SIMPLIFYING PELVIC ORGAN PROLAPSE - PowerPoint Presentation

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SIMPLIFYING PELVIC ORGAN PROLAPSE

Frank A.

Potestio

,

MSc

, MD, FRCSC

Associate Professor NOSM

Slide2

DISCLOSURE

No conflict of interest

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LEARNING OBJECTIVES

At the end of this session participants will be able to

Classify and quantify the compartments of pelvic organ

prolapse

(POP)

Plan the evaluation and appropriate referral of women with problematic POP

Select an ongoing maintenance and monitoring plan for women with a

pessary

in place

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CASE STUDY I

A 68

y.o

. female presents with pelvic pressure and a bulging vaginally. She also complains of urinary frequency and urgency, as well as

nocturia

. Examination reveals a stage 3 uterine

prolapse

with a stage 2

cystocoele

. The vagina is also atrophic. Urine culture 2 days ago was negative.

You recommend

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CASE STUDY I

Surgery to correct pelvic organ

prolapse

Use of a

pessary

Vaginal estrogen for

urogenital

atrophy

Medical therapy for overactive bladder

Referral to

urogynecologist

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INTRODUCTION

Pelvic hernia

Affects up to 50 % of

parous

women

10-20 % symptomatic

11 % undergo surgery by age 80

29 – 40 % reoperation within 3 years

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SYMPTOMS OF POP

Bulging

Pelvic pressure

Back ache

Bladder, bowel and sexual dysfunction

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RISK FACTORS

Parity

Intrinsic weakness or atrophy

Obesity

Hysterectomy

Constipation

Connective tissue disorders

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CONFOUNDERS

Urinary incontinence (latent)

Genitourinary syndrome of menopause

Urinary tract infections

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POP CLASSIFICATION

Anterior compartment

cystocoele

Posterior compartment

rectocoele

Apical compartment

uterine, vaginal vault,

enterocoele

anterior > posterior > apical

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BADEN-WALKER HALFWAY SYSTEM

Stage 0: no

prolapse

Stage 1: leading edge > 1cm above hymen

Stage 2: leading edge at level of hymen

Stage 3: leading edge > 1cm beyond hymen

Stage 4: complete

eversion

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POP QUANTIFICATION (POP-Q)

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ANATOMY OF PELVIC SUPPORT

Complex Interaction

Muscles (

levator

ani

)

Fasciae (

urogenital

diaphragm,

endopelvic

)

Ligaments (

uterosacral

, cardinal)

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PATHOPHYSIOLOGY OF POP

Attenuation or stretching of pelvic connective tissue

Site-specific breaks or tears

Anatomical defects in pelvic support

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PRINCIPLES OF SURGERY

Restore normal anatomy & function

Distal

plications

Site–specific repairs

Grafts, meshes bolster defect-specific repairs

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PROSPECT TRIAL (2017)

Synthetic mesh: biological graft: native tissue

Augmentation surgery did not improve outcomes in terms of effectiveness or quality of life

> 1/10 women had a mesh complication

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PESSARY FOR PROLAPSE

First-line treatment

70 – 90 % can be properly fitted

Bulging reduced in 70 – 90 %

Pressure symptoms relieved in 30 – 50 %

20 – 30 % continence rate

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TYPES OF PESSARIES

Support

ring,

Shaatz

, Smith, Hodge,

Gehrung

Space-occupying

cube, donut,

inflatoball

Combination

Gellhorn

Incontinence

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PESSARIES

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PESSARIES

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CHANGES IN POP SYMPTOMS AFTER PESSARY FITTING

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PESSARY CARE

Proper fitting and adequate patient education

Initial follow-up within 2-4 weeks

3 month follow-up if unable to perform self care

6 month or 1 year intervals if no complications arise

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CASE STUDY 2

The 68

y.o

. female who you successfully fitted with a ring

pessary

to manage her symptomatic

cystocoele

and uterine

prolapse

now presents at her 1 year follow-up with vaginal bleeding. She has been compliant with her routine 3 month

pessary

care visits with no concerns.

