Uterine prolapse in a non-pregnant bitch.

A ten-year-old mixed breed bitch was presented for a tissue prolapse protruding from her vulva. Following detailed examination and stabilization, the ovaries and uterine horns were removed by laparotomy, whereas the prolapsed tissue identified as uterus including cervix was removed vaginally. Histology confirmed uterine prolapse, a rare condition in bitches usually found shortly after birth especially due to dystocia. In contrast, the present case was found in a nulliparous non-pregnant bitch. Diagnostic and therapeutic approaches, including microbiological and histological findings, are described and discussed critically.

Total vaginal length: Does it matter for assessing uterine prolapse?

INTRODUCTION AND HYPOTHESIS: Using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system, uterine prolapse staging requires measurement of total vaginal length (TVL). The aim of this study was to determine whether TVT is a confounder of the relationship between uterine descent and POP symptoms. METHODS: This is a retrospective study on 721 patients seen in a tertiary urogynaecological unit. All patients had undergone a standardised, in-house, physician-led questionnaire and digital POP-Q examination. Patients with a history of hysterectomy or with a dominant prolapse in the anterior ± posterior compartment were excluded from analysis, leaving 393 complete data sets for analysis. Association between prolapse symptoms (lump/drag) and station of cervix (i.e. C) were tested. Age, body mass index (BMI), menospausal status and vaginal parity were tested as potential confounders. Variables that were significant on binary logistic regression (P < 0.05) were included in a model for receiver operting characteristic (ROC) statistical analysis. This was repeated after adding TVL to the model. Likelihood ratio test was performed to compare models. RESULTS: On binary logistic regression, prolapse symptoms were significantly associated with C, menopausal status and TVL (all P < 0.03). ROC analysis yielded an area under the curve (AUC) of 0.75 with menopausal status and C in the model. Adding TVL yielded an AUC of 0.773. The difference is statistically significant on the likelihood ratio test (P < 0.001). CONCLUSIONS: Adding TVL improved the performance of cervical station in predicting prolapse symptoms, validating the practice of using TVL in staging uterine prolapse.

What Is Uterine Prolapse?

This JAMA Patient Page describes the condition of uterine prolapse and its risk factors, symptoms, and treatment options.

Relationship of degree of uterine prolapse between pelvic examination in lithotomy position with cervical traction and pelvic examination in standing position.

INTRODUCTION AND HYPOTHESIS: The Pelvic Organ Prolapse Quantification (POP-Q) assessment is a standardized tool for evaluating pelvic organ prolapse (POP). However, intraoperative evaluation reveals greater apical prolapse than do POP-Q scores. There is a need to implement a method for performing POP-Q at the outpatient clinic that reveals maximal prolapse and causes the least pain. This study was performed to compare the degree of uterine prolapse between POP-Q with cervical traction and POP-Q in the standing position. Secondary objectives were to compare pain and acceptability scores between the two examinations. METHODS: Women with uterine prolapse stage I or II by routine examination were invited to participate. Comparison of degree of uterine prolapse, POP-Q stages, acceptability score, and pain score between the two types of examinations were undertaken. RESULTS: Seventy-eight participants were recruited. The median point C in routine POP-Q examination was -5 (-9 to +1), -0.5 (-3 to +4) with cervical traction, and -4 (-7 to +2) in the standing position. When examined with cervical traction, 61.5% women were upstaged by one and 9.0% by two compared with examination in the standing position; 39.7% reported visual analog scale (VAS) pain scores of ≥5 under examination with traction, but only 2.6% reported that level of pain in the standing position. There was no significant difference in acceptability scores between groups. CONCLUSION: In an outpatient clinic setting, POP-Q examination with cervical traction revealed maximal prolapse at an acceptable level of pain. Accordingly, this method is recommended for POP-Q examination.

Does Home Birth Reduce the Risk of Pelvic Organ Prolapse?

