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PubMed1983

Prolapse of the mitral valve in secundum atrial septal defect: a functional mechanism.

Prolapse of the mitral valve in patients with secundum atrial septal defect has been described angiographically and by two-dimensional echocardiography. It has been suggested that prolapse of the mitral valve in these patients is due to distortion of left ventricular shape and small left ventricular volume. To test this hypothesis 10 patients with unrepaired secundum atrial septal defect and 10 patients who had undergone repair of the defect were studied by two-dimensional echocardiography. The prevalence of mitral valve prolapse was 80% in the unrepaired group and 20% in the repaired group (P less than 0.01). Short axis of the left ventricle revealed septal bulging into the left ventricle, the end-diastolic ratio of minor to major axis being 0.71 in the unrepaired group and 0.93 in the repaired group (P less than 0.001). Systolic and diastolic cross-sectional areas were larger in the repaired group compared with the unrepaired group (P less than 0.05). Prolapse of the mitral valve in patients with secundum atrial septal defect may be related to the distorted left ventricular shape and small left ventricular volume.

Adolescent↗
PubMed2001

Genital prolapse: vaginal versus abdominal route of repair.

In the presence of an ageing population, we can expect to see a dramatic increase in the prevalence of genital prolapse including vault and recurrent vaginal prolapse. The best approach for managing upper genital prolapse remains controversial. We review the surgical management of genital prolapse, with a focus on comparing the vaginal and abdominal approaches.

Female↗
PubMed1993

Panic and prolapse. Meta-analysis.

Studies concerning the association of panic disorder and mitral valve prolapse have produced mixed results. Meta-analysis was used to quantitatively review the literature and explain conflicting results. Only 19 published and two unpublished studies have documented both panic and mitral valve prolapse in addition to including a control group, and were therefore included. The strength of association between panic disorder and mitral valve prolapse was measured as the odds ratio and study variables were included in the analysis. The overall weighted relative risk was 2.3 (confidence interval, 1.6 to 3.5). Important study variables were often not addressed in the literature and stepwise multiple regression found that auscultatory criteria, control group diagnosis, and sample size predicted relative risk (F = 11.34, p < .001). p-Values differed with publication status (t = 2.32, p = .033). Although the quality of literature is uneven, there appears to be a significant association between panic disorder and mitral valve prolapse. However, the suggestion of publication bias indicates that the published literature may present a biased view.

Adult↗
PubMed1996

Management of genital prolapse in neonates and young women.

The presence of genital prolapse in neonates and young women poses a challenging management problem to the gynecologist. Neonatal uterine prolapse is associated with congenital spinal defects, and successful correction has been achieved mainly with simple digital reduction or the use of a small pessary. Uterine prolapse can also occur in young or nulliparous woman who wish to preserve their fertility. Operations using sling, sacral cervicopexy, or transvaginal sacrospinal fixation techniques seem to provide excellent repair for these patients, including the possibility of childbearing. A review of the pathophysiology of genital prolapse in neonates and young women with emphasis on the surgical and nonsurgical options for management is presented.

Adolescent↗
PubMed2003

What's new in prolapse surgery?

PURPOSE OF REVIEW: There are very many types of operation for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task when selecting the most appropriate procedure(s) for an individual patient. Currently, the lifetime risk of undergoing prolapse or continence surgery in France is one in 11; up to 30% of patients will require repeat prolapse surgery, and 10% will require repeat continence surgery. Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for a definitive surgical cure. This review looks at the etiology, presentation and current surgical management of genital prolapse in females. RECENT FINDINGS: There are three primary routes of access in reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) for the repair of anterior, superior and posterior defects; the choice often depends on the surgeon's experience. Of the abdominal repairs, abdominal sacrocolpopexy with mesh remains the 'gold standard'; the retropubic paravaginal repair and laparoscopic techniques have not gained widespread acceptance. The laparoscopic approach appears to be the least utilized, because of the great degree of technical difficulty associated with laparoscopic suturing. Of the vaginal restorative procedures, uterosacral ligament vault suspension and iliococcygeous and sacrospinous fixation have their proponents. However, there is increasing interest in the use of biological prostheses (allografts/xenografts) and synthetic absorbable meshes. SUMMARY: Randomized controlled trials are required to evaluate the role of surgical procedures in reconstructive surgery, to determine which type of prosthesis is most suitable.

