Berek and Novak's Gynecology 15th Ed.

27 Pelvic Organ Prolapse

Jonathan L. Gleason

Holly E. Richter

R. Edward Varner

• Pelvic organ prolapse is an increasingly common condition seen in women with the aging of the population.

• Causes of pelvic organ prolapse are multifactorial and contribute to the weakening of the pelvic support connective tissue and muscles as well as nerve damage.

• Patients may be asymptomatic or have significant symptoms such as those related to the lower urinary tract, pelvic pain, defecatory problems, fecal incontinence, back pain, and dyspareunia.

• Physical examination includes thoughtful attention to all parts of the vagina, including the anterior, apical, and posterior compartments, levator muscle, and anal sphincter complex.

• Nonsurgical treatment options include pelvic floor muscle training and the use of intravaginal devices.

• Surgical treatment involves an individualized, multicompartmental approach consistent with the patient’s previous treatment attempts, activity level, and health status.

• Studies are needed to determine the characteristics of those patients who would derive long-term benefit from vaginal versus abdominal approaches to the surgical repair of pelvic organ prolapse.

Pelvic organ prolapse (POP) is a bulge or protrusion of pelvic organs and their associated vaginal segments into or through the vagina (1). It is a common and costly affliction of older women (2,3). It has been estimated that over the next 30 years, the demand for treatment of POP will increase 45%, commensurate with an increase in the population of women older than 50 years of age (4,5). As this problem grows in significance, it becomes increasingly important to comprehend the pathophysiology and risk factors associated with pelvic organ prolapse and try to prevent its occurrence. Furthermore, continued efforts are needed to understand factors that result in long-lasting, robust repair of pelvic organ prolapse for those patients undergoing surgical management. Despite extensive anecdotal experience, the optimal surgical approach to apical and other compartment prolapse remains elusive (6).

In the United States, 11% of women up to the age of 80 years have surgery for pelvic organ prolapse or urinary incontinence, and nearly one-third of procedures are repeat surgery (3). Data from the Women’s Health Initiative revealed anterior pelvic organ prolapse in 34.3%, posterior wall prolapse in 18.6%, and uterine prolapse in 14.3% of women in the study (7). In this study, a significant risk factor associated with prolapse was vaginal delivery. After adjusting for age, ethnicity, and body mass index, women with at least one vaginal delivery were twice as likely as nulliparous women to have pelvic organ prolapse. Causes of pelvic support disorders are most likely multifactorial, however; factors other than vaginal delivery also are associated with the development of these disorders. One study found that the incidence of prolapse doubled with each decade of life between the ages of 20 and 59 years (8). In another study, each year of increasing age was associated with a 12% increase in the risk of developing prolapse (9). Other associated risk factors for the development of POP include history of hysterectomy (8), obesity (7,10,11), history of previous prolapse operations, and race (11).

Pathophysiology

Pelvic organ prolapse results from attenuation of the supportive structures, whether by actual tears or “breaks” or by neuromuscular dysfunction or both. Support of the vaginal canal is provided by the enveloping endopelvic connective tissue and its condensations at the vaginal apex, which form the cardinal uterosacral ligament complex. The endopelvic connective tissue is the first line of support, buttressed intimately with the pelvic diaphragm, composed of the levator ani and coccygeus muscles. These muscles provide a supportive diaphragm through which the urethra, vagina, and rectum egress (Fig. 27.1). The muscular support provides basal tonicity and support of the pelvic structures; when contracted, as in the setting of increased abdominal pressure, the rectum, vagina, and urethra are pulled anteriorly toward the pubis.

Figure 27.1 A sagittal view of the female pelvis with bladder and uterus removed (ureters, trigone, and cervix intact) illustrating anterior and posterior vaginal fibromuscular planes, their endopelvic fascial attachments, and a functional pelvic floor. (Redrawn by J. Taylor from Skandalakis JE, ed. Hernia: surgical anatomy and technique. New York: McGraw-Hill: 244–250.)

The support system for the uterus and vagina has been described as consisting of three levels (12).

Level I refers to the uterosacral/cardinal ligament complex, which serve to maintain the vaginal length and axis.

Level II support consists of the paravaginal attachments of the lateral vagina and endopelvic fascia to the arcus tendineus that maintain the midline position of the vagina.

Level III support pertains to the distal vagina and is made up of the muscles and connective tissue surrounding the distal vagina and perineum.

Definitions

The more common pelvic support disorders include rectoceles and cystoceles (Fig. 27.2), enteroceles (Fig. 27.3), and uterine prolapse (Fig. 27.4); reflecting displacement of the rectum, small bowel, bladder, and uterus, respectively; resulting from failure of the endopelvic connective tissue, levator ani muscular support, or both (12).

Figure 27.2 A: Sagittal section of the pelvis showing normal anatomy. B: Cystocele and rectocele.

Figure 27.3 A: Posterior enterocele without eversion. B: Enterocele with eversion.

Figure 27.4 Uterine prolapse with apical detachment from the uterosacral ligament complex and lateral wall detachment from the endopelvic connective tissue.

A rectocele is a protrusion of the rectum into the vaginal lumen resulting from weakness in the muscular wall of the rectum and the paravaginal musculoconnective tissue, which holds the rectum in place posteriorly.

An enterocele is a herniation of the peritoneum and small bowel and is the only true hernia among the pelvic support disorders. Most enteroceles occur downward between the uterosacral ligaments and the rectovaginal space, but they may also occur primarily apically, especially in the setting of a previous hysterectomy.

A cystocele is descent of the urinary bladder with the anterior vaginal wall. Cystoceles usually occur when the pubocervical musculoconnective tissue weakens midline or detaches from its lateral or superior connecting points.

Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus.

Procidentia, which involves prolapse of the uterus and vagina, and total vaginal vault prolapse, which can occur after hysterectomy, represent eversion of the entire vagina (Fig. 27.5).

Figure 27.5 Procidentia of the uterus and vagina.

These descriptive terms are somewhat inaccurate and misleading, focusing on the bladder, rectum, small bowel, or uterus rather than the specific defects responsible for the alterations in vaginal support. Specific defect support issues will be discussed in the setting of the surgical management section.

Surgical Anatomy

Pelvic support structures include:

1. The muscles and connective tissue of the pelvic floor

2. The fibromuscular tissue of the vaginal wall

3. The endopelvic connective tissue

Endopelvic connective tissue includes:

1. The cardinal/uterosacral complex, which attaches the upper vagina and cervix posteriorly

2. Lateral connective tissue attachments of the anterior vaginal wall to the arcus tendineus pelvis and of the posterior vaginal wall to the fascia of the levator ani and to the posterior arcus tendineus near the ischial spine

3. Less dense areolar connective tissue surrounding retroperineal portion of the pelvic organs

The orientation of these structures is noted in Figure 27.1. In general, an intact pelvic floor, including a functional puborectalis muscle and an intact cardinal/uterosacral complex, should prevent pelvic organ prolapse by allowing posterior deflection of the rectum and vagina and compression of these structures against the pelvic floor in the upright position (Fig. 27.6). The fibromuscular layer of the vaginal wall and the other endopelvic connective tissue attachments augment the support structure and are particularly important when pelvic floor function is compromised.

Figure 27.6 Vaginograms from the same patient at rest (A) and during Valsalva maneuver (B). Illustrates posterior vaginal deflection maintained by apical cardinal/uterosacral posterior suspension and the anterior sling effect of the puborectalis muscle and more distal perineal structures. (From Nichols DH, Randall CL. Vaginal surgery. 4th ed. Baltimore, MD: Williams & Wilkins, 1996:4–5, with permission.)

Apical Compartment

Normal apical support includes the integrity of the cardinal/uterosacral ligaments, the upper paravaginal fibromuscular connective tissue, and, when the uterus is present, the paracervical fascia. The fibromuscular tissue of the upper vagina blends in with the paracervical fascia. Both of these are attached laterally and posterior laterally to the cardinal ligaments and uterosacral ligaments(Fig. 27.1). The vaginal fibromuscular tissue is also attached to the upper anterior rectum at its sigmoid junction and forms the inferior border of the cul-de-sac of Douglas. The cardinal and uterosacral ligaments are condensations of areolar connective tissue and they contribute level I support for the vagina. Their origin is at the lateral borders of sacral vertebra 2 to 4, and they travel retroperitoneally to their insertion at the upper vagina and cervix (Fig. 27.1). They serve as the anterior and lateral borders of the cul-de-sac and cross at or just anterior to the ischial spines. The ureter is closest to the uterosacral ligament at or just posterior to its insertion on the posterior lateral cervix. If anterior cephalad traction is placed on the ureter or cervix, frequently the cardinal uterosacral ligaments will stand out as ridges lateral to the cul-de-sac; however, peritoneal folds may have similar appearance. Therefore, placement of sutures in such structures based on visual appearance may not be reliable.

Defects in apical support include:

1. The loss of cardinal/uterosacral support with resultant cervical/uterine or vaginal cuff descent

2. The detachment of the fibromuscular vagina from the anterior rectum with resultant enterocele or, at times, sigmoidocele into the rectovaginal space

3. Tears or attenuation of the upper fibromuscular tissue, usually after hysterectomy, leading to a central apical descent that frequently presents as a ballooning defect

Often, these defects occur concurrently. Defects in cardinal/uterosacral attachment are at sites close to their insertion into the cervix and upper vagina where breaks or tears occur; in those with apical descent, condensations of cardinal/uterosacral tissue can be found adjacent to the peritoneum just cephalad to the ischial spines (13).

