Clinical Expert Series

Editor’s Note: Continuing medical education credit is available online at www.greenjournal.org. Pelvic Organ Prolapse

Anne M. Weber, MD, MS, and Holly E. Richter, PhD, MD

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. (Obstet Gynecol 2005;106:615–634)

CLINICAL IMPORTANCE prolapse or urinary incontinence is 11%, with up to Because the prevalence of pelvic organ prolapse one third of surgeries representing repeat proce- increases with age, the changing demographics of the dures.3 Although the overall rate of prolapse surgery world’s population will result in even more affected has dropped, this represents a substantial drop in the women. Based on projections from the United States rate of surgery for women less than 50 years old and Census Bureau, the number of American women a moderate increase for women aged 50 years and 4 aged 65 years and over will double in the next 25 greater (Fig. 1). Perioperative death is uncommon (3 years, to more than 40 million women by 2030.1 By per 10,000 surgeries), although that figure underesti- one estimate, the demand for health care services mates mortality occurring outside of the index hospi- related to pelvic floor disorders will increase at twice talization for surgery. The direct cost of prolapse 5 the rate of the population itself.2 The lifetime risk that surgery is greater than $1 billion per year. a woman in the United States will have surgery for Surgically treated prolapse represents the severe end of the clinical spectrum. Where is the cutoff between early prolapse and “normal” pelvic support? From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pitts- Two factors make this question difficult to answer. burgh, Pennsylvania; Department of Obstetrics and Gynecology, University of Changes in vaginal anatomy are exceedingly com- Alabama Hospital, University of Alabama at Birmingham School of Medicine, mon, especially in parous women; and beyond the Birmingham, Alabama. sensation of protruding tissue with advanced pro- Corresponding author: Anne M. Weber, MD, MS, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213; e-mail: [email protected]. lapse, symptoms of prolapse are notoriously nonspe- cific. Prolapse is commonly found on physical exam- © 2005 by The American College of Obstetricians and Gynecologists. Published 6,7 by Lippincott Williams & Wilkins. ination in women without pelvic symptoms. For the ISSN: 0029-7844/05 vast majority of asymptomatic women with physical

VOL. 106, NO. 3, SEPTEMBER 2005 OBSTETRICS & GYNECOLOGY 615 imagine a woman who is genetically predisposed to prolapse. She has a family history of prolapse, and unknown to her, she carries a subclinical defect in connective tissue remodeling. She experienced an inciting event in the birth of her 9-pound postterm son, with prolonged second stage followed by forceps delivery over midline episiotomy that extended to disrupt the anal sphincter. Over the next 10 years, she gained 60 pounds. She has chronic excessive straining at defecation. At menopause, she had a simple hys- terectomy for atypical endometrial hyperplasia, with no attention given to reattaching the uterosacral liga- ments to the vaginal cuff. At age 55, she is diagnosed with stage III vaginal prolapse. Now let’s give this woman an identical twin sister, Fig. 1. Age-adjusted rates of prolapse procedures per 1,000 women from 1979 to 1997 in the United States, stratified by who carries the same genetic predisposition but who patient age. Red line, all ages; blue line, women less than experiences different life events. She never experi- 50 years of age; green line, women 50 years or older. enced pregnancy or delivery. She maintained normal Modified from Boyles SH, Weber AM, Meyn L. Procedures weight and an active lifestyle. She never developed an for pelvic organ prolapse in the United States, 1979–1997. Am J Obstet Gynecol 2003;188:108–15. Copyright 2003, indication for hysterectomy. At age 55, her pelvic with permission from Elsevier. support is excellent. Although hypothetical, these 2 Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005. cases emphasize the multifactorial nature of prolapse. Risk factors have been and will continue to be findings of prolapse, no treatment is indicated. In identified; with progress such as the Human Genome contrast to traditional concepts that predict inevitable Project, eventually we may be able to predict those at progression of prolapse with time, prolapse is a highest risk of developing prolapse. Modifiable risk dynamic condition; regression of prolapse occurs at factors can be altered to decrease the likelihood of the same or higher rate as incidence.8 Factors related subsequent prolapse. to progression and remission need further study. This Risk factors for prolapse include increasing age, review will outline our recommendations, combined higher gravidity and parity (especially the number of with an evidence-based approach when available, for vaginal births), and history of hysterectomy, espe- the evaluation and treatment of the postreproductive cially hysterectomy for prolapse or other prolapse or woman with pelvic organ prolapse. incontinence operations.3,6,7,10 Although increased parity is a risk factor for prolapse, nulliparity does not PATHOPHYSIOLOGY provide absolute protection against prolapse. In the A useful approach to understanding the pathophysi- Women’s Health Initiative, almost one fifth of nullip- ology of prolapse is to consider risk factors as predis- arous women had some degree of prolapse.7 These posing, inciting, promoting, or decompensating data should give pause to enthusiasts promoting ce- events (Table 1).9 Depending on the combination of sarean delivery for all women to prevent prolapse. risk factors in an individual, prolapse may or may not Obesity is one of the few modifiable risk factors develop over her lifetime. As a hypothetical example, identified so far.7,10 In the Women’s Health Initiative,

Table 1. Potential Risk Factors for Pelvic Organ Prolapse Predispose Incite Promote Decompensate Genetic (congenital or hereditary) Pregnancy and delivery Obesity Aging Race: White Ͼ African-American Surgery such as hysterectomy Smoking Menopause for prolapse Gender: Female Ͼ Male Myopathy Pulmonary disease (chronic coughing) Neuropathy Neuropathy Constipation (chronic straining) Myopathy Recreational or occupational activities Debilitation (frequent or heavy lifting) Medication Adapted from Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:723–46. Copyright 1998, with permission from Elsevier.

616 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY body mass index greater than 30 kg/m2 conferred a so that any potentially adverse effects can be recog- 40–75% increased risk of prolapse.7 nized and addressed.16

Physical Examination DIAGNOSTIC APPROACH Physical examination focuses on the pelvic examina- Symptoms tion, beginning with a careful inspection of the vulva Symptoms are not specific to different compartments and vagina to identify erosions, ulcerations, or other of prolapse but may reflect the overall stage of lesions. Suspicious lesions should be biopsied imme- prolapse at its most advanced site.11 With descent of diately. Benign-appearing ulcers should be closely the cervix into the vagina, women may find they can observed and biopsied if they do not resolve with no longer wear tampons. Women are usually not treatment. aware of an actual protrusion while prolapse is above The extent of prolapse should be systematically the hymen, but they may have pelvic pressure or assessed. With advanced prolapse, determining the heaviness. Although pelvic pain and low back pain extent of prolapse and its constituents (anterior and have classically been considered symptoms of pro- posterior vagina; cervix or vaginal apex) is usually not lapse, a recent study found pelvic pain was not difficult. Paradoxically, with less advanced prolapse, associated with prolapse, and women with more it can be more difficult to identify its components, advanced prolapse actually had less back pain than particularly by inspection alone. The use of vaginal women with mild prolapse.12 speculums (eg, the posterior blade of a Graves specu- Women with prolapse often have urinary symp- lum) or retractors is very helpful in determining what toms, although the mechanism responsible for these vaginal sites are affected by prolapse. An unidentified symptoms can be markedly different. Some women vaginal bulge (Fig. 2) can be clearly identified as the have stress incontinence symptoms due to urethral vaginal apex, once the anterior and posterior vagina incompetence, but many women, particularly those are retracted (Fig. 3). Similarly, anterior vaginal pro- with advanced anterior vaginal prolapse, are conti- lapse can be seen more clearly after retracting the nent. In some women, this reflects normal urethral posterior vagina. At times, posterior vaginal prolapse sphincter competence despite lack of support. In other cases, women with urethral incompetence are continent only because the prolapse causes urethral kinking and obstruction.13 This is called potential, masked, latent, or occult stress incontinence because women do not have symptoms of incontinence as long as the prolapse is untreated. In one study, urethral obstruction occurred in 58% of women with grade 3 and 4 anterior vaginal prolapse, compared with 4% in women with grade 1 and 2 prolapse.14 As prolapse advances, women are less likely to have stress incontinence and more likely to manually re- duce prolapse to void. Women may have a remote history of stress incontinence that resolved as the prolapse became more advanced. Women with ure- thral obstruction commonly have voiding dysfunc- tion, manifested by symptoms of urinary hesitancy, frequency, or incomplete emptying. Defecatory symptoms such as excessive straining, incomplete rectal emptying, or the need for perineal or vaginal pressure to accomplish defecation should be sought in all women with prolapse. In addition, the influence of prolapse on sexual functioning should be Fig. 2. Stage II prolapse. By inspection, it is not possible to addressed in women of all ages.15 Some women with determine which components of the vagina (anterior, api- prolapse avoid vaginal intercourse out of concern or cal, posterior) are affected by prolapse. Reprinted from Weber AM, Brubaker L, Schaffer J, Toglia MR. Office embarrassment. Other women experience urinary or urogynecology: practical pathways in obstetrics & gynecol- fecal incontinence (or the fear of incontinence) that ogy. 1st ed. New York (NY): McGraw-Hill; 2004. Repro- interferes with sexual activity. Assessing sexual func- duced with permission of The McGraw-Hill Companies. tion is particularly important before and after surgery, Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

