Transcript POP - Medicine is an art

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Pelvic Organ Prolapse (POP)
o Herniation of the pelvic organs to or beyond the vaginal walls
o Annual cost of ambulatory care from 2005 to 2006 was almost
$300 million
o Surgical repair of prolapse was the most common inpatient
procedure performed in women older than 70 yrs from 1979 to
2006
o Approximately 11% of all women will undergo surgical repair for POP
or incontinence by age 80
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Anterior compartment prolapse (cystocele)
o Hernia of anterior vaginal wall often associated with descent of the bladder
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Posterior compartment prolapse (Rectocele)
o Hernia of the posterior vaginal segment often associated with descent of
the rectum
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Apical compartment prolapse (uterine prolapse, vaginal vault prolapse)
o Descent of the apex of the vagina into the lower vagina, to the hymen, or
beyond the vaginal introitus
o The apex can be either the uterus and cervix, cervix alone, or
vaginal vault
o Apical prolapse is often associated with enterocele.
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Enterocele
o Hernia of the intestines to or through the vaginal wall
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Procidentia
o Hernia of all three compartments through the vaginal introitus.
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The terms anterior vaginal wall prolapse and posterior
vaginal wall prolapse are preferred to cystocele and
rectocele because vaginal topography does not reliably
predict the location of the associated viscera in POP
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Division of the vagina into separate compartments is
somewhat arbitrary, because the vagina is a continuous
organ and prolapse of one compartment is often associated
with prolapse of another
o As an example, approximately half of anterior prolapse can be attributed to
apical descent
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Parity — The risk of POP increases with increasing parity
o Prospective cohort study of more than 17,000
o The risk of hospital admission for POP increased
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1st birth- 4-fold
2nd - 8-fold
3rd - 9-fold
4th- 10-fold
o Among parous women, it has been estimated that 75 percent of
prolapse can be attributed to pregnancy and childbirth
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Advancing Age- Older women are at increased risk for POP
o Every additional 10 yrs of age increased prolapse risk by 40%
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Obesity
o Overweight and obese women (body mass index >25) have a two-
fold higher risk of having prolapse than other women
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Hysterectomy
o Hysterectomy is associated with increased apical prolapse
o ? Vaginal > Abdominal ?
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Other risk factors
o Chronic constipation is a risk factor for POP, likely due to repetitive
increases in intraabdominal pressure
o COPD, etc conditions that also increase intraabdominal pressure
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Race and Ethnicityo African Americans lower prevalence than other ethnic groups
o Risk of Latina and white women is four to five fold higher than AA
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Patients may present with symptoms related specifically to
the prolapsed structures
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bulge or vaginal pressure or with associated symptoms including
urinary, defecatory or sexual dysfunction
Symptoms such as low back or pelvic pain have often been
attributed to POP, but this association is not supported by
well-designed studies
 Severity
of symptoms does not correlate well
with the stage of prolapse
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Symptoms are often related to position; they are often less
noticeable in the morning or while supine and worsen as
the day progresses.
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Many women with prolapse are asymptomatic; treatment is
generally not indicated in these women.
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Bulge Symptoms
o In a study of 1912 women presenting to a pelvic floor disorder
clinic, symptoms of “a bulge or that something is falling out of the
vagina” had a sensitivity of 67 percent and a specificity of 87
percent for POP at or past the hymen
o Although complaints of a bulge are associated with the presence of
prolapse, it is only weakly correlated with prolapse stage, and does
not predict site of prolapse
o Protrusion from the vagina may cause chronic discharge and/or
bleeding from ulceration
o Loss of support of the anterior vaginal wall or vaginal apex may affect
bladder and/or urethral function.
