CHAPTER 24: Pelvic Organ Prolapse

Pelvic organ prolapse is a common condition that can lead to genital tract dysfunction and diminished quality of life. Signs include descent of one or more of the following: the anterior vaginal wall, posterior vaginal wall, uterus and cervix, vaginal apex, or the perineum (Haylen, 2010). Symptoms include vaginal bulging, pelvic pressure, and splinting or digitation. Splinting is manual bolstering of the prolapse to improve symptoms, whereas digitation aids stool evacuation. For pelvic organ prolapse to be considered a disease state in a given individual, symptoms should be attributable to pelvic organ descent such that surgical or nonsurgical reduction relieves the symptoms, restores function, and improves quality of life.

Pelvic organ prolapse (POP) affects millions of women worldwide. In the United States, it is the third most common indication for hysterectomy. Moreover, a woman has an estimated cumulative lifetime risk of 12 percent to undergo surgery for POP (Wu, 2014). Estimates of disease prevalence are hampered by lack of consistent definitions. If the validated Pelvic Organ Prolapse Quantification examination alone is used to describe pelvic organ support, 30 to 65 percent of women presenting for routine gynecologic care have stage 2 prolapse (Bland, 1999; Swift, 2000, 2005; Trowbridge, 2008). In contrast, studies that define prolapse solely based on patient symptoms show a prevalence ranging from 3 to 6 percent in the United States (Bradley, 2005; Nygaard, 2008; Rortveit, 2007).

Obstetric-related Risks

Table 24-1 summarizes predisposing factors for POP. It develops gradually over a span of years, and its etiology is multifactorial. The relative importance, however, of each factor is not known.

Of these, vaginal childbirth is the most frequently cited risk factor. Some evidence suggests that pregnancy itself predisposes to POP. But numerous studies have clearly shown that vaginal delivery increases a woman’s propensity for developing POP. In the Pelvic Organ Support Study (POSST), increasing parity was associated with prolapse risk (Swift, 2005). Specifically, the risk of POP increased 1.2 times with each vaginal delivery. In the Reproductive Risks for Incontinence Study at Kaiser (RRISK) study, Rortveit and colleagues (2007) found that the prolapse risk increased significantly in woman with one vaginal delivery (odds ratio [OR] 2.8), two (OR 4.1), or three or more (OR 5.3) deliveries compared with nulliparas. In a longitudinal study of 1011 women, vaginal delivery was associated with a significantly greater risk of prolapse to the hymen or beyond compared with cesarean delivery without labor (OR 5.6) (Handa, 2011).

Although vaginal delivery is implicated in a woman’s lifetime risk for POP, specific obstetric risk factors remain controversial. These include macrosomia, prolonged second-stage labor, episiotomy, anal sphincter laceration, epidural analgesia, forceps use, and oxytocin stimulation of labor. Each is a proposed risk factor. As we await further studies, we can anticipate that although each may have an important effect, it is the cumulative sum of all events occurring as the fetus traverses the birth canal that predisposes to POP.

Currently, two obstetric interventions—elective forceps delivery to shorten second-stage labor and elective episiotomy—are not advocated. Both lack evidence of benefit and carry risks for maternal and fetal harm. First, forceps delivery is directly implicated in pelvic floor injury through its association with anal sphincter laceration. Additionally, recent evidence shows that operative vaginal birth significantly increases the odds for all pelvic floor disorders, especially prolapse (OR 7.5) (Handa, 2011). For these reasons, elective forceps delivery is not recommended to prevent pelvic floor disorders and may be a contributing factor. Likewise, at least six randomized controlled trials (RCTs) comparing elective and selective episiotomy have shown no proven benefit. These studies have shown an association with anal sphincter laceration, postpartum anal incontinence, and postpartum pain (Carroli, 2009).

Elective cesarean delivery to prevent pelvic floor disorders such as POP and urinary incontinence is controversial. Theoretically, if all women underwent cesarean delivery, fewer women would have pelvic floor disorders. Keeping in mind that most women do not have these disorders, cesarean delivery on maternal request (CDMR) would subject many women to a potentially dangerous intervention who would otherwise not develop the problem. Specifically, given the 12-percent lifetime risk of undergoing surgery for prolapse, for every one woman who would avoid pelvic floor surgery later in life by undergoing primary elective cesarean delivery, approximately nine women would gain no benefit yet would nevertheless assume the potential risks of cesarean delivery. Definitive recommendations will require further studies to define the potential risks and benefits of CDMR for primary prevention of pelvic floor dysfunction (American College of Obstetricians and Gynecologists, 2013b; Patel, 2006). Currently, decisions regarding CDMR to prevent pelvic floor disorders must be individualized. That said, the American College of Obstetricians and Gynecologists (2013a) recommends against CMDR for women desiring several children given the risk of abnormal placentation with accruing cesarean deliveries.

Age

Data from several studies show that POP prevalence increases steadily with age (Nygaard, 2008; Olsen, 1997; Swift, 2005). In the POSST study, in women aged 20 to 59 years, the incidence of POP roughly doubled with each decade. As with other risks for POP, aging is a complex process. The increased incidence may result from physiologic aging and degenerative processes and from hypoestrogenism. Research clearly demonstrates an important role for reproductive hormones in the maintenance of connective tissues and the extracellular matrix necessary for pelvic organ support. Estrogen and progesterone receptors have been identified in the nuclei of connective tissue and smooth muscle cells of both the levator ani stroma and uterosacral ligaments (Smith, 1990, 1993). Separating the effects of estrogen deprivation from the effects of the aging process is problematic.

Connective Tissue Disease

Women with connective tissue disorders may be more likely to develop POP. Histologic studies have shown that in women with POP, the ratio of collagen I to collagen III and IV is decreased (Moalli, 2004). This relative decline in well-organized dense collagen is believed to contribute to weakening of vaginal wall tensile strength and an increased susceptibility to vaginal wall prolapse. In a small case series study, one third of women with Marfan syndrome and three fourths of women with Ehlers-Danlos syndrome reported a history of POP (Carley, 2000).

Race

Racial differences in POP prevalence have been demonstrated in several studies (Schaffer, 2005). Black and Asian women show the lowest risk, whereas Hispanic and white women appear to have the highest risk (Hendrix, 2002; Kim, 2005; Whitcomb, 2009). Although differences in collagen content have been demonstrated between races, racial differences in the bony pelvis may also play a role. For instance, black women more commonly have a narrow pubic arch and an android or anthropoid pelvis. These shapes are protective against POP compared with the gynecoid pelvis typical of most white women.

In addition, emerging evidence suggests that POP may have a genetic component. Recent genome-wide linkage studies have identified specific predisposition genes that may contribute to POP (Allen-Brady, 2015).

Increased Abdominal Pressure

Chronically elevated intraabdominal pressure is believed to play a role in POP pathogenesis. Elevated pressures are present with obesity, chronic constipation, chronic coughing, and repetitive heavy lifting. Higher body mass index (BMI) correlates with POP risk. In the Women’s Health Initiative (WHI) trial, being overweight (BMI 25 to 30 kg/m²) increased the POP rate by 31 to 39 percent, and obesity (BMI >30 kg/m²) raised the POP rate 40 to 75 percent (Hendrix, 2002). With regard to lifting, a Danish study demonstrated that nursing assistants who were involved with repetitive heavy lifting were at increased risk to undergo surgical intervention for prolapse (OR 1.6) (Jorgensen, 1994). In addition, cigarette smoking and chronic obstructive pulmonary disease (COPD) have also been implicated in POP development (Gilpin, 1989; Olsen, 1997). In a matched case-control study, COPD was associated with an increased risk of future pelvic floor repair after hysterectomy (Blandon, 2009). The repetitive increases in intraabdominal pressure resulting from chronic coughing may predispose to POP. Instead, some believe that the inhaled chemical compounds in tobacco may cause tissue changes that lead to POP rather than the chronic cough itself (Wieslander, 2005).