VOL. 106, NO. 3, SEPTEMBER 2005 Weber and Richter Pelvic Organ Prolapse 617 Fig. 4. Diagrammatic representation of the pelvic organ prolapse quantitation system for staging prolapse by phys- ical examination findings, showing the 6 sites (points Aa and Ba anteriorly, points Ap and Bp posteriorly, point C for Fig. 3. Stage II prolapse of the vaginal apex (the same the cervix or apex, and point D for the cul-de-sac), genital patient as in Fig. 2). With retraction of the anterior and hiatus (gh), perineal body (pb), and total vaginal length (tvl) posterior vagina, it is now clear that this prolapse affects the used for pelvic organ prolapse quantitation. Modified from vaginal apex, possibly with an enterocele. Reprinted from Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Weber AM, Brubaker L, Schaffer J, Toglia MR. Office Klarskov P, et al. The standardization of terminology of urogynecology: practical pathways in obstetrics & gynecol- female pelvic organ prolapse and pelvic floor dysfunction. ogy. 1st ed. New York (NY): McGraw-Hill; 2004. Repro- Am J Obstet Gynecol 1996;175:10–7. Copyright 1996, duced with permission of The McGraw-Hill Companies. with permission from Elsevier. Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005. Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

(rectocele) will be easily identified by vaginal exami- 3 measurements: the most advanced extent of pro- nation. At other times, rectovaginal examination is lapse in centimeters relative to the hymen that affects invaluable in distinguishing between posterior vaginal the anterior vagina, the cervix or vaginal apex, and prolapse alone, high apical prolapse (possible entero- the posterior vagina. cele), or a combination of these. The maximal extent of prolapse is demonstrated Although many systems for staging prolapse have with a standing straining examination when the blad- been described, the standard is the system approved der is empty.18 Standing examinations are not always by the International Continence Society, the Pelvic practical, and small differences may not be clinically Organ Prolapse Quantification system.17 This system meaningful. However, if the initial examination does measures 9 locations on the vagina and vulva in not reproduce the patient’s symptoms or description centimeters relative to the hymen. These 9 locations of her prolapse, a standing straining examination are used to assign a stage (from 0 to IV) of prolapse at should be performed. Assessing paravaginal or lateral its most advanced site (Fig. 4). The pelvic organ anterior vaginal support is not included in the pelvic prolapse quantification system is probably more de- organ prolapse quantification system. Indeed, tailed than necessary for clinical care, but clinicians whether examination can reliably differentiate spe- should be familiar with it because most studies now cific defects of anterior vaginal support has been use the Pelvic Organ Prolapse Quantification system questioned.19 Until the existence of specific defects is to report research results. Its 2 most important advan- confirmed and better systems of measurement devel- tages over previous grading systems are 1) the stan- oped, prolapse assessment relative to the hymen dardized technique with quantitative measurements at seems to be the most reliable way to describe pro- straining relative to a constant landmark, the hymen, lapse. and 2) prolapse assessment at multiple vaginal sites Pelvic muscle function should be assessed in all (not just the most advanced). In lieu of using the full women.20 After the bimanual examination while the pelvic organ prolapse quantification system of 9 mea- patient is in lithotomy position, the examiner can surements, clinicians are encouraged to record at least palpate the pelvic muscles a few centimeters inside

618 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY the hymen, along the pelvic sidewalls at the 4 and 8 with prolapse reduction to avoid falsely negative o’clock positions. Baseline muscle tone and increased stress testing. In the setting of a positive reduction tone with voluntary contraction should be assessed, stress test, we recommend that an incontinence pro- along with the strength, duration, and symmetry of cedure should be performed at the time of prolapse contraction. This serves as a baseline measure for surgery. However, little evidence is available from comparison with subsequent examinations. It also controlled trials for patients with and those without identifies women who may benefit from focused preoperative symptoms of stress incontinence com- intervention to strengthen the pelvic muscles. If a bined with prolapse warranting surgery. We need to woman has no awareness of her pelvic muscles and counsel patients extensively about the risks and ben- cannot perform a voluntary contraction, one would efits of performing or withholding an incontinence expect little or no benefit from an unsupervised procedure in this clinical situation. When an inconti- program of pelvic muscle exercise. She will need to nence procedure is added to prolapse repair, at worst, be taught to locate and contract her pelvic muscles by the patient may receive overtreatment and risk void- an experienced clinician, whether a physical thera- ing dysfunction. Conversely, when the incontinence pist, nurse or nurse practitioner, or physician. procedure is not performed at the same time as the In addition, resting tone and voluntary contrac- prolapse repair, the patient may need a second sur- tion of the anal sphincters should be assessed during gery to treat new (unmasked) or persistent stress rectovaginal examination. With normal resting tone incontinence. With effective minimally invasive pro- of the anal sphincters, the examiner will feel the ring cedures that can be performed with local anesthesia, of muscle snugly around the examining finger; during this situation is less problematic than in the recent voluntary contraction, the ring of muscle should past. The key is open communication with the patient tighten circumferentially. Abnormalities should be about her options and expected outcomes, so that she noted, such as low resting tone (looseness of the ring can participate in making an informed decision. of muscle), weak or absent voluntary contraction, anal Imaging sphincter defect (usually at the 12 o’clock position, as a result of obstetric injury), hemorrhoids, or rectal Imaging is not usually necessary in women with prolapse. prolapse unless the information obtained would be critical in formulating recommendations for manage- ment. Imaging tests in women with prolapse, such as Testing magnetic resonance imaging21 and cystoproctogra- Bladder Testing phy,22 are primarily for research at this point; they are At a minimum, for all patients with prolapse, 3 pieces not recommended routinely for clinical care. of information should be obtained: 1) screening for urinary tract infection; 2) postvoid residual urine THERAPEUTIC APPROACH volume; and 3) presence or absence of bladder sen- Management for prolapse includes observation, pel- sation (by voided volume with sensation of fullness, vic floor rehabilitation, pessary use, and surgery. by voiding diary, or by bladder filling). Although Unfortunately, there is little evidence-based informa- there is no consensus on a postvoid residual cutoff tion with which to counsel our patients. There is a that is “normal” versus “abnormal,” less is better as an dearth of rigorously conducted trials that compare indicator of efficient bladder emptying. Provided the management approaches.23–25 In most cases, clinicians initial voided volume was more than 150 mL, must rely on their best judgment and the patient’s postvoid residual volume less than 100 mL indicates preferences to select a management plan. acceptable bladder emptying. Postvoid residual vol- ume over 100 mL indicates impaired bladder empty- Indications for Treatment ing, which may or may not be caused by prolapse. Choice of treatment for prolapse usually depends on Women with prolapse and urinary incontinence symptom severity and severity of prolapse, in line should have stress testing performed with the pro- with the patient’s general health and activity. Impor- lapse reduced because this will mimic bladder and tantly, the correlation between many pelvic symp- urethral function when the prolapse is treated. Pro- toms and the extent of prolapse is weak.26,27 Symp- lapse reduction with bladder testing has not been toms associated with stage I or stage II prolapse standardized. Different techniques include using the require careful evaluation, especially if surgery is posterior blade of a speculum, ring forceps, pessary, being considered.28 Many women with stress urinary vaginal packing, or large cotton swabs. Regardless of incontinence have stage I or II prolapse, although technique, avoid overcorrection of anterior vaginal stress incontinence is not a symptom of prolapse; it is prolapse and ensure that the urethra is not obstructed simply a coincident symptom. Factors that determine

