Functional: Pelvic Organ Prolapse: Difference between revisions

(16 intermediate revisions by the same user not shown)

Line 39:

*#* '''More common in Caucasian and Hispanic women''' when compared with African-American women

== Urinary incontinence and ~~POP~~ ==

== Urinary incontinence and Pelvic Organ Prolapse ==

* '''~~POP~~ can exacerbate storage lower urinary tract symptoms'''

* '''Pelvic organ prolapse can exacerbate storage lower urinary tract symptoms'''

** '''Important to identify and manage symptomatic prolapse when evaluating patients with UI'''

*** > 40% of women with SUI will have a significant cystocele

*** '''Procedures for UI [without correction of POP] can exacerbate certain types of POP'''

** '''Improvement of storage symptoms can be expected after POP surgery in a significant proportion of patients'''

** '''Improvement of storage symptoms can be expected after POP surgery in a significant proportion of patients'''

* '''Occult SUI is urethral sphincteric incompetence masked by the presence of high-stage anterior POP.'''

* '''Occult SUI is stress urinary incontinence that develops after prolapse reduction, due to urethral sphincteric incompetence that was previously masked by the presence of high-stage anterior POP.'''

** '''Failure to address occult SUI at the time of surgery for POP may lead to more severely symptomatic SUI postoperatively.'''

* '''Although POP is generally considered a QoL condition with few medical sequelae, untreated prolapse can become advanced to a point when a woman can develop urinary retention from urethral compression and, rarely, renal failure from ureteral compression.'''

Line 52:

== Diagnosis and evaluation ==

* '''History and Physical Exam~~'''~~

=== History and Physical Exam ===

** '''History'''

*** Whether the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing.

**** '''Sensation of a vaginal bulge remains the only symptom that is strongly associated with prolapse''' at or below the hymenal ring

***** '''Other symptoms, including UI and fecal incontinence, voiding and defecation difficulty, and sexual dysfunction, frequently coexist with POP''', but they correlate weakly with the severity or site of POP

****** Disorders of defecation, including fecal incontinence and urgency, should be carefully evaluated before considering POP surgery.

****** Treatment of POP may ameliorate symptoms of sexual dysfunction. Still, dyspareunia has been associated with some types of POP repair, and, as such, changes in sexual function are an important aspect of preoperative counseling.

*** Gynecologic and obstetric history, including gravity, parity, and hormonal status.

*** Determination of whether the patient is premenopausal, perimenopausal, or post-menopausal and whether she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy

*** Treatment expectations and an understanding of the balance between benefits and risks/burden of available treatment options.

** '''Physical examination'''

*** '''External genitalia:''' general appearance, estrogen status, lesions, and labial size, and adhesions.

**** Estrogen status can be evaluated based on the presence or absence of a urethral caruncle, urethral prolapse, and/or labial adhesions, all of which, if present, may indicate estrogen deficiency.

**** Attention to the overall tissue appearance and color is important. Hormonally deficient vaginal tissue has a pale, flat, dry appearance with no rugae, as opposed to the healthy, pink rugated tissue of well-estrogenized tissue

*** '''Assessment of prolapse ideally should be performed in both the lithotomy and standing position'''

*** Anal sphincter tone, which is a reflection of the function at S2-4, is particularly important in neurologic patients with pelvic floor dysfunction.

** Insert figure

** Imaging

*** For most clinicians, radiologic studies play a relatively small role in the evaluation of POP

==== History ====

* '''Signs and Symptoms'''

**Whether the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing.

*** '''Sensation of a vaginal bulge remains the only symptom that is strongly associated with prolapse''' at or below the hymenal ring

**** '''Other symptoms, including UI and fecal incontinence, voiding and defecation difficulty, and sexual dysfunction, frequently coexist with pelvic organ prolapse''', but they correlate weakly with the severity or site of pelvic organ prolapse.

***** Disorders of defecation, including fecal incontinence and urgency, should be carefully evaluated before considering POP surgery.

