This study reports one year outcomes in women who underwent transvaginal pelvic organ prolapse (POP) surgery with Prolift® transvaginal mesh.
Pre and post-operative objective vaginal (Pelvic Organ Prolapse Quantification, POP-Q) and subjective symptom and impact assessments (Pelvic Floor Distress Inventory-20, PFDI-20; Pelvic Floor Impact Questionnaire-7, PFIQ-7, respectively) were performed. Post- operative vaginal tenderness, stricture and patient satisfaction were also obtained. Paired t-tests were utilized for analysis.
Mean age was 61.8±9.8 years; mean follow-up interval was 425.0±80.0 days (range: 237–717). POP-Q measurements of Ba, Bp, and C were significantly improved (all p-values <0.001). PFDI and PFIQ subscales scores significantly improved (all p-values ≤0.004). Thirty-five of 48 (73%) were completely satisfied, 2 (4%) were not satisfied. Complications [n(%)] included graft exposure [1(2%)], dyspareunia [2(4%)], and granulation tissue [3(6%)].
Women undergoing transvaginal repair of POP with the Prolift® mesh system showed significant improvement in one-year anatomic and subjective measures.
Pelvic organ prolapse; surgery; Prolift® mesh; graft; outcomes
Introduction and hypothesis
To compare depressive symptoms in women with and without prolapse and evaluate impact on quality of life.
This is a secondary analysis of a case–control study assessing the effect of prolapse on body image. Cases had prolapse and sought surgery (Pelvic Organ Prolapse Quantification stage ≥2). Controls had stage ≤1. Subjects completed the Pelvic Floor Impact Questionnaire (PFIQ), Pelvic Floor Distress Inventory, and the Patient Health Questionnaire-9 (PHQ-9) at baseline. Cases completed measures 6 months post-operatively. We report: (1) the comparison of cases and controls at baseline and (2) comparison of baseline and post-operative scores in cases.
Baseline questionnaires were completed by 75 cases and 65 controls; 57 cases completed post-operative measures. Cases were 5-fold more likely than controls to have depressive symptoms. Cases with depressive symptoms had higher PFIQ scores than cases without symptoms. PHQ-9 scores improved post-operatively.
Depressive symptoms are common in women with prolapse and a decrease following surgical treatment.
Depressive symptoms; Quality of life; Pelvic organ prolapse; Surgery
This study aimed to compare TVT-Secur (TVT-S) and TVT-Obturator (TVT-O) suburethral slings for treatment of stress urinary incontinence (SUI).
This was a single-center, nonblinded, randomized trial of women with SUI who were randomized to TVT-S or TVT-O from May 2007 to April 2009. The primary outcome, SUI on cough stress test (CST), and quality-of-life and symptom questionnaires (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) were assessed at 12 weeks and 1 year.
Forty-three women were randomized to TVT-S and 44 to TVT-O. There were no differences in median baseline PFDI-20 and PFIQ-7. Twenty-two (52.4%) of 42 participants randomized to TVT-S had a positive CST result at evaluation after 12 weeks or 1 year, whereas 4 (9.1%) of the 44 in the TVT-O group had a positive CST result. The intent-to-treat analysis showed that the risk of a positive CST result was 6 times higher after TVT-S than TVT-O (risk ratio, 6.0; 95% confidence interval [CI], 2.3–16.0). Among women not lost to follow-up, the risk ratio for a positive CST result after TVT-S compared with TVT-O was 17.9 (95% CI, 2.5–128.0) at 12 weeks and 3.5 (95% CI, 1.1–11.0) at 1 year. Both TVT-S and TVT-O resulted in improved quality of life and symptoms at 12 weeks. There was no difference between the groups for PFDI-20 (P = 0.40) or PFIQ-7 (P = 0.43). A similar pattern was seen at 1 year (P = 0.85 and P = 0.36).
The TVT-S seems to have a higher risk of positive postoperative CST result; however, the procedures result in similar improvements in quality of life and symptoms.
TVT-Secur; TVT-Obturator; stress incontinence; efficacy
A prospective multicenter clinical study was performed to evaluate the safety and efficacy of a bovine dermal graft (Xenform® Matrix, Boston Scientific, Natick, MA, USA) during vaginal reconstructive surgery.
