Download pelvic organ prolapse - Malaysian Urological Association

PELVIC ORGAN PROLAPSE
AUC APRIL ‘14
JR SATHIYA
HOSPITAL PULAU PINANG
DEFINITION
• Pelvic organ prolapse is defined as the descent of one
or more of the following:
• anterior vaginal wall,
• posterior vaginal wall,
• and apex of the vagina (cervix/uterus) or vault (cuff)
after hysterectomy.
• Absence of prolapse is defined as stage 0 support;
prolapse can be staged from stage I to stage IV
IMPORTANCE OF PELVIC ORGAN
PROLAPSE TO THE UROLOGIST?
• Pelvic organ prolapse can occur in association with
UI and other lower urinary tract dysfunction and
may on occasion mask incontinence
DEFINITION
• Anterior vaginal wall prolapse- descent of the anterior vagina
so that the urethrovesical junction or any anterior point proximal to
this is less than 3 cm above the plane of the hymen.
• Prolapse of the apical segment of the vagina is defined as any
descent of the vaginal cuff scar (after hysterectomy) or cervix,
below a point that is 2 cm less than the total vaginal length above
the plane of the hymen.
• Posterior vaginal wall prolapse is defined as any descent of the
posterior vaginal wall so that a midline point on the posterior
vaginal wall 3 cm above the level of the hymen or any posterior
point proximal to this is less than 3 cm above the plane of the
hymen.
FIGURE 1B
Stage 0
Hymenal
remnants'
Stage I
Stage II
Stage III
Stage IV
1898
SECTION XIV ● Urine Transport, Storage, and Emptying
1963
Severity
(Porges)
1980
Grading system
(Beecham)
1972
Vaginal profile
(Baden)
Midplane of
vagina
Straining
Grade 1
Slight or
1st degree
Hymenal
ring
Grade 2
Introitus
1996
Quantitative POP
(ICS, AUGS, SGS)
Stage I
1st
degree
(–) 1 cm
Stage II
Straining Straining
(+) 1 cm
Moderate or
2nd degree
Grade 3
2nd degree
Complete
eversion
Marked or
3rd degree
Grade 4
3rd degree
Stage III
Stage IV
Figure 64–1. Visual comparison of systems used to quantify pelvic organ prolapse (From Theofrastous JP, Swift SE. The clinical evaluation
of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:783–804.)
Key Points: General Considerations
●
Pelvic floor disorders (PFDs) are a prevalent worldwide
health concern.
For the purposes of routine outpatient assessment, this quantification can be achieved on the basis of the number of pads used per
day or the frequency of clothing changes due to urinary leakage.
In the setting of research or an academic practice, more stringent
obstruct the urethra and give a false-negative result.
Once stress incontinence is confirmed, the prolapse repair
can be combined with surgery for stress incontinence. There is
a small risk of overcorrection and voiding dysfunction with this
strategy. The other equally common strategy is to do the repair
first and deal with any stress incontinence later if it persists. The
downside with this is that the patient will need two procedures.
If the second option is chosen, there is no need to do bladder
studies before the operation because this will have to be repeated
Pelvic muscle function
• Pelvic floor muscle function can be
qualitatively defined by the tone at
rest and the strength of a
voluntary or reflex contraction as
strong, weak, or absent or by a
validated grading system (e.g.,
Oxford 1 to 5).
Oxford grading of pelvic floor muscle strength
Grade 0
Absent contraction
Grade 1
Grade 2
Flicker, trace or minimal
Weak contraction – has greater potential for
strengthening than grade 0 or 1
Ability to move against mild resistance
Ability to move against some resistance
Ability to move and hold against resistance
Grade 3
Grade 4
Grade 5 Normal/
strong
Table 2
• Rectal examination - easiest
method of assessing pelvic floor
muscle function in children and
men. In addition, rectal
examination is essential in children
with UI to rule out fecal impaction
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 18:9
T
242
Relationship between prolapse and
incontinence
• Patients with severe prolapse may develop voiding symptoms as a
result of urethral kinking, leading to obstruction that is worsened
during straining effort
• For instance, a moderate or severe cystocele may promote urethral
compression and kinking, pressure dissipation, and an increase in
maximum urethral closure pressures
• Detrusor overactivity seen with cystocele.
• Occult or latent incontinence is urethral sphincteric incompetence
masked by the presence of pelvic prolapse (Rosenzweig et al, 1992).
• Incontinent women may note the decrease or disappearance of stress
incontinence as the degree of prolapse worsens.
