Options for Vaginal Prolapse. What is prolapse? What is prolapse? Disclosures 10/23/2013. Michelle Y. Morrill, M.D. None

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1 Options for Vaginal Prolapse Disclosures None Michelle Y. Morrill, M.D. Director of Urogynecology Kaiser, San Francisco Assistant Professor, Volunteer Faculty Department of Ob/Gyn, UCSF What is prolapse? What is prolapse? Objective Findings Objective Findings Subjective Bother Relaxation of the vaginal walls (30-40% of women, 98% of postmenopausal women) 1 Descent of the apex, anterior and or posterior of the vagina (almost 50% of women) 2 1 Nygaard et al. Pelvic Organ Prolapse in Older Women: Prevalence and Risk Factors Obstet Gynecol 2004;104: ACOG Practice Bulletin #85 Pelvic Organ Prolapse, September 2007 Vaginal wall or cervix at or below the hymen 1 Vaginal bulge or something falling out of the vagina 2 1 Barber MD, et al. Defining Success After Surgery for Pelvic Organ Prolapse. Obstet Gynecol September ; 114(3): Tan et al. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct May-Jun;16(3):

2 Symptoms? Prolapse Risk Factors Splinting Pelvic Pressure Defecation or Voiding problems Depression Poor Self Image Nygaard 2004 (WHI) 1) Age 2) Education 3) Vaginal parity 4) Weight of largest baby 5) Asthma 3% Age Education Vaginal parity 48% 24% 12% 12% Weight of larg... Asthma Prolapse Risk Factors Epidemiology Nygaard 2004 (WHI) Age Education (college worse) Vaginal parity Weight of largest baby Miedel 2009 (Swedes) Family history of POP Hx of deficient CT (varicose viens, hernia, hemorrhoids) BMI, waist circumfrence Heavy lifting job Low impact exercise (vs. none or high impact) ~3-8% POP Prevalence 1,2 11% Lifetime risk of surgery for prolapse or incontinence % Lifetime risk of surgery for prolapse 4 1 Nygaard et al. Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA 2008;300(11): Lukacz et al. Parity, Mode of Delivery, and Pelvic Floor Disorders. Obstet Gynecol 2006;107: Olsen et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. OG 1997 ;89: Wu J, et al. Lifetime Risk of Surgery for Stress Incontinence and Pelvic Organ Prolapse. Presented at AUGS 2013 Annual Meeting. 2

3 Evaluation 65yo G3P3 with the complaint of prolapse Symptoms!!» What is bothering her?» Need to confirm goals Exam Options for Treatment See the prolapse with the patient straining» Cough» Stand up Baden Walker half-way» Grade 0-4 POPQ» cm above (-) or below (+) the hymen Do Nothing Physical Therapy Symptom directed therapy / Lifestyle Pessary Surgery 3

4 Do Nothing? Expectant Management Prolapse is not dangerous Education Patients often are frightened Is this a tumor? 412 WHI subjects (postmenopausal) with at least 2 Baden-Walker evaluations» Progression and regression nearly equal» Grade 1 prolapse more likely to improve than worsen Handa et al. Progression and remission of pelvic organ prolapse: A longitudinal study of menopausal women. AJOG (2004) 190, Expectant Management Physical Therapy 259 women in WHI at one site had at least 2 POPQ exams 1 and 3 year change of at least 1 cm» Patients with prolapse above the hymen were more likely to progress» Patients with prolapse beyond the hymen were more likely to regress >2cm worsening in 5.8% after 1y >2cm improvement in 1.2% after 1y Bradley et al. Natural History of Pelvic Organ Prolapse in Postmenopausal Women. Obstet Gynecol 2007;109:848 54) 4

5 Physical Therapy Symptom Directed Therapy Cochrane review 2011» 3 studies included» Subjective improvement in study group in all 3 studies» Exercises have 17% chance of improving stage vs controls (pooled data from 2 studies) Vaginal estrogen» Decreases friction or awareness Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews 2011, Issue 12 Vardy MD, et al. Short-term urogenital effects of raloxifene, tamoxifen, and estrogen. Am J Obstet Gynecol Jul;189(1):81-8. Lifestyle Changes Pessary Weight control?» Gain bad» Loss doesn t help either 1 Avoid straining 2» Behavior training» Treat constipation 1 Kudish et al. Effect of Weight Change on Natural History of Pelvic Organ Prolapse. Obstet Gynecol 2009;113 2 Braekken IH, et al. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010;203:170.e1-7. 5

