Diagnosis and Management of Pelvic Organ Prolapse

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Diagnosis and Management of Pelvic Organ Prolapse

• Leslie Ablard M.D.

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• Pelvic Organ Prolapse (POP)
• Herniation of the pelvic organs to or beyond the
  vaginal walls
• Annual cost of ambulatory care from 2005 to 2006
  was almost 300 million
• Surgical repair of prolapse was the most common
  inpatient procedure performed in women older than
  70 yrs from 1979 to 2006
• Approximately 11 of all women will undergo
  surgical repair for POP or incontinence by age 80

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Terminology

• Anterior compartment prolapse (cystocele)
• Hernia of anterior vaginal wall often associated
  with descent of the bladder
• Posterior compartment prolapse (Rectocele)
• Hernia of the posterior vaginal segment often
  associated with descent of the rectum
• Apical compartment prolapse (uterine prolapse,
  vaginal vault prolapse)
• Descent of the apex of the vagina into the lower
  vagina, to the hymen, or beyond the vaginal
  introitus
• The apex can be either the uterus and cervix,
  cervix alone, or
• vaginal vault
• Apical prolapse is often associated with
  enterocele.
• Enterocele
• Hernia of the intestines to or through the
  vaginal wall

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Pelvic Organ Prolapse
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Terminology

• Procidentia
• Hernia of all three compartments through the
  vaginal introitus.

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Terminology

• The terms anterior vaginal wall prolapse and
  posterior vaginal wall prolapse are preferred to
  cystocele and rectocele because vaginal
  topography does not reliably predict the location
  of the associated viscera in POP
• Division of the vagina into separate compartments
  is somewhat arbitrary, because the vagina is a
  continuous organ and prolapse of one compartment
  is often associated with prolapse of another
• As an example, approximately half of anterior
  prolapse can be attributed to apical descent

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Risk Factors

• Parity  The risk of POP increases with
  increasing parity
• Prospective cohort study of more than 17,000
• The risk of hospital admission for POP increased
• 1st birth- 4-fold
• 2nd - 8-fold
• 3rd - 9-fold
• 4th- 10-fold
• Among parous women, it has been estimated that 75
  percent of prolapse can be attributed to
  pregnancy and childbirth
• Advancing Age- Older women are at increased risk
  for POP
• Every additional 10 yrs of age increased prolapse
  risk by 40

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Risk Factors

• Obesity 
• Overweight and obese women (body mass index gt25)
  have a two-fold higher risk of having prolapse
  than other women
• Hysterectomy 
• Hysterectomy is associated with increased apical
  prolapse
• ? Vaginal gt Abdominal ?
• Other risk factors 
• Chronic constipation is a risk factor for POP,
  likely due to repetitive increases in
  intraabdominal pressure
• COPD, etc conditions that also increase
  intraabdominal pressure

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Risk Factors

• Race and Ethnicity-
• African Americans lower prevalence than other
  ethnic groups
• Risk of Latina and white women is four to five
  fold higher than AA

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Clinical Manifestations

• Patients may present with symptoms related
  specifically to the prolapsed structures
• bulge or vaginal pressure or with associated
  symptoms including urinary, defecatory or sexual
  dysfunction
• Symptoms such as low back or pelvic pain have
  often been attributed to POP, but this
  association is not supported by well-designed
  studies
• Severity of symptoms does not correlate well with
  the stage of prolapse

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Clinical Manifestations

• Symptoms are often related to position they are
  often less noticeable in the morning or while
  supine and worsen as the day progresses.
• Many women with prolapse are asymptomatic
  treatment is generally not indicated in these
  women.