* '''Risk factors'''

**Gynecologic and obstetric history, including gravity, parity, and hormonal status.

** Determination of whether the patient is premenopausal, perimenopausal, or post-menopausal and whether she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy

* '''Treatment expectations''' and an understanding of the balance between benefits and risks/burden of available treatment options.

**Treatment of POP may ameliorate symptoms of sexual dysfunction. Still, dyspareunia has been associated with some types of POP repair, and, as such, changes in sexual function are an important aspect of preoperative counseling.

==== Physical examination ====

* '''External genitalia:''' general appearance, estrogen status, lesions, and labial size, and adhesions.

** '''Attention to the overall tissue appearance and color is important.''' Hormonally deficient vaginal tissue has a pale, flat, dry appearance with no rugae, as opposed to the healthy, pink rugated tissue of well-estrogenized tissue

**'''Signs of estrogen deficiency (3):'''

**#'''Urethral caruncle'''

**#'''Urethral prolapse'''

**#'''Labial adhesions'''

* '''Assessment of pelvic organ prolapse ideally should be performed in both the lithotomy and standing position'''

* '''Anal sphincter tone'''

**Reflection of the function at S2-4

**Particularly important in neurologic patients with pelvic floor dysfunction.

=== Imaging ===

* Radiologic studies play a relatively small role in the evaluation of pelvic organ prolapse

== Pelvic Organ Prolapse Quantification (POP-Q) system ==

* Several classification systems are used to quantify pelvic organ prolapse, the most widely used of which are the Baden-Walker classification and the Pelvic Organ Prolapse-Quantification (POP-Q) system.

* '''POP-Q'''

** See Interactive Pop-Q Tool

** See [https://pop-q.netlify.app/ Interactive Pop-Q Tool]

** '''6 defined points (Aa, Ba, C, D, Ap, Bp) and 3 other landmarks (GH, TVL, PB)'''

*** '''Each is measured in centimeters in relationship to a fixed reference point, the hymenal ring'''

*** '''Each is measured in centimeters in relationship to a fixed reference point, the hymenal ring'''

**** A negative number represents above or proximal to the hymen

**** A positive number represents below or distal to the hymen

Line 121:

Line 129:

== Management ==

* '''Anterior ~~wall~~ prolapse'''

* ''' Anterior prolapse'''

** '''Pessary'''

** '''Pessary'''

** '''Prolapse repair'''

** '''Prolapse repair'''

* '''Apical prolapse'''

* '''Apical prolapse'''

** '''Sacrocolpopexy'''

** '''Sacrocolpopexy'''

*** Sacral pain and osteomyelitis have been described after suspensions of the uterus, cervix, or vagina to the sacrum

*** CARE trial

Line 132:

Line 140:

**** Results:

***** Significantly higher incontinence rate at all points of follow-up in the women who did not undergo a Burch

* '''Posterior repair'''

* '''Posterior prolapse'''

** Levator ani, gluteal pain, and rectal penetration have been described after rectocele repairs performed with mesh augmentation

** '''Posterior (rectocele) repair'''

**Levator ani, gluteal pain, and rectal penetration have been described after rectocele repairs performed with mesh augmentation

* '''In 2011, the FDA released a safety communication (FDA website) regarding mesh placed transvaginally specifically for the repair of pelvic prolapse.'''