VOL. 106, NO. 3, SEPTEMBER 2005 Weber and Richter Pelvic Organ Prolapse 619 how clinicians make recommendations and how pa- potentially prevent worsening the prolapse. We rec- tients make decisions have not been well studied. ommend nonsurgical management if observation is Patient and clinician goals of treatment may differ not (or is no longer) suitable, when surgery presents considerably and lead to dissatisfaction if expectations higher-than-average risks, or in women who do not (that may be unrealistic) are not met. In symptomatic want surgery. Pessaries may also be used before women choosing treatment, patients were more likely prolapse surgery to estimate whether symptom relief to choose surgery, compared with expectant manage- will be obtained with surgery. This strategy is partic- ment or pessary use, with more advanced prolapse, ularly useful in patients whose symptoms do not with increasing age, and with prior prolapse surgery.28 match their physical findings (such as severe symp- toms with mild prolapse) or in patients with nonspe- Observation cific symptoms, such as back pain, that are not Observation is appropriate for women whose symp- definitely caused by prolapse. We recommend dis- toms are not sufficiently bothersome to warrant active cussing nonsurgical management with most, if not all, intervention. When first learning of prolapse, many women before surgery. In addition, some compo- women require only information and reassurance that nents of nonsurgical management can be effectively treatment is available when and if they become added to surgery to maximize outcomes. symptomatic. As outlined in the section “Diagnostic Approach,” a careful evaluation will serve as a base- Adjunct Therapy line with which subsequent examinations can be Adjunct therapy addresses symptoms of urinary, def- compared. For an otherwise healthy woman, repeat ecatory, and sexual dysfunction as appropriate to assessment can be conveniently performed at her each individual. As one example of a commonly yearly health maintenance visit. The patient should encountered clinical problem, patients will often be instructed to call for an interval visit if she experi- present with defecatory symptoms, such as excessive ences any symptoms that concern her. She can be straining at stool and a feeling of incomplete evacua- counseled that acute changes rarely occur in the tion, and physical examination reveals stage II or setting of early prolapse. There is virtually no indica- early stage III posterior vaginal prolapse (rectocele). It tion for treatment, particularly surgery, for women is usually not possible to determine whether the with asymptomatic prolapse “before the problem gets symptoms predated the physical findings, or vice any worse.” The old adage “You can’t make an versa. In fact, from a clinical standpoint, it is probably asymptomatic patient better; you can only make her irrelevant. First and foremost, the patient’s symptoms worse” was never more true than it is for prolapse. need to be addressed. The patient should have a Occasionally, a patient will present with ad- thorough evaluation from the gastrointestinal (GI) vanced prolapse, yet she will say that she is asymp- perspective, either by referral or by the interested tomatic. Is observation still appropriate? An impor- obstetrician-gynecologist. Age-appropriate screening tant consideration is her efficiency of bladder for colorectal cancer should be obtained. Begin with a emptying. If she has partial urinary retention, she is at focused diet history (including fiber and fluid intake), risk for persistent or recurrent urinary tract infections exercise history, review of medications for GI adverse and possibly urosepsis, depending on her overall effects, and bowel history, including frequency and medical status. The exposed vaginal epithelium is at consistency of bowel movements. Physical examina- risk for erosion, which rarely can become secondarily tion should focus on anorectal examination, prolapse infected and serve as a source for sepsis. Even more staging (if present), and pelvic muscle assessment. rare is the risk of evisceration, an event of high Provided no GI pathology is diagnosed, we rec- morbidity and mortality. After considering these risks ommend treatment to regulate her bowel habit and and discussing them with the patient (and family prevent straining. Based on the patient’s history, she members, as appropriate), if she still prefers observa- should alter her fluid and fiber intake (to a total of tion, we recommend close follow-up, such as every 3 6–8 glasses of fluid and at least 20 grams of fiber per months, to reassess potential risks and the decision for day) and her exercise level. She should arrange a observation versus active management. regular schedule to allow time for defecation after meals. Add osmotic (eg, polyethylene glycol) or ca- Nonsurgical Management thartic laxatives (eg, bisacodyl), as necessary. In se- Nonsurgical management of prolapse includes ad- lected cases, use suppositories or enemas on a daily or junct therapy to address concomitant symptoms, pel- as-needed basis. For women who contract (instead of vic floor muscle training, and pessaries. Ideally, non- relax) their pelvic muscles at attempted defecation, surgical management will decrease the frequency and consider adding biofeedback.29 If her symptoms are severity of symptoms, delay or avoid surgery, and relieved, we recommend no further treatment. Mon-

620 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY itor her posterior vaginal prolapse at regular intervals, women perform pelvic floor muscle exercises cor- such as annually. However, if the patient experiences rectly or with the necessary intensity (frequency, no relief from her defecatory symptoms despite an duration) to obtain maximum benefit. In our experi- adequate trial (eg, the above changes for a month with ence, having the patient work with an experienced escalating doses of cathartic laxatives), we recom- physical therapist or dedicated nurse practitioner mend a gastroenterology consultation. gives her the best chance of achieving benefit, usually If the patient is still bothered by protrusion of starting with a program of up to 2 visits per week for prolapse after resolution of her defecatory symptoms, 8–12 weeks, with ongoing maintenance exercises we recommend that surgery be considered. The cli- after that. A detailed discussion of pelvic floor muscle nician and patient should clearly understand the goal training is beyond the scope of this article, but it is of surgery, ie, to reduce the bulge in the posterior probably underused as a nonsurgical therapy for vagina. It is important to note that if this patient’s prolapse, either alone or in combination with pessary condition was approached in the opposite order (rec- use and other adjunct therapies. Interested readers are tocele surgery first, treatment of her defecatory symp- referred to recent review articles31–33 for more details. toms later), it is likely that she would not have a Professional organizations (such as the American satisfactory outcome. Counsel the patient to resume Physical Therapy Association, www.apta.org, under her individualized bowel regimen after surgery, in- Women’s Health) can often assist in locating practi- cluding fiber and fluids, with adjustments as necessary tioners in your geographic area. during recovery with its reduced activity level, possi- ble dietary changes, and use of constipating medica- Pessaries tions. Advise the patient to use laxatives early to avoid As for all types of nonsurgical management of pro- constipation and impaction. We recommend bisaco- lapse, we recommend pessaries to decrease symptom dyl, 5-mg tablets, to be taken as soon after surgery as frequency and severity, delay or avoid surgery, and liquids are tolerated, increased by 2 tablets each night potentially prevent worsening of prolapse. The most until a bowel movement occurs (usually the following important relative contraindication for pessary use morning). Instruct the patient to repeat this process as occurs when the patient cannot comply with follow- needed until her regular bowel habit is restored. up. Particularly concerning is the setting of dementia Adjunct therapy often includes advice on lifestyle or other medical or social conditions that may result alterations, weight loss, and a general exercise pro- in pessary neglect, with the resultant risk of the most gram. Although data are lacking to support these serious complications of pessaries, rectovaginal or recommendations specifically for prolapse, many fit vesicovaginal fistulae. The clinician providing the into general guidelines for a healthy lifestyle. pessary must ensure that appropriate follow-up care is provided, especially because the woman may transi- Pelvic Floor Muscle Training tion from her own home to an assisted living or skilled Pelvic floor muscle training is designed to increase the nursing facility. strength and endurance of the pelvic muscles, thereby Another relative contraindication to pessary use improving support to the pelvic organs. Although no is persistent vaginal erosions. Some women with direct evidence proves that pelvic floor muscle train- advanced prolapse will have extensive vaginal ero- ing prevents or treats prolapse, it is effective for sions at initial evaluation. If immediate surgery is not urinary and fecal incontinence and may be beneficial planned, an attempt to heal the erosions will usually for prolapse.30 In our experience, pelvic muscle require pessary use. Erosions with advanced prolapse strengthening often relieves symptoms of pelvic pres- will almost always persist if the prolapse remains sure that commonly accompany prolapse. Although it unreduced, the vagina being unable to heal under the seems unlikely that advanced prolapse will resolve continuous pressure of gravity and friction on the with pelvic floor muscle training, women may still woman’s underclothes. A different situation occurs experience a beneficial effect on their symptoms. when a woman develops persistent vaginal erosions in Therefore, we do not use any cutoff as to extent of the setting of longstanding pessary use. This may prolapse in recommending or not recommending indicate that local estrogen should be added or in- pelvic floor muscle training. With virtually no adverse creased, that a smaller pessary may now be necessary, effects, its only negative is the cost of providing or, rarely, that a vaginal neoplasm has developed. instruction and follow-up for patients and the invest- Pessary use must be discontinued occasionally for ment that patients must make, as in any exercise persistent vaginal erosions. program, for its potential success. Pessary use for prolapse is widespread in the Most women recognize what “Kegel” exercises clinical practices of gynecologists34 and urogynecolo- are; some have performed them on their own. But few gists35 in the United States. The most commonly used