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Clinical Manifestations

• Bulge Symptoms
• In a study of 1912 women presenting to a pelvic
  floor disorder clinic, symptoms of a bulge or
  that something is falling out of the vagina had
  a sensitivity of 67 percent and a specificity of
  87 percent for POP at or past the hymen
• Although complaints of a bulge are associated
  with the presence of prolapse, it is only weakly
  correlated with prolapse stage, and does not
  predict site of prolapse
• Protrusion from the vagina may cause chronic
  discharge and/or bleeding from ulceration

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Urinary Symptoms

• Loss of support of the anterior vaginal wall or
  vaginal apex may affect bladder and/or urethral
  function.
• Symptoms of stress urinary incontinence (SUI)
  often coexist with stage I or II prolapse 
• As prolapse advances, women may experience
  improvement in SUI, but increased difficulty
  voiding
• Advanced anterior or apical prolapse may kink
  the urethra and result in symptoms of obstructed
  voiding such as
• slow urine stream
• need to change position
• manually reduce (splint) the prolapse to urinate
• sensation of incomplete emptying
• complete urinary retention

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Urinary Symptoms

• 13 to 65 of continent women develop symptoms
  of SUI after surgical correction of prolapse
• Elevation of prolapse during pelvic examination
  with prolapse treatment may unmask occult SUI
• Women with POP have a two- to five-fold risk of
  overactive bladder symptoms (urgency, urge
  urinary incontinence, frequency) compared with
  the general population

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Diagnosis and Classification

• To POP-Q or not to POP-Q
• POPQ system The POPQ system is an objective,
  site-specific system for describing and staging
  POP in women
• The POPQ system involves quantitative
  measurements of various points representing
  anterior, apical, and posterior vaginal prolapse
  to create a "topographic" map of the vagina
• These anatomic points can then be used to
  determine the stage of the prolapse

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POP-Q
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Staging

• Stage 0- No prolapse
• Aa, Ba, Ap, Bp are -3 cm and C or D -(tvl - 2)
  cm
• Stage 1- Most distal portion of the prolapse -1
  cm (above the level of hymen)
• Stage 2- Most distal portion of the prolapse
  -1 cm but 1 cm (1 cm above or below the
  hymen)
• Stage 3 - Most distal portion of the prolapse gt
  1 cm but lt (tvl - 2) cm (beyond the hymen
  protrudes no farther than 2 cm less than the
  total vaginal length)
• Stage 4 - Complete eversion most distal portion
  of the prolapse (tvl - 2) cm

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Why POP-Q

• The POPQ has proven interobserver and
  intraobserver reliability
• The POPQ system is the POP classification system
  of choice of the International Continence Society
  (ICS), the American Urogynecologic Society
  (AUGS), and the Society of Gynecologic Surgeons
• It is the system used most commonly in the
  medical literature

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Baden-Walker System

• The Baden-Walker Halfway Scoring System is the
  next most commonly used POP staging system
• The degree, or grade, of each prolapsed structure
  is described individually
• The grade/degree is defined as the extent of
  prolapse for each structure noted on examination
  while the patient is straining
• The Baden-Walker system lacks the precision and
  reproducibility of the POPQ system

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Baden-Walker System

• The system has five degrees/grades
• 0 No prolapse
• 1 Leading edge of prolapsed structure descends
  halfway to vaginal introitus (hymen)
• 2 Leading edge of prolapsed structure descends
  to the vaginal introitus
• 3 Leading edge of prolapsed structure(s)
  protrudes up to halfway outside the vagina
• 4 Leading edge of prolapsed structure(s)
  protrudes more than halfway outside the vagina

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Examination

• Examination components 
• Visual inspection
• Speculum examination
• Bimanual pelvic examination
• Rectovaginal examination
• Pelvic Floor Muscle evaluation

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Equipment

• Instruments
• Sims retractor (single blade speculum) or a
  bivalve speculum that can be easily taken apart
  so that the anterior and posterior blades can be
  used separately to observe individual
  compartments of the vagina (anterior, posterior,
  apical).
• To make the measurements for the POPQ system, a
  ruler or a large cotton swab or sponge forceps
  marked in 1 cm increments is used
• Ring Forceps occasionally used for evaluation of
  occult incontinence to reduce prolapse

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Patient Positioning ???