** '''The communication specifically excluded slings and transabdominally placed mesh for prolapse repair'''

@@ Line 39: / Line 39: @@
 *#* '''More common in Caucasian and Hispanic women''' when compared with African-American women
-== Urinary incontinence and POP ==
+== Urinary incontinence and Pelvic Organ Prolapse ==
-* '''POP can exacerbate storage lower urinary tract symptoms'''
+* '''<span style="color:#ff0000">Pelvic organ prolapse can exacerbate storage lower urinary tract symptoms</span>'''
 ** '''Important to identify and manage symptomatic prolapse when evaluating patients with UI'''
 *** > 40% of women with SUI will have a significant cystocele
 *** '''Procedures for UI [without correction of POP] can exacerbate certain types of POP'''
-** '''Improvement of storage symptoms can be expected after POP surgery in a significant proportion of patients'''
+** '''<span style="color:#ff0000">Improvement of storage symptoms can be expected after POP surgery in a significant proportion of patients</span>'''
-* '''Occult SUI is urethral sphincteric incompetence masked by the presence of high-stage anterior POP.'''
+* '''<span style="color:#ff0000">Occult SUI is stress urinary incontinence that develops after prolapse reduction, due to urethral sphincteric incompetence that was previously masked by the presence of high-stage anterior POP.</span>'''
 ** '''Failure to address occult SUI at the time of surgery for POP may lead to more severely symptomatic SUI postoperatively.'''
 * '''Although POP is generally considered a QoL condition with few medical sequelae, untreated prolapse can become advanced to a point when a woman can develop urinary retention from urethral compression and, rarely, renal failure from ureteral compression.'''
@@ Line 52: / Line 52: @@
 == Diagnosis and evaluation ==
-* '''History and Physical Exam'''
+=== History and Physical Exam ===
-** '''History'''
-*** Whether the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing.
-**** '''Sensation of a vaginal bulge remains the only symptom that is strongly associated with prolapse''' at or below the hymenal ring
-***** '''Other symptoms, including UI and fecal incontinence, voiding and defecation difficulty, and sexual dysfunction, frequently coexist with POP''', but they correlate weakly with the severity or site of POP
-****** Disorders of defecation, including fecal incontinence and urgency, should be carefully evaluated before considering POP surgery.
-****** Treatment of POP may ameliorate symptoms of sexual dysfunction. Still, dyspareunia has been associated with some types of POP repair, and, as such, changes in sexual function are an important aspect of preoperative counseling.
-*** Gynecologic and obstetric history, including gravity, parity, and hormonal status.
-*** Determination of whether the patient is premenopausal, perimenopausal, or post-menopausal and whether she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy
-*** Treatment expectations and an understanding of the balance between benefits and risks/burden of available treatment options.
-** '''Physical examination'''
-*** '''External genitalia:''' general appearance, estrogen status, lesions, and labial size, and adhesions.
-**** Estrogen status can be evaluated based on the presence or absence of a urethral caruncle, urethral prolapse, and/or labial adhesions, all of which, if present, may indicate estrogen deficiency.
-**** Attention to the overall tissue appearance and color is important. Hormonally deficient vaginal tissue has a pale, flat, dry appearance with no rugae, as opposed to the healthy, pink rugated tissue of well-estrogenized tissue
-*** '''Assessment of prolapse ideally should be performed in both the lithotomy and standing position'''
-*** Anal sphincter tone, which is a reflection of the function at S2-4, is particularly important in neurologic patients with pelvic floor dysfunction.
-** Insert figure
-** Imaging
-*** For most clinicians, radiologic studies play a relatively small role in the evaluation of POP
+==== History ====
+* '''<span style="color:#ff0000">Signs and Symptoms</span>'''
+**Whether the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing.
+*** '''<span style="color:#ff0000">Sensation of a vaginal bulge remains the only symptom that is strongly associated with prolapse</span>''' at or below the hymenal ring
