Evaluation and Management of Pelvic Organ Prolapse

Alicia C. Ballard, MD Assistant Professor Division of Urogynecology and Pelvic Floor Reconstructive Surgery Department of OB/GYN University of Alabama at Birmginham [email protected]

This presentation is designed to present evidence-based best practices within the field of Female Pelvic Medicine and Reconstructive Surgery, with the goal of improving outcomes for patients with pelvic organ prolapse. Our goal is to provide the highest standard of care in the prevention and treatment of pelvic floor disorders.

Objective 1: Acquire and understand knowledge about:  The normal anatomic supports of the vagina, rectum, bladder, urethra and uterus  (or vaginal cuff), including the bony pelvic, pelvic floor nerves and musculature  and connective tissue.  The alterations in normal anatomic relationships associated with pelvic floor relaxation  Identification of the anatomic defects and terminology associated with various aspects of pelvic support disorders  The principal etiologies of pelvic support defects  The symptoms that may be experienced by a patient with pelvic support defects  The impact prolapse has on a woman’s health realted quality of life

Objective 2: Develop patient history-taking, diagnostic, and management-planning knowledge including:  The ability to obtain a pertinent history in a patient with a suspected pelvic floor defect  The ability to perform a focused physical examination utilizing the Pelvic Organ Prolapse Quantification (POP-Q) system to identify and characterize specific pelvic support defects, including: a. Anterior compartment b. Urethral hypermobility c. Posterior compartment d. Apical compartment (cervix/uterus or vaginal cuff)

 Knowledge regarding management of pelvic support defects nonsurgically (pelvic floor exercise regimens, pessary) and surgically  The ability to consider and explain surgical options for pelvic organ prolapse accounting for the patient’s age, medical condition, surgical history and functional status  Understanding considerations related to preoperative, intraoperative, and postoperative care

Objective 3: Be able to demonstrate understanding of  The indications, benefits, risks and limitations of the following non-surgical treatments: a. Pessary fitting b. Pelvic floor exercise/ Pelvic floor physical therapy  The ability to describe the accepted indications and risk as well as the patient centered outcomess for the following procedures for prolapse:  Reconstructive Repairs:  Transvaginal a. Anterior and posterior colporrhaphy b. Enterocele repair c. Perineorrhaphy d. Transvaginal colpopexy (uterosacral, sacrospinous)  Abdominal a. Open, laparoscopic or robotic sacrocolpopexy  Obliterative repairs a. Colpocleisis  Identify surgical complications of prolapse surgery  Identify evidence-based research on synthetic and non-synthetic materials used in the operative management of pelvic floor prolapse  Identification of patients who would benefit from referral to a specialist

Selected References

Paraiso MF et. al Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011; 118:1005-13.

Diwadkar GB, Barber MD, Feiner B, Maher C, Jelovsek JE, Complication and reoperation rates after apical vaginal prolapse surgical repair: a systematic review. Obstet Gynecol 2009; 113-367- 73.

Anand M et al, Perioperative Complications and Cost of Vaginal, Open Abdominal, and Robotic Surgery for Apical Vaginal Vault Prolapse. Female Pelvic Med Reconstr Surg. 2017 Jan/Feb;23(1):27-35. Nager CW et al, Pelvic Floor Disorders Network. The Design of a Randomized Trial of Vaginal Surgery for Uterovaginal Prolapse: Vaginal Hysterectomy With Native Tissue Vault Suspension Versus Mesh Hysteropexy Suspension (The Study of Uterine Prolapse Procedures Randomized Trial). Female Pelvic Med Reconstr Surg. 2016 Jul-Aug;22(4):182-9.

Haylen BT et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016 Feb;27(2):165-94.