VOL. 106, NO. 3, SEPTEMBER 2005 Weber and Richter Pelvic Organ Prolapse 621 pessaries are ring (with or without support), doughnut, If some perineal support is preserved, a ring and Gellhorn pessaries, although there are many pessary (without support when the cervix is present, other types (Fig. 5). Up to three quarters of women with support after hysterectomy) is a good first choice. with prolapse can be successfully fitted with a pessary. Many clinicians start with size 4 and then move to a Although many clinicians have biases about who can larger or smaller pessary, depending on fit. The ring and who cannot be fitted with pessaries, few charac- pessary is designed to sit with one end in the posterior teristics have been identified consistently in research. vaginal fornix and the other end behind the symphy- Unsuccessful fitting is associated with short vaginal sis pubis (Fig. 6). A well-fitted pessary should fill the length (less than 7 cm) and wide introitus (4 finger- vagina from side to side, with the clinician’s finger breadths).36 However, this should not preclude fitting able to easily pass between the pessary and the pelvic attempts in women with those characteristics, because sidewall. When the pessary is properly placed in the some women can still be successfully fitted. After 2 upper vagina, the patient should be unaware of its months, 92% of women who were successfully fitted presence. The patient should be asked to stand and were satisfied, with resolution of nearly all prolapse move about to see if the pessary remains in place. If symptoms.37 Urinary symptoms improved in about the patient becomes aware of the pessary at the half the women, but stress incontinence occurred as a introitus, the next larger size should be tried. If the new symptom in about one fifth.37 Women who are patient is aware of tightness, pressure, or any other sexually active accept pessary use, with 60% continu- discomfort, fitting with the next smaller size pessary ing long-term use (up to 2.5 years).38 should be attempted. It sometimes occurs that one Pessaries can be separated into 2 broad catego- size is too large and the next smaller size fails to ries: support and space-filling.39 The ring pessary adequately hold the prolapse in place. In that case, a (with diaphragm) and other support pessaries are different type of pessary can be chosen. In some commonly recommended for stage II and early stage women, such as those who have had previous vaginal III prolapse, whereas the space-filling pessaries such surgery, an oval pessary may fit when a ring does not. as the Gellhorn are usually used for more advanced Gellhorn pessaries are useful for women with prolapse. Most pessaries are silicone, plastic, or med- more advanced prolapse and less perineal support ical grade rubber. Silicone has many advantages: it is because they sometimes stay in place when ring nonallergenic, does not absorb odors or secretions, is pessaries do not. Gellhorn pessaries are sized based resistant to repeat cleaning, and is pliable and soft. Before using a pessary that contains rubber, be sure that the patient does not have a latex allergy.

Fig. 6. Ring pessary without support in place; patient with cervix and uterus. Note that the pessary rests at the level of the bladder neck anteriorly and behind the cervix posteri- orly. Reprinted from Weber AM, Brubaker L, Schaffer J, Toglia MR. Office urogynecology: practical pathways in obstetrics & gynecology. 1st ed. New York (NY): McGraw- Hill; 2004. Reproduced with permission of The McGraw- Fig. 5. A variety of pessaries. Hill Companies. Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005. Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

622 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY on the diameter of the disk. The stem and knob differ Women can remove the pessary at bedtime and only slightly in different brands of pessaries, some replace it in the morning. If daily changing is too with a string attached to the stem to aid in removal. bothersome, a schedule of weekly or twice-weekly The Gellhorn is fitted so that the disk is centered in removal can be used. In this setting, after an early the upper vagina and the stem points downward follow-up visit (such as 2–4 weeks later) to assess behind the perineal body (Figure 7). As with the ring whether the pessary is adequately relieving the pa- pessary, when well fitted, the disk should fill the upper tient’s symptoms and to review pessary maintenance, vagina yet still allow the examiner’s finger to pass women can be returned to annual care unless new easily between the disk and the pelvic sidewall. For symptoms develop in the meantime. removal, it is necessary to insert an examining finger Some patients will not be able or willing to behind the disk to break the suction between the disk manage pessary care themselves and thus require and the vagina, and then gently maneuver the disk more frequent office visits. After an early follow-up out. If removal is difficult in a Gellhorn without a visit to check the pessary’s effectiveness at relieving string, it is sometimes helpful to pull on the stem using symptoms, office care can be arranged, usually at a tenaculum or ring forceps to help in bringing the intervals of 3 months. At these visits, the pessary is pessary closer to reach behind the disk to break the removed, rinsed, and replaced after carefully inspect- suction. ing the vagina for irritation or erosions. Vaginal When initiating pessary use, ideally the physician discharge is commonly present, but unless the patient can teach the patient to remove and replace the expresses bother, treatment is not required. In some pessary herself. This will put control of the pessary in practice settings, visits related to pessary maintenance the patient’s hands, allowing her to use it as needed. can be efficiently accomplished by a nurse practitio- Ring pessaries are usually easy for patients to remove ner, physician’s assistant, or other staff. The patient and replace, especially for women who have used should be counseled to call if vaginal odor, discharge, diaphragms in the past. Gellhorn pessaries are more or bleeding occurs because these symptoms warrant challenging for patients to handle, but some women investigation for infection or erosion. will find it possible. The goal of changing the pessary Vaginal estrogen is commonly employed with at frequent intervals is to prevent vaginal irritation pessaries, although this should be individualized to that leads to discharge, infection, and erosion. each patient. Some patients will have sufficient endog- enous estrogen that atrophy does not occur and pessary use does not cause irritation. Some women use nonhormonal lubricants effectively with pessaries. However, in women with vaginal atrophy at pessary initiation, local estrogen is important to prevent vag- inal erosions, even if women are already taking systemic estrogen. Vaginal estrogen can be used in any form: cream, tablets, or sustained-release ring (Estring silicone ring with slow-release estradiol; Phar- macia & Upjohn, Kalamazoo, MI). It is particularly convenient to use Estring in women with a Gellhorn pessary; the Estring is placed behind the Gellhorn and is changed during office visits at 3-month inter- vals. Pessary use in some previously continent women will reveal or unmask latent stress incontinence. In selected cases, periurethral injection of bulking agents (such as collagen) can be used to treat the stress Fig. 7. Gellhorn pessary in place; patient with cervix and incontinence while pessary use is maintained for 40 uterus. Note that the disk of the Gellhorn pessary rests at the prolapse treatment. However, in most situations, level of the bladder neck anteriorly, and behind the cervix pessary use will be discontinued and plans made to posteriorly (similar to the position of a ring pessary) and that proceed with surgery. the knob rests behind the perineal body. Reprinted from In some patients with long-term pessary use, it is Weber AM, Brubaker L, Schaffer J, Toglia MR. Office urogynecology: practical pathways in obstetrics & gynecol- necessary to switch to smaller pessaries over time. A ogy. 1st ed. New York (NY): McGraw-Hill; 2004. Repro- recent study has provided evidence that supports duced with permission of The McGraw-Hill Companies. clinical observations of improved prolapse status with Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005. pessary use in some patients. In 19 women with

