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PubMed1986

Urethral prolapse in children: insights into etiology and management.

The pathophysiology of urethral prolapse has never been clearly elucidated. Following en bloc removal of the urethra, bladder, vagina, uterus and pelvic floor tissues from a 4-year-old burn victim with urethral prolapse at the time of death and from a female newborn cadaver, careful step-sectioning of the specimens at 5 mm. intervals for histological examination was performed. The anatomical defects of urethral prolapse noted were marked eversion of the urethral mucosa, vascular congestion of the "corpus spongiosum urethrae muliebris", and a cleavage plane between the inner longitudinal and outer circular-oblique smooth muscle layers of the urethra. We propose that urethral prolapse results from poor attachments between the smooth muscle layers of the urethra in association with episodic increases in intra-abdominal pressure. A clinical review of 12 cases revealed that at least 8 (67 per cent) had antecedent episodes of marked increases in intra-abdominal pressure. Obliteration of the cleavage plane between the smooth muscle layers is important for successful treatment of this lesion.

Abdomen↗

PubMed2002

Vaginal vault prolapse after nonsurgical and surgical treatment of MAAdullerian agenesis.

BACKGROUND: Women with Mayer-Rokitansky-Küster-Hauser syndrome fail to develop müllerian ducts, present with primary amenorrhea, and an absent or rudimentary uterus and vagina. After creation of a neovagina, vaginal vault prolapse may occur because of lack of support to the artificially created vagina. CASES: The first patient presented with vaginal vault prolapse 10 years after her vagina was mechanically dilated. The second patient presented with vaginal vault prolapse 27 years after a McIndoe procedure. CONCLUSION: Women with Mayer-Rokitansky-Küster-Hauser syndrome with an artificially created neovagina by dilatation or surgical procedure with a graft are at risk for vaginal vault prolapse. They can be successfully treated with abdominal sacrocolpopexy and paravaginal repair.

Adult↗

PubMed2003

Small bowel obstruction associated with post-hysterectomy vaginal vault prolapse.

BACKGROUND: Patients may present with post-hysterectomy vaginal vault prolapse in conjunction with small bowel obstruction. Prior pelvic surgery, malignancy, and radiation therapy may be associated with this presentation. CASE: An 83-year-old multiparous woman with a history of poorly differentiated endometrial adenocarcinoma was treated with radiation therapy, total abdominal hysterectomy, and salpingo-oophorectomy. Anterior exenteration was performed for a recurrence. Seventeen years after her last pelvic operation, she had small bowel obstruction that coincided with a worsening post-hysterectomy vaginal vault prolapse. Surgical management included a side-to-side ileoileostomy and excision with closure of the vaginal apex. CONCLUSION: Although pelvic organ prolapse primarily affects quality of life, clinicians should be alert for bowel obstruction occurring with post-hysterectomy vaginal vault prolapse.

Adenocarcinoma↗

PubMed1997

Combination of pessary and periurethral collagen injections for nonsurgical treatment of uterovaginal prolapse and genuine stress urinary incontinence.

BACKGROUND: The combination of severe uterovaginal prolapse and stress urinary incontinence in medically compromised patients in whom surgery is contraindicated is a difficult treatment dilemma. CASE: A 75-year-old woman with severe cardiac compromise and a history of pulmonary embolus presented with severe uterovaginal prolapse and stress urinary incontinence. The combination of a vaginal pessary and three periurethral collagen injections resulted in successful management of her prolapse and resolution of her stress urinary incontinence. CONCLUSION: Although pessaries are frequently a satisfactory treatment option for women with severe uterovaginal prolapse, the appearance or worsening of urinary incontinence may make the option of pessary use less attractive. The addition of periurethral collagen injections will improve or cure urinary incontinence symptoms.

Aged↗

PubMed2001

Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence.

