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1 How to Treat PULL-OUT SECTION Complete How to Treat quizzes online /cpd to earn CPD or PDP points. INSIDE Comprehensive assessment Primary pelvic organ prolapse surgery Recurrent vaginal prolapse Mesh surgery Complications and prognosis the author Associate Professor Bernard Haylen consultant urogynaecologist, St Vincent s, Mater and Prince of Wales Private Hospitals, Sydney; and conjoint associate professor, University of NSW, Sydney, NSW. Pelvic organ prolapse Part 2 This is the second week of a two-part series on pelvic organ prolapse. Last week, we discussed the nature of prolapse and conservative methods of management. This week, we explore the comprehensive assessment of a more complicated pelvic organ prolapse and its management. Introduction PART 1 of this update on pelvic organ prolapse outlined the epidemiology, definitions and staging, pathogenesis, clinical presentations and assessment and conservative management. It highlighted that prolapse was common, affecting up to half the adult female population, with a lifetime risk of requiring surgery up to 19%. 1 Prolapse is well defined with a clear staging schema. 2,3 A thorough primary clinical assessment involves little addition to a routine gynaecological examination. Most prolapse is early stage and is either mildly symptomatic or asymptomatic. Conservative management is appropriate initially in most clinical situations. However, as outlined at the end of Part 1, there are times when specialist referral for a comprehensive evaluation is required (see box below). For example, patients may present with a complicated clinical picture of multiple symptoms in addition to prolapse symptoms, such as symptoms of voiding or anorectal dysfunction, urinary incontinence or other symptoms. Alternatively, where the diagnosis is made, the required surgical treatment may only be provided by the specialist or subspecialist. In patients whose symptoms are prolonged or moderate to severe, or where initial conservative measures have failed, a specialist may be able to provide a more comprehensive assessment and management. Recurrent prolapse is another clear indication for offering specialist assessment. Clinical scenarios where specialist referral may be appropriate Diagnosis uncertain Surgical treatment desired Symptoms prolonged or moderate to severe Conservative measures fail Recurrent prolapse cont d next page Copyright 14 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the publisher. For permission requests, [email protected] 28 February 14 Australian Doctor 23

2 How To Treat Pelvic organ prolapse Part 2 Comprehensive assessment AS noted in the introduction, the need for a more comprehensive assessment of the interaction between pelvic organ prolapse and lower urinary tract function has been increasingly recognised. Up to 70% of gynaecologists in Australia and New Zealand would seek urodynamic assessment prior to major prolapse surgery. 4 With an urodynamic assessment, goals and outcomes for prolapse interventions in terms of lower urinary tract function can be determined. Surgeons can tailor the interventions appropriately, and duly counsel their patients, with the minimisation of adverse functional outcomes. Effects of prolapse interventions on anorectal dysfunction are, unfortunately, less predictable. There may, at times, be delays between primary and referred assessments or further delays until surgical interventions occur. If infective or inflammatory symptoms such as recurrent UTI, frequency, urgency and/or dysuria are present, MSU should be performed and UTI treated as indicated. It is my practice to then recommend antibacterial hexamine (Hiprex) 1g bd each with vitamin C 500mg as UTI prophylaxis. Urodynamic studies Urodynamics is formally defined as the functional study of the lower urinary tract. 2 The clinical sequence of urodynamic testing involves a woman attending with a comfortably full, assessment for stress incontinence with a fuller, free (ie, no catheter) uroflowmetry and post-void residual urine volume measurement. Prolapse is then assessed with the empty prior to filling and voiding cystometry. 2 Voiding function Prolapse will often have a negative impact on voiding function. Uterine prolapse, cystocoele or vaginal vault descent have a kinking effect, while rectocoele causes a pressure effect on outflow. The two main basic parameters of voiding function are uroflowmetry and the post-void residual urine volume. In the clinical sequence of testing, uroflowmetry precedes the post-void residual urine volume. Uroflowmetry This is the study of urine flow over time to achieve urine flow rates maximum and average urine flow rates for variable voided volumes. These data can be referenced to nomograms that plot the dependency of urine flow rates on voided volume. 5 Repeated measurements under the 10th percentile of the nomogram for both readings would be deemed to be abnormally slow. Most commercial uroflowmeters are accurate once calibrated. Figure 1A shows the schematic representation of urine flow over time while figure 1B shows the Liverpool Nomogram for the maximum urine flow rate. 2,5 A Urine flow rate (ml/ second) Voided volume (ml) Time to maximum urine flow rate (seconds) Figure 1: A: Schematic representation of urine flow over time. 2 B: The Liverpool nomogram for the maximum urine flow rate in women. 2 A Post-void residual This can be measured, following initial assessment, as part of a renal tract ultrasound looking for underlying causes of recurrent UTI or other urinary tract symptoms. Most convenient urogynaecological assessment is by transvaginal or perineal ultrasound. 