Forty-five women with ICS stage 2 or higher pelvic organ prolapse (POP) were enrolled at 4 centers. POP-Q, pelvic floor function (PFDI-20), sexual function (PISQ-12), and patient satisfaction tools were used to assess subjects at baseline, and at 2 and 6 weeks, and 3, 6 and 12 months post surgery. The significance of symptom score changes at 6 months and 1 year were determined by the t-test for paired data. Forty-three of the 45 patients completed the 12 month study.
The majority of the subjects had cystocele (98%) and/or rectocele (84%) defects at study entry. At 12 months, 74% of the defects had improved to a stage 0 or 1. Mean PFDI-20 scores improved by 72% (p < 0.001) at 12 months, and PISQ-12 scores were maintained during the follow-up period indicating no decline in sexual function. Three subjects experienced one serious adverse event each; one of the adverse events (constipation) was deemed by the study physician to be unrelated to Xenform®. One subject had severe pyelonephritis resulting in dialysis. This subject had a previous history of pyelonephritis, sepsis and acute renal failure. The third subject had a reported recurrent cystocele of moderate severity, possibly related to the device. No graft related erosions or pain lasting more than 30 days were reported. No subjects withdrew due to an adverse event.
This study is the first to investigate the use of Xenform® Matrix in vaginal reconstructive surgery among patients with POP. Significant improvement was maintained at 12 months utilizing both objective and subjective assessment tools, confirming the safety and efficacy of this material in vaginal surgery.
The purpose of this study was to determine the effect of posterior repair (PR) on sexual function in patients who have undergone incontinence and/or pelvic reconstructive surgery.
A cohort study of women who underwent incontinence and/or prolapse surgery was performed. Participants completed the pelvic organ prolapse urinary incontinence sexual questionnaire (PISQ) before and after the operation. PISQ scores were compared between women who underwent PR and women who did not.
Of 73 study participants, 30 women underwent PR; 43 women did not (no PR). Although there was no difference in dyspareunia between groups pre-op, dyspareunia prevalence post-op was significantly lower in the no PR group. Preoperative PISQ scores were similar between groups. After the operation, both groups significantly improved their PISQ scores, without a difference between groups.
Although the incidence of dyspareunia differed between PR and no PR groups, overall improvement in sexual function was reflected in improved total PISQ scores that occurred irrespective of PR performance.
dyspareunia; incontinence; posterior repair; prolapse; sexual function
Pelvic organ prolapse (POP) is a silent disorder with a huge impact on women's quality of life. There is limited data from community-based studies conducted to determine the prevalence of POP as its assessment needs a pelvic examination. We aimed to develop a simple screening inventory for identification of pelvic organ prolapse and then evaluate its sensitivity and specificity.
This study had two phases. In the first phase in order to develop a simple inventory for assessment of POP, the Pelvic Floor Disorder Inventory (PFDI) was completed for a convenience sample of 200 women, aged 18-45 years, referred for annual gynecologic examination, and their pelvic organ prolapse was assessed using the standard protocol. The most sensitive and specific questions were selected as pelvic organ prolapse simple screening inventory (POPSSI). In the second phase, using a stratified multistage probability cluster sampling method, the sensitivity and specificity of the POPSSI was investigated in a non selected sample of 954 women recruited from among reproductive aged women living in four randomly selected provinces of Iran.
The sensitivity and specificity of POPSSI for identification of pelvic organ prolapse in the general population were 45.5 and 87.4% respectively; these values were 96.7 and 20% among those women who were aware of their pelvic dysfunction.
Community based screening studies on pelvic organ prolapse could be facilitated by using the POPSSI, the sensitivity of which would be enhanced through conducting of public awareness programs.
Laparoscopic sacrocervicopexy appears to be an effective option for sexually active women with pelvic organ prolapse.
Background and Objectives:
To evaluate the efficacy of laparoscopic sacrocervicopexy for apical support in sexually active patients with pelvic organ prolapse.