OBJECTIVES: To determine the relationship between vaginal birth and the development of POP among women who deliv-ered in non-hospital settings (home birth). MATERIAL AND METHODS: Data were collected retrospectively from the files of patients who presented to a hospital outpatient clinic between April 1, 2011 and April 1, 2012 with complaints of urinary incontinence, uterine sagging, vaginal mass, or vaginal pain. The patients' age, height, weight, body mass index, menopause age, number of deliveries, and presence of hypertension and diabetes mellitus were noted. Patients whose urogynecologic evaluation included POP Quantification (POP-Q) scoring were included in the study. The patients were separated into a group of women who had never given birth and another group of women with one or more deliveries. RESULTS: Of the 179 patients in the study, 28 had never given birth and 151 had given birth at least once. The nulliparous patients had no cystocele, rectocele, or uterine prolapse. The prevalence rates of cystocele, rectocele, and uterine prolapse were significantly higher in the multiparous group. Cystocele, rectocele, and uterine prolapse development were significantly correlated with number of deliveries, but there was no statistical association with age, body mass index, menopausal age, diabetes mellitus, or hypertension. univariate analysis reveals that the only factor effective in the development of cytocele, rectocele and prolapse is the number of births. CONCLUSIONS: Our study suggests that only number of deliveries is associated with development of cystocele, rectocele, and uterine prolapse in women who gave birth by vaginal route in residential settings.

Exploring biomechanical methods to study the human vaginal wall.

AIMS: To critically review studies of the biomechanical properties of connective tissue in the normal and prolapsed human vaginal wall and to identify criteria that are suitable for in vivo measurements which could improve patient management. METHODS: This review covers past and current ex vivo and in vivo instrumentation and analytical methods related to the elastic and viscoelastic properties of vaginal wall connective tissues. RESULTS: Classical methods, including digital evaluation of the vagina, histological and biomechanical studies of fresh and frozen-thawed extracts, and biomechanical cadaveric tissue studies have important limitations and have yielded inconsistent results. Newer biomechanical methods may resolve these inconsistencies. One of the more promising is transient, vacuum-induced tissue expansion and relaxation, via cutometer-like devices. The technique permits noninvasive observation, applicable to longitudinal studies of patients. In vivo and ex vivo biomechanical methods may better match vaginal wall tissue properties to help with the design of surgical mesh materials, thus improving surgical support and healing. CONCLUSION: Methods have been identified to characterize the in vivo biomechanical behavior of the prolapsing vagina which may serve to advance the care of affected women. Neurourol. Urodynam. 36:499-506, 2017. © 2016 Wiley Periodicals, Inc.

Do patient characteristics impact the relationship between anatomic prolapse and vaginal bulge symptoms?

INTRODUCTION AND HYPOTHESIS: Seeing or feeling a vaginal bulge is the most specific symptom for identifying prolapse. Bulge symptoms are becoming increasingly important as a surgical outcome measure. Our objectives were to identify patient characteristics associated with the symptom of a vaginal bulge and to determine whether those characteristics impact the relationship between symptoms and anatomic prolapse. METHODS: A cross-sectional analysis of new urogynecology patients was performed. Standardized history and examination forms were used. Patient characteristics associated with vaginal bulge at p ≤0.10 were entered in logistic regression models. Interactions between patient characteristics and prolapse were tested to determine whether patient factors modified the association between anatomic prolapse and symptoms. RESULTS: We evaluated 685 patients with mean age of 58.5 years. Patients reporting a vaginal bulge were slightly older, more likely postmenopausal, and had greater parity and body mass index (BMI). They were more likely to report prior prolapse surgery (p <0.05) and more often previously underwent hysterectomy (p = 0.10). In multivariable analysis, prolapse, age group, and vaginal parity were associated with the bulge symptom. Receiver operating characteristic (ROC) area under the curve (AUC) was 0.87 [95 % confidence interval (CI) 0.84-0.90], suggesting good predictive value of maximum vaginal descent for a vaginal bulge symptom. The AUC for the youngest women was lower than for middle and older age groups (p < 0.01). The optimal cutoff for defining prolapse associated with a vaginal bulge symptom was the hymen. CONCLUSIONS: Age and vaginal parity were independently associated with the vaginal bulge symptom. The level of vaginal descent did not predict a bulge symptom as accurately in younger patients.

[Method of Surgical Management of Genital Prolapse with Cervical Elongation].