Anterior Compartment

The anterior vaginal compartment includes the anterior vaginal wall, its attachments, the urethra, and the bladder. The support structure for the bladder is the rhomboid-shaped anterior vaginal wall (specifically its fibromuscular layer), which is attached laterally to the arcus tendineus fascia (Fig. 27.7). Inferiorly, the fibromuscular layer blends in with the connective tissue, which spans the two bands of puborectalis and pubococcygeus muscles and the pubic rami. The urethra appears to be preferentially supported by these connective tissues as well as by the pubourethral ligaments. In the apical area, the vaginal fibromuscular layer blends in with the precervical fascia and the connective tissue of the cardinal ligament complex. In the upright position, the rhomboid-shaped anterior vaginal wall is oriented approximately 30 degrees from the horizon (from pubis to ischial spines). There is some downward bulge of the central area of the rhomboid plate, which should be minimized by the back-stop effect of the posterior vagina and rectum if the pelvic floor anatomy and function are normal.

Figure 27.7 View of the pelvic cavity with bladder, upper vagina, and sigmoid colon removed. The fibromuscular wall of the anterior vagina is attached to the arcus tendineus fascia pelvis by endopelvic connective tissue and supports the bladder. The pararectal fascia (Denonvillier’s fascia) includes the fibromuscular tissue of the posterior vagina and its lateral attachment to the fascia levator ani.

Defects of this support structure may include tears or attenuation of the vaginal fibromuscular wall, or detachment from the pelvic sidewalls, the cervix or cardinal ligament complex, or from the pubis. Specific sites of fibromuscular tears are frequently difficult to recognize.

Physical examination may reveal the following findings:

1. The presence of a central ballooning-type defect

2. Descent of the area of the vaginal wall below the bladder neck

3. Descent of the cervix or apical vaginal area

4. The presence or absence of sulci extending lateroanteriorly, which would indicate that lateral detachment to the arcus is maintained or lost.

Posterior Compartment

The support of the rectum and posterior vagina includes the pelvic floor musculature and connective tissue posteriorly and Denonvillier’s (pararectal) fascia, which is the fibromuscular layer of the posterior vaginal wall and its lateral attachments to the lateral pelvic floor (levator) musculature and its fascia (Fig. 27.8). This lateral attachment site, the fascia levator ani, fuses with the arcus tendineus fascia pelvis at the middle to upper level of the vagina and continues to the level of the ischial spine. Less dense, areolar, connective tissue surrounds the rectum and vagina and may supply some support to these structures as well.

Figure 27.8 Sagittal oblique view of the distal midvagina illustrating lateral connection of the posterior musculoconnective tissue wall to the fascia levator ani and anterior wall to the arcus tendineus pelvis. The attachment sites fuse together at a point closer to the ischial spine where the vagina assumes a more oval shape. (Modified by J. Taylor from illustration by Lianne Krueger Sullivan. From Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403–1421, erratum in Obstet Gynecol 2005;105:222, with permission.)

The fibromuscular layer at the upper vagina fuses with the paracervical fascia and the fan-shaped cardinal ligament structure. The integrity of the attachment of this posterior vaginal layer to the anterior rectal wall just below the rectal sigmoid junction prevents enterocele formation. In the distal vagina, the fibromuscular layer fuses laterally with the fascia of the puborectalis and then the bulbocavernous muscle and centrally with the perineal connective tissue. Thus, normal posterior support includes a plate of connective tissue that is attached laterally as noted, posteriorly toward sacral segments 2 to 4, and inferiorly to the perineum. This fibromuscular plane not only holds the rectum in place posteriorly, but also aids in preventing perineal descent by suspending the perineum to the sacrum. The constant resting tone of the pelvic floor muscles, particularly the puborectalis, serve to close the genital hiatus, pulling the distal vagina and anorectal junction toward the pubic symphysis and creating an anorectal angle and a posterior deflection of the rectum, vagina, and bladder base.

It has been hypothesized, based on careful cadaveric dissections, that most rectoceles were due to discrete tears in the Denonvillier’s fascia at its lateral, apical, and perineal attachments and centrally within the fascia itself (14). Perineal detachment, along with a defect in the perineal membrane, has been described as a perineal rectocele, which is most commonly associated with reports of difficulty with defecation. Apical attachment defects are generally associated with enteroceles and occasionally sigmoidoceles.

Evaluation

Although as many as 50% of women older than age 50 have some degree of pelvic organ prolapse (15), fewer than 20% seek treatment (16). This may result from a number of causes, including lack of symptoms, embarrassment, or misperceptions about available treatment options. Although pelvic organ prolapse is not life threatening, it can impose a significant burden of social and physical restrictions of activities, impact on psychological well-being, and overall quality of life.

Symptoms

Pelvic organ prolapse often is accompanied by symptoms of voiding dysfunction, including urinary incontinence, obstructive voiding symptoms, urinary urgency and frequency, and, at the extreme, urinary retention and upper renal compromise with resultant pain or anuria. Other symptoms often associated with POP include pelvic pain, defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal incontinence), back and flank pain, overall pelvic discomfort, and dyspareunia. Patients seeking care for prolapse may have one or several of these symptoms involving the lower pelvic floor. Choice of treatment usually depends on severity of the symptoms and the degree of prolapse consistent with the patient’s general health and level of activity (16).

Data relating pelvic floor symptoms to the extent and location of prolapse are weak (17–19). Any symptoms associated with physical findings of lower stage prolapse require careful evaluation, especially if surgery is being considered. A recent retrospective study of 330 patients reported that women with more advanced prolapse were less likely to have symptoms of stress incontinence and more likely to use manual reduction of the prolapse to void. Therefore, careful consideration of lower urinary tract symptoms is important. Prolapse severity was not associated with bowel or sexual problems in this study (20).

Physical Examination

In evaluating patients with pelvic organ prolapse, it is particularly useful to divide the pelvis into compartments, each of which may exhibit specific defects. The use of a Graves speculum or Baden retractor can help to evaluate the apical compartment of the vagina. The anterior and posterior compartments are best examined with the use of a univalve or Sims speculum. The speculum is placed posteriorly to retract the posterior wall downward when examining the anterior compartment and placed anteriorly to retract the anterior wall upward when examining the posterior compartment. A rectovaginal examination may be useful in evaluating the posterior compartment to distinguish a posterior vaginal wall defect from a dissecting apical enterocele or a combination of both.

If an anterior lateral detachment defect is suspected, an open ring forceps (or a Baden retractor) may be placed in the vagina at a 45-degree angle posteriorly cephalad to hold the lateral fornices adjacent to the pelvic sidewall.

During the evaluation of each compartment, the patient is encouraged to perform Valsalva so the full extent of the prolapse can be ascertained. If the findings determined with Valsalva are inconsistent with the patient’s description of her symptoms, it may be helpful to perform a standing straining examination with the bladder empty (20,21).

Pelvic Organ Prolapse Quantitation System

Many systems for staging prolapse have been described. Typically it is graded on a scale of 0 to 3 or 0 to 4, with the grade increasing with the severity of prolapse (22). Currently the system approved by the International Continence Society is the Pelvic Organ Prolapse Quantification system, or POP-Q (23). This standardized quantification system facilitates communication between physicians in practice and research and enables progression of these conditions to be followed accurately. In this system, anatomic descriptions of specific sites in the vagina are used in place of traditional terms. The system identifies nine locations in the vagina and vulva in centimeters relative to the hymen, which are used to assign a stage (from 0 to IV) of prolapse at its most advanced site (Fig. 27.9). Although probably more detailed than necessary for general practice, clinicians should be familiar with the POP-Q system because most published studies use it to describe research results. Its two most important advantages over previous grading systems are (i) it allows the use of a standardized technique with quantitative measurements at straining relative to a constant reference point (i.e., the hymen), and (ii) its ability to assess prolapse at multiple vaginal sites.

Figure 27.9 Standardization of terminology for female pelvic organ prolapse (POP-Q) classification. This diagram demonstrates the anatomic position of the POP-Q sites, including six sites involving the anterior (Aa, Ba), middle (C, D), and posterior (Ap, Bp) compartments with the genital hiatus (gh), perineal body (pb), and total vaginal length (tvl). (From Bump RC, Mattiason A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol1996;175:12, with permission.)

The classification uses six points along the vagina (two points on the anterior, middle, and posterior compartments) measured in relation to the hymen. The anatomic position of the six defined points should be measured in centimeters proximal to the hymen (negative number) or distal to the hymen (positive number), with the plane of the hymen representing zero. Three other measurements in the POP-Q examination include the genital hiatus, perineal body, and the total vaginal length (23).

The genital hiatus is measured from the middle of the external urethral meatus to the posterior midline hymen. The perineal body is measured from the posterior margin of the genital hiatus to the midanal opening. The total vaginal length is the greatest depth of the vagina in centimeters when the vaginal apex is reduced to its full normal position. All measurements except the total vaginal length are measured during maximal straining.

The anterior vaginal wall measurements are termed Aa and Ba, with the Ba point moving depending on the amount of anterior compartment prolapse. Point Aa represents a point on the anterior vagina 3 cm proximal to the external urethral meatus, which corresponds to the bladder neck. By definition, the range of position of this point is −3 to +3. Point Ba represents the most distal or dependent point of any portion of the anterior vaginal wall from point Aa to just anterior to the vaginal cuff or anterior lip of the cervix. This point can vary depending on the nature of the patient’s support defect. For example, point Ba is −3 in the absence of any prolapse (it is never less than −3) to a positive value equal to the total vaginal length in a patient with total eversion of the vagina.

The middle compartment consists of points C and D. Point C represents the most dependant edge of the cervix or vaginal cuff after hysterectomy. Point D is the location of the posterior fornix; it is omitted if the cervix is absent. This point represents the level of the attachment of the uterosacral ligament to the posterior cervix. It is intended to differentiate suspensory failure from cervical elongation.