o Symptoms of stress urinary incontinence (SUI) often coexist with stage I or II
prolapse
o As prolapse advances, women may experience improvement in SUI, but
increased difficulty voiding
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Advanced anterior or apical prolapse may “kink” the urethra and result in
symptoms of obstructed voiding such as
o slow urine stream
o need to change position
o manually reduce (splint) the prolapse to urinate
o sensation of incomplete emptying
o complete urinary retention
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13% to 65% of continent women develop symptoms of SUI after surgical
correction of prolapse
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Elevation of prolapse during pelvic examination with prolapse treatment may
unmask “occult” SUI
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Women with POP have a two- to five-fold risk of overactive bladder symptoms
(urgency, urge urinary incontinence, frequency) compared with the general
population
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POP-Q or not to POP-Q
o POPQ system The POPQ system is an objective, site-specific system
for describing and staging POP in women
o The POPQ system involves quantitative measurements of various
points representing anterior, apical, and posterior vaginal prolapse
to create a "topographic" map of the vagina
o These anatomic points can then be used to determine the stage of
the prolapse
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Stage 0- No prolapse
o Aa, Ba, Ap, Bp are -3 cm and C or D≤ -(tvl - 2) cm
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Stage 1- Most distal portion of the prolapse -1 cm (above
the level of hymen)
Stage 2- Most distal portion of the prolapse ≥ -1 cm but ≤
+1 cm (≤1 cm above or below the hymen)
Stage 3 - Most distal portion of the prolapse > +1 cm but <
+(tvl - 2) cm (beyond the hymen; protrudes no farther than
2 cm less than the total vaginal length)
Stage 4 - Complete eversion; most distal portion of the
prolapse ≥ + (tvl - 2) cm
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The POPQ has proven interobserver and intraobserver reliability
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The POPQ system is the POP classification system of choice of the
International Continence Society (ICS), the American Urogynecologic
Society (AUGS), and the Society of Gynecologic Surgeons
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It is the system used most commonly in the medical literature
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The Baden-Walker Halfway Scoring System is the next
most commonly used POP staging system
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The degree, or grade, of each prolapsed structure is
described individually
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The grade/degree is defined as the extent of prolapse for
each structure noted on examination while the patient is
straining
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The Baden-Walker system lacks the precision and
reproducibility of the POPQ system
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The system has five degrees/grades
0 – No prolapse
1 – Leading edge of prolapsed structure descends halfway to
vaginal introitus (hymen)
2 – Leading edge of prolapsed structure descends to the vaginal
introitus
3 – Leading edge of prolapsed structure(s) protrudes up to
halfway outside the vagina
4 – Leading edge of prolapsed structure(s) protrudes more than
halfway outside the vagina
 Examination
components
o Visual inspection
o Speculum examination
o Bimanual pelvic examination
o Rectovaginal examination
o Pelvic Floor Muscle evaluation
 Instruments
o Sims retractor (single blade speculum) or a bivalve
speculum that can be easily taken apart so that the
anterior and posterior blades can be used separately to
observe individual compartments of the vagina (anterior,
posterior, apical).
o To make the measurements for the POPQ system, a ruler
or a large cotton swab or sponge forceps marked in 1 cm
increments is used
o Ring Forceps occasionally used for evaluation of occult
incontinence to reduce prolapse
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The examination is performed with resting and maximal straining
position
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The patient is examined initially in the dorsal lithotomy position
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The examination is then repeated with the patient standing
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In the standing position, the patient places one foot on a well-supported
footstool. The examining gown is lifted slightly to expose the genital
area during the examination
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The first part of the examination is a visual inspection of the vulvar, perineal,
and perianal areas with the patient in the dorsal lithotomy position
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As during other components of the examination, the inspection should be
performed initially with the patient relaxed and then while straining
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Findings that should be noted during this component of the examination
include:
Transverse diameter of the genital hiatus (eg, the space between the labia
majora)
Protrusion of the vaginal walls or cervix to or beyond the introitus (procidentia)
Length and condition of the perineum
Rectal prolapse
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In patients with prolapse to or beyond the hymen, the vaginal tissue is examined
for ulceration.
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Any other findings (eg, skin or mucosal lesions) should be noted and evaluated
appropriately
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The speculum and bimanual examinations are the principal components
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Prolapse of each anatomic compartment is evaluated as follows:
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Apical prolapse (prolapse of the cervix or vaginal vault) – A bivalve speculum is inserted
into the vagina and then slowly withdrawn; any descent of the apex is noted
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Anterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum is
inserted into the vagina with gentle pressure on the posterior vaginal wall to isolate
visualization of the anterior vaginal wall
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Posterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum into
the vagina with gentle pressure on the anterior vaginal wall to isolate visualization of the
posterior vaginal wall
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To complete the exam, a bimanual examination is performed in order to evaluate for any
coexisting pelvic abnormalities
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Diagnose an enterocele
Differentiate between a high rectocele and an enterocele
Assess the integrity of the perineal body
Detect rectal prolapse
The best method for detecting an enterocele is to perform
the rectovaginal exam with the patient standing (?); the
small bowel can be palpated in the cul-de-sac between
thumb and forefinger
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Pelvic floor muscle testing
o The pelvic floor musculature is inspected to evaluate integrity and
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symmetry
The examiner should also note the presence of scarring and
whether pelvic floor contraction pulls the perineum inward
Palpation through the vagina or rectum helps in assessing pelvic
floor squeeze strength and levator muscle thickness.
The tone and strength of the pelvic floor muscles can be assessed
by asking the patient to contract the pelvic floor muscles around the
examining fingers.
