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Prolapse: General

Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse.
Chen L, Ashton-Miller JA, Hsu Y, Delancey JO
Obstet Gynecol. 2006 Aug;108(2):324-32.

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. LEVEL OF EVIDENCE: II-2.

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Pessary use in advanced pelvic organ prolapse.
Powers K, Lazarou G, Wang A, LaCombe J, Bensinger G, Greston WM, Mikhail MS
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2) :160-4. Epub 2005 May 10.

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patient's discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.

The history and evolution of pessaries for pelvic organ prolapse.
Shah SM, Sultan AH, Thakar R
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):170-5. Epub 2005 Apr 14.

The use of pessaries for the treatment of genital prolapse dates back prior to the days of Hippocrates and their use has been documented in early Egyptian papyruses. Throughout the centuries remedies such as honey, hot oil, wine and fumes have been used as treatment. Mechanical methods included succussion and leg binding. Pomegranates were also common remedies. In the middle ages, linen and cotton wool soaked in many different potions were used. As new materials were discovered, pessaries evolved and began to resemble those used today. Cork and brass were soon replaced with rubber. Modern day pessaries are made of non-reactive silicone and come in various designs and sizes to suit each individual. Pessaries can be used as an interim measure for women who wish to complete childbearing or women awaiting surgery. It can also be used as a permanent measure for women who are unsuitable for surgery. It remains to be established whether the use of modern pessaries over prolonged periods of time can prevent progression of or even cure, prolapse.

Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success.
Hanson LA, Schulz JA, Flood CG, Cooley B, Tam F
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Feb;17(2):155-9. Epub 2005 Jul 26.

OBJECTIVE: An aging population has resulted in higher prevalence of urinary incontinence (UI) and pelvic organ prolapse (POP). This study examines a nurse-run clinic and analyzes the factors contributing to successful pessary use. STUDY DESIGN: A retrospective chart review of 1,216 patients was completed. History, pelvic examination and pessary fitting was done. Data was analyzed utilizing a categorical model of maximum-likelihood estimation to investigate relationships. RESULTS: Median patient age was 63 years. Median number of pessaries tried was two. Eighty-five percent of post-menopausal women were on hormone replacement therapy (HRT) prior to fitting. Highest success rate of 78% was in the group on both systemic and local HRT. Success rates ranged from 58% for urge incontinence to 83% for uterine prolapse. Prior vaginal surgery was a factor impacting success. In our series highest success rates for fitting were obtained with ring pessaries, ring with support, and gellhorns. CONCLUSIONS: This model is a viable, option for the conservative management of UI and POP. Local HRT plays an important role in successful pessary fitting. Complications are rare.


[Descending perineum in women]
Villet R, Ayoub N, Salet-Lizee D, Gadonneix P
Gastroenterol Clin Biol. 2006 May;30(5):681-6.

Physiopathological and clinical interpretation of the descending perineum as described by A. Parks in 1970 remains difficult. This review is based on the literature between 1966 and 2004. The observed symptoms are more often due to associated lesions. The descending perineum on X-ray is not always symptomatic. Colpocystography shows the descent of the perineum and pelvic disorders from the anterior and middle parts of the perineum whereas defecography seems to provide a better diagnosis of dyschesia due to posterior damage (such as rectocele or endo-anal intussusception). The first step of treatment is reeducation and medical treatment because there is no consensus for surgical therapy. Soft sacrocolpopexy by the abdominal approach with three meshes, one under the bladder, one in front of and one behind the rectum can be proposed for complete descending perineum. Transanal rectal resection by staple could be useful when the descending perineum is only associated with a rectocele and/or an intra-anal intussusception.



Clinical implications of the biology of grafts: conclusions of the 2005 IUGA Grafts Roundtable.
Davila GW, Drutz H, Deprest J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:51-5.

With few exceptions, the current expansion of graft utilization in pelvic reconstructive surgery is not a product of evidence-based medicine. Abdominal sacrocolpopexy and suburethral sling procedures are two situations under which synthetic graft utilization is indicated, based on randomized prospective trials and reported clinical outcomes. Otherwise, indications and contraindications for graft utilization are unclear. Current published data on the biology of synthetic and biologic grafts are limited and overall not very helpful to the reconstructive surgeon who is faced with the selection of a graft for use during a reconstructive procedure. This Roundtable presented the opportunity for a series of basic science researchers to present their data to a group of reconstructive surgeons and provide publishable background information on the various currently available grafts. The occurrence of healing abnormalities after graft implantation is becoming increasingly recognized as a potentially serious problem. To date, definitions and a classification system for healing abnormalities do not exist. Based on the input from basic scientists and experienced surgeons, a simple classification is suggested based on the site of healing abnormality, timing relative to graft implantation, presence of inflammatory changes, and the viscera into which the graft is exposed. Many opportunities for clinical and basic science research exist. As the use of grafts in reconstructive surgery is expanded, surgeons are encouraged to familiarize themselves with currently published data, and determine whether a graft should, or should not be, utilized during a reconstructive procedure, and if so, the type of graft best indicated in each specific clinical situation.

Cadaveric fascia lata.
Moalli PA
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:48-50.

Evaluation of a unique bovine collagen matrix for soft tissue repair and reinforcement.
Connolly RJ
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:44-7.

