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PubMed1997

Gynecology Case Challenge: Uterine Prolapse?

Five weeks after a multiparous perimenopausal woman first noticed something "hanging out" of her vagina, she was referred for gynecologic evaluation. Looking through the speculum, what's your diagnosis?

Journal Article↗
PubMed1991

Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display.

The authors present a new method for assessing pelvic prolapse with dynamic fast magnetic resonance (MR) imaging. Twenty-six women with signs and symptoms suggesting pelvic prolapse and 16 control subjects were studied with a series of fast (6-12-second) MR images. Sagittal and coronal images were obtained with graded increase in voluntary pelvic strain, allowing for dynamic display and quantification of the pelvic prolapse process. The distance from the pubococcygeal line was used as an internal reference for measurement of descent in the maximal strain position. With use of control results for normal limit values, prolapse involving the anterior pelvic compartment (cystocele), the middle compartment (vaginal prolapse, uterine prolapse, and enterocele), and the posterior compartment (rectocele) was easily demonstrated. Significant differences between control subjects and patients with prolapse were seen at maximal strain but not in the relaxed state. Quantification of the pelvic descent process with use of fast MR imaging may be of value in surgical planning and postsurgical follow-up.

Adult↗
PubMed2000

Pelvic organ prolapse: a review.

Pelvic organ prolapse is a common medical problem in parous women. This condition usually refers to a combination of deficiencies of the pelvic organs as they relate to support mechanisms of the vaginal wall. Symptoms vary--an accurate diagnosis requires a careful and complete physical examination with attention directed toward the pelvis and perineum. Although many patients will not require surgical treatment for pelvic organ prolapse, a comprehensive approach to repair in which all of the anatomic defects affecting support are addressed is necessary for successful treatment. Patients presenting with pelvic organ prolapse often provide some of the most complex, challenging, and rewarding cases in reconstructive pelvic surgery. This article addresses the definitions and classifications, prevalence and risk factors, and anatomy and pathophysiology relevant to pelvic organ prolapse. Discussion also includes diagnosis and approaches to management (surgical and nonsurgical) of anterior vaginal wall prolapse, cystourethrocele, apical vaginal prolapse, uterine prolapse and enterocele, posterior vaginal wall prolapse, rectocele, and pelvic floor relaxation and perineal laxity, with indications for and approaches to surgery, along with possible complications.

Female↗
PubMed2005

Pelvic organ prolapse.

Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, and enterocele, is a common group of clinical conditions affecting millions of American women. This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse. The evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often challenging for the clinician to determine which symptoms are attributable to the prolapse itself and will therefore improve or resolve once the prolapse is treated. When treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; and surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms require additional management. Virtually all women with prolapse can be treated and their symptoms improved, even if not completely resolved.

Comorbidity↗
PubMed1998

Pelvic prolapse: diagnosing and treating uterine and vaginal vault prolapse.

Uterine prolapse is often associated with a concomitant rectocele, cystocele, and/or an enterocele. Moderate degrees of prolapse are often associated with a feeling of pelvic heaviness or fullness or low back pain. The symptoms usually worsen with exertion and ease with bed rest. In severe prolapse, the cervix may descend outside the vaginal introitus, and patients may complain that a "mass" is protruding from the vagina. Bleeding from mucosal ulcerations or from the cervical os may occur due to rubbing of the prolapsed tissue against the patient's clothing. The commonly associated problems of cystoceles and rectoceles may lead the patient to complain of difficulty voiding, recurrent urinary infections, and/or "splinting" to defecate. Mild cases of uterine prolapse do not require therapy unless the patient is symptomatic; in most cases of second- or third-degree prolapse, however, patients may be quite uncomfortable and desire therapy. Nonsurgical options, such as a pessary, are usually tried first if the patient desires conservative therapy. Operative repair for uterine prolapse is usually approached vaginally if the uterus is small. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the cul-de-sac. In either approach, the uterosacral and cardinal ligaments must be carefully ligated and tied together, and the cul-de-sac must be obliterated to reduce the risk of subsequent enterocele and to properly suspend the vaginal vault.

