Posterior wall prolapse, bulging or herniation of the bowel along the dorsal aspect of the vagina, is a component of the constellation of pelvic floor disorders. Pelvic floor dysfunction, primarily involving pelvic organ prolapse, urinary and fecal incontinence, affects nearly one in four (23.7%) community-dwelling women.1 As women age, prolapse and incontinence become more common. One-half of women aged 80 years and older have at least one pelvic floor disorder.1
The elderly population is expected to grow significantly over the next 40 years. By 2050, those 65 years of age or older are projected to more than double, from 38.6 million to 88.5 million.2 The population of people 85 years or older is expected to grow exponentially from 5.4 to 19 million and the majority of people in this category will be women.2 Therefore, the demand for prevention and treatment of pelvic floor dysfunction will also grow dramatically.
Treatment for pelvic floor disorders varies from conservative measures to surgical management. The lifetime risk of undergoing surgery for pelvic organ prolapse or urinary incontinence is approximately 11%.3,4 Currently, approximately 200,000 women undergo prolapse surgery in the United States each year.5 One-third to one-half of all the prolapse surgeries include posterior wall prolapse repair.3,5 Understanding the anatomy, etiology, and treatment options for posterior wall prolapse is vital and will become increasingly important as our aging population multiplies.
Prolapse of the posterior vaginal wall may be secondary to the presence of a rectocele, sigmoidocele, enterocele, or a combination of these entities.
Prolapse of the posterior vaginal wall may be secondary to the presence of a rectocele, sigmoidocele, enterocele, or a combination of these entities (Figure 13-1A, B and C). This loss of support may be defined symptomatically, radiographically, or by physical examination.
Sagital view of posterior vaginal wall prolapse. A. Schematic drawing of rectocele; B. Radiographic depiction of sigmoidocele; and C. Radiographic depiction of rectocele.
“The eye don’t see what the mind don’t know.”
—A. Cullen Richardson
To recognize and correct abnormal anatomy such as prolapse, you must understand normal anatomy. Support of the posterior vaginal wall is provided by a complex interaction of the integrity of the vaginal tube, the connective tissue support, and muscular support of the pelvic floor. John DeLancey divided the connective tissue support of the vagina into three levels.6 All three levels of support should be evaluated and addressed during the physical examination and in consideration of surgical management of the posterior vaginal wall.
At level I, the apical portion of the posterior vaginal wall is suspended and supported primarily by the cardinal-uterosacral ligaments.7,8 This mesentery of support originates at the sacrum and the pelvic sidewalls and inserts onto the posterior cervix and upper vagina. With normal support, the apical posterior wall of the vagina is dorsally directed to lie upon the rectum in a horizontal fashion overlying the levator ani muscles. With increases in abdominal pressure, the vaginal tube is closed and primarily supported by the pelvic floor muscles including the levator ani and coccygeus muscles.
Level II includes the support for the midportion of the vagina. This support is provided by the endopelvic fascia attaching the lateral posterior vaginal wall to the aponeurosis of the levator ani, specifically the pubococcygeus muscle, on the pelvic sidewall and by the tonically contracted sling-like component of the puborectalis muscle dorsally.8 Most of the fibers of the endopelvic fascia extend from the lateral edge of the vaginal tube to the pelvic sidewall.7 Very few of the fibers actually run uninterrupted, like a sheet from sidewall to sidewall. The proximal half of the anterior and posterior vagina is supported by endopelvic attachment to the arcus tendineus fasciae pelvis. The lateral attachment of the posterior wall diverges dorsally from the arcus tendineus fasciae pelvis in the distal vagina (Figure 13-2).
Level II support of the posterior vaginal wall. The proximal support begins at the ischial spine (IS) along the pelvic sidewall at the arcus tendineus fascia pelvis (ATFP). The distal lateral support is provided by the arcus tendineus fascia rectovaginalis (ATFR).
Level III or distal support of the posterior vaginal wall is primarily provided by the perineal body. The perineal body resists caudally directed abdominal pressure and imparts a physical barrier between the vagina and rectum. Distally, this 3-dimensional structure has the bony support of the ischiopubic rami through the interlacing fibers of the bulbospongiosus, superficial transverse perineal muscle, perineal membrane, and external anal sphincter. The perineal body extends cranially approximately 2 to 3 cm proximal to the hymenal ring and is suspended by the puborectalis muscle. On magnetic resonance imaging (MRI), the perineal body descends more caudally in women with posterior wall prolapse or with levator defects than controls.9,10
The puborectalis provides a sling of support, enclosing the genital hiatus, through which the urethra, vagina, and anorectum pass. In a woman with an intact pelvic floor, the puborectalis is in a chronic state of contraction and the anterior and posterior vaginal walls are in direct apposition. With defecation, the increased pressure placed on the posterior vaginal wall is equilibrated by the opposing pressure on the anterior vaginal wall. There is no stress placed on the endopelvic fascial attachments (Figure 13-3A). In the presence of muscular or neurologic damage to the puborectalis, the levator hiatus widens and the vaginal canal opens. The increased rectal pressure and distension associated with defecation now places strain on the endopelvic fascial attachments and the fibromuscularis of the posterior vaginal wall (Figure 13-3B).
Boat in a dry dock. A. With support of the water (analogous to the pelvic floor muscles), there is little stress placed on the rope tethers (analogous to the connective tissue support). B. When the water is removed, the rope has a tremendous amount of stress.
The rectovaginal space exists between the vaginal tube and the rectum. This potential space, occupied by areolar tissue, allows the vagina and rectum to function independent of one another.
Abnormalities in the complex interplay of bony and connective tissue support of the posterior vaginal wall, which is tonically and actively maintained by the pelvic floor muscles, can impact urinary, sexual, and defecatory function. This chapter will review the pathophysiology, evaluation, nonsurgical, and surgical management of posterior compartment disorders as well as factors associated with recurrence of posterior vaginal wall prolapse.
The vagina is a fibromuscular tube that extends from the abdominal cavity to the perineal body. The bony and muscular support and the connective tissue of this tube are dynamic. Disruption of support leading to a herniation of the surrounding organs (pelvic organ prolapse) is most likely due to an accumulation of injuries. Risk factors for the development of prolapse may begin at conception and continue to accrue until death (Table 13-1).
Risk Factors for the Development of Posterior Vaginal Wall Prolapse
||Download (.pdf) Table 13-1
Risk Factors for the Development of Posterior Vaginal Wall Prolapse
|Inheritable ||Trauma ||Promotional |
|Genetics || |
Women may carry a genetic code that predisposes to developing pelvic organ prolapse. Familial predisposition for the development of prolapse has been evaluated through chromosomal linkage analysis in affected families and phenotypical analysis of sisters. Extensive family study has linked the predisposition to the development of prolapse to an area on the long arm of chromosome 9 (9q21).11
Genetic damage to the structure of the pelvic floor affects the attributable risk of and the age of development of pelvic organ prolapse. Disorders dramatically affecting these structures, such as bladder exstrophy, may lead to the emergence of prolapse at an early age.12
Collagen is the most common protein in the body and is the primary fiber of the extracellular structure. There are 14 types of collagen. The amount, type, and cross-linking contributes to the property and strength of the tissue. Connective tissue disorders also predispose a woman to early onset pelvic organ prolapse. Ehlers-Danlos syndrome is a result of genetic mutations in the genes coding for collagen synthesis and processing and affects collagen types I, IV, and V. Clinical manifestations of Ehlers-Danlos syndrome include severe skin hyperelasticity, joint hypermobility, hernias, and pelvic organ prolapse.13 Women with Marfan’s syndrome are also more commonly afflicted with pelvic organ prolapse. Marfan’s syndrome is primarily due to a mutation in the gene coding for fibrillin-1 (a glycoprotein that is the main component of the microfibrils of the extracellular matrix).14 Women with less pronounced connective tissue disorders often have hyperextensible skin. Following a vaginal delivery, the vagina will not be able to “spring” back in shape and resultant prolapse commonly occurs.15 Women with joint hypermobility are more likely to have rectal evacuation disorders and rectocele.16 Histologic changes in the expression of collagen and the proteins that remodel collagen have been demonstrated in women with prolapse and incontinence.17,18 Further elucidation of the timing of the shift in balance of the remodeling process toward degradation will serve to establish if degradation contributes to the development of prolapse or merely is a result of previous prolapse development.