6,7 As most post-void residual urine volume readings tend to be low, transabdominal ultrasound is less accurate. Catheterisation (most accurately by a short plastic catheter) is a less accurate and more invasive alternative. With ultrasound, the post-void residual urine volume can be checked by an immediate second attempt at voiding (figure 2). 8 Voiding function and prolapse It has been shown that increasingstage prolapse correlates with an increasing post-void residual urine volume (figure 3) and slower urine flow. 8,9 More sophisticated testing with voiding cystometry is available to determine the function of the detrusor musculature during voiding. A chronic post-void residual urine volume of over 30mL has been shown to be associated with a significant increase in the prevalence of recurrent UTI, which is a most common clinical association of prolapse. 10 It can be expected that surgical treatment of prolapse will improve voiding parameters (with little or no post-void residual urine volume and improved urine flow) and symptomatic function and reduce the prevalence of recurrent UTI. Flow time (seconds) Maximum urine flow rate (MUFR-mL/second) - Q max Average urine flow rate (AUFR-mL/second) - Q ave Time (seconds) Incontinence and other lower urinary tract symptoms Prolapse, voiding dysfunction and recurrent UTI all have a prevalence of at least 10% in women with symptoms of lower urinary tract dysfunction presenting for comprehensive assessment. There are three other diagnoses that are similarly prevalent, namely, urodynamic stress incontinence, detrusor () overactivity and oversensitivity. Each of these can occur concurrently with prolapse, again influencing expectations and management including patient counselling. 2 Urodynamic stress incontinence Urodynamic stress incontinence (USI) is defined as involuntary leakage, associated with increased intra-abdominal pressure, in the absence of detrusor contraction. 2 Establishing this conclusively requires the urodynamic investigation of filling cystometry, although the sign of clinical stress leakage or leakage that occurs simultaneously with coughing or other causes of raised intra-abdominal pressure is strongly suggestive. Sometimes prolapse can conceal this sign. The occult stress incontinence may only be revealed with prolapse reduction. A clear diagnosis of urodynamic stress incontinence often prompts B Maximum urine flow rate (ml/second) Voided volume (ml) Figure 2: A: An image of post-void residual of 65mL by transvaginal ultrasound. B: This reduces to 4mL with a subsequent attempt at voiding. 6 B Per cent < >62 Age (years) counselling that a continence procedure may be needed at the time of a proposed prolapse procedure. This is a very common occurrence. It should be discussed with the patient preoperatively, when appropriate counselling can occur, rather than postoperatively when it can create patient dissatisfaction from a prolapse problem that was replaced with an incontinence problem. 95th 90th 75th 50th 25th 10th 5th No prolapse Grade 1 Grade 2 Grade 3/4 All patients Figure 3: Graph showing percentage of women with a higher than normal (over 30mL) post-void residual urine volume with age for differing stages of prolapse. 8 Detrusor overactivity and oversensitivity Detrusor overactivity is defined as the presence of involuntary detrusor contractions during filling cystometry. 2 Bladder oversensitivity is defined as increased perceived sensation during filling and decreased (maximum cystometric) capacity in the absence of any abnormal increases in pressure. 1 Both of these diagnoses, generally associated with symptoms such as nocturia, urgency, urge incontinence and frequency, rely on filling cystometry to confirm. Figure 4 shows a schematic diagram of filling cystometry showing detrusor overactivity. The different lines of the trace show filling volume; 24 Australian Doctor 28 February 14

3 P ves cmh 2 0 or the pressure during filling; P det cmh 2 0 or the detrusor (true ) pressure (P ves P det ) during filling; P abd cmh 2 0 or the abdominal (generally rectal) pressure during filling; and flow rate (ml/ second). These diagnoses may occur in association with prolapse and it is important to know they exist although there is no established direct relationship with prolapse. From a preoperative counselling point of view, one could suggest to a patient that anatomical restoration might see some relief although perhaps not cure, with ongoing medical treatment possibly necessary. Ultrasound and other imaging Transvaginal or translabial ultrasounds are very important in assessing postvoid residual urine volume and the uterine orientation. Ultrasound is also commonly used to assess neck and urethral morphology and mobility pre- and postoperatively, and to assess the descent of pelvic organs. An audit of my routine use of office-based 2D transvaginal ultrasound shows an 8% detection rate of significant pathology. 2 These include intercurrent pelvic pathology (eg, uterine especially large or fibroid uteri, endometrial, adnexal), abnormalities (eg, tumour, foreign body), and urethral abnormality (eg, diverticulum). These significant pathologies may not have been detected clinically and their detection carries the potential to alter management. More sophisticated analysis of soft tissue pelvic floor or levator defects generally requires the use of 3D or 4D ultrasound. 