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PubMed2001

Ultrasound in the quantification of female pelvic organ prolapse.

OBJECTIVES: To evaluate the use of ultrasound in the quantification of prolapse and compare findings with clinical assessments obtained in a blind study. METHODS: In a prospective comparative clinical study, 145 patients referred for urogynecological assessment were examined clinically by one operator and by translabial ultrasound by another operator. RESULTS: Clinical staging and International Continence Society coordinates were obtained for all 145 patients, as were ultrasound coordinates for descent of the anterior and posterior vaginal walls. Eighteen percent of the uteri of those women who had not had a hysterectomy in the past could not be seen; none of these women suffered from uterine prolapse clinically. Correlation with the prolapse assessment system recently endorsed by the International Continence Society was good (r = 0.77 for uterine prolapse, r = 0.72 for anterior vaginal wall and r = 0.53 for posterior vaginal wall descent). CONCLUSIONS: This study demonstrates that translabial ultrasound can be used to quantify female pelvic organ prolapse. Correlation with the International Continence Society prolapse assessment system is good. The method may be particularly suitable for objective outcome assessment after surgical intervention.

Cross-Over Studies↗

PubMed2000

Evaluation of Delorme's procedure as a treatment for full-thickness rectal prolapse.

BACKGROUND: Delorme's procedure is a well tolerated perineal operation for full-thickness rectal prolapse. However, prolapse recurrence is common and reported recurrence rates vary widely. This study attempted to standardize outcome assessment for recurrence following primary and subsequent Delorme's operations. Patient and operative factors were analysed to identify any that might improve patient selection. METHODS: Some 101 primary and 17 secondary Delorme's procedures were carried out on 113 consecutive patients presenting with rectal prolapse, who were followed for a minimum of 12 months, unless death or recurrent prolapse intervened. The rate of prolapse recurrence was calculated using the Kaplan-Meier method of analysis. Patient age, sex, grade of incontinence, presence of diverticular disease, length of mucosal resection and position in the operative series were analysed to identify factors affecting recurrence. RESULTS: The predicted recurrence-free period for 50 per cent of patients undergoing primary and secondary Delorme's procedures was 91 (95 per cent confidence interval 77-105) and 27 (15-39) months respectively. None of the patient or operative factors analysed was related to recurrent prolapse. CONCLUSION: Delorme's procedure is a simple operation with satisfactory functional results which can be considered in all patients of all ages. However, high recurrence rates for primary and repeat operations should be explained to patients when planning their surgical management.

Adult↗

PubMed2003

Anal sphincter tears in patients with rectal prolapse and faecal incontinence.

OBJECTIVE: Faecal incontinence often persists after surgery for rectal prolapse. Multiple mechanisms have been proposed as responsible, however, anal sphincter integrity has only been studied in a handful of cases. This study assesses the incidence of ultrasound detected anal sphincter tears in patients with rectal prolapse and faecal incontinence. METHODS: Retrospective search of medical records at Flinders Medical Centre over a 7-year period to identify patients with full thickness rectal prolapse and faecal incontinence who had undergone endosonographical imaging of the anal sphincter complex. Anal manometry and pudendal nerve terminal motor latency studies were also included. RESULTS: Twenty-one patients were identified (1 male, 20 female) of median age 67.5 years. Fifteen (71%) subjects had an abnormality in the anal sphincter complex on endoanal ultrasound. Of these, the defects in 4 (19%) patients were isolated to the internal sphincter, 3 (14%) to the external sphincter and in the remaining 8 (38%) subjects, defects were found in both internal and external sphincters. The degree of sphincteric defect was variable but at least 6 (29%) of the study group had full-length external sphincter tears. In the 19 patients studied, anal manometry revealed reduced basal and squeeze pressures in the majority. Delayed pudendal nerve terminal motor latency was evident in 9 of 18 patients studied. CONCLUSION: Anal sphincter tears are common in patients presenting with rectal prolapse and faecal incontinence. The faecal incontinence associated with prolapse appears to be multifactorial in aetiology. Anal sphincter defects are likely to contribute to persistent faecal incontinence or recurrence following rectal prolapse. Endoanal ultrasound derived knowledge of anal sphincter injury may guide surgical management in problematic cases.