Given the genetic link to pelvic organ prolapse, it is not surprising that a high concordance of prolapse was demonstrated between 101 pairs of nulliparous and parous postmenopausal sisters.19 While genetics predisposed sisters to prolapse, inciting factors were also important. The vast majority (88%–100%) of cases of discordancy between sisters found more advanced prolapse in the parous sister.19
Trauma to the posterior vaginal wall most commonly occurs at the time of pelvic surgery or vaginal delivery. In addition, hysterectomy has been identified as a risk factor for the subsequent development of pelvic organ prolapse.20 In a large case-control study, Dällenbach et al. found the primary risk factor for development of prolapse after a hysterectomy was the degree of prolapse before the hysterectomy. The risk of subsequent prolapse repair in a woman with prolapse to the hymen at the time of hysterectomy was eight times that of a woman without prolapse, regardless of the route of surgery.21
Pelvic surgery may promote the development of posterior wall prolapse through damage to connective tissue support, innervation, or due to a change in the vaginal axis. Ventral deviation of the anterior vaginal wall following a Burch colposuspension may expose the apex and posterior vaginal wall to increased abdominal pressure. A prospective, long-term study of the women who had undergone a colposuspension revealed that 29 of 77 (38%) of these women had developed symptomatic prolapse. Of those who developed prolapse, the majority (76%) had surgical repair.20 Cruikshank et al. described rectoceles or enteroceles in 57% of women 2 to 12 years after a colposuspension.22 Most of these women were asymptomatic at the time of the report. Development of pelvic organ prolapse is significantly lower following a “tension-free” midurethral sling as compared to a colposuspension.23
Vaginal delivery of a term infant is thought to be the most significant event promoting the development of pelvic organ prolapse. Vaginal delivery, particularly in the occiput-posterior position, may damage the connective tissue support, innervation, and levator ani muscles. Interruption in the support of the perineal body will allow the posterior vaginal wall, perineal body, and the distal portion of the anterior rectal wall to descend with increased rectal pressure (Figure 13-4A and B).
Perineocele. A. Abdominal pressure results in distention of posterior vaginal wall and perineum. B. Perineal body hypermobility is demonstrated.
Birth-related injury to the levator ani muscle has been visualized using MRI.25 Defects in the levator ani alter the anatomy of the pelvic floor. The perineal body and external anal sphincter are more caudally placed regardless of prolapse status.10 The alteration of anatomy due to levator ani damage and dysfunction may be causal in the development of prolapse.10
The levator hiatus has been shown to be larger in women with prolapse than in women with normal support.26,9 Women with pelvic organ prolapse more commonly have a major levator ani defect than those without prolapse (odds ratio [OR] 7.3).28
Whether inherited, surgically or obstetrically induced, the damaged posterior vaginal wall support may not be symptomatic for years. Aging or other promoting factors such as repetitive lifting and straining may be necessary for prolapse propagation.
As woman age, muscles weaken, connective tissue loses elasticity and strength, and devascularization and denervation occur throughout the body. Our understanding of how the aging process occurs is growing quickly. Hormonal and cellular changes contribute as well as the cumulative effects of living an active life.
During the lifetime of a woman, there are repetitive straining activities that she may perform that promote the development or recurrence of prolapse. The vector force created by a Valsalva maneuver is partially dissipated through the weakness in the rectovaginal septum. The woman will increase her strain in response to this, which leads to further increase in the size of the rectocele. Chronic illnesses such as chronic pulmonary disease may increase the repetitive abdominal pressure placed on the pelvis. Chronic pulmonary disease was found to be an independent risk factor for the development of prolapse after hysterectomy (OR 14.3, 95% confidence interval [CI] 1.2–178).29 Chronic constipation has been linked to the development of prolapse.30 Posterior vaginal wall prolapse is a common finding in women with constipation.31
The magnitude of pressure placed in the pelvis also impacts the support. Obesity is associated with an increased risk of prolapse and recurrent anatomic and symptomatic prolapse.32 Obesity is also an independent risk factor for prolapse progression. In an analysis of the 16,608 postmenopausal women (ages 50–79 years) enrolled in the Women’s Health Initiative, the risk of posterior vaginal wall prolapse progression increased by 37% in overweight and 58% in obese women as compared to women with a healthy body mass index (BMI).33 Additionally, repetitive heavy lifting may also be a risk factor. Woodman et al. found that women in the lower socioeconomic income who work as laborers or factory workers were more likely to have prolapse.34
The etiology of posterior vaginal wall prolapse is likely multifactorial. On the cellular level, changes are seen in the connective tissue supports, the vaginal wall, and the pelvic floor muscles. Pelvic trauma and aging result in tissue trauma, denervation, devascularization, and enhanced collagen degradation. With time, this weakened connective tissue and pelvic floor musculature can produce posterior wall prolapse.
Understanding the pathophysiology of the pelvic floor and posterior wall prolapse greatly enhances the provider’s ability to delineate and quantify posterior wall prolapse and interpret coexisting pelvic floor dysfunction. Symptoms related to posterior wall prolapse include the physical herniation of bowel contents into the vagina and the functional results of this herniation. A woman will commonly complain of a lump or bulge in the vagina that is more prominent after standing for long periods of time.
A bulging posterior wall of the vagina may provide structural support of the urethra, masking stress urinary incontinence. Cystometry with prolapse reduction can be performed to evaluate for occult incontinence. A distal or advanced posterior wall prolapse may partially obstruct the external urethral meatus resulting in spraying of the urine stream or sense of hesitancy. Multichannel urodynamic evaluation may be helpful in the diagnosis of urinary symptoms in women with stage III or stage IV posterior wall prolapse. With replacement of the posterior wall prolapse that simulates correction of the posterior wall prolapse, a significant decrease of the maximum urethral closure pressure and functional urethral length can occur, “unmasking” urinary incontinence.
Defecatory function may be impacted by a multitude of medical and behavioral factors. Dysfunction may be simply related to insufficient fiber or fluid intake. Systemic illnesses, such as diabetes, thyroid disorders, and neuromuscular disease may significantly impact defecatory function. Hirschsprung disease, malignancy, inflammatory bowel disease, rectal intussusceptions, or prolapse can cause mechanical bowel obstruction. Medications can alter bowel motility and lead to constipation. Common culprits include aluminum antacids, anticholinergics, antidepressants, anti-inflammatory drugs, beta-blockers, calcium channel blockers, iron sulfate, and opiates. Psychiatric conditions such as abuse (psychologic, physical, and sexual), eating disorders, and pelvic pain can also affect bowel function.35
Many women complain of constipation, which may be defined as excessive straining, hard lumpy stools, splinting, feeling of incomplete emptying, and infrequent stools. Women with slow-transit colon respond less favorably to surgical management of rectocele as compared to women with normal transit studies.36 The most common defecatory complaint noted in women with symptomatic posterior wall prolapse is difficulty or incomplete emptying of stool.37,35 Obstructed defecation is frequently related to issues other than posterior wall prolapse such as anismus or nonrelaxing pelvic floor or pelvic floor dyssynergia. While the symptom of incomplete rectal emptying is common in women with posterior wall prolapse, the defecatory symptom most specific for posterior wall prolapse is vaginal digitation to relieve the incomplete emptying.38
Sexual function is multifaceted. Pelvic organ prolapse can alter a woman’s body image.39 Both partners can be affected by the appearance or sensation of a change in the vaginal anatomy. An enlarged genital hiatus may lead to decreased sensation by both partners. If stool is trapped in the rectocele, intercourse may lead to fecal incontinence or instill a fear of fecal incontinence leading to avoidance of intercourse.
