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Barbier H, Carberry CL, Karjalainen PK, Mahoney CK, Galán VM, Rosamilia A, Ruess E, Shaker D, Thariani K. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction. Int Urogynecol J 2023; 34:2657-2688. [PMID: 37737436 PMCID: PMC10682140 DOI: 10.1007/s00192-023-05629-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/22/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction. METHODS An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed. RESULTS The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP. CONCLUSIONS The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.
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Affiliation(s)
- Heather Barbier
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Cassandra L Carberry
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University/Women & Infants Hospital, Providence, RI, USA
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | | | | | - Anna Rosamilia
- Urogynaecologist and Reconstructive Pelvic Floor Surgeon, Cabrini Hospital, Malvern, Victoria, Australia.
- Monash Health, Monash University Department of O&G, Hudson Institute of Medical Research, Melbourne, Australia.
| | - Esther Ruess
- Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland
| | - David Shaker
- Rural Clinical School Rockhampton Australia, Mater Private Hospital Rockhampton Australia, University of Queensland, St Lucia, Australia
| | - Karishma Thariani
- Fellowship in Urogynaecology & Pelvic Reconstructive Surgery, Consultant Urogynaecologist, Centre for Urogynaecology & Pelvic Health, New Delhi, India
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Arenholt LTS, Pedersen BG, Glavind K, Greisen S, Bek KM, Glavind-Kristensen M. Prospective evaluation of paravaginal defect repair with and without apical suspension: a 6-month postoperative follow-up with MRI, clinical examination, and questionnaires. Int Urogynecol J 2018; 30:1725-1733. [PMID: 30506182 DOI: 10.1007/s00192-018-3807-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Paravaginal defect (PVD) has been suggested as one of the main contributors to the development of prolapse in the anterior vaginal wall (AVW). We aimed to evaluate the descent of pelvic organs, presence of vaginal H configuration, and pubococcygeus (PC) muscle defect by pelvic magnetic resonance imaging (MRI), together with subjective symptoms of prolapse, before and 6 months after PVD repair. We also aimed to evaluate risk factors of recurrence. METHODS Fifty women with PVD diagnosed by gynecological examination and scheduled for vaginal PVD repair were planned for enrollment. Preoperatively and 6 months postoperatively, subjective symptoms were evaluated using the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) together with MRI of the pelvis to evaluate defects in the PC muscle, vaginal shape, and pelvic organ descent. RESULTS Forty-six women completed the study. Twenty had PVD repair alone, whereas 26 also had concomitant surgery performed. Prolapse grade, subjective symptoms, sexual problems, and quality of life (QoL) were significantly improved at follow-up. Missing vaginal H configuration was observed in 21 women before operation and was correlated with PC muscle defect. Recurrence rate was 39%, and significantly more women with recurrence had PC muscle defects and missing H configuration. CONCLUSION Vaginal PVD repair alone or combined with concomitant surgery significantly reduces objective prolapse and subjective symptoms. We could not demonstrate MRI findings of missing H configuration to be a sign of PVD but, rather, a sign of defect in the PC muscle. Risk of recurrence is significantly higher in women with major PC muscle defects and missing H configuration.
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Affiliation(s)
- Louise T S Arenholt
- Centre for Clinical Research, Department of Obstetrics and Gynaecology, North Denmark Regional Hospital, Bispensgade 37, 9800, Hjoerring, Denmark. .,Center for Clinical Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Karin Glavind
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Greisen
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Karl M Bek
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
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Paravaginal defect: anatomy, clinical findings, and imaging. Int Urogynecol J 2016; 28:661-673. [PMID: 27640064 DOI: 10.1007/s00192-016-3096-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to repair it. The aim of this article was to review the existing literature on paravaginal defect and discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging. METHODS Articles related to paravaginal defects were identified through a PubMed search ending 1 July 2015. RESULTS Support of the anterior vaginal wall is a complex system involving levator ani muscle, arcus tendineus fascia pelvis (ATFP), pubocervical fascia, and uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g., sagging of bladder base, loss of tenting), which all represent changes in pelvic floor support but that could be due to both paravaginal and levator ani defects. CONCLUSION Paravaginal support plays a role in supporting the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use.