+**** '''Other symptoms, including UI and fecal incontinence, voiding and defecation difficulty, and sexual dysfunction, frequently coexist with pelvic organ prolapse''', but they correlate weakly with the severity or site of pelvic organ prolapse.
+***** Disorders of defecation, including fecal incontinence and urgency, should be carefully evaluated before considering POP surgery.
+* '''<span style="color:#ff0000">Risk factors</span>'''
+**Gynecologic and obstetric history, including gravity, parity, and hormonal status.
+** Determination of whether the patient is premenopausal, perimenopausal, or post-menopausal and whether she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy
+* '''<span style="color:#ff0000">Treatment expectations</span>''' and an understanding of the balance between benefits and risks/burden of available treatment options.
+**Treatment of POP may ameliorate symptoms of sexual dysfunction. Still, dyspareunia has been associated with some types of POP repair, and, as such, changes in sexual function are an important aspect of preoperative counseling.
+==== Physical examination ====
+* '''<span style="color:#ff0000">External genitalia:</span>''' general appearance, estrogen status, lesions, and labial size, and adhesions.
+** '''Attention to the overall tissue appearance and color is important.''' Hormonally deficient vaginal tissue has a pale, flat, dry appearance with no rugae, as opposed to the healthy, pink rugated tissue of well-estrogenized tissue
+**'''<span style="color:#ff0000">Signs of estrogen deficiency (3):</span>'''
+**#'''<span style="color:#ff0000">Urethral caruncle</span>'''
+**#'''<span style="color:#ff0000">Urethral prolapse</span>'''
+**#'''<span style="color:#ff0000">Labial adhesions</span>'''
+* '''<span style="color:#ff0000">Assessment of pelvic organ prolapse ideally should be performed in both the lithotomy and standing position</span>'''
+* '''Anal sphincter tone'''
+**Reflection of the function at S2-4
+**Particularly important in neurologic patients with pelvic floor dysfunction.
+=== Imaging ===
+* Radiologic studies play a relatively small role in the evaluation of pelvic organ prolapse
 == Pelvic Organ Prolapse Quantification (POP-Q) system ==
 * Several classification systems are used to quantify pelvic organ prolapse, the most widely used of which are the Baden-Walker classification and the Pelvic Organ Prolapse-Quantification (POP-Q) system.
 * '''POP-Q'''
-** See Interactive Pop-Q Tool
+** See [https://pop-q.netlify.app/ Interactive Pop-Q Tool]
 ** '''6 defined points (Aa, Ba, C, D, Ap, Bp) and 3 other landmarks (GH, TVL, PB)'''
-*** '''Each is measured in centimeters in relationship to a fixed reference point, the hymenal ring'''
+*** '''Each is measured in centimeters in relationship to a <span style="color:#ff0000">fixed reference point, the hymenal ring</span>'''
 **** A negative number represents above or proximal to the hymen
 **** A positive number represents below or distal to the hymen
@@ Line 121: / Line 129: @@
 == Management ==
-* '''Anterior wall prolapse'''
+* ''' <span style="color:#ff0000">Anterior prolapse</span>'''
-** '''Pessary'''
+** '''<span style="color:#ff0000">Pessary</span>'''
-** '''Prolapse repair'''
+** '''<span style="color:#ff0000">Prolapse repair</span>'''
-* '''Apical prolapse'''
+* '''<span style="color:#ff0000">Apical prolapse</span>'''
-** '''Sacrocolpopexy'''
+** '''<span style="color:#ff0000">Sacrocolpopexy</span>'''
 *** Sacral pain and osteomyelitis have been described after suspensions of the uterus, cervix, or vagina to the sacrum
 *** CARE trial
@@ Line 132: / Line 140: @@
 **** Results:
 ***** Significantly higher incontinence rate at all points of follow-up in the women who did not undergo a Burch
-* '''Posterior repair'''
+* '''<span style="color:#ff0000">Posterior prolapse</span>'''
-** Levator ani, gluteal pain, and rectal penetration have been described after rectocele repairs performed with mesh augmentation
+** <span style="color:#ff0000">'''Posterior (rectocele) repair'''</span>
+**Levator ani, gluteal pain, and rectal penetration have been described after rectocele repairs performed with mesh augmentation
 * '''In 2011, the FDA released a safety communication (FDA website) regarding mesh placed transvaginally specifically for the repair of pelvic prolapse.'''
 ** '''The communication specifically excluded slings and transabdominally placed mesh for prolapse repair'''