International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

Effect of pelvic position on ultrasonic measurement parameters of pelvic floor in postpartum women

OBJECTIVE

To analyse the effect of pelvic position on ultrasonic measurement parameters of pelvic floor in postpartum women.

METHODS

This study included 132 postpartum participants who visited Fujian Maternity and Child Health Hospital from May 2020 to May 2024. All participants were assessed by medical professionals for general information and pelvic floor four dimensional ultrasound. Ultrasonic measurements were performed in three different positions of the pelvis (anterior pelvic tilt, posterior pelvic tilt, and neutral pelvic tilt) based on lithotomy position.

RESULTS

Our results indicated that the differences in the diagnosis of cystocele, uterine prolapse, perineal overactivity, and hiatal ballooning among the neutral position, anterior pelvic tilt, and posterior pelvic tilt were statistically significant (P<.001, P<.001, P<.001, and P<.001 respectively). The differences among neutral pelvic tilt, anterior pelvic tilt, and posterior pelvic tilt in hiatal area (during contraction), hiatal area (during rest), hiatal area (during valsalva), bladder neck descent, urethral rotation angle, cervical descent, rectal ampulla descent, hiatal area increase, and hiatal area decrease were statistically significant (P <.001, P <.001, P <.001, P <.001, P <.001, P <.001, P <.001, P <.001, and P <.001 respectively), with almost all the values of those parameters in posterior pelvic tilt the highest among three groups. The differences in cervical position (at rest), rectal ampulla position (at rest), and bladder neck position (during valsalva), cervical position (during valsalva), and rectal ampulla position (during valsalva) among neutral pelvic tilt, anterior pelvic tilt, and posterior pelvic tilt were statistically significant (P <.001, P =.035, P <.001, P <.001, and P <.001 respectively), with almost all the values of those parameters in posterior pelvic tilt the lowest among three groups.

CONCLUSION

During the pelvic floor muscle contraction, the posterior pelvic tilt showed the most reduction of hiatal area compared to that in other positions. During Valsalva, not only the most increase of the hiatal area, but also the greatest bladder neck descent, cervical neck descent, and rectal ampulla descent were observed in the posterior pelvic tilt position.

International Urogynecology Consultation Chapter 3 Committee 1 - Pessary Management

INTRODUCTION AND HYPOTHESIS

This manuscript is part of the International Urogynecological Consultation (IUC) on Pelvic Organ Prolapse (POP), Chapter 3, Committee 1 focusing on pessary management of POP.

METHODS

A narrative review was conducted by an international, multi-disciplinary group of clinicians working in the field of pelvic health following a search of the literature using the MeSH terms "pelvic organ prolapse" OR "urogenital prolapse" OR "vaginal prolapse" OR "uterovaginal prolapse" AND "pessary" OR "support device" OR "intravaginal device." Relevant studies, as determined after review using the Covidence manuscript review platform, were included.

RESULTS

A total of 540 articles were reviewed, of which 313 were included for this narrative review. The reported pessary fitting success rate ranges from 41% to 96.6%, and the continuation of successful use rate varied from 21% to 97.7%. The most likely predictors of unsuccessful fitting trials were previous POP surgery, previous hysterectomy, short vaginal length, wide genital hiatus, and posterior compartment involvement. Following successful pessary placement in individuals with POP, vaginal bulge and pressure resolved in over 90%. A significant improvement in obstructive voiding was reported in 40-97% of participants, urinary urgency in 38%, urgency urinary incontinence in 29-77%, and stress urinary incontinence in 9-45%. Older age and women who can self-manage the pessary care or had family support were factors associated with pessary continuation. Common reasons reported for discontinuation included expulsion, vaginal pain/discomfort, unwillingness to continue, erosions, desire for surgery, bleeding, symptoms not improved with pessary, and incontinence. More serious complications (fistula, bowel obstruction, pessary impaction, and vaginal cancer) are rare, and occur usually in older women in whom pessary maintenance has been neglected. There is no high-quality evidence to guide pessary choice. The current literature lacks studies specifically focused on determining the role of preventative measures, i.e., estrogen, pessary type/material as regards to pessary-associated complications (PACs). The review identified a lack of information about the relevant and required training and education (for healthcare professionals and patients) for pessary provision, use, and management.