One-hundred thirty-five women with symptomatic prolapse of the central compartment (Pelvic Organ Prolapse Quantitative [POP-Q] stage 2) underwent laparoscopic sacrocervicopexy. The operating physicians used synthetic mesh to attach the anterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory with subtotal hysterectomy. Anterior and posterior colporrhaphy was performed when necessary. The patients returned for follow-up examinations 1 month after surgery and then over subsequent years. On follow-up a physician evaluated each patient for the recurrence of genital prolapse and for recurrent or de novo development of urinary or bowel symptoms. We define “surgical failure” as any grade of recurrent prolapse of stage II or more of the POP-Q test. Patients also gave feedback about their satisfaction with the procedure.
The mean follow-up period was 33 months. The success rate was 98.4% for the central compartment, 94.2% for the anterior compartment, and 99.2% for the posterior compartment. Postoperatively, the percentage of asymptomatic patients (51.6%) increased significantly (P < .01), and we observed a statistically significant reduction (P < .05) of urinary urge incontinence, recurrent cystitis, pelvic pain, dyspareunia, and discomfort. The present study showed 70.5% of patients stated they were very satisfied with the operation and 18.8% stated high satisfaction.
Laparoscopic sacrocervicopexy is an effective option for sexually active women with pelvic organ prolapse.
Laparoscopy; Sacrocervicopexy; Pelvic organ prolapse; Colporrhaphy; Pelvic floor repair; Uterine prolapse
To determine if differences exist in pelvic symptom distress and impact in women randomized to pessary versus behavioral therapy for treatment of stress urinary incontinence (SUI).
Change in symptom and condition-specific health related quality of life (HRQOL) measures were compared between pessary and behavioral groups 3-months after randomization in the Ambulatory Treatments for Leakage Associated with Stress Incontinence [ATLAS]) trial. 446 women with symptoms of SUI were randomized to continence pessary, behavioral therapy (pelvic floor muscle training and continence strategies) or combination therapy. Validated measures utilized included urinary (UDI), prolapse (POPDI) and colorectal (CRADI) scales of the Pelvic Floor Distress Inventory; urinary (UIQ), prolapse (POPIQ) and colorectal (CRAIQ) scales of the Pelvic Floor Impact Questionnaire; and stress and urge scale of the Questionnaire for Urinary Incontinence Diagnosis (QUID). Student t- test and ANOVA was used to compare scores within and between groups.
Mean age of participants was 49.8±11.9 years; 84% were Caucasian and 10% African American. 149 were randomized to pessary and 146 to behavioral therapy. Baseline symptoms and HRQOL scores were significantly reduced within treatment arms at three months post randomization, but there was no statistically significant difference between groups.
There was no difference in pelvic floor symptom bother and HRQOL between the pessary and behavioral therapy arms in women undergoing conservative treatment for SUI. Individualized preference issues should be considered in the approach to the non-surgical treatment of SUI.
Pessary; Behavioral Therapy; Stress Urinary Incontinence
We aimed to evaluate the anatomical and functional outcomes of posterior intravaginal slingplasty (P-IVS) for the treatment of a vaginal vault or uterine prolapse (VP/UP).
Materials and Methods
This was a 12-month prospective, multicenter, observational study. Women aged over 30 years who presented with stage II or greater VP/UP underwent P-IVS by four urologists at four university hospitals. Preoperatively, pelvic examination by use of the Pelvic Organ Prolapse Quantification (POP-Q) system, the Pelvic Floor Distress Inventory (PFDI) questionnaire, the 3-day frequency volume chart, and uroflowmetry were completed. At the 12-month follow-up, changes in the POP-Q, PFDI, frequency volume chart, and uroflowmetry parameters were assessed. Cure was defined as VP/UP stage 0 and improvement as stage I.
The cure and improvement rates among the 32 women were 65.6% and 34.4%, respectively. All subscale scores of the Urinary Distress Inventory, the general subscale score of the Pelvic Organ Prolapse Distress Inventory, and the rectal prolapse subscale score of the Colo-Rectal-Anal Distress Inventory were significantly improved. There were no significant changes in the frequency volume chart or uroflowmetry parameters. There was one case of surgery-related transfusion.