OBJECTIVES: To determine the incidence of concomitant procedures performed for pelvic organ prolapse or vaginal reconstruction at the time of surgery for stress urinary incontinence in contemporary practice. METHODS: We recorded all concomitant procedures for pelvic organ prolapse or vaginal reconstruction in 264 women who underwent surgery for stress urinary incontinence at our institution from January 1995 to August 1997. RESULTS: Of 264 women, 111 (42%) had at least one concomitant procedure performed for pelvic organ prolapse or vaginal reconstruction, including 87 cystocele repairs, 31 rectocele repairs, 8 sacrospinous fixations, 5 enterocele repairs, 5 abdominal sacrocolpopexies, 4 perineoplasties, 3 urethral diverticulectomies, and 1 vaginal hysterectomy. Furthermore, 9% of patients had two or more procedures. CONCLUSIONS: We found that women who undergo surgery for stress urinary incontinence have a high incidence (42%) of associated pelvic organ prolapse requiring surgical repair. These additional repairs contribute to the overall success of surgery and should not be overlooked.

Diagnostic Techniques, Obstetrical and Gynecologic↗

PubMed1979

Biopsy evidence of left ventricular myocardial abnormality in patients with mitral-leaflet prolapse and chest pain.

Left ventricular endomyocardial biopsy specimens were obtained at cardiac catheterisation in 11 patients with mitral-leaflet prolapse, chest pain, and normal coronary arteries. Specimens were examined for birefringence before and after contraction induced by adenosine triphosphate and were also subjected to histochemical analysis. Biopsy specimens from a control group of patients with rigorously defined normal left ventricular function and another control group with poor left ventricular function were also studied. Biopsy specimens from patients with mitral-leaflet prolapse showed a markedly subnormal birefringence response to adenosine triphosphate, with the group mean value intermediate between values for controls with normal and poor left ventricular function. Histochemical studies in the prolapse group also revealed an abnormal pattern, particularly for monoamine-oxidase activity. This is further evidence of a cardiomyopathy in this symptomatic subgroup of patients with mitral-leaflet prolapse.

Adenosine↗

PubMed1982

Joint hypermobility in women with genital prolapse.

To assess the relation between joint mobility and genital prolapse, joint mobility in 76 women with genital prolapse was compared with that in an age and parity matched control group without prolapse. Mobility was scored on a scale of 0-9. The number of patients with hypermobile joints and the total mobility scores were higher in the genital prolapse group (p less than 0.005), which also had more joint complaints and twice the prevalence of backache when compared with the control group.

Adult↗

PubMed1989

Mitral valve prolapse as a risk factor for infective endocarditis.

The frequency of mitral valve prolapse was assessed in 48 patients with mitral valve endocarditis and in 96 controls matched for age and sex, attending a routine family screening clinic or having surgery of the limbs. The frequency of mitral valve prolapse in cases with endocarditis (9 of 48 patients) was more than three times that in controls (6 of 96) (odds ratio 3.5; 95% confidence interval [CI] 1.1-10.5). When patients with rheumatic heart disease, an established risk factor for infective endocarditis, were excluded from the study group, patients were nearly six times more likely to have infective endocarditis than were controls (odds radio 5.7; 95% CI 1.8-18.4). However, a higher risk of infective endocarditis was seen only in the subjects with mitral valve prolapse and a previously known systolic murmur (odds ratio 14.5; 95% CI 1.7-125). The results indicate that mitral valve prolapse constitutes a true risk factor for infective endocarditis only when associated with the presence of a precordial systolic murmur.

Adult↗

PubMed2003

Correction of uterine prolapse by the vaginal route using the uterosacral ligaments: Shirodkar procedure.

OBJECTIVE: To study long-term results of Shirodkar procedure for treatment of uterine prolapse in women wishing to retain their uterus. STUDY DESIGN: Fifty-one patients with a symptomatic uterine prolapse who desire to preserve their uterus without further childbearing were treated between 1988 and 2000. By the vaginal route, uterosacral ligaments were separated from the uterus, shortened, transposed in front of the uterine isthmus, and fixed bilaterally under the opposite lateral surface of the cervix or of the cervical stump after amputation. RESULTS: Median age of patients was 37 years. Median operating time was 120 min (range 60-190). One patient was re-operated four days after the initial surgery to drain a haematoma. Median follow-up was 81 months (range 11-134). Eight patients were lost of follow-up. Eleven (25.6%) patients underwent iterative surgery. The indication for re-operation was recurrence of prolapse in four patients, introital dyspareunia in three patients, cervix stenosis in two patients, urinary incontinence in one patient and pyosalpinx in one patient. Only one patient (2.3%) experienced a recurrence of the uterine prolapse. CONCLUSION: Shirodkar procedure is safe and effective. Long-term functional results are satisfactory but associated procedures may alter patient satisfaction.