The posterior compartment is measured similarly to the anterior compartment: the corresponding terms are Ap and Bp. The nine measurements can be recorded as a simple line of numbers (i.e., −3, −3, −8, −10, −3, −3, 11, 4, 3 for points Aa, Ba, C, D, Ap, Bp, total vagina length, genital hiatus, and perineal body, respectively). The six vaginal sites have possible ranges that depend on the total vaginal length (Table 27.1). After collection of the site-specific measurements, stages are assigned according to the most dependent portion of the prolapse (Table 27.2).

Table 27.1 Possible Ranges of the Six Site-Specific Pelvic Organ Prolapse Quantitative Examination Measurements

Points	Description	Range
Aa	Anterior wall 3 cm from hymen	−3 cm to +3 cm
Ba	Most dependent portion of rest of anterior wall	−3 cm to +TVL
C	Cervix or vaginal cuff	±TVL
D	Posterior fornix (if no prior hysterectomy)	±TVL or omitted
Ap	Posterior wall 3 cm from hymen	−3 cm to +3 cm
Bp	Most dependent portion of rest of posterior wall	−3 cm to +TVL
TVL, total vaginal length.
Adapted from Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:11–12, with permission.

Table 27.2 Stages of Pelvic Organ Prolapse

Stage 0	No prolapse is demonstrated. Points Aa, Ap, Ba, Bp are all at −3 cm, and point C is between total vaginal length (TVL) and –(TVL –2 cm).
Stage I	The most distal portion of the prolapse is greater than 1 cm above the level of the hymen.
Stage II	The most distal portion of the prolapse is less than 1 cm proximal or distal to the plane of the hymen.
Stage III	The most distal portion of the prolapse is less than 1 cm below the plane of the hymen but no further than 2 cm less than the total vaginal length.
Stage IV	Complete to nearly complete eversion of the vagina. The most distal portion of the prolapse protrudes to greater than (TVL –2) cm.
From Bump RC, Mattiassion A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:13, with permission.

The POP-Q examination often appears confusing on initial review; however, a measuring device (i.e., a marked ring forceps or marked cotton-tip applicator) can assist in instructing those unfamiliar with this staging system. The POP-Q examination provides a standardized measurement system to allow for more accurate assessments of postoperative outcome and to ensure uniform, reliable, and site-specific descriptions of pelvic organ prolapse.There is interest in using the POP-Q examination to measure prolapse as a continuous variable rather than in stages because it would provide greater statistical power in clinical research (24). The American Urogynecology Society provides a video (25) that describes the POP-Q exam and demonstrates its use.

In a clinical setting, at least three measurements should be obtained: the most advanced extent of the prolapse in centimeters relative to the hymen that affects the anterior vagina, the posterior vagina, and the cervix or vaginal apex.

As noted previously, whether the older staging systems or the POP-Q system is used, it is important to document the most pertinent findings on examination. This will help in documenting the baseline extent of prolapse and the results of treatment.

Pelvic Muscle Function Assessment

Pelvic muscle function should be assessed during the pelvic examination. Following bimanual examination with the patient in the lithotomy position, the examiner can palpate the puborectalis and pubococcygeus muscles inside the hymen along the pelvic sidewalls at approximately the 4 and 8 o'clock positions. One can appreciate basal muscle tone and whether there is increased tone with contraction as well as strength, duration, and symmetry of contraction (26). A rectovaginal examination should also be performed to assess basal and contraction muscle tone of the anal sphincter complex.

As a part of the pelvic organ prolapse examination, urethral mobility often is measured. Many women with prolapse will have urethral hypermobility (defined as a resting urethral angle greater than 30 degrees or a maximal strain angle greater than 30 degrees). The presence of urethral mobility in combination with symptoms of stress incontinence may help determine whether an incontinence procedure should be performed. However, studies have shown that nearly all women with stage II to IV prolapse have urethral hypermobility, and asymptomatic parous women have an average maximum straining angle of 54 degrees (27,28). During pelvic examination, the urethra is typically swabbed with Betadine, and lidocaine jelly is placed in the urethra or on a cotton tip swab. The swab is placed in the urethra at the urethrovesical junction and, with the use of a goniometer (Fig. 27.10), the baseline urethral angle from the horizontal and maximal strain angles is measured.

Figure 27.10 Goniometer, which is used to measure baseline urethral angle and maximal strain angle of the urethra with a cotton tip swab in place.

Bladder Function Evaluation

Patients with prolapse exhibit the full range of lower urinary tract symptoms. Despite the fact that some patients may not have significant symptoms, it is important to obtain objective information about bladder and urethral function. With severe POP, the urethral kinking effect of the prolapse may mask a potential urine leakage problem; therefore, basic office bladder testing with prolapse reduction should be performed to mimic bladder and urethral function if the prolapse were treated. At a minimum, the following assessments should be performed: a clean catch or catheterized urine sample to test for infection, a postvoid residual (PVR) volume, and assessment of bladder sensation, which can be performed as a part of office cystometrics. Although there is no consensus as to what constitutes an abnormal PVR volume, provided the patient has voided 150 mL or more, a PVR less than or equal to 100 mL is acceptable (27). Reduction stress testing at the time of simple office cystometrics can be performed with the use of a pessary, large cotton swab, ring forceps, or the posterior blade of a speculum. Care should be taken that the urethra not be overly straightened (with a resultant false-positive test result) or obstructed (with a resultant false-negative test result), or that tension is not placed on the puborectalis muscles by excessive posterior retraction. These risks can be minimized by orienting the vaginal apex toward the sacrum.

Bowel Function Evaluation

Once a decision is made to perform surgical repair of the posterior compartment based on symptoms, type, and location of defects, an appropriate approach should be determined and the patient should be made aware of the expected outcomes and potential adverse effects such as pain and sexual dysfunction. If the patient has defecatory dysfunction with a rectocele and symptoms of constipation, pain with defecation, fecal or flatal incontinence, or any signs of levator spasm or anal sphincter spasm, appropriate evaluation and conservative management of concurrent conditions could be initiated before repair of the rectocele and continued postoperatively (28).

Imaging

Diagnostic imaging of the pelvis in women with pelvic organ prolapse is not routinely performed. However, if clinically indicated, tests that may be performed include fluoroscopic evaluation of bladder function, ultrasound of the pelvis, and defecography for patients in whom intussusception or rectal mucosal prolapse are suspected. Magnetic resonance imaging is increasingly being used for the evaluation of pelvic pathology such as mullerian anomalies and pelvic pain; however, generalized use in women with prolapse is not currently clinically indicated and is used primarily for research purposes.

Treatment

Nonsurgical Therapy

Nonsurgical therapy of pelvic organ prolapse includes conservative behavioral management and the use of mechanical devices. A nonsurgical treatment approach usually is considered in women with mild to moderate prolapse, those who desire preservation of future childbearing, those in whom surgery may not be an option, or those who do not desire surgical intervention.

Conservative Management

Conservative management approaches include alteration of lifestyle or physical intervention such as pelvic floor muscle training (PFMT). These approaches are used mainly in cases of mild to moderate prolapse; however, their true role in managing prolapse and associated symptoms is unclear (29,30). The goals of a conservative therapy approach to the treatment of prolapse are as follows (31):

• Prevent worsening prolapse

• Decrease the severity of symptoms

• Increase the strength, endurance, and support of the pelvic floor musculature

• Avoid or delay surgical intervention

Lifestyle intervention includes such activities as weight loss and reduction of those activities that increase intra-abdominal pressure. This interaction is typically anecdotal in practice. No case series, prospective studies, or randomized control trials exist that have examined the effectiveness of this approach to the treatment of prolapse.

Pelvic floor muscle exercises may limit the progression of mild prolapse and related symptoms (32,33); however, a lower response rate has been noted when prolapse extends beyond the vaginal introitus (34).

The efficacy of biofeedback therapy in the treatment of impaired defecation associated with a rectocele has been determined (35). Thirty-two female patients, median age 52 years (range, 34–77 years), experiencing impaired rectal evacuation with a rectocele greater than 2 cm at proctography underwent a structured behavioral retraining. Immediate and medium-term follow-up results were reported (median 10 months; range 2–30 months). Fifty-six percent of patients (n = 14) felt a little and 16% (n = 4) felt major improvement in symptoms, including 3 (12%) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (67; 50%), feeling of incomplete evacuation (73; 59%), and need to assist defecation digitally (79; 63%) that was maintained at follow-up. Bowel movement frequency was significantly normalized at follow-up (p = .02). These investigators concluded that behavioral retraining, including biofeedback therapy, may be an effective primary therapy for some patients with a rectocele associated with impaired defecation.

Mechanical Devices

The use of mechanical devices such as pessaries is usually considered for women who cannot undergo surgery for medical reasons, desire to avoid surgery, or have a significant degree of prolapse that makes other nonsurgical approaches unfeasible. Some practitioners extend indications to include pregnancy-related prolapse as well as prolapse and incontinence in elderly women. Reports have shown that age older than 65 years, the presence of severe medical comorbidity, and sexual activity were associated with successful pessary user (36,37). Unsuccessful use or a preference for surgery has been associated with a shortened vaginal length (≤6 cm), a wide vaginal introitus, sexual activity, stress incontinence, stage III or IV posterior compartment prolapse, and desire for surgery at a first office visit (38). Few literature-based reviews and reports recommend pessaries as first-line treatment for women with POP, and there is little consensus regarding choice of pessary and management of pessary usage (39). Most of the information on pessary use is derived primarily from descriptive and retrospective studies, relatively small prospective series, manufacturer’s recommendations, and anecdotal experience.