Trans-vaginal repair by P-IVS is an effective and safe procedure for restoring the anatomical defect and improving the associated pelvic floor symptoms in women with VP/UP.
Prospective studies; Treatment outcome; Pelvic organ prolapse
To investigate whether episiotomy, perineal laceration, and operative delivery are associated with pelvic floor disorders after vaginal childbirth.
This is a planned analysis of data for a cohort study of pelvic floor disorders. Participants who had experienced at least one vaginal birth were recruited 5–10 years after delivery of their first child. Obstetric exposures were classified by review of hospital records. At enrollment, pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders.
Of 449 participants, 71 (16%) had stress incontinence, 45 (10%) had overactive bladder, 56 (12%) had anal incontinence, 19 (4%) had prolapse symptoms and 64 (14%) had prolapse to or beyond the hymen on examination. Forceps delivery increased the odds of each pelvic floor disorder considered, especially overactive bladder (odds ratio 2.92, 95% confidence interval 1.44, 5.93) and prolapse (odds ratio 1.95, 95% confidence interval 1.03, 3.70). Episiotomy was not associated with any of these pelvic floor disorders. In contrast, women with a history of more than one spontaneous perineal laceration were significantly more likely to have prolapse to or beyond the hymen (odds ratio 2.34, 95% confidence interval 1.13, 4.86). Our multivariable results suggest that one additional woman would develop prolapse for every 8 women who experienced at least one forceps birth (versus delivering all her children by spontaneous vaginal birth).
Forceps deliveries and perineal lacerations, but not episiotomies, were associated with pelvic floor disorders 5–10 years after a first delivery.
To estimate whether prolapse severity is a major contributor to urinary incontinence severity, as measured by validated incontinence questionnaires.
We analyzed data from two large female stress urinary incontinence (SUI) surgical cohorts: the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) study (N=655) and the subsequent Trial of Mid-Urethral Slings (TOMUS) study (N=597). All participants completed a standardized baseline assessment including validated measures of symptom severity, quality of life, objective measures of urine loss [Urogenital Distress Inventory (UDI), Medical, Epidemiologic, and Social Aspects of Aging questionnaire (MESA), Incontinence Impact Questionnaire (IIQ) and pad test], as well as the Pelvic Organ Prolapse – Quantification (POP-Q) assessment. Groups were compared using the χ2 test (categorical measures) or the one-way analysis of variance (continuous measures). Statistical significance was defined at p-value <0.05.
The SISTEr and TOMUS samples were similar for many variables including age (52 vs. 53 years, respectively), nulliparity (9 vs. 12%), prior UI surgery (14 vs. 13%), and prior hysterectomy (31 vs 28%), but other differences necessitated separate analysis of the two cohorts. There was not a statistically significant difference in UDI scores according to prolapse stage in either study population. Patients with prior surgery for POP and SUI had more incontinence symptoms and were more bothered by their UI, regardless of prolapse stage.
Prolapse stage is not strongly or consistently associated with incontinence severity in women who select surgical treatment of stress urinary incontinence. Prior POP and UI surgery is associated with worse UI severity and bother.
Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00064662 and NCT00325039.
The objective was to study the effect of colpocleisis on pelvic support, symptoms, and quality of life and report-associated morbidity and postoperative satisfaction. Women undergoing colpocleisis for treatment of pelvic organ prolapse (POP) were recruited at six centers. Baseline measures included physical examination, responses to the Pelvic Floor Distress Inventory, and Pelvic Floor Impact Questionnaire. Three and 12 months after surgery we repeated baseline measures. Of 152 patients with mean age 79 (±6) years, 132 (87%) completed 1 year follow-up. Three and 12 months after surgery, 90/110 (82%) and 75/103 (73%) patients following up had POP stage ≤1. All pelvic symptom scores and related bother significantly improved at 3 and 12 months, and 125 (95%) patients said they were either ‘very satisfied’ or ‘satisfied’ with the outcome of their surgery. Colpocleisis was effective in resolving prolapse and pelvic symptoms and was associated with high patient satisfaction.
