Do anxiety traits predict subjective short-term outcomes following prolapse repair surgery?

BACKGROUND: Studies conducted in orthopedic surgery have suggested that patients with anxiety have less symptomatic improvement following surgery than those without. We hypothesized for this study that patients with anxiety traits experience less symptomatic improvement following pelvic organ prolapse surgery than patients without. METHODS: All patients presenting for prolapse repair surgery were offered enrollment in this prospective cohort study. Prior to surgery, subjects were asked to complete the Spielberger State-Trait Anxiety Inventory and the Pelvic Floor Distress Inventory 20. Subjects were also asked to list up to five goals related to the outcome of surgery for goal-attainment scaling. At the 6-8-week postoperative visit, subjects were asked to repeat the STAI and PFDI questionnaires and respond to the single question tool assessing Patient Global Impression of Improvement. Subjects were also asked to rate on a Visual Assessment Scale how well preoperative goals were met. All three questionnaires were repeated at >12 weeks following surgery. RESULTS: A total of 32 patients with anxiety trait and 58 without were recruited. Preoperatively, the mean STAI-T was 45.0 (± 7.2.) and 27.7 (± 4.9) for subjects with and without anxiety; PFDI 20 scores were 96.1 (± 48.8) and 94.7 (± 57.5), respectively. At 12+ weeks postoperatively, the mean PFDI-20 for subjects with anxiety was 31.3 (± 20.9) and 30.3 (± 27.9) (p = 0.22) for those without. CONCLUSIONS: We did not find the anxiety trait to be a predictor of subjective outcomes following pelvic organ prolapse surgery.

Anaphylactic Shock After Intravenous Fluorescein Administration for Intraoperative Cystoscopy.

BACKGROUND: Rates of administration of intravenous sodium fluorescein during cystoscopy have increased since indigotindisulfonate sodium was removed from the market in 2014. Although sodium fluorescein has been extensively evaluated and found to be safe, side effects including anaphylaxis have been observed, with an incidence between 0.05% and 1.0%. CASE: We present a case of anaphylactic shock after administration of intravenous sodium fluorescein for the assessment of ureteral efflux in a patient with a history of frequent severe allergic reactions undergoing urethral lysis and cystoscopy for urinary retention. Cardiopulmonary structure and function were evaluated and found to be normal. An elevated serum tryptase level was identified, indicating an anaphylactoid reaction. Timely recognition of symptoms associated with a severe allergic reaction in the setting of hemodynamic instability with prompt supportive and pharmacologic therapy was vital in the patient's recovery. CONCLUSION: Health care providers must be aware of this potential complication, especially in patients with a history of severe allergic reactions.

Vaginal Obliterative Procedures for Pelvic Organ Prolapse: A Systematic Review.

IMPORTANCE: Pelvic organ prolapse is a common condition, the prevalence of which is likely to increase with the aging of our population. Also changing are parameters by which outcomes are assessed, shifting toward patient-centered care. OBJECTIVE: To review vaginal obliterative procedures for surgical treatment of advanced pelvic organ prolapse historically and to discuss evidence on indications for colpocleisis, outcomes, and complications, as well as review pros and cons for concomitant vaginal hysterectomy and anti-incontinence procedures. EVIDENCE ACQUISITION: Review predominantly of the English language literature on issues associated with obliterative vaginal surgery for advanced pelvic organ prolapse from LeFort's and Neugebauer's original description in the late 1800s to now. RESULTS: LeFort and total colpocleisis are effective procedures for surgical treatment of advanced pelvic organ prolapse with relatively low complication rates. Patient satisfaction is high. Loss of coital function is rarely a reason for regret. Hysterectomy is not required in most patients with procidentia. Anti-incontinence procedures can be performed at time of colpocleisis for patients with coexisting stress incontinence. Evidence is conflicting with regard to occult stress urinary incontinence. CONCLUSIONS AND RELEVANCE: Colpocleisis are valuable procedures for women with severe pelvic organ prolapse who do not wish to retain coital function. Results are maintained in women with recurrent prolapse after prior failed reconstructive surgery. Considering a patient's goals for surgery and comprehensive presurgical counseling are important determinants of patient satisfaction. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES: After completing this activity, the learner should be better able to list indications and contraindications for vaginal obliterative procedures, discuss risks and benefits of sling placement at time of colpocleisis, list perioperative complications, and discuss perioperative workup for LeFort colpocleisis.