Adult↗

PubMed2006

[Treatment of genital prolapse with a polypropylene mesh inserted via the vaginal route. Anatomic and functional outcome in women aged less than 50 years].

OBJECTIVES: We evaluated the results of surgical insertion of a polypropylene mesh via the vaginal route in young women presenting genital prolapse. MATERIAL AND METHODS: Retrospective study concerning 20 women under age 50 who underwent between July 2000 and December 2003 surgical insertion of an anterior (n=14), posterior (n=3) or double (anterior and posterior) (n=3) polypropylene mesh via the vaginal route. A minimum follow-up of 6 months was required for inclusion in the study. Anatomical results were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) according to ICS (International Continence Society) recommendations. To document the functional results, the patients answered 3 validated self-assessment questionnaires related to pelvic symptoms, sexual behaviors and quality of life. RESULTS: Mean follow-up was 21 months (6 to 52 months). A vaginal erosion of the mesh occurred in 2 women (10%). Cystocele recurred in one woman among the 17 patients who had an anterior polypropylene mesh (Gynemesh, Gynecare, Ethicon). Seventeen women were sexually active before the surgical procedure and 19 post-operatively. Among these women, 5 (26%) reported alteration of sexual activity after surgery (with dyspareunia in 4 cases (21%)), and 14 women (74%) reported no changes or improvement in sexual activity. CONCLUSION: Surgical management of genital prolapse using a polypropylene mesh inserted via the vaginal route has proven its anatomical efficacy in young women. The potential adverse consequences on sexual life would require clinical research concerning the surgical approach (abdominal or vaginal route) and synthetic materials used in prolapse surgery for young women.

Adult↗

PubMed1988

Reconsideration of echocardiographic standards for mitral valve prolapse: lack of association between leaflet displacement isolated to the apical four chamber view and independent echocardiographic evidence of abnormality.

Mitral valve prolapse by current echocardiographic criteria can be diagnosed with surprising frequency in the general population, even when preselected normal subjects are examined. In most of these individuals, however, prolapse is present in the apical four chamber view and absent in roughly perpendicular long-axis views. Previous studies have shown that systolic annular nonplanarity can cause apparent prolapse in the four chamber view without actual leaflet displacement above the most superior points of the anulus, and there is evidence for such nonplanarity in vivo. It is then reasonable to ask whether superior leaflet displacement limited to the four chamber view has any pathologic significance or complications. The purpose of this study, therefore, was to address the following hypothesis: that patients with superior leaflet displacement confined to the four chamber view have no higher frequency of associated echocardiographic abnormalities than do patients without displacement in any view. Such abnormalities, which would provide independent evidence of mitral valve pathology or dysfunction, include leaflet thickening, left atrial enlargement and mitral regurgitation. Leaflet displacement was measured in the parasternal long-axis and apical four chamber views in 312 patients who were studied retrospectively and selected for the absence of forms of heart disease other than mitral valve prolapse. Leaflet thickness and left atrial size were measured and mitral regurgitation was graded. Patients with leaflet displacement limited to the four chamber view were no more likely to have associated abnormalities than were patients without displacement in any view (0 to 2% prevalence, p greater than 0.5). In contrast, patients with leaflet displacement in the long-axis view were significantly more likely to have associated abnormalities (12 to 24%, p less than 0.005), the frequency of which increased with the extent of leaflet displacement in that view (p less than 0.0001). These results suggest that displacement limited to the apical four chamber view is, in general, a normal geometric finding unassociated with echocardiographic evidence of pathologic significance.

Adult↗

PubMed1995

Mechanism of iris prolapse: a qualitative analysis and implications for surgical technique.