2 Radiological studies such as videocystourethrography, or the synchronous radiological screening of the and abdominal pressures Fill volume pves cmh2o pdet cmh2o pabd cmh2o Flow rate FD = first desire to void, ND = normal desire to void, SD = strong desire to void, U = urgency, L = leakage, MCC = maximum cystometric capacity Figure 4: Urodynamic studies of a 52-year-old female with urgency and frequency showing phasic detrusor activity during filling. Leakage is associated with urgency and detrusor contractions. Table 1: Common diagnoses in women who present for comprehensive specialist assessment including urodynamics with symptoms of lower urinary tract dysfunction of pelvic organ prolapse Diagnosis Prevalence Pelvic organ prolapse 61% Urodynamic stress incontinence up to 72% Detrusor overactivity 13-% Bladder oversensitivity 10-13% Voiding dysfunction 14-39% Recurrent UTIs 11% or 19%* *Figure depends on whether the cut-off is three or two symptomatic and medically diagnosed UTIs in the previous 12 months. Source: Haylen et al. IUGA-ICS Terminology Report. 2 during filling cystometry, are used less routinely than years ago. 2 IV urography, often by CT, may be used if upper urinary tract pathology is suspected. A micturating cystogram can be useful to evaluate vesico ureteric reflux, some fistulae and diverticulae. 2 Defecatory function Pelvic organ prolapse, particularly posterior vaginal compartment prolapse, can impact on defecatory function. Particular care is needed in anatomical restoration of the posterior vaginal compartment to avoid Filling cystometry Voiding cystometry FD ND SD U L U L MCC any negative impact on both defecatory and sexual functions. Restoration of the posterior vaginal anatomy in a systematic way is likely to result in a more satisfactory anatomical and functional result than less comprehensive ad hoc and subjective approaches. This restoration would be done in a way in which all defects from the vaginal vault to the perineum are addressed. In some cases, there may be a need for additional specialised anorectal functional assessment. This generally falls under the specialty of colorectal Primary pelvic organ prolapse surgery A VERY common presentation is that all three vaginal compartments (anterior, central, posterior) have prolapsed together to a variable degree (figure 6). Surgical management may be indicated if the patient is symptomatic, the diagnosis is confirmed objectively and if conservative measures are not deemed appropriate. The aims of surgery would be both anatomical and functional. These would include restoration of all anatomical defects, preservation or improvement of voiding function (and reduction in the number of UTI associated with higher post-void residual urine volumes), preservation or improvement of defecatory function, preservation or improvement of sexual function and the appropriate management Anterior repair (colporrhaphy) Anterior colporrhaphy is the repair of the anterior vaginal pro- cont d next page Figure 6: The very common clinical scenario of concurrent uterine prolapse, cystocoele and rectocoele. (Illustrations available at Used with permission from Dr Levent Efe, CMI.) A B C Figure 5: Stages of pelvic organ prolapse. 2 A: Stage II anterior vaginal wall prolapse. B: Stage III uterine prolapse. C: Stage IV vaginal vault prolapse. of any actual or potential coexistent urinary incontinence issues. If preservation of future fertility is not desired, the most common option in Australia and New Zealand is a vaginal hysterectomy, anterior and posterior repair. 4 Vaginal hysterectomy This is usually a three-pedicle procedure. Recently the first pedicle was anatomically confirmed as a confluence of the cardinal and uterosacral ligaments, thus entitled the cardinal uterosacral confluence (figure 7A, see next page). 11 It is usual to attach these shortened pedicles bilaterally into the vaginal vault to provide post-hysterectomy vaginal vault support and lessen the risk of subsequent vaginal prolapse (figure surgery rather than gynaecology or urogynaecology. The most common investigations performed are endosonography (anal ultrasound), defecography and a functional study of anorectal physiology. Endosonography is the gold standard investigation in the assessment of anal sphincter integrity. There is a high incidence of defecatory symptoms in women with anal sphincter defects. Defecography demonstrates normal anatomy of the ano as well as disorders of rectal evaluation. Barium paste is inserted rectally and radiographs of the defecation are taken with the patient positioned over a radiolucent commode. Rectocoeles, enterocoeles, rectal intersussception and mucosal prolapse may be diagnosed as well as pelvic floor spasm (anismus). Common diagnoses after a comprehensive assessment About 61% of women presenting for urogynaecological assessment will have some degree of pelvic organ prolapse, not always symptomatic. The diagnosis of pelvic organ prolapse by symptoms and clinical examination, assisted by relevant imaging, involves the identification of descent of one or more of the anterior vaginal wall (central, paravaginal or combination cystocoele), posterior vaginal wall (rectocoele), the (cervix) or the apex of the vagina (vaginal vault or cuff scar) after hysterectomy (figure 5). The presence of any such sign should correlate with relevant prolapse symptoms. Other diagnoses Other common diagnoses include urodynamic stress incontinence, detrusor overactivity, oversensitivity, voiding dysfunction, and recurrent urinary tract infections (table 1). 7B, see next page). 4 Recent studies confirm that good support using the strong cardinal and uterosacral ligaments is routinely possible. 11 However, this ligamentous support only influences the anterior vaginal vault. 12 Depending on the intraoperative findings, additional posterior vaginal vault support (eg, sacrospinous colpopexy) may be required. This is common practice. If the prolapsing has large fibroids, or there is intercurrent adnexal or other uterine pathology, occasionally an abdominal approach (laparoscopic or open) may be required. 28 February 14 Australian Doctor 25

