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Practice bulletins > #214 Pelvic Organ Prolapse > Flashcards

#214 Pelvic Organ Prolapse Flashcards

1
Q

What are possible symptoms of pelvic organ prolapse?

A

Vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction

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2
Q

What % of women in the US undergo surgery for pelvic organ prolapse in their lifetime?

A

13%

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3
Q

At what age range is the peak incidence of pelvic organ prolapse in women?

A

70-79 years

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4
Q

What is the definition of pelvic organ prolapse?

A

Descent of one or more aspects of the vagina and uterus: anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy)

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5
Q

When should pelvic organ prolapse be considered a problem?

A

Prolapse symptoms (pressure with or without a bulge) or sexual dysfunction or if disrupting normal lower urinary tract or bowel function

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6
Q

Most women feel symptoms of pelvic organ prolapse when the leading edge is within how many centimeters (proximal or distal) of the hymenal ring?

A

0.5cm distal to the hymenal ring

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7
Q

What % of women in the US report symptoms of vaginal bulge?

A

3%

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8
Q

In women who do not want treatment for their pelvic organ prolapse, does the prolapse typically significantly worsen, stay the same, or improve over the course of the next year?

A

Typically no change or only a small increase in the size of the POP

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9
Q

What is stage 0 pelvic organ prolapse?

A

No prolapse; anterior and posterior points are all -3cm and C or D (cervix; posterior fornix) is between -TVL and - (TVL - 2) cm

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10
Q

What is stage 1 pelvic organ prolapse?

A

The criteria for stage 0 are not met, and the most distal prolapse is more than 1 cm above the level of the hymen (less than -1cm)

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11
Q

What is stage 2 pelvic organ prolapse?

A

The most distal prolapse is between 1cm above and 1cm below the hymen (at least one point is -1, 0, or +1)

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12
Q

What is stage 3 pelvic organ prolapse?

A

The most distal prolapse is more than 1cm below the hymen but no further than 2cm less than TVL

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13
Q

What is stage 4 pelvic organ prolapse?

A

Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL -2) cm.

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14
Q

What are risk factors for developing symptomatic pelvic organ prolapse?

A

Parity, vaginal delivery, age, obesity, connective tissue disorders, menopausal status, and chronic constipation

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15
Q

What are risk factors for recurrent pelvic organ prolapse in women after vaginal surgery?

A

Age younger than 60yo, obesity, and preoperative stage III or stage IV prolapse

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16
Q

What are the components of the initial evaluation for a woman with suspected pelvic organ prolapse?

A

Thorough history, assessment of symptom severity, physical examination, and goals for treatment

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17
Q

What is one way with history taking that you can infer that pelvic organ prolapse is causing urinary symptoms?

A

If voiding becomes more difficult when the effects of gravity are more pronounced, such as after long periods of standing

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18
Q

What is it called when a woman needs to push on or support bulging vaginal tissue in order to initiate or complete voiding?

A

Splinting

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19
Q

What history questions should be asked regarding bowel function in a patient being assessed for pelvic organ prolapse?

A

History of straining with bowel movement, laxative use, fecal incontinence, and incomplete rectal emptying. Splinting for defecation. Coital incontinence.

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20
Q

What are the components of the physical exam for a patient suspected to have pelvic organ prolapse?

A
  • abdominal and pelvic examination to rule out pelvic masses
  • visualization of external genitalia and vaginal epithelium to evaluate for vaginal atrophy, skin irritation, or ulceration
  • Split speculum for detailed examination of the POP
  • POP-Q exam recommended prior to treatment for objective measure
  • assess pelvic floor muscle tone (contract and relax voluntarily; strength [absent, weak, normal, strong])
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21
Q

What if a patient’s pelvic organ prolapse symptoms are not confirmed by the extent of prolapse observed during supine pelvic examination?

A

Repeat the pelvic examination in the standing position

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22
Q

Is additional testing beyond the history and physical examination needed to evaluate women with pelvic organ prolapse?

A

In general, no. However:

  • if prolapse beyond hymen or patient has voiding symptoms, a postvoid residual urine volume should be recorded either with catheter or ultrasound.
  • UA w/ reflex culture/microscopy if lower urinary tract symptoms
  • urodynamics if bothersome incontinence w/ stage II+ POP or voiding dysfunction
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23
Q

What are the two common pelvic organ prolapse staging systems?

A

Baden-Walker system

Pelvic organ prolapse quantification (POP-Q)

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24
Q

What is in each box for the 3x3 chart for POP-Q?

A

[line 1] Anterior wall (Aa) | Anterior wall (Ba) | Cervix or cuff (C)
[line 2] Genital hiatus (gh) | Perineal body (pb) | Total vaginal length (TVL)
[line 3] Posterior wall (Ap) | Posterior wall (Bp) | Posterior fornix (D)

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25
Q

How do you determine pelvic organ prolapse stage based on the POP-Q?

A

Converted to stages based on the most severely prolapsed vaginal segment

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26
Q

What is point Aa on POP-Q?