A theoretical explanation of the mechanism of iris prolapse is presented using simple flow mechanics and the Bernouille principle, which states that fluid pressure varies inversely to fluid velocity. Rapid aqueous escape into an anterior chamber perforation thus creates a relative vacuum anterior to the iris. Further analysis shows that the tendency of the iris to prolapse into an anterior chamber wound increases as an inverse function of the fourth power of the radial distance between the iris and the perforation. Anterior wound placement, clear of the iris plane, should help to prevent iris prolapse. Minimizing the irrigation velocity (and hence the fluid outflow velocity) should also help to prevent intraoperative prolapse.

Acute Disease↗

PubMed1997

Chordal transposition for anterior mitral prolapse: early and long-term results.

OBJECTIVE: Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations. METHODS: From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda. RESULTS: Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3+ mitral regurgitation of 88.6 +/- 4.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation/left atrium area ratio greater than patients without annular calcification (15.8 +/- 11.5% vs. 6.1 + 9.9%; P = 0.009). CONCLUSIONS: Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction.

Adult↗

PubMed2002

Longterm followup of posthysterectomy vaginal vault prolapse abdominal repair: a report of 85 cases.

BACKGROUND: There are many surgical procedures to treat posthysterectomy vaginal vault prolapse. Abdominal sacral colpopexy is one of these procedures. The aim of this study was to review the cases of 85 consecutive patients treated by this technique since 1978 by the same surgical team using the same procedure. Our surgical procedure will be explained. STUDY DESIGN: Eighty-five patients were treated in our department between 1978 and 1998 for posthysterectomy vaginal vault prolapse. The mean age was 55.42 years. The mean weight was 63.37 kg. Their parity ranged from 0 to 5 (mean, 2.54). The interval of time between hysterectomy and vaginal vault prolapse repair ranged from 1 to 37 years (mean, 17.92 years). The main indication for hysterectomy was uterine leiomyomas. Of these patients, 67.05% had stress urinary incontinence, and mean urethral closure pressure was 48.7 cm H2O. All patients had abdominal sacral colpopexy associated with a Burch procedure and a posterior perineal repair. RESULTS: Seventeen patients had postoperative fever. Twenty-two had urinary tract infections. Two patients had to undergo blood transfusion. Three patients had postoperative urinary retention. The median longterm followup was 10.5 years; 27.05% of patients had relapsing stress urinary incontinence. Two patients had a relapse of the vaginal vault prolapse. CONCLUSIONS: The abdominal sacral colpopexy is a safe operation with low morbidity and long-standing good results. It can be recommended for sexually active women. Nevertheless, the Burch procedure performed with this operation failed to prevent recurrence of urinary incontinence.

Adult↗

PubMedDate not supplied

Functional results after laparoscopic rectopexy for rectal prolapse.

We investigated the functional results after laparoscopic rectopexy for rectal prolapse in 29 patients at least 12 months postoperatively. Twenty patients were evaluated completely pre- and postoperatively (median 22 months postoperatively, range 12 to 54 months). Six patients were interviewed by telephone, two patients were lost to follow-up, and one patient died of causes unrelated to rectal prolapse. Patients underwent a proctologic examination, anoscopy, rigid sigmoidoscopy, fluoroscopic defecography, and anorectal manometry pre- and postoperatively, and an additional standardized interview postoperatively. Anorectal manometry showed a significant increase in maximum anal resting and squeeze pressures postoperatively (resting pressure 72 +/- 8 vs. 95 +/- 13 mm Hg, pre- vs. postoperatively; P = 0.046; squeeze pressure 105 +/- 17 vs. 142 +/- 19 mm Hg, pre- vs. postoperatively; P = 0.035), and continence improved postoperatively (Wexner incontinence score 6.0 +/- 1.0 vs. 3.9 +/- 0.8 pre- vs. postoperatively, P = 0.02). Twenty (77%) of 26 patients were satisfied with the operative result, but functional morbidity was observed in four patients, with two patients complaining of severe evacuation problems. Rectal prolapse recurred in one patient 42 months postoperatively (recurrence rate 1 [3.8%] of 26 patients). Functional results were very similar to those obtained after open rectopexy, with symptoms of prolapse and incontinence improved in the great majority of patients.