Pessaries provide pelvic organ support within the vaginal vault. Two categories of pessaries—support and space filling—exist for prolapse (39). The ring pessary (with diaphragm) is a commonly used support pessary, and the Gelhorn pessary is a commonly used space-filling pessary. The ring and other support pessaries are recommended for stage I and II prolapse, whereas the space-filling pessaries are used for stage III and IV prolapse(40). It is unclear whether pessaries can prevent the progression of POP with regular use. A prospective cohort study addressed this issue in a series of 56 women who were fitted with a pessary, of which 33.9% (n = 19) continued use for at least 1 year (41). Baseline and follow-up pelvic examinations were performed using the POP-Q system (23). The women removed the pessary 48 hours before one visit, but there was no information to ascertain adherence to pessary use. No woman had worsening of the prolapse, and four women (21.1%; 95% confidence interval [CI], 0.2%–43.7%) had an improvement. Improvement overall was noted in women with anterior compartment prolapse.

In women with stages I and II prolapse with stress urinary incontinence, a continence pessary may be considered and has been shown to produce patient satisfaction above 50% at 12 months (42). There are no randomized controlled trials of pessary use in women with POP (43). Likewise, there are no consensus guidelines on the care of pessaries (i.e., intervals between changes), the role of local estrogens, or the type of pessary indicated for specific types of POP (43). Manufacturers recommendations and different pessary types can be seen in Figure 27.11. Effective and satisfactory outcomes have been reported for stage II or greater prolapse using the Gelhorn and ring diaphragm pessary (36). After 2 to 6 months, 77% to 92% of women with a successful pessary fitting were satisfied and, using intention-to-treat analysis, 44% to 67% of all women who were treated initially with a pessary for prolapse were satisfied. There are few other series describing pessary use for prolapse with greater than 4 weeks follow-up (36,38,44,45).

Figure 27.11 Pessaries used to treat the various degrees of prolapse. (Milex Company, a Division of Cooper Surgical.)

Possible complications associated with pessary use include vaginal discharge and odor. Failure to retain the pessary may occur or, conversely, the pessary may be too large, which could lead to excoriation or irritation. With reduction of vaginal prolapse, de novo or increased stress incontinence may occur, and in rare instances, more severe complications, including vesicovaginal or rectovaginal fistula, small bowel entrapment, hydronephrosis, and urosepsis, have been described (46–48).

Placement and Management

Pessary placement involves consideration of a number of issues, primarily the patient’s desire and motivation to use this type of device. Typically, if she has had previous surgery or strongly desires to avoid surgery, she may be motivated enough for a primary attempt at pessary placement. Other issues include current sexual function status, type and duration of exercise in which the patient engages, and the status of the vaginal walls and cervix. In hypoestrogenic women, treatment of the vagina with estrogen and maintenance of intravaginal estrogen treatment is recommended.

Fitting a Pessary

The patient should be examined in the lithotomy position after emptying her bladder. The clinician should use a dry glove to better grasp the pessary and water-soluble lubricants as needed. The size of the pessary is estimated after a digital examination and use of ring forceps to reduce the prolapse or bladder neck. Once the approximate size is determined, the appropriate type is selected based on the patient’s needs and activity level. When fitted, the patient is asked to stand, perform Valsalva, and cough to ensure the pessary is retained. The pessary should be assessed to ensure it is providing the desired support and leakage control. The patient should be able to void with the pessary in place before leaving the office. Proper size is ensured by the ability to sweep the index finger between the pessary and the vaginal wall. The patient should feel comfortable with the pessary in place.

Insertion of the pessary is eased by using a water-soluble lubricant for insertion, folding or collapsing the pessary to reduce its size, and when it is inside the vagina, pushing it high to an area behind the symphysis pubis and inserting the device more posteriorly to avoid the urethra. Instructing the patient how to insert and remove the pessary may be done with the patient in a standing or supine position, depending on her dexterity (49).

Ring pessaries, with or without support, are the most commonly used type. They are the easiest to fold, insert, and remove. Gellhorn and cube pessaries are typically more difficult to insert and remove by the patient. They are held in place by significant space occupation and suction and offer strong support. The suction of the cube pessary needs to be broken, facilitating removal. Cube pessaries should be removed daily; Gelhorns can stay in longer (up to 6–8 weeks). Donut pessaries, which are very popular, are considered a space-fitting pessary for large vaginal vault prolapse, complete procidentia with decreased perineal support, and good introital integrity. The patient should be questioned about a latex allergy and instructed to remove and clean the device every 2 to 3 days. Continence pessaries, rings, and dishes with support typically also are easy to fold, insert, and remove (50).

Follow-Up Recommendations

After the initial fitting, the patient should return in 1 to 2 weeks and then at 4 to 6 weeks, depending on her independence with the pessary, her proficiency in placement and removal, and her cognitive and motor abilities (44). After this initial follow-up, follow-up should continue at 6- to 12-month intervals at the discretion of the provider and depending on the patient’s ability to insert and remove the pessary effectively. If the patient needs to return to the provider for removal and cleaning of the pessary, 4- to 12-week intervals are more appropriate.

On follow-up visits, proper placement of the pessary and support of the prolapse as well as continence efficacy should be ensured. Because pessaries are fitted through a process of trial and error, it is not uncommon to change the size or type at least once after the initial fitting. The pessary’s integrity should be checked, and the tissues should be evaluated for irritation, pressure sores, ulceration, and lubrication (44).

Surgical Management

The primary aims of surgery are to relieve symptoms, which may be caused by prolapse, and, in most cases, to restore vaginal anatomy so that sexual function may be maintained or improved without significant adverse effects or complications. Occasionally, when sexual function is not desired, obliterative or constrictive surgery is more appropriate and also may relieve symptoms. There is no steadfast rule as to when surgery is indicated. Many patients with more advanced prolapse have few or no symptoms, whereas some with lesser degrees of prolapse have what they describe as severe symptoms. This is confounded by the observation that many of the “symptoms” may not be specifically related to the anatomic defect or may be worsened by anxiety. In general, surgery should be offered to patients who have tried conservative therapy and were not satisfied with the results or who do not desire conservative therapy. The prolapse should be symptomatic or should be greater than or equal to stage II with apparent progression. All patients should be given the alternative of trying conservative treatments when applicable (51).

Approaches to surgery include vaginal, abdominal, and laparoscopic routes, or a combination of approaches. Depending on the extent and location of prolapse, surgery may involve a combination of repairs directed to the anterior vagina, vaginal apex, posterior vagina, and perineum. Concomitant surgery may be planned for urinary or fecal incontinence. The surgical route is chosen based on the type and severity of prolapse, the surgeon’s training and experience, the patient’s preference, and the expected or desired surgical outcome.

Procedures for prolapse can be broadly categorized into three groups: (i) restorative, which use the patient’s endogenous support structures; (ii) compensatory, which attempt to replace deficient support with permanent graft material; and (iii) obliterative, which close or partially close the vagina (51).

These groupings are somewhat arbitrary and not entirely exclusive. For example, grafts may be used to reinforce repairs, such as colporrhaphy, or to replace support that is deficient or lacking. Graft use in sacrocolpopexy substitutes for the connective tissues attachments (cardinal and uterosacral ligaments) that would normally support the vaginal apex. In addition to the primary goal of relieving symptoms related to prolapse, urinary, defecatory, and sexual function must be considered in choosing the appropriate procedures.

Whether to repair all defects is controversial. Restorative repairs may be less successful than compensatory repairs in patients with generally “poor tissue,” and at times one defect repair may exert more tension on the repair of another defect. Management should be based on the patient’s presentation, expectations, the specific anatomical defects noted (preoperatively and, at times, intraoperatively), and on the presence or absence of lower urinary and bowel dysfunction (51).

Vaginal Procedures

The Apical Compartment

Examination for apical defects is at times difficult. Such defects may be missed when large anterior or posterior defects are present. In cases when apical defects are suspected but not confirmed, surgeons should evaluate the apical support intraoperatively and plan for management of these defects when they are found. Traction on the cervix with a tenaculum or on the vaginal cuff both centrally and laterally with Allis clamps may reveal otherwise unrecognized defects.

Transvaginal repairs include extraperitoneal procedures such as sacrospinous suspensions, iliococcygeal suspensions, and high paravaginal suspensions of the apical vaginal fornices to the arcus tendineus at the level of the ischial spine or to the endopelvic fascia, and intraperitoneal suspensions such as uterosacral suspensions and McCall culdoplasties (51). Accepted practice is that the vaginal apex should be resuspended in a posterior cephalad direction to a site or sites posterior and caudad to the sacral promontory. Anterior apical suspensions change the direction of the vaginal axis and may be fraught with a greater incidence of posterior compartment defects, including rectoceles, enteroceles, and sigmoidoceles.

The general principles of the repair should include management of the specific apical defects:

1. If present, the attenuated part of the upper vaginal wall (fibromuscular defect) should be repaired or covered by graft material.

2. The vaginal cuff or, in some instances, the cervix should be suspended without excessive tension.

3. Any defect in the attachment of the upper vagina to the rectum at or below its sigmoid junction should be corrected.

Enterocele repairs may include:

1. Removal of the peritoneal sac with closure of the peritoneal defect, followed by closure of the fascial or fibromuscular defect or both below it

2. Dissection and reduction of the peritoneal sac and closure of the defect

3. Obliteration of the peritoneal sac from within with transabdominal Halban or Moschcowitz type procedures or transvaginal McCall or Halban procedures (52).

Historically, the treatment for symptomatic uterine prolapse has been hysterectomy, which is performed vaginally or abdominally in combination with an apical suspension procedure, and repair of coexisting defects. Apical support procedures that have been described for use when the uterus or cervix is to be kept in place include Manchester and Gilliam procedures and fixation of the cervix to the sacrospinous ligament . The other procedures described in this section may also be used in women who desire uterine conservation. Adequate outcome data on such uterine-sparing procedures are not yet available. When the cervix is absent, in addition to repair of fibromuscular defects, both fibromuscular planes anterior and posterior to the vaginal cuff should be attached to whatever suspension is employed.