Adult↗

PubMed2001

[Pelvic organ prolapse].

Pelvic organ prolapse of the female is a common disease with age dependent increase in incidence. The committee for standardisation of the International Continence Society recently suggested to avoid classical terms such as cystocele, rectocele or enterocele for the description of prolapse and to replace them by defined landmarks. The "Pelvic Organ Prolapse Quantification" (POPQ) was developed and five different grades of prolapse were defined. This is a true gain for scientific documentation but needs some effort to be implemented in routine practical work. Previous normal vaginal delivery is statistically highly correlated with prolapse, followed by climacteric involution, constitutional factors, physical work, chronic bronchitis, and overweight respectively. The diagnosis is confirmed by clinical examination. Defects of the supportive structures can be precisely assessed with dynamic magnetic resonance imaging. Time will show whether this costly method will become part of routine diagnostic procedures. A patient with moderate prolapse or few complaints may be treated conservatively with pelvic floor training or electrotherapy. Modern pessaries are tried as first line therapy or for patients unwilling to undergo surgery. Local estrogen application should routinely be prescribed for perimenopausal patients. In the last decade laparoscopic techniques have been established in addition to standard methods of pelvic floor reconstruction. These techniques do not follow a new surgical strategy but realise the minimal invasive approach to established methods of pelvic floor reconstruction. Of note, laparoscopic fixation is very convenient for young women who want to preserve their uterus. Long time follow up is not available for most techniques.

Female↗

PubMed1989

Identification of high-risk and low-risk subgroups of patients with mitral-valve prolapse.

Mitral-valve prolapse is a common cardiac valvular disorder with a wide range of severity and diverse clinical outcomes. The lack of a standard definition of mitral-valve prolapse may explain the variation in reported complication rates. To identify high-risk and low-risk subgroups, we retrospectively analyzed clinical and two-dimensional echocardiographic data from 456 patients with mitral-valve prolapse. Mitral-valve prolapse was defined on the basis of echocardiographic findings as systolic displacement into the left atrium of one or both leaflets beyond the plane of the mitral annulus in the parasternal long-axis view. Two groups of patients were compared: those with thickening of the mitral-valve leaflets and redundancy (designated the classic form; n = 319) and those without leaflet thickening (designated the nonclassic form; n = 137). The two groups were similar in age and sex ratio. Complications or a history of complications was more prevalent in the classic than the nonclassic form: infective endocarditis, 3.5 percent and 0 percent, respectively (P less than 0.02); moderate-to-severe mitral regurgitation, 12 percent and 0 percent (P less than 0.001); and the need for mitral-valve replacement, 6.6 percent and 0.7 percent (P less than 0.02). However, the frequency of stroke was similar in the two groups: 7.5 percent and 5.8 percent (P not significant). We conclude that in a selected population of patients with mitral-valve prolapse, those with the classic form (leaflet thickening and redundancy) are at higher risk than those without these features for the infectious and hemodynamic complications of mitral-valve prolapse, but not for stroke.

Cerebrovascular Disorders↗

PubMed2003

Vaginectomy with pelvic herniorrhaphy for prolapse.

OBJECTIVE: The study was undertaken to report our experience with vaginectomy and pelvic herniorrhaphy for vaginal prolapse. STUDY DESIGN: This was an observational study of patients undergoing vaginectomy (n=41) or hysterovaginectomy (n=13) for stage III/IV vaginal prolapse. Morbidity was compared with cohorts who had undergone transvaginal repair of prolapse, by using the Mann-Whitney U test. RESULTS: Morbidity did not differ significantly (estimated blood loss) between the vaginectomy and hysterovaginectomy groups. There were no recurrent hernias (6-56 months). Operative time, estimated blood loss, and day of discharge were significantly greater for the posthysterectomy prolapse group compared with the vaginectomy group. Operative time was significantly greater for the uterovaginal prolapse group versus the hysterovaginectomy group. CONCLUSIONS: Vaginectomy with or without hysterectomy with pelvic herniorrhaphy is associated with a low rate of morbidity in a high-risk patient population. Hysterovaginectomy is not associated with a clinically significant difference in morbidity over vaginectomy alone. Vaginectomy with or without hysterectomy should be offered as a surgical option to selected patients with severe genital prolapse.