VOL. 106, NO. 3, SEPTEMBER 2005 Weber and Richter Pelvic Organ Prolapse 623 pessary use for at least 1 year, no woman had worse als; and 3) obliterative, which close the vagina. These prolapse and 4 women (21.1%, 95% confidence inter- groupings are somewhat arbitrary and not entirely val 0.2–43.7%) improved.41 exclusive. Grafts may be used to reinforce repairs, such as colporrhaphy, or to replace support that is Surgical Management deficient or lacking. For example, graft use in abdom- The primary aim of surgery is to relieve or improve inal sacral colpopexy substitutes for the connective prolapse symptoms and, if possible, symptoms asso- tissue attachments (DeLancey’s level I) that would ciated with the lower urinary and gastrointestinal normally support the vaginal apex.47 In addition to tracts. In some women, this means an attempt to the primary goal of relieving symptoms related to restore normal vaginal anatomy and maintain or prolapse, urinary, defecatory, and sexual function improve sexual function. In others, an obliterative must be considered as well in choosing the appropri- approach is more appropriate and still yields the ate prolapse procedures. The types of procedures will desired result of symptom relief. be briefly reviewed. Detailed discussion of technique is beyond the scope of this article and interested Approach readers are referred to surgical atlases, videos, and Approaches to prolapse surgery include vaginal, ab- textbooks. dominal, and laparoscopic routes or a combination of approaches.42–44 Depending on the extent and loca- Prolapse Procedures tion of prolapse, surgery usually involves a combina- Anterior Vaginal Repair tion of repairs addressing the anterior vagina, vaginal Recurrent anterior vaginal prolapse continues to be apex, posterior vagina, and perineum; concomitant the Achilles’ heel of reconstructive pelvic surgery. surgery may be planned for the bladder neck or anal Anterior vaginal prolapse has traditionally been re- sphincters. Procedures for posterior vaginal prolapse paired with anterior colporrhaphy, where the vaginal most commonly use a transvaginal approach, or less epithelium is separated from the underlying fibromus- commonly, a transanal approach. Apical and anterior cular connective tissue, followed by midline plication vaginal prolapse can be approached by either vaginal of the vaginal muscularis with a series of interrupted or abdominal routes. There is clear benefit when stitches, usually of absorbable suture, excision of comparing the vaginal approach with the abdominal excess epithelium, and closure.48 Variations include approach (ie, laparotomy), from the perspective of placing graft material on top of or instead of the complications and short-term effects on recovery. By midline plication. The results of 2 randomized trials avoiding laparotomy, the vaginal approach results in suggest modest improvement in success, adding 12– fewer wound complications, less postoperative pain, 18% to the “cure” rates after 1 year, when polyglactin shorter hospital stay, and less cost than abdominal mesh (Vicryl; Ethicon, Somerville, NJ) was placed surgery.42,43 Whether prolapse repaired abdominally over the midline plication compared with standard is more effective or durable than vaginally repaired repair.49,50 Until there is evidence showing long-term prolapse is controversial; the evidence supporting benefit from the use of graft material with anterior both sides of this argument will be reviewed in a later colporrhaphy, we recommend the use of delayed section. Adding to the debate is the potential benefit absorbable sutures such as Vicryl or No. 1 polydiox- of the laparoscopic approach compared with the anone (PDS; Ethicon, Somerville, NJ), with midline abdominal or vaginal route for prolapse surgery.45 In plication. laparoscopic surgery for stress incontinence, the per- Richardson reintroduced the concept of paravag- ceived cost advantage of reduced hospital time is inal repair, which reattaches the anterior lateral vag- often offset and even exceeded by increased operative inal sulcus to the obturator internus muscle and fascia time and expense of laparoscopic instruments.46 at the level of the arcus tendineus fascia pelvis (“white There are no comparable data for prolapse opera- line”), usually performed as a bilateral procedure, via tions. transvaginal or retropubic (abdominal or laparo- Surgical route is chosen based on the type and scopic) access.51,52 With advanced anterior vaginal severity of prolapse, the surgeon’s training and expe- prolapse, midline excision of redundant tissue may be rience, the patient’s preference, and the expected or necessary in addition to paravaginal repair. The an- desired surgical outcome. Procedures for prolapse can terior vaginal apex can be supported by placing be broadly categorized into 3 groups: 1) restorative, stitches to the level of the ischial spine on each side, which use the patient’s endogenous support struc- although this procedure should not be used as the sole tures; 2) compensatory, which attempt to replace treatment for vaginal vault prolapse. The long-term deficient support with some type of graft, including effectiveness of paravaginal repair is unknown. Fur- synthetic, allogenic, xenogenic, or autologous materi- thermore, performance of the vaginal paravaginal

624 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY repair requires specific expertise to perform correctly. According to Richardson, isolated defects of the There are no randomized trials that compare out- rectovaginal “fascia” (layers that include the vaginal comes after anterior colporrhaphy versus paravaginal muscularis, rectovaginal septum, and adventitia) oc- repair. cur in some women with posterior vaginal prolapse.55 When prolapse repair is approached vaginally, The site-specific repair is approached by dissecting we recommend anterior colporrhaphy when indi- the vaginal epithelium from the underlying layers to cated for anterior vaginal prolapse. If the surgeon has expose the defect and close it with interrupted stitches the clinical experience and expertise and feels that of usually absorbable suture, followed by closing the lateral detachment is causing the anterior vaginal vaginal epithelium. Initial retrospective56 and pro- prolapse, a vaginal paravaginal repair is performed, spective57 uncontrolled case series reported short- but robust apical vaginal support should also be term results similar to or better than posterior colpor- present or added with a specific apical suspension. rhaphy. However, with longer follow-up, one series When abdominal sacral colpopexy for prolapse re- has reported recurrent prolapse after site-specific re- pair is planned, retropubic paravaginal repair can be pair at higher rates than after traditional posterior 58 performed when the surgeon judges that support of colporrhaphy. No randomized clinical trials exist the anterior vagina would be insufficient without it. In comparing these techniques. our experience, this happens infrequently. We recom- We recommend reattachment of the rectovaginal mend that retropubic paravaginal repair be added to connective tissue to the perineal body in all repairs Burch colposuspension when necessary to provide when separation is identified. Until data demonstrate additional support to the mid-vagina (DeLancey level superior or equivalent long-term outcomes with site- II).47 specific defect repairs, we recommend traditional posterior colporrhaphy, with careful attention to pre- Posterior Vaginal Repair vent narrowing of the vagina or introitus, when Traditional posterior colporrhaphy involves separa- indicated to relieve symptomatic posterior vaginal tion of the vaginal epithelium from the underlying prolapse. Lateral rectovaginal connective tissue is fibromuscular connective tissue (which includes the plicated in the midline using a delayed absorbable rectovaginal septum, in between the vaginal muscu- suture, such as Vicryl or PDS, taking care not to laris and the rectovaginal adventitia), followed by create strictures in the vagina with initiation of the midline plication with interrupted stitches, excision of plication too far laterally. A finger in the rectum helps excess epithelium, and closure.53 As with anterior identify the integrity of the supportive layer formed colporrhaphy, variations include placing graft mate- with plication. rial on top of or instead of the midline plication. In many cases, mild-to-moderate posterior vagi- Other procedures can be combined with posterior nal prolapse is identified as one component of pro- colporrhaphy, such as levator ani plication and perin- lapse in women with more advanced apical or ante- eorrhaphy, although the indications for these addi- rior prolapse. In those situations, clinicians and tions are controversial. patients must carefully weigh the risks (particularly of Dyspareunia after posterior repair has been dyspareunia) and benefits in deciding whether to blamed on levator ani plication if a band or narrowing repair otherwise asymptomatic posterior vaginal pro- is formed inside the vagina.54 Narrowing can also lapse. Although traditional teaching has held that all occur with overzealous perineorrhaphy or combina- “defects” should be repaired at one surgical setting, tions of procedures that alter normal vaginal contours. this may be the exception, where the patient is better For example, the vaginal configuration is altered by served in avoiding or delaying surgery of the posterior the Burch procedure, where the upward displacement vagina until specific symptoms need to be addressed. of the anterior vaginal tube creates a transverse ridge In this way, many women will avoid dyspareunia for in the posterior vagina. A similar vaginal configura- the few women who will ultimately require a separate tion may be created by other incontinence procedures posterior repair. that elevate the anterior vagina. Dyspareunia is espe- Perineorrhaphy should be performed with any cially likely to occur when Burch is combined with repair where there is separation of the perineal mus- posterior repair, when the altered vaginal contour and cles. This also facilitates the natural posterior deflec- posterior transverse ridge is overlaid with the plica- tion of the vagina in the pelvis. After dissection to free tion of the posterior repair. Despite careful attention the ends of the superficial perineal and bulbocavern- to ensure adequate introital caliber after posterior osus muscles, they are reapproximated in the midline repair, 38% of women after Burch and posterior without tension. Levator ani plication is associated repair had persistent dyspareunia 1 year or more after with postoperative dyspareunia, and we recommend surgery.16 that this not be performed in sexually active women.