Visual Descriptors

Pelvic organ prolapse is descent of the anterior vaginal wall, posterior vaginal wall, uterus (cervix), the vaginal apex after hysterectomy, rectum, or the perineum, alone or in combination. The terms cystocele, cystourethrocele, uterine prolapse, uterine procidentia, rectocele, and enterocele have traditionally been used to describe the structures behind the vaginal wall thought to be prolapsed (Fig. 24-1). However, these terms are imprecise and misleading, as they focus on what is presumed to be prolapsed rather than what is objectively noted to be prolapsed.

Although these terms are deeply entrenched in the literature, it is more clinically useful to describe prolapse in terms of what one actually sees: anterior vaginal wall prolapse, apical prolapse, cervical prolapse, posterior vaginal wall prolapse, rectal prolapse, or perineal descent.

Pelvic Organ Prolapse Quantification (POP-Q)

In 1996, the International Continence Society defined a system of Pelvic Organ Prolapse Quantification (POP-Q) (Bump, 1996). Demonstrating high intra- and interexaminer reliability, the POP-Q system allows clinicians and researchers to report findings in a standardized, easily reproducible fashion. This system contains a series of site-specific measurements of a woman’s pelvic organ support. Prolapse in each segment is measured relative to the hymen, which is an anatomic landmark that can be identified consistently. Six points are located with reference to the plane of the hymen: two on the anterior vaginal wall (points Aa and Ba), two at the apical vagina (points C and D), and two on the posterior vaginal wall (points Ap and Bp) (Fig. 24-2). The genital hiatus (Gh), perineal body (Pb), and total vaginal length (TVL) are also measured. All POP-Q points, except TVL, are measured during patient Valsalva and should reflect maximum protrusion.

Anterior Vaginal Wall Points

Point Aa defines a point that lies in the midline of the anterior vaginal wall and is 3 cm proximal to the external urethral meatus. This corresponds to the proximal location of the urethrovesical crease. In relation to the hymen, this point’s position ranges from –3 (normal support) to +3 cm (maximum prolapse of point Aa).

Point Ba represents the most distal position of any part of the upper anterior vaginal wall, that is, the segment of vagina that normally would extend cephalad from point Aa. It is –3 cm in the absence of prolapse. In a woman with total vaginal eversion posthysterectomy, Ba would have a positive value equal to the position of the cuff from the hymen.

Apical Vaginal Points

The two apical points, C and D, which are located in the proximal vagina, represent the most cephalad locations of a normally positioned lower reproductive tract. Point C defines a point that is at either the most distal edge of the cervix or the leading edge of the vaginal cuff after total hysterectomy.

Point D defines a point that represents the location of the posterior fornix in a woman who still has a cervix. It is omitted in the absence of a cervix. This point represents the level of uterosacral ligament attachment to the proximal posterior cervix and thus differentiates uterosacral-cardinal ligament support failure from cervical elongation. The total vaginal length (TVL) is the greatest depth of the vagina in centimeters when point C or D is reduced to its fullest position.

Posterior Vaginal Wall Points

Point Ap defines a point in the midline of the posterior vaginal wall that lies 3 cm proximal to the hymen. Relative to the hymen, this point’s range of position is by definition –3 (normal support) to +3 cm (maximum prolapse of point Ap).

Point Bp represents the most distal position of any part of the upper posterior vaginal wall. By definition, this point is at –3 cm in the absence of prolapse. In a woman with total vaginal eversion posthysterectomy, Bp would have a positive value equal to the position of the cuff from the hymen.

Genital Hiatus and Perineal Body

In addition to the hymen, remaining measurements include those of the genital hiatus (Gh) and the perineal body (Pb) (see Fig. 24-2). The genital hiatus is measured from the middle of the external urethral meatus to the midline of the posterior hymenal ring. The perineal body is measured from the posterior margin of the genital hiatus to the midanal opening.

Assessment with POP-Q

With the hymenal plane defined as zero, the anatomic position of these points from the hymen is measured in centimeters. Points above or proximal to the hymen are described with a negative number. Positions below or distal to the hymen are noted using a positive number. The point measurements can be organized using a three-by-three grid as shown in Figure 24-3. Figures 24-4 and 24-5 illustrate the use of POP-Q in evaluating different examples of POP.

The degree of prolapse can also be quantified using a five-stage ordinal system as summarized in Table 24-2 (Bump, 1996). Stages are assigned according to the most severe portion of the prolapse.

Baden-Walker Halfway System

This descriptive tool is also used to classify prolapse during physical examination and is widely used. Although not as informative as the POP-Q, it is adequate for clinical use if each compartment (anterior, apical, and posterior) is evaluated (Table 24-3) (Baden, 1972).

Pelvic organ support is maintained by complex interactions among the pelvic floor muscles, pelvic floor connective tissue, and vaginal wall. These work in concert to provide support and also maintain normal physiologic function of the vagina, urethra, bladder, and rectum. Several factors are implicated in failure of this support, but none fully explain its pathogenesis. These include genetic predisposition, loss of pelvic floor striated muscle support, vaginal wall weakness, and loss of connective attachments between the vaginal wall and the pelvic floor muscles and pelvic viscera. As noted earlier, vaginal birth and aging are two major risk factors for POP (Mant, 1997). The loss of support that evolves decades after vaginal delivery may stem from an initial insult compounded by aging and other contributors.

Levator Ani Muscle

The levator ani muscle is a pair of striated muscles composed of three regions. The iliococcygeus muscle forms a flat horizontal shelf spanning from one pelvic sidewall to the other (Figs. 38-7 and 38-8). The pubococcygeus muscle arises from the pubic bone on either side; is attached to the walls of the vagina, urethra, anus, and perineal body; and inserts on the coccyx. The pubococcygeus muscle thereby helps suspend the vaginal wall to the pelvis. The puborectalis muscle forms a sling that originates from the pubic bone. This wraps around and behind the rectum. Connective tissue covers the superior and inferior fascia of the levator ani muscle. In the healthy state, baseline resting contractile activity of the levator ani muscle elevates the pelvic floor and compresses the vagina, urethra, and rectum toward the pubic bone (Fig. 38-10). This narrows the genital hiatus and prevents prolapse of the pelvic organs.

When the levator ani muscle has normal tone and the vagina has adequate depth, the upper vagina lies nearly horizontal in the standing female. Thus, during periods of increased intraabdominal pressure, the upper vagina is compressed against the levator plate. It is theorized that when the levator ani muscle loses tone, the vagina drops from a horizontal to a semivertical position (Fig. 38-11). This widens or opens the genital hiatus and predisposes pelvic viscera to prolapse. Without adequate levator ani muscle support, the visceral fascial attachments of the pelvic contents are placed on tension and are thought to stretch and eventually fail.

Theoretically, the levator ani muscle may sustain either direct muscle or denervation injury during childbirth, and these injuries are involved in POP pathogenesis. During second-stage labor, nerve injury from stretch or compression or both is believed to partially denervate the levator ani muscle. Denervated muscle loses tone, the genital hiatus opens, and pelvic viscera prolapse (DeLancey, 1993; Peschers, 1997; Shafik, 2000).

The experimental evidence for this theory of denervation-induced injury leading to POP has been difficult to obtain and is contradictory. Some studies demonstrate histomorphologic abnormalities in the levator ani muscle from women with prolapse and stress incontinence, whereas other studies fail to find histologic evidence of levator ani muscle denervation (Gilpin, 1989; Hanzal, 1993; Heit, 1996; Koelbl, 1989). In addition, levator ani muscle biopsies obtained from parous and nulliparous cadavers failed to find evidence of atrophy or other important muscle changes (Boreham, 2009). This suggests that pregnancy and parturition have little or no effect on levator ani muscle histomorphology. Additionally, experimental denervation of the levator ani muscle in the squirrel monkey led to significant muscular atrophy but did not affect pelvic organ support. Taken together, experimental evidence does not support a role for denervation-induced injury in POP pathophysiology.

Importantly, however, loss of skeletal muscle volume and function occurs in virtually all striated muscles during aging. Results obtained from young and older women with POP indicate that the levator ani muscle undergoes substantial morphologic and biochemical changes during aging. Thus, loss of levator tone with age may contribute to pelvic organ support failure in older women, possibly those with preexisting defects in connective tissue support. As striated muscles lose tone, ligamentous and connective tissue support of the pelvic organs must sustain more forces conferred by abdominal pressure. As connective tissues bear these loads for long periods, they stretch and may eventually fail, resulting in prolapse.