A

3cm proximal to the external urethral meatus

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27
Q

What is point Ba on POP-Q?

A

Most prolapsed portion of the anterior vaginal wall

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28
Q

What is point C on POP-Q?

A

Leading edge of the cervix or vaginal cuff

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29
Q

What is gh on POP-Q?

A

genital hiatus. Middle of the urethral meatus to the midline of the posterior hymen

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30
Q

What is pb on POP-Q?

A

Perineal body. middle of the posterior hymen to the middle of the anal opening

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31
Q

What is TVL on POP-Q?

A

Total vaginal length. Maximum depth of the vagina with prolapse reduced

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32
Q

What is Ap on POP-Q?

A

3cm proximal to the posterior hymen

33
Q

What is Bp on POP-Q?

A

most prolapsed portion of the posterior vaginal wall

34
Q

What is D on POP-Q?

A

Posterior fornix in a women who has a cervix

35
Q

What lifestyle modifications may help with symptoms related to pelvic organ prolapse?

A

Defecatory dysfunction may improve with fiber supplementation and use of an osmotic laxative. Sitting with feet elevated may decrease bulge symptoms. Pelvic muscle exercises, performed either independently or under professional supervision, may improve symptoms or slow the progression of POP

36
Q

What is an alternative to surgery for treatment of pelvic organ prolapse (apart from lifestyle modifications)?

A

Pessary.

37
Q

Up to what % of women can be successfully fitted with a pessary?

A

Up to 92%

38
Q

If a woman is unable to remove her pessary on her own, how often does she need to follow up? How about if they are able to remove on their own?

A

Every 3-4 months if patient cannot remove pessary. Annually if patient can remove themselves and are able to maintain pessary hygiene on their own.

39
Q

What is the risk of local devascularization or erosion with pessary use?

A

2-9%

40
Q

How do you treat vaginal erosion from pessary use?

A

Remove pessary for 2-4 weeks and use local estrogen therapy. Resolution may occur without local estrogen therapy

41
Q

What should you do if a patient has recurrent vaginal erosions from a pessary?

A

Consider more frequent pessary changes or a different pessary

42
Q

When is surgery indicated for pelvic organ prolapse?

A

For the treatment of POP in women who are bothered by their POP and have failed or declined nonsurgical treatments

43
Q

Are vaginal surgical approaches effective for the management of pelvic organ prolapse?

A

Vaginal hysterectomy and vaginal apex suspension with vaginal repair of anterior and posterior vaginal wall prolapse as needed are effective treatments for most women with uterovaginal and anterior and posterior vaginal wall prolapse

44
Q

If a patient has uterine prolapse, is vaginal hysterectomy alone adequate treatment?

A

No, vaginal apex suspension should be performed at the time of hysterectomy to reduce risk of recurrent POP

45
Q

What are the options for vaginal apex suspension after vaginal hysterectomy?

A

Uterosacral or sacrospinous

46
Q

How do uterosacral and sacrospinous ligament suspensions for apical pelvic organ prolapse compare in terms of efficacy, functional and adverse outcomes?

A

Comparable anatomic, function, and adverse outcomes

47
Q

What are the 2-year follow-up surgical success rates for uterosacral and sacrospinous ligament suspension?

A
  1. 5% for uterosacral

63. 1% for sacrospinous

48
Q

How is a uterosacral ligament suspension performed?

A

Attaching vaginal apex bilaterally to the ipsilateral uterosacral ligament or by attaching the vaginal apex to the uterosacral ligament complex that is plicated in the midline. Important that an adequate segment of the uterosacral ligament is secured to teh vagina

49
Q

How is a sacrospinous ligament suspension performed?

A

Unilateral right sacrospinous ligament fixation usually is used for the attachment point to avoid dissection around the colon

50
Q

What are paravaginal defects (re: POP)? How is it addressed? Is it reliably diagnosed on physical exam?

A

Lateral detachments of the vaginal wall from the fascial condensations over the levator ani muslces. PE is unreliable. Apical support procedures may address these defects.

51
Q

Why should you avoid placing tension on the levator ani muscles when performing a midline plication of the posterior vaginal wall fibromuscular connective tissue for POP?

A

May lead to dyspareunia

52
Q

For a sacrocolpopexy, where is the mesh attached?

A

Apex of the vagina/cervix to the anterior longitudinal ligament of the sacrum

53
Q

Which women are at increased risk of synthetic mesh-related complications with sacrocolpopexy?

A

Chronic steroid use, current smoker

54
Q

What is the 7 year mesh complication rate after abdominal sacrocolpopexy (erosion into the vagina, visceral erosions, and sacral osteitis) according to the CARE trial?

A

10.5% with a significant number of reoperations. Many of the procedures were performed with non type 1 mesh, which may have increased the complication rate

55
Q

How do LSC versus open sacrocolpopexy compare in terms of surgical time, inpatient days, blood loss, long-term outcomes?

A

LSC - longer surgical time, fewer inpatient days, less blood loss.
Long-term outcomes similar

56
Q

Is posterior vaginal wall prolapse repair more effective with a transanal or transvaginal incision?