Barriers to urogynecological care in a population of gynecological oncology patients.

INTRODUCTION AND HYPOTHESIS: The objective was to identify barriers to urogynecological evaluation in a population of new patients presenting to a gynecological oncology practice with symptoms of pelvic floor dysfunction. METHODS: A pelvic floor dysfunction screening questionnaire was given to new patients presenting to a university-based gynecological oncology practice between 1 August 2010 and 31 August 2012. Patients indicating symptoms related to pelvic floor dysfunction in the survey were offered urogynecological evaluations. Charts of those patients declining further evaluation were reviewed. Results of the pelvic floor dysfunction questionnaires were assessed. Reasons provided for not desiring further evaluation were extracted from the questionnaire and stratified. RESULTS: A total of 549 surveys were reviewed. Two hundred and thirty-six patients (42.0 %) of the patients surveyed reported being bothered by pelvic floor dysfunction symptoms. Only 6.7 % (16 out of 236) wanted a referral for an urogynecological evaluation; 93.2 % declined an evaluation. Of patients reporting moderate to severe bother from pelvic floor symptoms, the most frequently cited barrier to care was feeling overwhelmed with the current medical situation (28 %). Other reasons for declining an urogynecological evaluation included a previous evaluation (14 %), financial concerns (6.9 %), and believing that oncological treatment would cure pelvic floor symptoms (6 %). CONCLUSIONS: Quality of life after cancer treatment is important. The ability to provide treatment for gynecological cancer and pelvic floor disorders concomitantly has the potential to improve the quality of life in this patient population. Understanding barriers to care of gynecological oncology patients seeking evaluation for conditions affecting their quality of life is essential in alleviating fears, preventing misconceptions, and for making informed decisions.

Utility of anterior vaginal wall length measurement in vaginal reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: The pelvic organ prolapse quantification system (POP-Q) is the most commonly used method to quantify the extent of pelvic organ prolapse. However, it does not include assessment of anterior vaginal wall length (AVL). The objectives of this study were to characterize AVL and distance to the sacrospinous ligament (SSL), and to examine associations between total vaginal length (TVL), AVL, body mass index (BMI) and age. METHODS: This was a retrospective chart review of 139 patients with cervix in situ presenting during an 8-month period for initial evaluation to the University of Rochester Medical Center Urogynecology practice. AVL, TVL and distance to the SSL were measured in addition to POP-Q measurements. Age, height, BMI, presenting complaint and prolapse stage were obtained from medical records. Simple linear regression was used to assess the relationship between TVL and AVL. Multivariate regression was used to test independent variables. RESULTS: The mean ± SD TVL, AVL and distance to the SSL were 9.4 ± 1.2 cm, 7.4 ± 0.9 cm and 7.2 ± 0.9 cm, respectively. All three measurements approached a normal distribution. TVL decreased slightly with age. No association was found between vaginal length and BMI or parity. CONCLUSIONS: AVL is a useful measurement that may aid in surgical decision-making. Providers should consider using AVL when planning sacrospinous hysteropexy.

Sodium fluorescein use during intraoperative cystoscopy.

BACKGROUND: Indigotindisulfonate sodium has been used during cystoscopy to identify the ureteral meatuses and to verify ureteral efflux during pelvic surgery. The U.S. Food and Drug Administration announced the shortage of indigotindisulfonate sodium in June 2014. Surgeons have since been searching for safe alternatives with comparable visualization and an economically favorable profile. METHOD: The recent shortage of indigotindisulfonate sodium prompted our search for alternative options for visualizing ureteral patency during intraoperative cystoscopy. Multiple methods were considered, including instilling the bladder with D50 water, sterile water, or methylene blue-tinged saline and visualizing the contrast in either viscosity or color of the urine against the instilled medium, preoperative oral phenazopyridine, and intravenous methylene blue. Collectively, these methods proved suboptimal. As an alternative, we injected the 10% preparation of sodium fluorescein at 0.25-1 mL intravenously and observed a brilliant yellow ureteral jet minutes after injection (see Video 1). EXPERIENCE: Ten percent sodium fluorescein given intravenously in doses ranging from 0.25 to 1.0 cc results in good visualization of ureteral jets. One patient experienced transient yellowing of the sclera and palms. CONCLUSION: Sodium fluorescein is an effective alternative to indigotindisulfonate sodium for visualization of ureteral jets during intraoperative cystoscopy.