Connective Tissue

A continuous interdependent system of connective tissues and ligaments surrounds the pelvic organs and attaches them to the levator ani muscle and bony pelvis. The connective tissue of the pelvis is comprised of collagen, elastin, smooth muscle, and microfibers, which are anchored in an extracellular matrix of polysaccharides. The connective tissue that invests the pelvic viscera provides substantial pelvic organ support.

Of these, the arcus tendineus fascia pelvis is a condensation of parietal fascia covering the medial aspects of the obturator internus and levator ani muscle (Fig. 38-7). It provides the lateral and apical anchor sites for the anterior and posterior vagina. The arcus tendineus fascia pelvis is therefore poised to withstand descent of the anterior vaginal wall, vaginal apex, and proximal urethra. Experts now believe that a major inciting factor for prolapse is loss of connective tissue support at the vaginal apex leading to stretching or tearing of the arcus tendineus fascia pelvis. The result is apical and anterior vaginal wall prolapse.

The uterosacral ligaments contribute to apical support by suspending and stabilizing the uterus, cervix, and upper vagina. The ligament contains approximately 20 percent smooth muscle. Several studies have shown a decrease in the fractional area and distribution of smooth muscle in the uterosacral ligaments of women with prolapse (Reisenauer, 2008; Takacs, 2009). These studies suggest that abnormalities in uterosacral ligament support of the pelvic organs contribute to prolapse development.

Abnormalities of connective tissue and connective tissue repair may predispose women to prolapse (Norton, 1995; Smith, 1989). As noted, women with connective tissue disorders such as Ehlers-Danlos or Marfan syndrome are more likely to develop POP and urinary incontinence (Carley, 2000; Norton, 1995).

The pelvic floor fascia and connective tissues may also lose strength consequent to aging and loss of neuroendocrine signaling in pelvic tissues (Smith, 1989). Estrogen deficiency can affect the biomedical composition, quality, and quantity of collagen. Estrogen influences collagen content by increasing synthesis or decreasing degradation. Exogenous estrogen supplementation has been found to increase the skin collagen content in postmenopausal women who are estrogen deficient (Brincat, 1983). Moreover, estrogen supplementation prior to prolapse surgery and/or postoperatively is considered essential by many pelvic reconstruction surgeons. In a systematic review, Rahn and coworkers (2015) found that vaginal estrogen application before POP surgery improved the vaginal maturation index and increased vaginal epithelial thickness. This suggests a possible role in healing and future support. Although this practice may seem logical and empirically sound, evidence does not yet show improved surgical outcomes with this use of adjuvant estrogen.

Vaginal Wall

Abnormalities in the vaginal wall and its attachments to the pelvic floor muscles may be involved in POP pathogenesis. The vaginal wall is composed of mucosa (epithelium and lamina propria), a fibroelastic muscularis layer, and an adventitial layer that is made up of loose areolar tissue, abundant elastic fibers, and neurovascular bundles (Fig. 24-6). The muscularis and adventitial layers together form the fibromuscular layer, which was previously referred to as “endopelvic fascia.” The fibromuscular layer coalesces laterally and attaches to the arcus tendineus fascia pelvis and superior fascia of the levator ani muscle. In the lower third of the vagina, the vaginal wall is attached directly to the perineal membrane and the perineal body. This suspensory system, together with the uterosacral ligaments, prevents the vagina and uterus from descent when the genital hiatus is open.

Abnormalities in the anatomy, physiology, and cellular biology of vaginal wall smooth muscle may contribute to POP. Specifically, in fibromuscular tissue taken at the vaginal apex from both the anterior and posterior vaginal walls, vaginal prolapse is associated with loss of smooth muscle, myofibroblast activation, abnormal smooth muscle phenotype, and increased protease activity (Boreham, 2001, 2002a,b; Moalli, 2005; Phillips, 2006). Additionally, abnormal synthesis or degradation of vaginal wall collagen and elastin fibers appears to contribute to prolapse.

The Defect Theory of Pelvic Organ Prolapse

This theory states that tears in different sites of the “endopelvic fascia” surrounding the vaginal wall allow herniation of the pelvic organs. Specifically, attenuation of the vaginal wall without loss of fascial attachments is called a distention cystocele or rectocele (Fig. 24-7). With distention-type prolapse, the vaginal wall appears smooth and without rugae, due to abdominal contents pressed against the vagina from within. In contrast, anterior and posterior wall defects due to loss of the connective tissue attachment of the lateral vaginal wall to the pelvic sidewall are described as displacement (paravaginal) cystocele or rectocele (Fig. 24-8). With displacement-type prolapse, vaginal rugae are visible. Both defect types could result from the stretching or tearing of support tissues during second-stage labor.

Many experts now believe the primary defect leading to prolapse is loss of support at the vaginal apex. This allows the apical portions of the anterior and posterior vaginal walls to descend. As such, resuspension of the vaginal apex will restore support to both the anterior and posterior walls.

Levels of Vaginal Support

The vagina is a fibromuscular, flattened, cylindrical tube with three levels of support, as described by DeLancey (1992). Level I support suspends the upper or proximal vagina. Level II support attaches the midvagina along its length to the arcus tendineus fascia pelvis. Level III support results from fusion of the distal vagina to adjacent structures. Defects in each level of support result in identifiable vaginal wall prolapse: apical, anterior, and posterior.

Level I support consists of the cardinal and uterosacral ligaments attachment to the cervix and upper vagina (Fig. 38-15). The cardinal ligaments fan out laterally and attach to the parietal fascia of the obturator internus and piriformis muscles, the anterior border of the greater sciatic foramen, and the ischial spines. The uterosacral ligaments are posterior fibers that attach to the presacral region at the level of S2 through S4. Together, this dense visceral connective tissue complex maintains vaginal length and horizontal axis. It allows the vagina to be supported by the levator plate and positions the cervix just superior to the level of the ischial spines. Defects in this support complex may lead to apical prolapse. This is frequently associated with small bowel herniation into the vaginal wall, that is, enterocele.

Level II support consists of the paravaginal attachments that are contiguous with the cardinal/uterosacral complex at the ischial spine. These are the connective tissue attachments of the lateral vagina anteriorly to the arcus tendineus fascia pelvis and posteriorly to the arcus tendineus rectovaginalis. Detachment of this connective tissue from the arcus tendineus fascia pelvis leads to lateral or paravaginal anterior vaginal wall prolapse.

Level III support is composed of the perineal body, superficial and deep perineal muscles, and fibromuscular connective tissue. Collectively, these support the distal one third of the vagina and introitus. The perineal body is essential for distal vaginal support and proper function of the anal canal. Damage to level III support contributes to anterior and posterior vaginal wall prolapse, gaping introitus, and perineal descent.

Symptoms

Pelvic organ prolapse involves multiple anatomic and functional systems and is commonly associated with genitourinary, gastrointestinal, and musculoskeletal symptoms (Table 24-4). Prolapse rarely creates severe morbidity or mortality, however, it can greatly diminish quality of life. In contrast, many women with mild to advanced prolapse lack bothersome symptoms. Thus, initial evaluation must include a careful assessment of prolapse-related symptoms and their effect on activities of daily living.

Symptoms are carefully reviewed to determine if they are caused by the prolapse or by other etiologies. “Bulge” symptoms, which are pelvic pressure, the feeling of sitting on a ball, or heaviness in the vagina, are most likely to correlate with prolapse. Other symptoms, such as back pain, constipation, and abdominal discomfort, may coexist with prolapse but not result from it. A thorough history and physical examination will often help delineate the relationship between POP and symptoms.

During symptom inventory, several tools may be useful in assessing severity. Two commonly used questionnaires are the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) (Barber, 2005b). The PFDI assesses urinary, colorectal, and prolapse symptoms, whereas the PFIQ seeks a diminished quality of life due to prolapse (Tables 24-5 and 24-6).