CONCLUSIONS

There is a considerable body of published work on the use of pessaries for POP, including effectiveness, factors associated with success and failure, and complications. However, there is a dearth of published literature regarding how pessary types are selected by providers, how providers are trained, what defines competency in pessary provision, and what constitutes appropriate patient education related to pessary use and management.

Impact of Lifestyle Modifications on the Prevention and Treatment of Pelvic Organ Prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript is a part of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) chapter three, committee three, on the impact of lifestyle modifications (i.e., weight loss, treatment of constipation, activity restriction, etc.) on the prevention and treatment of POP.

MATERIALS AND METHODS

An international group containing ten female pelvic medicine specialists and one university-based medical librarian performed a systematic search of the literature in Medline using the MeSH terms: pelvic organ prolapse (ID: D056887), cystocele (ID: D052858), uterine prolapse (ID: D014596), rectocele (ID: D020047), and women (ID: D014930) to identify studies addressing lifestyle modifications as prevention or treatment for POP on 10/18/21. Relevant studies were included in this review.

RESULTS

A total of 18,483 studies were identified in the initial literature search; 187 full-text articles were deemed pertinent and independently reviewed and double-screened by ten reviewers. After full-text review, information from 86 articles was included in this review.

CONCLUSION

Women may consider various lifestyle modifications to help prevent and treat POP, even if it is challenging to quantify the efficacy of these interventions.

Genetic Etiology in Pelvic Organ Prolapse: Role of Connective Tissue Homeostasis, Hormone Metabolism, and Oxidative Stress

Background: Pelvic organ prolapse (POP) has become a common health problem among the aging population and affects an increasing number of elderly women worldwide. Studies within family and twin pairs provided strong evidence for the contribution of genetic factors to POP. Given the incomplete penetrance, polygenic traits, and small effect sizes of each variant in complex diseases, it is not always easy to evaluate the genetic susceptibility and molecular mechanisms involved in POP. Objectives: This review intends to comprehensively summarize the current studies on genetic variants associated with POP. Methods: We performed a comprehensive review to summarize the genetic findings from genome-linkage studies, genome-wide association studies, candidate association studies, and gene expression analyses. Results: We summarized genetic variants associated with connective tissue homeostasis, hormone metabolism, and oxidative stress, which were potentially related to the pathophysiology of POP. We also reviewed the limited polygenic risk score (PRS) studies generated for each individual's genetic risk stratification and its integration into clinical risk factors for disease prediction. Conclusions: This pooled analysis provides moderate epidemiological credibility for associations of these genetic variants with POP to bridge the gap between genetic research and clinical medicine towards understanding the genetic etiology of POP. It also highlights the potential of PRS as a risk prediction model.

Cost-Effectiveness of 2 Models of Pessary Care for Pelvic Organ Prolapse: Findings From the TOPSY Randomized Controlled Trial

OBJECTIVES

Pelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation.

METHODS

A randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period.

RESULTS

There was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%.

CONCLUSIONS

Results suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations.

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

BACKGROUND

Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing.

AIM

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

METHODS

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

RESULTS

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

CONCLUSIONS

Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021256956.

Pelvic floor and sexual function 3 years after hysterectomy - A prospective cohort study

INTRODUCTION

Long term effects after hysterectomy, such as a worsening of pelvic floor and sexual function, have been studied with diverse results. Therefore, we investigated the long-term effects of hysterectomy for benign indication on pelvic floor and sexual function as well as differences in outcome depending on mode of hysterectomy.

MATERIAL AND METHODS

In a prospective clinical cohort study, we included 260 women scheduled for hysterectomy who answered validated questionnaires; pelvic floor impact questionnaire (PFIQ-7), pelvic floor distress inventory (PFDI-20) and female sexual function index (FSFI). Participants were followed up to 3 years after surgery. Nonparametric statistics and mixed effect models were used in analyses of the data.

