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Pelvic Prolapse: General

A three-year prospective assessment of rectocele repair using porcine xenograft.
Altman D, Zetterstrom J, Mellgren A, Gustafsson C, Anzen B, Lopez A
Obstet Gynecol. 2006 Jan;107(1):59-65.

OBJECTIVE: To prospectively evaluate clinical outcome of rectocele repair using xenograft 3 years after surgery. METHODS: Twenty-three patients who completed evaluation preoperatively and 1 year after surgery were assessed at a 3-year follow-up. Clinical examination was performed preoperatively, and at the 1- and 3-year follow-ups, with the pelvic organ prolapse quantification system. Symptom assessment was performed with a validated bowel function questionnaire including questions on sexual function. RESULTS: There were no graft-related complications during the 3 years following surgery. Preoperatively, all patients had stage II prolapse of the posterior vaginal wall and a rectocele verified at defecography. At the 1-year follow-up, 11 of 29 patients (38%) had rectocele of stage II or more, and 4 patients were reoperated. At 3-year follow-up 7 of 23 patients (30%) had rectocele of stage II or more. When including the 4 early anatomical recurrences, a total of 11 of 27 patients (41%) had rectocele of stage II or more at 3-year follow-up. Preoperatively, all patients reported varying degrees of rectal emptying difficulties and symptoms of bowel dysfunction. There was a significant decrease in rectal emptying difficulties (P < .01), sense of incomplete evacuation (P < .01), need for manually assisted defecation (P < .05), and symptoms of pelvic heaviness (P < .001) at the 3-year follow-up compared with preoperatively. Cure of rectal emptying difficulties was reported by fewer than 50% of patients. There were no significant changes in anal incontinence scores or symptoms of sexual dysfunction at the 3-year follow-up compared with preoperatively. CONCLUSION: Rectocele repair using porcine dermal graft was associated with an unsatisfactory anatomical cure rate and persistent bowel-emptying difficulties in the majority of patients 3 years postoperatively. LEVEL OF EVIDENCE: II-3.

Initial experience with rectocele repair using nonfrozen cadaveric fascia lata interposition.
Kobashi KC, Leach GE, Frederick R, Kuznetsov DD, Hsiao KC
Urology. 2005 Dec;66(6):1203-7; discussion 1207-8.

OBJECTIVES: To describe a rectocele repair reinforced with solvent-dehydrated, gamma-irradiated, human fascia lata and report our early results with a technique we are confident will have a greater, more durable success rate, with a lower incidence of dyspareunia, than the classic repair. METHODS: A total of 73 patients, aged 31 to 86 years, with symptomatic (stool trapping and/or vaginal/perineal splinting or postural modifications to facilitate stool evacuation) rectoceles underwent a site-specific repair reinforced with cadaveric fascia. Perioperative questionnaires, retrospective chart review, and telephone interview by a blinded third-party reviewer and physical examination was conducted. Issues thought to be relevant to the rectocele repair were assessed. RESULTS: Of the 73 patients, 62 responded to the postoperative questionnaire and 50 underwent physical examination. The mean follow-up was 13.7 months (range 6 to 23). Of the 62 patients, 52 (93.6%) denied postoperative stool trapping requiring vaginal/perineal splinting. Of the 39 sexually active patients, 4 (10.3%) experienced de novo dyspareunia. Minor complications were seen in 15 patients (24%). One developed a symptomatic enterocele. CONCLUSIONS: Interposition of cadaveric fascia lata avoids dependence on weakened native rectovaginal support to facilitate the rectocele repair. Our technique uses fascial interposition, rather than obliteration of the defect, preventing vaginal narrowing, and should thereby decrease the incidence of dyspareunia. Patient symptom improvement and satisfaction rates were competitive with those after traditional rectocele repair. Follow-up is ongoing with the hope that the fascial reinforcement will translate into more durable results.

Familial tranmission of genitovaginal prolapse.
Jack GS, Nikolova G, Vilain E, Raz S, Rodriguez LV
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 20;:1-4.

Some females with little to no risk factors develop prolapse, while other females with multiple risk factors do not. It appears that some women may have a predisposition for prolapse in the setting of equivalent risk factors. We identified 10 patients younger than 55 years old with a family history of prolapse. Their average age was 37 years (range 27-51), the mean number of deliveries was 1.8, and their mean birth weight was 8 lbs. Genetic analysis of the inheritance pattern within these families demonstrated that pelvic organ prolapse segregated in a dominant fashion with incomplete penetrance in these families. Both maternal and paternal transmissions were observed. The relative risk to siblings of affected patients was five times that of the risk for the general population. Further investigation of these families may identify a genetic defect responsible for prolapse.