Bulge symptoms most strongly correlate with POP. These are typified by feeling or seeing a vaginal or perineal protrusion, and the sensation of pelvic pressure. Women may comment on feeling a ball in the vagina, sitting on a weight, or noting a bulge rubbing against their clothes. These symptoms worsen with prolapse progression (Ellerkmann, 2001). Specifically, women with prolapse beyond the hymen are more likely to report a vaginal bulge and have more symptoms than those with prolapse that stops above the hymen (Bradley, 2005; Tan, 2005; Weber, 2001a). If bulge symptoms are the primary complaint, successful replacement of the prolapse with nonsurgical or surgical therapy will usually provide adequate symptom relief.

Urinary symptoms often accompany POP and may include stress urinary incontinence (SUI), urgency urinary incontinence, frequency, urgency, urinary retention, recurrent urinary tract infection, or voiding dysfunction. Although these symptoms may be caused or exacerbated by POP, it should not be assumed that surgical or nonsurgical correction of prolapse will be curative. For example, irritative bladder symptoms (frequency, urgency, and urgency urinary incontinence) may not improve with prolapse replacement. Moreover, they may be unrelated to the prolapse and require alternative therapy. In contrast, urinary retention has been found to improve with prolapse treatment if the symptom is due to an obstructed urethra (FitzGerald, 2000).

For these reasons, urodynamic testing is a valuable adjunct in women with urinary symptoms who are undergoing treatment of prolapse (Chap. 23). This testing attempts to determine the relationship between urinary symptoms and POP and will help guide therapy. Additionally, consideration may also be given to temporarily placing a pessary prior to surgery to determine if urinary symptoms improve. This may predict whether surgical reduction of prolapse will be beneficial.

Constipation is often present in women with POP, although it is generally not caused by POP. Thus, surgical repair or treatment with a pessary will not usually cure constipation and may actually worsen it. In one study of defect-directed posterior repair, constipation resolved postoperatively in only 43 percent of patients (Kenton, 1999). Therefore, if a patient’s primary symptom is constipation, treatment of prolapse may not be indicated. Constipation should be viewed as a problem distinct from prolapse and evaluated separately.

Digital decompression of the posterior vaginal wall, the perineal body, or the distal rectum to evacuate the rectum is the most common defecatory symptom associated with posterior vaginal wall prolapse (Burrows, 2004; Ellerkmann, 2001). Surgical approaches to this problem provide variable success, and symptom resolution rates range from 36 to 70 percent (Cundiff, 2004; Kenton, 1999).

Anal incontinence of flatus, liquid, or solid stool may also associate with POP. On occasion, prolapse may lead to stool trapping in the distal rectum with subsequent leakage of liquid stool around retained feces. If symptoms are present, a full anorectal evaluation is performed (Chap. 25). Most types of anal incontinence would not be expected to improve with surgical repair of prolapse. However, if evaluation reveals an anal sphincter defect as the cause of anal incontinence, anal sphincteroplasty may be performed concurrently with prolapse repair.

Female sexual dysfunction is present in women with dyspareunia, low libido, problems with arousal, and inability to achieve orgasm. The etiology is frequently multifactorial and includes psychosocial factors, urogenital atrophy, aging, and male sexual dysfunction. Sexual dysfunction is often also seen in women with POP. However, findings from studies evaluating sexual function in women with prolapse are inconsistent. In one study, a validated sexual function questionnaire was used to compare frequency of intercourse, libido, dyspareunia, orgasmic function, and vaginal dryness in women with and without prolapse (Weber, 1995). No differences were seen between the two groups. In another cross-sectional study of 301 women, pelvic floor symptoms were associated with dyspareunia, reduced arousal, and infrequent orgasm (Handa, 2008). In addition, sexual dysfunction was worse in women with symptomatic prolapse versus those with asymptomatic prolapse. In another study of sexual function in women with prolapse, decreased activity was associated with decreased vaginal length, and one quarter of women avoided sexual activity due to pelvic floor symptoms (Edenfield, 2015). Accordingly, women with an obstructing bulge as a cause of sexual dysfunction may benefit from therapy to reduce the prolapse. Unfortunately, some prolapse procedures such as posterior repair with levator plication and vaginal placement of mesh may contribute to postoperative dyspareunia. Therefore, care is taken in planning appropriate surgical procedures for women with concomitant sexual dysfunction (Ulrich, 2015).

Pelvic and back pain is another complaint in women with POP, but little evidence supports a direct association. A cross-sectional study of 152 consecutive patients with POP did not find an association between pelvic or low back pain and prolapse after controlling for age and prior surgery (Heit, 2002). Swift and colleagues (2003) found that back and pelvic pain were common among 477 women presenting for routine annual gynecologic examination and had no relationship to POP. Some suggest that low back pain in a patient with prolapse may be caused by altered body mechanics. However, if pain is a primary symptom, other sources should be sought (Chap. 11). In the absence of an identifiable etiology, temporary pessary placement is considered to determine whether prolapse reduction will improve pain symptoms. Referral to a physical therapist may also shed light on a connection among prolapse, altered body mechanics, and pain.

Importantly, although POP is associated with varied complaints, symptoms and their severity do not always correlate well with advancing stages of prolapse. In addition, many common symptoms do not differentiate between compartments (Jelovsek, 2005; Kahn, 2005; Weber, 1998). Thus, when planning surgical or nonsurgical therapy, realistic expectations should be set with regard to symptom relief. A patient is informed that symptoms directly related to prolapse such as vaginal bulge and pelvic pressure are likely to improve with a successful anatomic repair. However, other associated symptoms such as constipation, back pain, and urinary urgency and frequency may or may not improve.

Physical Examination

Perineal Examination

Physical examination begins with a full body systems evaluation to identify pathology outside the pelvis. Systemic conditions such as cardiovascular, pulmonary, renal, or endocrinologic disease may affect treatment choices and should be identified early.

The initial pelvic examination is performed with a woman in lithotomy position. The vulva and perineum are examined for signs of vulvar or vaginal atrophy or other abnormalities. A neurologic examination of sacral reflexes is performed using a cotton swab. First, the bulbocavernosus reflex is elicited by tapping or stroking lateral to the clitoris and observing contraction of the bulbocavernosus muscle bilaterally. Second, evaluation of anal sphincter innervation is completed by stroking lateral to the anus and observing a reflexive contraction of the anus, known as the anal wink reflex. Intact reflexes suggest normal sacral pathways. However, they can be absent in women who are neurologically intact.

POP examination begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina (Fig. 24-9). Patients who are unable to adequately complete a Valsalva maneuver are asked to cough. This “hands-off” approach more accurately displays true anatomy. Namely, with speculum examination, structures are artificially lifted, supported, or displaced. Importantly, this assessment helps answer three questions: (1) Does the protrusion come beyond the hymen? (2) What is the presenting part of the prolapse (anterior, posterior, or apical)? (3) Does the genital hiatus significantly widen with increased intraabdominal pressure?

During examination, a clinician verifies that the full extent of the prolapse is being seen. Specifically, a woman is asked to describe the extent of prolapse beyond the hymen during real-life activities. This degree may be conveyed in terms of inches. Alternatively, a mirror may be placed at the perineum and visual confirmation can be obtained from the patient.

Prolapse is a dynamic condition that responds to the effects of gravity and intraabdominal pressure. It frequently worsens over the course of a day or during physical activity. Thus, prolapse might not be evident during office examination early in the morning. If the full extent of prolapse cannot be demonstrated, a woman should be examined in a standing position and during Valsalva maneuver.

Vaginal Examination

If the POP-Q examination is performed, the genital hiatus (Gh) and perineal body (Pb) are measured during Valsalva maneuver (Fig. 24-10). The total vaginal length (TVL) is then measured by placing a marked ring forceps, or a ruler, at the vaginal apex and noting the distance to the hymen. A bivalve speculum is then inserted to the vaginal apex. It displaces the anterior and posterior vaginal walls, and points C and D are then measured with Valsalva. The speculum is slowly withdrawn to assess descent of the apex.

