Assessment Of Pelvic Organ Prolapse Research Articles

Epidemiology and outcome assessment of pelvic organ prolapse

The aim was to determine the incidence and prevalence of pelvic organ prolapse surgery and describe how outcomes are reported. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews, level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. A grade C recommendation usually depends on level 4 studies or "majority evidence" from level 2/3 studies or Delphi processed expert opinion. A grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi . Pelvic organ prolapse (POP) when defined by symptoms has a prevalence of 3-6% and up to 50% when based upon vaginal examination. Surgery for prolapse is performed twice as commonly as continence surgery and prevalence varies widely from 6 to 18%. The incidence of POP surgery ranges from 1.5 to 1.8 per 1,000 women years and peaks in women aged 60-69. When reporting outcomes of the surgical management of prolapse, authors should include a variety of standardised anatomical and functional outcomes. Anatomical outcomes reported should include all POP-Q points and staging, utilising a traditional definition of success with the hymen as the threshold for success. Assessment should be prospective and assessors blinded as to the surgical intervention performed if possible and without any conflict of interest related to the assessment undertaken (grade C). Subjective success postoperatively should be defined as the absence of a vaginal bulge (grade C). Functional outcomes are best reported using valid, reliable and responsive symptom questionnaires and condition-specific HRQOL instruments (grade C). Sexual function is best reported utilising validated condition-specific HRQOL that assess sexual function or validated sexual function questionnaires such as the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) or the Female Sexual Function Index (FSFI). The sexual activity status of all study participants should be reported pre- and postoperatively under the following categories: sexually active without pain, sexually active with pain or not sexually active (grade C). Prolapse surgery should be defined as primary surgery, and repeat surgery sub-classified as primary surgery different site, repeat surgery, complications related to surgery and surgery for non-prolapse-related conditions (grade C). Significant variation exists in the prevalence and incidence of pelvic organ prolapse surgery and how the outcomes are reported. Much of the variation may be improved by standardisation of definitions and outcomes of reporting on pelvic organ prolapse surgery.

Lower urinary tract symptoms in women with benign joint hypermobility syndrome: a case–control study

Benign joint hypermobility syndrome (BJHS) is a connective tissue disorder associated with joint hypermobility. BJHS is under-recognised by medical professionals and is poorly managed. The aim of our study was to determine whether lower urinary tract symptoms (LUTS), including urinary incontinence (UI) and anterior compartment prolapse, are more common in women with BJHS than in the normal population. This was a prospective case-control study. Women diagnosed with BJHS according to the Brighton criteria were recruited from a tertiary referral clinic. Controls were recruited from hospital personnel. Both groups completed the King's Health Questionnaire (KHQ) and the Prolapse Quality of Life Questionnaire (P-QoL). Objective assessment of pelvic organ prolapse (POP) was undertaken using the Pelvic Organ Prolapse Quantification (POP-Q) system. Analyses were performed using SPSS version 17.0. The statistical difference was analysed using McNemar's test. Comparison of QoL scores was performed with the Wilcoxon signed-rank test. Sixty individuals were recruited and matched with 60 healthy women. The prevalence of UI in those with BJHS was significantly higher than in controls(73.3 % vs. 48.3 %). The impact of UI on QoL was statistically significant in all domains of the KHQ. There was a significant difference between groups in most urinary-specific symptoms of the KHQ. A significant number of women with BJHS suffer from voiding difficulties. Prolapse of the anterior vaginal wall was objectively more severe in those with BJHS. Women with BJHS have LUTS and anterior compartment prolapse, which significantly impair their QoL. It is important to identify women who are symptomatic. The addition of a systematic active case-finding approach may be more effective in identifying these cases.

Image based measurements for evaluation of pelvic organ prolapse

Magnetic resonance imaging (MRI) measurements are essential for the diagnosis of pelvic organ prolapse given the inaccuracy of clinical examination. However, MRI pelvic floor measurements are currently performed manually and can be inconsistent and time-consuming. In this paper, we present a scheme for semi-automatic measurement modeling on MRI based on image segmentation and intersecting point identification methods. The segmentation algorithm is a multi-stage mechanism based on block grouping, support vector machine classification, morphological operation and prior shape information. Block grouping is achieved by classifying blocks as bone or background based on image texture features. The classified blocks are then used to find the initial segmentation by the first phase morphological opening. Prior shape information is incorporated into the initial segmentation to obtain the final segmentation using registration with the similarity type transformation. After segmentation, points of reference that are used for pelvic floor measurements are identified using morphological skeleton operation. The experiments on the MRI images show that the presented scheme can detect the points of reference on the pelvic floor structure to determine the reference lines needed for the assessment of pelvic organ prolapse. This will lead towards more consistent and faster pelvic organ prolapse diagnosis on dynamic MRI studies, and possible screening procedures for predicting predisposition to pelvic organ prolapse by radiologic evaluation of pelvic floor measurements.

