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Management of Uterine Prolapse: Is Hysterectomy Necessary?

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Management of Uterine Prolapse: Is Hysterectomy Necessary? DOI: 10.1111/tog.12220 2016;18:17–23 Review The Obstetrician & Gynaecologist http://onlinetog.org Management of uterine prolapse: is hysterectomy necessary? a b b, Helen Jefferis MRCOG, Simon Robert Jackson MD FRCOG, Natalia Price MD MRCOG * aSubspeciality Trainee in Urogynaecology, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK bConsultant Urogynaecologist, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK *Correspondence: Natalia Price. Email: [email protected] Accepted on 1 June 2015 Key content Fertility preservation remains the one absolute indication for Management of uterine prolapse is currently heavily influenced by hysteropexy. Other potential advantages include stronger apical patient and surgeon preferences. support and reduced vaginal surgery. The traditional approach to uterine prolapse is vaginal Colpocleisis remains a valid option for a small cohort of patients. hysterectomy. However, this does not address the underlying Learning objectives deficiency in connective tissue pelvic floor support, and prolapse Options for the management of uterine prolapse. recurrence is common. How to help patients decide on a management plan. Uterine preservation surgery is increasing in popularity, both with surgeons and patients; there is currently little evidence to show Keywords: colpocleisis / hysteropexy / pelvic organ prolapse / superior outcome to hysterectomy. uterine preservation surgery / vaginal hysterectomy Please cite this paper as: Jefferis H, Jackson SR, Price N. Management of uterine prolapse: is hysterectomy necessary? The Obstetrician & Gynaecologist 2016;18: 17–23. DOI: 10.1111/tog.12220 Introduction significantly associated with regression of prolapse, leading the authors to suggest that the damage obesity causes to the When a woman presents with pelvic organ prolapse, the pelvic floor may be irreversible. management options are doing nothing, offering Women are often given advice regarding pelvic floor conservative treatment such as physiotherapy and vaginal muscle training and may receive targeted physiotherapy. A pessaries, or surgery. Many women will ask for their 2014 multicentre randomised controlled trial (RCT)2 gynaecologist’s opinion as to the best course of action. This comparing individualised pelvic floor muscle training with will depend on symptomatology, impact on quality of life, no intervention found a statistically significant improvement desire for sexual function and medical comorbidities, among in subjective assessment of prolapse symptoms in the other factors. It is important that gynaecologists are aware of intervention group. No significant improvement in all available treatment modalities and can counsel objective assessment of anatomy, as assessed by the pelvic women about the potential benefits and risks. Some organ prolapse quantification system (POP-Q), patients will simply require reassurance that there is no was reported. sinister pathology. Women have used mechanical devices to reduce pelvic organ prolapse since ancient times, and the use of vaginal Conservative management pessaries remains a simple and satisfactory treatment. One study of 100 women using this method3 showed a 92% Gynaecologists will often recommend lifestyle measures to satisfaction rate in terms of prolapse symptoms and a 50% patients presenting with symptomatic pelvic organ prolapse. improvement in urinary symptoms. Of particular interest is the correlation between increasing Studies have shown that older women and those with body mass index and prevalence of prolapse. Weight loss is comorbidities are most likely to persist with the use of therefore often recommended to patients as part of a vaginal pessaries. Women more likely to pursue surgery are conservative approach to managing prolapse symptoms. younger, more likely to be sexually active and more likely to However, one large study1 showed that weight loss was not have more advanced prolapse.4 Factors predicting failure of ª 2016 Royal College of Obstetricians and Gynaecologists 17 Management of uterine prolapse pessary treatment are short vaginal length, deficient perineal organs. The request frequently arises after women have body and a wider vaginal introitus. conducted an internet literature search and become aware of The side effects associated with vaginal pessary use are alternatives to hysterectomy. usually minor and include vaginal discharge, odour and vaginal erosions. More serious complications such as fistulae The history of uterine preserving prolapse are predominately seen in neglected or forgotten pessaries. surgery The current debate Uterine preservation surgery can be considered