A split speculum is then used to displace the posterior vaginal wall and allow for viewing of the anterior wall and measurement of points Aa and Ba. Attempts are made to characterize the anterior vaginal wall defect. Sagging lateral vaginal sulci with vaginal rugae still present suggest a paravaginal defect, that is, a lateral loss of support (Fig. 24-11). A central bulge and loss of vaginal rugae is called a midline or central defect (see Fig. 24-7). If loss of support appears to arise from detachment of the anterior vaginal wall’s apical segment, it is termed a transverse or anterior apical defect (Fig. 24-12). Transverse defects are assessed by replacing the anterior apical segment and observing whether the prolapse descends during Valsalva maneuver. The urethra is also evaluated during anterior vaginal wall assessment, and Q-tip testing can be performed to determine urethral hypermobility (Chap. 23).

The split speculum is then rotated 180 degrees to displace the anterior wall and allow examination of the posterior wall. Points Ap and Bp are measured (Fig. 24-13). If the posterior vaginal wall descends, attempts are made to determine if rectocele or enterocele is present. Enterocele can only definitively be diagnosed by observing small bowel peristalsis behind the vaginal wall (Fig. 24-14). In general, bulges at the apical segment of the posterior vaginal wall should implicate enteroceles, whereas bulges in the distal posterior wall are presumed to be rectoceles. Further distinction may be found during standing rectovaginal examination. With this, a clinician’s index finger is placed in the rectum and thumb on the posterior vaginal wall. Small bowel may be palpated between the rectum and vagina, confirming enterocele.

Differentiation of midline, lateral, apical, and distal defects of the anterior and posterior vaginal walls has not been shown to have good inter- or intraexaminer reliability. However, individual evaluation may help assess prolapse severity and clarify anatomy if surgical correction is planned (Barber, 1999; Whiteside, 2004).

As mentioned, apical prolapse is believed to be the cause of most anterior and posterior wall descent. Therefore, careful attention is paid to the relationship of the apex to these structures. The apex should be replaced to its normal position. If this maneuver restores anterior and posterior support, it can be determined that the primary defect is at the apex.

Bimanual examination is performed to identify other pelvic pathology. In addition, we strongly recommend assessment of pelvic floor musculature (Fig. 11-5). This examination is essential if pelvic floor rehabilitation is being considered as treatment. During part of the evaluation, an index finger is placed 1 to 3 cm inside the hymen, at 4 and then 8 o’clock (Fig. 24-15). Muscle resting tone and strength is assessed using the 0 through 5 Oxford grading scale, in which 5 represents normal tone and strength (Laycock, 2002). Muscle symmetry is also evaluated. Asymmetric muscles, with palpable defects or scarring, may be associated with a prior obstetric forceps delivery, episiotomy, or laceration.

For women who are asymptomatic or mildly symptomatic, expectant management is appropriate. It is difficult to predict if prolapse will worsen or if symptoms will develop. In this situation, benefits of treatment are balanced against risks. Therefore, in the absence of other factors, invasive therapy is typically not selected for asymptomatic women. Pelvic floor muscle rehabilitation may be offered to a patient seeking to prevent prolapse progression. However, no data support the effectiveness of this practice (Hagen, 2011).

For women with significant prolapse or for those with bothersome symptoms, nonsurgical or surgical therapy may be selected. Treatment choice depends on the type and severity of symptoms, age and medical comorbidities, desire for future sexual function and/or fertility, and risk factors for recurrence. Treatment goals strive to provide symptom relief, but therapy benefits should always outweigh risks.

Often a combination of nonsurgical and surgical approaches may be selected. Symptoms are ranked by severity, and options for each are discussed. An evidence-based appraisal of each option’s success rate is included. In the simplest case, a patient with prolapse of the vaginal apex beyond the hymen, whose only symptom is bulge or pelvic pressure, could be offered pessary or surgical treatment. In a more complicated case, a woman with prolapse beyond the hymenal ring may note a bulge, constipation, urgency urinary incontinence, and pelvic pain. Symptoms would be ranked by severity and importance of resolution. To address all complaints, therapy might involve pessary or surgery for bulge symptoms, and nonsurgical treatment of constipation, incontinence, and pelvic pain.

Pessary

Pessary Indications

Throughout history, various vaginal devices and materials have been used to physically support vaginal prolapse. Today’s pessaries are usually made of silicone or inert plastic, and they are safe and simple to manage. Despite a long history of use, literature describing their indications, selection, and management is often anecdotal or contradictory.

The most common indication for vaginal pessary is POP. Traditionally, pessaries have been reserved for women either unfit or unwilling to undergo surgery. A survey of the American Urogynecologic Society (AUGS) membership confirmed this sentiment among gynecologists with more than 20 years in practice (Cundiff, 2000). However, the same survey showed that younger gynecologists, particularly those who described themselves as urogynecologists, used pessaries as a first-line therapy before recommending surgery.

Of other indications, pessaries may also help some women with prolapse and associated urinary incontinence. One RCT compared two pessary types for relief of prolapse symptoms and urinary complaints. This study demonstrated that pessaries provide a modest improvement in urinary obstructive, irritative, and stress symptoms (Chap. 23) (Schaffer, 2006).

Pessaries may also be used diagnostically. As previously discussed, symptoms may not correlate with the type or severity of prolapse. Short-term pessary use may help clarify this relationship. Even if a patient declines long-term pessary use, she may agree to a short trial to determine if her chief complaint is improved or resolved. A pessary may also be placed diagnostically to identify which women are at risk for urinary incontinence after prolapse-correcting surgery (Chaikin, 2000; Liang, 2004).

Pessary Selection

Pessaries are divided into two broad categories: support and space-filling (Fig. 24-16). Support pessaries, such as the ring pessary, use a spring mechanism that rests in the posterior fornix and against the posterior aspect of the symphysis pubis. Vaginal support results from elevation of the superior vagina by the spring, which is supported by the symphysis pubis. Ring pessaries may be constructed as a simple circular ring or as a ring with support that looks like a large contraceptive diaphragm (Fig. 24-17). These are effective in women with first- and second-degree prolapse. Also, the diaphragm portion of a support ring is especially useful in women with accompanying anterior vaginal wall prolapse. When properly fitted, the device should lie behind the pubic symphysis anteriorly and behind the cervix posteriorly.

In contrast, space-filling pessaries maintain their position by creating suction between the pessary and vaginal walls (cube), by creating a diameter larger than the genital hiatus (donut), or by both mechanisms (Gellhorn). The Gellhorn is often used for moderate to severe prolapse and for complete procidentia. It contains a concave disc that fits against the cervix or vaginal cuff and has a stem that is positioned just cephalad to the introitus. The concave disc supports the vaginal apex by creating suction, and the stem is useful for device removal. Of all pessaries, the two most commonly used and studied devices are the ring and the Gellhorn pessaries.

Patient Evaluation and Pessary Placement

A patient must be an active participant in the treatment decision to use a pessary. Its success will depend upon her ability to care for the pessary—either alone or with the assistance of a caregiver—and her willingness and availability to come for subsequent evaluations. Vaginal atrophy should be treated before or concomitantly with pessary initiation. In women who are suitable candidates for estrogen therapy, vaginal estrogen cream is recommended (Table 22-5). In one regimen, 1 g of conjugated equine estrogen cream (Premarin cream) is inserted nightly for 2 weeks, then two times per week thereafter.

Device selection integrates patient factors such as hormonal status, sexual activity, prior hysterectomy, and stage and site of POP. After a pessary is chosen, a woman is fitted with the largest size that can be comfortably worn. If a pessary is ideally fitted, a patient is not aware of its presence. As a woman ages and gains or loses weight, alternate sizes may be required.