Quality of Life Questionnaires for the Assessment of Pelvic Organ Prolapse: Use in Clinical Practice.

Over the past decade, the use of quality of life (QOL) questionnaires in the evaluation of pelvic organ prolapse (POP) has become a standard part of most clinical studies. Investigators have attempted to correlate QOL scores with objective findings and treatment efficacy and as outcome measures in comparing different treatment modalities. Many of the QOL questionnaires are available in short forms, making them easier to adapt to clinical settings. This article includes an overview of several validated QOL questionnaires and their application in studies whose results provide useful guidelines for health care professionals who diagnose and manage women with POP.

Does neuromuscular blockade affect the assessment of pelvic organ prolapse?

The purpose of this study was to determine if anesthesia with neuromuscular blockade alters the Pelvic Organ Prolapse Quantification (POP-Q) examination. A prospective, multi-center trial was conducted of women undergoing pelvic surgery. A POP-Q examination performed pre-operatively was compared with an examination performed intra-operatively under neuromuscular blockade. For the latter examination, an Allis clamp was used to apply gentle traction until the point being examined did not undergo further descent. International Continence Society (ICS) stages and individual POP-Q points were compared using a paired sample t test. A sample size of 32 provided 80% power to detect a clinically significant difference between office and operating room measurements (Sample Power, SPSS, 1997). Of 153 women, 76% received general endotracheal anesthesia and 21% laryngeal mask airway. With an increase of 3 cm, the apical compartment was significantly more prolapsed in the operating room (OR; p < 0.05); however, a comparison of the mean values demonstrated a larger change in means for all points except total vaginal length. When separated into anterior, apical, and posterior compartments, the ICS stages were systematically different in the OR than in the office for all stages (p < 0.0005). Neuromuscular blockade leads to significantly greater increases in POP-Q examination measurements compared with the office measurements, and this increase is most pronounced apically.

Doppler ureteric jet in urogenital prolapse

This work was conducted to study the Doppler ureteric jets in the assessment of pelvic organ prolapse (POP) patients. Forty POP-Q stage ≧ III patients and 20 without POP were assessed with color Doppler ultrasonography. Among 40 POP, 28 had bladder outlet obstruction (BOO) and 4 had hydronephrosis. Comparing POP and controls, the difference in mean frequency, mean duration, and mean maximum velocity of ureteric jets was not statistically significant. The ureteric jets of POP with BOO are of longer duration and lower velocity. The frequency of ureteric jets was lower in POP with hydronephrosis. Plateau-type waveforms were much more common among POP associated with voiding and ureteric dysfunction. The longer duration and lower velocity of the ureteric jet are strongly correlated with prolapse-associated BOO. The plateau-type waveform and decrease in frequency of ureteric jets indicate possible hydronephrosis. Further investigation is needed to confirm the consistency of this study.

The time factor in the assessment of prolapse and levator ballooning

The goal of the study was to define the time needed to obtain maximal organ descent and hiatal distension during Valsalva measured by transperineal ultrasound. Secondarily, we aimed to describe the timing of these events in relationship to each other. We undertook a retrospective review of the stored ultrasound volume datasets of 50 patients with pelvic organ prolapse. Data on organ descent and hiatal distension were obtained in 10 volumes from rest to maximal Valsalva. On average, a Valsalva maneuver lasted 9.4 s (range 5 to 18). It took patients on average about six volumes (approximately 5-6 s) to reach 80% of maximum organ descent. The time to maximum organ descent was 8.9 s and the time to maximum distension of the levator hiatus was 8.2 s, p = 0.031. In order to obtain adequate assessment of pelvic organ prolapse, a Valsalva maneuver should last at least 6 s. Hiatal distension seems to precede pelvic organ descent.

Assessment of pelvic organ prolapse

Pelvic organ prolapse (POP) is a common presenting complaint in gynaecology. It is therefore important that clinicians understand how to accurately assess women with prolapse. The aim of this article is to provide a comprehensive description of the assessment required. Anatomical assessment should be made using the standardized Pelvic Organ Prolapse quantification system (POP-Q). The use of POP-Q in women with POP allows effective communication between clinicians, reproducible evaluation of surgical outcomes, meaningful comparison of published series and comparison of different populations. The main focus of the article is a detailed and practical explanation of the POP-Q.