Veritas((R)) Collagen Matrix, a product of Synovis Surgical Innovations, is derived from bovine pericardium. It can be used for a number of applications including body wall repair and replacement. In this study, we evaluated its efficacy as an adhesion barrier in a rabbit model of uterine horn surgery. When Veritas((R)) was placed on the uterine horn stump it reduced the incidence of adhesions by 50% (n.s.) compared with untreated controls. Histologic analysis of recovered material showed that the surface was covered with a monolayer of mesothelial-like cells. In addition, there was an infiltration of host cells into the matrix of the product, which suggests a replacement of the material with host tissue.

Tissue engineering a clinically useful extracellular matrix biomaterial.
Hiles M, Hodde J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:39-43.

Implantable biomaterials are one of the most useful tools in the surgeon's armamentarium, yet there is much room for improvement. Chronic pain, tissue erosion, and late infections are just a few of the serious complications that can occur with conventional, inert materials. In contrast, tissue-inductive materials exist today. Combinations of biologically important molecules for directing cell growth and providing structural stability can be found in naturally occuring extracellular matrices. These "soft-tissue skeletons" of Mother Nature can be harvested, processed, and provided in a medically safe and biologically active form for repairing many different tissues in the human body. The future of surgical practice may well be determined by how well these new implant materials recreate the tisues they replace.

InteXen tissue processing and laboratory study.
Winters JC
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:34-8.

The goal of this manuscript is to discuss the utilization of InteXen graft material, which is a natural, biocompatible matrix. There is unfortunately little data concerning this material; so, many of the concepts introduced in this manuscript are theoretical. We will discuss the rationale behind using InteXen as the biologic material of choice.

Surgipro mesh: not all multifilaments are the same.
Rodeheaver GT
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:31-3.

Biology of polypropylene/polyglactin 910 grafts.
Barbolt TA
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:26-30.

The biological evaluation of polypropylene (PP)/polyglactin 910 grafts was reviewed including regulatory considerations, biocompatibility assessment, tissue reaction and integration, and infection potentiation of these synthetic materials used in urogynecological surgical procedures. The physical characteristics of the grafts including base composition, monofilament vs multifilament, and non-absorbable vs absorbable materials were compared. Grafts were implanted in rats to evaluate the tissue reaction and integration characteristics of the materials over time. Grafts were also implanted in mice and inoculated with Staphylococcus aureus to assess the potential for bacterial attachment and growth. The tissue reaction to PP/polyglactin 910 grafts was characterized by minimal to mild inflammation with some qualitative differences related to the physical construction of the different grafts. The tissue reaction to polyglactin 910 mesh was also mild but resolved after the material was absorbed 70 days post-implantation. The integration of PP/polyglactin 910 grafts by fibrosis with surrounding tissue was initially mild for all materials but decreased over time for the lightweight and multifilament PP-based grafts, including a graft with an absorbable polyglactin 910 component. Residual fibrosis was not observed for the graft constructed from polyglactin 910 alone. Grafts constructed from PP did not potentiate infection after inoculation with S. aureus whereas the number of bacteria recovered from naturally derived collagen-based materials increased by three to four logs. The biological performance of PP/polyglactin 910 grafts is dependent on multiple factors including the composition and physical construction of the base materials, the overall biocompatibility of the materials, particularly tissue reaction and integration of the grafts, and the resistance of the grafts to bacterial attachment and growth.

The biology behind fascial defects and the use of implants in pelvic organ prolapse repair.
Deprest J, Zheng F, Konstantinovic M, Spelzini F, Claerhout F, Steensma A, Ozog Y, De Ridder D
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:16-25.

Implant materials are increasingly being used in an effort to reduce recurrence after prolapse repair with native tissues. Surgeons should be aware of the biology behind both the disease as well as the host response to various implants. We will discuss insights into the biology behind hernia and abdominal fascial defects. Those lessons from "herniology" will, wherever possible, be applied to pelvic organ prolapse (POP) problems. Then we will deal with available animal models, for both the underlying disease and surgical repair. Then we will go over the features of implants and describe how the host responds to implantation. Methodology of such experiments will be briefly explained for the clinician not involved in experimentation. As we discuss the different materials available on the market, we will summarize some results of recent experiments by our group.

Evolution of biological and synthetic grafts in reconstructive pelvic surgery.
Dwyer PL
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:10-5.

Surgery is an evolving science in the attempt to make surgical procedures more effective, safer, and less invasive. Recurrence and subsequent re-operation for stress incontinence and prolapse has been reported to be necessary in one of three patients, so there is a need for improvement [1]. In reconstructive pelvic surgery (RPS), the use of biological and synthetic grafts for the transabdominal and transvaginal treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SI) has improved long-term support and function after surgery. However, the potential benefits of using grafts need to be carefully balanced against the risks of using materials foreign to the patient's body. Pelvic organ prolapse develops secondary to defective endopelvic fascial and muscular support. The levator ani provides resting tonic muscular support for all three pelvic compartments. Once neuromuscular damage occurs, extra strain is placed on the connective tissue supports, which may also subsequently fail. To date, there is no surgery that adequately addresses the issue of neuromuscular damage of the pelvic floor musculature. In conventional POP surgery, defective support is repaired by suturing of the patient's own connective tissue, fascia, or ligaments. The rationale for the use of grafts is to reinforce and strengthen pelvic organ repairs similar to the use of grafts to strengthen abdominal hernia repair.

Introduction to the 2005 IUGA Grafts Roundtable.
Davila GW
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:4-5.

International Urogynecological Association: The Usage of Grafts in Pelvic Reconstructive Surgery Symposium 2005 : July 8-10, 2005, Lago Mar Resort, Fort Lauderdale, FL, USA.
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr;17 Suppl 7:1-3.



Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life.
Jelovsek JE, Barber MD
Am J Obstet Gynecol. 2006 May;194(5):1455-61.

OBJECTIVE: Women who seek treatment for pelvic organ prolapse strive for an improvement in quality of life. Body image has been shown to be an important component of differences in quality of life. To date, there are no data on body image in patients with advanced pelvic organ prolapse. Our objective was to compare body image and quality of life in women with advanced pelvic organ prolapse with normal controls. STUDY DESIGN: We used a case-control study design. Cases were defined as subjects who presented to a tertiary urogynecology clinic with advanced pelvic organ prolapse (stage 3 or 4). Controls were defined as subjects who presented to a tertiary care gynecology or women's health clinic for an annual visit with normal pelvic floor support (stage 0 or 1) and without urinary incontinence. All patients completed a valid and reliable body image scale and a generalized (Short Form Health Survey) and condition-specific (Pelvic Floor Distress Inventory-20) quality-of-life scale. Linear and logistic regression analyses were performed to adjust for possible confounding variables. RESULTS: Forty-seven case and 51 control subjects were enrolled. After controlling for age, race, parity, previous hysterectomy, and medical comorbidities, subjects with advanced pelvic organ prolapse were more likely to feel self-conscious (adjusted odds ratio 4.7; 95% confidence interval 1.4 to 18, P = .02), less likely to feel physically attractive (adjusted odds ratio 11; 95% confidence interval 2.9 to 51, P < .001), less likely to feel feminine (adjusted odds ratio 4.0; 95% confidence interval 1.2 to 15, P = .03), and less likely to feel sexually attractive (adjusted odds ratio 4.6; 95% confidence interval 1.4 to 17, P = .02) than normal controls. The groups were similar in their feeling of dissatisfaction with appearance when dressed, difficulty looking at themselves naked, avoiding people because of appearance, and overall dissatisfaction with their body. Subjects with advanced pelvic organ prolapse suffered significantly lower quality of life on the physical scale of the SF-12 (mean 42; 95% confidence interval 39 to 45 versus mean 50; 95% confidence interval 47 to 53, P < .009). However, no differences between groups were noted on the mental scale of the SF-12 (mean 51; 95% confidence interval 50 to 54 versus mean 50; 95% confidence interval 47 to 52, P = .56). Additionally, subjects with advanced pelvic organ prolapse scored significantly worse on the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 than normal controls (mean summary score 104; 95% confidence interval 90 to 118 versus mean 29; 95% confidence interval 16 to 43, P < .0001), indicating a decrease in condition-specific quality of life. Worsening body image correlated with lower quality of life on both the physical and mental scales of the SF-12 as well as the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 in subjects with advanced pelvic organ prolapse. CONCLUSION: Women seeking treatment for advanced pelvic organ prolapse have decreased body image and overall quality of life. Body image may be a key determinant for quality of life in patients with advanced prolapse and may be an important outcome measure for treatment evaluation in clinical trials.

Mesh erosion in abdominal sacral colpopexy with and without concomitant hysterectomy.
Wu JM, Wells EC, Hundley AF, Connolly A, Williams KS, Visco AG
Am J Obstet Gynecol. 2006 May;194(5):1418-22.

OBJECTIVE: The purpose of this study was to examine risk factors for mesh erosion, including concomitant hysterectomy, in abdominal sacral colpopexies. STUDY DESIGN: We conducted a retrospective cohort study of 313 women who underwent an abdominal sacral colpopexy. Data regarding patient demographics, operative techniques, length of follow-up, postoperative complications, and mesh erosion were collected. RESULTS: Of 313 subjects, 101 (32.3%) had concomitant hysterectomies and 212 (67.7%) had had previous hysterectomies. The overall rate of mesh erosion was 5.4%. In bivariate analysis, concomitant hysterectomy was not associated with erosion (6.9% vs 4.7% previous hysterectomy, P = .42); however, estrogen therapy was an effect modifier. In women on estrogen, hysterectomy (OR 4.9, CI 1.2-19.7) and anterior imbrication (OR 5.6, CI 1.1-28.6) were associated with mesh erosion. No risk factors were identified in women not on estrogen. CONCLUSION: In women on estrogen therapy, hysterectomy was associated with mesh erosion in abdominal sacral colpopexy.

Effect of patient age on increasing morbidity and mortality following urogynecologic surgery.
Sung VW, Weitzen S, Sokol ER, Rardin CR, Myers DL
Am J Obstet Gynecol. 2006 May;194(5):1411-7.

OBJECTIVE: The purpose of this study was to estimate the effect of age on the risk of in-hospital mortality and morbidity following urogynecologic surgery and to compare risks associated with obliterative versus reconstructive procedures for prolapse in elderly women. STUDY DESIGN: We conducted a retrospective cohort study utilizing data from 1998 to 2002 from the Nationwide Inpatient Sample. Multivariable logistic regression was performed to obtain odds ratios estimating the effect of age on risk of death and complications, adjusting for comorbidities and demographic factors. RESULTS: There were 264,340 women in our study population. Increasing age was associated with higher mortality risks per 1000 women (< 60 years, 0.1; 60-69 years, 0.5; 70-79 years, 0.9; > or = 80 years, 2.8; P < .01) and higher complication risks per 1000 women (< 60 years, 140; 60-69 years, 130; 70-79 years, 160; > or = 80 years, 200; P < .01). Using multivariable logistic regression, increasing age was associated with an increased risk of death (60-69 years, odds ratio [OR] 3.4 [95% CI 1.7-6.9]; 70-79 years, OR 4.9 [95% CI 2.2-10.9]; > or = 80 years, OR 13.6 [95% CI 5.9-31.4]), compared with women < 60 years. The risk of peri-operative complications was also higher in elderly women 80 years of age and older (OR 1.4 [95% CI 1.3-1.5]) compared with younger women. Elderly women 80 years and over who underwent obliterative procedures had a lower risk of complication compared with those who underwent reconstructive procedures for prolapse (17.0% vs 24.7%, P < .01). CONCLUSION: Although the absolute risk of death is low, elderly women have a higher risk of mortality and morbidity following urogynecologic surgery.

Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse.
Barber MD, Walters MD, Cundiff GW
Am J Obstet Gynecol. 2006 May;194(5):1492-8.

OBJECTIVE: This study was undertaken to evaluate the responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women with pelvic organ prolapse undergoing surgical and nonsurgical management. STUDY DESIGN: The responsiveness of the prolapse, urinary and colorectal scales of the PFDI and PFIQ were assessed in 2 independent populations: (1) 42 women with stage II or greater prolapse enrolled in an ongoing multicenter randomized trial comparing 2 different pessaries (Pessary group) and (2) 64 women with stage III or greater prolapse who underwent vaginal reconstructive surgery (Surgery group). All subjects completed the PFDI and PFIQ at baseline and again either 3 months (Pessary group) or 6 months (Surgery group) after initiation of treatment. Responsiveness was assessed with standardized response mean (SRM), effect size (ES), and the paired t test. RESULTS: In the Pessary group, there was a significant improvement in the prolapse and urinary scales of the PFDI, with each demonstrating moderate responsiveness (prolapse: SRM 0.69, ES 0.68; urinary: SRM 0.57, ES: 0.50, P < .001 for each). The colorectal scale of the PFDI and each of the 3 scales of the PFIQ demonstrated no significant change in scores with pessary use. In the Surgery group, there was a significant improvement in the prolapse, urinary, and colorectal scales of both the PFDI and PFIQ (P < .01 for each). The prolapse and urinary scales of the PFDI demonstrated excellent responsiveness with SRM and ES 1.20 or greater for the prolapse scale and equal to1.05 for the urinary scales. The colorectal scale of the PFDI and the urinary and prolapse scales of the PFIQ demonstrated moderate responsiveness (SRM 0.61-0.70 and ES 0.56-0.60) after surgery. Subjects who had a recurrence of their prolapse develop after surgery (6%) had significantly less improvement in the prolapse scale of the PFDI than those who did not. After controlling for preoperative prolapse stage and baseline quality of life scores, subjects in the Surgery group had significantly greater improvement in each of the scales of the PFDI and the prolapse and urinary scales of the PFIQ than did the Pessary group (P < .05 for each). CONCLUSION: The PFDI and PFIQ are responsive to change in women undergoing surgical and nonsurgical treatment for pelvic organ prolapse. The PFDI is more responsive than the PFIQ.

Can we screen for pelvic organ prolapse without a physical examination in epidemiologic studies?
Barber MD, Neubauer NL, Klein-Olarte V
Am J Obstet Gynecol. 2006 May 6;.

OBJECTIVE: Large population-based epidemiologic studies of pelvic organ prolapse are rare. One barrier is the need for physical examination in order to confirm disease status. The objectives of this study were to develop a simple screening question for pelvic organ prolapse (POP) and to evaluate its test characteristics in high and low prevalence populations. STUDY DESIGN: Data from 100 women enrolled in the validation study of the Pelvic Floor Distress Inventory (PFDI) were used to identify the question or questions that most accurately identified women with advanced pelvic organ prolapse. After identifying an accurate and reliable screening question from this original group, its test characteristics were evaluated prospectively in 2 additional distinct populations: a group of 120 women presenting to a tertiary care urogynecology clinic (High prior probability of POP) and 448 women presenting to a nurse practitioner for annual gynecologic examination (Low prior probability of POP). Subjects in these 2 groups each completed the screening question and underwent a POPQ examination by a blinded examiner. RESULTS: A single question was identified from the original study population that most accurately and reliably identified those women with POP "Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?" An affirmative answer to this question was 96% sensitive (95%CI 92-100) and 79% specific (95%CI 77-92) for prolapse beyond the hymen. The 1-week test-retest reliability was good (kappa .84). The prevalence of POP in this group was 29%. No other single question or group of questions had better test characteristics. When prospectively evaluated in the second High probability population (prevalence 39%), similar test characteristics were noted: sensitivity 85% (95%CI 71-93), specificity 86% (95%CI 75-92). However, when evaluated in the Low prior probability group (POP prevalence 3.8%) the specificity improved to 99% (95%CI 98-99), while the sensitivity decreased dramatically to 35% (95%CI 15-61). CONCLUSION: Screening for POP without a physical examination is subject to spectrum bias. Spectrum bias occurs when a diagnostic test performs differently in different groups of patients. In groups with a high prior probability of POP, a simple screening question can accurately screen for advanced POP without a physical exam. However, in groups with a low prior probability of POP such as might be seen in a population-based epidemiologic study, this question has poor sensitivity.

Clinical and physiologic outcomes after transvaginal rectocele repair.
Yamana T, Takahashi T, Iwadare J
Dis Colon Rectum. 2006 May;49(5):661-7.