Generally, a patient is fitted with a pessary while in the lithotomy position after she has emptied both her bladder and rectum. A digital examination is performed to assess vaginal length and width, and an initial estimation of pessary size is made. Figure 24-18 shows Gellhorn pessary placement. For ring pessary placement, the device is held in the clinician’s dominant hand in a folded position. Lubricant is placed on either the vaginal introitus or the pessary’s leading edge. While holding the labia apart, the pessary is inserted by pushing in a cephalad direction and against the posterior vaginal wall. Next, an index finger is directed into the posterior vaginal fornix to ensure that the cervix is resting above the pessary. The clinician’s finger should barely slide between the lateral edges of the ring pessary and the vaginal sidewall. The pessary should fit snugly but not tightly against the symphysis pubis and the posterior and lateral vaginal walls. Too much pressure may increase the risk for pain.

Following pessary placement, a woman is prompted to perform a Valsalva maneuver, which might dislodge an improperly fitted pessary. She should be able to stand, walk, cough, and urinate without difficulty or discomfort. Instruction on removal and placement then follows. For removal of a ring pessary, an index finger is inserted into the vagina to hook the ring’s leading edge. Traction is applied along the vaginal axis to bring the ring toward the introitus. Here, it may be grasped by the thumb and index finger and removed.

Ideally, a pessary is removed nightly to weekly, washed in soap and water, and replaced the next morning. Women also receive instructions describing the management of commonly encountered problems (Table 24-7). After initial placement, a return visit may follow in 1 to 2 weeks. For patients comfortable with their pessary management, return visits may be semiannual. If the patient and the provider are motivated, most women can be taught to self-manage a pessary. For those unable or unwilling to remove and replace a device themselves, a pessary may be removed and the patient’s vagina inspected at the provider’s office every 2 or 3 months. Delaying visits longer than this may lead to problematic discharge and odor.

Pessary Complications

Serious complications such as erosion into adjacent organs are rare with proper use and usually result only after years of neglect. At each return visit, the pessary is removed, and the vagina is inspected for erosions, abrasions, ulcerations, or granulation tissue (Fig. 24-19). Vaginal bleeding is usually an early sign and should not be ignored. Pessary ulcers or abrasions are treated by changing the pessary type or size to alleviate pressure points or by removing the pessary completely until healed. Treatment of vaginal atrophy with local estrogen is commonly required. Alternatively, water-based lubricants applied to the pessary may help prevent these complications. Prolapse ulcers have the same appearance as pessary ulcers, however, the former result from the prolapsed bulge rubbing against patient clothing. These are treated by replacing the prolapse either with a pessary or by surgery.

Pelvic pain with pessary use is not normal. This usually indicates that the size is too large, and a smaller pessary would be more suitable. All pessaries tend to trap vaginal secretions and obstruct normal drainage to some degree. The resultant odor may be managed by encouraging more frequent nighttime device removal, washing, and reinsertion the next day. Alternatively, a woman may use a pH-based deodorant gel such as oxyquinoline sulfate gel (Trimo-San) once or twice weekly or may douche with warm water. Trimo-San gel helps restore and maintain normal vaginal acidity that aids in reducing odor-causing bacteria.

Pelvic Floor Muscle Exercises

These exercises have been suggested as a therapy that might limit progression and alleviate prolapse symptoms. Also known as Kegel exercises, these muscle-strengthening techniques are described in Chapter 23. Two hypotheses describe the benefits of pelvic floor muscle exercises for prolapse prevention and treatment (Bø, 2004). First, from these exercises, women learn to consciously contract muscles before and during increases in abdominal pressure. This prevents organ descent. Alternatively, regular muscle strength training builds permanent muscle volume and structural support.

Unfortunately, high-quality scientific evidence supporting pelvic exercise for prevention and treatment of prolapse is lacking (Hagen, 2011). However, pelvic floor exercise has minimal risk and low cost. For this reason, it may be offered to asymptomatic or mildly symptomatic women who are interested in preventing prolapse progression or who decline other treatments.

In preparing for prolapse surgery, the patient should have an understanding of the expected results, and the surgeon should have an understanding of the patient’s expectations. Treatment success varies widely based on the definition of success. Thus, the surgeon and the patient must agree on the desired results. Generally, patients seek relief of symptoms, whereas surgeons may view surgical success as restoration of anatomy. In the CARE trial, absence of vaginal bulge symptoms had the strongest relationship to a patient’s assessment of overall improvement and surgical success, whereas anatomic success alone did not (Barber, 2009). It is therefore recommended that surgical success be defined as absence of bulge symptoms in addition to anatomic criteria.

Obliterative Procedures

The two categories of prolapse surgery are obliterative and reconstructive. Obliterative approaches include Lefort colpocleisis and complete colpocleisis (Chap. 45). These can be performed for women with posthysterectomy prolapse or those retaining a uterus. These procedures involve removing vaginal epithelium, suturing anterior and posterior vaginal walls together, obliterating the vaginal vault, and effectively closing the vagina. Obliterative procedures are only appropriate for elderly or medically compromised patients who have no desire for future coital activity.

Obliterative procedures are technically easier, require less operative time, and offer superior success rates compared with reconstructive procedures. Success rates for colpocleisis range from 91 to 100 percent, although the quality of evidence-based studies supporting these rates is poor (FitzGerald, 2006). After colpocleisis, fewer than 10 percent of patients express regret, often due to loss of coital activity (FitzGerald, 2006; Wheeler, 2005). Thus, the consenting process must include an honest and thoughtful discussion with the patient and her partner regarding future sexual intercourse. Latent SUI can be unmasked with colpocleisis due to resulting downward traction on the urethra. However, the morbidity of a concurrent antiincontinence procedure may outweigh the potential incontinence risk and is considered before adding surgeries in women who may already be medically compromised.

In patients who still have a uterus, vaginal hysterectomy may be performed prior to colpocleisis. However, concurrent hysterectomy increases blood loss and operative time. Again, in compromised patients, this can counteract some of the major benefits of colpocleisis. If retention of the uterus at time of colpocleisis is planned, neoplasia is excluded preoperatively. For this, Pap testing for cervical neoplasia should be current. For endometrial neoplasia, endometrial sampling and/or sonographic interrogation of endometrial stripe thickness is performed.

Reconstructive Procedures

These surgeries attempt to restore normal pelvic anatomy and are more commonly performed for POP than obliterative procedures. Vaginal, abdominal, laparoscopic, and robotic routes may be used, and in the United States, a vaginal approach is preferred by most for prolapse repairs (Boyles, 2003; Brown, 2002).

Approach selection is individualized and factors the patient’s unique characteristics and surgeon’s expertise. An abdominal approach may be advantageous for women with prolapse recurrence following a vaginal approach, those with a shortened vagina, or those believed to be at higher risk for recurrence, such as young women with severe prolapse (Benson, 1996; Maher, 2004). In contrast, a vaginal approach typically offers shorter operative time and a quicker return to daily activities. Laparoscopic and robotic approaches may offer smaller incisions, decreased hospital stay, and quicker short-term recovery compared with abdominal approaches.

Of these, laparoscopic and robotic approaches to prolapse repair are becoming more common. Procedures include sacrocolpopexy, paravaginal repair, and vaginal vault suspension to the uterosacral ligaments. One randomized trial in the United Kingdom compared open and laparoscopic sacrocolpopexy and found similar anatomic and subjective outcomes after 1 year (Freeman, 2013). Perceived advantages to the laparoscopic approach such as earlier return to usual activities were not seen. Several small RCTs have compared laparoscopic and robotic sacrocolpopexy (Anger, 2014; Paraiso, 2011). In general, these studies have found similar short-term outcomes but increased cost with the robotic approach.

The prolapse surgeon should be versatile. Procedure route selection is individualized, and compelling evidence does not support one approach as superior to another. Adoption of new surgical techniques should be driven by patient motives, as determined by evidence-based medicine (American College of Obstetricians and Gynecologists, 2015).

Surgical Plan

Reconstructive prolapse repair will often involve a combination of procedures in several vaginal compartments. However, the decision regarding which compartments to repair is not always straightforward. In the past, a defect-directed approach to prolapse repair was preferred. With this strategy, all current, latent, or potential defects are evaluated and repaired. However, current expert opinion suggests that asymptomatic areas of prolapse do not always warrant repair, and correction can lead to de novo symptoms in some cases. For instance, repair of an asymptomatic posterior wall prolapse may lead to dyspareunia. Thus, surgery in general is planned to relieve current prolapse symptoms.