The posterior vaginal wall may be evaluated for evidence of prolapse through physical examination or imaging. Further physiologic testing may be indicated. The physical examination includes a quantification of prolapse. The pelvic organ prolapse quantification (POP-Q) system is a standard, validated tool that permits comparisons of patients and allows individual patients to be followed longitudinally40 (Figure 13-5). The patient is generally examined in the dorsal lithotomy position and asked to Valsalva maneuver to maximize descent of the prolapse. If this fails to recreate the degree of prolapse that the patient describes, a standing examination should be performed. It is physically more difficult to make measurements of the prolapse in this position. The perineal body should be evaluated for support and descent. A rectovaginal examination can facilitate evaluation of the support and descent of the perineal body as well as evaluate the protrusion of the anterior rectum into the posterior vaginal wall. Palpation of loops of small bowel or sigmoid colon in the rectovaginal space may confirm an enterocele or sigmoidocele, respectively. Performing this examination in the standing position can allow gravity to bring the bowel into the rectovaginal space and facilitate detection of an enterocele or sigmoidocele (Figure 13-6). Pressure on the posterior wall of the vagina, directed toward the rectum, may facilitate identification of rectal prolapse. Assessment of the anal sphincter may also be performed including evaluation of anal tone, squeeze, and symmetry.
Pelvic Organ Prolapse Quantification System (POP-Q). Posterior wall is measured at points Ap (3 cm from hymen) Bp (most dependent portion of the remaining vaginal wall) D (culdesac) TVL (total vaginal length) GH (genital hiatus), PB (perineal body), C (cervix or cuff). The anterior vaginal wall measurements include Aa (3 cm from hymen), and Ba (most dependent measurement of the remaining anterior vaginal wall). (Reproduced with permission from Ref.40)
Standing rectovaginal examination. (Reproduced with permission from Ref.41)
A focused neurologic examination includes evaluation of sensation, motor function, and reflexes of sacral nerves 2–4. The patient is asked to discriminate between sharp and dull on the perineum. Pelvic floor muscle strength may be assessed by asking the patient to contract and relax the pelvic floor muscles around the examiner’s fingers in the vagina. Reflex testing includes the bulbocavernosus reflex and anal wink.
The clinical examination enables documenting the presence or absence of prolapse, but is not accurate in identifying the location of the connective tissue defect or presence of an enterocele or sigmoidocele.42 Imaging and functional evaluation of the bowel may be warranted.
A woman with defecatory dysfunction and pelvic organ prolapse may benefit from further testing. Defecography provides a two-dimensional view of the efficiency of anorectal emptying during simulated defecation and quantification of rectal parameters. Prior to the test, a woman ingests diluted barium, the rectum is filled with a barium paste that has the consistency of soft stool and the barium gel is placed in the vagina. Evaluation includes rest, squeeze, strain, and evacuation. Rectocele, enterocele, and rectal intussusception can be graded based on the anatomic evaluation obtained with defecography (Figure 13-1B, C and Table 13-2). Diagnostic categories obtained are internal procidentia, rectocele, enterocele, sigmoidocele, descending perineum, and the functional description of spastic pelvic floor.
Grading of Pelvic Descent by Defecography
||Download (.pdf) Table 13-2
Grading of Pelvic Descent by Defecography
| ||Grade 1 ||Grade 2 ||Grade 3 |
|Rectocele ||<2 cm ||2–4 cm ||>4 cm |
|Enterocele ||Proximal third of vagina ||Middle third of vagina ||Distal third of vagina |
|Intussusception ||Above the puborectalis ||At puborectalis ||In anal canal |
Some degree of rectocele is present in most symptomatic women and up to 20% of asymptomatic women.43 Radiographically, a rectocele is considered significant if the anterior rectal wall extension is greater than 2 cm from the midrectal canal (grade 2 or 3). Descent of the perineal body and descent of the bowel into the rectovaginal space can be visualized and graded (Table 13-3). Retention of more than 10% of the barium following defecation is referred to as barium trapping. It should be recognized that this examination provides an artificial environment, which may make the patient more prone to incomplete emptying. Paradoxical contraction of the puborectalis and rectal intussusception may be diagnosed with this functional test. The advantages of defecography over magnetic resonance (MR) defecography or perineal ultrasound are that it is simple to perform, cost-effective, and widely available. The disadvantages include exposure to radiation and inability to image soft tissues.
Rectocele Classification According to Level of Descent and Potential Concomitant Pathology37
||Download (.pdf) Table 13-3
Rectocele Classification According to Level of Descent and Potential Concomitant Pathology37
| ||Level III ||Level II ||Level I |
|Rectocele || |
|Middle rectocele ||High rectocele |
|Concomitant pathology || |
Anal sphincter defect
|Rectal intussusception || |
The performance of MR defecography requires the patient’s rectum to be filled with synthetic stool such as potato starch mixed with 1.5 mL of gadopentetate dimeglumine or ultrasound gel. The vagina may be delineated with insertion of ultrasound gel. Ideally, the patient is able to complete this study in an open configuration MR imaging system in the sitting position, although some studies are done with the patient in the supine position. The pelvis is imaged at rest, maximum squeeze, maximum strain, and evacuation. The technique in the sitting position simulates the functional testing achieved with defecography with the added advantages of superb soft tissue imaging, large field of view, avoidance of ionizing radiation, direct multiplanar capability, and high temporal resolution. If an open configuration MRI is not available, the test may be performed in a closed MRI. However, an accurate picture of the extent of prolapse may not be demonstrated with a Valsalva maneuver in the supine position and the woman’s legs closed to fit in the MRI scanner. Furthermore, this is not a normal position for defecation and may not simulate the woman’s ability to defecate. Disadvantages of MR defecography primarily include cost and availability of open MR imaging.43,45
Translabial, perineal, and three-dimensional endoanal ultrasound has been described to evaluate the pelvic organs at rest, contraction, and maximum Valsalva maneuver.44 Ultrasonography has been found to compare favorably to defecography in the identification of rectocele, enterocele, paroxysmal contraction of the puborectalis, and rectal intussusception.44,46 The advantages of ultrasound evaluation includes avoidance of ionizing radiation, less expense, physician view in real-time rather than static images, and the avoidance of the embarrassment of defecating in public. However, to date there is no standardization of parameters or techniques. Evaluation of efficiency of evacuation is not performed.
At this time, a standardized method of establishing a radiologic diagnosis of a rectocele is lacking. There is poor correlation between imaging and clinical examination.47,48 Clinical examination fails to identify women with enteroceles as defined by defecography.48 While defecatory dysfunction is common in women with prolapse, the extent of the prolapse generally correlates with the symptom of feeling or seeing a bulge rather than functional complaints.49 If a woman’s primary complaint is defecatory dysfunction or fecal incontinence rather than a bulge, correction of a rectocele or perineal body defect may not correct her symptoms. Ancillary testing is then pursued based on the woman’s complaints. Validated functional and quality-of-life questionnaires are now available. These questionnaires may be performed pre- and postoperatively to provide a standardized method of evaluating functional surgical outcomes. The patient’s preoperative symptoms and surgical goals will guide the provider in the selection of additional testing.
A woman who describes life-long infrequent bowel movements defined as less than one bowel movement per week and an absence of a daily urge to defecate is unlikely to be cured of her constipation with a rectocele repair. A colon transit study may be helpful in identifying patients with slow transit colon. Dietary modifications including fiber and laxatives should be encouraged in any woman whose main complaint is constipation. Severely constipated women tend to have multiple findings on defecography.43
Women who have failed conservative management of fecal incontinence should undergo further evaluation prior to rectocele repair. An endoanal ultrasound will provide anatomical detail of the integrity of the external and internal anal sphincter, while electromyography (EMG) study of the external anal sphincter and pudendal nerve can provide neurologic information on the innervation of these muscles.
The pelvic floor muscles are constantly active and contracted. During straining, a coordinated relaxation of the levator ani and external anal sphincter occurs. Failure to relax the pelvic floor muscles is a sign of anismus. The balloon expulsion test (BET) and manometry can indirectly measure the function of the pelvic floor muscles. A woman with a normally functioning pelvic floor should easily be able to expel a 60 mL balloon filled with air or water. Failure to expel the balloon suggests a functional abnormality.43 Women with anismus should be treated with biofeedback.
Treatment options for posterior wall prolapse vary from reassurance that the mass (bulge) that the woman feels is not cancer to surgery to correct the defect. The options in between include counseling on management of risk factors for progression of prolapse, such as chronic constipation, coughing, and limiting weight gain to use of a pessary.