• The examination is performed with resting and
  maximal straining position
• The patient is examined initially in the dorsal
  lithotomy position
• The examination is then repeated with the patient
  standing
• In the standing position, the patient places one
  foot on a well-supported footstool. The examining
  gown is lifted slightly to expose the genital
  area during the examination

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Visual Inspection

• The first part of the examination is a visual
  inspection of the vulvar, perineal, and perianal
  areas with the patient in the dorsal lithotomy
  position
• As during other components of the examination,
  the inspection should be performed initially with
  the patient relaxed and then while straining
• Findings that should be noted during this
  component of the examination include
• Transverse diameter of the genital hiatus (eg,
  the space between the labia majora)
• Protrusion of the vaginal walls or cervix to or
  beyond the introitus (procidentia)
• Length and condition of the perineum
• Rectal prolapse
• In patients with prolapse to or beyond the hymen,
  the vaginal tissue is examined for ulceration.
• Any other findings (eg, skin or mucosal lesions)
  should be noted and evaluated appropriately

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Speculum and Bimanual Exam

• The speculum and bimanual examinations are the
  principal components
• Prolapse of each anatomic compartment is
  evaluated as follows
• Apical prolapse (prolapse of the cervix or
  vaginal vault) A bivalve speculum is inserted
  into the vagina and then slowly withdrawn any
  descent of the apex is noted
• Anterior vaginal wall A Sims retractor or the
  posterior blade of a bivalve speculum is inserted
  into the vagina with gentle pressure on the
  posterior vaginal wall to isolate visualization
  of the anterior vaginal wall
• Posterior vaginal wall A Sims retractor or the
  posterior blade of a bivalve speculum into the
  vagina with gentle pressure on the anterior
  vaginal wall to isolate visualization of the
  posterior vaginal wall
• To complete the exam, a bimanual examination is
  performed in order to evaluate for any coexisting
  pelvic abnormalities

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Rectovaginal Examination

• Diagnose an enterocele
• Differentiate between a high rectocele and an
  enterocele
• Assess the integrity of the perineal body
• Detect rectal prolapse
• The best method for detecting an enterocele is to
  perform the rectovaginal exam with the patient
  standing (?) the small bowel can be palpated in
  the cul-de-sac between thumb and forefinger

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Neurologic/Pelvic Floor Muscle Evaluation

• Pelvic floor muscle testing  
• The pelvic floor musculature is inspected to
  evaluate integrity and symmetry
• The examiner should also note the presence of
  scarring and whether pelvic floor contraction
  pulls the perineum inward
• Palpation through the vagina or rectum helps in
  assessing pelvic floor squeeze strength and
  levator muscle thickness.
• The tone and strength of the pelvic floor muscles
  can be assessed by asking the patient to contract
  the pelvic floor muscles around the examining
  fingers.
• Women with poor pelvic floor muscle function may
  benefit from pelvic physical therapy

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Treatment

• Establishing patient goals 
• Treatment is individualized according to each
  patients symptoms and their impact on her
  quality of life
• Patient satisfaction after POP surgery correlates
  highly with achievement of self-described,
  preoperative surgical goals, but poorly with
  objective outcome measures
• Management options
• Women with symptomatic prolapse can be managed
  expectantly, or treated with conservative or
  surgical therapy
• Both conservative and surgical treatment options
  should be offered.
• There are no high quality data comparing these
  two approaches

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Treatment

• Physical Therapy-
•  Pelvic floor muscle exercises (PFME) appears to
  improve stage and symptoms
• The best designed randomized trial included 109
  women with stage I to III prolapse who were
  assigned to either PFME for six months or control
  group
• Women in the PFME group had significant
  reductions in the frequency and bother of most
  prolapse, bladder, and bowel symptoms (exceptions
  were urge urinary incontinence symptoms,
  difficulty with stool emptying, and solid stool
  fecal incontinence)
• Improvement in POP stage was found more
  frequently in the PFME group (19 versus 8 percent)

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Treatment

• Estrogen therapy ?
• Use of estrogen and estrogenic agents
  (raloxifene) appears to be associated with a
  decrease in undergoing surgery for POP, according
  to a systematic review of randomized trials
• This systematic review included six trials,
  however, none of these evaluated the role of
  estrogen in treating POP