Anterior Compartment

Many procedures for anterior vaginal wall prolapse repair have been described. Historically, anterior colporrhaphy has been the most common operation, yet long-term anatomic success rates are poor. In a randomized trial of three anterior colporrhaphy techniques, Weber and associates (2001b) found a low rate of anatomic success. Specifically, satisfactory anatomic results were obtained in only 30 percent of their traditional midline plication group, 46 percent of the ultralateral repair group, and 42 percent of the group undergoing traditional plication plus lateral reinforcement with synthetic mesh. These differences were not statistically significant. Despite anatomic results that may appear suboptimal, symptom relief from anterior colporrhaphy may be acceptable. One reanalysis of data from this trial instead used clinically relevant definitions of surgical success that included no prolapse beyond the hymen, lack of prolapse symptoms, and no retreatment requested. With these, 88 percent of subjects met the definition of success (Chmielewski, 2011). Thus, if a central or midline defect is suspected, anterior colporrhaphy may be performed (Chap. 45).

Mesh or biomaterial may also be used in conjunction with anterior colporrhaphy or by itself. Mesh is used to reinforce the vaginal wall and is sutured in place laterally. However, the use of mesh and mesh kits for anterior vaginal wall prolapse remains controversial (American College of Obstetricians and Gynecologists, 2013b). Although recent studies show improved anatomic success when mesh is used for anterior wall repair, there are significant risks. These include mesh erosion, pain, and dyspareunia and are discussed on page 556 (Sung, 2008).

In many cases, anterior vaginal wall prolapse results from fibromuscular defects at the anterior apical segment or transverse detachment of the anterior apical segment from the vaginal apex. In these situations, an apical suspension procedure such as an abdominal sacrocolpopexy or uterosacral ligament vaginal vault suspension will resuspend the anterior vaginal wall to the apex and reduce anterior wall prolapse. With these procedures, continuity is also reestablished between the anterior and posterior vaginal fibromuscular layers to prevent enterocele formation.

Alternatively, if a lateral defect is suspected, paravaginal repair can be performed through a vaginal, abdominal, or laparoscopic route (Chap. 45). Paravaginal repair is performed by reattaching the fibromuscular layer of the vaginal wall to the arcus tendineus fascia pelvis.

Vaginal Apex

Support of the vaginal apex is thought by many to be an essential cornerstone of a successful prolapse repair (Brubaker, 2005a). The vaginal apex can be resuspended with several procedures that include abdominal sacrocolpopexy, sacrospinous ligament fixation, or uterosacral ligament vaginal vault suspension. These are all illustrated in Chapter 45.

Of these, abdominal sacrocolpopexy suspends the vaginal vault to the sacrum using synthetic mesh. Advantages include the procedure’s durability over time and conservation of normal vaginal anatomy. For example, compared with other vault suspension procedures, sacrocolpopexy offers greater vaginal apex mobility and avoids vaginal shortening. In addition, sacrocolpopexy provides enduring correction of apical prolapse, and long-term success rates approximate 90 percent. This procedure may be used primarily or as a second surgery for women with recurrences after failure of other prolapse repairs. Sacrocolpopexy may be performed as selected an abdominal, laparoscopic, or robotic procedure. When hysterectomy is performed in conjunction with sacrocolpopexy, consideration is given to performing a supracervical rather than a total abdominal hysterectomy. With the cervix left in situ, the risk of postoperative mesh erosion at the vaginal apex is believed to be diminished (McDermott, 2009). In this case, the mesh is not exposed to vaginal bacteria, which occurs when the vagina is opened with total hysterectomy (Griffis, 2006). In addition, the strong connective tissue of the cervix allows for an additional anchoring point for the permanent mesh.

Another option, sacrospinous ligament fixation (SSLF), is one of the most popular procedures for apical suspension. The vaginal apex is suspended to the sacrospinous ligament unilaterally or bilaterally using a vaginal extraperitoneal approach. After SSLF, recurrent apical prolapse is uncommon. However, anterior vaginal wall prolapse develops postoperatively in 6 to 28 percent of patients and is thought to develop from redirection of abdominal forces anteriorly (Benson, 1996; Morley, 1988; Paraiso, 1996). Complications associated with SSLF include buttock pain from nerve involvement with supporting ligatures in 3 percent of patients and vascular injury in 1 percent (Sze, 1997a,b). Although infrequent, significant and life-threatening hemorrhage can follow injury to blood vessels located near the sacrospinous ligament.

Uterosacral ligament vaginal vault suspension is another apical surgery. With this procedure, the vaginal apex is attached to remnants of the uterosacral ligament at the level of the ischial spines or higher. Performed vaginally or abdominally, the uterosacral ligament vaginal vault suspension is believed to replace the vaginal apex to a more anatomic position than SSLF, which deflects the vagina posteriorly (Barber, 2000; Maher, 2004; Shull, 2000). This procedure has been adopted by many surgeons in the United States in attempts to reduce the rates of anterior vaginal prolapse recurrence following SSLF (Shull, 2000). Although uterosacral ligament vaginal vault suspension has gained popularity, studies supporting its use are limited to retrospective case series (Amundsen, 2003; Karram, 2001; Silva, 2006). In these studies and others, anterior vaginal prolapse recurrence rates range from 1 to 7 percent, and overall recurrence rates from 4 to 18 percent. One landmark RCT compared SSLF and uterosacral ligament vaginal vault suspension and did not find significant differences in anatomic or functional outcomes between the two procedures at 2 years (Barber, 2014).

Hysterectomy at the Time of Prolapse Repair

In the United States, hysterectomy is often performed concurrently with prolapse surgery. Conversely, in many European countries, it is rarely performed during pelvic floor reconstruction. Although this has not been compared in RCTs, arguments exist for both. If apical or uterine prolapse is present, hysterectomy will more readily allow the vaginal apex to be resuspended with the previously described apical suspension procedures. If hysterectomy is not performed in the context of apical prolapse, these procedures must be modified or specific uterine suspension procedures performed (not described in this text). Alternatively, if apical or cervical prolapse is not present, hysterectomy need not be incorporated into prolapse repair.

Posterior Compartment

Posterior vaginal wall prolapse may be due to enterocele or rectocele. Enterocele is defined as herniation of the small bowel through the vaginal fibromuscular layer, usually at the vaginal apex. Discontinuity of the anterior and posterior vaginal wall fibromuscular layers allows for this herniation. Accordingly, enterocele repairs have as their goal reattachment of these fibromuscular layers. If posterior wall prolapse is due to enterocele, repair of this defect should reduce the posterior wall prolapse.

If due to rectocele, posterior vaginal wall prolapse is repaired with one of several techniques, which are illustrated in Chapter 45. Of these, traditional posterior colporrhaphy aims to rebuild the fibromuscular layer between the rectum and vagina by performing a midline fibromuscular plication. The anatomic cure rate is 76 to 96 percent, and most studies report a greater than 75-percent improvement rate of bulge symptoms (Cundiff, 2004). To narrow the genital hiatus and prevent recurrence, some surgeons plicate the levator ani muscle concurrently with posterior repair. However, this practice may contribute to dyspareunia rates of 12 to 27 percent (Kahn, 1997; Mellegren, 1995; Weber, 2000). Thus, it is best avoided in women who are sexually active.

Site-specific posterior repair is an approach based on the assumption that specific tears in the fibromuscular layer can be repaired in a discrete fashion. Defects may be midline, lateral, distal, or superior. This approach is conceptually analogous to a fascial hernia, in which the fascial tear is identified and repaired. Thus, its theoretical advantage lies in its restoration of normal anatomy rather than plication of tissue in the midline. Although site-specific repair has gained wide acceptance, anatomic cure rates range from 56 to 100 percent, similar to that with traditional posterior colporrhaphy (Muir, 2007). Moreover, anatomic and functional long-term outcomes are unknown.