Aged↗

PubMed2003

Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence.

OBJECTIVE: The purpose of this study was to measure the risk of reoperation for surgically treated pelvic organ prolapse and urinary incontinence in a community-based population. STUDY DESIGN: A 5-year prospective, observational study was conducted of women who had undergone pelvic organ prolapse and urinary incontinence surgery in 1995. The cohort of 376 women was identified by International Classification of Diseases, 9th revision, and current procedural terminology codes in 149,554 reproductive-aged women within the Kaiser Permanente Northwest membership. RESULTS: Thirty-six women underwent 40 cases of reoperation. By survival analysis, 13% of women underwent reoperation by 71 months. Having undergone previous pelvic organ prolapse and urinary incontinence surgery increased the risk of reoperation to 17% compared with 12% for women who underwent a first procedure (log rank, P=.04). No association was observed with age, body mass index, parity, previous hysterectomy not for prolapse, vaginal versus abdominal approach, severity of prolapse, ethnicity, chronic lung disease, smoking, previous corticosteroid use, and estrogen status. CONCLUSIONS: Future reoperation is a significant risk of morbidity for women who undergo pelvic organ prolapse and urinary incontinence surgery.

Cohort Studies↗

PubMed2006

Primary surgery of genital prolapse: a shift in treatment tradition.

BACKGROUND: The use of complete repairs in genital prolapse surgery has been questioned because of the possible adverse effects of the surgery on the urogenital and sexual function and selective repairs have been advocated. The aims of this study were to establish information about genital prolapse surgery and to analyze whether a shift from extensive prolapse surgery with complete repairs to selective repairs occurred during a 10-year period. METHODS: A retrospective study of 610 consecutive patients operated upon for genital prolapse during 1983 (Period I) and 1993 (Period II) in a sample of three Swedish hospitals was conducted. Data were obtained from the patient records. 542 women had primary surgery and were analyzed with emphasis on demographic, clinical, and surgical data. RESULTS: The demographic and clinical data of the patients showed no significant differences between the two periods. In Period I, 69% of the patients underwent complete repair compared with 37% in Period II (p<0.001). The proportion of prolapse operations without posterior colporrhaphy increased significantly from the first to the second period from 14 to 43% (p<0.001). CONCLUSION: The surgery for genital prolapse seems to have changed from complete repairs towards selective repairs and posterior colporrhaphy was more often avoided in the second period. The implication of this shift in surgical treatment on pelvic floor function is not known. Further studies are needed to disclose the effect of the surgery on pelvic floor function and dysfunction in the long term.

Adult↗

PubMed2004

Tension-free vaginal tape procedures in women with stress urinary incontinence with and without co-existing genital prolapse.

PURPOSE OF REVIEW: Although the tension-free vaginal tape procedure has emerged as a feasible and effective alternative for a majority of urinary stress incontinence patients, the adaptation of the technique for genital prolapse has recently attracted much attention. This review focuses on the development of the tension-free vaginal tape procedure performed with transvaginal pelvic reconstructive surgery. RECENT FINDING: Articles since 1 April 2003 with older articles included for historical purposes were focused. Tension-free vaginal tape procedures used in prolapse surgery have mainly been performed according to the original technique. Adjustment of the vaginal tape is carried out after completion of the necessary prolapse procedures. The objective and subjective cure rate for urinary incontinence after tension-free vaginal tape with concurrent prolapse procedures is between 84.9 and 94%, and 67.3 and 88.6%, respectively. The mean complication rate, bladder perforation rate, transient urinary retention rate, period of catheterization and postoperative hospital stay are between 2.7 and 34%, 0 and 13%, 9 and 43%, 3.7 and 5.1 days, and 3.4 and 6.9 days, respectively. The implanted vaginal tape seems to 'give way' to the urethra and causes no urinary obstruction at least in studies with a short follow-up period. SUMMARY: The tension-free vaginal tape procedure performed with concurrent pelvic relaxation surgery appears to be a safe and effective treatment for urinary stress incontinence with co-existing vaginal pelvic prolapse. The implanted vaginal tape is prolapsed with the adjacent pelvic tissue, but the possibility of voiding dysfunction needs to be observed in a longer follow-up period.