Female↗
PubMed1997

Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse and to determine whether hydronephrosis is associated with the type and severity of prolapse. METHODS: The charts of 375 consecutive patients undergoing surgery for pelvic organ prolapse at the Cleveland Clinic Foundation between January 1, 1990, and December 31, 1993 were reviewed. Preoperative renal ultrasounds and intravenous pyelograms (IVP) were evaluated for hydronephrosis based on the final diagnosis established by the radiologists. The severity of prolapse was determined from the preoperative office examination or from the examination under anesthesia at the time of surgery. RESULTS: Of 375 patients, 323 had either a preoperative renal ultrasound or IVP. The mean age was 66.0 +/- 10.2 years (range 35-93) and median parity was 3.0 (range 0-10). Of the 323 patients, 25 (7.7%, 95% confidence interval 5, 11) had hydronephrosis. Thirteen patients (4.0%) had mild hydronephrosis, nine (2.8%) had moderate hydronephrosis, and three (0.9%) had severe hydronephrosis. The prevalence of hydronephrosis increased with increasing severity of prolapse. Two patients with hydronephrosis had evidence of renal insufficiency (creatinine > or = 1.6), and both had severe bilateral hydronephrosis and complete procidentia. The prevalence of hydronephrosis was lower in patients with vaginal vault prolapse versus uterine prolapse (3.9% compared with 12.6%, P < .01), CONCLUSION: The prevalence of hydronephrosis in patients undergoing surgery primarily for pelvic organ prolapse is low, increases with worsening pelvic organ prolapse, and is lower in patients with vaginal vault prolapse that in those with uterine prolapse.

Adult↗
PubMed1997

[Uterine adenosarcoma. Apropos of a case of uterine and vaginal adenosarcoma with a corrected genital prolapse].

Uterine adenosarcoma is an apparently benign mixed tumor with a muller type epithelial component and a sarcomatous stromal component. We present a patient with remodeled genital prolapse who developed a bifocal localization in the endometrium and vagina. These tumors are uncommon, 8% of the sarcomatous tumors of the uterus. Their usual presentation may mimic cervical or endometrial polyps. Pathology is required for positive diagnosis which evidences the two components. The diagnosis may be missed at the first examination (two-thirds of the cases in certain series). Treatment is surgical with hysterectomy in peri- or post-menopaused women and tumoral excision or curettage in younger women. The prognosis is good but can worsen if invasion extends beyond one-third of the myometrial thickness or if pure sarcomatous transformation occurs.

Adenosarcoma↗
PubMed1999

Urine flow rates and residual urine volumes in urogynecology patients.

Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfunction underwent a full clinical and urodynamic assessment. Their urine flow rates and residual urine volumes were analyzed. The urine flow rates of the urogynecology patients were found to be significantly less than those of an asymptomatic population. There were significant declines in urine flow rates in the presence of a previous hysterectomy and with increasing grades of prolapse, particularly uterine prolapse, cystocele and enterocele. Unlike the normal female population, there was also deterioration with increasing parity and age, the latter largely due to the increasing incidence of hysterectomy and prolapse with age. The 10th centile of the Liverpool Nomogram for the maximum urine flow rate was found to be the most useful discriminant for a final urodynamic diagnosis of voiding difficulties. Most urogynecology patients have no or small residual urine volumes, 74% <10 ml and 81% <30 ml (vs 95% <30 ml in asymptomatic women). In urogynecology patients residuals were larger where there had been a prior hysterectomy or with grade 2 or higher uterine prolapse, cystocele and enterocele. Mean residual was 14.8 ml (vs 4.8 ml in asymptomatic women). These data indicate a higher incidence of voiding difficulties (abnormally slow urine flow (under 10th centile) and/or abnormally high residual urine volume (over 30 ml) in urogynecology patients, particularly those with higher grades of prolapse and with prior hysterectomy.

Female↗
PubMed1992

Submucosal uterine leiomyomas: diagnosis of prolapse into the cervix and vagina based on MR imaging.