Prevalence of symptomatic pelvic floor disorders among gynecologic oncology patients.

OBJECTIVE: To describe the prevalence of urinary incontinence and pelvic organ prolapse (POP) in patients with gynecologic cancer before cancer treatment. METHODS: A screening questionnaire on pelvic floor dysfunction was administered as part of the baseline health questionnaire to 549 consecutive new patients presenting to a gynecologic oncology practice. Patients were asked whether they felt a bulge from their vagina or experienced loss of urine associated with activity or urge to urinate. The prevalence of urinary incontinence, POP, or both was determined for each malignancy and benign conditions. χ2 analyses and logistic regression were used to assess significance of differences. RESULTS: Among the 347 women with a gynecologic malignancy, 49.9% women had uterine, 21.0% ovarian, and 14.4% cervical cancer. More than half of the patients with cancer reported baseline urinary incontinence (UI) and 10.9% felt a bulge from their vagina. Approximately 19% of these women had moderate-to-severe symptoms. The prevalence of baseline UI (P=.86) and POP (P=.08) did not differ by gynecologic cancer nor did they differ compared with women with benign gynecologic conditions (UI P=.89, POP P=.20). Logistic regression demonstrated an association between incontinence symptoms and increased age and body mass index (BMI). CONCLUSIONS: Women with gynecologic cancer show high prevalence of symptomatic POP and UI. Age and BMI are risk factors for UI. Coordinated surgical intervention to address both the malignancy and pelvic floor dysfunction could be considered in select patients to enhance postoperative quality of life and to reduce the economic and quality-of-life costs of multiple surgeries. LEVEL OF EVIDENCE: II.

Bowel function after minimally invasive urogynecologic surgery: a prospective randomized controlled trial.

OBJECTIVES: The goals of this study were to assess the effect of a standardized postoperative bowel regimen of over-the-counter medications on (1) time to first bowel movement (BM) and (2) pain level associated with first BM in subjects undergoing minimally invasive urogynecologic surgery. METHODS: Eligible patients scheduled to undergo minimally invasive urogynecologic surgery were offered participation. Enrolled subjects were randomized by computerized schedule. Demographic and perioperative data were collected. Subjects completed a validated questionnaire preoperatively and postoperatively assessing preexisting constipation, frequency and consistency of bowel movements, use of pain medications, mean daily pain level (using visual analog scale), stool consistency, and pain associated with first postoperative bowel movement. The control group was instructed to take docusate sodium twice daily postoperatively. The treatment group took docusate sodium plus Miralax, fiber wafers, and bisacodyl suppositories as directed by protocol. Wilcoxon or t testing was used to compare continuous variables; χ testing was used for categorical relationships, and backward-elimination multiple regression was used to assess independent effects. RESULTS: Seventy-two subjects were enrolled and randomized. Twelve subjects withdrew, leaving 60 (30 per group) completing the study. There were no statistically significant differences between groups in baseline characteristics. Mean (SD) age was 63 (9) years for the control group and 58 (10) for the study group (P = 0.06). Mean pelvic organ prolapse stage was III in each group. The mean (SD) operating room time was 198 (65) minutes for the controls and 216 (74) for the study subjects. Sixty-five percent underwent robot-assisted surgery (50% hysterectomy and 63% sacrocolpopexy). Ninety-eight percent of surgeries were performed under general anesthesia.Before adjustment, the mean (SD) time to first BM was 77 (24) hours in controls versus 64 (21) in the study patients (P = 0.03). Using multiple regression, baseline frequency of defecation (1-2 BMs/wk) was directly associated with the time to first BM (added 25.2 hours; P = 0.009) and being in the study group was inversely associated (first BM, 11.7 hours sooner; P = 0.04). No other variables were retained.There was no difference in pain associated with first postoperative BM (visual analog scale, 3.6 (3.2) vs 3.7 (2.8); P = 0.98), but those with prior complaints of vaginal or rectal splinting had higher pain scores (1.9 and 2.8 points higher, respectively; P = 0.04 for both). There was a trend toward higher pain scores with higher postoperative daily narcotic intake (P = 0.06). No other variables were retained.There was a significant difference in recorded compliance between control versus study regimens (94% vs 81%, respectively; P = 0.002). CONCLUSIONS: Mean time to first postoperative BM after minimally invasive urogynecologic surgery is more than 3.5 days with use of docusate sodium alone and is only slightly shorter when combination therapy is used. First BM after surgery is considered to be painful despite the use of medications. Future studies targeting postoperative discomfort/pain with defecation could target preoperative bowel regimens or more aggressive postoperative interventions. Regimens should remain simple to increase compliance.