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Treatment

• Vaginal pessary 
• The mainstay of non-surgical treatment for POP is
  the vaginal pessary
• Pessaries are silicone devices in a variety of
  shapes and sizes, which support the pelvic organs
• Approximately half of the women who use a pessary
  continue to do so in the intermediate term of one
  to two years
• Pessaries must be removed and cleaned on a
  regular basis
• CONTRAINDICATIONS 
• Local infection Active infections of the vagina
  or pelvis, such as vaginitis or pelvic
  inflammatory disease, preclude the use of a
  pessary until the infection has been resolved
• Latex sensitivity The Inflatoball pessary is
  made of latex therefore, it is contraindicated
  in women with latex allergies. The other
  pessaries discussed below are nonallergenic.
• Noncompliance Noncompliance with follow-up
  could be harmful since an undetected and
  untreated erosion could put the patient at risk
  of developing a fistula
• Sexually active women who are unable to remove
  and reinsert the pessary Inability to manage
  the pessary around coital activity could be
  discouraging

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Treatment
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Treatment

• Fitting the pessary 
• Women to be fitted for a pessary are first
  examined with an empty bladder in the dorsal
  lithotomy position
• Pessaries are inserted into the vagina with the
  dominant hand, while the nondominant hand
  separates the introitus and depresses the
  perineal body.
• After the pessary is inserted into the vagina,
  the woman is asked to strain and cough repeatedly
  on the examination table, ambulate in the office,
  and void and strain while sitting on a toilet
• This "office trial" helps determine if she will
  be able to retain the pessary and void when she
  returns home, and if bothersome urinary
  incontinence will develop.
• She should have a negative cough stress test
  following pessary placement, as she is unlikely
  to be satisfied if there are significant SUI
  symptoms
• Women should be reassured that it is not an
  emergency if the pessary is expelled they should
  just bring the pessary back to the office and a
  different type or size of pessary will likely be
  effective

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• Follow-up
• A follow-up visit is scheduled one to two weeks
  later.
• The pessary is removed and cleaned with soap and
  water, and the vagina is examined for erosions
• If the pessary fits well and there were no side
  effects, motivated and able patients are taught
  how to remove, clean, and reinsert their pessary
  at least once per week, with follow-up in one to
  two months, and every 6 to 12 months thereafter
• If the patient cannot, or chooses not, to remove
  and reinsert her pessary, then she returns for
  follow-up in one to two months, and every three
  to four months thereafter for pessary cleaning
  and assessment by the provider.

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Treatment

• Offer most women low-dose estrogen vaginal cream
  (0.25 to 0.5 g applicator, two to three nights
  per week) to treat co-existing vaginal atrophy
  and dryness from estrogen deficiency
• KY or other non-hormonal lubrication may be used
  for those patients where estrogen is
  contraindicated (breast ca, etc)
• In some women, the width of the introitus may
  decrease in size after several weeks of pessary
  use. In such women, a new smaller size pessary is
  prescribed to allow for easier removal and
  insertion

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Treatment-Surgical

• Candidates
• Symptomatic POP
• Failed or declined conservative management
• Women finished with childbearing
• Reports of uterine sparing procedures
• Young or Elderly-
• Risk of recurrence in young (sacral colpopexy)
  and comorbidities in elderly (colpocliesis)

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Treatment- Surgical

• Reconstructive or obliterative
• Most women with symptomatic POP are treated with
  a reconstructive procedure
• Obliterative procedures (eg, colpocleisis) are
  reserved for women who cannot tolerate more
  extensive surgery or who are not planning future
  vaginal intercourse
• Concomitant hysterectomy
• When apical prolapse is repaired, the decision
  must be made whether to perform a hysterectomy as
  a part of the procedure.

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Treatment- Surgical

• Surgical route for repair of multiple sites of
  prolapse
• Reconstructive surgery for POP often involves
  repair of multiple anatomic sites of prolapse
  (apical, anterior, posterior)
• The choice of surgical route depends upon the
  optimal approach for the combination of prolapse
  sites.
• Concomitant anti-incontinence surgery
• Symptomatic POP often coexists with SUI and, in
  some women, anal incontinence
• POP repair must be coordinated with treatment of
  incontinence.
• Use of surgical mesh
• Surgical mesh is used in abdominal POP repair
• Use in transvaginal procedures has increased, but
  questions have arisen about the safety of this
  approach.

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