Recent Advances in Pelvic Floor Surgery
Pelvic organ prolapse (POP) occurs commonly in parous women. Physical examination of a sub-set of post-menopausal parous women, recruited as part of the Women’s Health Initiative Hormone Replacement Therapy Clinical Trial, showed that 41% of women with and 38% of women without a uterus had some form of prolapse.1 Of the nulliparous women in this study, 19% of those with a uterus also had genital prolapse. For all groups of women the anterior vagina was the most common single site of prolapse (34%); however, almost 20% of women had prolapsed of two or more compartments. The aetiology of POP is multifactorial, with risk factors including pregnancy, spontaneous and instrumental vaginal delivery, pelvic surgery, obesity, connective tissue disorders, pelvic floor denervation, ageing, post-menopausal status and all causes of chronically raised intra-abdominal pressure.2,3
The estimated lifetime risk of undergoing surgery for urinary incontinence or POP has been estimated as 11%.4,5 In the study by Olson4 the risk of re-operation was 29%. Therefore, the direct andindirect costs of treating POP are substantial. Using Diagnosis-Related Group (DRG) reimbursement rates and estimates of surgical admissions for 2005, we have estimated the direct surgical cost for POP repair to be € 140,000,000, € 83,000,000 and € 81,000,000 in Germany, France and England, respectively (Slack M, personal communication). Additional studies assessing the direct costs of conservative management (clinic appointments and pessaries) and the indirect costs associated with POP morbidity are needed.
The Assessment of Pelvic Organ Prolapse
The assessment of POP and its treatment must take into account the multidimensional nature of the condition6 and as such should include assessment of patient symptoms, quality of life (QOL), patient expectations and anatomical prolapse staging. Patients may present with mechanical, lower urinary tract, bowel or sexual dysfunction symptoms.7 The impact of a particular symptom on QOL is related to symptom frequency, with symptoms occurring more than once per week causing ‘severe bother’.8 Structured QOL tools standardise the collection of data and allow comparison of information obtained in different centres.9 These tools also allow the significance of a statistical change in symptoms to be assessed in terms of its global impact on health. These questionnaires need to be reliable (produce consistent results on different occasions, when there is no evidence of change), valid (measure what they supposed to measure) and responsive (able to detect change over time).
A variety of long- and short-form QOL questionnaires have been validated for use in women with POP before and after treatment;10–13 however, the number of such questionnaires is limited. At the third International Consultation on Incontinence in 2004, no questionnaires received a grade A recommendation for POP. The Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) were recommended grade B evidence. A number of other questionnaires, including the P-QOL/St Mary’s Questionnaire, the Electronic PersonalAssessment Questionnaire (e-PAQ) and the International Consultation on Incontinence Questionnaire (ICIQ)–vaginal symptoms questionnaire, were graded as having potential. The ICI is developing a set of modular questionnaires that it hopes will become the international standard forwork on POP.14
Patient-centred goals have been used to assess the outcome of reconstructive and obliterative POP surgery.15,16 The relief of symptoms and the resumption of activity are the most commonly cited patient centred goals for POP surgery and the attainment of these goals, as assessed on a five-point ‘goal-assessment scale’, appears to correlate with disease-specific QOL tools.17
The Pelvic Organ Prolapse Quantification (POPQ) system aims to standardise the anatomical quantification of POP. POPQ requires measuring, to within half a centimetre, nine points relative to the hymen. These measurements are then translated into an ordinal staging system.18 Since its introduction in 1996, POPQ has had limited uptake by urogynaecologists,19 probably because it is perceived as time-consuming and difficult to perform without repetition. A simplified POPQ in which four points (the anterior and posterior vaginal walls, the apex/cuff and the cervix) are measured has been developed and has been shown to have good inter-observer agreement.20 However, again this system is not widely used.
The position in which the patient is assessed during the POPQ assessment has an impact on POP staging. One-third of patients examined at 45º in a birthing chair were shown to be upstaged compared with those who were assessed in a supine position.21 Also, in our experience examination under anaesthesia in lithotomy often reveals more significant prolapse than POPQ staging when awake and supine. We have therefore moved towards the assessment of patients at maximum valsalva when standing, as this often recreates patient reported anatomical and symptomatic POP.
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22. Maher C, Baessler K, Glazener CM, et al., Surgical management of pelvic organ prolapse in women, Cochrane Database Syst Rev, 2007;CD004014.
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