Female↗
PubMed2004

Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse.

OBJECTIVE: We sought to demonstrate that a positive pessary test could predict postsurgical stress urinary incontinence in women with severe pelvic organ prolapse and that performing tension-free vaginal taping (TVT) could effectively prevent its occurrence. METHODS: Among the 79 patients evaluated for severe pelvic organ prolapse without symptoms of stress urinary incontinence, all underwent meticulous urogynecologic evaluations and pessary testing. In group 1, 32 patients had positive pessary tests and underwent vaginal hysterectomy, anterior and posterior colporrhaphy, and TVT. In group 2, 47 patients (17 of whom had positive pessary tests and 30 of whom had negative pessary tests) underwent vaginal hysterectomy and anterior and posterior colporrhaphy alone. A comparison in terms of surgical outcome and clinical manifestations was made between these 2 groups of patients. RESULTS: After surgery, a small proportion of patients had de novo idiopathic detrusor overactivity (7.6%, n = 6), urinary tract infections (7.6%, n = 6), mild recurrent prolapse (5.1%, n = 4), and urinary retention (3.8%, n = 3). Eleven (64.7%) of 17 patients with positive pessary tests who did not undergo TVT had urine leakage after their hysterectomies in contrast with the 30 patients who had negative pessary test, none of whom developed symptomatic stress urinary incontinence after vaginal hysterectomy. Among the 32 patients with positive pessary tests who had TVT with their hysterectomies, 3 developed urine leakage later; the cure rate was 90.6%. CONCLUSION: Continent patients suffering from severe pelvic organ prolapse but with a positive pessary test are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence. Among the patients in our medium-range study, TVT effectively prevented postsurgical urinary incontinence. LEVEL OF EVIDENCE: II-1

Female↗
PubMed2005

Fallopian tube prolapse after laparoscopic resection of pelvic endometriosis.

BACKGROUND: Fallopian tube prolapse is an unusual but often reported complication after hysterectomy. This problem has not yet been reported in a patient undergoing laparoscopy but not hysterectomy. CASE: Fallopian tube prolapse was diagnosed in a patient after laparoscopic excision of pelvic endometriosis, without hysterectomy. The prolapsed fallopian tube was preserved by laparoscopic retrieval from the vagina and closure of the vaginoperitoneal fistula. CONCLUSION: Laparoscopic surgery, when associated with the creation of a vaginoperitoneal fistula, is a risk factor for fallopian tube prolapse. This problem can be diagnosed and safely managed with a laparoscopic approach.

Adult↗
PubMed2006

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse.

OBJECTIVE: To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure. METHODS: All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months. RESULTS: Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71-12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction. CONCLUSION: A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3.

Aged↗
PubMed2006

Quantification of levator ani cross-sectional area differences between women with and those without prolapse.

OBJECTIVE: Compare levator ani cross-sectional area as a function of prolapse and muscle defect status. METHODS: Thirty women with prolapse and 30 women with normal pelvic support were selected from an ongoing case-control study of prolapse. For each of the two groups, 10 women were selected from three categories of levator defect severity: none, minor, and major identified on supine magnetic resonance scans. Using those scans, three-dimensional (3D) models of the levator ani muscles were made using a modeling program (3D Slicer), and cross-sections of the pubic portion were calculated perpendicular to the muscle fiber direction using another program, I-DEAS. An analysis of variance was performed. RESULTS: The ventral component of the levator muscle of women with major defects had a 36% smaller cross-sectional area, and women with minor defects had a 29% smaller cross-sectional area compared with the women with no defects (P < .001). In the dorsal component, there were significant differences in cross-sectional area according to defect status (P = .03); women with major levator defects had the largest cross-sectional area compared with the other defect groups. For each defect severity category (none, minor, major), there were no significant differences in cross-sectional area between women with and those without prolapse. CONCLUSION: Women with visible levator ani defects on magnetic resonance imaging had significantly smaller cross-sectional areas in the ventral component of the pubic portion of the muscle compared with women with intact muscles. Women with major levator ani defects had larger cross-sectional areas in the dorsal component than women with minor or no defects. LEVEL OF EVIDENCE: II-2.