6 Pessary Contraindications Can significantly improve symptoms and quality of life 1,2 Almost any patient can be a candidate» Exceptions Poor compliance (loss to follow-up)?vaginal infection Latex allergy (latex Inflato-Ball) 1 Patel et al. Impact of pessary use on prolapse symptoms, quality of life, and body image. Am J Obstet Gynecol 2010;202: Cundiff et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol 2007;196:405. 6

7 Contraindications? How do I fit it? Prior hysterectomy or prolapse surgery POP-Q? Hypoestrogen Sexual activity Erosion from prolapse Short vaginal length and large genital hiatus decrease success 1 Clemons, JL, Aguilar, VC, Tillinghast, TA, et al. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004; 190:345. How do I fit it? Pessary Fitting Whatever way is comfortable and effective for the patient TRIAL and ERROR» Set patient expectations! Can position it differently from the intended placement Can even use more than 1 7

8 Pessary During fitting In the PESSRI trial a successful fit required refit of the time 1) 2% 2) 10% 3) 30% 4) 50% 31% 2% 40% 27% 1) Place pessary and ask how she feels 2) Have patient - strain - sit-up - stand - walk - sit on toilet (use toilet hat to not lose pessary) 3) Repeat from step 1 as needed Cundiff et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol 2007;196:405. 2% 10% 30% 50% Pessary placement Pessary placement Anterior-Posterior View Lateral View 8

9 Pessary placement Pessary placement Pessary placement Pessary placement Pelvic Exam View 9

10 After fitting Pessary Management Remind patient that this is Trial and Error she may need to return soon if the pessary is uncomfortable/falls out Removal» In office every 1-3 months 1» By patient every See patient back in 2-6 weeks for check 1 Alperin M, et al. Patterns of Pessary Care and Outcomes for Medicare Beneficiaries with Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg. 2013;19(3):142-7 Erosions Erosions These will happen, it s OK Treat with vaginal estrogen and check in 1 month, many resolve Pessary checks more frequently Teach patient to move pessary if she can t take it out Biopsy if persistent Recheck to confirm it s not worsening 10

11 Vaginal Bleeding Fistulas» Common with fitting and manipulation» Evaluate new vaginal bleeding as you would without pessary» Generally take years to occur» Make sure the patient will follow-up Infections Trimo-San Vaginal Infections» Discharge is physiologic Check / remove more frequently May use estrogen or Trimo-San? UTIs» No studies have been done» Likely risk factor is age 1 Hydroxyquinoline sulfate sodium lauryl sulfate jelly has been evaluated in articles in PubMed 1) 0 2) 7 3) 12 4) 76 93% 3% 3% 3% Morrill MY, et al. Is an Elevated Post-Void Residual a Risk Factor for Urinary Tract Infection? Poster at Society for Urodynamics and Female Urology Winter Meeting, San Diego, CA, February,

12 Trimo-San Surgery Surgery Surgery Identify the defect» Apical» Anterior» Posterior Apical suspension? Procedures % Reoperation rate Difference (p value) A alone A + apical A+P alone A+P + apical Eilber KS, et al. Outcomes of Vaginal Prolapse Surgery Among Female Medicare Beneficiaries The Role of Apical Support. Obstet Gynecol 2013;0:1 7 [Epub ahead of print] 12

13 Prolapse Reduction Stress Incontinence Can SUI after anterior or apical procedure be predicted?» Short answer no 1 Augmentation with Synthetic or Biologic Graft What is the need?» Weber study clinically meaningful outcomes at 1y 1 No prolapse past hymen 83-96% No bulge symptoms % No reoperation %» 5 year re-op rate for NT 2.5-9% (lower if all compartments repaired) 2 1 Ellström Engh AM, et al. Can de novo stress incontinence after anterior wall repair be predicted? Acta Obstet Gynecol Scand May;90(5): Chmielewski L, et al. Reanalysis of a randomized trial of 3 techniques of anterior colporrhaphy using clinically relevant definitions of success. Am J Obstet Gynecol 2011;205(1):69. e1-8 2 Oversand SH, et al. Long-term follow-up after native tissue repair for pelvic organ prolapse. Int Urogynecol J Jul 6. [Epub ahead of print] Review Approach and Options for Prolapse Assess her symptoms Discuss goals Offer all options» Expectant management» Pelvic floor exercises / Lifestyle changes» Pessary» Surgery 13

14 Thank You! Questions? 14