Pelvic organ prolapse; Urinary incontinence; Pelvic floor disorders; Colpocleisis; Quality of life; Surgical outcomes
Participants in the multi-center, randomized Total or Supracervical Hysterectomy (TOSH) trial showed within-group improvement in pelvic floor symptoms 2 years post-surgery and no differences between supracervical (SCH) versus total hysterectomy (TAH). This study describes longer term outcomes from the largest recruiting site.
Questionnaires addressing pelvic symptoms, sexual function, and health-related quality of life were administered. Linear models and McNemar’s test were utilized.
Thirty-seven participants (69%) responded (19 TAH, 18 SCH); mean follow up was 9.1±0.7 years. No between-group differences emerged in urinary incontinence, voiding dysfunction, pelvic prolapse symptoms and overall health related quality of life (HRQOL). Within-group analysis showed significant improvement in the ability to have and enjoy sex (P = 0.002) and in the SF-36 physical component summary score (P = 0.03) among women randomized to TAH.
9 years after surgery, TOSH participants continue to experience improvement and show no major between-group differences in lower urinary tract or pelvic floor symptoms conferring no major benefit of SCH over TAH.
To determine the lifetime risk of undergoing pelvic floor surgery in a cohort of UK parous women and the re-operation rates for pelvic floor surgery, time intervals for repeat surgery and independent risk factors for undergoing primary and repeat pelvic floor surgery.
A register linkage study.
Main outcome measures
The primary outcome was lifetime risk of parous women in the UK undergoing pelvic floor surgery for pelvic organ prolapse (POP), urinary incontinence (UI), and rectal prolapse or faecal incontinence (RP-FI). Secondary outcomes were re-operation rates and time interval of repeat surgery for POP/UI, and independent risk factors for undergoing primary and repeat pelvic floor surgery.
34 631 women identified from the Aberdeen Maternity and Neonatal Database were linked with the Scottish Morbidity Records databases of NHS Scotland to assess relevant outcomes. The lifetime risk for women by age 80 years of undergoing any form of pelvic floor surgery was 12.2%. 2130 (6.2%) women had at least one pelvic floor surgery, of whom 407 (19%) had repeat operations. The median time intervals (IQR) between index and repeat UI and POP surgery were 2.80 (0.94–8.07) years and 3 (1.00–8.25) years, respectively. There is a reduced lifetime risk of pelvic floor surgery in women who had all deliveries by caesarean section (p<0.001) and those aged <20 years at first delivery (p=0.021). Women who sustained at least one perineal laceration (in the absence of a classified perineal tear) during delivery or who had at least one instrumental delivery with forceps use were at increased risk (p<0.001 and p=0.015, respectively).
Our study shows that in the UK more than one in 10 parous women will require at least one surgical procedure for pelvic floor disorders over their lifetime. The study also identifies independent risk and protective factors for pelvic floor surgery in parous women.
Lifetime risk of undergoing various types of pelvic floor surgery in a cohort of UK women.
Re-operation rates for various types of pelvic floor surgery and time intervals for repeat surgery.
Independent risk factors for undergoing primary and repeat pelvic floor surgery.
The lifetime risk for women by age 80 years undergoing any form of pelvic floor surgery was 12.2%.
The re-operation rate for pelvic floor surgery was 19%.
There was a reduced lifetime risk of pelvic floor surgery in women who had all deliveries by caesarean section only and those aged <20 years at first delivery, while women who sustained at least one perineal laceration during delivery or who had at least one instrumental delivery with the use of forceps were at increased risk.
Strengths and limitations of this study
To our knowledge, this is the first study to report the lifetime risk for women in the UK of undergoing surgical treatment for pelvic floor dysfunction.
As the study represents the general population rather than a selected population, we are confident that our findings are generalisable to the UK or indeed any European population.
The Aberdeen Maternity and Neonatal Database and Scottish Morbidity Records (SMR) databases used in this study are subjected to quality control measures at regular intervals and there are numerous consistency checks in place to ensure the validity of data entry.
We were unable to link 27% of women with the SMR databases.
The objective of this study was to determine the minimum threshold level at which maximum anatomic prolapse predicts bothersome pelvic floor symptoms.