Anatomic relationships of infracoccygeal sacropexy (posterior intravaginal slingplasty) trocar insertion.
Jelovsek JE, Sokol AI, Barber MD, Paraiso MF, Walters MD
Am J Obstet Gynecol 2005 Dec;193(6):2099-104.

OBJECTIVE: The purpose of this study was to describe the distances of the major bony, vascular, neurologic, and visceral structures to the path of the infracoccygeal sacropexy trocar and to determine the point of trocar entry into the vagina. STUDY DESIGN: Infracoccygeal sacropexy trocars were inserted bilaterally into 6 fresh frozen cadavers. Dissection was performed and the maximal length of the vagina, ischiorectal fossa, and pararectal spaces were measured bilaterally. Mean distances with 95% CIs to important anatomic structures were made from fixed points along the trocar's path. RESULTS: The path of the trocar began dorsal and lateral to the anus, passed through the ischiorectal fossa, iliococcygeus muscle, into the pararectal space, and into the posteriolateral vagina. Along this course, the mean distance (95% CI) to the pudendal vessels at the exit of Alcock's canal was 2.8 cm (2.1 to 3.4 cm) and rectum was 0.5 cm (0.2 to 0.9 cm). The closest inferior rectal vessel was 0.1 cm (0 to 0.3 cm). In the pararectal space, the mean distance to the ischial spine was 2.6 cm (1.7 to 3.5 cm). In 12 of 12 trocar passages, the inferior rectal branches of the pudendal artery and the rectum were within 1 cm or less of the trocar. The mean distance of trocar entry into the vagina was only 4.8 cm (4.3 to 5.4 cm) proximal to the hymenal ring compared with a mean total vaginal length of 8.7 cm (8.0 to 9.3 cm). CONCLUSION: This anatomic study suggests that the rectum and the inferior rectal branches of the pudendal neurovascular bundle may be at risk of injury during infracoccygeal sacropexy trocar placement. Additionally, this procedure appears to provide support to the mid-posterior vaginal wall, not the vaginal apex.

Abdominal sacral suspensions: analysis of complications using permanent mesh.
Bensinger G, Lind L, Lesser M, Guess M, Winkler HA
Am J Obstet Gynecol 2005 Dec;193(6):2094-8.

OBJECTIVE: This study was undertaken to determine the complication rates of abdominal sacral suspensions (ASC) using polypropylene mesh and to compare the erosion rates in women who underwent ASC at the time of supracervical hysterectomy (SCH) versus total abdominal hysterectomy (TAH) versus ASC in women who had previously undergone TAH. STUDY DESIGN: A retrospective analysis of patients from the urogynecology practice at North Shore University Hospital, who underwent ASC with polypropylene mesh between March 1997 and July 2004. Office and hospital charts were reviewed for patient demographics, preoperative history and physical examinations, intraoperative and postoperative findings, and complications. Women were stratified into 3 groups: group I: SCH with ASC; group II: TAH with ASC; and group III: ASC alone in women with a history of prior TAH. RESULTS: A total of 121 patients were analyzed and comprised group I, 30.6% (n = 37); group II, 40.5% (n = 49); and group III, 28.9% (n = 35). Four patients (3.3%) had mesh erosions develop. There were no significant differences in age, weight, parity, menopause status, estrogen therapy, previous surgery, or degree of preoperative prolapse between the patients with and without erosions. All the erosions occurred in group II (8.2%, 95% CI (2.3%-19.6%, P = .0389). The intraoperative complication rate was 2.5% and included a cystotomy (n = 2) and a small bowel laceration (n = 1). Immediate postoperative complications included partial SBO/ Ileus (3.5%), febrile morbidity (9.6%), and autologous blood transfusions (1.7%). Long-term complications included persistent vaginal discharge (4.7%), vaginal bleeding (1.6%), dysparuenia (6.3%), and recurrent prolapse (2.5%). There were no significant differences in short- or long-term complications among the 3 groups (P > .05). CONCLUSION: ASC with polypropylene mesh is a safe surgical procedure for vaginal vault prolapse with low complication rates. Mesh erosion occurred in 8.2% of patients who underwent TAH with concurrent ASC. Patients having ASC at the time of TAH had a 7-fold increased risk for mesh erosion compared with patients who underwent SCH with ASC.

Evolution of the female pelvis and relationships to pelvic organ prolapse.
Schimpf M, Tulikangas P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):315-20. Epub 2005 Jan 15.

The female pelvis provides support for the lower limbs as well as for the gastrointestinal tract, the bladder, and the reproductive organs. It must also serve as a passageway for defecation, urination, and, possibly, delivery of an infant. The bones, ligaments, and muscles of the human female pelvis have evolved from our early ancestors. Pelvic organ prolapse may occur because of the limitations involved with adapting the pelvic bones, muscles, and ligaments previously used for other purposes into a supportive role. Here we review these changing roles and functions of nonhuman primate and human female anatomy.