Case-Control Studies↗
PubMed2006

Repair of vaginal vault prolapse and pelvic floor relaxation using polypropylene mesh.

PURPOSE OF REVIEW: Innumerable techniques have been described for vaginal vault prolapse and enterocele repair including abdominal (open, laparoscopic, and robotic) and vaginal techniques. Recently, the use of surgical mesh in pelvic floor surgery has become increasingly popular due to the high incidence of recurrence with primary repairs and no surrogate material. The increasing variety of available materials and techniques, combined with a lack of well conducted clinical trials, make the choice of repair to use difficult. RECENT FINDINGS: This article provides an update review on the different procedures available to the urogynecologist and female urologist for repair of vault prolapse. We will also discuss a new surgical technique for the repair of vault prolapse, which recreates the sacrouterine-cardinal ligament complex and reconstructs the pelvic floor with mesh. SUMMARY: The best approach to vaginal vault prolapse remains unknown. Surgeon comfort and preference as well as proper patient selection remain critical. The use of graft materials in pelvic floor reconstruction should have limited use in a carefully selected patient population. There is a need for well powered, controlled, long-term, randomized studies with patient generated quality-of-life questionnaires comparing the short and long-term outcomes of these techniques.

Female↗
PubMed2004

Porcine dermis interposition graft for repair of high grade anterior compartment defects with or without concomitant pelvic organ prolapse procedures.

PURPOSE: Recent literature suggests that graft interposition may decrease the incidence of cystocele recurrence. We describe our experience with porcine dermis interposition grafts for the repair of high grade cystoceles. MATERIALS AND METHODS: We retrospectively reviewed the charts of all women who underwent surgical repair of high grade cystocele. Prolapse was graded with the Baden-Walker and Pelvic Organ Prolapse Quantitation systems, and all patients were evaluated with multichannel videourodynamics. Concomitant stress urinary incontinence was corrected with a pubovaginal sling and vault prolapse was corrected with iliococcygeus vault suspension. Postoperatively patients were evaluated at 2 weeks, 2 months, 6 months and annually thereafter. RESULTS: A total of 70 patients underwent cystocele repair with a porcine dermis interposition graft. Concomitant procedures included a pubovaginal sling in 65 patients and vaginal vault suspension in 50. Mean followup was 24 months. There were no intraoperative complications. Of the patient 59 (91%) are currently dry. One patient had recurrent vault prolapse without cystocele (C -2), which was successfully repaired with abdominal sacral colpopexy. Six patients (8.6%) experienced recurrent grade II (Ba 0) cystocele but continued to be asymptomatic. Three others (4.3%) had recurrence of grade III (Ba +2) cystocele and elected not to undergo reoperation. Two of 6 de novo rectoceles (grade II, Ap and -1 and Bp 0) were repaired with site specific repairs. Superficial vaginal wound separation in 1 case was successfully treated conservatively. CONCLUSIONS: In cases of high grade cystocele interposition of porcine dermis represents a successful and safe treatment option. Cystocele recurrence is typically low grade and it frequently may not require additional surgery.

Animals↗
PubMed2005

Cadaveric prolapse repair with sling: intermediate outcomes with 6 months to 5 years of followup.

