I PELVIC ORGAN PROLAPSE
Pelvic organ prolapse occurs with descent of one or more pelvic structures: the uterine cervix or vaginal apex, anterior vaginal wall (usually with bladder, cystocele), posterior vaginal wall (usually with rectum, rectocele), or peritoneum of the cul-de-sac (usually with small intestine, enterocele).
However, a specific definition of what constitutes clinically significant prolapse remains elusive. Although almost one half of parous women can be identified as having prolapse by physical examination criteria, most are not clinically affected; the finding of prolapse on physical examination is not well correlated with specific pelvic symptoms.The prevalence of pelvic organ prolapse has increased as life expectancy has increased. National population-based estimates using validated measures report an overall 2.9% prevalence of symptomatic pelvic organ prolapse. However, other population-based surveys have revealed prevalence estimates as high as 8%. In the United States, an estimated 300,000 surgical procedures are performed annually for prolapse. A woman’s lifetime risk of undergoing a surgical intervention for symptomatic pelvic floor disorders is approximately 11-19%. A large percentage of these women, 6-29%, will require additional surgery for recurrent pelvic organ prolapse or urinary incontinence, and those who have undergone at least two prior prolapse procedures have reoperation rates higher than 50%. Pelvic organ prolapse is the leading indication for hysterectomy in postmenopausal women and accounts for 15-18% of hysterectomies in all age groups.
Risk Factors
Possible risk factors for pelvic organ prolapse include genetic predisposition, parity (particularly vaginal birth), menopause, advancing age, prior pelvic surgery, connective tissue disorders, and factors associated with elevated intra-abdominal pressure (eg, obesity, chronic constipation with excessive straining).
Women with symptomatic pelvic organ prolapse usually are postreproductive and have had vaginal deliveries or chronic repetitive increases in intra-abdominal pressure, though women who have never been pregnant also may exhibit pelvic relaxation. Weakness of the pelvic floor tissues, which may be congenital, also can cause pelvic floor dysfunction.Evaluation and Diagnosis
Many patients with prolapse are asymptomatic. Patients who are symptomatic typically have symptoms of vaginal bulging or pressure and may have related bladder, bowel, or sexual dysfunction. It is advisable to examine a symptomatic woman in lithotomy and standing positions before and after a maximum Valsalva maneuver. Urinary or rectal incontinence can be assessed at the same time. One evaluation tool for the assessment of pelvic relaxation is the Pelvic Organ Prolapse Quantification system. It promotes universal standards to determine and measure pelvic floor defects. Further urogynecologic investigation can be helpful if urinary incontinence or fecal incontinence, extensive vaginal prolapse, or voiding difficulty are present (see also the “Urinary Incontinence” section later in Part 4). Urodynamic testing, cystoscopy, and pelvic floor imaging may be useful adjuncts before surgical repair, and the decision to perform these procedures should be individualized.
Management
Clinician knowledge and experience with normal pelvic floor function and its variations are required to initiate treatment. It is important to be fully cognizant of noninvasive treatments (pelvic floor muscle exercises, pessaries) and surgical interventions. Treatment is determined by the following:
• Patient age
• Physical activity level
• Severity of symptoms and physical findings
• Degree of disability
• Coital activity
• Desire for future fertility
• Desire for surgery
Women with pelvic organ prolapse who are asymptomatic or mildly symptomatic can be observed at regular intervals, unless new bothersome symptoms develop.
Nonsurgical Interventions
Pessary use should be considered before surgical intervention in all women with symptomatic prolapse. Although pessary use is the only specific nonsurgical treatment, pelvic floor muscle rehabilitation and symptom- directed therapy may be offered. Supplemental approaches to improve outcomes and decrease failure rates may include weight loss and exercise (to promote general health), intensive pelvic muscle exercises, and treatment of patients with chronic respiratory or metabolic conditions, constipation, and other intra-abdominal disorders.
Surgical Interventions
Multiple surgical techniques are available to address the various anatomic and functional problems in women with pelvic organ prolapse. Data are evolving regarding the efficacy of available surgical interventions, which include transvaginal native tissue repair; abdominal, laparoscopic, and robotic options; and transvaginal mesh augmentation approaches. Pelvic organ prolapse vaginal mesh repair should be reserved for high-risk individuals in whom the benefit of mesh placement may justify the risk, such as individuals with recurrent prolapse (particularly of the anterior compartment) or with medical comorbidities that preclude more invasive and lengthier open and endoscopic procedures. Surgeons placing vaginal mesh should undergo training specific to each device and have experience with reconstructive surgical procedures and a thorough understanding of pelvic anatomy. The American College of Obstetricians and Gynecologists strongly supports audit and review of outcomes with vaginal mesh implants.
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Resources
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