Comparison of 2 techniques to predict voiding efficiency after inpatient urogynecologic surgery.

PURPOSE: We compared 2 techniques used to assess adequate postoperative bladder emptying. MATERIALS AND METHODS: We performed a prospective, randomized, crossover study of 2 voiding trial techniques. 1) For back fill the bladder is filled with 300 cc saline before the Foley catheter is removed. 2) For auto fill the catheter is removed and the bladder is allowed to fill spontaneously. Patients were randomized into 2 groups for voiding trials, including group 1-auto fill followed by back fill or group 2-back fill followed by auto fill. Within 15 minutes of each void we measured post-void residual urine by straight catheterization. A void of two-thirds or greater of total bladder volume (voided volume plus post-void residual urine) at void 2 of the 2 voids was considered successful voiding. Patients who voided successfully were discharged home without a urethral catheter. We used the chi-square test with κ to determine successful bladder emptying. RESULTS: We recruited 79 patients, of whom 65 with a mean age of 59.7 years (range 33 to 81) had complete data sets available for analysis. Of the patients 38 (58%) underwent prolapse repair only, 1 (2%) underwent a continence procedure only and 26 (40%) underwent each procedure. The back fill void trial correlated better with a successful voiding trial than the auto fill trial (κ = 0.91, 95% CI 0.81-1.00 vs κ = 0.56, 95% CI 0.39-0.74). Overall 40.5% of patients had an unsuccessful void trial on day 1 postoperatively and were discharged home with a catheter. None subsequently experienced urinary retention. CONCLUSIONS: The back fill technique appears to be a better predictor of adequate postoperative bladder emptying than the auto fill technique for inpatient void trials.

TVT or TOT? When to avoid retropubic trocar passage.

Most surgeons have a preferred method for placing a minimally invasive suburethral sling for treatment of stress urinary incontinence. However, unique clinical circumstances may necessitate altering this approach. We describe two cases for which a retropubic approach to sling placement may be contraindicated.

Symptom-based, clinical, and urodynamic diagnoses of urinary incontinence: how well do they correlate in postmenopausal women?

OBJECTIVE: : The objective of this study was to determine the correlation between symptom-based, clinical, and urodynamic (UD) diagnoses of urinary incontinence in postmenopausal women. METHODS: : This is a review of results of UD findings in postmenopausal women with signs and/or symptoms of urinary incontinence. Positive predictive values (PPVs) were calculated for symptom-based and clinically assigned diagnoses by subtype of incontinence and UD diagnosis. RESULTS: : A total of 105 postmenopausal women with signs and/or symptoms of urinary incontinence underwent UD testing. Subjects were predominantly white (95.1%), with average age 61 (SD, ±9). Overall, symptom diagnosis matched UD diagnosis 27% of the time. Similarly, clinical diagnosis matched UD diagnosis 27% of the time. All 3 diagnoses (symptom, clinical, and UD) matched 18% of the time. Report of urine loss with Valsalva had a PPV of 0.57, for UD diagnosis of stress incontinence. For symptoms of urge and mixed incontinence, PPVs were 0.22 and 0.11, respectively. Clinical diagnoses of stress, urge, and mixed incontinence as compared with UD diagnosis showed PPVs of 0.64, 0.30, and 0.09, respectively. PPV for any UD diagnosis of incontinence was 0.69 by symptoms and 0.71 by clinical evaluation. CONCLUSIONS: : The correlation between type of urinary incontinence based on symptoms, clinical evaluation, and UD findings is poor overall in postmenopausal women. It is highest with stress and lowest with mixed incontinence. The voiding diary and cough stress test are valuable tools in predicting type of incontinence by UD testing.