VOL. 106, NO. 3, SEPTEMBER 2005 Weber and Richter Pelvic Organ Prolapse 625 In non–sexually active women, levator ani plication anterior vaginal prolapse, attributed to the exagger- can be performed to reinforce the repair and inten- ated posterior deflection of the vaginal axis with tionally narrow the mid and lower vagina; high sacrospinous ligament fixation.61 However, whether perineorrhaphy can be added to further close the this is unique to sacrospinous ligament fixation or introitus. simply represents the predilection of anterior support to fail remains unknown. When a decision has been Vaginal Apical Repair made to perform this procedure, we recommend the Apical vaginal prolapse includes uterine prolapse use of delayed absorbable suture material such as with or without enterocele and vaginal vault prolapse, PDS. typically with enterocele. Some cases of uterine pro- Iliococcygeal Vaginal Suspension. Iliococcy- lapse present with marked elongation of the cervix as geal vaginal suspension involves attachment of the well. In other cases, despite what appears to be vaginal apex to the iliococcygeus muscle and fascia, normal uterine support, the elongated cervix pro- usually bilaterally.62 The extraperitoneal dissection to trudes to or past the hymen. This occurs particularly the area of the ischial spine is approached from a when the uterus is restricted to the abdomen, as in midline posterior vaginal incision. Using the ischial uterine enlargement greater than the equivalent of spine as the landmark for identifying the sacrospinous 12–14 weeks of gestation. The standard treatment for ligament medially and posteriorly and the iliococcy- symptomatic uterine prolapse is hysterectomy with geus fascia anteriorly and caudad, a No. 1 polydiox- procedure(s) to suspend the vaginal apex, address anone (PDS) suture is placed and attached to the enterocele when indicated, repair coexisting anterior vaginal apex with a pulley stitch. We perform the and posterior vaginal prolapse, and perform anti- procedure bilaterally. Compared with other vaginal incontinence procedures as needed. It is particularly suspension procedures, the iliococcygeal suspension important to emphasize that, when hysterectomy is has the fewest case series in the literature,62–65 but cure performed for prolapse, hysterectomy alone (or hys- rates appear comparable to the sacrospinous suspen- terectomy with colporrhaphy) is inadequate; a spe- sion technique.65 We consider the iliococcygeal ap- cific vaginal vault suspension procedure must be proach to apical suspension mainly to avoid perito- performed in addition to hysterectomy. neal entry or as a fall-back procedure when Enterocele Repair. Enterocele repair is usually uterosacral ligament suspension was planned but peri- performed in the setting of concomitant procedures for prolapse, in which case the approach is based on toneal entry is not feasible. In addition, iliococcygeal the combination of procedures required. Whether by suspension works well in the case of a foreshortened vaginal, abdominal, or laparoscopic access, entero- vagina when a vaginal approach is planned. cele repair is traditionally performed by sharply dis- Uterosacral Ligament Suspension. Originally 66 secting the peritoneal sac from the rectum and blad- described by McCall in 1938, surgical variations of der. A purse-string suture can be used to close the the uterosacral ligament suspension can be used peritoneum as high (cephalad) as possible. Whether prophylactically at hysterectomy or therapeutically 67 excision of the peritoneum itself is necessary has not for vaginal apical suspension. Once access to the been determined. In addition to closing the entero- posterior cul-de-sac has been attained, the uterosacral cele sac, we recommend approximation of the ante- ligament remnant can be found with the use of Allis rior to the posterior fibromuscular connective tissue clamps placed at the posterior medial aspect of the of the vagina. Suspension of the vaginal apex is almost ischial spine. Up to 3 sutures are placed in each always necessary, except in rare cases when the ligament and incorporated into the anterior and pos- enterocele occurs in the presence of adequate apical terior fibromuscular layer of the vagina as well as the support. vaginal epithelium (Fig. 8).67 Some surgeons approx- Sacrospinous Ligament Suspension. Sacrospi- imate the ligaments in the midline, as described by nous ligament fixation entails attachment of the vag- McCall, to close the cul-de-sac with the intention of inal apex to the sacrospinous ligament, the tendinous treating or preventing enterocele formation. We rec- component of the coccygeus muscle.59 Initially de- ommend this in the presence of an unduly enlarged or scribed as a unilateral procedure, later series reported redundant cul-de-sac. However, we usually prefer to bilateral fixation. Access is traditionally extraperito- suspend the right and left vaginal apex to the ipsilat- neal via the posterior vagina, although variations have eral uterosacral ligament, leaving the cul-de-sac open been described using the anterior vagina or even to avoid impinging on the rectum and adversely laparoscopic access. Although initial case series re- affecting bowel function. If permanent sutures are ported high success rates for correcting apical pro- used, the knots should be tied to the peritoneal side of lapse,60 subsequent reports described high rates of the repair. Absorbable sutures can be tied in the

626 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY Fig. 8. A modification of the high uterosacral vaginal suspension de- scribed by Shull, whereby single monofilament permanent sutures are placed through the residual uterosacral remnants cephalad to and at the same posterior level of the ischial spines, then secured in locking fashion to the paravaginal connective tissue of the anterior and posterior vaginal cuff. After the beginning of closure from each lateral angle, the suspension suture is tied to “pulley” the vagi- nal apex to a more physiologic position. Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005. vaginal lumen with the expectation that they will surgically useful in patients of advanced age and dissolve over time. debility. In addition, sacrospinous ligament suspen- sion may be more difficult to teach, a factor to Comparison of Vaginal Approaches to Apical Repair consider for those involved in resident education. In a review by Sze and Karram42 of vaginal surgeries for apical prolapse, recurrent prolapse was reported The iliococcygeal suspension is a straightforward in 8–18%, with variable follow-up in mostly retro- procedure to learn and teach. It carries virtually no spective case series. Until controlled trials are avail- risk of ureteral or small bowel injury, and in contrast able, clinicians should counsel patients that the vagi- to sacrospinous ligament fixation, there are no vital nal approaches to apical suspension are probably structures nearby at risk for surgical injury. In addi- similar in outcomes related to prolapse repair. In tion, the iliococcygeus muscle and fascia are uni- choosing which procedure to recommend for individ- formly present regardless of patient age, prolapse ual patients, clinicians should consider their own status, or general debility. Some surgeons are con- training and experience, as well as technical aspects cerned that the iliococcygeal suspension leaves the and risks of complications specific to each procedure. vagina shorter than other procedures, although this Sacrospinous ligament suspension may leave the has not been described in the literature. It is possible anterior vagina at greater risk for subsequent failure,61 that the iliococcygeal suspension has been underused because of the pronounced posterior deviation of the as a vaginal apical suspension procedure. vaginal axis, although the risk of recurrent anterior Uterosacral ligament suspension traditionally vaginal prolapse seems high regardless of which vaginal requires peritoneal entry, which may be challeng- suspension procedure is used. Because the procedure ing in posthysterectomy prolapse, especially in the is extraperitoneal, there should be little if any risk of setting of bowel adhesions, engendering the rare ureteral injury; rectal injury is a rare complication of occurrence of bowel injury. Bowel packing may posterior dissection. Because sutures are passed delay the return of bowel function in occasional through the sacrospinous ligament, risks unique to patients. Uterosacral ligament suspension carries a this procedure include pudendal or inferior gluteal risk of ureteral injury (usually kinking due to medial vessel injury with intraoperative hemorrhage, or sci- displacement or suture ligation that impedes urinary atic or pudendal nerve injury, manifested as severe flow, rather than transection) as high as 11%.68 As buttocks pain (that may radiate down the back of the long as ureteral injury is recognized and addressed thigh) postoperatively. The pain may resolve sponta- intraoperatively, most patients will not incur morbid- neously when absorbable sutures are used, but suture ity. However, if ureteral injury is not identified at the removal may be necessary for permanent sutures. index surgery and recognition is delayed, a second The sacrospinous ligament may be atrophied and less surgery is usually necessary and subsequent morbid-