Objectives: According to different authors, the percentage of genital prolapse among gynaecological diseases that require surgical correction reaches 28−38,9%. Pelvic muscle wasting is a special kind of pelvic prolapse, often leading to cervical elongation and hypertrophy. Contemporary methods of treatment for this condition have the high rate of relapse­ 8,9−22%, thus urging to improve the existing techniques. Purpose: This research was to estimate the effectiveness of novel modification of Manchester operation in comparison with classic Manchester operation in the management of pelvic prolapse with cervical elongation. Methods: We enrolled 83 patients with pelvic prolapse and cervical elongation and divided them into two groups. In GroupI (n=47) we used the novel surgical method, supplementing original Manchester procedure with cervical stump fixation and other improvements. In GroupII we used original Manchester procedure. We compared laboratory measures as well as surgery duration, blood loss, incidence of complications, and duration of post-operational hospital stay. Patients were followed-up for 2years to estimate long-term effectiveness of surgical intervention. Statistical analysis was performed in SPSS 17.0. Results: Surgery duration in GroupII was significantly longer (47,8±26,2 vs 57,5±35,1 minutes, p<0.05). There were no significant differences in lab tests, post-operational hospital stay (5,2±0,9 vs 7,3±1,2) and incidence of post-operational complications (3 vs 4 cases). Over the 2 years of follow-up we registered 1 case of relapse in Group I and 3 cases of relapse in Group II, thus estimating the effectiveness of surgery as 97,9 vs 91,7%, a non-significant difference. We noticed that all relapsed women had signs of systemic dysplasia of connective tissue. Conclusion: Suggested modification of Manchester operation improves duration of surgical intervention itself, while providing a comparable level of effectiveness.

The effect of vaginal pelvic organ prolapse surgery on sexual function.

AIMS: Data on female sexual function after prolapse surgery are conflicting. The aim of the study was to evaluate the change in sexual function and vaginal symptoms using patient reported outcomes following prolapse surgery in addition to the anatomical stage. METHODS: Prospective observational study of women undergoing pelvic organ prolapse (POP) surgery. The validated International Consultation on Incontinence modular Questionnaire-Vaginal Symptoms (ICIQ-VS) questionnaire was completed preoperatively, 6 and 12 months postoperatively. RESULTS: Ninety-three women participated in the study with 83 (89%) returning the 6 months questionnaire and 80 (86%) the 12 months questionnaire. Twenty-four healthy women without prolapse were included as a control group. The mean vaginal- and sexual-symptom score both improved with a significant decrease at 6 months and 12 months after surgery (P < 0.001, P < 0.05, respectively). The POP-Q scores of each compartment also improved significantly after 6 and 12 months (P < 0.001) with 75% reaching anatomical success. There was no correlation between anatomical success and subjective ICIQ-VS outcomes. The vaginal and sexual matters score had a lesser reduction in women who had additional levator plication sutures during posterior vaginal repair compared to those without. Women with levator plication also showed a significant increase in postoperative dyspareunia. CONCLUSIONS: Surgical intervention for POP improved the vaginal and sexual matters scores at 6 and 12 months postoperatively. Levator plication additionally to posterior vaginal repair is associated with an increase in postoperative dyspareunia rates and with decreased sexual function.

Relationship between levator ani and bony pelvis morphology and clinical grade of prolapse in women.

The aim of this study was to assess the morphological features of the levator ani and bony pelvis in women with different grades of prolapse. Ninety Chinese women with different grades of uterine prolapse were studied, 18 in each stage of prolapse from I to IV, and 18 asymptomatic nulliparous volunteers as normal controls. Three-dimensional (3D) models that included the pelvic bones, levator ani, pubic symphysis, sacrum, and coccyx were generated from magnetic resonance (MR) images. The width and length of the levator hiatus and levator symphysis gap, the width of the iliococcygeus, and the iliococcygeal angle were measured to quantify levator ani morphology; the intertuberous diameter, interspinous diameter, subpubic angle, and pubococcygeal line were measured to characterize the morphology of the bony pelvis. Four patterns of levator ani morphology among women with and without prolapse were distinguished. Among the bony pelvis parameters, no measurement differed significantly between the subjects with prolapse and normal controls, or among subjects with different grades of prolapse. There were significant differences in the width and length of the levator hiatus and levator symphysis gap between women with prolapse and normal controls. Our pilot data help to elucidate bony pelvis and levator ani morphology in women with and without pelvic organ prolapse. In contrast to the iliococcygeus muscle, changes in the morphological features of the pubovisceral muscle are more likely to accompany prolapse.

