Brian J. Linder, M.D., a Mayo Clinic urogynecologist, talks about current options for surgical and nonsurgical management of pelvic organ prolapse. This condition is prevalent. Therapeutic options selected correspond to assessment results, the degree of bother to the patient, and shared decision-making with the physician and patient.
Hi I'm DR brian linder, an associate professor of neurology and obstetrics and gynecology here at Mayo Clinic in Rochester. I'm excited to talk to you today about the evaluation and management options for pelvic organ Prolapse. Pelvic organ prolapse is a common clinical entity that significantly impacts our patient's quality of life, secondary to pelvic pressure, a vaginal bulge as well as urinary, bowel or sexual dysfunction. It's highly prevalent, with estimates that up to one in eight women will undergo surgical management for prolapse in their lifetime. Fortunately there are a wide variety of treatment options, both surgical and nonsurgical. Today we'll talk about the presentation, evaluation and management of this condition. The diagnosis of prolapse is largely clinical centering around a history and physical exam. A detailed history, including the duration of prolapse symptoms, degree of a vaginal bulge and symptomatic bother are helpful. Additionally, assessment for concomitant bowel bladder or sexual dysfunction is routinely performed as these may coexist with prolapse physical exam is how you confirm the diagnosis. Typically the exam proceeds in a stepwise manner. And while there's no universal technique, it includes an assessment of the vulva vaginal epithelium, pelvic floor muscles, extent and location of pelvic organ, prolapse urinary incontinence and assessment of other pelvic organs such as the Alexa when the diagnosis of prolapse is made. No additional testing is routinely required. Additional testing may be useful when patients. No other pelvic floor symptoms such as bladder or bowel dysfunction or planning surgery. For instance, your dynamic testing with assessment of a post void residual may be helpful regarding treatment options. Prolapse is a benign condition and therefore treatment selection is based on symptoms, degree of bother and in shared decision making with the individual patient. Overall treatment options for women with pelvic organ prolapse include observation, conservative measures, possessory use or surgery. The degree of bother is a critical consideration in terms of managing prolapse. That is. While some women may have an atomic prolapse, it may not always be symptomatic. For those with asymptomatic prolapse, they can typically be reassured that prolapse can safely be managed conservatively and that rapid progression would be uncommon. Well, it's an understudied topic. The available evidence suggests that prolapse may remain stable or gradually worsen over time. For instance, in one study of patients undergoing observation, 2/3 remained on observation at two years while a third progressed to either using a pizzeria or surgery. Additional conservative measures such as pelvic floor. Physical therapy may be helpful for those with mild symptoms, though to a lesser extent may impact the an atomic extent of a vaginal bulge. For those would bother some symptoms who do not desire to undergo surgery. Best replacement is an effective intervention that can significantly improve prolapse related symptoms. Accessory is a device that's placed in the vaginal canal to support the prolapsed organs and return them to a more anatomical position Among patients who prefer this treatment option up to 90% can successfully be fitted with accessory for the initial placement of pelvic exam is performed in an appropriate size and shape of history has chosen when feasible, patients are taught to remove and reinsert the pastries themselves. For those that are unable to do this more continuous. Where is utilized with interval visits with a provider for pest removal, cleaning and maintenance inappropriate candidates, topical estrogen can improve comfort with pastry use and help prevent ulcers from forming on the vaginal epithelium surgery is indicated in patients with symptomatic prolapse who decline or have not had adequate success with nonsurgical management surgeries can be performed via vaginal laparoscopic or robotic or open approaches, each with their own unique risk and benefit profile. Ultimately deciding between these is based on the compartments of prolapse involved the extent of prolapse, medical and surgical comorbidities, differences in durability and risk between the surgeries and in shared decision making with the patient factoring in their preferences. As mentioned, one route of prolapse surgery is via the Vagina. Here, there are no abdominal incisions and the procedures typically performed using the patient's own tissue. Without the use of mesh. This type of native tissue repair is aimed at the prolapse in compartments that is either the anterior a pickle or post your compartments or a combination of these. In general, native tissue vaginal prolapse surgeries are well tolerated with good long term efficacy and low risk of major complications. For instance, in our own institutional experience managing a pickle prolapse using a native tissue. Trans vaginal approach. The re treatment rate at five years was roughly 6% And at 10 years, roughly 19%. A similar re treatment rate 6% with a mean follow up of 6.5 years was identified in a population based study as well for patients interested in trans vaginal surgery for advanced prolapse but do not desire to maintain a vaginal canal and obliterated procedure can be performed. These procedures are also known as a couple crisis. Similar to the previous surgery we discussed. They don't use mesh or a synthetic graft material. Rather, they use the patients own tissue essentially these procedures approximate the anterior and posterior vaginal walls closing the canal for future of sexual function. The benefit of this type of surgery is a high success rate and fewer complications than other surgical options. But of course this is only suitable for patients who are comfortable with closing the vaginal canal with regard to sexual function. In addition to the native tissue, trans vaginal surgery, we discussed. An additional option is the use of abdominal laparoscopic or robotic approach to prolapse surgery. The most common procedure performed in this fashion is a sacred cotopaxi. During the surgery, a y shaped mesh is attached to the anterior and posterior vagina and secured to the interior longitudinal ligament overlying the sacrum. In contemporary series, these are most commonly performed in a laparoscopic or robotic manner, though an open approach is still utilized in some cases, shown here is an example of a robotic soccer copa pixie. The space over the sacrum and along the inter and post your vaginal walls have been dissected. The mesh is then attached to the ante and post your vaginal wall and then secured to the sacrum compared to a native tissue. Trans vaginal approach, psycho koppel pixie has its own advantages and disadvantages. An advantage of this route is that it's associated with lower prolapse recurrence rates than the native tissue. Trans vaginal surgery. However, it adds the risk of using a synthetic mesh material. For instance, following sacred couple pixie. There is a risk of vaginal mesh exposure where the mesh protrudes through the vaginal epithelium and may need additional management. While the use of mission surgeries for female pelvic floor disorders has been an area of controversy, it's important to note that the recent FDA notifications relate specifically to the use of mesh that's placed via a trans vaginal route for prolapse. Not specifically to secret cotopaxi though there are, as was mentioned, specific risk of mesh related complications that still exist. A detailed conversation of these risks with the patient is important when counseling about surgical options again, to allow for shared decision making based on patient preferences. In summary pelvic organ prolapse is a common condition affecting women that may be encountered by providers. Typically patients with asymptomatic or mildly symptomatic prolapse could be managed with observation or conservative measures for those with bothersome symptoms. Nonsurgical and surgical options are available that are effective. Ultimately, the appropriate prolapse management strategy is based on the patient's presentation and symptoms, with a choice of treatment made via shared decision making with the individual patient. There's no one size fits all treatment when it comes to prolapse. Thank you for your attention.