Urodynamic prediction of occult stress urinary incontinence before vaginal surgery for advanced pelvic organ prolapse: evaluation of postoperative outcomes.

OBJECTIVES: : To evaluate the use of urodynamics for assessment of occult stress urinary incontinence (SUI) in women undergoing vaginal surgery for advanced pelvic organ prolapse (POP). METHODS: : Retrospective chart review of women who underwent vaginal surgery for advanced POP at the University of Rochester Medical Center. RESULTS: : The study sample was composed of 41 women (mean age: 65.6 years; range: 42-88 years). Prolapse was stage 3 or 4 in 40 (97.6%) women. Urodynamics identified 17 (41.5%) women with occult SUI. Postoperatively, 3 (7.3%) women reported urinary incontinence: 1 with stress and 2 with urge-related symptoms. The woman with postoperative SUI had been diagnosed with occult SUI, but declined continence repair. None of the women without occult SUI on urodynamics reported postoperative SUI. CONCLUSIONS: : Urodynamic evaluation prior to vaginal surgery for advanced POP can identify women at risk for SUI, who may benefit from concomitant continence repair.

Uroflow measurements in healthy female volunteers.

OBJECTIVE: : There is not currently a standard definition of "normal" for uroflowmetry parameters, particularly with respect to spontaneous voids or multiple repeated measurements within an individual. Our study aimed to describe uroflow parameters for "normal" in a group of healthy women based on repeated measurements. METHODS: : Spontaneous voids of twelve healthy women were recorded over two weeks. Additionally, one prompted void per subject was recorded. Prompted voids were compared to the subjects' spontaneous voids. These voids were also compared to those of patients evaluated for urinary incontinence. Groups were compared using paired t tests. RESULTS: : The mean voided volume was 306 ml and the mean maximum flow rate was 49 ml/s. The prompted voids were lower in volume, maximum flow, and duration than spontaneous voids. When corrected for volume, these differences were not significant. Maximum flow rates in patients evaluated for urinary incontinence were lower than those of volunteers. CONCLUSIONS: : Uroflowmetry parameters vary widely between and within healthy volunteers. Prompted voids are representative of spontaneous voids. Maximum flow rates of patients evaluated for urinary incontinence were lower than those of volunteers. In a group of healthy volunteers voiding in a private, spontaneous setting, a maximum flow rate of lower than 17 ml/s (2 SDs below the mean) might be considered abnormally low.

Recovery after robot-assisted laparoscopic sacrocolpopexy: the patients' perspective.

Little information exists about recovery after robot-assisted laparoscopic sacrocolpopexy. We sought to report on subjects' perioperative experience. Subjects were queried about resumption of activities such as work and driving, bowel function, whether recovery went as expected, and whether they would recommend this surgery. Use of pain medications, pain scores, and perioperative data were collected N = 21. All would recommend surgery to a friend. 13/18 (72%) felt their recovery went better than expected, and none responded it was worse than expected. 9/21 (43%) did not use narcotics after the day of surgery, with 15/21 (71%) no longer taking narcotics by postoperative day 4. Fifty-five percent experienced their first postoperative bowel movement as painful. Based on this survey, most patients undergoing robot-assisted laparoscopic sacrocolpopexy will not require narcotics beyond postoperative day 3. Nonsteroidals are the mainstay of pain management. This survey highlights the importance of preventing postoperative constipation/ painful defecation.

Incontinence and pelvic organ prolapse in parous/nulliparous pairs of identical twins.

AIM: To evaluate the role of vaginal delivery in the development of urinary incontinence and pelvic organ prolapse in four sets of identical twins. METHODS: Four sets of identical twins were identified from 101 pairs of parous/nulliparous postmenopausal sister pairs, who completed a comprehensive questionnaire, and underwent clinical evaluation of urinary incontinence and pelvic organ prolapse as part of a study. Findings of identical twin sisters were compared to each other. RESULTS: Ages ranged from 52 to 56 years; the parous sister in each pair had two vaginal deliveries. Two twin pairs reported no incontinence. One pair reported incontinence with activities and stress incontinence was confirmed with VLPP of 120 and 130 cm H(2)O in the nulliparous and parous sister respectively. In one pair only the nulliparous sister reported incontinence, however both sisters were diagnosed with stress incontinence with VLLP of 130 and 120 cm in the nulliparous and parous sister respectively. Using POP-Q staging for relaxation of the pelvic support system, only one twin pair had a greater than 1 stage difference in any compartment. CONCLUSIONS: All four pairs of identical twins were diagnosed with identical continence status. Three pairs were identical with regard to support in all three compartments. Vaginal delivery was not associated with urinary incontinence or clinically relevant differences in relaxation of the pelvic support system within four sets of postmenopausal identical twins with different parity status.