Relationship between prolapse and
incontinence
• A large rectocele may cause incomplete bowel evacuation
and tenesmus
• The prevalence of fecal incontinence increases to 17% in
populations with pelvic organ prolapse and UI
• The most common mechanisms are an incompetent
sphincteric mechanism (secondary to a structural defect
or pudendal nerve damage) and overflow incontinence.
Pelvic floor support mechanism
• Deficiency causes pelvic organ prolapse or
incontinence, or both
• Continuum between Hypermobility and Intrinsic
Sphincter Deficiency
• Urethral Support Mechanisms
ISD & hypermobility
• In patients with stress incontinence there is a
spectrum between the two components of ISD and
urethral hypermobility
• some patients have primary sphincteric problems,
whereas others have an adequately functioning
sphincter but significant hypermobility.
• The majority lie somewhere between these two
extremes.
Urethral support mechanism
• The urethral support mechanism comprises all the
structures extrinsic to the urethra that offer a supportive
backplate on which the proximal urethra and midurethra lie
• Connective tissue
• Pelvic musculature
• Support and suspension of the pelvic organs is dependent
on a healthy pelvic floor striated muscle, intact robust
connective tissue, and their attachment to the bony frame of
the pelvis
Urethral support mechanism
-Connective tissue
• Pubourethral ligament attaches the midurethra to the
inferior side of the pubic symphysis and prevents its
downward rotational descent.
• It works in conjunction with the pubourethralis
muscle, that forms a sling around the proximal
urethra. Forms the midurethral complex
• Has been postulated that an elongation of the
posterior pubourethral ligaments may be a significant
contributory factor to the loss of urethral support seen
in stress incontinence
Urethral support mechanism
-Connective tissue
• Endo-pelvic fascia/pubocervical fascia, extending between the bladder
and the vagina, suspends and attaches the vagina and cervix to the pelvic
sidewall and to each arcus tendineus fascia pelvis, thereby offering posterior
support to the bladder and bladder neck.
• It has two surfaces: the perivesical fascia on the vaginal side and the endopelvic fascia on the abdominal side.
• Its upper zone supports the bladder above the cervix,
• the middle zone supports the trigone, and
• the lower zone supports the bladder neck.
• Laxity of the fascia in each of the zones will result in uterine prolapse,
cystocele, and urethrocele, respectively (DeLancey, 2001).
Urethral support mechanism
-Connective tissue
• The arcus tendineus fasciae pelvis are tensile
structures located bilaterally on either side of the urethra
and vagina that act like the ropes of a suspension bridge
and provide the necessary support needed to hang the
urethra on the anterior vaginal wall. They originate as
fibrous bands from the pubic bone and broaden out as
aponeurotic structures moving dorsally to insert into the
ischial spine
• The cardinal ligaments and the more medially placed
uterosacral ligaments support the uterus and cervix;
their relaxation results in uterine prolapse.
Pubocervical fascia
Tendinous arch
Pelvis
Bladder
s
ment of
r.
Cardinal
ligament
Cervix
Uterosacral
ligament
Figure 63–7.
Rectum
Sacrum
Relationship of ligaments to pelvic organs.
Urethral support mechanism
- Pelvic musculature
• levator ani muscles, carries the weight of the pelvic
contents and prevents the abdominal pressure from
stretching the ligamentous support structures.
• puborectalis
• pubococcygeus
• iliococcygeus
Prevalence
• POP based on a sensation of a mass bulging into
the vagina ranges between 5% and 10%
• prolapse occurs most frequently in the anterior
compartment, next most frequently in the posterior
compartment, and least in the apical compartment.
• Two studies that examined prolapse by race found
that black women had the lowest prevalence and
Hispanic women the highest
Table 3. Risk Factors for Prolapse From the WHI
Risk Factors
Moderate Increased Risk
No Increased Risk
Age
Waist circumference
Education
Race
Increasing parity
Occupation
Body mass index
Constipation
Quality of life
Parity
Chronic illness
Time since menopause
Breast-feeding
Hysterectomy
Past smoking
Coffee consumption
Physical activity
WHI indicates Women’s Health Initiative.
Adapted from Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: gravity and
gravidity. Am J Obstet Gynecol. 2002;186(6):1160-1168.
about twice the rate of cystocele compared with white
women.The large cohort allowed for multivariate analysis of
these data, thus eliminating confounding factors such as
number of vaginal births and body mass index (BMI; in
kg/m2) when comparing relative risk.
lapse in this cohort of women after menopause.”8 They go
on to say that an even higher rate of POP might have been
found were the study subjects examined at a 45-degree
angle using the POP-Q rather than in the supine position.