4 How To Treat Pelvic organ prolapse Part 2 from previous page lapse by excision and suturing of redundant vaginal skin plus the repair of damaged fascia. It is the preferred primary repair of 54% of Australian and 77% of UK gynaecologists, based on surveys in the UK in 07 and Australia in 10. 4,13 There was an increasing use of prostheses (mesh) between these two surveys. A variety of techniques are used. The aim is to open the vesico vaginal space, repair generally by plication any damaged fascia (variably called the pubovesical or prevesical) thus displacing the superiorly, then excise the redundant skin, and finally close the vaginal wall (figure 8). Posterior repair (colporrhaphy) Posterior repair involves excising any introital scarring or other defects, opening the recto-vaginal space, repairing any damaged fascia (thus displacing the posteriorly), excising the redundant skin, and finally closing the vaginal skin (figure 9). As discussed earlier, to address all defects from the vaginal vault to the perineum, and to try to avoid any negative impact on both defecatory and sexual functions, particular care is needed in anatomical restoration of the posterior vaginal compartment. Figure 7: The anatomy of the uterine suspensory ligaments: A: Diagrammatically represented. The cardinal ligament (CL) provides lateral and slightly posterior support to the (preoperatively) and vaginal vault (posthysterectomy) while the uterosacral ligament (USL) provides support superoposteriorly. B: Cardinal uterosacral confluence (CUSC), the first pedicle of a vaginal hysterectomy seen at time of surgery. Fascia Uerus Rectum Uerus Rectum Stitch vaginal skin Fascia Figure 9: Posterior vaginal wall repair (colporrhaphy). A: Posterior vaginal prolapse. B: Opened recto-vaginal space and repairing damaged fascia by plication. C: Closing the posterior vaginal wall. (Illustrations available at www. medicalartbank.com. Used with permission from Dr Levent Efe, CMI.) sacrum Additional posterior vaginal vault support at vaginal hysterectomy The two most common options to add additional posterior vaginal vault support at vaginal hysterectomy are sacrospinous colpopexy ( hitch ) and McCall culdoplasty. 4 Sacrospinous colpopexy Sacrospinous colpopexy (fixation or hitch ) is used to support the posterior aspects of the vaginal vault by attachment to the sacrospinous ligament, between the sacrum and ischial spine (figure 10). This is the strongest vaginal supportive ligament in the pelvis (stronger than the uterosacral ligament). New techniques using a fine, generally permanent suture applicator have minimised invasiveness and improved ease and safety of surgery. There is the tendency for the vaginal axis to be slightly posteriorised, increasing the risk of recurrent cystocoele. 4,14 fascia stitch vaginal skin Figure 8: Anterior vaginal wall repair (colporrhaphy). A: Anterior vaginal prolapse. B: Opened vesico-vaginal space and repairing damaged fascia by plication. C: Closing the anterior vaginal wall. (Illustrations available at www. medicalartbank.com. Used with permission from Dr Levent Efe, CMI.) McCall culdoplasty McCall culdoplasty improves vaginal vault support at vaginal hysterectomy. The technique involves inserting one or more sutures in a continuous path from vaginal vault skin (mucosa) through one uterosacral ligament (USL) alone across the peritoneum of the pouch of Douglas, through the contralateral USL and out through vaginal skin. 15 Studies have shown some satisfactory longer-term results. Preserving fertility When fertility or uterine preservation is desired, 62% of Australasian gynaecologists initially recommend a trial with a ring or other pessary. 4 Surgically there are several options. These include the following, with the level of preference among Australasian gynaecologists in a 10 survey given in parentheses: Laparoscopic hysteropexy (39%). Sacrospinous hysteropexy (27%). Manchester (Fothergill) repair (9%). Abdominal sacrocolpopexy (7%). Laparoscopic hysteropexy A range of laparoscopic uterine supportive procedures have been developed. Some of these would involve USL fixation or plication in the intermediate segment of the USL. 16 Care pubic bone pelvic floor muscles labia stitches in ligament has to be taken to avoid ureteric, nerve or vascular involvement. 16,17 A further range of procedures involves attachment of mesh retroperitoneally from the rear of the uterine isthmus to the sacrum (ie, mesh sacrohysteropexy). The principle is similar to that of a vaginal vault suspension to the sacrum (ie, mesh sacrocolpopexy). Sacrospinous hysteropexy Sacrospinous hysteropexy, generally combined with an anterior and posterior colporrhaphy is a common option. Sacrospinous vaginal vault sacrospinous ligaments Figure 10: Sacrospinous colpopexy. Attachment of the vaginal vault (posterior aspect) to the (generally unilateral right) sacrospinous ligament. (Illustrations available at Used with permission from Dr Levent Efe, CMI.) support is on the posterior aspects of the uterine cervix. Manchester (Fothergill) repair Manchester (Fothergill) repair is a very traditional option that is less commonly used these days. This method amputates a variable degree of the cervix, shortens the cardinal uterosacral confluence bilaterally before approximating the latter over the anterior cervix. 