OBJECTIVE: We describe the MR appearance, signs and symptoms, and pathologic findings in five patients with submucosal leiomyomas that prolapsed into the cervical or vaginal canal. SUBJECTS AND METHODS: During the past 3 years, five women aged 33-53 years (mean, 43 years) were identified prospectively at MR imaging as having prolapsing uterine leiomyomas. The diagnosis was confirmed by surgical pathology. MR imaging was performed on a 1.5-T unit, using both T1- and T2-weighted spin-echo or fast spin-echo sequences. The images were analyzed for signal intensity, presence of a stalk, and caudal extent of the prolapsed leiomyoma. RESULTS: These leiomyomas, the presence of prolapse, and the caudal extent of prolapse were detected prospectively on MR images in all five cases. Prospective localization of the stalk in two cases aided subsequent hysteroscopic resection. MR imaging correctly indicated the presence of hemorrhage in one, degeneration in a second, and the absence of these complications in two others. In the fifth case, a hemorrhagic focus in the distal tip of the leiomyoma was not detected on MR images obtained 3 days before surgery. CONCLUSION: MR imaging is useful for the diagnosis and characterization of uterine leiomyomas that have prolapsed into the cervical or vaginal canal.

Adult↗
PubMed2006

Is sensory urgency part of the same spectrum of bladder dysfunction as detrusor overactivity?

It has been suggested that the urogynecological diagnosis of sensory urgency is an early form of detrusor overactivity and may be just earlier in the spectrum of disease. The former term is generally defined as increased perceived bladder sensation during filling, a low first desire to void and low bladder capacity in the absence of recorded urinary tract infection (UTI) or detrusor overactivity. The aims of this study are to determine the prevalence and associations of sensory urgency in comparison with detrusor overactivity, and whether sensory urgency is shown to be in the same spectrum of bladder dysfunction as detrusor overactivity. Five hundred and ninety-two women attending for an initial urogynecological/urodynamic assessment took part in this prospective study. In addition to a full clinical assessment, all women underwent free uroflowmetry, residual urine volume measurement (by vaginal ultrasound) and multichannel filling and voiding cystometry. Data were separated into those having (1) sensory urgency or (2) detrusor overactivity. Apart from prevalence figures, comparative associations were sought for (3) age; (4) parity; (5) presenting symptoms; (6) presence of at least one (medically) documented UTI in the previous 12 months; (7) two or more (recurrent) documented UTIs in the previous 12 months; (8) prior hysterectomy; (9) prior continence surgery; (10) menopause; (11) menopause and HRT use; (12) sign of clinical stress leakage; (13) retroverted uterus; (14) anterior vaginal wall prolapse; (15) uterine prolapse; (16) posterior vaginal wall prolapse; (17) apical vaginal prolapse; (18, 19) maximum, average urine flow rate (MUFR, AUFR) centiles, Liverpool Nomograms; (20) median residual urine volume (RUV) in milliliters; (21, 22) voiding difficulty: VD1,VD2 (MUFR, AUFR under 10th centile Liverpool Nomogram and/or RUV >30 ml); (23) diagnosis of urodynamic stress incontinence and (24) diagnosis of uterine and/or vaginal prolapse (grade >0). The prevalence of sensory urgency was 13%. The only differences in the clinical and urodynamic profiles of it and detrusor overactivity were (1) significantly increased prevalence of the symptom of urge incontinence and (2) (by definition) abnormal detrusor contractions during filling cystometry in women with detrusor overactivity. Overall, sensory urgency and detrusor overactivity appear to be part of the same spectrum of bladder dysfunction.

Adolescent↗
PubMed1981

[Treatment of genital prolapse by transposition of the uterine isthmus below the urethra (author's transl)].

The authors describe a new per vaginam method devised to treat both uterine prolapse and associated or latent urinary incontinence in menopausal women. After amputation of the cervix, the uterine isthmus is brought down below the urethra and kept in this position by the uterosacral ligaments, which are separated from the uterus and sutured to the subpelvic fibrous tissues. This is followed by the subtotal colpectomy in women who have given up sexual intercourse and by partial colpectomy of a special design in those who wish to pursue sexual activity. Thirty-one operations of this kind have been performed with immediate success in 29 and delayed success in 12.

Aged↗
PubMed1998

Should sacrospinous ligament fixation for the management of pelvic support defects be part of a residency program procedure? The University of Miami experience.