PURPOSE: This study was designed to evaluate the clinical and physiologic outcomes after transvaginal rectocele repair. METHODS: Between June 2000 and January 2003, 30 females (mean age, 62 (range, 45-78) years) with a symptomatic large rectocele (>3 cm) underwent transvaginal rectocele repair (anterior levatorplasty). Six months after surgery, a physiologic evaluation was performed by using defecography (depth of rectocele) and anorectal manometry (maximum resting pressure, maximum squeeze pressure, rectal threshold, and maximum tolerable volume). Using a questionnaire, a clinical evaluation was performed one year after surgery to analyze symptoms, including difficult evacuation, digital support, sexual discomfort, as well as patient satisfaction. Follow-up of all patients was conducted during a median duration of 38 (range, 23-54) months. RESULTS: There were no operative complications, such as hematoma, wound infection, or rectovaginal fistula.Difficult evacuation improved in 27 of 30 patients (90 percent) and completely disappeared in 9 patients. Postoperatively, digital support was no longer necessary during evacuation in 15 of 21 patients (71 percent). Overall patient satisfaction reached 25 of 30 (83 percent). Although mild sexual discomfort was observed in nine patients, it disappeared gradually and only one patient complained of persistent symptoms. No patient reported symptomatic recurrences at the end of the follow-up. The radiologic mean depth of the rectocele was significantly reduced: preoperative, 3.9 cm; postoperative, 0.5 cm. None of the physiologic parameters significantly changed after surgery. CONCLUSIONS: Transvaginal rectocele repair can provide excellent long-term symptomatic relief and a high rate of patient satisfaction without any alteration in anorectal physiologic function.



Obturator hernia as a cause of chronic pain after inguinal hernioplasty: elective management using tomography and ambulatory total extraperitoneal laparoscopy.

Moreno-Egea A, la Calle MC, Torralba-Martinez JA, Morales Cuenca G, Girela Baena E, del Pozo P, Aguayo-Albasini JL
Surg Laparosc Endosc Percutan Tech. 2006 Feb;16(1):54-7.

Obturator hernia is a rare variety of pelvic hernia. Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis. Subsequently, elective treatment via the total extraperitoneal laparoscopic approach seems to offer the best results for both the patient and the hospital. This management might reduce the high rates of associated morbidity and mortality. We present the case of a patient with chronic pelvic pain after hernia surgery in whom tomography confirmed the existence of a bilateral obturator hernia. Details are given of diagnostic and therapeutic management using ambulatory total extraperitoneal laparoscopy. We recommend ruling out obturator hernia as a possible cause of chronic pain after hernia repair.

Skeletal muscle heavy-chain polypeptide 3 and myosin binding protein H in the pubococcygeus muscle in patients with and without pelvic organ prolapse.
Hundley AF, Yuan L, Visco AG
Am J Obstet Gynecol. 2006 Mar 28;.

OBJECTIVE: The purpose of this study was to compare gene expression of skeletal muscle heavy-chain polypeptide 3 (MYH3) and myosin binding protein H (MyBP-H) in the pubococcygeus muscle of patients with pelvic organ prolapse and controls. STUDY DESIGN: Genes previously identified by microarray genechip analysis of pubococcygeus muscle biopsies were examined using real-time quantitative reverse transcriptase polymerase chain reaction (RT-PCR) analysis. Specimens were obtained from 17 patients with stage III or IV pelvic organ prolapse and 23 controls with minimal to no prolapse. Glyceraldehyde 3-phosphate dehydrogenase (GAPDH) was used as the housekeeping gene. Samples and controls were run in triplicate in separate wells, and the levels of gene expression were analyzed quantitatively using the comparative critical threshold (Ct) method. Differences in gene expression were analyzed using Wilcoxon rank-sum testing. RESULTS: Significant differences in gene expression were observed between patients with prolapse and controls for both genes. Skeletal muscle myosin heavy-chain polypeptide 3 was 6.5 times underexpressed in patients with pelvic organ prolapse compared to controls (P = .028). Similarly, myosin binding protein H was 3.2 times underexpressed in patients with prolapse (P = .042). Overall, patients had a mean age of 62.4 +/- 6.5 years compared with controls with a mean age of 45.3 +/- 7.4 years (P < .001), so analysis was also performed on an age-matched subset of 8 patients and controls (mean ages of 58.1 +/- 5.4 years and 53.3 +/- 5.0 years, respectively, P = .02) with similar results. Prolapse patients in this subset were similar in parity and race to controls but had lower body mass index (23.2 vs 29.9, P = .04). MYH3 was 10.9 times underexpressed in patients with pelvic organ prolapse compared to controls (P = .027). MyBP-H was 10.4 times underexpressed in patients with prolapse (P = .036). CONCLUSION: These findings suggest that the differences between patients with advanced pelvic organ prolapse and controls may be related to differential gene expression of structural proteins related to myosin. Specifically, advanced pelvic organ prolapse may be related to down-regulation of skeletal muscle heavy-chain polypeptide 3 and myosin binding protein H.

Can pelvic floor muscle training prevent and treat pelvic organ prolapse?
Bo K
Acta Obstet Gynecol Scand. 2006;85(3):263-8.

