact of his actions before his implementation. In this work, the simulation will be based on a patient-specific approach in which each geometrical model will be carried out starting from magnetic resonance image (MRI) acquisition of pelvic organs of one patient. To determine the strain and stress in the soft biological tissues, hyperelastic constitutive laws are used in the context of finite element analysis. The Yeoh model has been implemented into an in-house finite element code FER to model these organ tissues taking into account large deformations with multiple contacts. The 2D and 3D models are considered in this preliminary study and the results show that our method can help to improve the understanding of different forms of POP.

Trends in hysterectomy for genital prolapse: rural experience

The present study was conducted to investigate the trends of vaginal hysterectomy for genital prolapse in last 20 years by analyzing case records of affected women.

During the analysis period, 4831 women underwent hysterectomy; records of 4223 (87.5%) were available. Of these, 911 (21.6%), 2.7% of 34,080 gynecological admissions, had vaginal hysterectomy for genital prolapse (study subjects).

Eighty percent women who had vaginal hysterectomy for genital prolapse were over 40 years of age; however, most of these women had had the disorder for years before they presented. Only 4 (0.4%) women had not given birth, 874 (96%) women had had two or more births, and 383 (42%) had had 5 or more births. Having given birth was the major factor responsible for genital prolapse. In all, 94.2% of women presented with something coming out of the vagina.” Some women presented with abnormal vaginal bleeding or pain in abdomen as the chief complaint although they had had uterovaginal prolapse for years.

There was no mortality and morbidity decreased over the years. There has been no change in the rate of vaginal hysterectomy for genital prolapse over the years. Surgical morbidity decreased trend, possibly because of the preoperative, intraoperative, and postoperative precautions taken, especially preoperative treatment of urinary and genital tract infection.

Attempts need to be made to have safe births and a healthy life style so as to prevent genital prolapse and in case it occurs, therapy to prevent progression so that major interventions like hysterectomy are averted. Meticulous preoperative evaluation and planned therapy help in reducing surgical morbidity, if surgery becomes essential.

Comparative effect of 2 packages of pelvic floor muscle training on the clinical course of stage I-III pelvic organ prolapse

OBJECTIVE

To compare the effect of 2 packages of pelvic floor muscle training (PFMT) on the clinical course of pelvic organ prolapse (POP) among women attending a gynecology outpatient department in Chandigarh, India.

METHODS

A randomized controlled trial was conducted between August 8, 2010, and October 31, 2011. Overall, 140 women with stage I-III POP were allocated to a 24-week behavioral therapy intervention. Group A (n=70) received 1-to-1 PFMT and a self-instruction manual (SIM), whereas Group B (n=70) received SIM alone. Symptoms were assessed using the POP symptom scale (POP-ss), visual analog scale (VAS), and pelvic floor impact questionnaire-7 (PFIQ-7) scores.

RESULTS

Marked improvements in mean POP-ss, VAS, PFIQ-7 scores were observed in both groups from baseline to week 24. However, significant between-group changes in mean POP-ss scores were observed from baseline to 6 weeks (P<0.001), 18 weeks (P=0.001), and 24 weeks (P=0.002). Significant between-group changes in mean VAS scores were observed at 18 and 24 weeks (P=0.009 and P=0.005). Significant between-group changes in mean PFIQ-7 scores were observed at 6 (P=0.001), 18 (P<0.001), and 24 weeks (P<0.001).

CONCLUSION

Provision of both 1-to-1 PFMT and SIM led to greater improvements in POP symptoms than provision of SIM alone. ctri.nic.in: CTRI/2010/091/001190.

Conservative prevention and management of pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse is common, and some degree of prolapse is seen in 50% of parous women. Women with prolapse can experience a variety of pelvic floor symptoms. Treatments include surgery, mechanical devices and conservative management. Conservative management approaches, such as giving lifestyle advice and delivering pelvic floor muscle training (PFMT), are often used in cases of mild to moderate prolapse. This is an update of a Cochrane review first published in 2004, and previously updated in 2006.

OBJECTIVES

To determine the effects of conservative management (physical and lifestyle interventions) for the prevention or treatment of pelvic organ prolapse in comparison with no treatment or other treatment options (such as mechanical devices or surgery).