when it is appropriate to offer a surgical remedy for uterine prolapse. Vaginal hysterectomy has long been the standard approach The most obvious indication is fertility preservation in for the management of uterine prolapse, with the first women who have not yet completed childbearing. However, successful planned case being credited to Langenback in 1813. this is a small group of patients. Most women requiring It remains a safe and readily available surgical solution to surgery for prolapse have no desire for further children; uterine prolapse. Various techniques are described for indeed the majority are postmenopausal. reducing the risk of subsequent vaginal prolapse. The In the authors’ experience other more prevalent McCall culdoplasty (which involves approximating the indications for uterine preservation include patient request uterosacral ligaments so as to obliterate the peritoneum of and superior outcome. The latter is a contentious statement the posterior cul-de-sac as high as possible) is considered as clinical data remains sparse and will be discussed in this superior to a vaginal Moschowitz procedure, or closure of the article. However, when there is loss of apical support, peritoneum of the cul-de-sac in preventing enterocoele traditional vaginal hysterectomy will not correct the defect. formation.5 Suturing the cardinal and uterosacral ligaments This is most readily apparent when women present with to the vaginal cuff may also reduce subsequent procidentia; it is self-evident that hysterectomy will not treat vault prolapse.6 vaginal eversion. The Royal College of Obstetricians While vaginal hysterectomy has served patients and and Gynaecologists (RCOG) Green-top Guideline, gynaecologists well for many years, its continued routine ‘Management of Post Hysterectomy Vaginal Vault use has been subject to debate. Many gynaecologists argue Prolapse’,12 recommends sacrospinous fixation if the that the uterus itself is healthy and the underlying vaginal vault is at the introitus at the end of a vaginal pathophysiology is a connective tissue deficiency,7 whether hysterectomy procedure. congenital or acquired through childbirth or ageing, and that The concept of uterine preservation surgery for pelvic uterine prolapse is merely a symptom, not the disease. organ prolapse is not new, but it has attracted a resurgence in Vaginal hysterectomy fails to address this underlying interest over recent years. In 1888 Archibald Donald first deficiency in connective tissue, with relatively high described the Manchester repair as an alternative to vaginal recurrence rates of 10–40% described in the literature.8,9 hysterectomy for patients with uterine prolapse, although this Recurrence can manifest with vaginal vault eversion, or more may have been a more useful technique for patients with an commonly recurrent enterocoele or cystocoele. We know that elongated cervix rather than true uterine descent. In 1930 cystocoele commonly arises because of loss of apical (type 1) Victor Bonney highlighted the passive role of the uterus in vaginal support, and until apical support is established, a uterovaginal prolapse, which underpins the theory behind cystocoele will recur after surgery. Furthermore, uterine preservation surgery. Subsequent surgeons have hysterectomy removes a healthy organ that may play a role developed techniques for uterine preservation using a in a woman’s individual and sexual identity. vaginal, abdominal or laparoscopic approach. On the other hand, vaginal hysterectomy has been part of core gynaecology training for decades; more recently part of Vaginal approach the popular vaginal surgery advanced training skills module In 1966 Williams13 described a technique for transvaginal (ATSM). Most gynaecologists are therefore well trained and uterosacral-cervical ligament plication. He reported on the comfortable doing the procedure with good outcomes. In outcomes of 20 women undergoing this procedure, with addition, there is evidence that the procedure is associated three ‘failures’ encountered within a 6-month follow-up with high patient satisfaction rates, which are not period. His method involved a posterior colpotomy with significantly different from uterine preservation.10 Some division of the uterosacral ligaments from the cervix, uterine preservation procedures have also been associated plication across the midline and reinsertion into the cervix. with high rates of recurrent anterior wall prolapse.11 The cardinal ligaments are then plicated anteriorly across Women are increasingly requesting uterine conservation. the midline. This may be because of the wish to preserve fertility, or the The concept of sacrospinous hysteropexy was first belief that female identity is bound up in the female genital described by Richardson14 in 1989. The cervix or 18
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