High-Grade Prolapse

Abstract

Prolapse is a common condition predominantly in the parous population. Complex recurrent cases are therefore more often encountered in parous women. The aim of this chapter is to discuss an example of a complex case of prolapse, ways of approaching and managing and tailoring the choice of options according to the individual needs. Different modes of management are discussed with more detailed explanation on the surgical options. The different operations that are included are infracoccygeal vaginal vault mesh suspension, sacrocolpopexy (SCP) and sacrospinous ligament fixation (SSLF). The three procedures are discussed in detail, describing the basis of each one with emphasis on the advantages and disadvantages.

Commentary by Una Lee, Virginia Mason Medical Center, Department of Urology, Seattle, WA, USA

Commentary

• Una Lee 

This chapter on high-grade pelvic prolapse by Phillip Toozs Hobson and Amallia Brair concisely reviews prevalence, risk factors, conservative and surgical management options, surgical complications and prevention. High-grade prolapse is a particularly challenging clinical scenario because it reflects a severe loss of native support and has been associated with a higher rate of recurrence over time. Pelvic prolapse is an intimate condition in which education and counselling is critical to patient’s understanding, expectations and treatment satisfaction. A patient-centred approach is important to capture the patient’s perspective and meet their needs.

Patients often ask why prolapse occurs and how they can prevent it from worsening. The chapter clearly outlines the risk factors that contribute to the pathophysiology of prolapse, of which the top three listed include: childbirth injury, the post-menopausal state and hysterectomy. Prevention of prolapse is also on patients’ minds as women want to pro-actively prevent worsening or recurrence of prolapse. Patients can be counselled on maintaining a healthy weight, stopping smoking and using proper form when lifting, and can also be informed that prolapse can also worsen or recur due to biologic factors that are beyond their control. Counselling patients on the potential risk of prolapse recurrence over time is part of a thorough informed consent process and can help patients have realistic expectations of this disease.

In this case, the patient is a 67-year-old woman with history of prior hysterectomy and prior rectocele repair. Her prolapse symptoms include vaginal bulge and difficulty evacuating bowels. Eliciting a patient’s pelvic floor symptoms explicitly allows one to address their symptoms with directed treatment. Women with female pelvic floor disorders often have concerns that may or may not related to their pelvic prolapse, and these concerns can be treated separate from the prolapse. For example educating patients on the differences between urinary incontinence and prolapse is an important distinction.

In her case, she has one of the most common symptoms associated with pelvic organ prolapse: vaginal bulge symptoms. Patients describe the feeling of a bulge or ball that may worsen later in the day or with activity and is bothersome due to its constant or intermittent presence. The absence of vaginal bulge symptoms has been shown to be the prolapse symptom most likely to be associated with patient-reported treatment success [6]. Also, in her case, she has difficulty evacuating her bowels. This symptom has been shown to improve or resolve in two-thirds of women after rectocele repair, with 11% developing new symptoms and 50% having one or more persistent symptoms [7]. It would be important to ask her about whether she splints, where she splints and for how long she has needed to splint to evacuate her bowels, as a longer history of splinting is associated with persistent splinting post-operatively [8]. Normal post-operative vaginal support is associated with a reduced risk of incomplete bowel emptying [7]. “Support” can be improved in women with attenuated tissues through surgical reconstruction that aims to create additional support. The three levels of support described by Delancey are fundamental surgical principles in prolapse repair.

On her exam, the post-hysterectomy vaginal vault is 3 cm beyond the hymen, and the posterior vaginal wall is bulging 1 cm beyond the hymen. She is a candidate for surgical repair that aims to restore her vaginal and pelvic floor anatomy, while minimizing risk of complications. A combination of surgical techniques can be utilized to both address the vaginal vault and the posterior compartment. Addressing the vault with an abdominal or vaginal approach apical procedure would likely improve her vaginal bulge symptoms tremendously. Support for the vaginal apex is an essential component of a durable surgical repair for women with advanced prolapse [9]. For her bowel symptoms, a directed exam and clinical history could help determine if she would benefit from a transvaginal rectocele repair with or without perineorrhaphy in addition to an apical procedure.

The use of transvaginal mesh in the posterior compartment has been associated with an unacceptably high rate of complications including erosion and pain, and therefore is not recommended. Sacrocolpopexy mesh has been associated with a lower rate of complications, but still has a known risk of mesh erosion into the vagina, bowel and bladder, as well as pelvic pain and dyspareunia. Native tissue rectocele repair also has a known risk of pain, dyspareunia and recurrence, but the complications associated with native tissues rectocele repair will not be mesh-specific complications.

For an individual patient, the most important outcome of her prolapse surgery is the relief of her symptoms and improvement in her quality of life, while at the same time, avoiding long-term surgical complications. Every patient and surgeon desires to restore normal and natural pelvic floor anatomy in a durable, safe manner and therefore restore vaginal, urinary, bowel, sexual, and general function and support. The authors of the chapter discuss the significance of counselling patients on the difference between anatomy and physiology, and even when the anatomy is restored, bowel dysfunction or symptoms may persist. As surgeons and physicians, we recognize that there are limitations to our reconstructive (restorative and/or compensatory) surgical techniques and the pathophysiology of the pelvic floor is complex. Given the multi-dimensional nature of prolapse, we can do better in listening to and educating patients, as well as counselling patients with realistic expectations of what can and what cannot be achieved through surgery. To quote Dr. Francis Peabody, “The secret of the care of the patient is in caring for the patient” [10]. Listening to the patient’s specific prolapse symptoms and counselling them with a thorough informed consent is key to meeting the needs of women with pelvic prolapse.