PURPOSE: We present the prospective, intermediate-term results for cadaveric prolapse repair with sling as combined treatment of stress urinary incontinence and cystocele. MATERIALS AND METHODS: A total of 251 of 295 (85%) patients undergoing cadaveric prolapse repair with sling (CaPS) had at least 6 months of questionnaire and pelvic examination followup. All patients had objectively demonstrated stress urinary incontinence and grade 2 to 4 cystocele before surgery. Followup outcome measures included a validated subjective continence and patient satisfaction questionnaire, SEAPI (stress incontinence, emptying, anatomy, protection, inhibition) scores, pelvic examination for prolapse recurrence and complications, and quality of life scores. RESULTS: The overall patient reported subjective incontinence cured/dry rate (no incontinence episodes of any type) was 114 of 251 (45%), the cured/improved rate (50% improvement or greater) was 192 of 251 (76%) and the failed rate (less than 50% improvement) was 59 of 251 (24%). When considering stress urinary incontinence the cured/dry rate was 141 of 251 (56%), cured/improved rate was 207 of 251 (82%) and failed rate was 44 of 251 (17.5%), with 17 of the 44 (39%) cases having mixed urinary incontinence. Of the 59 failures 33 (56%) occurred after 12 months of followup. Of 153 patients 13 (8.5%) experienced de novo urge incontinence. The symptomatic cystocele recurrence rate was 18 of 251 (7%). There were statistically significant improvements in SEAPI and prolapse quality of life scores. Of 251 patients 200 (80%) were at least 50% satisfied and of 251 193 (77%) stated they would undergo the CaPS procedure again. CONCLUSIONS: With a maximum followup of 5 years in patients undergoing CaPS, we have seen excellent, durable cystocele repair results. While our subjective continence rates have decreased with an increasing number of late failures, we continue to observe significant improvement in SEAPI scores and quality of life with good patient satisfaction and low morbidity.

Adult↗
PubMed1990

'Diamond-shaped' crypts and mucosal elastin: helpful diagnostic features in biopsies of rectal prolapse.

The biopsy diagnosis of prolapsing rectal mucosa syndrome can be difficult. We present two newly described features--'diamond-shaped' crypts and mucosal elastin--which appear to be helpful in histological diagnosis. Of 32 biopsies of prolapsing rectal mucosa syndrome, all showed diamond-shaped crypts or mucosal elastin, and 28 contained both. Control biopsies comprised cases of normal or irritable bowel syndrome (46), irradiation colitis and ischaemic colitis (16), inflammatory bowel disease (26), and adenomas (30). Mucosal elastin and 'diamond-shaped' crypts with distinctive scalloped edges, which were never seen in prolapse, were observed in half the cases of irradiation and ischaemic colitis. Diamond-shaped crypts were seen in one case of inflammatory bowel disease. Diamond-shaped crypts and elastin were seen in the base of adenomas large enough to cause localized prolapse, and in four biopsies from patients with irritable bowel syndrome, all of whom had given a history of straining at stool.

Adenoma↗
PubMed1993

Prolapse-induced inflammatory polyps of the colorectum and anal transitional zone.

A clinicopathological study of polypoid lesions of the lower gastrointestinal tract from 12 patients was undertaken. Clinically, the majority had signs and symptoms of rectal prolapse despite having a variety of other primary diagnoses (e.g. carcinoma of the bowel or diverticular disease). Three patients were asymptomatic. The polyps were more common in females and were usually solitary. Histologically, fibrin 'caps', fibromuscular hypertrophy and obliteration of the lamina propria, goblet cell hypertrophy and serrated tubules were consistently noted. The fibromuscular tissue often extended into the lamina propria in a radial fashion. This study shows that mucosal prolapse underpins a variety of lesions that are part of a histological spectrum of changes. Inflammatory cloacogenic polyps, inflammatory 'cap' polyps, polypoid prolapsing mucosal folds of diverticular disease and inflammatory myoglandular polyps are all due to mucosal prolapse.

Adult↗
PubMed1983

An investigation into the frequency of mitral valve prolapse in von Willebrand disease.

The reported extremely high incidence of mitral valve prolapse in von Willebrand patients (60%) in combination with multiple signs of mesenchymal dysplasia points to a hitherto unknown pleiotropic effect of the von Willebrand gene and needs further confirmation. Therefore, we looked for the presence of mitral valve prolapse in 19 patients with classical von Willebrand disease. While 58% of these patients had one or more physical findings which could be interpreted as symptoms of mesenchymal dysplasia, we found only one patient with a mitral valve prolapse (5.3%), comparable to the 6% incidence in the normal population. Therefore, we must conclude that there is no association between mitral valve prolapse and von Willebrand disease.

Adolescent↗
PubMed2006

A surgical technique with connective tissue repair for the management of subconjunctival orbital fat prolapse.