Adult↗

PubMed2006

Simple device for treating prolapsing loop colostomy.

Stoma prolapse is a common complication of intestinal stoma. Although various surgical methods yield satisfactory results, nonsurgical treatment may be better for a temporary stoma. We report a case of a patient with a distal limb prolapse of a right transverse colostomy who received nonsurgical treatment with satisfactory results. For the treatment of a temporary transverse loop colostomy with distal limb prolapse, we designed a simple device consisting of a pediatric plastic medicine cup, which was rolled into a towel to shape the bottom of the cup into a compressor. The towel was put on the stoma outside of the colostomy bag with the compressor above the prolapsing limb of the colostomy. An abdominal binder was applied to fix the towel.

Child, Preschool↗

PubMed2003

Prevalence of urinary and fecal incontinence and symptoms of genital prolapse in women.

BACKGROUND: Urinary incontinence is common in women. How often incontinence occurs has been only briefly investigated. Studies on the prevalence of fecal incontinence are few. The epidemiology of genital prolapse symptoms is unknown. This epidemiological study describes a general population of women aged 40 and 60 years with regard to the prevalence and frequency of urinary and fecal incontinence and the prevalence of genital prolapse symptoms. METHODS: A questionnaire on medical background, urinary and fecal incontinence, and genital prolapse symptoms was sent to 1000 40-year-old and 1000 60-year-old randomly selected women. RESULTS: Sixty-seven per cent answered: 53% were continent for urine; 9% of the 40-year-olds and 19% of the 60-year-olds had urinary incontinence weekly or more often. Detrusor instability score was significantly higher in the 60-year-olds. Incontinence of flatus, weekly or more often, was reported by 9% and 19%, loose feces by 5% and 8%, and solid feces by 0.3% and 1.7% according to the 40- and 60-year-olds, respectively. Fifty-three per cent reported no flatus incontinence. Of the prolapse symptoms investigated, 15% of the females reported pelvic heaviness, 4% genital bulge, and 12% use of fingers in the vagina or perineum by defecation. CONCLUSIONS: Incontinence of urine is common in this population. Flatus incontinence is as common, but the concept must be operationalized if used as an endpoint in research. The International Continence Society's (ICS) definition of urinary incontinence is unpractical for use in epidemiological research. We suggest leakage weekly or more often as a criterion for significant incontinence in epidemiological research.

Adult↗

PubMed1998

Pathophysiology and treatment of anterior rectal mucosal prolapse syndrome.

BACKGROUND: The study was designed to investigate the clinical presentation and laboratory findings of anterior rectal mucosal prolapse (ARMP) and to assess the results of two therapeutic modalities. METHODS: Some 162 women with ARMP were assessed clinically and by defaecography and rectoanal manometry before and 1 year after one or two sessions of submucosal sclerotherapy or, in the case of recurrence, after transanal excision of the prolapsing mucosa. RESULTS: Almost all patients reported a combination of symptoms suggesting obstructive defaecation. At defaecography anterior rectocele and excessive perineal descent at straining were present in 78 and 72 per cent respectively. The size of coexisting anterior rectocele and the extent of perineal descent were significantly related to the duration of the disease (P< 0.001). One or, in the event of recurrence, two sessions of sclerotherapy led to an overall success rate of 51 per cent. Improvement after sclerotherapy was associated with partial recovery of anal tone and improvement of anal sampling and rectal sensation. Failure of sclerotherapy was related to rectocele of larger size (P< 0.001) and a longer perineal descent at straining (P< 0.001) than in patients with a successful outcome. Excision of the prolapsing mucosa resulted in symptomatic improvement in 42 of 47 patients and was associated with significant improvement of the defaecographic and manometric findings. CONCLUSION: ARMP is usually associated with anterior rectocele and excessive perineal descent. Submucosal sclerotherapy is successful in half of the cases, but only in the presence of a rather small anterior rectocele and short perineal descent. Failures after sclerotherapy can be treated by transanal excision of the prolapsing mucosa.

Defecation↗