RESULTS

After exclusions, 242 women remained in the study, with a response rate at the 3-year follow-up of 154/242 (63.6%) for all questionnaires. There was an improvement of pelvic floor function with a mean score of PFIQ-7 at baseline of 42.5 (SD 51.7) and at 3 years 22.7 (SD 49.4), (p < 0.001) and mean score of PFDI-20 at baseline was 69.6 (SD 51.1) and at 3 years 56.2 (SD 54.6), (p = 0.001). A deterioration of sexual function was seen among the sexually active women after 3 years with a mean score of FSFI at baseline 25.2 (SD 6.6) and after 3 years 21.6 (SD 10.1), (p < 0.001). However, this was not consistent with the unaltered sexual function for the whole cohort. No difference in pelvic floor or sexual function was detected when comparing robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy.

CONCLUSIONS

Three years after surgery robotic assisted laparoscopic hysterectomy, total laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent. Among the sexually active women, a decline of sexual function was seen after 3 years, not consistent with the entire cohort and independent of surgical methods. Whether this is a trend associated with aging or menopausal transition remains to be studied.

International urogynecological consultation chapter 4.1: definition of outcomes for pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

This manuscript of Chapter 4 of the International Urogynecological Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature and makes recommendations on the definition of success in the surgical treatment of pelvic organ prolapse.

METHODS

An international group containing seven urogynecologists performed an exhaustive search of the literature using two PubMed searches and using PICO methodology. The first search was from 01/01/2012-06/12/2022. A second search from inception to 7/24/2022 was done to access older references. Publications were eliminated if not relevant to the clinical definition of surgical success for the treatment of POP. All abstracts were reviewed for inclusion and any disagreements were adjudicated by majority consensus of the writing group. The resulting list of articles were used to inform a comprehensive review and creation of the definition of success in the surgical treatment of POP.

OUTCOMES

The original search yielded 12,161 references of which 45 were used by the writing group. Ultimately, 68 references are included in the manuscript. For research purposes, surgical success should be primarily defined by the absence of bothersome patient bulge symptoms or retreatment for POP and a time frame of at least 12 months follow-up should be used. Secondary outcomes, including anatomic measures of POP and related pelvic floor symptoms, should not contribute to a definition of success or failure. For clinical practice, surgical success should primarily be defined as the absence of bothersome patient bulge symptoms. Surgeons may consider using PASS (patient acceptable symptom state) or patient goal attainment assessments, and patients should be followed for a minimum of at least one encounter at 6-12 weeks post-operatively. For surgeries involving mesh longer-term follow-up is recommended.

A comparison of MRI-based pelvic floor support measures between young and old women with prolapse

INTRODUCTION AND HYPOTHESIS

We sought to 1) test the hypothesis that young women (≤45 years) with pelvic organ prolapse have a higher prevalence of major levator ani muscle (LAM) defects than old women (≥70 years) with prolapse and 2) compare level II/III measurements between young and old women with prolapse and age-matched controls to evaluate age-related mechanistic differences in the disease process.

METHODS

A secondary analysis examined four groups of parous women: young prolapse (YPOP, n = 17); old prolapse (OPOP, n = 17); young controls (YC, n = 15); old controls, (OC, n = 13). Prolapse was defined as any compartment at or beyond the hymen with vaginal bulge symptoms. Genital hiatus (GH) was measured on clinical exam. Major LAM defects and level II/III measurements (UGH: urogenital hiatus, LA: levator area, and apex location) were assessed on MRI at rest and strain, and the difference (Δ) between measurements calculated. Principal component analysis was used to evaluate levator plate (LP) shape.

RESULTS

Major LAM defects occurred in 42% of YPOP and 47% of OPOP (p > .99). GHrest was 1.5 cm larger in OPOP versus YPOP (p < .001) and 2 cm larger in OPOP versus OC (p < .001). Regardless of prolapse status, LArest and UGHrest on MRI increased with age. YPOP had larger ΔLA (p = .04), ΔUGH (p = .03), and Δapex than OPOP (p = .01). Resting LP shape was more dorsally oriented in OPOP versus YPOP (p = .02) and OC versus YC (p = .004).

CONCLUSIONS

Prolapse in young women cannot be solely explained by a higher LAM defect prevalence. GH size and other measures of level II/III pelvic support worsen with age regardless of prolapse status.