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SS, Lowry AC, Lange EO, Hall GM, Bleier JI, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O’Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:92-136. [DOI: 10.1067/j.cpsurg.2015.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/23/2022]
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Minassian VA, Parekh M, Poplawsky D, Gorman J, Litzy L. Randomized Controlled Trial Comparing Two Procedures for Anterior Vaginal Wall Prolapse. Neurourol Urodyn 2013; 33:72-7. [DOI: 10.1002/nau.22396] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/14/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Vatche A. Minassian
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology; The Brigham and Women's Hospital; Boston, Massachusetts
| | - Mitesh Parekh
- Prime Care of SE OH, Medical Director; Genesis Health System; Zanesville, Ohio
| | - Deborah Poplawsky
- Department of Obstetrics and Gynecology; Geisinger Health System; Danville, Pennsylvania
| | - Jennifer Gorman
- Department of Obstetrics and Gynecology; Geisinger Health System; Danville, Pennsylvania
| | - Louise Litzy
- Department of Obstetrics and Gynecology; Geisinger Health System; Danville, Pennsylvania
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Clinical efficacy of a trocar-guided mesh kit for repairing lateral defects. Int Urogynecol J 2012; 24:249-54. [DOI: 10.1007/s00192-012-1833-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 05/20/2012] [Indexed: 10/28/2022]
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Milani AL, Withagen MI, Vierhout ME. Outcomes and predictors of failure of trocar-guided vaginal mesh surgery for pelvic organ prolapse. Am J Obstet Gynecol 2012; 206:440.e1-8. [PMID: 22397899 DOI: 10.1016/j.ajog.2012.01.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 01/07/2012] [Accepted: 01/31/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The objective of the study was to compare the 1 year conventional and composite outcomes of trocar-guided vaginal mesh surgery and the identification of the predictors of failure. STUDY DESIGN This was a prospective observational cohort study. Failure outcome definitions were as follows: I, prolapse stage II or greater in mesh treated compartments; II, overall prolapse stage II or greater; III, composite outcome of overall prolapse greater than the hymen and the presence of bulge symptoms or repeat surgery. We used logistic regression to identify predictors of failure. RESULTS The results of the study were 1 year follow-up of 433 patients. Treated compartment failure (I) was 15% (95% confidence interval [CI], 12-19). Overall prolapse failure (II) was 41% (95% CI, 36-45). Composite failure (III) was 9% (95% CI, 7-13). Predictor of failure in all outcomes was the combined anterior/posterior mesh with the uterus in situ. CONCLUSION Outcome of prolapse surgery depends on outcome definition. The mesh treated compartment failure outcome (I) and the composite failure outcome (III) appeared not to be statistically different. Consistent factor for failure in all outcomes was the combined anterior/posterior mesh insertion with the uterus in situ.
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Shobeiri SA, White D, Quiroz LH, Nihira MA. Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison. Int Urogynecol J 2012; 23:1047-53. [DOI: 10.1007/s00192-012-1721-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 02/09/2012] [Indexed: 11/30/2022]
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Lensen EJM, Stoutjesdijk JA, Withagen MIJ, Kluivers KB, Vierhout ME. Technique of anterior colporrhaphy: a Dutch evaluation. Int Urogynecol J 2011; 22:557-61. [PMID: 21350970 PMCID: PMC3072509 DOI: 10.1007/s00192-010-1353-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 12/16/2010] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To evaluate the variation in techniques of anterior colporrhaphy among members of the Dutch Urogynecologic Society. METHODS A questionnaire evaluating the technique of anterior colporrhaphy, preoperative and postoperative care, and use of the POP-Q score was sent out by e-mail. RESULTS One hundred thirty-three completed questionnaires were received. The response rate was 65%. There are large variations in incisions, use of hydrodissection, method of plication, and excision of redundant vaginal epithelium. The urinary catheter was generally removed on day 2 after surgery and the vaginal pack on day 1. Less than half of the respondents used the POP-Q score routinely. CONCLUSIONS Dutch gynecologists use a variety of surgical techniques to operate on a cystocele. This suggests that there is no widely accepted opinion on the best surgical approach. The lack of differentiation between central and lateral defects is striking and in contrast with the, mostly, American literature.
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Affiliation(s)
- Ellen J M Lensen
- Obstetrics and Gynecology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands.
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Wieslander CK. Clinical approach and office evaluation of the patient with pelvic floor dysfunction. Obstet Gynecol Clin North Am 2009; 36:445-62. [PMID: 19932409 DOI: 10.1016/j.ogc.2009.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pelvic floor disorders are common health issues for women and have a great impact on quality of life. These disorders can present with a wide spectrum of symptoms and anatomic defects. This article reviews the clinical approach and office evaluation of patients with pelvic floor disorders, including pelvic organ prolapse, urinary dysfunction, anal incontinence, sexual dysfunction, and pelvic pain. The goal of treatment is to provide as much symptom relief as possible. After education and counseling, patients may be candidates for non-surgical or surgical treatment, and expectant management.
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Affiliation(s)
- Cecilia K Wieslander
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, 27-139 Center for Health Sciences, Los Angeles, CA 90095-1740, USA.