18 The skin over the cervix is then reconstituted and any colporrhaphies required are then performed. Recurrent vaginal prolapse RECURRENT vaginal prolapse commonly involves the vaginal vault. The need for recurrent prolapse surgery is not infrequent. While there are a large number of surgical and patient variables that may be contributory, failure of the vaginal vault support is common. It has been shown that about 50% of cystocoele is due to vaginal vault descent while my current (unpublished) research has shown that about 54% of posterior mid-vaginal laxity is due to posterior vaginal vault descent. 19 Repeat colporrhaphy may, at times, be more challenging than the equivalent primary procedures, although the techniques should be similar. There is a general need to assess for and manage any accompanying vaginal vault failure. The choice of pelvic ligamentous support for the vaginal vault is restricted to either the sacrospinous and uterosacral ligaments with the cardinal ligament no longer accessible post-hysterectomy. 11 The main bony support is the sacrum. In a 10 Australasian survey, for post- hysterectomy vaginal vault prolapse the procedure of choice was: Sacrospinous colpopexy and repair (37%). Vaginal mesh repair (33%). Abdominal sacrocolpopexy and repair (11%) (although, if there were a current survey, it may well indicate an increasing trend towards laparoscopic sacrocolpopexy). Uterosacral ligament suspension and repair (9%). 4 Sacrospinous colpopexy This procedure is as previously described, generally combined with an anterior and posterior colporrhaphy. Sacrospinous support is on the posterior aspects of the vaginal vault. Vaginal mesh repairs A vast range of these synthetic cont d page Australian Doctor 28 February 14

5 How To Treat Pelvic organ prolapse Part 2 from page 26 (some biological) products has come onto, and off, the market. These will be covered in the mesh surgery section (see below on this page). Laparoscopic or open sacrocolpopexy This involves the use of sutures or more commonly mesh to attach the vaginal vault to the sacrum (figure 11). The final position of either should be retroperitoneal to minimise bowel complications. At the distal end, mesh is attached to both anterior and posterior vaginal walls. Mesh surgery hip bone vagina L5 Uterosacral (bilateral) fixation procedures Intraperitoneal and extraperitoneal techniques are available to fix the vaginal vault bilaterally to the uterosacral ligaments. -22 A midline plicatory extraperitoneal technique also exists. 23 The extraperitoneal techniques generally involve associated anterior and posterior colporrhaphy. sacrum Figure 11: Sacrocolpopexy: mesh from the sacrum supporting the anterior and posterior aspects of the vaginal vault and walls. (Illustrations available at www. medicalartbank.com. Used with permission from Dr Levent Efe, CMI.) uterosacral ligaments vagina The choice of technique for vaginal vault support will be based on a variety of patient clinical features, surgeon experience and success rates both anatomically and functionally, weighed Figure 12: Uterosacral ligament suspension. In the recurrent prolapse scenario, the most common techniques are intra- or extraperitonal bilateral fixation of the vaginal vault to the uterosacral ligaments. (Illustrations available at www. medicalartbank.com. Used with permission from Dr Levent Efe, CMI.) up against the risks of intraoperative and postoperative complications. THE use of prostheses in pelvic organ prolapse repairs increased from 02 to 10, as improved anatomical results became available. Functional results were perhaps, in earlier times, a secondary consideration. However, as complications became more frequently reported, the US Food and Drug Administration issued alerts in 08 and 11 that adverse events from vaginal mesh were no longer considered rare. An accompanying literature search concluded that most cases of prolapse could be treated without mesh and there was no compelling evidence that vaginal mesh repairs were more successful or durable than conventional surgery. This was particularly true for the vaginal vault and posterior vaginal compartments. 25 This and other recommendations influenced the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, American College of Obstetricians and Gynecologists and the American Urogynecology Society Following this, there was an up to % reduction in the use of vaginally implanted mesh. One manufacturer has withdrawn wholly from this market and there has been much published debate including some input from this author and international colleagues. 28 Joint Urogynaecological Society of Australasia (UGSA)/ RANZCOG recommendations are available on the issues of informed patient consent; surgical training; monitoring of efficacy and safety of implants; and who would benefit from a transvaginal mesh implant. 25 While the careful use of intraabdominal (retroperitoneal) mesh is desirable in selective prolapse surgeries (sacrocolpopexy, sacrohysteropexy), the use of vaginal mesh remains controversial. Each clinician will need to acknowledge the above FDA/College/Society statements and any available evidence to determine whether POP surgeries using mesh are in the best interests of their patients, overall or selectively. 29 This policy should be no different when considering the different native tissue prolapse surgeries, each having different success and complication rates. 