Abstract Subconjunctival orbital fat prolapse is an uncommon benign entity. In addition to insufficient information concerning the mechanisms of the prolapse, detailed surgical methods that can be followed are uncommon in the literature. We prospectively studied six consecutive eyes in four males who were to undergo our novel surgical sequence, attempting to avoid postoperative complications by reconstructing intermuscular septa on the basis of the assumption that the spontaneous prolapsed fat at the superior temporal quadrant stemmed from intraconal fat. Intraoperative findings were in agreement with our hypothesis that the anterior part of the herniated fat is covered by both the intermuscular septum and Tenon's capsule. All the surgeries were uneventful and cosmetic improvement without postoperative complications was obtained. Our early results indicated the safety and efficacy of this newly developed technique for spontaneous orbital fat prolapse.

Adipose Tissue↗
PubMed1992

Perineal proctectomy for rectal prolapse in elderly and debilitated patients.

This paper details the indications, operative technique and results of perineal proctectomy in the management of complete rectal prolapse in a high risk, elderly and debilitated group of patients. Eighteen procedures were performed by one surgeon (A.L.P.) on 16 consecutive patients over a 5 year period. Data collection was via: (i) retrospective analysis of hospital and office records; and (ii) response to a postal questionnaire by the patient, a relative or attending nursing staff. There were 14 females and two males with a mean age of 81 years. All patients had significant associated medical conditions. The interval from the time of a surgical procedure until review varied from 3 to 37 months with a mean follow-up period of 16 months. Total hospital stay varied between 6 and 20 days with a mean of 7 days. Eleven procedures were performed under general anaesthesia and seven under spinal anaesthesia. There was no postoperative mortality. One patient suffered an anastomotic haemorrhage that required operative intervention and another patient suffered a rectal stricture that necessitated dilatation. Two patients were re-operated for recurrent symptomatic prolapses at 34 and 36 months after the initial procedure. Continence improved in seven patients, worsened in one and was unchanged in the remaining patients. Fifteen of 16 patients were considered to have had a successful result from the operation with satisfactory control of the symptom of rectal prolapse. Perineal proctectomy is a low risk operative procedure for the elderly and debilitated group of patients in controlling complete rectal prolapse. If the condition recurs, the procedure can be repeated with equally low morbidity.

Aged↗
PubMed2004

A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function.

OBJECTIVE: To compare the effects of vaginal hysterectomy (combined with anterior and/or posterior colporraphy) and abdominal sacro-colpopexy (with preservation of the uterus) on urogenital function. DESIGN: Randomised trial. SETTING: Three teaching hospitals in The Netherlands. POPULATION: Eighty-two patients undergoing surgical correction of uterine prolapse stages II-IV. METHODS: Participating patients completed the urogenital distress inventory (UDI), before and at six weeks, six months and one year after surgery, to measure discomfort of prolapse and micturition symptoms. Domain scores of the UDI (ranging from 0 to 100, higher scores indicating more discomfort) were compared between groups at all time points. Findings at pelvic examination, number of doctor visits within the first year after surgery because of pelvic floor symptoms and performed or planned surgery of recurrent genital prolapse were also compared. MAIN OUTCOME MEASURE: Domain scores of the UDI at one year after surgery. RESULTS: At one year after surgery, scores on the discomfort/pain domain (mean difference 7.1, 95% confidence interval [CI] 1.1-13.2), overactive bladder domain (mean difference 8.7, 95% CI 0.5-16.9) and obstructive micturition domain (mean difference 10.3, 95% CI 0.6-20.1) of the UDI were significantly higher in the abdominal group than in the vaginal group. Findings at pelvic examination were similar in both groups. Doctor visits because of pelvic floor symptoms were more frequent in the abdominal group than in the vaginal group. Re-operation was performed or planned in 9 of the 41 patients who underwent abdominal surgery and in 1 of the 41 patients who underwent vaginal surgery (odds ratio [OR] = 11.2, 95% CI 1.4-90.0). CONCLUSIONS: Our findings suggest that vaginal hysterectomy with anterior and/or posterior colporraphy is preferable to abdominal sacro-colpopexy with preservation of the uterus as surgical correction in patients with uterine prolapse stages II-IV.

Colpotomy↗