Emerging trends on the mechanism of pelvic organ prolapse from 1997 to 2022: visualization and bibliometric analysis

Objective

At present, there is no feature description of the mechanism of pelvic organ prolapse (POP) in the literature. This study aimed to map the emerging trends regarding the mechanism of POP from inception to 2022 by bibliometric analysis and to analyze its research hotspots and frontiers.

Methods

We downloaded pertinent publications from inception to 2022 from the Web of Science Core Collection (WoSCC) on 30 June 2022. The data were then examined using the Bibliometrix program in R (Version 4.1.0), CiteSpace software, the Online Analysis Platform of Literature Metrology (https://bibliometric.com), and a bibliometrix online interface.

Results

A total of 290 qualified records on the mechanism of POP were identified and included in the analysis. The most productive journal was International Urogynecology Journal. Bump RC and Olsen AL were the most cited authors. Extracellular matrix, collagen, apoptosis, elastin, oxidative stress, gene expression, matrix metalloproteinase, and tissue engineering were among the 25 most relevant terms. According to the analysis of trending topics, tissue engineering has become a new research hotspot.

Conclusion

Extracellular matrix remodeling, oxidative stress and apoptosis are the three main directions for studying the mechanism of POP. In addition, tissue engineering has become a new research hotspot. In the future, in-depth research on the interaction between different mechanisms will be carried out, and attempts will be made to combine biomimetic materials and seed cells to achieve the regeneration and reconstruction of POP-related organs.

What women want now!

IMPORTANCE

Stress urinary incontinence and pelvic organ prolapse are common conditions affecting women with many different conservative and surgical treatment options available for women.

OBJECTIVES

Our primary aim was to determine patient views and preferences surrounding theoretical potential future treatment options for pelvic floor dysfunction (PFD): pelvic organ prolapse/SUI and determine what level of success patients would find acceptable and see if their choice was dependent on severity of their symptoms. All patients had either just completed or were about to start a course of 3 months physiotherapy. All patients with overactive bladder symptoms were excluded.

STUDY DESIGN

We conducted an service evaluation study of 100 consecutive women attending our urogynaecology clinic. Patients attending clinic completed a questionnaire. They were asked to choose a preferred treatment between "Option A": A surgical procedure which had an 80% success rate in curing symptoms but would require 1-2 day hospital stay and carry a small risk of complications. Or "Option B": A hypothetical course of outpatient, non-surgical treatments which would have a variable chance of improving (but not curing) symptoms (ranging from 70%, 50% or 25% chance of improvement) but would require no "down-time" and have no long term safety issues.

RESULTS

Our results showed 100% of women with severe PFD would chose a surgical procedure. However those with mild/moderate symptoms would prefer a non-surgical treatment (if one were available) which may only improve their symptoms but had no long-term complications. There was a moderate correlation (r = 0.46) between severity of symptoms and chance of success.

CONCLUSIONS

This study is important as it highlights a change in patient demand from one of highest efficacy to possibly one with the greatest safety profile and quickest recovery time. Newer treatment technologies such as energy-based devices (radiofrequency, laser and magnetic therapy) have shown to have lower success rates but may be favourable for some women. This supports the need for further research in these areas.

Patient-Centered Goals for Treatment of Pelvic Floor Disorders

Purpose of review

To review the current literature on patient centered goals for the treatment of pelvic floor disorders (PFDs).

Recent findings

Patients have a poor understanding of their PFDs, regardless if they had prior PFD treatments or received counseling, emphasizing the need for improved education from healthcare providers. Understanding the patient perspective provides insights into identifying patient goals, which facilitates communication and allows for tailored counseling, management of expectations, and assessment of treatment response. Functional outcomes are consistently important to patients, often listed as their main treatment goals. The achievement of these goals is fundamental to satisfaction. IMPACT and PROMIS are examples of PCO measures that can be utilized in both research and clinical settings. Finally, telemedicine has emerged as a viable alternative to clinic visits that offers improved access to care with no increase in adverse events or dissatisfaction, in order to aid in monitoring and meeting patient treatment goals.

Summary

Patient involvement is fundamental to providing value-based care. Provider understanding of the patient perspective is necessary to guide counseling and treatment. Patient-centered goals offer a way to engage patients, facilitate communication, and improve patient satisfaction. Although there are multiple validated PCO tools, further development and research involving patient input is needed.