Sacrospinous Ligament Fixation

The fixation of the vaginal apex to the sacrospinous ligament, the tendineus component of the coccygeus muscle, was first described in 1958 and was subsequently modified in Europe and the United States (53–56). Access is traditionally extraperitoneal via the rectovaginal space with penetration of the pararectal (Denonvillier’s fascia) at the level of the ischial spine to expose the muscle and ligament. Variations in this approach to the ligament include entrances through an anterior lateral access, an apical passage posterior to the uterosacral ligament, and a laparoscopic approach (57–59). Bilateral sacrospinous ligament suspensions have also been advocated; however, these techniques may impose a greater degree of tension on the sutures and, at times, create a band of apical vagina across the rectum at the level of the suspension (60,61). Whether this can cause defecatory dysfunction remains unknown. The advantages of the sacrospinous fixation procedure include (i) its transvaginal extraperitoneal approach, (ii) resultant posterior vaginal deflection, and (iii) the fact that it is a durable repair if performed correctly. Reported success for apical support has been good (89%–97%) with follow-up times ranging from 1 month to 11 years (51,62). However, there have been subsequent reports of high rates of anterior vaginal prolapse (63,64). It is not clear whether this observation is related to the procedure and its exaggerated posterior vaginal deflection or to the fact that many patients with apical descent also have defects in the upper vaginal fibromuscular tissue. Failure to address an anterior defect concurrently with suspension of the posterior apical vagina may predispose the patient to such a defect postoperatively. Other disadvantages of the procedure include (i) relative difficulty in adequately exposing the ligament, (ii) an unnatural lateral vaginal deflection toward the fixation site, (iii) an inability to perform without excessive tension when the vaginal length is compromised, as may be the case in repeat procedures, (iv) potential risk for injury to the sciatic nerve or pudendal nerve or vessel, and (v) occasional need to shorten or narrow the upper vagina when a fibromuscular defect involves much of the apical area.

Iliococcygeal Vaginal Suspension

Iliococcygeal vaginal suspension involves the attachment, usually bilaterally, of the vaginal apex to the iliococcygeus muscle and fascia (61,65,66). Extraperitoneal access is achieved via the posterior vagina. Compared with other vaginal suspension procedures, the iliococcygeal suspension has the fewest case series in the literature (65–67); however, cure rates appear comparable to the sacrospinous suspension technique (51). The dissection of the area to the ischial spine is approached from a midline posterior vaginal wall incision using the ischial spine as a landmark for identifying the sacrospinous ligament and the iliococcygeal fascia anteriorly and caudad to it. A no. 1 polydioxanone suture is placed through the fascia and attached to the vaginal apex as a pulley stitch. This procedure is more easily performed bilaterally than the sacrospinous suspension and should be considered preferentially in the presence of a shortened vagina. Risk of major vessel, nerve, or ureteral injury should be relatively low compared with other transvaginal suspensions.

Uterosacral Ligament Suspension

Surgical variations of the uterosacral ligament suspension originally described in 1938 have been used prophylactically during hysterectomy or therapeutically for vaginal apical suspension (68). A therapeutic procedure in which the vaginal apex is suspended to the uterosacral ligaments above the level of the ischial spines had excellent success rates in an observational study of 302 participants (69). When access to the posterior cul-de-sac is attained, the uterosacral ligament remnant can usually be found adjacent to the pelvic sidewall peritoneum just cephalad to the palpable ischial spine. Up to three sutures are placed in each ligament and incorporated into the anterior and posterior fibromuscular layer of the vagina. Some surgeons approximate the ligaments in the midline to close the cul-de-sac with the intention to treat or prevent enterocele formation (70). Other surgeons suspend the right and left vaginal apex to the ipsilateral uterosacral ligament, leaving the cul-de-sac open to avoid impinging on the rectum and adversely affecting bowel function.

Outcome studies have shown that recurrent apical prolapse occurs in 2% to 5% of cases within the first few years following the procedure, which is a rate comparable or superior to other transvaginal apical repairs, and the incidence of recurrent anterior defects may be less than that reported with sacrospinous suspensions (69,71). The most common serious complication was ureteral obstruction secondary to ureteral kinking or incorporation of an ureter in a suspension stitch. This occurred in as many as 11% of cases (71). Intraoperative cystoscopy—with documentation of ureteral patency after administration of indigo carmine dye, whereby such a problem can be corrected—is recommended.

Multiple sutures may increase the incidence of tissue devascularization and necrosis, thus resulting in failure of the suspension. One case series of bilateral single suture uterosacral suspensions demonstrated a 15% stage I and no stage II recurrence among 71 women with a mean follow-up of 21.3 months (72). Exposure can be accomplished through the vaginal cuff after hysterectomy, a transverse incision at the vaginal cuff in cases of vaginal vault prolapse or descent, and, rarely, through a posterior colpotomy when uterine or cervical conservation is desired. When the apical vaginal wall is attenuated, it is excised. The pelvic sidewall, lateral to the sigmoid colon, is exposed using Breisky-Navratil retractors and a pack to hold the small bowel cephalad and to place the sigmoid colon and sidewall peritoneum on stretch (Fig. 27.12A). After palpation of the ischial spine, single permanent sutures of 0 or 1 polypropylene are placed through the peritoneum and adjacent ligament approximately 1 cm cephalad to and at the same posterior level as the ischial spines. Traction on the sutures and palpation of the site should reveal that the sutures are firmly attached to the ligamentous structures. The sutures are tagged for use after repair of defects of the anterior compartment. The peritoneum is dissected off the vaginal fibromuscular wall posterior to the vaginal cuff. The suspension sutures are then secured with large bites into the posterior vaginal fibromuscular tissue and anterior fibromuscular tissue, then locked in place to approximate anterior to posterior connective tissue and to fix the suture to the vaginal apex so that it may be moved up to the ligament (Fig. 27.12B). If a rectovaginal enterocele is present, it is dissected, reduced, and closed, approximating the prerectal fascia or anterior rectal wall to the posterior fibromuscular vaginal tissue just caudad to the suspension sutures. Absorbable cuff closure sutures are placed at each cuff angle and one to two bites are taken to approximate anterior to posterior vaginal cuff over the suspension suture sites. When indicated, plication of the central cuff anterior to the posterior fibromuscular tissue with a box stitch is also performed. These sutures are secured after the suspension (pulley) sutures are tied, then cuff closure is completed from each side with the absorbable sutures in a running fashion. Cystoscopy is performed to document ureteral patency. Ureteral compromise has been noted in only 2 of 150 cases performed. The procedure provides adequate support of POP-Q point C and D in all 58 subjects evaluated more than 1 year postoperatively (72).

Figure 27.12 Diagrams illustrating open vaginal apical area with (A) exposure of site for suture placement or lateral pelvic side wall and (B) suture placement through ligament then through the posterior and anterior paravaginal tissue where they are locked to enable pulley action to the ligaments when tied. (Redrawn from an image by J. Taylor.)

The Anterior Compartment

Anterior Vaginal Colporrhaphy

Anatomic correction of an anterior defect or cystocele will generally relieve symptoms of protrusion and pressure and usually will improve micturition function when abnormal micturition is associated temporally with the defect and if there is no associated neuropathy. If a single, well-defined midline defect is recognized, excision of the weak vaginal wall and an imbricating closure of the defect may be performed. Most central anterior defects require a more extensive dissection of the vesicovaginal space. Following this dissection, many surgeons then separate the vaginal mucosa and submucosal layers from the fibromuscular layer out to a point lateral to the defect, followed by midline plication of this tissue, then excision of excess epithelium, and closure (72–78). It appears important to maintain the continuum of repaired fibromuscular tissue to a well-supported vaginal apex. If the repair is being performed simultaneously with a vaginal apical suspension, the anterior colporrhaphy is typically performed after the apical support sutures have been placed and prior to tying them down. The dissection is carried out starting from the everted vaginal cuff edge and dissecting toward the bladder neck. A high central defect may also be corrected via a transabdominal approach by dissecting between the base of the bladder and the upper one-third of the anterior vaginal wall. The defective tissue may then be wedged out and the defect closed with running or interrupted sutures. This approach may be of use when performing transabdominal procedures for apical suspension.

If the patient has significant stress incontinence (based on report or the presence of occult or potential incontinence), an appropriate bladder neck suspension may be performed simultaneously with the anterior repair. When performing midurethral sling procedures, it may be preferable not to extend the repair procedure below the urethra, but instead to make a separate incision for the sling. Maintaining some degree of the urethrovesical angle may improve the results of any incontinence procedure. If the patient has voiding dysfunction (reports of incomplete emptying and a high residual urine) and stress incontinence, appropriate urodynamic evaluation should be performed before a procedure is selected, and the patient should be made aware of the potential for continued problems after surgery (78).

Recurrence rates of traditional “fibromuscular plication” anterior repairs vary from 3% to 92%; however, studies define recurrence in numerous ways, from minimal prolapse to stage III descent (63,73–81). The clinical significance of recurrent mild cystoceles (stage I) that are asymptomatic is debatable because many of these defects do not progress to larger ones. When traditional anterior repairs are performed in patients with POP-Q stage II or greater cystoceles (frequently concurrently with other procedures), a 20% recurrence rate of stage II or greater prolapse is not uncommon, although overall recurrence rates as low as 3% have been reported (76). Many studies do not define how the participants were evaluated postoperatively and vary with respect to patient populations, type and severity of defects, presence of concurrent defects, surgical technique, and follow-up time and length. Some studies have suggested higher recurrence rates when these repairs are performed concurrently with sacrospinous suspensions and hypothesize that this type of apical suspension may predispose the repaired anterior wall to greater pressure transmission (63,64). These studies may show higher failure rates because patients having such concurrent repairs may be more likely to have more complicated forms of prolapse or more extensive pelvic floor defects than other patients.