EVALUATION OF PATIENT
History
• History of present illness
• Incontinence; Stress, Urgency incontinence, without
sensory awareness?
• Quantification of leakage
• Voiding pattern; Frequency, daytime/night time
• Duration of symptoms and inciting event
• QOL & bother
History
• Previous pelvic surgery
• Obstetric history
• Neurological condition
• Trauma
• Radiation therapy
• Current medications
Physical examination
• Abdominal examination
• Examination of external genitalia
• Pervaginal examination
• Urethral mobility test (Q-tip test) <30% : Normal
• POP-Q
• Neurological examination
• DRE
Table 64–4.
Components of a Focused Pelvic Examination
• Inspection and palpation of breasts (e.g., masses or lumps,
tenderness, symmetry nipple discharge)
• Digital rectal examination including sphincter tone, presence of
hemorrhoids, rectal masses
Pelvic examination (with or without specimen collection for smears
and cultures) including:
• External genitalia (e.g., general appearance, hair distribution,
lesions)
• Urethral meatus (e.g., size, location, lesions, prolapse)
• Urethra (e.g., masses, tenderness, scarring)
• Bladder (e.g., fullness, masses, tenderness)
• Vagina (e.g., general appearance, estrogen effect, discharge,
lesions, pelvic support, cystocele, rectocele)
• Cervix (e.g., general appearance, lesions, discharge)
• Uterus (e.g., size, contour, positions, mobility, tenderness,
consistency, descent or support)
• Adnexa/parametria (e.g., masses, tenderness, organomegaly,
nodularity)
• Anus and perineum
• The POP-Q
At press time, 7 of 11 bullet points listed above are required to be considered a
complete female genitourinary examination. However, other organ systems/
body areas not limited to the genitourinary system may be included in a report
to accomplish the requirements of various levels of examination.
Data from Centers for Medicare/Medicaid (CMS): Single organ system
examination—Genitourinary: 1997 Documentation Guidelines for Evaluation
and Management (E/M) Services, jointly approved by the American Medical
Association and HCFA with revisions November, 1997.
• Done in lithotomy and standing
• With Valsalva
to the patient during insertion of the Q-tip can be minimized
with the use of intraurethral lidocaine jelly. The Q-tip is inserted
into the bladder through the urethra, and the angle that the Q-tip
moves from horizontal to its final position with straining is measured. Hypermobility is defined as a Q-tip angle of greater than 30
degrees from horizontal.
Assessment of prolapse should ideally be performed in
both the lithotomy and standing positions, the latter facilitated by having the patient stand with one foot elevated on a short
stool. Each compartment—the anterior, posterior, and apical
(uterus/cervix or vaginal cuff)—should be evaluated methodically
and the perineal body assessed for laxity. A complete systematic
examination is performed using two posterior blades of a split
Grave speculum with and without straining. First, one blade is
used to retract the posterior wall to facilitate anterior compart-
• Tedious
A
Point
Description
Range of values
Aa
Anterior vaginal wall 3 cm proximal
to the hymen
–3 cm to +3 cm
Ba
Most distal position of remaining
upper anterior vaginal wall
–3 cm to +tvl
C
Most distal edge of cervix or vaginal
cuff scar
–
D
Posterior fornix (N/A if
post-hysterectomy)
–
Ap
Posterior vaginal wall 3 cm proximal –3 cm to +3 cm
to the hymen
Bp
Most distal position of remaining
upper posterior vaginal wall
gh (genital
hiatus)
Measured from middle of external
urethral meatus to posterior midline
hymen
–
pb (perineal
body)
Measured from posterior margin of
gh to middle of anal opening
–
tvl (total
vaginal length)
Depth of vagina when point D or C
is reduced to normal position
–
–3 cm to +tvl
Aa
Ba
XX
X
C
Bp X
X
Ap
–3
4.5
+2
Aa
gh
Ap
–3
1
+5
Ba
pb
Bp
–6
8
C
septum. Demonstra
rior pressure applied
ter tone, which is a
important in neuro
voluntarily tighten
flow of urine midst
suggest a possible
patient lack of unde
the specific muscle
In men, genitou
function should al
stenosis and, particu
urinary leakage wi
leakage is ideally
position.
tvl
––
Figure 64–3. Line drawing example of posterior support defect.