The natural history of pelvic organ prolapse is not well understood due to a paucity of literature on the subject. Recently, physical examination over a five-year period of the women participating in the estrogen plus progesterone arm of the Women’s Health Initiative (WHI) Hormone Therapy Clinical Trial showed an overall increase in the rate of prolapse by 4% during this time frame.33 Interestingly, prolapse both progressed and regressed. Prolapse may be present one year and not present two or five years later even without surgical intervention.
Women are typically more symptomatic if the prolapse extends beyond the vaginal introitus. A pessary may effectively manage the prolapse, especially if the posterior wall prolapse has an apical component. The vaginal apex may be stretched in the cephalad direction resolving the bulging posterior vaginal wall. The Gehrung pessary may be used to treat women with posterior vaginal wall prolapse. The Gehrung pessary may be molded to fit the woman’s type of prolapse. A woman can be taught how to remove, clean, and replace her pessary. However, many women are unable to maneuver the pessary due to medical conditions such as arthritis. Therefore, the ability to attend follow-up evaluations and pessary maintenance is crucial to selecting this method of prolapse management. Clemens et al. evaluated 100 consecutive women who underwent an attempt at pessary placement. He found that a short vaginal length (<6 cm) and a wide genital hiatus (four fingerbreadths) were risk factors for unsuccessful pessary placement.50 Women with a large perineal body defect will lack the distal support to maintain a pessary in place.
The impact on defecatory complaints by pessary placement is unresolved. Fernando et al. described no significant improvement in defecatory symptoms at four months, and Komesu et al. did not show improvement in bowel symptoms.51,52 Abdool et al. followed 554 women with symptomatic prolapse for one year.53 In this study, 359 women elected to use a pessary, while 195 women underwent surgical correction of her prolapse. At the conclusion of one year, there was a similar, significant overall improvement in prolapse and functional complaints of bowel, sexual, and urinary management. Fecal urgency was improved in both pessary and surgical groups, but incomplete bowel emptying was improved only in the surgery group. Frequency of intercourse was also better in the surgery group as compared to the pessary group.53
Common complications associated with pessary use include excoriation, ulceration, vaginal bleeding, and rarely, impaction of the pessary in the vaginal canal when neglected. Vaginal estrogen cream can help prevent and treat these vaginal mucosal complications.
Some data suggest that there may be a therapeutic effect associated with long-term use of the pessary. It may be that the replacement of the prolapse through the levator hiatus allows the pelvic floor muscles an opportunity to rehabilitate, and prolapse to regress.
Strengthening of the pelvic floor muscles may improve apposition of the anterior and posterior vaginal walls by decreasing the levator hiatus. A recent randomized, controlled trial of 109 women with stage I to III prolapse, randomized women to physical therapy versus control. Eleven (19%) of the women in the physical therapy group improved their prolapse stage while four (8%) in the control group improved (P =.035).54
The decision to undergo surgical management for the treatment of prolapse is influenced by personal, cultural, and physician factors. Issues contributing to the decision to proceed with surgery include the severity of prolapse, medical comorbidities, patient knowledge of prolapse, personal preference, access to medical care, socioeconomic status, cultural norms, and physician preference.5 The surgical experiences of a woman’s social network and her caregiving obligations also impact her decision.
Prolapse may affect woman across the reproductive life cycle. While the greatest percentage of prolapse surgery is performed in the perimenopausal period, the elderly are more frequently affected by prolapse.5 Women and family members, as well as physicians, frequently exclude the option of surgical management solely based on the patient’s age. However, the surgical outcomes and complications in the elderly are very similar to those found in younger women.5 The quality of life and satisfaction are both very high in the elderly population undergoing surgical repair of prolapse.55 With the elderly population expanding rapidly, age should not be the sole factor in determining surgical eligibility.
Posterior vaginal wall surgery is performed in at least one in three prolapse surgery cases according to data from the National Hospital Discharge Survey and National Census, 2003.5 Physician surveys to determine the surgical method of choice for women undergoing posterior wall prolapse repair have found that currently most are performing posterior colporrhaphy, followed by site-specific repair, and a growing trend is a vaginal mesh repair primarily using a commercially available kit.56 While posterior wall prolapse repair has been commonly performed for more than a century, the long-term functional and anatomic outcomes and ideal procedure has not been determined.
The posterior colporrhaphy was introduced in the 19th century. This involves a plication of the fibromuscularis or rectovaginal fascia of the posterior vaginal wall in the midline, decreasing the width of the posterior vaginal wall and increasing the fibromuscularis support in the midline. The traditional posterior colporrhaphy has an anatomic cure rate of 76% to 100% (Table 13-4).36,57-64
Efficacy of Posterior Colporrhaphy for Treatment of Posterior Wall Prolapse. Anatomic Cure and Functional Results
||Download (.pdf) Table 13-4
Efficacy of Posterior Colporrhaphy for Treatment of Posterior Wall Prolapse. Anatomic Cure and Functional Results
|Primary Author, Year ||Patients at Follow-up/Initial Presentation ||Mean Follow-up, Months ||Anatomic Cure, % ||Incomplete Evacuation Pre-op, % ||Incomplete Evacuation Post-op, % ||Sexual Dysfunction Pre-op, % ||Sexual Dysfunction Post-op, % |
|Arnold (1990)36 ||22/29 ||24 ||77* ||20 ||NS ||NS ||23 |
|Francis (1961)57 ||243 ||>24 ||94 ||NS ||NS ||9 ||50 |
|Mellgren (1995)58 ||25 ||12 ||80† ||88 ||0 ||6 ||19 |
|Kahn (1997)59 ||140 ||44 ||76 ||27 ||38 ||18 ||27 |
|Sand (2001)60 ||70/80 ||12 ||90‡ ||NS ||NS ||NS ||NS |
|López (2002)61 ||25 ||9 ||83† ||68 ||36 ||18 ||23 |
|Maher (2004)62 ||38 ||12.5 ||87 ||100 ||16 ||37 ||5 |
|Abramov (2005)63 ||183 ||12 ||86‡ ||NS ||NS ||8 ||17 |
|Paraiso (2006)64 ||28/37 ||17.5 ||86%§ ||62 ||45 ||55 ||45 |
The vaginal epithelium of the posterior wall is opened in the midline and dissection of the epithelium off the underlying fibromuscularis is performed. Plication of the fibromuscularis begins proximally and progresses toward the hymen. The plication creates a shelf of support by ensuring that each of the plication sutures is in continuity with the previous one. If continuity is not maintained, transverse ridging of the posterior vaginal wall may occur and be a source of dyspareunia. Adequate caliber of the vagina at the conclusion of the vaginal reconstruction should be maintained throughout the length of the vagina; in general, this is three fingerbreadths in sexually active women. Short-term vaginal packing for hematoma prevention can be used for all posterior vaginal wall prolapse repairs.
Complications associated with the posterior colporrhaphy include injury to the underlying rectum during dissection, changes in defecatory function, dyspareunia, and recurrence.
Traditionally, a perineorrhaphy is included in this repair. This includes plication of the bulbospongiosus and transverse perinei portion of the perineal membrane. Care should be taken to avoid ridging at the vaginal introitus. Splinting the perineum to defecate is an indication for perineal body reconstruction.65 Otherwise, the perineorrhaphy may not be necessary and may increase the risk of dyspareunia.