Paravaginal Repair

The paravaginal or “lateral defect” repair involves reattachment of the anterior lateral vaginal sulcus to the obturator internus fascia and, in some cases, muscle at the level of the arcus tendineus pelvis (“white line”)(82,83). It is usually performed as a bilateral procedure via transvaginal or retropubic (abdominal or laparoscopic) access. The procedure essentially restores normal anatomy; however, because it is not practical to rebuild the defective endopelvic–fascial bridge to the pelvic sidewall, it attaches the vaginal wall itself. Observational studies have reported good success with this procedure (80%–95%); however, long-term data on durability and function are lacking (12,84–88). Most women with anteriolateral detachments usually have separation of the upper vaginal fornices from the arcus tendineus immediately adjacent to the ischial spine (Fig. 27.13) (89). Thus, it is important to resuspend those specific areas.

Figure 27.13 Schematics illustrating normal attachments of the anterior fibromuscular vaginal plane (A and C) and bilateral detachments of that plane from the arcus tendineus up to the level of the ischial spines (B and D). Note: For B and D to occur, there will either be concurrent apical descent or a detachment of the upper fibromuscular plane from the apical structures. (From Delancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187:93–98, with permission.)

It is difficult to achieve optimal results when the paravaginal repair is used in combination with traditional central repairs because of the creation of tension on opposing suture lines. A repair that removes a weakened central vaginal wall may decrease the side-to-side dimensions of the anterior vaginal wall, making it difficult to suspend its lateral points more laterally. When large central defects coexist with lateral defects, one option is an extensive central repair accompanied by an apical support procedure. This changes the shape of the vagina to a more cylindrical structure. Another choice is placement of a graft to span the entire anterior rhomboid-shaped plate, thus augmenting anterior paravaginal tissue strength. The graft with tension adjusted may be anchored to the arcus tendineus along with the adjacent vaginal wall from the level of the pubic rami to the ischial spine (88).

Although most reports indicate that repair of anterior defects with all of these procedures relieves symptoms directly related to prolapse, there are very few data on patient satisfaction and quality-of-life improvement over time (88).

The Posterior Compartment

Traditional Posterior Colporrhaphy

The first description of the posterior colporrhaphy involved plication of the pubococcygeus muscles across the anterior rectum as well as perineal body reconstruction (90). The technique has subsequently been modified in attempts to preserve sexual function. Typically a midline incision is extended from the perineal body to the vaginal apex or to the cephalad border of a small or distal rectocele. The Denonvillier’s fascia is mobilized from the vaginal epithelium, leaving as much of this tissue as possible attached laterally to the levator fascia. After obvious defects in the rectal muscularis are repaired, the fascia is then plicated in the midline with interrupted or continuous sutures. The authors prefer delayed absorbable sutures for this plication. Permanent nonbraided suture material also can be used. Braided permanent suture material is associated with a greater incidence of stitch infection and formation of granulation tissue (91). The vaginal epithelium is trimmed and closed with absorbable sutures.

When a defective perineal body or perineal membrane is present, reconstruction is performed after accompanying posterior colporrhaphy. The superficial muscles of the perineum and bulbocavernous fascia are plicated in the midline and the skin closed as in an episiotomy repair. Detachments of the inferior portion of the Denonvillier’s fascia from the perineal body are also corrected. The puborectalis muscles are plicated concurrently with these procedures by some surgeons, but this approach is associated with a high incidence of sexual dysfunction and thus is not recommended routinely (91). It may be worth consideration in patients who have severe prolapse accompanied by a large genital hiatus with palpable levator weakness or who are unable to contract their pelvic floor muscles. Sutures should be placed carefully through the puborectalis muscles at least 3 cm or greater posterior to their insertion on the pubic rami, thereby decreasing the tension of the plication. For those women with an enlarged hiatus and weakened puborectalis muscles who desire sexual function, an attempt can be made to plicate the muscles far enough posteriorly to allow two fingers to easily pass through the vaginal introitus and to reconstruct the distal posterior vagina and perineum, whereby there will not be a ledge at the site of the puborectalis plication (91). Outcome data on such procedures are inadequate to make conclusions regarding its efficacy; however, it is reasonable to postulate that pelvic floor defects producing an enlarged genital hiatus are common reasons for failure of support procedures, and puborectalis plication may decrease the incidence of such failures.

A complete review of rectocele, anorectal functional disorders, and various repairs can be found elsewhere (92). Reported anatomic cure rates for traditional posterior colporrhaphy have ranged from 76% to 90% with variable follow-up intervals (93–97). Most studies show a benefit in ease of defecation if patients are using splinting preoperatively; however, overall defecatory dysfunction (defined as constipation) was not relieved in most patients and increased (approximately 30%) after the procedure in one study (95). These repairs appear to have little to no benefit in the treatment of fecal incontinence. It is not surprising that the repairs are not particularly effective for defecatory dysfunction related to disorders of constipation or for fecal incontinence because these problems have multifactorial causes. De novodyspareunia is reported to occur in 8% to 26% of sexually active patients who have traditional posterior colporrhaphy and is not always associated with levator plication procedures (93–96,98,99). Potential causes for dyspareunia, other than vaginal strictures or introital tightness, include scarring with immobility of the vaginal wall, levator spasm, and neuralgia associated with sutures or dissection. Dyspareunia also may occur when a Burch procedure or other procedures that anteriorly displace the vaginal canal are combined with a posterior repair (96). Careful surgical technique and appropriate choice of procedure should decrease the incidence of postoperative dyspareunia.

Defect Specific Posterior Repair

Defect or site-specific posterior repairs are restorative procedures by which posterior defects are corrected. These repairs begin with midline posterior vaginal incision through the epithelium and continue with separation of the epithelium from the fibromuscular wall. After irrigation to provide better exposure, a finger is inserted into the rectum to help define defects of the rectal wall and the fibromuscular layer that has been dissected from the vaginal wall submucosa. The specific defects are closed with either interrupted or running sutures (preferably the delayed absorbable type). Defect closure is accomplished in such a way as to minimize tension on the surrounding tissue and may involve vertical, horizontal, or oblique approximation. When fibromuscular tissue has separated from the perineum, the upper anterior rectum, or a well-supported cervix or vaginal cuff, it is important to reapproximate these connections. Repairs of coexistent perineal and apical support defects are important. The object of the surgery is to reestablish an intact plane of connective tissue that positions the rectum against the pelvic floor and obliterates any potential space between a well-supported cervix or vaginal cuff and the cephalad edge of the tissue plane and upper rectum. The technique should minimize tension and potential strictures, which may be more likely to occur with traditional posterior colporrhaphy (97).

Initial case series reveal anatomical cure rates with mean follow-up times less than 18 months from 82% to 100% and de novo dyspareunia rates of 2% to 7%, which are much lower than those seen with traditional repairs (99–103). Symptom relief appears to be as good or better than that seen with traditional repairs. The greatest concern with these and other procedures has been durability. A recent report indicates that the recurrence rate of rectocele beyond the midvaginal plane was higher with defect-specific posterior repairs than with side-to-side plication procedures using laterally attached fascia pulled to the midline (33% vs. 14%) and beyond the hymenal ring (11% vs. 4%) (97). The study was not randomized; however, the procedures were performed during the same period with consistent follow-up evaluations 1 year after surgery. Symptoms (dyspareunia, constipation, and fecal incontinence) after surgery did not differ between the two groups. Long-term follow-up of previously reported case series that had good short-term success or prospective randomized trials looking at modifications of traditional repairs versus defect-specific repairs should clearly delineate durability of these procedures.

Transanal Posterior Repair

The aim of transanal rectocele repair, usually performed by colorectal surgeons rather than gynecologists, is to remove or plicate redundant rectal mucosa, to decrease the size of the rectal vault, and to plicate the rectal muscularis. The rectovaginal adventitia and septum are plicated as well, probably along with the posterior vaginal muscularis. The vaginal epithelium is not incised or excised with this procedure, which probably accounts for the reported lack of adverse affects on sexual function in contrast to the vaginal approach to posterior repair. Two randomized trials and several case series from transanal repairs with mean follow-up intervals of 12 to 52 months report anatomic cure rates of 70% to 98%, improved constipation and fecal incontinence, with less need for vaginal digitation to expel stool (104–108). Complications included infections and rectovaginal fistulas, which are surprisingly rare in the reported series. From the gynecologic perspective, transanal posterior repair is an option only when the procedure is performed for defecatory dysfunction and not for prolapse of the posterior vaginal wall. The question remains whether the transanal approach with defect excision and repair improves defecatory dysfunction better than a defect-specific transperineal or transvaginal approach with imbrication of tissues to correct palpable weakness in the rectal wall and its adjacent connective tissues.