VOL. 106, NO. 3, SEPTEMBER 2005 Weber and Richter Pelvic Organ Prolapse 627 ity can be severe, at worst irretrievable loss of kidney infection or erosion. Intraoperative hemorrhage that function on the affected side. Cystoscopy should occurs when lacerated sacral veins retract into the always be performed after the uterosacral sutures are sacrum can be difficult to control. The consequences tied to confirm ureteral patency. Some surgeons can be as severe as intraoperative death from exsan- question whether the uterosacral ligaments are appro- guination. Complications due to laparotomy are usu- priate sources of support in women with advanced ally related to adhesions and small bowel obstruction. prolapse, although other surgeons maintain that the Although the risk seems highest in the immediate ligaments can virtually always be identified as surgically postoperative period, the risk is lifelong. Synthetic useful structures. No trials compare outcomes after graft material holds the highest risk of infection or different procedures for vaginal apical suspension. erosion, although these complications have been re- ported with all types of graft material. As with small Abdominal Apical Repair bowel obstruction, mesh erosion or infection has been Abdominal Sacral Colpopexy. Abdominal sacral reported years after the index surgery. Although colpopexy uses graft material attached to the anterior mesh erosion can usually be successfully treated with and posterior vaginal apex and suspended to the a relatively minor excision of the exposed mesh, anterior longitudinal ligament of the sacrum for repair occasionally the entire graft must be removed, with 69 of apical prolapse. Surgical variations are legion, high levels of surgical morbidity. including graft configurations on the vagina, the ex- Laparoscopic Approach to Apical Prolapse tent to which the anterior and posterior vagina are Repair. Virtually all procedures for apical prolapse attached to the graft, different graft and suture mate- repair have been approached by the laparoscopic rials, peritoneal closure over the graft, and oblitera- route, although it is sacral colpopexy that seems most tion of the cul-de-sac for treatment or prevention of likely to offer patient benefit, provided effectiveness is enterocele. In case series, cure rates range from 78% equivalent.73 The potential applicability of these pro- to 100% for apical prolapse. When cure is defined as cedures is limited by the relatively high level of no postoperative prolapse, the range widens, from technical skill required for advanced laparoscopic 56% to 100%, although subsequent anterior or poste- techniques. rior vaginal prolapse has not been as consistently reported as apical prolapse.70 Comparison of Abdominal and Vaginal Approaches We recommend the use of 2 permanent sutures in to Apical Repair the anterior sacral ligament. The peritoneum overly- Few randomized trials compare abdominal and vag- ing the vaginal apex is removed and polypropylene inal approaches for the treatment of apical prolapse mesh, fashioned in a Y configuration, is affixed to the (Table 2).74–77 Success rates appear to favor the ab- vaginal apex posteriorly from the rectovaginal junc- dominal approach to apical vaginal prolapse. Ran- tion to the bladder reflection anteriorly. No overt domized trials are important to compare outcomes in tension is placed on the vagina while attaching the an unbiased rigorous fashion, but the data obtained third arm of the mesh to the anterior sacral ligament. may not always be generalizable. In the Benson We reperitonealize over the mesh. In the setting of a study,74 the external validity is reduced because nee- deep cul-de-sac, we place Halban culdoplasty sutures dle urethropexy is no longer regarded as effective with No. 1 polydioxanone (PDS). We perform cystos- treatment for stress incontinence. In the trial by copy at the end of the procedure. Roovers et al76 the 2 treatment groups were unequal When abdominal sacral colpopexy is planned for as to the performance of hysterectomy. Again, use of apical prolapse and concomitant high rectocele is the needle suspension technique for subjects with present, some advocate extending the graft down the urinary incontinence predisposed to increased failure. posterior vagina to address this.69 Cundiff et al71 In the trial of Maher et al,77 the colposuspension for described the technique of sacral colpoperineopexy stress incontinence in the sacrospinous group may to reconstruct the normal vaginal suspensory liga- have protected the anterior vaginal compartment. In ments and “fascial sheet” that runs from the sacrum to addition, open colposuspension combined with a the perineal body. Because mesh erosion occurred vaginal approach for prolapse would be less general- frequently when the vagina was opened (16% for izable today with the increased use of midurethral vaginally placed sutures and 40% for vaginally placed sling procedures. Furthermore, history of previous mesh72), we recommend avoiding opening the vagina hysterectomy type was not equal between groups, whenever possible. introducing bias, and the vaginal group had more loss Complications associated with to abdominal sa- to follow-up. cral colpopexy fall into 3 major categories: 1) intra- Despite the shortcomings of uncontrolled series operative hemorrhage, 2) laparotomy, and 3) graft and the few randomized trials, clinicians can be