BACKGROUND AND METHODS: Pelvic floor muscle dysfunction may cause urinary and fecal incontinence, pelvic organ prolapse (POP), pain, and sexual disturbances. The aim of the present study is to review the literature on the effectiveness of pelvic floor muscle training (PFMT) to prevent and treat POP, and the possible theories and mechanisms on how PFMT could prevent or reverse prolapse. RESULTS: No studies were found on prevention of POP. One uncontrolled study and one low-quality RCT were found in the treatment of prolapse. The results showed a positive effect of PFMT in severe, but not in mild prolapse. A review is presented of the main hypothesis of mechanisms on how PFMT may be effective. The two mechanisms are morphological changes occurring after strength training and use of a conscious contraction during increase in abdominal pressure in daily activities. CONCLUSIONS: In addition to the theory of functional anatomy and exercise science, one randomized controlled trial (RCT) is supportive for a positive effect of PFMT in the treatment of POP. There is an urgent need for more RCT with high methodological quality, use of valid and reproducible methods to assess degree of prolapse, and appropriate training protocols to evaluate the effect of PFMT in the prevention and treatment of POP.

Levator plate angle in women with pelvic organ prolapse compared to women with normal support using dynamic MR imaging.
Hsu Y, Summers A, Hussain HK, Guire KE, Delancey JO
Am J Obstet Gynecol. 2006 Mar 28;.

OBJECTIVE: The purpose of this study was to determine whether the levator plate is (1) horizontal in women with normal support, (2) different between women with and without prolapse, (3) related to levator hiatus and perineal body descent. STUDY DESIGN: Cohorts of cases with prolapse at least 1 cm below the hymen and normal controls with all points 1 cm or more above the hymen were prospectively enrolled in a study of pelvic organ support to be of similar age, race, and parity. Subjects underwent supine midsagittal dynamic magnetic resonance imaging (MRI) during Valsalva. Levator plate angle (LPA) was measured relative to a horizontal reference line. Levator hiatus length (LH) and perineal body location (PB) were also measured. Student t tests and Pearson correlation coefficients (r) were performed. RESULTS: Sixty-eight controls and 74 cases were analyzed. During Valsalva, controls had a mean LPA of 44.3 degrees . Cases, compared to controls, had 9.1 degrees (21%) more caudally directed LPA (53.4 degrees vs 44.3 degrees , P < .01), 15% larger LH length (7.8 cm vs 6.8 cm, P < .01), and 24% more caudal PB location (6.8 cm vs 5.5 cm, P < .01). Increases in LPA were correlated with increased LH length (r = 0.42, P < .0001) and PB location (r =.51, P < .0001). CONCLUSION: The measured levator plate angle in women with normal support is 44.3 degrees . During Valsalva, women with prolapse have a modest (9.1 degrees ) though statistically greater levator plate angle compared to controls. This larger angle showed moderate correlation with larger levator hiatus length and greater displacement of the perineal body in women with prolapse compared to controls.

Stapled Transanal Rectal Resection Under Laparoscopic Surveillance for Rectocele and Concomitant Enterocele.
Petersen S, Hellmich G, Schuster A, Lehmann D, Albert W, Ludwig K
Dis Colon Rectum. 2006 Apr 5;.

PURPOSE: Stapled transanal rectal resection recently became a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential threat to structures located in front of the anterior rectal wall. We decided to perform a combined procedure of transanal rectal resection with a simultaneous laparoscopy for patients with obstructed defecation syndrome and an enterocele. METHODS: Between November 2002 and May 2005 a total of 41 patients were treated surgically for obstructed defecation syndrome. Four patients with concomitant enterocele underwent stapled transanal rectal resection under laparoscopic surveillance. Before surgery all patients underwent preoperative assessment, including clinical examination, colonoscopy, conventional video defecography, dynamic magnetic resonance imaging defecography, gynecology examinations, and psychologic evaluation. RESULTS: The mean operative time was 50 (+/-16.5) minutes for the conventional stapled transanal rectal resection and 67 (+/-14.1) minutes for combined laparoscopy and stapled transanal rectal resection (P < 0.01). Three major complications were observed: two had bleeding in the staple line (one from each group) and one had a late abscess in the staple line. CONCLUSIONS: The combination of the stapled transanal rectal resection procedure and laparoscopy provides the opportunity to perform transanal rectal resection without the threat of intra-abdominal lesions caused by enterocele.



Pelvic organ prolapse: is it time to define it?
Swift S
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):425-7.
scrivergli IPGH e PFD

Expression of lysyl oxidase and transforming growth factor beta2 in women with severe pelvic organ prolapse.
Kobak W, Lu J, Hardart A, Zhang C, Stanczyk FZ, Felix JC
J Reprod Med. 2005 Nov;50(11):827-31.