Transvaginal Mesh Procedures

Graft materials have been employed in repairing defects or hernias throughout the body. The purpose of grafts is to either completely replace “weak” tissue by spanning across that tissue or to provide a scaffold for fibroblast infiltration. The patient’s own connective tissue may grow into the graft, and, if the graft is degradable, replace the graft as a supportive structure. An ideal graft material should (i) be nonantigenic, (ii) exhibit a low infection rate, (iii) decrease or negate recurrence of anatomic defects, (iv) cause no harm with respect to bowel or renal function, and (v) be relatively inexpensive. Graft materials include autologous tissues, cadaveric allografts and fascia, dermis and other connective tissues, xenografts from animal sources, and various synthetic materials. Allografts and xenografts are treated with processes to remove living cells, thus negating their antigenic potential and allowing them to serve as a temporary connective tissue scaffold. It is assumed that fresh, autologous grafts work similarly; however, there may be some fibroblast survival in fresh harvested tissue. Autologous grafts have limitations in size and shape compared with tissue taken from cadaveric or animal sources. Synthetic grafts are permanent and, as long as the tissues to which they are secured retain their position and strength, they should be durable. Autografts, allografts, and xenografts depend on adequate tissue growth from the subject and potentially may have higher failure rates than synthetic ones. Synthetic grafts are more subject to erosion. Graft erosion may produce bothersome discharge, pain, and sexual dysfunction with vaginal scarring. This may be more likely to occur in women with attenuated, scarred, or less vascular tissue at the time of the repair. More loosely woven polypropylene meshes appear to exhibit fewer problems with erosion and infection than the synthetic graft material that was previously used (109–113).

Midurethral sling procedures that use such mesh have reported erosion rates of 1% or less as compared with rates as high as 6% with more tightly woven polypropylene and polyethylene grafts(109–113). A greater incidence of graft infection has been reported when other synthetic grafts are used. One would expect higher rates of erosion and infection when large pieces of graft material are used adjunctively to the vaginal wall; however, there have been favorable reports in which loosely woven polypropylene mesh was used in this manner. Small areas of eroded polypropylene graft may be removed with the surrounding tissue to the point where there is good tissue growth into the graft, and the defect can then be closed. Graft erosion into the bladder, urethra, or rectum is less common than into the vagina. When erosion occurs, however, management is more difficult and long-term adverse effects more common. Numerous surgeons have been reticent to use synthetic graft materials to augment paravaginal musculoconnective tissue support because of complications from erosion. There remains a need for long-term follow-up on patients who have repairs with graft material, not only to assess anatomical results and complications, but also to assess subsequent sexual function, presence and absence of pain, and patient satisfaction.

Synthetic transvaginal mesh kits have become commonplace in the treatment of pelvic organ prolapse. These devices were quickly adopted by many surgeons in an effort to improve outcomes, particularly in patients who had failed native tissue repairs. Studies have provided mixed results as to the effectiveness of these devices. There may be a lower recurrence rate in the anterior compartment when compared with native tissue repairs; however, mesh erosions occur in 2% to 19% of those treated (109–113). The severity of mesh erosions ranges from subclinical to severe dyspareunia requiring surgical resection. Small mesh erosions are sometimes successfully managed with vaginal estrogen alone. As with anterior compartment procedures, graft materials have been used to improve the success of posterior compartment repairs. One recent systematic review concluded that there is insufficient evidence to evaluate the use of synthetic mesh in the repair of pelvic organ prolapse (114). It is also notable that the U.S. Food and Drug Administration (FDA) has recently released a warning about complications that may arise from the use of transvaginal mesh procedures for pelvic organ prolapse.

The FDA recommendations are that physicians should:

1. Obtain specialized training for each mesh placement technique, and be aware of its risks.

2. Be vigilant for potential adverse events from the mesh, especially erosion and infection.

3. Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder, and blood vessel perforations.

4. Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication.

5. Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair).

In summary, transvaginal mesh procedures that are currently in use utilize predominantly synthetic materials. These devices may reduce recurrence of pelvic organ prolapse and are associated with some risk of vaginal mesh extrusion and chronic pain or dyspareunia. Patients should be counseled extensively about the risks and benefits of the use of these devices. Surgeons who use these devices should carefully follow their cases to identify complications.

Abdominal Procedures

Abdominal Uterosacral Suspension

Abdominal uterosacral colposuspension has been used prophylactically after hysterectomy and therapeutically for apical prolapse with cardinal/uterosacral defects (115). It can be performed through laparotomy incisions or by laparoscopic techniques. For the therapeutic procedure, a no. 1 polypropylene or delayed absorbable suture is placed cephalad and at the same level posterior as the ischial spines, which may be palpated transabdominally or with a vaginal finger to push a vaginal fornix to the spine under observation with a laparoscope. One technique is to place one or two permanent sutures through one ligament, then, after reefing across the cul-de-sac peritoneum at the sigmoid border, through the contralateral ligament, and then through the fibromuscular tissue just anterior to the vaginal cuff. Tying the suture suspends the vaginal cuff and obliterates any enterocele defect. Another technique employs separate sutures placed at the same level into each uterosacral ligament and anchored anteriorly and posteriorly to the ipsilateral side of the vaginal cuff, similar to procedures performed transvaginally. Cystoscopy is performed after the procedure to document ureteral patency. One study found subjective and objective recurrence rates to be low (12% and 5%, respectively) (115).

Abdominal Approach to Posterior Repair

When abdominal sacrocolpopexy is planned for apical vaginal prolapse and concomitant rectocele is present, some have advocated extending the posterior graft down the posterior vaginal wall to correct the defect(116). The technique of sacral colpoperineopexy is used to replace the normal vaginal suspensory ligaments and to augment or replace the posterior fibromuscular plane with graft material that runs from the sacrum to the perineal body (116). Its purpose is to correct the posterior compartment defects and to suspend the perineal body, thus preventing descent and opening of the genital hiatus. It has been performed transabdominally or as a combined abdominal and vaginal procedure with both Mersilene mesh and dermal allografts (116,117). Mesh erosion occurred frequently when the vagina was open: 16% for vaginal placed sutures and 40% for transvaginally placed mesh (117). The use of dermal allografts results in an anatomical cure rate of 82% with short-term follow-up and a mean of 12 months following surgery (116,117). Significant improvements also were seen in bowel symptoms. One author reported results on 205 of 236 subjects who underwent an abdominal sacral colpoperineopexy with polypropylene mesh (Marlex) without opening the vagina (118). This procedure included two straps of mesh attached from the lateral anterior vagina to Cooper’s ligament. Ten-year satisfaction rates were 68%, and erosion rates were 5%.

Laparoscopic Approach to Posterior Repair

Laparoscopic rectocele repair involves the dissection of the rectovaginal space to the perineal body with either plication of levator fascia or suturing absorbable or permanent mesh in place (119,120). A few small case series have been reported with variable results.

Abdominal Sacrocolpopexy

The standard approach to transabdominal apical vaginal suspension procedures is the abdominal sacrocolpopexy. A complete review of published data on these procedures developed by the Pelvic Floor Disorders Network, which is sponsored by the National Institute of Child Health and Human Development (NICHD), has been published (121). These procedures use graft material attached to the prolapsed region of the anterior and posterior vaginal walls at or encompassing the vaginal apex and suspended to the anterior longitudinal ligament of the sacrum. Cervical sacral suspensions may also be performed when uterine or cervical conservation is desired. Surgical variations abound and include configuration of the graft on the vagina, the extent to which the anterior and posterior vagina are attached to the graft, variable graft and suture materials, presence or absence of peritoneal closure over the graft, and obliteration of the cul-de-sac for treatment or prevention of the enterocele or sigmoidocele. A thorough preoperative evaluation is important to exclude more distal defects or stress incontinence, which should be repaired concurrently, and other lower urinary tract or anorectal problems. In published reports, cure rates for apical prolapse range from 78% to 100% (most greater than 90%); when cure is defined as no postoperative prolapse, the range widens from 56% to 100%, although subsequent anterior or posterior vaginal prolapse has not been as consistently reported as has apical prolapse (122–131). Potential advantages of this procedure over transvaginal procedures are less paravaginal scarring and denervation than may be present with transvaginal approaches, and fixation of the entire vaginal apical area by a permanent piece of material to a stable structure (the anterior sacral ligament), which may be more durable than the transvaginal techniques that use the patient’s own connective tissue.

Complications of these procedures include (i) erosions of graft material or suture material, which may be caused by graft or suture infection usually secondary to vaginal wall penetration, or performing the procedure adjacent to a vaginal incision, or securing the graft to an attenuated avascular wall with inadequate fibromuscular tissue (3.4%); (ii) significant intraoperative hemorrhage (especially in the presacral space) (4.8%); (iii) postoperative ileus, which may be secondary to the need for excessive packing of the bowel or to extensive Halban or Moschcowitz culdoplasty procedures (3.6%); (iv) small bowel obstruction, requiring reoperation (1.1%); (v) development of intra-abdominal adhesions with resultant pain and bowel dysfunction (unknown incidence); and (vi) wound complications, such as seromas and infections (4.6%) (120).

Several management techniques have been advocated to minimize these problems. Empiric ways to prevent graft erosions include (i) preoperative tissue optimization with vaginal administration of estrogen and treatment of vaginitis and infection of eroded areas; (ii) the use of small-gauge monofilament sutures placed in the fibromuscular tissue, thus avoiding full thickness passage; and (iii) excision of a portion of the vaginal apex when the vaginal wall is thin and depleted of its fibromuscular layer and vascularity. Graft attachment to “healthy” fibromuscular tissue rather than to thin avascular tissue should help prevent erosion. If such excision is necessary, or if the suspension is to be performed concurrently with a hysterectomy, good approximation of the fibromuscular layers above the mucosa, thorough irrigation, prophylactic use of antibiotics, and avoidance of graft placement across the suture line may decrease the likelihood of graft erosion. Choice of graft material may also be important. One would expect synthetic grafts to have greater durability than tissue grafts; however, erosion rates are more serious with the synthetic grafts. Anecdotally, some surgeons are convinced that less porous graft material, such as GORE-TEX, has a greater likelihood of becoming infected and eroding than do macroporous, filamentous polypropylene meshes. Numerous case series report serious episodes of hemorrhage from the presacral venous plexus (mean incidence 4.8%; range 0.18%–16.9% of sacrocolpopexies requiring, at a minimum, transfusion) (121). This problem is less likely if dissection and graft fixation is limited to the level of S1 and S2 just caudad to the promontory and with the use of good light and meticulous dissection techniques to expose the anterior sacral ligament.