30 Since May 09, I have adopted an expectant approach to prosthetic use in prolapse surgeries, ceasing the use of vaginal mesh for prolapse and concentrating on optimising the knowledge and use of native tissues in prolapse surgeries. 11,12,16,23 It should be noted that the term prostheses used in prolapse surgeries refers to meshes. Tapes used for incontinence surgeries involve the use of a much smaller amount of prosthetic material. 24 Tapes are still very much the mainstay of continence surgeries. Definitions of these are given in the box. Definitions Prosthesis: A fabricated substitute to assist a damaged body part or to augment or stabilise a hypoplastic structure. Mesh: A (prosthetic) network fabric or structure; open spaces or interstices between the strands of the net. The use of this term would be for prolapse surgery with synthetic materials. Tape (sling): A flat strip of synthetic material. The use of this term would be for incontinence surgery with synthetic materials. Source: Haylen, et al. 24 Complications and prognosis Complications ALL surgeries may be associated with complications. In surgical selection, the aim should always be to minimise the risk of complications. In the case of untreated pelvic organ prolapse, there may be varying levels of discomfort and interference with lifestyle, even though the pathology is benign. One would not wish to create unwanted anatomical issues or urinary tract, defecatory or sexual functional morbidity that may be harder to correct. Worst of all, one would not wish to leave the patient with chronic somatic or neuropathic pain requiring the ongoing use of analgesics. Prognosis Primary surgery for pelvic organ prolapse, in experienced hands, can have very good medium-term success rates. Care needs to be taken in identifying all the compartments involved. Particular attention to the vaginal vault is needed. Most commonly the cardinal-uterosacral confluence at vaginal hysterectomy is shortened and attached to the vaginal vault to prevent subsequent vaginal prolapse. As indicated, a sacrospinous colpopexy or McCall culdoplasty can provide additional posterior vault support as needed. The area most prone to recurrence is the anterior compartment, particularly higher stage (III or IV) cystocoele. Even in such cases, if most of the cystocoele is due to vaginal vault descent and this area is effectively supported, good long-term success is still possible. Surgery for recurrent vaginal prolapse can also be successful with many satisfactory options. To an even greater degree, attention needs to be directed to vaginal vault defects to ensure such results. Even more so than primary surgeries, complications need to be kept in mind. The surgeries are clearly best performed by experienced hands after comprehensive assessment. Case study DENISE is a 57-year-old who presents with a 12-month history of a bulge at the vaginal introitus, which is worse when she is on her feet and at the end of the day. She also reports some suprapubic pressure and low backache, also worse in the evening. She had undergone a vaginal hysterectomy, anterior and posterior repair at age for stage II uterovaginal prolapse (retroverted ). Recently she has been performing a lot of lifting of her ailing mother prior to the latter s passing. She has been experiencing symptoms of incontinence (postural) when getting out of bed or a car, or sometimes after sitting for a long time, as well as with any running. There is occasional urge incontinence. She noted her micturition is definitely slower with the sense of incomplete emptying. She has experienced about four UTIs in the past 12 months. There is no other relevant history. Her GP examines her and confirms it is a recurrent stage II vaginal prolapse. Referral for comprehensive assessment is clearly indicated because mixed diagnoses are likely, the prolapse is recurrent, the symptoms are relatively prolonged, definitive treatment is likely to be required, and the role for conservative management is not apparent. An MSU is arranged that shows a UTI. Appropriate antibiotics are arranged followed by prophylaxis using hexamine (Hiprex) 1g taken with vitamin C 500mg each twice a day. At her urogynaecological consultation, a full history is again taken with nothing more to note. With a comfortably full presenting volume, the prolapse is reduced with a Sims speculum and Denise asked to cough. Clinical stress leakage is readily apparent. Uroflowmetry is then performed in a private room. The trace shows an initial satisfactory urine flow, however there is considerable slowing and some interruption of the flow towards the end of the 2mL void. There can often be a prolapse effect on voiding as the volume decreases. Maximum urine flow rate is on the th percentile of the respective nomogram while the average urine flow rate is around the 5th percentile. Immediate post-void residual urine volume using transvaginal ultrasound shows a residual of 45mL (enough to account for recurrent UTI) which Denise could not clear with a subsequent attempt at voiding. Clinical examination for prolapse with the as empty as possible reveals a definite stage II cystocoele, stage I vaginal vault descent (cuff seen halfway down the vagina) and a close to stage II rectocoele. Filling cystometry is then performed with a normal capacity of 4mL. There had, however, been two abnormal contractions at about 15cmH 2 O during filling, consistent with a diagnosis of mild detrusor overactivity. Stress incontinence is elicited both in the left lateral (Sims) position with the prolapse reduced and the standing position at capacity. Voiding from the larger volume is much improved with better urine flow (maximum urine flow rate 50th percentile, average urine flow rate th percentile) and less terminal slowing and an immediate post-void residual urine volume down to 15mL. The voiding detrusor cont d page Australian Doctor 28 February 14

