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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 33 - Pelvic Organ Prolapse

"But I don't want comfort. I want God, I want poetry, I want real danger, I want freedom, I want goodness. I want sin." - Aldous Huxley, Brave New World

2017 Russian River Valley from Siduri Winery


PB#214 - Published November 2019

Five Pearl

  1. If a patient isn't bothered by prolapse (or other symptoms), they don't necessarily need therapy. BOTHER IS QUEEN

  2. Try conservative measures first before recommending surgery

  3. Study pelvic anatomy early and often

  4. Prophylactic apical support should always be considered in POP surgery

  5. BOTHER IS QUEEN

Some background info on POP...

- descent of one or more of: anterior vagina, posterior vagina, cervix/uterus, or apex of vaginal vault (if s/p hysterectomy)

- weakness in these components can cause organs to "prolapse" into the vagina and, in severe cases, to protrude beyond the introitus

- mild descent is common, doesn't generally need repair (most won't progress, even if symptomatic)

- if prolapse is symptomatic or causing urinary or bowel dysfunction, repair may be appropriate

- 3% of women in the U.S. report a vaginal "bulge", incidence of POP otherwise isn't known due to (a) low self-reporting and (b) clinicians not looking


Risk factors

- parity, history of vaginal delivery, age, obesity, connective tissue disorder, menopause, and chronic constipation

- unclear if hysterectomy for non-POP indications is an independent risk factor

- 6-30% of patients who undergo POP surgery will require 2nd operation (most contemporary estimates fall on the lower end of that range)


Important elements of your clinical encounter


History

- ask about urinary incontinence, urgency, ability to void completely

- ask about fecal or gas incontinence, constipation

- ask if splinting is necessary to void bladder or rectum

- is leakage of any kind limiting to daily activities, valsalva or enjoyment of intercourse

- PDFI-20 pelvic floor dysfunction questionnaire


Physical exam

- external exam: vulvar atrophy, bleeding lesions, obvious bulge beyond the introitus

- post-void residual + cough test

- rectal exam to evaluate sphincter tone, patient-directed control

- place single blade of speculum into vagina to compress posterior compartment, evaluate anterior compartment and apex with valsalva

- flip it over to compress anterior compartment, evaluate posterior compartment and perineal body with valsalva

- if you aren't seeing much but she's stating that she's feeling a bulge, perhaps repeat the exam with her standing

- if any urinary symptoms, gets UA and culture in the very least; urodynamics may also be helpful if stage II prolapse or greater or voiding dysfunction


Classifying pelvic organ prolapse





Note: Terms cystocele and rectocele had been abandoned in favor of "anterior", "posterior", and "apical" prolapse


What conservative approaches can be tried before surgery is recommended?

- laxatives if constipated (colace doesn't count...it's useless...trust me. Try Miralax or Dulcolax)

- fiber if loose stools

- elevating feet to reduce bulge at rest

- pelvic floor PT

- pessaries (more below)

- local estrogen alone won't reduce prolapse, but it may help with irritation related to POP


Photo credit: https://www.stressnomore.co.uk/

Notes on pessaries

- great alternative to surgery for patients who wish to maintain fertility or for patients who are poor surgical candidates

- effective in up to 90% of women w/ POP

- ring pessary likely to be sufficient for stage II and III POP

- Gellhorn may be required for stage IV (effective in up to 65% of cases)

- women should be taught to maintain pessaries at home

- if patient can't reliably do this, f/u q3-4 months is recommended

- if patient can reliably maintain it on her own, f/u annually is sufficient

- erosions are seen in up to 10% of patients

- topical estrogen applied to the pessary can decrease likelihood of erosions

- if you diagnose an erosion, remove pessary for 2-4 weeks and treat w/ topical estrogen




Some notes on surgical techniques

- vaginal approach is relatively safe and very effective for most women w/ POP

- native techniques don't use mesh

- hysterectomy alone isn't sufficient if a patient has POP

- uterosacral versus sacrospinous fixation: equally effective (~64%) at 2 years; and low adverse event rate at 2 years (~16%)

- anterior prolapse is often accompanied by concurrent apical prolapse (fix them both and you'll reduce risk of recurrence)


Abdominal sacrocolpopexy whosawhatsit?!

- involves placement of synthetic mesh or biologic graft to attached apex to the anterior longitudinal ligament of the sacrum

- may be better option for patients w/ intra-abdominal pathology, shortened vaginal length, or risk factors for recurrence (young age, stage III/IV prolapse, BMI >26)

- for patients at risk for mesh complications (chronic steroid use, active smoker), biologic graft may be better option

- native tissue can also be used; less complications than mesh (ileus, SBO, VTE, and mesh or suture complications), less likely to have recurrence, less likely to have anatomic success

- CARE trial: risk of mesh erosion into vagina or sacral osteitis was 10% (varying pore sizes used)

- large pore size mesh has lower risk of complications, and this is the type used in the U.S.

- can be done through minimally invasive approach: shorter operating time, less blood loss, and shorter hospitalization

- jury isn't out regarding benefit of robot over classic straight stick laparoscopic sacrocolpopexy: more $$$, longer operating time, and greater post-op pain found in some studies


Obliterative procedures

- candidates include women with significant comorbidities who no longer desire sexual intercourse

- they carry low risk of recurrent POP and are highly effective (90%) at subjective improvement of POP

- very low risk of complications (< roughly 5%), low risk of regret (~10%)

- sling procedure should be performed at time of obliterative procedure to reduce risk of post-op urinary incontinence

- Le Fort-style partial colpocleisis: uterus preserved; anterior and posterior segments are denuded and sutured together, drainage canals are left in place to allow for cervical drainage

- Total colpectomy: done in patients who are already post-hysterectomy; entire vagina is denuded and sutures are place to evert the vagina


Pearl: After a Le Fort, endometrial cavity and cervix aren't easily evaluated, so evaluate for endometrial hyperplasia and cervical dysplasia before the procedure


Few words on mesh

- Currently no approved mesh products by FDA for transvaginal POP repair

- Doesn't apply to transabdominal mesh (as described above in sacrocolpopexy) or in midurethral sling procedures

- no revisions or actions need to be taken for patients who had transvaginal mesh placed in the past as long as they are asymptomatic and not experiencing any complications

- use of synthetic mesh or biologic grafts in anterior or posterior repair did not show improved outcomes over native tissue repair


To cysto or not to cysto

- if a surgical procedure carries significant risk of injury to bladder or obstruction of ureters, do cysto while patient is still under anesthesia

- those procedures: slings, uterosacral suspension, and anterior colporrhaphy


What if she wants to keep her uterus?

Le Fort (see above)

or

hysteropexy: attachment of the cervix to the longitudinal ligament of the sacrum using mesh or biologic graft, approach can be vaginal, abdominal or laparoscopic

- advantage over hysterectomy is shorter operating time and lower change of mesh erosion (if mesh used)

- no difference in sexual experience


Should a midurethral sling always be offered with POP surgery?

- most of the time, yes

- "all women with significant apical prolapse, anterior prolapse, or both should have a preoperative evaluation for occult stress urinary incontinence, with cough stress testing or urodynamic testing with the prolapse reduced."

- prophylactic concurrent sling at time of POP repair reduces risk of post-op urinary incontinence in half (25% verusus 50%)

- risks of extra procedure versus benefits must be weighed


Management of complications related to POP surgery

- shortened vagina or restriction of vaginal caliber can be managed with vaginal estrogen and dilators

- mesh can erode through the vaginal epithelium or dyspareunia


Management of recurrent POP

- repeat primary POP surgery or you may recommend obliterative procedure, pessary, or they may elect nothing at all

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