Careful tissue handling and packing technique may minimize postoperative ileus and adhesions. Incorporation of the sigmoid into a closure of the cul-de-sac posterior to the graft may also slow bowel function postoperatively. Small bowel obstruction has resulted from direct adhesive processes involving grafts to small bowel (120). Complete extra peritonealization of the graft using flaps of peritoneum dissected from the prolapsed area and the peritoneum anterior to the sacral promontory and lateral to the right side of the sigmoid colon should prevent this complication. However, loops of bowel have been seen to prolapse through small defects in peritoneal closure with the same effect. Careful technique with adherence to basic surgical principles may help prevent this and other complications related to laparotomy.

Laparoscopic and Robotic Techniques

As with most pelvic operations, sacrocolpopexy has been successfully accomplished by the laparoscopic and robotic route and has the potential to offer patients the benefits of less postoperative discomfort and faster recovery as well as potential lower risks for adhesions and ileus. Outcomes depend on the expertise and experience of the surgeon; “cutting corners” to shorten the procedure could affect anatomical success. The applicability of the laparoscopic technique is limited by the need for a relatively high level of technical skill. In the authors' experience, ipsilateral suturing (through same sided ports) is preferred to contralateral suturing. The authors have also found that straight self-righting needle drivers and non-self-righting curved needle drivers are useful in attaching the mesh to the vagina. The Carter-Thompson suturing device is sometimes helpful to aid in elevating the sigmoid colon away from the pelvic cul-de-sac by tagging the peritoneal edge. The robot has provided an easier platform for a minimally invasive approach to the sacrocolpopexy. Data about its use are limited to several case series that demonstrate comparable short-term results with open and laparoscopic techniques (121).

For sacrocolpopexy, whether through laparotomy or laparoscopy, the pelvis should be completely exposed with the lower sigmoid colon stretched cephalad (Fig. 27.14).

Figure 27.14 Sacrocolpopexy. A: Illustrates (i) graft attachment to the posterior area of prolapsed vagina to or below the rectal-sigmoid junction after the overlying peritoneum has been dissected and flapped laterally and (ii) exposure of the presacral space with suture placement through the anterior sacral ligament. An appropriately shaped second graft is placed anteriorly. B: Illustrates attachment of both grafts without tension to the sacrum. Prevention of subsequent enterocele and/or sigmoidocele is accomplished by box closure of the cul-de-sac peritoneum lateral to the left side of the sigmoid, attachment of the presigmoid fat to the graft centrally, and reperitorealization of the graft through the right side of the cul-de-sac. EEA, end-to-end anastomosis sizer. (Redrawn by J. Taylor.)

1. With a vaginal obturator (an EEA sizer) placed vaginally to visualize the area that is not covered by the bladder or rectum, the peritoneum is dissected from the underlying vaginal fibromuscular layer anteriorly to bladder reflection and posteriorly at least to the level of the sigmoid rectal junction, creating bilateral peritoneal flaps. Laterally, vascular bundles are visible.

2. Two separate loosely woven polypropylene mesh grafts are shaped similar to boat paddles. The “paddle” portions are shaped to cover the areas anterior to the apex and posterior to the apex, respectively, and the “handles,” which are approximately 8 to 10 cm in length and 1 cm wide, are anchored to the anterior sacral ligament. The paddle portions are secured circumferentially to the fibromuscular layers anteriorly and posteriorly with six to eight monofilament 3-0 nylon sutures and one or two sutures placed centrally (Fig. 27.14 A).

3. When the fibromuscular tissue in the area is attenuated, a portion of the vaginal wall is excised and closed, as noted previously.

4. The peritoneum overlying sacral vertebrae 1 and 2 is incised while retracting the sigmoid colon to the left, and careful dissection is employed down to the anterior ligament. Care is taken to stay well medial to the right ureter and hypogastric vessels.

5. Hemoclips are placed caudad and cephalad on the middle sacral vessels if it is felt that this will allow more optimal suture placement. The peritoneal incision is extended into the right cul-de-sac area adjacent to the sigmoid.

6. Closure of the cul-de-sac lateral to the sigmoid on the left and approximation of the distal presigmoid fat to the distal edge of the posterior graft is accomplished with box stitches of 0-delayed absorbable sutures. It is thought that these procedures and the retroperitonealization of the graft through the right side of the cul-de-sac will prevent posterior enterocele and sigmoidocele as well as a Halban or Moschcowitz procedure.

7. The two “handle” ends of the graft are then brought to the point of sacral attachment, where their length is adjusted to remove any tension on the vaginal sutures and secured to the anterior sacral ligament with no. 1 permanent braided nylon sutures (Fig. 27.14B).

8. Reperitonealization of the graft is then performed using the right cul-de-sac peritoneum and peritoneal flaps dissected from the vaginal apical area; occasionally presigmoid fat is used.

Following this procedure, adjunctive procedures, such as paravaginal repair, Burch procedure, midurethral sling, and any transvaginal procedure that is indicated, are performed. When rectocele and pelvic floor defects are present, one option is the sacral colpoperineopexy, as discussed in the posterior compartment section (116). A vaginal pack is inserted for approximately 24 hours to ensure that the graft is well applied to the fibromuscular layer at points other than where sutures are placed.

Vaginal Obliterative Procedures

Colpocleisis or vaginal narrowing procedures may be appropriate choices for debilitated patients who do not desire vaginal function, because complete vaginal reconstructive procedures may last several hours and are associated with potentially higher blood loss and increased morbidity (132,133). Many variations exist, from partial colpocleisis (where some portion of the vaginal epithelium is left to provide drainage tracts for cervical or upper genital discharge) to total colpectomy (where all of the vaginal epithelium is removed from the hymen posteriorly to within 0.5–2 cm of the external urethral meatus anteriorly). If hysterectomy is performed, blood loss is greater and operative time is longer than procedures without hysterectomy (134). These techniques should include a high perineorrhaphy and often a plication of the puborectalis muscles to reinforce posterior support and to reduce the genital hiatus, with the goal of decreasing the chance of recurrent prolapse. Case series have reported success rates as high as 100%, although the population of patients, by nature of their relatively short life expectancy and limited activity, are probably at lower risk for recurrence. In some instances in which most of the defects are anterior and posterior, a modified anterior and posterior colporrhaphy may be performed, whereby relatively large portions of the anterior and posterior vaginal wall are removed and closed, creating a narrow (1–2 cm diameter) cylindrical vagina. As with the colpocleisis, the success of the procedure is augmented by an extensive perineorrhaphy and puborectalis plication. Such a procedure may be performed quickly and with relatively low morbidity. The prevention or treatment of stress incontinence, voiding dysfunction, and colorectal dysfunction in the context of these procedures can be problematic. Careful preoperative history and evaluation, if indicated, is important so that additional conservative therapies or operative techniques such as pubourethral plications or less invasive tension-free slings may be employed.

Management of Urinary Symptoms with Pelvic Organ Prolapse Repair

All women who are undergoing surgery for repair of pelvic organ prolapse should be evaluated for urinary incontinence. Women who report stress urinary incontinence and who demonstrate it on preoperative examination and have no contraindications to a continence procedure should have concomitant procedures for the treatment of these symptoms. Women who do not report stress urinary incontinence may also benefit from a prophylactic procedure if they demonstrate incontinence with reduction of their prolapse. There is also evidence that the addition of a continence procedure in the absence of any evidence of urinary incontinence may improve outcomes without significantly increasing the number of complications (135). The addition of continence procedures to prolapse procedures in patients who have both significant stress incontinence and voiding dysfunction remains controversial.

Comparison of Abdominal versus Vaginal Approaches

In recent years there has been controversy as to whether transvaginal or transabdominal procedures are best for prolapse. One cannot discern which is optimal from reports of retrospective and prospective case series because of the considerable differences in numerous factors, including follow-up, characteristics of the subjects, definitions of success and failure, and the expertise or experience of the surgeons performing the procedures. Three prospective randomized trials have compared sacrocolpopexy and sacrospinous suspension procedures (136–138). All three trials showed some increased durability in the sacrocolpopexy group; however, in one of these studies the differences were not statistically significant (138). In the study in which sexual function was examined, there was a greater incidence of dyspareunia in the transvaginal group (137). Most case series reveal that the incidence of serious complications, such as small bowel obstructions, significant hemorrhage, presacral graft infections, pulmonary embolus, and short-term problems (i.e., ileus, hernias, wound seromas or infections, and longer hospitalizations), are more likely to occur in the group undergoing sacrocolpopexy. Vaginal scarring, strictures, and vaginal wall erosions or granulation tissue appear more likely in the group undergoing transvaginal surgery. To date, there is no randomized comparison of vaginal procedures using high uterosacral suspensions and innovative repairs of the fibromuscular tissues, which are less likely to produce strictures than was the case 10 or more years ago.

Most pelvic surgeons would agree that (i) older, less healthy individuals who are more likely to have surgical and medical complications and cannot or will not tolerate a pessary would derive greater benefit from transvaginal approaches and occasionally obliterative approaches, and (ii) relatively healthy, sexually active women with relatively short vaginas and apical prolapse or with isolated apical defects would derive greater benefit from sacrocolpopexy. For the remainder of the patients with apical prolapse, with or without more distal defects, it would be ideal if surgeons were equally skilled, knowledgeable, and experienced in both abdominal and vaginal approaches to provide care that is truly individualized, rather than emphasizing one approach to the exclusion of another.

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