Urinary incontinence secondary to severe labial agglutination.

The purpose of the study was to describe the presentation and management of urinary incontinence because of severe labial adhesions. Records of all patients diagnosed with labial agglutination and urinary incontinence at the Division of Gynecologic Specialties between January 1999 and February 2006 were reviewed. Clinical presentation, management, and treatment outcome were extracted from the records. Five subjects were identified. Mean age was 78 (range 59-87) years. Four subjects presented with mixed and one with urge urinary incontinence. Four reported change in flow of stream with voiding. Physical examination showed near-total occlusion of the introitus and urethral meatus in four subjects and partial occlusion in one subject. All were treated topically with estrogen and/or steroids. None of the subjects improved with conservative management, and all required lysis of the labial adhesions. Postoperatively, all were treated with daily topical estrogen and three with concurrent topical steroids. All subjects reported resolution of voiding dysfunction; three had complete resolution of their incontinence. Lysis of labial adhesions combined with postoperative topical estrogen and steroids appears to be an effective treatment in women with this condition.

Is parity in the eye of the beholder?

To investigate whether parity status can be predicted by physical examination and which findings are most predictive. A retrospective chart review of 75 postmenopausal nulliparous/parous sister pairs who underwent gynecological examination as part of a study. An examiner, blinded to parity status, predicted parity status based on physical findings recorded on 146 women. Parity status was correctly predicted for 84.9% of the women. Of the 22 women for whom parity prediction was incorrect, 11 were nulliparous and 11 parous. The physical findings most commonly used for prediction were presence or absence of abdominal striae, appearance of the cervical os, and condition of hymen. Absence of the hymen at 6 o'clock alone correctly predicted parity in 11 of 12 parous and 11 of 11 nulliparous women. Parity status can be predicted based on physical exam in the majority of women. Blinding of investigators to parity status may not be feasible.

Outcome of transvaginal radiofrequency for treatment of women with stress urinary incontinence.

The objective of the study was to assess the outcome and patient acceptance of the transvaginal radiofrequency bladder neck suspension procedure. A retrospective chart review of 18 women treated with the transvaginal radiofrequency bladder neck suspension procedure for stress urinary incontinence was conducted. Data on demographics, urodynamics, daily leakage episodes, complications, patient satisfaction, and further intervention were collected. The mean number of leaks per day was 5.7. There were no complications. Postoperatively, two patients were continent, four were improved, and ten were unimproved. The mean number of daily leaks was reduced to 2.7. Five patients reported to be extremely satisfied with the procedure. One patient was satisfied, and ten were not satisfied. Seven patients sought additional treatment within 1 year. Low cure rate, low patient satisfaction, and high rate of additional treatment led us to discontinue transvaginal radiofrequency bladder neck suspension procedure as a treatment option. It is important that long-term outcome data of the initial studies be made public.

Pelvic organ prolapse in nulliparous women and their parous sisters.

OBJECTIVE: To investigate the role of vaginal delivery and familial factors in the development of pelvic organ prolapse by comparing the prevalence of this condition in nulliparous women and their parous sisters. METHODS: Pairs of nulliparous and parous postmenopausal sisters were recruited for assessment of pelvic organ prolapse. One hundred one sister pairs underwent clinical evaluation. Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification System. RESULTS: The majority of women had no pelvic organ prolapse. By compartment there was a 74.3% to 91.1% concordance in prolapse stage within sister pairs. In discordant sister pairs, the parous sister was found to have the more advanced prolapse 88% of the time. CONCLUSION: High concordance of pelvic organ prolapse in nulliparous and parous sister pairs suggests a familial predisposition toward developing this condition. However, vaginal delivery does appear to confer a risk for more advanced pelvic organ prolapse. LEVEL OF EVIDENCE: II-2.