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Posterior compartment anatomy as seen in magnetic resonance imaging and 3-dimensional reconstruction from asymptomatic nulliparas. Am J Obstet Gynecol 2008; 198:651.e1-7. [PMID: 18241813 DOI: 10.1016/j.ajog.2007.11.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 08/28/2007] [Accepted: 11/19/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of the study was to identify characteristic anatomical features of the posterior compartment using magnetic resonance (MR) cross-sectional anatomy and 3-dimensional (3-D) modeling. STUDY DESIGN Supine, static proton-density MR images of 20 nulliparas were analyzed. MR images were used to create models in a selected exemplar. RESULTS The compartment's upper, mid, and lower segments are best seen in the axial plane. It is bounded inferiorly by the perineal body, ventrally by the posterior vaginal wall, and dorsally by the levator ani muscles and coccyx. In the upper portion, the compartment is bordered laterally by the uterosacral ligaments, whereas in the middle portion, there is more direct contact with the lateral levator ani muscles. In the lower portion, the contact becomes obliterated because the vagina and levator ani muscles become fused to each another and to the perineal body. CONCLUSION The posterior compartment has characteristic anatomic features in MR cross-sectional anatomy that can be further elucidated and integrated with 3-D anatomy.
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Simsiman AJ, Luber KM, Menefee SA. Vaginal paravaginal repair with porcine dermal reinforcement: correction of advanced anterior vaginal prolapse. Am J Obstet Gynecol 2006; 195:1832-6. [PMID: 17010297 DOI: 10.1016/j.ajog.2006.07.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 07/11/2006] [Accepted: 07/11/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of the study was to determine the efficacy of the vaginal paravaginal repair using porcine dermal graft reinforcement for the correction of advanced anterior vaginal prolapse. STUDY DESIGN One hundred eleven women underwent reinforced vaginal paravaginal repair between September 2001 and January 2004 and met our inclusion criteria. Postoperatively patients were evaluated at 6 weeks, 6 months, and yearly thereafter. Objective cure was defined as point Ba -1 or less. RESULTS Eighty-nine of the 111 (80%) patients were available for follow-up. Mean age of patients was 59.5 +/- 11.6 years (range 26 to 82), mean body mass index was 29 +/- 5.5 (range 20 to 44), and median parity was 3 (range 0 to 15). Mean follow-up was 24 +/- 10.1 months (range 6 to 44) with minimum follow-up required for cure of 12 months. Overall cure rate was 78% (68 of 89). Data were analyzed using the Wilcoxon rank test. CONCLUSION The reinforced vaginal paravaginal repair procedure is safe and effective for correction of advanced anterior vaginal prolapse.
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Affiliation(s)
- Amanda J Simsiman
- Department of Reproductive Medicine, University of California, San Diego, CA, USA
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Summers A, Winkel LA, Hussain HK, DeLancey JOL. The relationship between anterior and apical compartment support. Am J Obstet Gynecol 2006; 194:1438-43. [PMID: 16579933 PMCID: PMC1475726 DOI: 10.1016/j.ajog.2006.01.057] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 11/14/2005] [Accepted: 01/13/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether the degree of anterior compartment (bladder) and apical compartment (cervix) prolapse are correlated, and whether 2 anterior compartment elements (urethra and bladder) are related at maximal Valsalva. STUDY DESIGN Women with a complete spectrum of pelvic support were recruited for a pelvic support study. Dynamic magnetic resonance scans were taken during Valsalva. A convenience sample of 153 women with a mean age of 53.3 +/- 12.5 (SD) years with a uterus in situ was studied. Anterior compartment status was assessed by the most caudal bladder point and the internal urinary meatus. The external cervical os was used to assess the apical compartment. The position of the bladder, urethra, and uterus were determined in 20 nulliparous women to determine their reference locations. The distances of each structure below the reference positions were calculated at maximum Valsalva. RESULTS Average distances of the bladder base, urethra, and uterus from the reference positions at maximal Valsalva were 4.1 +/- 2.4 cm, 3.1 +/- 1.3 cm, and 4.3 +/- 2.4 cm, respectively. The Pearson correlation coefficient of the relationship between the bladder base and uterine distances was r = 0.73 (r2 = 0.53). The Pearson correlation coefficient of the bladder distance and urethral distance was r = 0.82 (r2 = 0.67). CONCLUSION Half of the observed variation in anterior compartment support may be explained by apical support.
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Affiliation(s)
- Aimee Summers
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Abstract
Pelvic organ prolapse is prevalent among older women. Milder stages of prolapse, cranial to the hymen, are common and usually symptomless. A specific symptom is a bulge outside the vagina. Functional symptoms from the bladder, bowel and sexual life frequently coexist without a known cause/effect relationship to prolapse. Prolapse should be measured by the validated internationally approved pelvic organ prolapse quantification (POPQ) system that can measure prolapse in the three compartments and three levels of the vagina. We should work on a common classification system and agreement in which symptoms should be recorded as related to prolapse and expected to improve by prolapse surgery.
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Affiliation(s)
- Lone Mouritsen
- Department of Gynecology & Obstetrics, Glostrup Hospital, University of Copenhagen, 2600 Glostrup, Denmark.
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Abstract
Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, and enterocele, is a common group of clinical conditions affecting millions of American women. This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse. The evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often challenging for the clinician to determine which symptoms are attributable to the prolapse itself and will therefore improve or resolve once the prolapse is treated. When treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; and surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms require additional management. Virtually all women with prolapse can be treated and their symptoms improved, even if not completely resolved.
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Affiliation(s)
- Anne M Weber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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