We performed a cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using Pelvic Organ Prolapse Quantification (POP-Q) examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms. Across the spectrum of prolapse severity, we calculated receiver operating characteristic (ROC) curves and areas under the curves (AUCs) for each symptom.
Of 296 participants, age was 56.3 ± 11.2 years, and 233 (79%) were white. POP-Q stage was 0 in 39 (13%), 1 in 136 (46%), 2 in 89 (30%), and 3 in 33 (11%). ROC analysis for each symptom revealed an AUC of 0.89 for bulging/protrusion; 0.81 for splinting to void; 0.55–0.62 for other prolapse and urinary symptoms; and 0.48–0.56 for bowel symptoms. Using a threshold of 0.5 cm distal to the hymen, the sensitivity (69%) and specificity (97%) were high for protrusion symptoms but poor for most other symptoms considered.
Vaginal descensus 0.5 cm distal to the hymen accurately predicts bulging/protrusion symptoms; however, we could not identify a threshold of prolapse severity that predicted other pelvic floor symptoms.
bulging and protrusion symptoms; Pelvic Floor Distress Inventory; Pelvic Organ Prolapse Quantification System; prolapse; receiver operating characteristic curve; threshold
To evaluate the efficacy and safety of the tension-free placement of a monofilament polypropylene mesh for the repair of an anterior vaginal wall prolapse (AVWP).
Materials and Methods
Women aged ≥ 30 years with an AVWP stage of II or greater were included. Forty-nine women underwent trans-vaginal repair using a Gynemesh™ PS. Forty-six women who had symptomatic stress urinary incontinence received a midurethral sling (MUS). At the 12-month follow-up, evaluations were made for changes in the Pelvic Organ Prolapse Quantification (POP-Q) stage and Pelvic Floor Distress Inventory. Cure was defined as a POP-Q stage of 0 and improvement as a stage of I. Complications were also evaluated.
The cure rate was 71.4%, and the improvement rate was 18.4%. Obstructive/discomfort, irritative, and stress subscale scores of the Urinary Distress Inventory anterior and posterior subscale scores of the POP Distress Inventory and the obstructive subscale score of the Colo-Rectal-Anal Distress Inventory were significantly improved. Thirty-two of the 46 women (69.6%) who received MUS procedures reported no leakage after surgery. Complications were 2 cases of increased intraoperative bleeding and 1 case of vaginal erosion.
Trans-vaginal repair using a Gynemesh™ PS is a feasible and effective procedure for the treatment of AVWP with no significant complications.
Pelvic organ prolapse; Lower urinary tract symptoms; Surgery
Purpose of review
Pelvic floor disorders affect women of all ages and are associated with significant economic burden and poor quality of life. Current literature suggests an association between childbirth and these disorders. In this review, we summarize recent advancements in our understanding of this association.
Vaginal childbirth appears to be strongly associated with stress urinary incontinence and pelvic organ prolapse. There is less evidence to suggest an association between vaginal delivery and overactive bladder symptoms. History of more than one perineal laceration increases the likelihood of developing prolapse. Similar association has not been established for episiotomy. Disruption or denervation of structural components of pelvic floor support system, particularly levator ani muscle complex, is associated with later development of pelvic floor disorders. Imbalance in homeostasis of connective tissue remodeling of the vaginal wall from overstretching during childbirth is another possible mechanism.
Pelvic floor disorders represent a significant health problem affecting women of all ages. Identification of potential modifiable risk factors and advancement in understanding of the underlying pathophysiology is crucial for primary and secondary prevention of these disorders and for improvement in treatment strategies.
prolapse; urinary incontinence; vaginal childbirth
To explore the association of anal sphincter laceration and sexual function 6 months postpartum in the Childbirth and Pelvic Symptoms (CAPS) cohort.
The primary CAPS study, a prospective cohort study, was designed to estimate the postpartum prevalence and incidence of urinary and fecal incontinence. Three cohorts of new mothers (vaginal delivery with a third- or fourth-degree anal sphincter tear, vaginal delivery without a third- or fourth-degree anal sphincter tear, and cesarean delivery without labor) were compared at 6 months postpartum. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Short Form Questionnaire (PISQ-12). Urinary and fecal incontinence were assessed using the Medical Epidemiological and Social Aspects of Aging questionnaire and the Fecal Incontinence Severity Index, which is embedded within the Modified Manchester Health Questionnaire.