6 How To Treat Pelvic organ prolapse Part 2 from page 28 pressure is slightly increased (about cmh 2 O). This improvement in micturition parameters when voiding from a higher volume is complementary to the prolapse effect on micturition at lower voided volumes. Denise thus has five diagnoses after comprehensive clinical and urodynamic assessment: Recurrent UTI (on history). Stage II pelvic organ prolapse (cystocoele, rectocoele, vaginal vault descent). Voiding dysfunction (abnormally slow free uroflowmetry and high post-void residual urine volume). Urodynamic stress incontinence (partially protected by the obstructive effect of the prolapse and likely to be revealed to an even greater degree by prolapse surgery. Mild detrusor overactivity. After appropriate preoperative counselling, Conclusion THE management of more advanced and symptomatic prolapse is far more complicated than merely identifying the cause and arranging surgery. It involves the interpretation of possible pathogenesis and all relevant symptoms, signs, prolapse and intercurrent diagnoses. There may Denise chooses surgical management, undergoing a sacrospinous colpopexy, anterior and posterior repair for the prolapse and voiding dysfunction, with a concomitant retropubic stress incontinence for the urodynamic stress incontinence. At her seven-week postoperative visit, the prolapse and the stress incontinence are symptomatically cured with minimal urinary urgency and defecatory function much improved. Post-void residual urine volume is zero with Denise staying on the Hiprex/vitamin C regime until this visit. A very satisfactory anatomical result is achieved and sexual comfort is likely. Denise is kept on the same UTI prophylaxis for a further three months. At the subsequent visit, the improvement in prolapse, urodynamic stress incontinence, voiding and defecatory function are maintained. Denise is sexually comfortable, no urgency is being experienced, post-void residual urine volume is zero and the UTI prophylaxis is discontinued. still be a role for conservative management (eg, pessary) for a time. Surgical options need clear aims, with the clinician adhering to the best evidence-based techniques available.the principle primum non nocere (first do no harm), should be kept in mind, as benign pathology is involved. Summary Referral for comprehensive specialist assessment is indicated for higher-stage prolapse with symptoms of other organ involvement, recurrent prolapse or if conservative measures have failed. Comprehensive specialist assessment involves confirming the anatomical diagnosis of the pelvic organ prolapse and if any of the five common urodynamic diagnoses (voiding dysfunction, urodynamic stress incontinence, detrusor overactivity, oversensitivity, recurrent UTI) are present. The most common primary surgery for stage II uterine and vaginal prolapse, where uterine preservation is not required, is a vaginal hysterectomy, with anterior and posterior repairs. Pessary use is the most popular first operation for the same scenario when fertility preservation is required. However, there are several effective surgical options. Surgery for recurrent vaginal prolapse can be safe and effective, provided attention is paid to the diagnosis of any vaginal vault defects. The use of mesh in vaginal approaches to pelvic organ prolapse surgeries remains controversial. Its use in more complex abdominal pelvic organ prolapse surgeries is increasing. Online resources Bladder/Urogynaecology/Prolapse (author s own website) References Available on request from [email protected] Acknowledgements Associate Professor Bernard Haylen thanks medical illustrator Dr Levent Efe (illustrations available at and the International Urogynecological Association (IUGA) including public relations committee chair Dr Lynsey Haywood and administrator Maureen Hodgson for use of the excellent POP anatomical and surgical diagrams. He also acknowledges his gynaecological Fellows at St Vincent s Hospital Dr Dianne Avery and Dr Tin Lok Chiu who assisted with different aspects of literature search and review. How to Treat Quiz Pelvic organ prolapse Part 2 28 February 14 Instructions Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes by post or fax. The mark required to obtain points is %. Please note that some questions have more than one correct answer. GO ONLINE TO COMPLETE THE QUIZ /education/how-to-treat 1. Which THREE components may be part of the comprehensive assessment of pelvic organ prolapse? a) Urodynamic studies to assess goals and outcomes for prolapse interventions b) Colonoscopy to exclude diverticular disease c) Investigations of defecatory function in select cases d) Filling cystometry to assess detrusor activity 2. Which TWO statements are correct regarding the use of urodynamics studies in pelvic organ prolapse? a) Uroflowmetry may help identify significant reductions in urine flow rates that may be caused by a prolapse b) Catheterisation to assess post-void residual urine volume is much more accurate and preferable to a transvaginal ultrasound c) Post-void residual urine volume assessment can help ascertain the cause of recurrent UTIs in patients with prolapse d) Urodynamic studies are not recommended prior to major prolapse surgery 3. Which TWO statements are