OBJECTIVE: To determine the mRNA expression of lysyl oxidase (LOX) and transforming growth factor beta2 (TGF beta2) in subjects with advanced pelvic organ prolapse as compared to asymptomatic controls. STUDY DESIGN: Seventeen women undergoing vaginal hysterectomy were recruited for the study. Nine women with grade > or = 3 pelvic organ prolapse by the Baden-Walker grading scale were recruited. Eight subjects without pelvic organ prolapse or urinary incontinence undergoing hysterectomy for other indications were recruited as asymptomatic controls. A 1-cm portion of the bilateral distal uterosacral ligaments was excised and immediately frozen at -80 degrees C. Total RNA was extracted, quantified and subjected to reverse transcription for cDNA synthesis. beta-Actin was used as the reference for the semiquantitative analysis. Known volumes of the polymerase chain reaction (PCR) products for each reaction were electrophoresed in agarose gels stained with ethidium bromide and photographed with a digital camera. The optical density for each sample was measured by using computerized image analysis software. The relative abundance of each specific message was calculated as the ratio of PCR product for LOX or TGF beta2 divided by the amount of PCR product for beta-actin from the same sample. RESULTS: The mean age of the study subjects was 55.7 years (38-67) versus 47.1 for the controls (44-54). Mean parity was 4.4 for the study subjects and 2.7 for the controls. Seventy-eight percent of the study subjects were postmenopausal, and 14% of the controls postmenopausal. All postmenopausal subjects had at least 1 month of estrogen therapy prior to surgery. The mean LOX/beta-actin ratio for the study group was 0.35 as compared to 0.72 for the control group. This was statistically significant with a p value of 0.049. The mean TGF beta2/beta-actin ratio for the study group was 0.12 as compared to 0.20 for the control group. This was not statistically significant (p = 0.46). CONCLUSION: Patients with severe pelvic organ prolapse (grade > or = 3) have a significant reduction in the mRNA expression of lysyl oxidase as compared to asymptomatic controls. The mRNA expression of TGF beta2 was not statistically different between the 2 groups. These findings lend further credence to the concept of specific biochemical changes in the pelvic floor in women with pelvic organ prolapse.

Perineocele: symptom complex, description of anatomic defect, and surgical technique for repair.
Schlunt Eilber K, Rosenblum N, Gore J, Raz S, Rodriguez LV
Urology. 2006 Jan 25;.

OBJECTIVES: To describe the patient characteristics, physical examination and magnetic resonance imaging findings, and method of surgical repair of perineocele. A perineocele is a rare condition of an isolated central defect and herniation of the posterior perineum in patients without diffuse vaginal prolapse. METHODS: The evaluation consisted of history and physical examination and magnetic resonance imaging. With the patient in the dorsal lithotomy position, an inverted Y incision was made from the posterior vagina to the posterior rectum. The transverse perineal musculature, superficial perineal membrane, and external anal sphincter were approximated. The perineal distance from the posterior fourchette to the anus was measured preoperatively and postoperatively. Symptom and anatomic assessments were done at each postoperative visit. RESULTS: A total of 6 patients were treated, with a mean follow-up of 9.5 months. The symptoms at presentation consisted of perineal pressure, severe constipation, and the need for manual perineal reduction for defecation. The physical findings included a lack of vaginal prolapse, convexity of the perineum, and an increase in the distance from the posterior fourchette to the rectum. Dynamic magnetic resonance imaging showed no anomaly of the vaginal wall. Preoperatively, the average perineal distance was 11.2 cm and postoperatively it was 4 cm. The perineocele was successfully repaired in all patients. All but 1 patient had significant relief of constipation. CONCLUSIONS: Posterior levator defects can result in perineal hernia with perineal body attenuation, separation of the transverse perineal and anal sphincter musculature, and development of a perineocele. The relief of symptoms and correction of the anatomic defect can be achieved by reapproximation of these structures.

Use of porcine small intestinal submucosa in the surgical treatment of recurrent rectocele in a patient with Ehlers-Danlos syndrome type III.
Sardeli C, Axelsen SM, Bek KM

Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):504-5. Epub 2005 Jan 12.
Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders involving various organ systems. We report the case of a female patient with Ehlers-Danlos syndrome type III (EDS III) presenting with a recurrent rectocele in whom porcine small intestinal submucosa mesh was used successfully to correct the defect in the rectovaginal fascia.

Severity of pelvic organ prolapse associated with measurements of pelvic floor function.
Ghetti C, Gregory WT, Edwards SR, Otto LN, Clark AL
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):432-6. Epub 2005 Jan 20.

This study tested the hypothesis that clinical measurements of the superficial perineum and of pelvic floor muscle (PFM) function correlate with the severity of pelvic organ prolapse. This retrospective cross-sectional study assessed 1037 women in an academic urogynecologic practice. Greatest descent of prolapse, by the Pelvic Organ Prolapse Quantification system, was correlated with two assessments of levator function--the Oxford grading scale and levator hiatus (LH) size measured by digital examination. Correlations were calculated using Pearson's correlation for continuous variables and Kendall's tau-b. Severity of prolapse correlated moderately with genital hiatus (GH) (r = 0.5, p<0.0001) and with LH (transverse r = 0.4, p < 0.0001; longitudinal r = 0.5, p < 0.0001), but weakly with the Oxford grading scale (r = -0.16, p < 0.0001). LH correlated with GH (r = 0.5, p < 0.0001) but not with perineal body (r = 0.06, p = 0.06). Both GH and LH size are associated with the severity of prolapse. LH size correlates more strongly to prolapse severity than assessment of PFM function by the Oxford grading scale.

Roles of estrogen receptor, progesterone receptor, p53 and p21 in pathogenesis of pelvic organ prolapse.
Bai SW, Chung da J, Yoon JM, Shin JS, Kim SK, Park KH
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):492-6. Epub 2005 May 25.

The aim of this study is to compare the levels of estrogen receptor (ER), progesterone receptor (PR), p53 and p21 between pelvic organ prolapse (POP) and control groups in order to evaluate their roles in pathogenesis of POP, and to find out the relationship among these proteins. Through the year of 2002, uterosacral ligaments were obtained from 20 prolapsus and 24 non-prolapsus hysterectomized uteruses. ER, PR, p53, and p21 proteins were extracted by Western blot analysis and relative levels of proteins were compared by Student t-test and Pearson correlation coefficient. P value <0.05 was considered statistically significant. All patients were postmenopausal and had never taken hormone replacement therapy. ER, PR, p53, and p21 were significantly lower in the study than control group (p<0.0001). Positive correlations were found among all proteins in the prolapse group. Further researches are needed to elucidate the interrelationship among these proteins and their precise roles in pathogenesis of POP.