The anterior compartment is well supported. The leading point of
the prolapse is point Bp (+5), which is 5 cm beyond the hymen.
Total vaginal length is 8 cm, and point C (−6), the cuff position,
has descended 2 cm. (From Bump RC, Mattiasson A, Bo K, et al.
The standardization of terminology of female pelvic organ
prolapse and pelvic floor dysfunction. Am J Obstet Gynecol
1996;175:10–7.)
Key Points: Evalu
A properly per
the evaluation
● The Centers fo
of both male a
to meet codin
● Assessment of
performed in b
● Several classifi
able for assess
●
SUPPLEMENTAL
EVALUATION
Supplemental evaluation
• Urinalysis
• Post Void residual
• Bladder diaries ( ICS requires 3 days)
• Pad Test (1 day, 1.3g is significant)
Supplemental investigation
• Urodynamics
• Voiding cystourethrogram
• Dynamic MRI
TREATMENT
Non Operative Treatment
Figure 5. Pessaries
• Watchful waiting
• Pelvic Floor Exercise
• Pessaries
Photo courtesy of Cooper Surgical.
us
tio
tra
na
ca
Pa
du
flo
T
is
an
of
Pe
Pe
an
ap
sh
M
th
th
be
Operative Treatment
• The goal of POP repair is to restore the normal anatomy
and function of the vagina and the lower urinary and GI
tracts.
• The decision regarding whether to proceed with a
transvaginal or a transabdominal approach is dependent on
• which of the three compartments is affected,
• the degree of prolapse, and
• patient and surgeon preference
Decade among United States Urologists
http://dx.doi.org/10.1016/j.juro.2013.10.076
Vol. 191, 1022-1027, April 2014
Printed in U.S.A.
with this condition undergo surgical
treatment.1 The lifetime risk of prolapse surgery in a woman in the
United States is 11% to 19% by age 80
Changes in Pelvic Organ Prolapse Surgery in the Last
Decade among
United
States Urologists
Dean S. Elterman,* Bilal I. Chughtai,*
Emily
Vertosick,
Alexandra Maschino,
James A. Eastham and Jaspreet
Sandhu†,‡
Dean S. S.
Elterman,*
Bilal I. Chughtai,* Emily Vertosick, Alexandra Maschino,
James A. Eastham and Jaspreet S. Sandhu†,‡
From the Division of Urology, Department of Surgery, University Health Network, University of Toronto (DSE), Toronto, Ontario,
From the Division of Urology, Department of Surgery, University Health Network, University of Toronto (DSE), Toronto, Ontario,
Canada and Brady Department of Urology, Weill
Cornell
Medical
College
(BIC),
and Department
of Epidemiology
Biostatistics
Canada
and Brady
Department
of Urology,
Weill Cornell
Medical College (BIC),
and Department of and
Epidemiology
and Biostatistics
AM), and (JAE,
Urology Service,
Surgery (JAE, JSS), Memorial
Sloan-Kettering
Cancer York,
Center, New
New York,
New York
(EV, AM), and Urology Service, Department of(EV,Surgery
JSS), Department
Memorialof Sloan-Kettering
Cancer
Center, New
York
Abbreviations
and Acronyms
ABU ¼ American Board of
Urology
FDA ¼ Food and Drug
Administration
0022-5347/14/1914-1022/0
THE JOURNAL OF UROLOGY®
© 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
POP ¼ pelvic organ prolapse
PELVIC organ prolapse is a common
condition that affects about half of
women and correlates with increasing
age.1 Approximately 10% of women
Accepted for publication October 11, 2013.
Supported by the Sidney Kimmel Center for
Prostate and Urological Cancers, Memorial
Sloan-Kettering Cancer Center.
* Equal study contribution.
† Correspondence: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, Sidney Kimmel Center for Prostate
and Urologic Cancers, 353 East 68th St., New
York, New York 10065 (e-mail: sandhuj@mskcc.
org).
‡ Financial interest and/or other relationship
with American Medical Systems.
Purpose: Surgical correction of pelvic organ prolapse underwent transformation
Abbreviations
Purpose:
Surgical correction
of pelvic
organ
prolapse
underwent
in the last decade.
Training
in pelvic
organ prolapse
surgery, the transformation
ease of mesh kit
and Acronyms
use, and Food and Drug Administration warnings about mesh have influenced
in
lastBoard
decade.
Training
in pelvic organ prolapse surgery, the ease of mesh kit
ABUthe
¼ American
of
practice patterns. We investigated trends in pelvic organ prolapse procedures.