The plication of the fibromuscularis may include a plication of the levator ani muscles. Interrupted sutures are placed in the muscular sidewall near the attachment of the fibromuscularis and brought to the midline. This is not an anatomic position of the levator ani muscles, but a compensatory way to close the levator and genital hiatuses. This provides a sturdy posterior shelf, but may further constrict the vaginal caliber or serve as a source of postoperative pain and/or significant dyspareunia.59
The site-specific defect repair became very fashionable in the late 1990s. The epithelium is dissected off the underlying connective tissue and the object of the repair is to fix the connective tissue defects. The anatomic cure rates vary from 67% to 100% (Table 13-5).63,64,66-70
Efficacy of Site-Specific Posterior Repair for Treatment of Posterior Wall Prolapse: Anatomic Cure and Functional Results
||Download (.pdf) Table 13-5
Efficacy of Site-Specific Posterior Repair for Treatment of Posterior Wall Prolapse: Anatomic Cure and Functional Results
|Primary Author, Year ||Patients at Follow-up/Initial Presentation ||Mean Follow-up, Months ||Anatomic Cure, % ||Incomplete Evacuation Pre-op, % ||Incomplete Evacuation Post-op, % ||Sexual Dysfunction Pre-op, % ||Sexual Dysfunction Post-op, % |
|Cundiff (1998)66 ||43 ||12 ||82† ||39¶ ||25 ||29 ||19 |
|Kenton (1999)67 ||46/66 ||12 ||77 ||52 ||30 ||28 ||7 |
|Porter (1999)68* ||89/125 ||18 ||82 ||61 ||44 ||67 ||46 |
|Glavind (2000)69 ||65 ||3 ||100 ||40 ||6 ||12 ||6 |
|Abramov (2005)63 ||124 ||12.2 ||67‡ ||NS ||NS ||8 ||16 |
|Paraiso (2006)64 ||27/37 ||17.5 ||78§ ||69 ||51 ||48 ||28 |
|Sardeli (2007)70 ||51 ||26.7 ||68|| ||59 ||45 ||6 ||8 |
The patient is placed in the dorsal lithotomy position. The posterior vaginal wall is split with the epithelial layer dissected away from the underlying connective tissue. The dissection is extended to the border of the puborectalis. A finger in the rectum directed anteriorly coupled with irrigation of the fibromuscularis facilitates identification of defects in the connective tissue support. Allis clamps may be placed on the edges of the defect and the edges approximated to simulate the repair to assess reduction of the rectocele. The defects are closed with interrupted sutures of delayed-absorbable or permanent sutures. Occasionally, a plication of the fibromuscularis is performed if there is connective tissue laxity remaining after site-specific repair. The levator ani muscles are not plicated.
The complications are similar to those of the posterior colporrhaphy. The attraction of the site-specific repair is that this approach is less likely to narrow the vaginal caliber excessively and avoid the pain associated with the levator plication.
The rectovaginal septum can be reinforced with mesh. The plane of dissection is in the rectovaginal space rather than splitting the vaginal wall. This can be accomplished through an abdominal, vaginal, or perineal body incision, or a combination of these approaches.
An abdominal approach either through an abdominal incision, or through laparoscopic or robotic-assisted routes to repair posterior wall prolapse may be used when pelvic organ prolapse involves many compartments or is recurrent. The rectosigmoid is retracted to the left and the right ureter identified. The presacral space is opened and the peritoneal dissection is extended to the apical posterior vaginal wall. The vagina is deviated ventrally and the rectum is deviated dorsally and the rectovaginal space is entered. Dissection is continued to the perineal body on the ventral side of the rectum. The mesh is attached to the posterior vaginal wall with a series of sutures and to the anterior longitudinal ligament of the sacrum in a tension-free fashion. The mesh is typically covered with peritoneum.
Through a perineal body or vaginal approach, deep dissection into the rectovaginal space can be facilitated by injection with dilute epinephrine solution. Dissection is continued to the point of apical attachment (usually the sacrospinous ligament). Lateral dissection is extended to the pelvic sidewall. D’Hoore describes attaching the mesh to the sacral promontory, perineal body, and the anterior seromuscularis of the rectum to prevent anterior intussusception of the rectum.37
The avenue of approach, the mesh of choice (synthetic vs biologic), the anchoring points, and type of suture can all vary dependent upon the surgeon. An anatomic cure rate ranging from 54% to 92% reflects the variation in type of mesh, method of placement, and definition of cure.60,64,71-74 Standardization of a method of transvaginal mesh placement has been developed by various device companies.
Tension-free Vaginal Mesh Kit Procedures
Compensatory procedures, such as the abdominal sacrocolpopexy, enjoy the stasis of the gold standard surgical repair of pelvic organ prolapse.75 The new tension-free vaginal mesh procedures attempt to capitalize on the durability and efficacy of the abdominal sacrocolpopexy while maintaining the advantages of a vaginal approach. Preoperative and postoperative MRI of a woman undergoing transvaginal mesh kit procedure (Prolift Ethicon, Somerville, NJ) illustrated an improvement in the levator ani anatomy.27 Currently, the short-term results associated with the prolapse mesh have produced anatomic cure rates of 77% to 100%, but the long-term efficacy over native tissue repairs remains unclear (Table 13-6).76-86
Efficacy of Tension-free Vaginal Mesh Procedures
||Download (.pdf) Table 13-6
Efficacy of Tension-free Vaginal Mesh Procedures
|Author, year ||Patients at Follow-up/Initial Presentation ||Kit ||Mean Follow-up, Months ||Anatomic Cure, % ||Incomplete Emptying Pre-op, % ||Incomplete emptying Postop, % ||Dyspareunia Preop ||Dyspareunia Postop, % ||Mesh exposure, % |
|Fatton (2007)79 ||86/88* ||Prolift ||6 (median) ||95 ||NS ||NS ||25.8 ||9.1 ||4.7 |
|Gauruder-Burmester (2007)78 ||48† ||Apogee ||12 ||100 ||28 ||5% ||12.5 ||0 ||0 |
|Argirovic (2010)76 ||31†† ||Prolift ||14.1 ||90.4 ||NS ||NS ||NS ||15.6 ||0 |
|Culligan (2010)77 ||21‡‡ ||Avaulta ||14.4 ||90 ||NS ||NS ||NS ||3 ||11.7 |
|Zyczynski (2010)82 ||100/105§ ||Prosima ||12 ||84 ||NS ||NS ||14 ||5 ||8 |
|Takahashi (2010)81 ||310# ||Prolift ||12 ||92.3 ||NS ||NS ||NS ||NS ||3 |
|Lo (2010)80 ||42/43 ||Total Prolift ||15.7 ||97.6 ||NS ||NS ||NS ||NS ||0|| |
|Velemir (2010)83 ||62** ||Prolift ||17.9 ||93.5 ||NS ||NS ||NS ||NS ||9.9 |
|McDermott (2011)84 ||89/189‡ ||Total Prolift ||10.8 ||94 ||NS ||NS ||35 ||24 ||9 |
|Milani (2011)85 ||86¶ ||Prolift+M ||12 ||77.4¶ ||NS ||NS ||29.5 ||8 ||8¶ |
Many device companies have introduced trocar-based “kits” that facilitate placement of mesh in the posterior compartment. The majority of the kits use the bilateral apical anchoring points in the sacrospinous ligament. Typically, the rectovaginal space is injected with a dilute vasocontrictive agent or normal saline. The plane of dissection is under the vaginal wall rather than splitting the vaginal wall as performed in posterior colporrhaphy or site-specific repair (Figure 13-7A and B). An incision is made through the entire vaginal wall, most commonly in a vertical fashion. The rectovaginal space is dissected vertically from the perineal body to the ischial spines and sacrospinous ligaments, then horizontally from sidewall to sidewall. Various methods are employed to suspend the mesh without tension to the sacrospinous ligament.
Plane of dissection. A. posterior colporrhaphy; and B. transvaginal mesh placement.
The mesh is additionally attached with sutures to the vaginal apex or cervix near the internal os and to the perineal body. Tacking sutures to the vaginal sidewall may be performed in an attempt to prevent the mesh from bunching up. The mesh should be flat but not under tension. While setting the mesh in place, the surgeon must realize that shrinkage decreasing the surface area of the mesh of up to 20% may occur. Shrinkage of the mesh may cause complications such as vaginal pain, which worsens with movement, focal tenderness over contracted portions of the mesh (particularly mesh arms), dyspareunia, or recurrence of prolapse.76
Trimming of the vaginal skin is minimal or not performed. A rectal examination should be done to rule out a palpable rectal injury. A vaginal pack is placed. Prophylactic antibiotics have been reported to be given for up to seven days. Pre- and postsurgical treatment of the vaginal epithelium with topical estrogen is advocated to decrease the incidence of mesh erosion.78 Women who are using a pessary preoperatively should remove the pessary two weeks prior to surgery to decrease vaginal irritation.
