Your Pelvic Floor

The following pathway is meant as an evidence based guide developed by leading and internationally recognised Gynaecologist and Colorectal surgeons to offer guidance to both clinicians and patients.  The green lines demonstrate preferred options for treatment and the yellow represent reasonable options.

You should recognise the pathway is only guidance and is no substitute for one-on-one consultation with your specialist who is best placed to individualise your care and treatment.

An interactive version can also be found HERE.

The chart below can be used by clicking on any of the cells to display further information.

ICI 2017 Surgical Treatment POP

POP Surgery
Bladder function
Bowel
function
Risk of
recurrent prolapse
Reconstructive surgery
Obliterative surgery
Apical support
Anterior
support
Posterior support
Vault
Uterine
Graft repair
Suture repair
Hysterectomy ±BSO
Hysteropexy
Vaginal hysterectomy
Sub-total hysterectomy ASC
ASC + hysterectomy
Vaginal SS hysteropexy
Sacral hysteropexy
LSC + repair
Sacrospinous colpopexy
Uterosacral colpopexy
Preferred Option
Possible Pathway
Further Data Required

Pathway for the surgical treatment of pelvic organ prolapse
  • Prolapse is the protrusion of vaginal tissue within and outside of vagina
  • While 50% of women who have had children have prolapse only 12-20% women undergo prolapse surgery
  • So not all prolapse requires surgery!!!
  • Pelvic floor excercises can help with early prolapse
  • Vaginal ring pessaries can help however less than 10% continue to use pessary after 5 years

Reconstructive surgery

Reconstructive surgery involves repair of anterior (bladder), posterior (Bowel) and/or apical (upper) prolapse.

Obliterative surgery
  • Represent 1-2% POP interventions
  • More common USA > Europe, Australasia
  • Usually performed elderly, medically compromised and not sexually active
  • Advantages: low morbidity, quick recovery, good results
  • Disdvantage: sacrifice sexual activity

Apical (upper) vaginal prolapse
Vault prolapse (after hysterectomy)
Uterine prolapse
GoR
Apical suspension at vaginal repair significantly reduces the need for subsequent prolapse surgery
 B

Anterior repair + apical repair ↓ reoperation rate by ½ at 10 years compared to AC
Posterior repair + apical repair ↓ reoperation rate by 1/3 at 10 years compared to PC

Anterior support
GoR
Isolated cystocele:
Anterior Colporrhaphy (AC) is generally recommended however permanent synthetic mesh could be considered for recurrent prolapse if women understand the risk/benefit profile A
Biological grafts offer no significant advantage over AC B
Anterior compartment prolapse is a cystocele

Posterior support
GoR
Isolated rectocele:
Posterior Colporrhaphy (PC) is the procedure of choice B
Fascial plication superior to site specific posterior vaginal repair C
Levatorplasty associated with high rate of dyspareunia B
No evidence demonstrating benefit for synthetic or biological graft C
PC reduced prolapse with equal functional outcome compared to transanal approach B
No data demonstrates ventral rectopexy + vaginal graft is effective for rectocele D
Those with combined rectal and vaginal prolapse benefit from colorectal & gynaecologist collaboration C
Posterior compartment prolapse called rectocele

Vault prolapse
GoR
Sacral colpopexy has significant anatomical and functional advantages when compared with a broad group of vaginal surgery (+mesh) A
Vaginal apical suspensions appropriate those not suitable for SC (Delphi) C
Transvaginal apical mesh confers no advantage when compared to native tissue repairs A
Uterosacral & sacrospinous colpopexy have similar efficacy for apical prolapse B

Apical compartment prolapse (2016)

6 trials compared vaginal surgery (sacrospinous or uterosacral suspension, transvaginal mesh) to ASC
Abdominal sacral colpopexy (ASC)

ASC: ↓ awareness of prolapse, prolapse on exam, reoperation prolapse, urinary leakage & painful intercourse compared to vaginal surgery

Vaginal surgery: 21mins quicker

Uterine prolapse
At surgery the uterus can be either
  • Retained (hysteropexy pathway: hitched back up!)
  • Removed (hysterectomy pathway)
Relative contraindications to uterine preservation include:
Uterine abnormalities
  • Fibroids, adenomyosis, endometrial pathology sampling
  • Current or recent cervical dysplasia
  • Abnormal menstrual bleeding
  • Post-menopausal bleeding
  • Cervical elongation
Familial cancer BRAC1 & 2: ↑ risk ovarian cancer and theoretical risk fallopian tube and serous endometrial cancer
Hereditary Non-Polyposis Colorectal Cancer (Lynch Syndrome): 60% lifetime risk endometrial cancer
Tamoxifen therapy
Obesity: up to 3-fold increased risk endometrial cancer
Unable to comply with routine gynaecology surveillance

Graft repair

Suture repair

Hysterectomy ±BSO

In post-menopausal women should ovaries be removed at hysterectomy?

  • Life time risk Gynaecology Cancer
    Cervical 0.6% Uterine 2.7% Ovarian 1.4% Pearce 2015 AACR
  • Routine removal of tubes & ovaries (±BS0) 10x ↓ risk of ovarian cancer without ↑ Morbidity when stratified for age Jacoby 2011 Acrh Int Med, Parker 2013 Obstet Gynecol
  • Routine ±BSO more difficult at vaginal than laparoscopic surgery
  • Consider routine ±BSO at time of hysterectomy for prolapse surgery

In pre-menopausal women should ovaries be removed at hysterectomy?