Anterior vaginal wall suspension procedure for moderate bladder and uterine prolapse as a method of uterine preservation.

PURPOSE: We report our experience with anterior vaginal wall suspension for moderate anterior vaginal compartment prolapse and uterine descent less than stage 2. MATERIALS AND METHODS: Data on patients who underwent anterior vaginal wall suspension with uterine preservation by hysteropexy and had a 1-year minimum followup were extracted from a long-term, prospective, institutional review board approved, surgical prolapse database. The indication for uterine preservation was uterine descent not beyond the distal third of the vagina with traction with the patient under anesthesia, and negative Pap smear and pelvic ultrasound preoperatively. The upper suture of the anterior vaginal wall suspension secures the cardinal ligament complex, allowing for uterine suspension once the suture is transferred suprapubically. Failure was defined as prolapse recurrence greater than stage 2 on physical examination or the need for reoperation for uterine descent. Outcome measures at serial intervals included validated questionnaires, physical examination, standing voiding cystourethrogram at 6 months postoperatively and complications. RESULTS: From May 1996 to March 2012, 52 of 739 patients met inclusion criteria. Mean followup was 55 months (range 12 to 175, median 44). Mean patient age was 62 years (range 38 to 81), mean body mass index was 26.7 kg/m(2) (range 18.3 to 49.4) and mean parity was 2.7. There were no transfusions or intraoperative complications. Overall 7 (13%) patients underwent subsequent hysterectomy for uterine prolapse recurrence at 7 months to 6 years postoperatively. CONCLUSIONS: The anterior vaginal wall suspension procedure offers a simple, mesh-free surgical alternative with acceptable long-term followup in patients with moderate uterine prolapse who wish for uterine preservation. However, patients should be appropriately counseled about the low risk of subsequent hysterectomy.

Randomized controlled trial comparing two procedures for anterior vaginal wall prolapse.

OBJECTIVE: To compare success rates between anterior colporrhaphy and abdominal paravaginal defect repair for treatment of anterior vaginal wall prolapse. METHODS: This was a prospective randomized controlled trial comparing anterior colporrhaphy plus polyglactin 910 mesh (vaginal) to paravaginal defect repair (abdominal) in women with symptomatic anterior vaginal wall prolapse. Pelvic organ prolapse quantification staging (POP-Q), pelvic floor distress inventory, pelvic floor impact questionnaire, and pelvic organ prolapse/urinary incontinence sexual questionnaires were administered pre and post-operatively. Women were followed up to 2 years. The primary outcome was anterior POP-Q stage, with failure defined as ≥stage II. RESULTS: We enrolled 70 patients, 35 in each group. Demographic and most peri-operative characteristics were similar between the groups. Mean anterior vaginal wall prolapse repair time (39 min) was shorter for vaginal versus abdominal repair (60 min; P < 0.001), with more concurrent hysterectomies in the vaginal (71%) versus abdominal group (42%), P = 0.01. At 2 years, objective failure rates for the vaginal and abdominal groups were 32% and 40%, respectively, P = 0.56. Subjective failure rates were lower and similar for both groups. Patient satisfaction rates were 88% for the vaginal and 73% for the abdominal group, P = 0.11. Quality of life questionnaires showed significant improvement from baseline but no difference between the groups (P = 0.12). CONCLUSIONS: At 2 years follow-up, anterior colporrhaphy with polyglactin 910 mesh and abdominal paravaginal defect repair have similar success rates, with most objective failures being asymptomatic.

Safety and one year outcomes following vaginally assisted laparoscopic uterine sacropexy (VALUES) for advanced uterine prolapse.

AIMS: To assess the safety and outcomes of vaginally assisted laparoscopic uterine sacropexy (VALUES) as a surgical treatment for stage 3 and 4 uterine prolapse. METHODS: Seventy consecutive women with stage 3 and 4 uterine prolapse who underwent VALUES over 2-year period were prospectively evaluated. Women filled the Prolapse Quality of Life Questionnaire (P-QOL), and underwent examination using pelvic organ prolapse quantification system (POP-Q) pre- and post-operatively. In addition, patients filled the patient global impression of improvement questionnaire post-operatively. Mesh related complications were evaluated post-operatively. Patients were followed up at 3 and 12 months following surgery. This study reports the 12 months outcomes. RESULTS: Sixty-four women (91.4%) reported cure of their prolapse symptoms. On examination, 67 women (95.7%) had POP-Q stage 0 or 1 uterine support at 12 months. Six women needed further surgical intervention for prolapse (8.5%); three women developed recurrent uterine prolapse and three other women developed symptomatic recurrent anterior vaginal wall prolapse. The total vaginal length was not different between the pre- and post-operative periods. Two patients developed mesh related complications. Significant improvement was noted in prolapse symptoms and quality of life. CONCLUSIONS: VALUES is a safe and effective treatment for women with stage 3 and 4 uterine prolapse up to 12 months without the risk of vaginal shortening. Long-term results are needed to fully establish the value of this technique.