The most commonly reported complication with mesh-augmented procedures is erosion. The short-term erosion rate using the mesh kit in the anterior vaginal wall is up to 15.6% and is bound to be higher the longer these women are followed.87 The anterior vaginal wall has been found to be more at risk for mesh erosion than the posterior vaginal wall.78,88
Healing is dependent upon vascularization, collagen formation, age, estrogen status, immune status, and avoidance of hematoma and infection. Erosion is related to the mesh properties including the type of mesh and its surface area, operative technique including the length and depth of placement of the vaginal incision, the presence of infection, and the health of the woman receiving the mesh.90 Lightweight, macroporous type 1 (monofilament) synthetic mesh is the most common mesh used for prolapse repair. Mesh with a pore size greater than 75 μm allows leukocytes and macrophages to patrol the mesh for bacteria. A loose weave also allows for fibroblast ingrowth.
Some investigators have found that a concomitant hysterectomy or trachelectomy increases the length of the vaginal incision and increases the risk of vaginal erosion by eight- to ninefold.88 Tissue oxygenation is impacted by a hysterectomy, age, obesity, and smoking. Smoking, with many deleterious effects on the health of vaginal tissue and healing, is a risk factor for mesh erosion in both transabdominal and transvaginal procedures.91 Smoking can significantly alter vascularization through vasoconstriction, microthrombi formation, and direct endothelial damage.92 Araco et al. revealed that a smoking history of 6.85 pack years increased the risk of erosion to the same degree as old age, defined in this study as aged 60 years and beyond.93
Obesity (BMI ≥30) increased the risk of erosion more than 10-fold in a retrospective analysis of 460 women undergoing transvaginal mesh kit repair.92 In this analysis, the combination of risk factors significantly elevated the risk of erosion. In women ≥60 years of age and with a BMI ≥30, the erosion rate was 26.6%. Twenty-two percent of the women who smoked and had a BMI ≥30 developed erosions.92
Further elucidation of the etiology of early and late erosions is needed. Late erosions were significantly more common in women who were sexually active compared to those who were not (17.3% vs 2%, respectively, OR 10.47 [95% CI 1.27 to 85.96 P =.029]).89
The U.S. Food and Drug Administration notification was posted in 2008, and updated in 2011, encouraged extensive preoperative counseling for transvaginal mesh procedures. Preoperatively, women should be informed that the implantation of mesh is permanent, complications associated with mesh placement may require additional surgery that may or may not correct the complication, and that there is potential for serious complications that may affect quality of life including pain, dyspareunia, scarring, or narrowing of the vagina.94 Many of these complications are present for other posterior wall prolapse procedures.
Rectal perforation has also been reported to occur in 0.7% to 2.8% of cases.88,95 If a rectal injury occurs, the posterior tension-free vaginal mesh placement should be abandoned.79
Many of the kit procedures involve blind passage of needles to place the mesh. Bleeding and hematoma may occur. The needles of the posterior pass of Prolift, Prolift + M (Johnson and Johnson, Ethicon, Somerville, NJ), Avaulta (Bard, Covington, GA), and Apogee (American Medical Systems, Minnetonka, MN) travel through a large expanse of the ischiorectal fossa on the way to the sacrospinous ligament. Reisenauer et al. found in a study on cadavers that the sacrospinous ligament cannulas passes 0.5 to 1 cm medial to the internal pudendal nerve and vessels.96 Hematomas may be more insidious in presentation. They may become symptomatic and require surgical drainage days after the original procedure.79,97
Pelvic pain has been associated with many reconstructive surgical procedures. The tension-free vaginal mesh procedures have also been associated with vaginal pain, defecatory pain, and dyspareunia.88 When evaluated, de novo dyspareunia occurs in up to 12.8% of women.88 de Tayrac et al. reported that vaginal pain and de novo dyspareunia was the reason given by three out of five women reporting dissatisfaction with the tension-free vaginal mesh kit procedure.88 Surgical management is generally performed after a period of conservative management, consisting of pelvic floor physical therapy and possibly trigger point injections. Banding of the mesh may contribute to pain, therefore, release of the sling arm at their point of attachment to the levator plate may help relax the vaginal wall.
The prolapse transvaginal mesh kit procedures have received widespread acceptance by the gynecologic community of surgeons. The success of the midurethral slings should not be directly translated to the tension-free vaginal mesh kit procedures for prolapse. The surface area of mesh that is placed with the kits is much larger. The first-generation total mesh kits include long blind passes of needles through the ischiorectal fossa. More recent changes include fixing the apical support directly into the sacrospinous ligament with self-fixing arms Posterior elevate (AMS), Capio transvaginal suture capturing device—Pinnacle, and Uphold (Boston Scientific, Natik, MA), or without fixation—Prosima, (Ethicon). Importantly, the possible long-term surgical complications are yet to be determined. The management of complications is potentially more difficult with the mesh in place. The surgeon must weigh the possible gain in anatomic efficacy, efficiency of the procedure, attractiveness of a vaginal approach, and potential durability (yet to be demonstrated) against the potential morbidity associated with mesh erosion, pain, and potential, unforeseen complications.
Transperineal and Transanal Repair
The rectovaginal space may be approached through an incision in the perineal body. A transverse incision in the perineal body above the subcutaneous portion of the external anal sphincter is performed. Dissection in the rectovaginal space throughout the length of the posterior vaginal wall is accomplished with sharp and blunt dissection. The rectal submucosa may be plicated with absorbable suture. The rectovaginal septum plication with or without levatorplasty may be performed. Mesh may also be placed with this approach.
Colorectal surgeons will often approach the repair of a rectocele transanally. A Cochrane review of the prolapse literature identified only two randomized trials comparing transanal and transvaginal approach to rectocele repair. The vaginal approach was associated with a lower rate of recurrent rectocele, enterocele, or both as compared to a transanal approach (relative risk [RR] 0.24, 95% CI 0.09–0.64).98 The transanal approach was associated with a lower blood loss and postoperative use of narcotics.98
Farid et al. randomized 48 women to one of three approaches to rectocele repair—transanal, transperineal with a levator plication, and transperineal without a levator plication.99 Radiographically, the rectocele decreased in size in all three groups. However, rectal evacuation and functional scores improved significantly in the transperineal groups, but not in the transanal group.99 The transperineal repair was associated with a reduction in urge to defecate volume and an increase in the volume required to induce maximum anal relaxation. Therefore, obstructed defecation that is caused by a large rectal volume may be improved with the transperineal repair.
The transanal approach uses a prone-jackknife position. The anal sphincter is paralyzed with injection of lidocaine with epinephrine. The anus is gently dilated. Beginning 1 cm above the dentate line, the anterior rectal mucosa is opened in the midline along the extent of the rectocele. Mucosal flaps are developed to expose the lateral fibromuscular tissue, which is plicated in the midline, closing the defect. The mucosa is then closed.
The transperineal and transanal route may be complicated by rectal perforation, fistula, defecatory dysfunction, dyspareunia, defecatory pain, and recurrence. There have been no significant differences in postoperative defecatory dysfunction, fecal incontinence, or dyspareunia between the transanal and transvaginal procedures.98
Sexual Function and Posterior Repair
Sexual function is a complex issue that involves a woman and her partner’s physical and emotional health, interlaced with the intimacy of their relationship. The complexities of sexual function are reflected in postoperative evaluation of sexual function. Physical issues, such as vaginal caliber and the development of pain, emotional response to change in body image, and the woman’s sexual partner’s response to the change in anatomy, all contribute to the postoperative interpretation of sexual function.