A

More effective with transvaginal incision

57
Q

What, if any, surgical options are available to women with pelvic organ prolapse who have significant medical comorbidities?

A

If do not desire future vaginal intercourse or vaginal preservation, can do obliterative procedures which can be performed under local or regional anesthesia

58
Q

What are the common types of obliterative surgical repair of pelvic organ prolapse?

A

Le Fort-style partial colpocleisis (uterus is preserved) and total colpectomy.

59
Q

What additional procedures are often recommended at the time of any obliterative procedure?

A

A suburethral plication or midurethral sling and a perineorrhaphy often are recommended to decrease the risk of postoperative stress urinary incontinence and recurrent posterior vaginal wall prolapse

60
Q

What FDA-approved transvaginal mesh products for the treatment of pelvic organ prolapse are available?

A

None, removed from market in 2019

61
Q

After FDA removing transvaginal mesh products from the market in 2019 for treatment of pelvic organ prolapse, how do you counsel patients with transvaginal mesh currently in place?

A

No intervention needed if not experiencing any symptoms or complications. Patients should be counseled to continue with routine care and report any complications or symptoms, including persistent vaginal bleeding or discharge, pelvic pain, or dyspareunia

62
Q

Can providers still offer transvaginal mesh to patients with pelvic organ prolapse

A

Transvaginal mesh POP repair products were removed from market in 2019. However, some surgeons may still offer transvaginal mesh-augmented surgery for select patients w anterior and apical POP. Limited to high-risk individuals (recurrent POP or med comorbidities precluding more invasive/lengthier procedures)

63
Q

What is the rate of mesh exposure after transvaginal mesh for pelvic organ prolapse repair?

A

12%

64
Q

What is the state of evidence available for biologic grafts for vaginal prolapse repair?

A

Low quality, scarce. Most of the biologic grafts that were used in studies to date are no longer available.

65
Q

Does use of synthetic mesh or biologic grafts in transvaginal repair of posterior vaginal wall prolapse improve outcomes compared to native tissue repair?

A

No; and there are increased complications

66
Q

Does use of biologic grafts in transvaginal repair of anterior vaginal wall prolapse improve outcomes compared to native tissue repair?

A

Only minimal benefit

67
Q

Is it necessary to perform intraoperative cystoscopy during pelvic organ prolapse surgery?

A

Routine cysto recommended when the surgical procedure performed is associated with significant risk of injury to the bladder or ureter (uterosacral ligament suspension, sacrocolpopexy, anterior colporrhaphy, and placement of mesh in the anterior and apical compartments)

68
Q

What surgical options for pelvic organ prolapse are available for women who want to avoid hysterectomy?

A

Hysteropexy (ie, uterine suspension) and Le Fort colpocleisis

69
Q

How is a vaginal hysteropexy performed?

A

Vaginal incision attaching the cervix to the sacrospinous ligament with sutures or mesh

70
Q

How is an abdominal or laparoscopically performed hysteropexy done?

A

Placing a mesh or biologic graft from the cervix to the anterior longitudinal ligament

71
Q

What are benefits of hysteropexy compared with total hysterectomy for pelvic organ prolapse repair?

A

Hysteropexy has shorter operative time and lower incidence of mesh erosion if mesh augmentation is used.
Women who choose hysterectomy have lower risk of uterine and cervical cancer, not become pregnant, not have uterine pain or bleeding

72
Q

Does incontinence evaluation need to be performed in women undergoing pelvic organ prolapse surgery even if they do not have symptoms of incontinence?

A

All women with significant apical prolapse, anterior prolapse, or both should have a preoperative evaluation for occult stress urinary incontinence w/ cough stress testing or urodynamic testing w/ prolapse reduced

73
Q

How can apical/anterior pelvic organ prolapse mask stress urinary incontinence?

A

May obstruct the urethra or the urethra might kind from an anterior vaginal wall prolapse.

74
Q

What % of women after sacrocolpopexy and vaginal prolapse repair alone had stress urinary incontinence?
What % after sacrocolpopexy + burch colposuspension and vaginal prolapse repair + midurethral sling placement had post op stress urinary incontinence?

A

57% sacrocolpopexy
49% vaginal prolapse repair
34% sacrocolpopexy + burch
25% vaginal prolapse repair + midurethral sling

75
Q

What are the complications after native tissue pelvic organ prolapse surgery?

A

bleeding, infection (typically UTI), voiding dysfunction (typically transient). Less common: rectovaginal or vesicovaginal fistula, ureteral injury, foreshortened vagina, or a restriction of the vaginal caliber

76
Q

What is the incidence of dyspareunia after native tissue pelvic organ prolapse surgery?

A

16% after 24 months

77
Q

How can you manage short vagina or vaginal constriction after pelvic organ prolapse surgery?

A

Vaginal estrogen and progressive dilators

78
Q

What should be considered for management of symptomatic pelvic organ prolapse in a woman who wishes to become pregnant in the future?

A

A pessary

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