Most women (459 [90%]) of those with partners reported sexual activity at the 6-month visit. Fewer women whose delivery was complicated by anal sphincter laceration reported sexual activity when compared with those who delivered vaginally without sphincter laceration (88 compared with 94%, P=.028). The mean PISQ-12 score (39±4) did not differ between delivery groups (P=.92). Pain (responses of “sometimes,” “usually,” or “always”) during sex affected one of three sexually active women (164 [36%]).
At 6 months postpartum, primiparous women who delivered with anal sphincter laceration are less likely to report sexual activity.
Introduction. Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on women's quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualised, taking into consideration the surgeon's experience, patients age, comorbidities, previous surgery and sex life. Result. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced at hysterectomy to prevent vault prolapse. Studies have shown the McCall's culdoplasty under direct visualisation to be superior.
Vault prolapse repair rely on either the use of patient's tissue or synthetic materials and can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures, with literature in favour of abdominal sacrocolpopexy over sacrospinous fixation due to its reported higher success rate of about 90%. Other less commonly performed procedures include uterosacral ligament suspension and illiococcygeal fixation, both of which are equally effective, with the former having a high risk of ureteric injury. Colpoclesis will play a greater role in the future as the aging population increases. Mesh procedures are gaining in popularity, and preliminary data from vaginal mesh procedures is encouraging. Laparoscopic techniques require a high level of skill and experience. There are many controversies on the mechanism of prolapse and management techniques, which we have tried to address in this article. Conclusion. As the aging population increases, the incidence of prolapse will also rise, older techniques using native tissue will continue, while new techniques using the mesh needs to be studied further. The later may well be the way forward in future.
Introduction and hypothesis
The aim of the study was to determine whether patients’ symptoms agree with findings on clinical examination and dynamic MR imaging of the pelvic floor.
Symptoms of pelvic organ dysfunction were measured with the use of three validated questionnaires. The domain scores were compared with POP-Q and dynamic MR imaging measurements. The Spearman’s rank correlation coefficient (rs) was used to assess agreement.
Only the domain score genital prolapse was significantly correlated in the positive direction with the degree of pelvic organ prolapse as assessed by POP-Q and dynamic MR imaging (rs = 0.64 and 0.27, respectively), whereas the domain score urinary incontinence was inversely correlated (rs = −0.32 and −0.35, respectively).
The sensation or visualization of a bulge in the vagina was the only symptom which correlated positively with the degree of pelvic organ prolapse, and clinical examination and dynamic MR imaging showed similar correlation in this respect.
Agreement; Magnetic resonance imaging; Pelvic organ prolapse; POP-Q; Questionnaire; Symptom
To estimate differences in pelvic floor disorders by mode of delivery.
We recruited 1,011 women for a longitudinal cohort study, 5-10 years after first delivery. Using hospital records, we classified each birth as: cesarean without labor, cesarean during active labor, cesarean after complete cervical dilation, spontaneous vaginal birth, or operative vaginal birth. At enrollment, stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders.
Compared to cesarean without labor, spontaneous vaginal birth was associated with a significantly greater odds of stress incontinence (odds ratio (OR) 2.9; 95% confidence interval (CI) 1.5, 5.5) and prolapse to or beyond the hymen (OR 5.6; 95% CI 2.2, 14.7). Operative vaginal birth significantly increased the odds for all pelvic floor disorders, especially prolapse (OR 7.5; 95% CI 2.7, 20.9). These results suggest that 6.8 additional operative births or 8.9 spontaneous vaginal births, relative to cesarean births, would lead to one additional case of prolapse. Among women delivering exclusively by cesarean, neither active labor nor complete cervical dilation increased the odds for any pelvic floor disorder considered, although the study had less than 80% power to detect a doubling of the odds with these exposures.
Although spontaneous vaginal delivery was significantly associated with stress incontinence and prolapse, the most dramatic risk was associated with operative vaginal birth.