Female↗

PubMed2006

Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse.

OBJECTIVE: To use a biomechanical model to explore how impairment of the pubovisceral portion of the levator ani muscle, the apical vaginal suspension complex, or both might interact to affect anterior vaginal wall prolapse severity. METHODS: A biomechanical model of the anterior vaginal wall and its support system was developed and implemented. The anterior vaginal wall and its main muscular and connective tissue support elements, namely the levator plate, pubovisceral muscle, and cardinal and uterosacral ligaments were included, and their geometry was based on midsagittal plane magnetic resonance scans. Material properties were based on published data. The change in the sagittal profile of the anterior vaginal wall during a maximal Valsalva was then predicted for different combinations of pubovisceral muscle and connective tissue impairment. RESULTS: Under raised intra-abdominal pressure, the magnitude of anterior vaginal wall prolapse was shown to be a combined function of both pubovisceral muscle and uterosacral and cardinal ligament ("apical supports") impairment. Once a certain degree of pubovisceral impairment was reached, the genital hiatus opened and a prolapse developed. The larger the pubovisceral impairment, the larger the anterior wall prolapse became. A 90% impairment of apical support led to an increase in anterior wall prolapse from 0.3 cm to 1.9 cm (a 530% increase) at 60% pubovisceral muscle impairment, and from 0.7 cm to 2.4 cm (a 240% increase) at 80% pubovisceral muscle impairment. CONCLUSION: These results suggest that a prolapse can develop as a result of impairment of the muscular and apical supports of the anterior vaginal wall.

Biometry↗

PubMed2006

Remodeling of vaginal connective tissue in patients with prolapse.

PURPOSE OF REVIEW: Pelvic organ prolapse is a common disease that negatively affects the lives of women. To date, basic science research into the pathogenesis of prolapse has been limited. The vagina and its supportive connective tissues provide one of the primary mechanisms of support to the pelvic organs. This review summarizes our current understanding of the alterations in these tissues in women with prolapse. RECENT FINDINGS: Current research suggests that the vagina and its supportive tissues actively remodel in response to different environmental stimuli. The literature has many shortcomings due to restricted access to tissue, absence of longitudinal data, and limited animal models. Nevertheless, recent studies indicate that within prolapsed tissue metabolism of collagen and elastin is altered. Thus, not only the synthesis of those structural proteins but also the balance between the activity of the major proteolytic enzymes that degrade them and the inhibitors of proteolysis are important components to consider in studies on the pathogenesis of pelvic organ prolapse. SUMMARY: Biochemical studies of the vagina and its supportive connective tissues have improved understanding of the contribution of altered connective tissue to the pathogenesis of prolapse. It is important to continue research in this area, as the knowledge gained from these studies will allow for the development of innovative reconstructive procedures and the establishment of preventive measures.

Connective Tissue↗

PubMed1992

Perineal video-ultrasonography in the assessment of vaginal prolapse: early observations.

OBJECTIVE: To investigate the efficacy of perineal ultrasonography in the assessment of vaginal prolapse. DESIGN: A prospective descriptive study. SETTING: Urodynamic Unit, St. George's Hospital, London. SUBJECTS: Six women, three of them were awaiting colposuspension and three had had a colposuspension. INTERVENTIONS: Perineal ultrasound scans were performed on women with and without incontinence and prolapse, both before and after continence surgery. Movement of the bladder, urethra, uterus, vaginal vault and enterocele were observed during coughing and the valsalva manoeuvre. MAIN OUTCOME MEASURES: To assess reproducibility, six patients had six different measurements taken of bladder neck and prolapse position and movement relative to the symphysis. The measurements were plotted upon an X-Y co-ordinate axis. Each measurement was repeated three times and one way analysis of variance performed upon the readings. RESULTS: Perineal ultrasonography clearly demonstrated movement of the whole pelvic floor. Minor degrees of both anterior and posterior vaginal wall prolapse could be seen and quantified. An increase in posterior vaginal wall mobility was noted in women after colposuspension. All measurements taken were found to be reproducible. CONCLUSIONS: Perineal ultrasonography is easy to perform and is reproducible. It may improve understanding of why some women develop posterior vaginal wall prolapse after colposuspension and, conversely, why some women develop incontinence following anterior repair for prolapse.