Urology and Food and Drug Administration warnings about mesh have influenced
use,
Materials and Methods: Case logs of pelvic organ prolapse procedures, mesh use
FDA ¼ Food and Drug
and pessary placement were obtained from the American Board of Urology for
practice
Administration patterns. We investigated trends in pelvic organ prolapse procedures.
2003 to 2012. We evaluated associations between surgeon characteristics and the
POP
¼
pelvic
organ
prolapse
Materials and Methods:
logs prolapse
of pelvic
organ prolapse procedures, mesh use
use ofCase
pelvic organ
procedures.
Results:
Of 6,355
nonpediatric
applying for Board
certification
recertifi- for
and
placement
were
obtained
fromurologists
the American
of orUrology
Acceptedpessary
for publication October
11, 2013.
cation 2,192, representing a 10% annual sample of all urologists, reported perSupported by the Sidney Kimmel Center for
2003
to 2012. We evaluated
associations
between
surgeon
and the
Prostate and Urological Cancers, Memorial
forming pelvic
organ prolapse
procedures
during thecharacteristics
study period. The number
Sloan-Kettering Cancer Center.
of procedures
increased steadily from 930 in 2003 to 6,978 in 2012. The number
use
of pelvic organ prolapse
procedures.
* Equal study contribution.
of
colporrhaphies
increased from 806 to 2,670 and the number of colpopexies
† Correspondence: Urology Service, DepartResults:
OfSloan-Kettering
6,355Can- nonpediatric
urologists
applying
for 2012.
certification
recertifiment
of Surgery, Memorial
increased from 32 to 1,414 between
2003 and
The number or
of vaginal
cer Center, Sidney Kimmel Center for Prostate
colpopexies
increased
from 24 sample
to 1,016 during
theurologists,
study period. The
number ofpercation
2,192,
representing
a 10%
annual
of all
reported
and
Urologic Cancers,
353 East 68th
St., New
sacrocolpopexies increased from 8 to 398 with exponential increases in laparoYork, New York 10065 (e-mail: sandhuj@mskcc.
forming pelvic organ scopic
prolapse
procedures
during
the Mesh
studyinsertion
period.
The number
org).
sacrocolpopexy
(282 cases
by 2012).
increased
from
‡ Financial interest and/or other relationship
10 cases
reportedfrom
by applicants
2005 toto
1,552
reported
in 2012 (p
<0.0005).
ofAmerican
procedures
increased
steadily
930 inin2003
6,978
in 2012.
The
number
with
Medical Systems.
Mesh revision, first reported in 2007 with 52 performed, consistently increased to
of colporrhaphies increased
806
to 2,670
the
number
of ofcolpopexies
214 in 2012.from
Urologists
trained
in femaleand
urology
performed
a median
16 pelvic
prolapse
procedures,
double
the number
by surgeonsoftrained
increased from 32 toorgan
1,414
between
2003
and
2012. reported
The number
vaginal
other urological fellowships. Urologists of the female gender also reported
colpopexies increasedin
from
24 to 1,016 during the study period. The number of
performing approximately 8 more procedures annually than male urologists.
sacrocolpopexies increased
from
to 398
with
exponential
increases
in laparoConclusions:
The8number
of pelvic
organ
prolapse operations
done by urologists
increased
last decade
with insertion
a similar increase
in mesh use.
scopic sacrocolpopexy
(282 dramatically
cases byin the
2012).
Mesh
increased
from
More colpopexies are now performed with laparoscopic sacrocolpopexy showing
10 cases reported by an
applicants
in 2005
1,552
reported
in 2012
(p <0.0005).
exponential increase.
Theto
recent
trend
of mesh revision
is notable
with a
much
faster
rate
of
increase
than
mesh
insertion.
Mesh revision, first reported in 2007 with 52 performed, consistently increased to
214 in 2012. Urologists trained
in female urology performed a median of 16 pelvic
Key Words: pelvic organ prolapse; reoperation; surgical mesh;
physicians,
physician’s
practiceby
patterns
organ prolapse procedures, double
thewomen;
number
reported
surgeons trained
in other urological fellowships. Urologists of the female gender also reported
performing approximately 8 more procedures annually than male urologists.
with this condition undergo surgical
PELVIC organ prolapse is a common
1
The done
lifetimeby
riskurologists
of procondition
affects
about prolapse
half of
treatment.