P187 MRI in assessment of pelvic organ prolapse

P187 MRI in assessment of pelvic organ prolapse

Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms

At present little information is available to help define whether a certain degree of pelvic organ prolapse is clinically relevant. We performed a retrospective study to define cut-offs for significant pelvic organ descent on the basis of prolapse symptoms. At a tertiary urogynecological center, 735 women with symptoms of lower urinary tract dysfunction and prolapse were seen for interview, clinical examination, multi-channel urodynamics and ultrasound imaging, while supine and after voiding, for prolapse quantification. Women with multi-compartment prolapse, i.e. those in whom no compartment was clearly dominant were excluded. Receiver-operator statistics were used to test pelvic organ descent as a predictor of prolapse symptoms. Mean age was 55.1 years, mean parity 2.8 (range, 0-12). Symptoms of prolapse were reported by 188 women (25.6%). Seventy-four showed a symptomatic multi-compartment prolapse and were excluded, 56 symptomatic women had cystoceles and 48 had rectoceles. Symptomatic cystoceles descended on average to 23.8 mm below the symphysis pubis and symptomatic rectoceles to 21.4 mm below the symphysis pubis. Descent was strongly associated with symptoms of prolapse (both, P < 0.001). Receiver-operating characteristics (ROC) statistics suggested a cut-off of 10 mm below the symphysis pubis for cystocele, and 15 mm below the symphysis pubis for rectocele. ROC curves were similar for both compartments (area under the curve, 0.857 and 0.821, respectively). Descent of the bladder to > or = 10 mm and of the rectum to > or = 15 mm below the symphysis pubis are strongly associated with symptoms, and these values are proposed as cut-offs for the diagnosis of significant prolapse on the basis of ROC statistics.

Pelvic Organ Prolapse in Nulliparous Women and Their Parous Sisters

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. 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. 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. 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. II-2.

Pelvic Organ Support and Prevalence by Pelvic Organ Prolapse-Quantification (POP-Q) in Korean Women

We evaluated pelvic organ support and the prevalence of pelvic organ prolapse in Korean women using the Pelvic Organ Prolapse-Quantification system as the assessment tool. The study population consisted of 713 women 18 to 72 years old who were seen for annual Papanicolaou testing and pelvic examinations. Pregnant patients and patients who had delivered within the previous 6 weeks were not recruited. All pelvic examinations were performed by a single examiner. The patient was examined in the dorsal lithotomy position in a pelvic examination chair positioned at a 15-degree angle. All 9 measurements except total vaginal length were taken with the patient performing the maximal Valsalva maneuver. Mean patient age was 41.6 years (range 18 to 72), mean weight +/- SD was 55.8 +/- 7.4 kg (range 40 to 83), mean height was 158.7 +/- 5.4 cm (range 138 to 177), mean body mass index was 22.3 +/- 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). Mean scores for the position of the cervix and posterior fornix, and total vaginal length were -5.0, -6.6 and 7.0 cm, respectively. In the 713 women with a uterus the incidence of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of pelvic organ prolapse quantification system stage was stages 0 to 4 in 68.3%, 19.9%, 11.2%, 0.6% and 0.0% of patients, respectively. Vaginal size in Korean women differs from that in Western women. The prevalence of any degree of prolapse was approximately 31.7%. Korean women were at relatively higher risk for anterior and posterior vaginal prolapse than for uterine prolapse.

The use of ultrasound in the evaluation of pelvic organ prolapse

Pelvic organ prolapse is a common problem significantly affecting women's quality of life, particularly in later years. Transperineal, two-dimensional ultrasonography can be used for the assessment of female pelvic floor dysfunction for pelvic organ morphology, tissue biomechanics and in vivo properties of prosthetic implants. The role of transperineal ultrasound for the assessment of pelvic organ prolapse is still developing, but with the rapid development of three- and four-dimensional technology may allow dynamic assessment of anatomy in the axial plane. Three-dimensional ultrasound also permits the storage of data volumes for analysis at a later stage, which introduces the ability to independently review images in any plane offline. Further evaluation and research of this imaging tool is required to identify its place in the assessment of women for pelvic organ prolapse and its role in surgical audit.

Interobserver variation in the assessment of pelvic organ prolapse.

The aim of this study was to determine the interobserver agreement of two grading systems for pelvic organ prolapse: the vaginal profile and the International Continence Society (ICS) draft proposal. Forty-nine consecutive women referred for evaluation of urinary incontinence and/or pelvic organ prolapse were studied. Patients were first examined by a physician and a nurse clinician using the vaginal profile, followed by an examination according to the technique described in the ICS draft proposal for standardization of terminology (1994). kappa statistic and Pearson's correlation coefficient were used to determine interobserver variability for the ICS system by overall stage, by stage-specific comparison, and by specific anatomic location. The vaginal profile was evaluated by obtaining a kappa for overall degree of prolapse, stage-specific comparison and by anatomic area. The kappa for the ICS stage was 0.79 (P < 0.001), and the kappa for the vaginal profile by area of greatest prolapse was 0.68 (P < 0.001), indicating substantial interobserver agreement for both systems. The ICS system was noted to have substantial interobserver agreement by a stage-specific comparison. All anatomic locations of the ICS staging system were found to correlate significantly, and a high degree of interobserver precision was found. The vaginal profile also showed significant interobserver agreement by overall degree of prolapse, by specific degree of prolapse, and by anatomic area. It was concluded that both the proposed ICS staging system and the traditional vaginal profile show significant interobserver agreement both by overall stage, stage-specific analysis and specific location. The registered nurse examination correlated well with the physician examination, indicating that the most important factor in obtaining reproducible results may be definition and close attention to examination technique.