Cough↗

PubMed1995

The mortality and morbidity associated with umbilical cord prolapse.

OBJECTIVE: To examine the management of cord prolapse and its morbidity and mortality. DESIGN: Retrospective study of consecutive babies born after cord prolapse, identified using the Oxford Obstetric Data System, and those with registered handicap, identified by the Oxford Region Register of Early Childhood Impairments. SETTING: District maternity hospital managing more than 6000 deliveries annually. SUBJECTS: One hundred and thirty-two babies born after the identification of cord prolapse in the John Radcliffe Hospital between January 1984 and December 1992. MAIN OUTCOME MEASURES: Survival rates, condition at birth assessed by Apgar scores at 1 and 5 minutes and blood gas values on cord blood samples, and incidence of major handicap at three years of age. RESULTS: The incidence of cord prolapse was 1 in 426 total births. There were six stillbirths and six neonatal deaths. One baby died as a result of birth asphyxia. The uncorrected perinatal mortality rate was 91 per 1000. Of 120 survivors, only one baby was known to suffer a major neurological handicap. Electronic cardiotocographs aided the diagnosis of cord prolapse in 41% of cases. Apgar scores were better with a shorter diagnosis to delivery interval, but cord gas results did not correlate well with Apgar scores or the diagnosis to delivery interval. CONCLUSIONS: Cord prolapse occurs with a relatively stable incidence in this population irrespective of changes in obstetric practices. Despite the high incidence of ominous cardiotocographs, low Apgar scores and acidaemia on blood gas analysis, the fetal outcome is not as poor as might be expected and mortality is predominantly attributable to congenital anomalies and prematurity rather than birth asphyxia.

Cardiotocography↗

PubMed1982

Mitral valve prolapse and joint hypermobility: evidence for a systemic connective tissue abnormality?

Clinical evidence for an abnormally of extracardiac connective tissue was sought in 21 patients with idiopathic mitral valve prolapse and was compared to that in 21 matched controls. The incidence of rheumatic and orthopaedic complaints and the prevalence of hypermobile joints, Marfanoid habitus, and skeletal deformity were compared in the 2 groups. Skin thickness and elasticity were measured, and the mean values in the 2 groups were compared. hypermobile joints were significantly commoner in patients with mitral valve prolapse. Easy bruising was reported significantly more commonly by patients with mitral prolapse; the incidence of other rheumatic complaints was similar in the 2 groups. There was no significant difference in skin thickness, skin elasticity, and the prevalence of either skeletal deformity or Marfanoid habitus between patients with mitral valve prolapse and controls. The results support previous evidence of an association between mitral valve prolapse and benign hypermobility of the joints, but emphasise that many patients with mitral valve prolapse have no clinically apparent connective tissue abnormality outside the heart. It remains uncertain whether the valve lesion in these patients represents a tissue-specific abnormality of mitral valve collagen or the only clinical expression of a minor systemic connective tissue abnormality.

Adult↗

PubMed1983

Prevalence of mitral prolapse by two dimensional echocardiography in healthy young women.