Uterine prolapse during late pregnancy in a nulliparous woman.

A pregnancy that is complicated by a uterine prolapse is rare and primarily occurs in multiparous women during their first or second trimester. In the present report, we describe a case of a 31-year-old nulliparous woman who experienced sudden uterine prolapse at 38 weeks' gestation without labor pains. The cervix was congested, the cervical mucosa was partially lacerated, and bleeding was noted; the protruding cervix could not be repositioned into her vagina. Although the cervical congestion worsened over time, she still did not experience any labor pains. She was delivered by emergency cesarean section. Following delivery, the prolapse promptly improved and did not recur before her 1-month postpartum examination. To our knowledge, this is the first case where uterine prolapse occurred in a nulliparous woman during late gestation.

A unique case of late complication of rectum mesh erosion after laparoscopic sacrocolpopexy.

Sacrocolpopexy, a surgical technique with a low morbidity rate, is a valid procedure for repairing vaginal vault prolapse. To our knowledge, only 1 case of rectum erosion after open sacrocolpopexy has been reported in the literature, and there is no record of any such incident after laparoscopic sacrocolpopexy. We report the first case of mesh erosion involving the rectum instead of the vagina assessed 8 years after laparoscopic sacrocolpopexy.

Neonatal uterine prolapse - a case report.

Uterine prolapse is commonly seen in the geriatric age group. Congenital vaginouterine prolapse is a rare condition occurring in neonates and is usually associated with spinal cord malformations in about 85% of cases. Several modalities of treatment have been described for neonatal uterine prolapse. Conservative treatment in the form of simple digital reposition, use of pessary or other self-retaining device is usually sufficient to treat this condition, which is self-limiting and regressive. Here we report our first case of neonatal uterine prolapse, managed successfully with simple digital reposition.

Rectal and genital prolapse in Nigerian newborns: case reports and review of the literature.

Genital prolapse in the newborn is a rare clinical condition often times seen in association with congenital myelo-meningocele, or this could occur following shigellosis infection. We therefore report two neonates with rectal prolapse following diarrhea and utero-vaginal prolapse associated with congenital spinal bifida.

The predictive value of a cystocele for concomitant vaginal apical prolapse.

PURPOSE: Recent studies showing a correlation between descent of the anterior and apical vaginal compartments suggest that cystoceles may recur if associated apical prolapse is not corrected. However, to date the anatomical relationship of apical prolapse with respect to cystocele has been incompletely reported. We present the predictive value of a cystocele for clinically significant vaginal apical prolapse. MATERIALS AND METHODS: We retrospectively reviewed the records of all new patient visits to a urogynecology clinic in a 30-month period. Women with a point Ba value of -1 or greater (stage 2 cystocele and above) were included in analysis. Predictive values of clinically significant apical prolapse, defined as point C -3 or greater, were calculated and stratified by cystocele stage. RESULTS: A total of 385 women were included in study. Point Ba was the leading edge of prolapse in 83.9% of cases. The position of Ba strongly correlated with that of the vaginal apex (Spearman ρ = 0.769, p <0.001). Overall 59.7% of patients had a point C of -3 or greater. The finding of clinically significant apical prolapse increased significantly with increasing Ba values. Of patients with stage 2, 3 and 4 cystocele point C was -3 or greater in 42%, 85% and 100%, respectively. CONCLUSIONS: The finding of stage 2 or greater cystocele is highly suggestive of clinically significant apical vaginal descent to -3 or greater. Furthermore, as cystocele stage increases, the predictive value of apical prolapse also increases. Surgeons contemplating cystocele repair should have high suspicion for vaginal apical prolapse and consider concomitant repair.