Conclusions: The number
ofthat
pelvic
organ
operations
lapse surgery in a woman in the
women and correlates with increasing
increased dramatically
in the last decade with a similar
increase in mesh use.
United States is 11% to 19% by age 80
age.1 Approximately 10% of women
More colpopexies are now performed with laparoscopic sacrocolpopexy showing
http://dx.doi.org/10.1016/j.juro.2013.10.076
0022-5347/14/1914-1022/0
an exponential increase.
The recent trend of mesh revision
is notable with a
Vol. 191, 1022-1027, April 2014
THE JOURNAL OF UROLOGY
1022 j www.jurology.com
Printed in U.S.A.
© 2014 by A
U
A
E
R
,I .
much faster rate of increase than mesh insertion.
®
MERICAN
ROLOGICAL
SSOCIATION
DUCATION AND
ESEARCH
NC
EAU 2013
Evidence summary
Women with prolapse + UI
s3URGERYFOR0/035)SHOWSAHIGHERRATEOFCUREINTHESHORTTERMTHAN0/0SURGERYALONE
s4HEREISCONFLICTINGEVIDENCEONTHERELATIVEBENEFITOFCOMBINEDSURGERYLONGTERM
s#OMBINEDSURGERYFOR0/035)CARRIESAHIGHERRISKOFADVERSEEVENTS
Continent women with POP
s!REATRISKOFDEVELOPING5)POSTOPERATIVELY
s4HEADDITIONOFAPROPHYLACTICANTIINCONTINENCEPROCEDUREREDUCESTHERISKOFPOSTOPERATIVE5)
s4HEADDITIONOFAPROPHYLACTICANTIINCONTINENCEPROCEDUREINCREASESTHERISKOFADVERSEEVENTSTO
the same extent
Women with prolapse and occult SUI
s3URGERYFOR0/035)SHOWSAHIGHERRATEOFCUREINTHESHORTTERMTHAN0/0SURGERYALONE
s#OMBINEDSURGERYFOR0/035)CARRIESAHIGHERRISKOFADVERSEEVENTS
LE
Recommendations for women requiring surgery for bothersome POP who have symptomatic or
unmasked stress urinary incontinence
Offer simultaneous surgery for POP and stress urinary incontinence.
Warn women of the increased risk of adverse events with combined surgery compared to prolapse
surgery alone.
Recommendations for women requiring surgery for bothersome POP without symptomatic or
GR
1a
1b
1b
1a
1b
1b
1a
1b
A
A
GR
s#OMBINEDSURGERYFOR0/035)CARRIESAHIGHERRISKOFADVERSEEVENTS
Continent women with POP
s!REATRISKOFDEVELOPING5)POSTOPERATIVELY
s4HEADDITIONOFAPROPHYLACTICANTIINCONTINENCEPROCEDUREREDUCESTHERISKOFPOSTOPERATIVE5)
s4HEADDITIONOFAPROPHYLACTICANTIINCONTINENCEPROCEDUREINCREASESTHERISKOFADVERSEEVENTSTO
the same extent
Women with prolapse and occult SUI
s3URGERYFOR0/035)SHOWSAHIGHERRATEOFCUREINTHESHORTTERMTHAN0/0SURGERYALONE
s#OMBINEDSURGERYFOR0/035)CARRIESAHIGHERRISKOFADVERSEEVENTS
1b
Recommendations for women requiring surgery for bothersome POP who have symptomatic or
unmasked stress urinary incontinence
Offer simultaneous surgery for POP and stress urinary incontinence.
Warn women of the increased risk of adverse events with combined surgery compared to prolapse
surgery alone.
Recommendations for women requiring surgery for bothersome POP without symptomatic or
unmasked stress urinary incontinence
Warn women that there is a risk of developing de novo stress urinary incontinence after prolapse
surgery.
Inform women that the benefit of prophylactic stress urinary incontinence surgery is uncertain.
Warn women that the benefit of surgery for stress urinary incontinence may be outweighed by the
increased risk of adverse events with combined surgery compared to prolapse surgery alone.
POP = pelvic organ prolapse.
GR
EAU 2013
1a
1b
1b
1a
1b
A
A
GR
A
C
A
5.3.1.2 References
1.
Maher CM, Feiner B, Baessler K, et al.Surgical management of pelvic organ prolapse in women: the
UPDATEDSUMMARYVERSION#OCHRANEREVIEW)NT5ROGYNECOL*.OV
http://www.ncbi.nlm.nih.gov/pubmed/21927941
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