Postoperative sexual dysfunction has been of significant concern for a number of decades with the surgical management of posterior wall prolapse. Francis and Jeffcoate observed a high rate of sexual dysfunction following prolapse surgery. Seventy of 140 (50%) sexually active women reported apareunia or dyspareunia after an anterior and posterior colporrhaphy and perineorrhaphy. On postoperative examination, 43 of these 70 women with sexual dysfunction were found to have a vagina narrowed to admit only one finger.57
With attention to preserving vaginal caliber, nearly 40 years later Weber and colleagues evaluated pre- and postoperative sexual function and vaginal caliber and length in 165 women.100 The vaginal length and caliber did significantly decrease in women undergoing prolapse surgery, however there was no correlation with sexual function and vaginal dimensions. Dyspareunia increased in women undergoing prolapse surgery (8% preoperatively vs 19% postoperatively) and women who had a posterior colporrhaphy as part of their repair had a significantly higher dyspareunia rate (26%, P = 0.01).100 Even though dyspareunia increased with prolapse surgery, the satisfaction with their sexual function also improved from 82% preoperatively to 89% postoperatively.100
Correction of prolapse and concomitant improvement of body image may be a dominant factor in postoperative sexual function, despite postoperative dyspareunia. Azar et al. found that sexual function significantly improved following anterior and posterior colporrhaphy.101 The domains of desire, arousal, lubrication, orgasm, and satisfaction were all significantly increased three months postoperatively. Unfortunately, pain with intercourse did increase in this immediate postoperative period; in this study, three levator plication sutures were included during the posterior colporrhaphy procedure.101 Levator ani plication has been implicated as a possible cause of postoperative dyspareunia.59 Jeong et al. found a similar improvement in sexual function in women who had undergone a midurethral sling with and without a posterior colporrhaphy. There was no difference in the pain component of sexual function between women who had undergone a midurethral sling alone or one performed with a posterior colporrhaphy.102
Correction of posterior wall prolapse by other methods is also related to dyspareunia. The transanal route of rectocele repair is also associated with dyspareunia. Arnold and colleagues found similar rates of dyspareunia among women who had undergone a transvaginal approach (23%) versus an endoanal approach to rectocele repair (21%).36
Graft placement can have a negative effect on sexual function. Lim et al. described a 27% incidence of de novo dyspareunia in women three years after a posterior repair using a polyglactin 910/polypropylene soft mesh (Vypro 2).103 The high erosion rate of 30% was thought to contribute to the dyspareunia. Even if erosion does not occur, the “behavior” of the graft underneath the epithelium of the vagina after it is placed may also be a cause for discomfort with intercourse. The graft may shrink or have been placed under tension and be a source of pain. The graft may become encapsulated and fibrotic, or completely disappear. These factors may have profound effects on the function of the vagina as a sexual organ.
Insight into the relationship between sexual function and pelvic organ prolapse has been enhanced through the development of validated disease-specific questionnaires such as the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ).104 Novi et al. compared the preoperative and postoperative sexual function in women undergoing a site-specific posterior repair with women undergoing a posterior repair with porcine dermis graft using the PISQ. They found that both repairs significantly lowered the rate of dyspareunia; the site-specific repair lowered the dyspareunia rate from 36% preoperatively to 10% postoperatively, and the graft repair lowered it from 40% preoperatively to 8% postoperatively.105 While both repairs significantly improved sexual function in women postoperatively, the women undergoing the porcine dermis repair, which was simply sutured in place with an emphasis on “tension-free” placement, had a significantly greater increase in sexual function than the site-specific repair.105
Most women who undergo a surgical procedure for the management of their prolapse anticipate that they will never have to deal with the problem again. In the United States, it is estimated that more than 225,000 women annually undergo surgery for pelvic organ prolapse106 with the direct costs of the surgery in excess of $1 billion.107 However, it is estimated that nearly 30% of procedures are for recurrent prolapse.3 Reoperation rate for posterior wall prolapse are 5% to 20%.108 The lifetime of a surgical repair for prolapse is largely unknown. Many women with recurrent prolapse will choose to treat the prolapse conservatively. In a cross-sectional questionnaire study of women who had prior surgery for pelvic organ prolapse, 42% had current symptoms of prolapse.24
Recurrent pelvic organ prolapse most commonly involves the same anatomic site.32,109 In a cohort of women in the Pacific Northwest, the time interval between the first pelvic organ prolapse or urinary incontinence procedure and the second averaged 12.5 years.109
We know very little about why some women have a recurrence of their prolapse. The recurrence may be a surgical failure that is obvious at the first preoperative visit or one that recurs more slowly. The recurrence may be at a new site due to a deviation of the angle of the vagina from the surgery performed to correct the prolapse or incontinence. “Recurrence” may be identified at a new site because it was not recognized and corrected at the time of the original repair. Recurrence may occur due to a connective tissue defect in the patient including collagen or extracellular matrix defects. Alternatively, the recurrence may occur following the “lifetime” of the repair, similar to the lifespan of joint replacements.
Women who undergo prolapse surgery at a younger age have been found to be at risk for recurrence.32,110 The durability of a repair may expire sooner for women with a higher stage of prolapse. Whiteside et al. found that women who were operated on with a higher stage prolapse were more likely to have a recurrence within one year of the operation than women with a lesser degree of prolapse.110 Diez-Itza et al. found a correlation between anatomical recurrence at five years and preoperative stage of prolapse.32
The development of prolapse may be secondary to some specific identifiable risk factors. If the risk factors for the development of prolapse are recognized, some of them may be modifiable for the prevention of the development of prolapse or the development of recurrence.
Each woman with prolapse is an individual. She brings into the operating room many etiologic factors that led to the development of the primary posterior wall prolapse. Many of these risk factors may persist after the initial surgery including genetic predisposition, occupational exposures, and/or injured pelvic floor muscles. For example, while pregnancy and vaginal delivery appears to be the most significant factor in the development of pelvic organ prolapse, only 2.4% to 18% of nulliparous women develop prolapse.19,24 However, nulliparous women who undergo surgery may have less risk for recurrence.32 Once prolapse is corrected, the repaired vagina is nestled in an “intact” pelvic floor, which has not suffered the consequences of vaginal birth.
Identification of modifiable risk factors for recurrence should prompt targeted therapies for management of these factors including weight loss, smoking cessation, aggressive management of chronic lung disease, and constipation.
ER. Forecasting the prevalence of pelvic floor disorders in US women: 2010 to 2050. Obstet Gynecol.
AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol.
NS. Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct.
L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct.
JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol.
1992;166:1717–1724; discussion 1724–1728.CrossRef
JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol.
JO. Posterior compartment anatomy as seen in magnetic resonance imaging and 3-dimensional reconstruction from asymptomatic nulliparas. Am J Obstet Gynecol.
A, Larson Kindra
A, Fenner Dee
E, Delancey John
OL. Structural position of the posterior vagina and pelvic floor in women with and without posterior vaginal prolapse. Am J Obstet Gynecol. 2010;202:497.e1–497.e6.
JO. Levator defects affect perineal position independently of prolapse status. Am J Obstet Gynecol. 2010;203:595.e17–595.e22.
LA. Significant linkage evidence for a predisposition gene for pelvic floor disorders on chromosome 9q21. Am J Hum Genet.
MD. Recurrent pelvic organ prolapse in a woman with bladder exstrophy: a case report of surgical management and review of the literature. Int Urogynecol J Pelvic Floor Dysfunct.
RA. A “hyperextensive” review of Ehlers-Danlos syndrome. Cutis.
J. Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers-Danlos syndrome. Am J Obstet Gynecol.
KM. Use of porcine small intestinal submucosa in the surgical treatment of recurrent rectocele in a patient with Ehlers-Danlos syndrome type III. Int Urogynecol J Pelvic Floor Dysfunct.
et al. Joint hypermobility and rectal evacuatory dysfunction: an etiological link in abnormal connective tissue? Neurogastroenterol Motil.
J. Clinical study on collagen
and stress urinary incontinence. Clin Exp Obstet Gynecol.
A. Connective tissue alterations in women with pelvic organ prolapse and urinary incontinence. Acta Obstet Gynecol Scand.
DS. Pelvic organ prolapse in nulliparous women and their parous sisters. Obstet Gynecol.
M. Risk factors for pelvic organ prolapse repair after hysterectomy. Obstet Gynecol.
M. Incidence rate and risk factors for vaginal vault prolapse repair after hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct.
SH. Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. Am J Obstet Gynecol.
P, UK and Ireland TVT Trial Group. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up. BJOG.
M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. Int Urogynecol J.
S. The appearance of levatorani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol.
JO. Levator plate angle in women with pelvic organ prolapse compared to women with normal support using dynamic MR imaging. Am J Obstet Gynecol.
et al. Changes in levatorani muscle after vaginal hysterectomy and prolapse repair using the Total Prolift procedure. Int J Gynaecol Obstet.
et al. Comparison of levatorani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol.
JB. Risk factors for pelvic floor repair after hysterectomy. Obstet Gynecol.
PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am.