To evaluate validity and responsiveness of PFDI and PFIQ short forms across 4 multi-center studies and develop conversion formulas between short and long versions.
1006 participants in 4 prospective studies of pelvic floor disorders completed long versions of the PFDI, PFIQ and SF-36 (or SF-12) at baseline and 3 and 12 months after treatment. Responses were used to calculate scores for the short versions. We calculated correlations between scale versions using Pearson’s correlation coefficient and compared their relative responsiveness using the standardized response mean.
PFDI and PFIQ short form scale scores demonstrated excellent correlations with long versions and similar responsiveness. Responsiveness was good to excellent for PFDI-20 urinary and prolapse scales, moderate for PFDI-20 colorectal scale and each of the PFIQ-7 scales, and poor for SF-36 (or SF-12) summary scores. Conversion formulas demonstrated excellent goodness of fit.
The long and short forms of the PFDI and PFIQ correlate well and have similar overall responsiveness in participants from 4 different prospective multicenter studies consisting of diverse patient populations with a broad range of pelvic floor disorders. The short forms provide a reliable and valid alternative in situations where reduced response burden is desired.
quality of life; pelvic organ prolapse; urinary incontinence; pelvic floor; questionnaires; responsiveness
Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect quality of life. Focus on the global symptom complex, rather than the individual symptoms, may help the clinician identify the condition. The primary care provider is in a position to intervene early, efficiently, and effectively by (1) recognizing the range of symptoms that might suggest nonrelaxing pelvic floor dysfunction, (2) educating patients, (3) performing selective tests when needed to confirm the diagnosis, and (4) providing early referral for physical therapy.
Sexual function is an important dimension of adult life and yet very little is known about the relationships between female sexuality and chronic health conditions, including pelvic floor disorders. Our goal was to investigate the hypothesis that pelvic floor disorders are associated with female sexual problems, independent of other related factors.
The study population included 301 adult women seeking outpatient gynecologic and urogynecologic care. Pelvic floor disorders were assessed with the Pelvic Floor Disorders Inventory-20 (PFDI) and the Pelvic Organ Prolapse Quantification examination. Sexual function was assessed with the Personal Experiences Questionnaire. Using ordinal regression analysis, we identified characteristics and conditions associated with decreased libido, infrequent orgasm, decreased arousal, and dyspareunia.
Sexual function was poorer among 78 women (26%) without a current sexual partner than among 223 with a partner (p<0.01). Among the 223 with a current partner, women with a high PFDI score were significantly more likely to report decreased arousal (p<0.01), infrequent orgasm (p<0.01) and increased dyspareunia (p<0.01). A similar pattern was observed for the urinary, colorectal-anal, and prolapse scales of the PFDI, although some associations were marginally significant. Stage III–IV prolapse was significantly associated with infrequent orgasm (p=0.02), but other sexual complaints were not more common with increasing prolapse stage.
Pelvic floor symptoms are significantly associated with reduced sexual arousal, infrequent orgasm, and dyspareunia. Clinicians who care for women with pelvic floor disorders should be aware of this association and should specifically address sexual concerns with women seeking treatment of incontinence and prolapse.
Pelvic floor disorders including urinary incontinence, pelvic organ prolapse and fecal incontinence are common problems encountered by the older woman. With the increasing population of older American women, urologists and gynecologists can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are amenable to both medical and surgical therapies.
Materials and Methods
Contemporary published articles (year 2003 to present) that included older women undergoing urogynecologic surgical procedures were included in this review. Current data on morbidity, mortality and/or surgical outcomes are presented along with evidence-based pre, intra and post-operative surgical management strategies.
The older woman can expect similar operative risks as well as subjective and objective anatomic and quality-of-life outcomes as that of younger women undergoing pelvic floor surgery.
The decision for surgical intervention for the treatment of pelvic floor disorders should not be based on chronologic age alone. Prior to selection of a specific surgical procedure, all existing pelvic floor defects should be evaluated. Further research is required to understand the impact that surgery for pelvic floor disorders has on anatomic, physiologic, and functional outcomes in older women.
geriatrics; pelvic floor surgery; pelvic organ prolapse; urogynecology; incontinence