13: Introduction to Pelvic Organ Prolapse
- Page ID
- 15653
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)- 13.1: Viginal Suspensory Procedures
- Sacrospinous ligament suspension (SSLS) or fixation is popular, allowing simultaneous repair of anterior or posterior vaginal wall defects with less postoperative bowel dysfunction. Infrequent complications include buttock pain or a sacral / pudendal nerve injury. The recurrence of a high cystocoele is around 22% and may be a problem. Randomized trials favour the robust abdominal approach of the sacrocolpopexy, with the reservations mentioned previously.
- 13.2: Anterior Prolapse Procedures
- The surgical management of anterior vaginal prolapse is controversial with limited and often conflicting data available. The traditional vaginal repair for cystocoeles was first described by Kelly in 1913, and in controlled trials has a 57% chance of curing cystocoeles. An abdominal approach is also feasible with the abdominal paravaginal repair having a success rate of up to 97%. But the abdominal approach may carry significant complications – including ureteric obstruction, bleeding, haematoma
- 13.3: Prosthetic Materials and Surgery
- There are insufficient data at present to draw any evidence - based conclusions with regard to the role of prosthetic materials in prolapse surgery. Part of the problem arises from the paucity of baseline data regarding the efficacy of “traditional” anterior and posterior vaginal repairs. As a result of this the efficacy of adding prosthetic material for primary or recurrent prolapse affecting these compartments is difficult to assess. While adding synthetic type 1 mesh grafts suggests a theoret
- 13.6: How Common Is Prolapse?
- Pelvic organ prolapse (POP) is a distressingly common condition and 11% of women have a lifetime risk of surgery for this condition. Despite this, its aetiology is poorly understood, and the natural course of prolapse is grasped more in the anecdotal than scientific arena.
- 13.7: New Definitions
- Pelvic Organ Prolapse(POP) is the descent of one or more of anterior vaginal wall, posterior vaginal wall, and apex of the vagina (cervix / uterus) or vault (cuff) after hysterectomy.
- 13.8: Is prolapse "Normal"?
- Clearly some degree of prolapse is the norm, especially in a parous population. Women with prolapse beyond the hymenal ring have a significantly increased likelihood of having symptoms. In a general population of women between 20 – 59, the prevalence of prolapse was 31%, whereas only 2% of all women had prolapse that reached the introitus. Some estimations suggest that a degree of prolapse is found in 50% of parous women, and up to 20% of these cases are symptomatic. An estimated 5% of all hyste
- 13.9: Urinary Incontinence And Prolapse
- Urinary incontinence and POP are separate clinical entities that may or may not coexist. Significant protrusion of the vagina may obstruct voiding and defecation. Surgical repair of one pelvic support defect without repair of concurrent asymptomatic pelvic support defects appears to predispose to accentuation of unrepaired defects and new symptoms.
- 13.10: When to Operate?
- Prolapse is not always progressive, and will not necessarily worsen with the time. Thus it may be an over simplification to suggest surgery to avoid an operation “at a later stage”.
- 13.11: Route Of Surgery
- There are hundreds of operations described for the correction of POP, with either an abdominal or a vaginal approach. Most textbooks suggest that prolapse surgeons be adept at both abdominal and vaginal procedures, but in reality the majority of POP surgery is performed via the vaginal route.
- 13.12: Prolapse And Concomitant Hysterectomy
- Theoretically at least, cervical conservation at abdominal hysterectomy should maintain apical support and prevent vault prolapse. Randomized trials will be needed to asses whether cervical conservation prevents vault prolapse in the long term.
- 13.13: Apical Support Procedures Post Hysterectomy
- Sacrocolpopexy is durable with level 1 evidence supporting its use, and several workers have reported that concomitant hysterectomy is safe without any increase in surgical risks. Mesh erosions range from 3% to 40%. There is at present no data to clarify the use of routine culdoplasty with the procedure, and there are no standardized outcome measures to assess sacrocolpopexy success.