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Table 2. Randomized Trials for the Management of Apical Vaginal Prolapse Criteria for Success Development Other Study N Follow-up Success Rate Rate Prolapse/ Incontinence Complications Benson et al, 199674 80/88 Mean 2.5 years, Physical 29% vaginal Apex above levator Majority failure in vaginal No significant Bilateral SSS, VPV, versus, (range 1–5.5 group; 58% abdominal plate, no protrusion group anterior compartment differences; more ASC, APV Incontinence years) group; satisfaction beyond hymen severe in abdominal procedure: Abdominal: 33% vaginal group, (standing physical group retropubic urethropexy 16% abdominal group examination); Vagina: needle urethropexy satisfaction Lo and Wang, 199875 118/138 Mean 2.1 years, 80.3% (53.66) vaginal No protrusion vaginal Incontinence: 2 ASC, none 10.6% vs 7.7%, SSS vs ASC vs unilateral SSS (No (range 1–5.2 group; 94.2% (49/52) wall greater than SSS ASC, respectively, incontinence procedure) years) abdominal group stage II requiring reoperation (P ϭ .029) (P ϭ .75). Dyspareunia: ASC 1; SSS 7, apareunia: ASC 0, SSS 4. Roovers et al, 200476 82 12 months Scores on 3/6 domains Based on Dutch UDI Reoperation in 9/41 patients No significant (Only women with uterine significantly higher in scores 6 domains abdominal group. At one differences prolapse) abdominal group vs year: 5% vaginal and TVH, possible A/P repair, US vaginal group; no abdominal group stage II vaginal vault suspension, difference PE vault prolapse; 39% vaginal possible needle group, 36% abdominal urethropexy versus group min stage II ee n Richter and Weber sacrocolpopexy, uterine cystoceles; 15% vaginal preservation, culdoplasty, group, 5% abdominal group possible Burch at least stage II rectoceles. colposuspension Abdominal group increased subsequent surgery Maher et al, 200477 82/95 Mean 22 months Subjective: 94% (43/46) Objective: no prolapse Cumulative anterior vaginal Significant difference in ASC vs unilateral SSS; vaginal, 24 abdominal, 91% (39/ greater than or equal wall and apex: 13% (6/46) operating time, women with stress months 43) vaginal, P ϭ .19; to grade 2 at any abdominal group, 45% (19/ P ϭ .01; return to incontinence stratified abdominal satisfaction 85% (39/ vaginal site; 42) vaginal group, P ϭ .01; activities of daily evcOgnProlapse Organ Pelvic between groups: Burch (range 6–60 46) abdominal, 81% subjective: no cumulative posterior wall: living, P ϭ .01 colposuspension months) (35/43) vaginal, P ϭ symptoms of 33% (15/46) abdominal, 19% .78; objective: 76% prolapse, satisfaction (8/42) vaginal, P ϭ .22 (35/46) abdominal, 69% (29/42) vaginal, P ϭ .46. SSS, sacrospinous suspension; VPV, vaginal paravaginal repair; ASC, abdominal sacral colpopexy; APV, anterior paravaginal repair; TVH, total vaginal hysterectomy; US, uterosacral; UDI, Urogenital Distress Inventory; A/P, anterior and posterior colporrhaphy; PE, physical examination. 629 guided by the literature and their own clinical expe- bidity, rather than enhancing durability, is the most rience in offering abdominal versus vaginal surgery to important goal. patients with apical prolapse. It seems likely that These are not absolute indications for the differ- abdominal sacral colpopexy is more durable in pro- ent apical procedures and every woman’s manage- viding apical support, but at the cost of increased ment should be individualized, based in large part on complications, both immediate and long term. There- her own preferences once she has been informed of fore, patients for abdominal sacral colpopexy should the choices. Ideally, surgeons would be equally skilled be those most likely to benefit from its durability and and experienced in both abdominal and vaginal at lowest risk for complications or those most likely to approaches to apical prolapse to provide care that is recover from complications that might occur. Age is truly individualized, rather than emphasizing one often used as an important determining factor; for approach to the exclusion of the other. example, we usually recommend abdominal sacral colpopexy to younger women with prolapse for 2 Colpocleisis reasons. Younger women benefit more from durabil- Reconstructive procedures may last several hours and ity, with the reduced chance they will need prolapse are associated with potentially higher blood loss and surgery in the future. Younger women are also likely increasing morbidity with longer anesthesia. For older to be more active and subject their prolapse repair to patients who do not desire vaginal function, colpoclei- greater stress than older women who may be more sis may be an appropriate choice.79 Many variations sedentary. Women who develop prolapse requiring exist, from partial colpocleisis (where some portion of surgery at a young age may be intrinsically at higher the vaginal epithelium is left, providing drainage risk for prolapse recurrence.78 Therefore, they may tracts for cervical or other upper genital discharge) to have better outcomes with abdominal sacral col- total colpectomy (where all the vaginal epithelium is popexy that provides extrinsic apical support through removed from the hymen posteriorly to within 0.5– synthetic graft material, compared with vaginal apical 2.0 cm of the external urethral meatus anteriorly). If repairs that rely on the patient’s own tissues for hysterectomy is performed, blood loss is greater and support. (Vaginal colporrhaphies augmented with operative time is longer than procedures without grafts would not and should not be expected to have hysterectomy.80 The technique often includes a leva- any effect on apical support unless the graft is incor- tor plication and high perineorrhaphy to reinforce porated into the uterosacral ligaments. No data exist posterior support and reduce the genital hiatus, with regarding outcomes in this clinical situation.) the goal of reducing the chance of recurrent prolapse. We do not use an upper age limit for recom- Case series have reported success rates ranging from mending abdominal sacral colpopexy. For older 91% to 100%, although the patient population, by its women who are medically healthy and physically nature of relatively short life expectancy and limited active, an abdominal approach to apical repair may activity level, is probably at low risk for recurrence. be appropriate with careful counseling. Chronological We typically perform a partial LeForte-type colpoclei- age is not always the most important determinant of sis with the use of delayed absorbable suture. This benefit versus risk. Health status, ie, the presence of leaves the potential for egress of blood associated with comorbid conditions, is often a better predictor of risk the procedure and cervicovaginal secretions postop- than age. A clinical dilemma often arises as a woman eratively. We recommend levator plication using with prolapse ages—when is the best time to intervene permanent sutures and high perineorrhaphy to fur- surgically, if ever? Say a woman has chosen pessary ther reinforce vaginal closure. management for her prolapse and this has worked The prevention or treatment of stress inconti- well for her from ages 65 to 70. But now her cognitive nence in the context of colpocleisis is problematic. function is declining and she may not be able to Some surgeons treat stress incontinence with sling provide ongoing care for her pessary as she has in the procedures, although elderly patients are at high risk past. Or she has developed hypertension, and al- for postoperative urinary retention requiring sling though it is well controlled currently, she worries that takedown.81 Other surgeons minimize the risk of her risk of surgery will increase with time. Perhaps her retention by performing suburethral Kelly plication to prolapse is progressing despite pessary use, and only provide differential support to the urethra and then a cube pessary effectively relieves her symptoms now. treat persistent or recurrent postoperative stress in- It seems likely that there is a window of time, in continence with periurethral injection. The impact of choosing between nonsurgical and surgical manage- colpocleisis on bowel function is unknown, as well as ment of prolapse as a woman ages, that favors sur- its overall impact on quality of life. The issue of regret gery. In cases such as these, we recommend vaginal after colpocleisis has not been well studied.82 A cohort apical repairs or colpocleisis, when minimizing mor- study is currently underway through the Pelvic Floor

630 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY Disorders Network to collect data prospectively on the patient’s own tissue. Surgeons, frustrated by recur- incontinence, other pelvic symptoms, and life impact rent prolapse, actively seek means to reduce the risk after colpocleisis. of recurrence, but in their enthusiasm, they may misjudge the risk presented by new materials that Diagnosis and Treatment of Stress Incontinence have not been well studied in the vaginal environ- with Pelvic Organ Prolapse ment. Currently, the most common prolapse proce- In patients with stress incontinence symptoms con- dures using adjunctive materials are abdominal sacral firmed by stress testing, it seems straightforward to colpopexy and anterior and posterior vaginal repairs. recommend anti-incontinence surgery in the setting The ideal adjunctive material should be biocompat- of prolapse repair. However, as discussed previously, ible yet inert, nonallergenic and noninflammatory, how to treat the finding of latent stress incontinence in noninfectious, resistant to mechanical stress or shrink- symptomatically continent women with prolapse is age, and conveniently available. Several reviews have less clear. Positive stress testing with prolapse reduc- evaluated the various types of synthetic and biologic tion is not the equivalent of confirming stress incon- materials used in prolapse surgery,89–90 although their tinence in a symptomatic woman. The false positive widespread use has leapfrogged ahead of scientific rate of such testing is unknown. Postoperative stress evidence of their safety and effectiveness.91 The im- incontinence develops in up to one quarter of previ- pact of adjunctive materials on sexual function and ously stress-continent women who did not receive a long-term outcomes is unknown. Different grafts have continence procedure with prolapse repair.82,83 How- different complication rates, depending on where and ever, concern has been raised that “prophylactic” how they are used. Unlike graft material used in continence procedures in women with latent stress abdominal sacral colpopexy, typical graft use in vag- incontinence may represent overtreatment and result inal repairs involves a much greater area of contact in new voiding dysfunction, including urgency, urge between the graft and the vagina after the vaginal wall incontinence, and urinary retention.84 Nevertheless, has been split by surgical dissection. It is critically some studies report that patients benefit when anti- important for surgeons to discuss the use of adjunctive incontinence procedures are added to prolapse repair materials with their patients before surgery so patients to treat latent incontinence, with low rates of both are well-informed of the unknown risks and benefits stress incontinence (8–10% at one year) and new urge and can participate in the decision to use such mate- incontinence (8–16%).85–87 Tension-free vaginal tape rials. It cannot be assumed that graft use is automat- procedure is more effective in preventing stress incon- ically the same or better than existing procedures. tinence than suburethral plication.87 The likelihood that outcomes will actually be worse The Pelvic Floor Disorders Network is currently must be considered by the clinician and the patient conducting a randomized trial88 for symptomatically considering the use of graft materials. Until we have stress-continent women with advanced prolapse who evidence that graft materials are beneficial, we recom- are undergoing abdominal sacral colpopexy, with mend that their use be restricted to subjects in re- randomization to the addition of Burch colposuspen- search protocols. This will ensure that evidence sup- sion versus no Burch. The objectives are to determine porting or refuting their use actually becomes whether a trade-off exists in reducing stress inconti- available over the next several years. nence versus worsening voiding dysfunction, and whether preoperative prolapse reduction testing accu- REFERENCES rately predicts who benefits from the Burch proce- 1. U.S. Census Bureau. U.S. interim projections by age, sex, race, dure. Enrollment in the trial was halted early (at and Hispanic origin. Available at: http://www.census.gov/ipc/ www/usinterimproj. Retrieved June 28, 2005. approximately 350 subjects) based on interim results 2. Luber KM, Boero S, Choe JY. 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