Uterosacral ligament in postmenopausal women with or without pelvic organ prolapse.
Gabriel B, Denschlag D, Gobel H, Fittkow C, Werner M, Gitsch G, Watermann D
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):475-9. Epub 2005 Apr 22.

The uterosacral ligaments are thought to contribute to pelvic support. The objective of this study was to compare the structural components of these ligaments in women with and without pelvic organ prolapse (POP). We characterized uterosacral ligaments of 25 postmenopausal women with POP and 16 controls histomorphologically and immunohistochemically by quantifying their content of collagen I, III, and smooth muscle using a computerized image analysis. In 84% the uterosacral ligaments were composed of more than 20% of smooth muscle cells. There was no difference in collagen I expression and smooth muscle cell amount between women with POP and those without. In contrast, the collagen III expression was significantly related to the presence of POP (p<0.001) rather than age or parity. Our findings suggest that the higher collagen III expression might be a typical characteristic of POP patients' connective tissue. The considerable amount of smooth muscle cells in uterosacral ligaments may provide pelvic support.

Prevalence of symptomatic pelvic organ prolapse in a Swedish population.
Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):497-503. Epub 2005 Jun 29.

Our aim was to estimate the prevalence of symptomatic pelvic organ prolapse (POP) in a Swedish urban female population. The cross-sectional study design included 8,000 randomly selected female residents in Stockholm, 30-79-year old. A postal questionnaire enquired about symptomatic POP, using a validated set of five questions, and about urinary incontinence and demographic data. Of 5,489 women providing adequate information, 454 (8.3%, 95% confidence interval 7.3-9.1%) were classified as having symptomatic POP. The prevalence rose with increasing age but leveled off after age 60. In a logistic regression model that disentangled the independent effects, parity emerged as a considerably stronger risk factor than age. There was a ten-fold gradient in prevalence odds of POP with parity, the steepest slope (four-fold) being between nulliparous and primiparous women. The prevalence of frequent stress urinary incontinence was 8.9% and that of frequent urge incontinence 5.9%. Out of the 454 women with prolapse, 37.4% had either or both types of incontinence.

The asymptomatic hernia: "if it's not broken, don't fix it".
Flum DR
JAMA. 2006 Jan 18;295(3):328-9

Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial.
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, Neumayer LA, Barkun JS, Hoehn JL, Murphy JT, Sarosi GA Jr, Syme WC, Thompson JS, Wang J, Jonasson O
JAMA. 2006 Jan 18;295(3):285-92.

[Choice of prosthesis in genital prolapse surgery]
Roumeguere T
Prog Urol. 2005 Dec;15(6):1042-5.

Genital prolapse is an increasingly frequent condition and surgical repair is associated with a high recurrence rate. Many technical modifications have been proposed in order to improve these results. Synthetic and biological prostheses have been developed and marketed often in the absence of well conducted randomized controlled studies, and simply claiming the ease of use of a new material. However, urologists must be well informed about the efficacy of these prostheses, their potential limitations and the associated morbidity. The authors report the currently known characteristics of prostheses for genital prolapse repair. There is a consensus in favour of large pore size polypropylene monofilament mesh. Biomaterials are still under investigation for their applications in urology. Randomized, prospective, controlled trials must be conducted to determine the long-term efficacy and potential morbidity of the various materials used. Morbidity is also related to surgical technique and the use of prostheses does not eliminate the need for expertise in prolapse surgery.

Which bowel symptoms are most strongly associated with a rectocele?
Dietz HP, Korda A
Aust N Z J Obstet Gynaecol. 2005 Dec;45(6):505-8.

Abstract Background: Posterior vaginal wall prolapse is common in parous women and may be due to rectocele, enterocele or perineal hypermobility. Translabial ultrasound can be used to detect defects of the rectovaginal septum, that is, a 'true rectocele', potentially avoiding the need for defecation proctography. However, it is currently unknown whether specific sonographic appearances are associated with bowel symptoms. Aims: To correlate symptoms of bowel dysfunction and sonographic findings. Methods: In a prospective observational study, 505 women were seen during attendance at tertiary urogynaecological clinics and underwent a standardised interview, which included a set of questions regarding bowel function. They were assessed clinically and by translabial ultrasound, supine and after voiding. The presence of a rectocele was determined on maximal Valsalva. Results: Clinically, 314 women (64%) were found to have a rectocele. There were associations between clinical staging and ampullary descent on ultrasound (P < 0.001), the presence of a true rectocele (P < 0.001) and the depth of a defect (P < 0.001). Defects of the rectovaginal septum ('true rectocele') were identified in 54%. They were associated with symptoms of incomplete bowel emptying (P < 0.001) and digitation (P = 0.002), and less so with dyschezia (P = 0.01), faecal incontinence (P = 0.02) and chronic constipation (P = 0.04). Conclusions: True rectoceles are found in more than half of women presenting with pelvic floor disorders. This finding correlates strongly with clinical prolapse grading - large clinical rectoceles are more likely to be caused by a fascial defect. Incomplete bowel emptying and digitation are significantly associated with such defects detected on ultrasound.