Women with poor pelvic floor muscle function may benefit from
pelvic physical therapy
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Establishing patient goals
o Treatment is individualized according to each patient’s symptoms
and their impact on her quality of life
o Patient satisfaction after POP surgery correlates highly with
achievement of self-described, preoperative surgical goals, but
poorly with objective outcome measures
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Management options
o Women with symptomatic prolapse can be managed expectantly, or
treated with conservative or surgical therapy
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Both conservative and surgical treatment options should be offered.
o There are no high quality data comparing these two approaches
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Physical TherapyPelvic floor muscle exercises (PFME) appears to improve stage and
symptoms
o The best designed randomized trial included 109 women with stage
I to III prolapse who were assigned to either PFME for six months or
control group
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• Women in the PFME group had significant reductions in the frequency
and bother of most prolapse, bladder, and bowel symptoms (exceptions
were urge urinary incontinence symptoms, difficulty with stool
emptying, and solid stool fecal incontinence)
• Improvement in POP stage was found more frequently in the PFME
group (19 versus 8 percent)
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Estrogen therapy ?
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Use of estrogen and estrogenic agents (raloxifene) appears to be associated with a decrease in
undergoing surgery for POP, according to a systematic review of randomized trials
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This systematic review included six trials, however, none of these evaluated the role of estrogen in
treating POP
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Vaginal pessary
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The mainstay of non-surgical treatment for POP is the vaginal pessary
Pessaries are silicone devices in a variety of shapes and sizes, which support the pelvic organs
Approximately half of the women who use a pessary continue to do so in the intermediate term of
one to two years
Pessaries must be removed and cleaned on a regular basis
CONTRAINDICATIONS
o Local infection — Active infections of the vagina or pelvis, such as vaginitis or pelvic inflammatory
disease, preclude the use of a pessary until the infection has been resolved
o Latex sensitivity — The Inflatoball pessary is made of latex; therefore, it is contraindicated in
women with latex allergies. The other pessaries discussed below are nonallergenic.
o Noncompliance — Noncompliance with follow-up could be harmful since an undetected and
untreated erosion could put the patient at risk of developing a fistula
o Sexually active women who are unable to remove and reinsert the pessary — Inability to manage
the pessary around coital activity could be discouraging
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Fitting the pessary
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Women to be fitted for a pessary are first examined with an empty bladder in the
dorsal lithotomy position
Pessaries are inserted into the vagina with the dominant hand, while the
nondominant hand separates the introitus and depresses the perineal
body.
After the pessary is inserted into the vagina, the woman is asked to strain
and cough repeatedly on the examination table, ambulate in the office, and
void and strain while sitting on a toilet
This "office trial" helps determine if she will be able to retain the pessary
and void when she returns home, and if bothersome urinary incontinence
will develop.
She should have a negative cough stress test following pessary placement,
as she is unlikely to be satisfied if there are significant SUI symptoms
Women should be reassured that it is not an emergency if the pessary is
expelled; they should just bring the pessary back to the office and a
different type or size of pessary will likely be effective
 Follow-up
o A follow-up visit is scheduled one to two weeks later.
o The pessary is removed and cleaned with soap and water, and the
vagina is examined for erosions
o If the pessary fits well and there were no side effects, motivated and
able patients are taught how to remove, clean, and reinsert their
pessary at least once per week, with follow-up in one to two months,
and every 6 to 12 months thereafter
o If the patient cannot, or chooses not, to remove and reinsert her
pessary, then she returns for follow-up in one to two months, and
every three to four months thereafter for pessary cleaning and
assessment by the provider.
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Offer most women low-dose estrogen vaginal cream (0.25 to 0.5 g
applicator, two to three nights per week) to treat co-existing vaginal
atrophy and dryness from estrogen deficiency
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KY or other non-hormonal lubrication may be used for those patients where estrogen
is contraindicated (breast ca, etc)
In some women, the width of the introitus may decrease in size after
several weeks of pessary use. In such women, a new smaller size
pessary is prescribed to allow for easier removal and insertion
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Candidates
o Symptomatic POP
o Failed or declined conservative management
o Women finished with childbearing
• Reports of uterine sparing procedures
o Young or Elderly-
• Risk of recurrence in young (sacral colpopexy) and comorbidities in
elderly (colpocliesis)
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Reconstructive or obliterative
• Most women with symptomatic POP are treated with a
reconstructive procedure
• Obliterative procedures (eg, colpocleisis) are reserved for women
who cannot tolerate more extensive surgery or who are not planning
future vaginal intercourse
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Concomitant hysterectomy
• When apical prolapse is repaired, the decision must be made
whether to perform a hysterectomy as a part of the procedure.
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Surgical route for repair of multiple sites of prolapse
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Concomitant anti-incontinence surgery
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Reconstructive surgery for POP often involves repair of multiple anatomic sites of
prolapse (apical, anterior, posterior)
The choice of surgical route depends upon the optimal approach for the combination
of prolapse sites.
Symptomatic POP often coexists with SUI and, in some women, anal incontinence
POP repair must be coordinated with treatment of incontinence.
Use of surgical mesh
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Surgical mesh is used in abdominal POP repair
Use in transvaginal procedures has increased, but questions have arisen about the
safety of this approach.