  • Ovarian function should be retained in those who are not menopausal as oestrogen offers benefits to, cardiovascular system, bones and a general sense of well-being.
  • Bilateral salpingectomy (removal of tubes)can be considered in those retaining ovaries as this ↓ risk of ovarian Ca by 50% (OR 0.51, 95% CI 0.35-0.75) Yoon 2016 Eur J Cancer

Hysteropexy

Is Uterine preservation right for me?

This is a complicated decision usually based upon medical facts and womens self-perception

Generally

  • If possible defer any prolapse surgery until your family is completed
  • Hysteropexy quicker to perform than hysterectomy however recovery and inpatient time same
  • Better anatomic success rate with hysterectomy
  • Can't develop cancer of cervix or endometrium if you have had hysterectomy ( lifetime risk small 2%)
  • Sexual function same both groups

Based on medical grounds alone hysterectomy preferred to hysteropexy however discuss with your Gynaecologist

Vaginal hysterectomy
GoR
Vaginal hysteropexy is equally effective as vaginal hysterectomy with apical suspension and is associated with reduced blood loss and operating time B
Vaginal hysterectomy with apical suspension has a lower reoperation rate for prolapse than abdominal sacro-hysteropexy B
Although data is not complete, vaginal based apical suspensions should generally be considered for uterine prolapse reserving SC for recurrent or post hysterectomy prolapse C

Sub-total hysterectomy ASC

Should I have my cervix retained ( supracervical hysterectomy)?

The cervix should not retained if:

  • Current or recent cervical dysplasia
  • Cervical elongation
  • Not compliant with cervical screening

Supracervical hysterectomy had a higher recurrence rate for subsequent prolapse when compared to hysterectomy at time of sacral colpopexy in a single study Myers 2015 Int J Urogynecol

Until more data available supracervical hysterectomy not recommended

ASC + hysterectomy
GoR
Sacral colpopexy with hysterectomy is not recommended due to high rate of mesh exposure B

Vaginal SS hysteropexy
GoR
Vaginal hysteropexy is equally effective as vaginal hysterectomy with apical suspension except in those with large uterine prolapse B
Vaginal hysteropexy is associated with reduced blood loss and operating time compared to vaginal hysterectomy B

Sacral hysteropexy
GoR
Vaginal hysterectomy with apical suspension has a lower reoperation rate for prolapse than abdominal sacro-hysteropexy B
Although data is not complete, vaginal based apical suspensions should generally be considered for uterine prolapse reserving SC for recurrent or post hysterectomy prolapse C

LSC + repair

I'm having a sacral colpopexy

How should it be performed?

  • Open ( Cut)
  • Laparoscopic ( Keyhole)
  • Robotic

Generally the laparoscopic approach has some advantages over both open and robotic approach

GoR
Laparoscopic sacral colpopexy is quicker, with less post-operative pain than both the robotic and open approach and the cost is significantly lower than the robotic approach. B
However the laparoscopic approach also a longer learning curve than the other approached and you should be guided by your surgeon

GoR
Although data is not complete, vaginal based apical suspensions should generally be considered for uterine prolapse reserving SC for recurrent or post hysterectomy prolapse C
SSF (186) vs HUSL (187)
Barber Jama 2014
  • No difference detected at 2 yrs between sacrospinous and uterosacral colpopexy
  • Both equally effective for apical suspension at hysterectomy for uterine prolapse
  • Vaginal based native tissue repairs are satisfactory alternatives in those not suitable for sacral colpopexy at vault prolapse ie
    • Obese
    • Poor medical health
    • Prior radiation pelvis
    • Lots of prior pelvic surgery

Risk of recurrent prolapse
GoR
Age < 60 years C
Stage 3 or Stage 4 prolapse B
Preoperative widened genital hiatus or levator defects on USS: data are inconclusive D
Less experienced surgeons have higher rates of recurrent prolapse after transvaginal surgery C
Low volume surgeons have ↑ rate of complications compared to high volume surgeons B
Perioperative physiotherapy did not reduce the rate of recurrent prolapse A

Bladder function

Should I have continence surgery at the time of prolapse surgery?

Generally

  • Yes if you have SUI ( Leaking with coughing, sneezing, or exercising)
  • Yes if you have occult stress urinary incontinence (OSUI: leaking with coughing when your doctor reduces your prolapse in those without symptoms of SUI)
  • No if you have no symptoms of SUI or OSUI
  • No if you have bladder urgency symptoms

Bowel function

I'm having prolapse surgery and have the following bowel symptoms

  • No bowel symptoms
  • Obstructed defecation ( incomplete evacuation, I digitate to defecate)
  • Faecal incontinence
  • Constipation (this is a cause of prolapse and prolapse surgery will not correct constipation. In fact constipation is a risk factor for recurrence of prolapse)

Summary of pathway findings:

• Obliterative surgery is a safe and efficacious option for the elderly or medically compromised who are happy to sacrifice sexual activity.

• In reconstructive surgery consider addition of apical support to both anterior and posterior vaginal repair

• The vaginal native tissue repair (sutures) is the preferred treatment of anterior vaginal prolapse

• The vaginal native tissue repair (sutures) is the preferred treatment of posterior vaginal prolapse (rectocele)

• In those with post-hysterectomy (vault) prolapse sacral colpopexy is the preferred apical option with vaginal based colpopexy being a reasonable alternative.

• In those with uterine prolapse hysterectomy and hysteropexy (uterine preservation) are both reasonable options however based solely on medical grounds the vaginal hysterectomy with apical support is the preferred option.

• Bilateral salpingo-oopherectomy (BSO) should be discussed at the time of hysterectomy in post-menopausal women.

• At prolapse surgery, those with pre-operative urinary stress incontinence and occult stress urinary incontinence should consider concomitant continence surgery.