correct regarding the assessment of incontinence and other lower urinary tract symptoms (LUTS) in pelvic organ prolapse? a) Prolapse, voiding dysfunction and recurrent UTI all have a prevalence of less than 1% in women with symptoms of lower urinary tract dysfunction presenting for comprehensive assessment b) Establishing urodynamic stress incontinence and the cause of LUTS conclusively requires filling cystometry c) Assessing for urodynamic stress incontinence before prolapse surgery may highlight the need for a concomitant continence procedure d) Prolapse will greatly exaggerate any preexisting stress incontinence or LUTS 4. Which TWO statements are correct regarding the use of ultrasound and other imaging techniques in the comprehensive assessment of pelvic organ prolapse? a) Transvaginal ultrasounds are useful in assessing post-void residual urine volume and the uterine version b) Ultrasound is too inaccurate to assess neck or urethral problems c) Ultrasound has a detection rate of 8% of other significant pathologies if used concurrently with urodynamic assessment d) Videocystourethrography to screen and abdominal pressures during filling cystometry are the gold standard for assessing prolapse effect on the 5. Which TWO statements are correct regarding the primary surgical management of pelvic organ prolapse? a) An essential objective of primary surgical management of prolapse is the appropriate management of concomitant urinary incontinence issues b) The aim of primary surgical management of prolapse is purely functional, not anatomical restoration c) If fertility or uterine preservation is desired in the primary surgical management of prolapse and associated symptoms, surgery is the first-line treatment of choice d) If future fertility is not desired, the most common option of primary surgery for prolapse is a vaginal hysterectomy, anterior and posterior repair 6. Which TWO statements are correct regarding the use of meshes in the management of pelvic organ prolapse? a) Adverse events from vaginal mesh are considered rare b) There is no compelling evidence that the use of vaginal mesh showed greater success rates or durability over conventional surgery c) In common usage, the term prosthesis in prolapse surgery refers to both mesh and tapes d) The careful use of intra-abdominal (retroperitoneal) mesh is recommended in selective prolapse surgeries 7. Which TWO statements are correct regarding the complications and prognosis of pelvic organ prolapse surgery? a) About 50% of recurrent cystocoeles are due to vaginal vault descent b) Despite surgical cure of prolapse, post-void residual urine flow and urine flow can still be expected to be poor c) Attention to vaginal vault defects in surgery for recurrent vaginal prolapse ensures a better prognosis d) The area most prone to recurrence after primary prolapse surgery is the posterior compartment 8. Which THREE prevalence rates are correct for the urodynamic diagnoses found on comprehensive specialist assessment of pelvic organ prolapse? a) Up to 72% of patients will have urodynamic stress incontinence b) Up to % of patients will have detrusor overactivity c) Up to 50% of patients will have recurrent UTIs in the preceding 12 months d) Less than 39% will have voiding dysfunction 9. Rosie is a 44-year-old woman with a heavy bulge at the opening of her vagina for 12 months. She has urinary and defecatory dysfunction. Which TWO statements are correct regarding a comprehensive assessment of her presentation? a) A referral for a specialist comprehensive assessment is appropriate because of the complicated presentation involving urinary and defecatory dysfunction b) If there will be a delay waiting for specialist comprehensive assessment, Rosie should be advised to avoid any antibiotics that may cloud the clinical picture c) Endosonography (anal ultrasound) is no longer recommended for assessing women with suspected anal sphincter defects d) More sophisticated analysis of soft tissue pelvic floor or levator defects would generally require the use of 3D or 4D ultrasound 10. Rosie was found to have an anterior and posterior compartment prolapse and underlying stress incontinence when the pelvic organ prolapse is reduced. Which TWO statements are correct regarding her management? a) Vaginal hysterectomy does not require vaginal vault support b) More than % of specialists prefer to use mesh rather than colporrhaphy in anterior pelvic organ prolapse repair c) Sacrospinous colpopexy can add additional posterior vaginal vault support at vaginal hysterectomy, although there can be an increased risk of recurrent cystocoele d) Rosie may be advised that there is a variety of techniques that may be used to preserve fertility including laparoscopic hysteropexy and sacrospinous hysteropexy CPD QUIZ UPDATE The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the triennium. You can complete this online along with the quiz at. Because this is a requirement, we are no longer able to accept the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online. how to treat Editor: Dr Steve Liang [email protected] Next week In recent years, there has been increasing recognition of the importance of preventive care. GPs are central to the administration of such care, but there are some barriers that work against its effective implementation. The next How to Treat discusses how GPs can improve their provision of preventive care. The author is Professor Danielle Mazza, head, department of general practice, school of primary health care, Monash University, Melbourne, Victoria. 30 Australian Doctor 28 February 14