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 6 May 2010), EMBASE (1 January 1996 to 6 May 2010), CINAHL (1 January 1982 to 10 May 2010), PEDro (January 2009), the UK National Research Register (January 2009), ClinicalTrials.gov (April 2009), Current Controlled Trials register (April 2009), CENTRAL (Issue 1, 2009) and ZETOC (January 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials in women with pelvic organ prolapse that included a physical or lifestyle intervention in at least one arm of the trial.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Six trials were included; three of these trials are new to this update. Four trials were small (less than 25 women per arm) and two had moderate to high risk of bias. Four trials compared PFMT as a treatment for prolapse against a control group (n = 857 women); two trials included women having surgery for prolapse and compared PFMT as an adjunct to surgery versus surgery alone (n = 118 women).PFMT versus controlThere was a significant risk of bias in two out four trials in this comparison. Prolapse symptoms and women's reports of treatment outcomes (primary outcomes) were measured differently in the three trials where this was reported: all three indicated greater improvement in symptoms in the PFMT group compared to the control group. Pooling data on severity of prolapse from two trials indicated that PFMT increases the chance of an improvement in prolapse stage by 17% compared to no PFMT. The two trials which measured pelvic floor muscle function found better function (or improvement in function) in the PFMT group compared to the control group; measurements were not known to be blinded. Two out of three trials which measured urinary outcomes (urodynamics, frequency and bother of symptoms, or symptom score) reported differences between groups in favour of the PFMT group. One trial reported bowel outcomes, showing less frequency and bother with symptoms in the PFMT group compared to the control group.PFMT supplementing surgery versus surgery aloneBoth trials were small and neither measured prolapse-specific outcomes. Pelvic floor muscle function findings differed between the trials: one found no difference between trial groups in muscle strength, whilst the other found a benefit for the PFMT group in terms of stronger muscles. Similarly findings relating to urinary outcomes were contradictory: one trial found no difference in symptom score change between groups, whilst the other found more improvement in urinary symptoms and a reduction in diurnal frequency in the PFMT group compared to the control group.

AUTHORS' CONCLUSIONS

There is now some evidence available indicating a positive effect of PFMT for prolapse symptoms and severity. The largest most rigorous trial to date suggests that six months of supervised PFMT has benefits in terms of anatomical and symptom improvement (if symptomatic) immediately post-intervention. Further evidence relating to effectiveness and cost-effectiveness of PFMT, of different intensities, for symptomatic prolapse in the medium and long term is needed. A large trial of PFMT supplementing surgery is needed to give clear evidence about the usefulness of combining these treatments. Other comparisons which have not been addressed in trials to date and warrant consideration include those involving lifestyle change interventions, and trials aimed at prolapse prevention.

A 5-year prospective study of vaginal pessary use for pelvic organ prolapse

OBJECTIVE

To evaluate prospectively the use of vaginal pessaries for pelvic organ prolapse (POP) and to identify complications and reasons for discontinuing pessary use over a 5-year period.

METHODS

A prospective observational study was conducted among all women with POP referred to the urogynecology clinic of a UK hospital between June 2002 and June 2005 who opted to use a vaginal pessary. Patients were followed-up for 5 years.

RESULTS

Of the 246 women who chose to use a vaginal pessary, 187 successfully retained the pessary 4 weeks after insertion. Over a 5-year period, 36 (19.3%) of the 187 women were lost to follow-up. Of the 151 women included in the analysis, 21 (13.9%) discontinued use at some point after 4 weeks, whereas 130 (86.1%) used the pessary successfully over 5 years. Overall, 12.1% of the women experienced minor complications (6.9% pain or discomfort, 3.2% excoriation or bleeding, and 2.0% disimpaction or constipation). Most failures (73.8%) occurred within 4 weeks of pessary insertion. After cessation of pessary use, 70 (28.5%) of the 246 women chose surgery and 10 (4.1%) chose no further treatment.

CONCLUSION

If treatment of POP with a vaginal pessary is successful at 4 weeks, most women will continue to use the pessary over 5 years without a concomitant increase in complications.

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review

Pessaries have been used to treat women with pelvic organ prolapse (POP) since the beginning of recorded history. This review aims to assess the effect of pessary treatment on the disease-specific, health-related quality of life in women with pelvic organ prolapse. After a Medline search using the Mesh term ‘pessary’ and critical appraisal, 41 articles were selected and used in this review. Pessaries are widely used to treat pelvic organ prolapse. It is minimally invasive and appears to be safe. Although there is evidence that the use of pessaries in the treatment of pelvic organ prolapse is effective in alleviating symptoms and that patient satisfaction is high, the follow-up in many published papers is short, and the use of validated urogynaecological questionnaires is limited. Comparison with surgical treatment of pelvic organ prolapse is rare and not assessed in a randomised controlled trial.

The history and usage of the vaginal pessary: a review

It is expected that with the rising female life expectancy the prevalence of pelvic organ prolapse will increase. From ancient times mechanical devices have been used to reposition prolapsed organs. Given that surgical correction of prolapse is associated with high recurrence rates, pessaries offer a favorable alternative. In spite of the antiquity of pessary usage the evidence for its use, the effectiveness of symptom relief, and the nuances of clinical management with the pessary in situ have not been studied methodically. There is a need for controlled trials to assess the efficacy of pessaries as opposed to other non-surgical and surgical methods of treating pelvic organ prolapse. Additionally, the long term effects and complications of pessary usage have not been assessed in trials, and knowledge about the potential complications caused by the pessary rests mainly on anecdotal data. This review provides a historical perspective and appraises the current knowledge regarding the indications, effectiveness and the potential complications associated with pessary use. Data were obtained from an electronic search of Medline (1966-2010) and by hand searching the citations which were not available online. Keywords used were pelvic organ prolapse, pelvic floor dysfunction, vaginal pessary and urinary incontinence. Textbooks are also quoted where relevant. Most studies report moderate success rates in the short term following insertion of a pessary for the management of prolapse and concur in the remission of almost all symptoms attributable to the prolapse. Reported success is variable in the remission of urinary and bowel symptoms. We conclude that based on the available evidence (mostly retrospective and prospective cohort studies), treatment with a vaginal pessary is a feasible option that can be offered in the short term to women with prolapse. There is a need for controlled trials to assess the long term efficacy.

Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial

OBJECTIVE

The aim of this study was to investigate the effectiveness of pelvic floor muscle training in reversing pelvic organ prolapse and alleviating symptoms.

STUDY DESIGN

This assessor-blinded, parallel group, randomized, controlled trial conducted at a university hospital and a physical therapy clinic randomly assigned 109 women with prolapse stages I, II, and III to pelvic floor muscle training (n = 59) or control (n = 50). Both groups received lifestyle advices and learned "the Knack." In addition, pelvic floor muscle training comprised individual physical therapy sessions and home exercise. Student t test, Mann-Whitney U test, odds ratio, and effect size were used to compare groups.

RESULTS

Eleven (19%) women in the pelvic floor muscle training group improved 1 Pelvic Organ Prolapse Quantification System stage vs 4 (8%) controls (P = .035). Compared with controls, the pelvic floor muscle training group elevated the bladder (difference: 3.0 mm; 95% confidence interval, 1.5-4.4; P < .001) and rectum (5.5 mm; 95% confidence interval, 1.4-7.3; P = .022) and reduced frequency and bother of symptoms compared with controls.

CONCLUSION

Pelvic floor muscle training is without adverse effects and can be used as treatment for prolapse.

Body image and sexuality in women with pelvic organ prolapse

INTRODUCTION

The effect of physical changes associated with pelvic organ prolapse on a woman's body image and how that may influence sexuality has not been well studied.

OBJECTIVE

The goal of this study was to assess the implementation and utility of a body image questionnaire in women with pelvic organ prolapse. Two research questions were asked: (1) What is the impact of pelvic organ prolapse on women's body image and how does this affect their sexual health?, and (2) Does the Vaginal Changes Sexual and Body Esteem (VSBE) Scale show utility for use in assessing body image and sexual health in women with pelvic organ prolapse?

METHOD

A qualitative design was used for this study. Telephone interviews were conducted using a semi-structured questionnaire and an adapted body image and sexuality questionnaire specific to genital body image.

RESULTS

Thirteen women with pelvic organ prolapse completed the study. Eight women were classified as sexually active, and 5 women were not sexually active. Data showed women with pelvic organ prolapse, classified as sexually active, scored significantly lower on the VSBE scale than women who were not sexually active. There was a positive correlation between severity of prolapse and VSBE scores.

CONCLUSION

The VSBE scale questionnaire showed utility and potential for demonstrating change in body image in women with pelvic organ prolapse. This tool may assist clinicians in a more thorough assessment of body image and sexuality in this population of women.

Operations and pelvic muscle training in the management of apical support loss (OPTIMAL) trial: design and methods

The primary aims of this trial are: 1) to compare surgical outcomes following sacrospinous ligament fixation to uterosacral vaginal vault suspension in women undergoing vaginal surgery for apical or uterine pelvic organ prolapse and stress urinary incontinence and 2) to examine the effects of a structured perioperative program consisting of behavioral techniques and pelvic floor muscle training compared to usual care. This trial is performed through the Pelvic Floor Disorders Network (PFDN), which is funded by National Institute of Child Health and Human Development. Subjects will be enrolled from hospitals associated with seven PFDN clinical centers across the United States. A centralized biostatistical coordinating center will oversee data collection and analysis. Two approaches will be investigated simultaneously using a 2x2 randomized factorial design: a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (behavioral and pelvic floor muscle training versus usual care). Surgeons have standardized essential components of each surgical procedure and have met specific standards of expertise. Providers of the behavioral intervention have undergone standardized training. Anatomic, functional, and health-related quality of life outcomes will be assessed using validated measures by researchers blinded to all randomization assignments. Cost-effectiveness analysis will be performed using prospectively collected data on health care costs and resource utilization. The primary surgical endpoint is a composite outcome defined by anatomic recurrence, recurrence of bothersome vaginal prolapse symptoms and/or retreatment and will be assessed 2 years after the index surgery. Endpoints for the behavioral intervention include both short-term (6-month) improvement in urinary symptoms and long-term (2-year) improvement in anatomic outcomes and prolapse symptoms. This article describes the rationale and design of this randomized trial, focusing on several key design features of potential interest to researchers in the field of female pelvic floor disorders and others conducting randomized surgical trials.