Scott G. Chudnoff, MD

Disclosures

March 09, 2006

Question

A 58-year old woman with a history of 2 vaginal deliveries now presents with complete uterine prolapse, rectocele, and vesicocele. Patient had total knee replacement in July 2004. The patient is also sexually active. With possibilities of various complications arising from such extensive dissection for pelvic floor repair, would you recommend long-term pessary/ring placement?

Response From the Expert

Scott G Chudnoff, MD 
Assistant Professor, Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, New York, NY; Staff Physician, Obstetrics and Gynecology and Women’s Health, Bronx, New York

 

Recent advances in technology and surgical methods have created many more options for the treatment of pelvic organ prolapse. However, it is critical to consider each patient on a case-by-case basis, individualizing the treatment plan to that patient. When evaluating the appropriate method for treatment of these conditions, several issues need to be considered. The first relates to the patient's functional status (eg, whether the patient is bed-bound, living an active lifestyle, and/or sexually active). The second consideration is whether the patient is having symptoms related to the prolapse (eg, pain, incontinence, constipation). The last issue relates to comorbid conditions and history of prior surgery, which would determine the degree of risk and difficulty that would be associated with the procedure.

In patients who are sexually active and at low risk for complications from a surgical procedure, a surgical repair would likely give the optimal results. If the patient is symptomatic (eg, has incontinence), this argument would be even stronger. Unfortunately, there is no single correct answer for the appropriate management, and this is something that needs to be explained to the patient when involving her in the decision.

In the case described, I do not see why surgical management should be withheld. Despite the fact that pelvic floor dissection and repair would be required, surgery would likely give the best long-term results in this relatively young and healthy patient. The only consideration relating to the knee replacement that may affect the plan would be the ability to place the patient in a dorsal lithotomy position. If the patient has little or no mobility at the knee, a vaginal repair would be extremely difficult. The fact that she is sexually active is important and needs to be addressed as to any dysfunction that may presently exist surrounding the prolapse.

Granted, surgical procedures are associated with potential complications and therefore need to be weighed heavily against noninvasive strategies. However, in appropriately selected cases, the potential risks will be outweighed by the potential benefits. It may be prudent to give a trial with the pessary and see whether the patient has appropriate resolution of the prolapse and finds it acceptable. This is something that needs to be individualized.

If a surgical repair is selected, I would likely utilize a vaginal approach. A vaginal hysterectomy with an anterior and posterior repair would be in order. The procedure utilized for supporting the vaginal apex may be a little more controversial. Although you might be able to get adequate support with a McCall's procedure (potentially with shortening of the uterosacral ligaments), the likelihood of a recurrent prolapse is fairly high given her present complete procidencia. A sacrospinous fixation would be a good choice, with consideration given to the potential for sexual difficulties if the vagina has a significant lateral deviation. This can potentially be overcome by utilizing a bilateral fixation, but many people are not familiar or comfortable with this method. The gold standard of sacrocolpopexy might be an option, but the vaginal approaches are probably a better initial choice. A note of caution that pertains to the correction of pelvic organ prolapse is the need to check for potential incontinence. It is possible that the patient is continent now due to severe angulation of the urethral-vesico junction, but when the prolapse is repaired, the patient may suddenly present with stress incontinence.

It is also critical when approaching these procedures to be comfortable with the anatomy and dissection in these spaces. If there is any hesitation, a pelvic surgery consultation may be helpful.

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