JN. Gender influence on defecographic abnormalities in patients with posterior pelvic floor disorders. World J Gastroenterol.
A. Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: a review at 5 years after surgery. Int Urogynecol J Pelvic Floor Dysfunct.
et al. Effect of weight change on natural history of pelvic organ prolapse. Obstet Gynecol.
et al. Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study. Int Urogynecol J Pelvic Floor Dysfunct.
A. Constipation and evacuation disorders. Best Pract Res Clin Gastroenterol.
PS. Rectocele repair. Four years’ experience. Dis Colon Rectum.
F. Clinical, physiological and radiological assessment of rectovaginal septum reinforcement with mesh for complex rectocele. Br J Surg.
HP. Rectocele or stool quality: what matters more for symptoms of obstructed defecation? Tech Coloproctol.
MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol.
et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol.
D. Reoperative Gynecologic Surgery. St. Louis, MO: Mosby Year Book, Inc.; 1981:104.
GW. The accuracy of clinical evaluation of posterior vaginal wall defects. Int Urogynecol J Pelvic Floor Dysfunct.
2003;14:160–163; discussion 163.CrossRef
et al. Imaging of obstructed defecation. Clin Radiol.
RD. A novel three-dimensional dynamic anorectal ultrasonography technique (echodefecography) to assess obstructed defecation, a comparison with defecography. Surg Endosc.
et al. MRI of pelvic floor dysfunction: dynamic true fast imaging with steady-state precession versus HASTE. AJR Am J Roentgenol.
G. Clinical relevance of transperineal ultrasound compared with evacuation proctography for the evaluation of patients with obstructed defaecation. Colorectal Dis.
JM. Magnetic resonance imaging of pelvic organ prolapse: comparing pubococcygeal and midpubic lines with clinical staging. Int Urogynecol J Pelvic Floor Dysfunct.
AG, van der Hulst
GJ. Correlation between posterior vaginal wall defects assessed by clinical examination and by defecography. Int Urogynecol J Pelvic Floor Dysfunct.
KB. Symptoms of pelvic floor dysfunction are poorly correlated with findings on clinical examination and dynamic MR imaging of the pelvic floor. Int Urogynecol J Pelvic Floor Dysfunct.
DL. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol.
PW. Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse. Obstet Gynecol.
et al. Pelvic floor symptom changes in pessary users. Am J Obstet Gynecol. 2007;197: 620.e1–620.e6.
RS. Prospective evaluation of outcome of vaginal pessaries versus surgery in women with symptomatic pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct.
K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol.
MD. Quality of life after surgery for genital prolapse in elderly women: obliterative and reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct.
P. Survey of current management of prolapse in Australia and New Zealand. Aust N Z J Obstet Gynaecol.
TN. Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw.
et al. Results of rectocele repair. Dis Colon Rectum.
SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol.
et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol.
et al. Cystodefecoperitoneography in patients with genital prolapse. Int Urogynecol J Pelvic Floor Dysfunct.
PJ. Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation. Obstet Gynecol.
PK. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol.
MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol.
MD. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol.
RC. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol.
1998;179:1451–1456; discussion 1456-1457.CrossRef
L. Outcome after rectovaginal fascia reattachment for rectocele repair. Am J Obstet Gynecol.
1999;181:1360–1363; discussion 1363-1364.CrossRef
MM. The anatomic and functional outcomes of defect-specific rectocele repairs. Am J Obstet Gynecol.
1999;181:1353–1358; discussion 1358-1359.CrossRef
H. A prospective study of the discrete fascial defect rectocele repair. Acta Obstet Gynecol Scand.
KM. Outcome of site-specific fascia repair for rectocele. Acta Obstet Gynecol Scand.
KC. Initial experience with rectocele repair using nonfrozen cadaveric fascia lata interposition. Urology.
2005;66: 1203–1207; discussion 1207–1208.CrossRef
et al. Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography. Int Urogynecol J.
MA. Functional outcome after transperineal rectocele repair with porcine dermal collagen
implant. Dis Colon Rectum.
M. Transperineal rectocele repair with polyglycolic acid mesh: a case series. Dis Colon Rectum.
2007;50:2085–2092; discussion 2092–2095.CrossRef
L. Controversies and uncertainties: abdominal versus vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol.
RB, GudovicAM, Babovic
MV. Transvaginal repair of genital prolapse with polypropylene mesh using a tension-free technique. Eur J Obstet Gynecol Reprod Biol.
A. Evaluation of a transvaginal mesh delivery system for the correction of pelvic organ prolapse: subjective and objective findings at least 1 year after surgery. Am J Obstet Gynecol.
R. Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse. Int Urogynecol J Pelvic Floor Dysfunct.
B. Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift technique)—a case series multicentric study. Int Urogynecol J Pelvic Floor Dysfunct.
TS. One-year outcome of concurrent anterior and posterior transvaginal mesh surgery for treatment of advanced urogenital prolapse: case series. J Minim Invasive Gynecol.
et al. Tension-free vaginal mesh procedure for pelvic organ prolapse: a single-center experience of 310 cases with 1-year follow up. Int J Urol.
et al. One-year clinical outcomes after prolapse surgery with nonanchored mesh and vaginal support device. Am J Obstet Gynecol.
B. Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study. Ultrasound Obstet Gynecol.
DS. Surgical outcomes following total Prolift: Colpopexy versus hysteropexy. Aust N Z J Obstet Gynaecol.
V, van Drie
M. Prolift+M Investigators. Trocar-guided mesh repair of vaginal prolapse using partially absorbably mesh; 1 year outcomes. Am J Obstet Gynecol.
ME. Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse. Int Urogynecol J Pelvic Floor Dysfunct.
et al. Vaginal Mesh for Prolapse: a randomized controlled trial. Obstet Gynecol.
et al. Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study. Int Urogynecol J Pelvic Floor Dysfunct.
A. Age and sexual activity are risk factors for mesh exposure following transvaginal mesh repair. Int Urogynecol J Pelvic Floor Dysfunct.
S. Rising use of synthetic mesh in transvaginal pelvic reconstructive surgery: a review of the risk of vaginal erosion. J Minim Invasive Gynecol.
et al. Risk factors for mesh/suture erosion following sacral colpopexy. Am J Obstet Gynecol.
et al. The influence of BMI, smoking, and age on vaginal erosions after synthetic mesh repair of pelvic organ prolapses. A multicenter study. Acta Obstet Gynecol Scand.
R, de Vita
E. Risk evaluation of smoking and age on the occurrence of postoperative erosions after transvaginal mesh repair for pelvic organ prolapses. Int Urogynecol J Pelvic Floor Dysfunct.
JY. Use of vaginal mesh in the face of recent FDA warnings and litigation. Am J Obstet Gynecol.
C. Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair. Obstet Gynecol.
D. Anatomical conditions for pelvic floor reconstruction with polypropylene implant and its application for the treatment of vaginal prolapse. Eur J Obstet Gynecol Reprod Biol.
D. Retrovesical haematoma after anterior Prolift procedure for cystocele correction. Int Urogynecol J Pelvic Floor Dysfunct.
CM. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2010;(4):CD004014.
W. Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation. World J Surg.
MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol.
MH. Sexual function in women after surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct.
JT. The effect of posterior colporrhaphy performed concurrently with midurethral sling surgery on the sexual function of women with stress urinary incontinence. Int Neurourol J.
A. A long-term review of posterior colporrhaphy with Vypro 2 mesh. Int Urogynecol J Pelvic Floor Dysfunct.
C. A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Int Urogynecol J Pelvic Floor Dysfunct.
2003;14:164–168; discussion 168.CrossRef
LA. Sexual function in women after rectocele repair with acellular porcine dermis graft vs site-specific rectovaginal fascia repair. Int Urogynecol J Pelvic Floor Dysfunct.
DH, van den Eeden
E. Pelvic organ prolapse surgery in the United States, 1997. Am J Obstet Gynecol.
LE, van den Eeden
JS. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol.
S. Surgical management of pelvic organ prolapse in women: a short version Cochrane review. Neurourol Urodyn.
R. Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol.
MD. Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol.
TA. Genesis of the vaginal profile: a correlated classification of vaginal relaxation. Clin Obstet Gynecol.