In order to establish the relative prevalence of mitral valve prolapse as diagnosed by two dimensional echocardiography, we studied 100 presumably healthy young women with two dimensional echocardiography and M-mode echocardiography, history, physical examination, electrocardiography, and phonocardiography. Two dimensional echocardiograms were obtained from parasternal, apical, and subcostal acoustic windows. Mitral valve prolapse was defined as extension of leaflet tissue cephalad to the plane of the mitral annulus into the left atrium; note was also made of any valvular thickening, redundancy, or excessive annular motion. One subject had a midsystolic click and late systolic murmur with evidence of mitral prolapse on both M-mode and two dimensional echocardiography. One subject had a midsystolic click with mitral prolapse demonstrated by two dimensional but not on M-mode echocardiography. One subject had a thick mitral valve on echocardiography but no click or murmur. Four subjects had midsystolic clicks without echocardiographic abnormalities. Mild artefactual pansystolic posterior bowing of the mitral valve on the M-mode echocardiogram could be produced in 20 subjects by incorrect transducer position. We conclude that the prevalence of mitral valve prolapse by two dimensional echocardiography is relatively low in presumably healthy young women. Use of two dimensional echocardiography may avoid overdiagnosis of mitral prolapse and identify a smaller group of individuals with true anatomical abnormalities of the mitral valve.

Adolescent↗

PubMed1986

Age and the clinical profile of idiopathic mitral valve prolapse.

The prevalence of mitral valve prolapse was determined in two independent populations (6887 consecutive adults and children referred for echocardiography during a three year period and 206 non-referred first degree relatives of 65 patients with mitral valve prolapse). In the 118 adults with echocardiographic evidence of prolapse those aged greater than or equal to 50 years were significantly more likely to have pansystolic murmurs and increased echocardiographic dimensions than those aged less than 50 years; and patients with complications of mitral valve prolapse were significantly older than those without. In the population referred for echocardiography and in the non-referred relatives there was a significant increase in prevalence in the two decades after adolescence (20-39 years) compared with that in the first two decades. The data suggest that prolapse principally becomes manifest in late adolescence when the growth spurt is complete and that thereafter the severity of prolapse increases with age in an important subset of patients. The latter findings accord with the predictions of the response to injury hypothesis for the pathogenesis of progressive changes.

Adolescent↗

PubMed1988

Patterns and determinants of rectal prolapse in a herd of pigs.

A prospective cohort study was designed to describe the patterns and to determine the factors associated with the risk of rectal prolapse in a commercial swine herd in California, USA. Thirty (1.0 per cent) of 2862 pigs prolapsed between 12 and 28 weeks of age with the peak incidence occurring in 14- to 16-week-old pigs. The overall prolapse rate was 9.1 cases per 100,000 days at risk. Prolapse rates were highest during the winter and autumn months. Other factors associated with an increased risk of prolapse were maleness (relative risk 2.3) birthweight less than 1000 g (relative risk 3.4) Yorkshire boar A (relative risk 2.8) and dams of litter number 1 (relative risk 14.9), 2 (relative risk 8.2) and 3 (relative risk 9.8). No evidence was found to support the hypothesis that diarrhoea and coughing are factors associated with a risk of prolapse.

Age Factors↗

PubMed1991

Nutritional factors associated with vaginal prolapse in ewes.

Serum calcium, magnesium and phosphate values of ewes recently affected by vaginal prolapse were compared with unaffected ewes in four flocks. Subclinical hypocalcaemia was demonstrated in some affected and unaffected ewes in three flocks. Magnesium and phosphate values were normal. In two flocks the body condition of ewes recently affected by vaginal prolapse was variable and reflected the variation in condition found in the flock. In a third flock affected ewes had significantly lower body condition scores than unaffected ewes (P less than 0.001). Analysis of the fourth flock was not possible. Oestrogenic mycotoxins were not detected in any of the feed samples taken from these flocks. The following year the management, nutrition and energy, and the protein and calcium status of ewes in 12 flocks of greyface/mule ewes with a history of a regular high (greater than 3 per cent) or low (less than 1 per cent) prevalence of vaginal prolapse were compared. A high prevalence was not associated with any particular feedstuff. A high or intermediate (1 to 3 per cent) prevalence of vaginal prolapse was found in three of the four flocks managed as a single group and these three flocks were fed on an unrestricted basis. Body condition scoring and beta-hydroxybutyrate estimation confirmed that ewes in these flocks were overfed. The prevalence of vaginal prolapse in the flocks was not related to the serum albumin, calcium or urea of the ewes. Therefore subclinical hypocalcaemia was probably a consequence of vaginal prolapse rather than a cause.

Animal Feed↗