Mesh reinforcement with allograft, xenograft, or synthetic mesh has been used in conjunction with posterior colporrhaphy and site-specific repair to help reduce prolapse recurrence. However, the efficacy and safety of graft augmentation in the posterior vaginal wall has not been established. Paraiso and coworkers (2006) randomly assigned 105 women to posterior colporrhaphy, site-specific repair, or site-specific repair plus a graft using porcine small intestine submucosa. After 1 year, those with graft augmentation had a significantly higher anatomic failure rate (46 percent) than those who received site-specific repair alone (22 percent) or posterior colporrhaphy (14 percent). More research is needed to determine the safety, efficacy, and optimal material for posterior wall graft augmentation. Until then, the use of mesh in the posterior vaginal wall should generally be avoided.

Last, sacrocolpoperineopexy is a modification of sacrocolpopexy. It may be selected for correction of posterior vaginal wall descent when an abdominal approach is employed for other prolapse procedures or if treatment of perineal descent is necessary (Cundiff, 1997; Lyons, 1997; Sullivan, 2001). With this procedure, the posterior sacrocolpopexy mesh is extended down the posterior vaginal wall to the perineal body. In several case series, anatomic cure rates were greater than 75 percent.

Perineum

The perineal body provides distal support to the posterior vaginal wall and anterior rectal wall and anchors these structures to the pelvic floor. A disrupted perineal body will allow descent of the distal vagina and rectum and will contribute to a widened levator hiatus.

To recreate normal anatomy, perineorrhaphy is often done in conjunction with posterior colporrhaphy (Chap. 45). During surgery, the perineum is rebuilt through midline plication of the perineal muscles and connective tissue. Importantly, overly aggressive plication can narrow the introitus, create a posterior vaginal wall ridge, and lead to entry dyspareunia. However, in a woman who is not sexually active, high perineorrhaphy with intentional introital narrowing is believed to decrease the risk of posterior wall prolapse recurrence.

Mesh in Reconstructive Pelvic Surgery

Mesh Indications

Approximately 30 percent of women undergoing surgery for prolapse will require a repeat operation for recurrence (Olsen, 1997). As such, continuous efforts strive to improve surgical procedures and outcomes.

Synthetic mesh for sacrocolpopexy and midurethral slings has been widely studied and is safe and effective. Mesh erosion develops in a small percentage of cases but can be managed with local estrogen therapy and limited vaginal wall mesh excision. Rarely is excision of the entire mesh warranted. In an attempt to limit erosion rates, surgeons have used biologic material grafts, including cadaveric fascia. However, high rates of prolapse recurrence are associated with this material (FitzGerald, 1999, 2004; Gregory, 2005). Therefore, synthetic mesh is recommended for sacrocolpopexy and midurethral slings.

The use of biologic grafts or synthetic mesh for other transvaginal reconstructive pelvic surgery has expanded rapidly and in the absence of supporting long-term safety and efficacy data. Some surgeons routinely use graft or mesh augmentation, others never use it, and some use it only for limited indications. Selective use may include: (1) the need to bridge space, (2) weak or absent connective tissue, (3) connective tissue disease, (4) high risk for recurrence (obesity, chronically increased intraabdominal pressure, and young age), and (5) shortened vagina.

Despite the common use of mesh or grafts, one systematic review on their use in transvaginal prolapse repair found a lack of high-quality scientific data to support this practice (Sung, 2008). Since this review, several RCTs have found that mesh use compared with no mesh for anterior colporrhaphy yields higher short-term rates of successful prolapse treatment. However, more surgical complications and postoperative adverse events are associated with mesh use in these studies (Altman, 2011). In 2011, the Food and Drug administration (FDA) reported the potentially serious complications associated with surgical mesh for transvaginal repair of POP. Noted complications include mesh erosion, scarring, pain, and dyspareunia. Additionally, synthetic mesh may become ingrown and difficult to remove. Complications may therefore be irreversible. Thus, the FDA urges clinicians to weigh the risks versus theoretical benefit of this practice. The American College of Obstetricians and Gynecologists (2011) and AUGS (2012) echo these concerns and recommend that vaginal synthetic mesh for the treatment of POP should be reserved for high-risk women in whom the benefits outweigh the risks.

Mesh Material

Surgeons using mesh or grafts should be familiar with the different types and their characteristics. Biologic grafts may be autologous, allograft, or xenograft. Autologous grafts are harvested from another part of the patient’s body such as rectus abdominis fascia or thigh fascia lata. Morbidity is low but may include increased operative time, pain, hematoma, or weakened fascia at the harvest site. Allografts come from a human source other than the patient and include cadaveric fascia or cadaveric dermis. Xenografts are biologic tissue obtained from a source or species foreign to the patient such as porcine dermis, porcine small intestinal submucosa, or bovine pericardium. Biologic materials have varying biomechanical properties and, as noted earlier, are associated with high rates of prolapse recurrence. Thus, recommendations on the appropriate clinical situations for biologic material are limited.

Synthetic mesh is classified as types I through IV, based on pore size (Table 24-8) (Amid, 1997). Pore size is the most important property of synthetic mesh. Bacteria generally measure less than 1 μm, whereas granulocytes and macrophages are typically larger than 10 μm. Thus, a mesh with pore size <10 μm may allow bacterial but not macrophage infiltration and thereby predispose to infection. Accordingly, type I mesh has the lowest rate of infection compared with types II and III. Pore size is also the basis of tissue ingrowth, angiogenesis, flexibility, and strength. Pore sizes of 50 to 200 μm allow for superior tissue ingrowth and collagen infiltration. This again favors type I. Meshes are either monofilament or multifilament. Multifilament mesh has small intrafiber pores that can harbor bacteria, therefore, monofilament mesh is recommended. From these findings, consensus suggests that if synthetic mesh is used, type I monofilament is the best choice for reconstructive pelvic surgery.

Mesh or graft augmentation will undoubtedly persist due to the current poor cure rates with traditional transvaginal repairs. However, evidence to guide the surgeon and provide a patient with accurate safety and efficacy information is scant. Moreover, industry-driven, premature adoption of untested materials and procedures has historically led to unacceptable complications. For these reasons, randomized, prospective trials comparing traditional repairs with graft or mesh augmentation are needed.

Concomitant Prolapse and Incontinence Surgery

Prior to prolapse repairs, women should be evaluated for SUI (Chap. 23). Those with bothersome SUI symptoms are considered for concurrent antiincontinence surgery. However, in women without SUI symptoms, latent stress incontinence may be unmasked or SUI may develop de novo following prolapse repair. Therefore, preoperative urodynamic testing with the prolapse replaced is recommended. If SUI is demonstrated, these patients also are considered for a concurrent antiincontinence operation. This has been a difficult decision for patients and surgeons because a procedure with known risks is being performed for a problem that does not currently exist and may never develop.

The CARE (Colpopexy and Urinary Reduction Efforts) trial has helped clarify this problem (Brubaker, 2006). In this trial, women undergoing abdominal sacrocolpopexy for prolapse who did not exhibit symptoms of SUI were randomized to undergo concurrent Burch colposuspension or not. Preoperative urodynamic testing was performed, but surgeons were blinded to the results. Three months after surgery, 24 percent of women in the Burch group and 44 percent of women in the control group met one or more criteria for SUI. The incontinence was bothersome in 6 percent of the Burch group and 24 percent of the control group.

These data can be interpreted in several ways. It can be argued that all women undergoing sacrocolpopexy for stage 2 or greater anterior vaginal wall prolapse should undergo Burch colposuspension, as 44 percent will develop SUI symptoms. However, the opposing argument is that only 24 percent will develop bothersome incontinence symptoms, thus three quarters of women would be subjected to an unnecessary operation.

In a similar trial, the Outcomes Following Vaginal Prolapse Repair and Mid Urethral Sling (OPUS) trial, women undergoing vaginal surgery for POP who did not have SUI symptoms were randomly assigned to receive a midurethral sling or sham incision. Twelve months after surgery, 27 percent of women in the sling group and 43 percent of women in the sham group had incontinence (Wei, 2012).

Importantly, these studies provide high-quality evidence for a surgeon to share during patient counseling. The decision to perform a concurrent antiincontinence operation in women without SUI should be individualized and based on risks, benefits, and patient goals and expectations.