You recommend

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CASE STUDY 2

Cleaning & reinsertion of

pessary

with reassurance

Removal of

pessary

& examination (including swabs)

Pap smear

Endometrial biopsy

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PESSARY COMPLICATIONS

Erosions (2-9 %)

local pressure leads to

devascularization

Infections (2-3 %)

physiologic response to friction

Rarely major

vesicovaginal

fistulae, bowel fistulae, incarceration

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DISCONTINUATION OF PESSARY

Posterior wall

prolapse

Urinary incontinence

Complications

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SUMMARY

Examination documenting defects in pelvic support (compartment, stage)

Refer women who desire reconstructive surgery that restore normal support and function

Pessaries

should be considered in all women presenting with symptomatic

prolapse

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REFERENCES

Chan M et al., What are the Clinical Factors that are Predictive of Persistent

Pessary

Use at 12 Months? JOGC 2019;41(9):1276-1281.

Larouche

M et al.,

Transvaginal

Mesh Procedures for Pelvic Organ

Prolapse

. JOGC 2017;39(11):1085-1097.

Glazener

C et al. Mesh, Graft or Standard Repair for Women having Primary

Transvaginal

Anterior or Posterior Compartment

Prolapse

Surgery: Two Parallel-Group Multicentre

Randomised

, Controlled Trials (PROSPECT). Lancet 2017; 389(1):381-392.

Magali

R et al., Technical Update on

Pessary

Use. JOGC 2013;35(7):1276-1281.

Beckmann R et al. Pelvic Support Defects, Urinary Incontinence and Urinary Tract Infections. Obstetrics and Gynecology 7

th

edition 2014;30:277-286.

Rock J et al., Surgical / Nonsurgical Correction of Defects in Pelvic Support.

Telinde’s

Operative Gynecology 10

th

ed., 2011.

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CASE STUDY II

A 88

y.o

. female presents with painful vaginal vault

prolapse

and has tried a number of

pessaries

without success. She had an abdominal hysterectomy 40 years ago. Medical review reveals CAD with persistent angina and moderate COPD from prior smoking. She desires surgical correction if possible and is not sexually active. The most reasonable procedure for her is

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CASE STUDY II

Transabdominal

sacrocolpopexy

Sacrospinous

ligament suspension

LeFort

partial

colpocleisis

Total

colpocleisis

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POP QUANTIFICATION

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POP STAGING

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PELVIC SUPPORT ANATOMY

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PELVIC SUPPORT ANATOMY

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PATHOPHYSIOLOGY (LEVEL I)

Damage to support at or above the

ischial

spines

Involves primarily

uterosacral

ligaments and lesser extent cardinal ligaments

Uterovaginal

prolapse

,

posthysterectomy

vault

prolapse

,

enterocoele

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PATHOPHYSIOLOGY (LEVEL II)

Lateral

midvaginal

support is severed to pelvic sidewall

Involves

endopelvic

fasciae attachment to

arcus

tendineus

fascia

Paravaginal

and

pararectal

defects

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PATHOPHYSIOLOGY (LEVEL III)

Damage to fusion of

urogenital

diaphragm

anteriorly

or proximal perineum

posteriorly

Central defects of fabric of

pubocervical

and

rectovaginal

septa

Cystocoele

,

rectocoele

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PELVIC SUPPORT DISORDERS

Historic: attenuation or stretching of pelvic connective tissue

Recent: site-specific breaks or tears in connective tissue

Identifiable anatomical defects in pelvic support (Levels I,II,III)

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LEVEL OF SUPPORT

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PESSARIES

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PESSARIES

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PREGNANCY

Prolapse

or urinary retention secondary to incarcerated uterus

Decrease preterm birth in parturient women with shortened cervix (< 25 mm)

Use for incontinence not yet described

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PROCEDURES FOR POP

Anterior and posterior

colporrhaphy

McCall

culdoplasty

Sacrospinous

and

uterosacral

ligament vault suspensions

Abdominal / laparoscopic sacral

colpopexy

colpocleisis

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GRAFT USE IN PELVIC FLOOR SURGERY

Synthetic

polypropylene

Xenografts

porcine dermis, porcine small intestine

submucosa

Allografts

cadaveric

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TRANSVAGINAL MESH PROCEDURES

Address specific anatomical defects of the pelvic floor

Maintain durability of repair

Adverse

sequelae

include mesh erosion,

dyspareunia

, pelvic pain, mesh shrinkage, de novo stress incontinence