OBJECTIVE: The objective of this article is to determine the safety and effectiveness of transvaginal sacrospinous ligament fixation as part of the management of pelvic support defects in a residency program. STUDY DESIGN: A retrospective chart review of patients undergoing sacrospinous ligament fixation at the Division of Gynecology, Jackson Memorial Hospital, University of Miami School of Medicine, between July 1990 and December 1995, was performed. Patients with vaginal vault prolapse and uterine prolapse with documented preoperative evaluation were included in this study. Data were obtained using a detailed predetermined flow sheet. RESULTS: A total of 160 patients was included in the study. All patients underwent right sacrospinous ligament fixation, anterior and posterior colporrhaphy, and perineorrhaphy. In addition, 31 (19%) underwent enterocele repair, 5 (3%) underwent trachelectomy, and 9 (6%) underwent Burch procedure. Complications included fever 13 (8.1%), urinary tract infection 16 (10%), blood loss requiring transfusion 7 (4.3%), sciatic neuralgia 2 (1.2%), and rectovaginal fistula 2 (1.2%). The mean follow-up was 40 months (range 18 to 78 months). The success of the operation was gauged by recurrence. Ninety-four percent of the patients had no evidence of vaginal vault prolapse on follow-up, and 85% had no recurrence of any pelvic support defect. Eleven of the 24 patients with recurrence underwent repeat surgery, whereas 13 opted for conservative management with pessaries. CONCLUSION: Transvaginal unilateral sacrospinous ligament fixation is a safe and successful operation for the treatment of pelvic support defect and should be an essential component in the training of gynecologic residents.

Adult↗
PubMed2003

Value of express T2-weighted pelvic MRI in the preoperative evaluation of severe pelvic floor prolapse: a prospective study.

OBJECTIVES: To report our prospective experience with extended-phase conjugate-symmetry rapid spin-echo sequence (EXPRESS) magnetic resonance imaging (MRI) of the female pelvis in the preoperative staging of severe pelvic floor prolapse (PFP). Severe PFP represents a significant diagnostic and reconstructive challenge for clinicians. Although the clinical utility of dynamic MRI has already been demonstrated, EXPRESS MRI has not been prospectively studied in the evaluation of PFP. METHODS: Between January 1999 and December 2001, 31 consecutive female patients with severe PFP were referred to our institution. Twenty of them underwent EXPRESS dynamic pelvic MRI. The physical examination, MRI, and intraoperative findings were statistically correlated. RESULTS: The mean age of the 20 patients undergoing preoperative EXPRESS MRI was 67 years. The mean duration of prolapse was 6.1 years. All 20 patients underwent surgery for symptomatic PFP with or without associated voiding dysfunction. No postoperative complications or recurrent PFP had occurred at a median follow-up of 19 months. Significant correlations were found between the preoperative pelvic examination findings and operative findings of cystourethrocele and vaginal cuff prolapse, and significant correlations were found between MRI findings and operative findings of enterocele, cystourethrocele, vaginal cuff prolapse, and uterine prolapse. CONCLUSIONS: EXPRESS MRI can accurately stage PFP. The technique is rapid, precise, and noninvasive. Practitioners should consider obtaining dynamic, rapid-sequence sagittal pelvic MRI scans in cases of severe PFP when the diagnosis is not clear before surgery. More accurate preoperative information may ultimately result in improved long-term surgical outcomes and guide the refinement of surgical techniques.

Adult↗
PubMed2006

Transvaginal repair of enterocele and vaginal vault prolapse using autologous fascia lata graft.

BACKGROUND: The aim was to describe the operative technique of transvaginal repair of enterocele and apical prolapse using autologous fascia lata and report intra- and postoperative complications and long-term outcome. METHODS: A retrospective chart review of 74 consecutive patients who had repair of a symptomatic enterocele and vaginal vault prolapse or uterine prolapse from January 1987 to August 1999. All patients were followed for a minimum of 3 months and 61 were available for long-term evaluation at 18-106 months (median 52 months). RESULTS: Intra- and postoperative complications were few. Pelvic examination at long-term follow-up disclosed a recurrence rate for enterocele of 1.7%, vaginal vault prolapse of 8.3%, and cystocele of 15%. Ninety-one per cent were subjectively satisfied with the relief of mechanical vaginal symptoms. Only 35% (6/17) were cured of constipation. Out of the 22 women who were sexually active after the procedure, 12 (54%) experienced improved quality. CONCLUSION: Repair of the posterior compartment defect and suspension of the vaginal vault using autologous fascia lata graft provides acceptable intra- and postoperative complication and long-term results.

Adult↗