Rectocele Repair Using Biomaterial Augmentation: Current Documentation and Clinical Experience.
Altman D, Mellgren A, Zetterstrom J
Obstet Gynecol Surv 2005 Nov;60(11):753-760.

Although the etiology of rectocele remains debated, surgical innovations are currently promoted to improve anatomic outcome while avoiding dyspareunia and alleviating rectal emptying difficulties following rectocele surgery. Use of biomaterials in rectocele repair has become widespread in a short time, but the clinical documentation of their effectiveness and complications is limited. Medline and the Cochrane database were searched electronically from 1964 to May 2005 using the Pubmed and Ovid search engines. All English language publications including any of the search terms "rectocele," "implant," "mesh," "biomaterial," "prolapse," "synthetical," "pelvic floor," "biological," and "compatibility" were reviewed. This review outlines the basic principles for use of biomaterials in pelvic reconstructive surgery and provides a condensation of peer-reviewed articles describing clinical use of biomaterials in rectocele surgery. Historical and new concepts in rectocele surgery are discussed. Factors of importance for human in vivo biomaterial compatibility are presented together with current knowledge from clinical studies. Potential risks and problems associated with the use of biomaterials in rectocele and pelvic reconstructive surgery in general are described. Although use of biomaterials in rectocele and other pelvic organ prolapse surgery offers exciting possibilities, it raises treatment costs and may be associated with unknown and potentially severe complications at short and long term. Clinical benefits are currently unknown and need to be proven in clinical studies. Target Audience: Obstetricians & Gynecologists, Family Physicians Target Audience: After completion of this article, the reader should be able to explain that the objective of surgical treatment is to improve anatomic outcome and alleviate rectal emptying difficulties, describe the efficacy of biomaterials in rectocele repair, and summarize the potential risks and problems associated with use of biomaterials in rectocele and pelvic reconstructive surgery.

Posterior intravaginal slingplasty for vaginal prolapse.
Jordaan DJ, Prollius A, Cronje HS, Nel M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep 27;:1-4.

OBJECTIVE: To evaluate the results of the posterior intravaginal slingplasty (IVS). PATIENTS AND METHODS: From a urogynecology database, 42 patients who had undergone posterior IVS procedures were analyzed. All the selected patients had also had a posterior colporrhaphy (88% with mesh inserted into the rectovaginal space). RESULTS: Intraoperatively, there was one complication, a rectum perforation. All patients were followed-up, with a median of 13 months. Recurrent prolapse, grade 3 or 4, developed in 12 patients (29%) which included ten cystoenteroceles (24%), four rectoenteroceles (10%), and three cases of utero/vault prolapse (7%). Repeat surgery was performed in six patients (14%). For utero/vault prolapse, eight patients presented preoperatively with grades 3 and 4 prolapse. On follow-up, three patients had utero/vault prolapse, one of whom did not have utero/vault prolapse on presentation. Therefore, of the eight patients presenting with utero/vault prolapse, only two had repeat prolapse on follow-up, which reflected an improvement of 75%. CONCLUSION: The posterior IVS delivered satisfactory results for vault and posterior compartment prolapse, with a 75% improvement in vault prolapse. It was not possible, however, to separate the effect of posterior IVS and posterior colporrhaphy on the prevention of recurrent prolapse nor on the improvement of difficulty in defecation. Due to the utilization of the now-abandoned vaginal anterior colposuspension procedure for the treatment of anterior compartment prolapse, no conclusions regarding the impact of the posterior IVS on the anterior compartment can be made.

Pelvic organ prolapse: is it time to define it?
Swift S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Sep 22;.

Classification and evaluation of prolapse.
Mouritsen L
Best Pract Res Clin Obstet Gynaecol 2005 Sep 23;.

Pelvic organ prolapse is prevalent among older women. Milder stages of prolapse, cranial to the hymen, are common and usually symptomless. A specific symptom is a bulge outside the vagina. Functional symptoms from the bladder, bowel and sexual life frequently coexist without a known cause/effect relationship to prolapse. Prolapse should be measured by the validated internationally approved pelvic organ prolapse quantification (POPQ) system that can measure prolapse in the three compartments and three levels of the vagina. We should work on a common classification system and agreement in which symptoms should be recorded as related to prolapse and expected to improve by prolapse surgery.

Childbirth and pelvic floor trauma.
Dietz HP, Wilson PD
Best Pract Res Clin Obstet Gynaecol 2005 Sep 21;.

The issue of traumatic damage to the pelvic floor in childbirth is attracting more and more attention amongst obstetric caregivers and laypersons alike. This is partly due to the fact that elective caesarean section as a potentially preventative intervention is increasingly available and perceived as safe. As there is a multitude of emotive issues involved, including health economics and the relative roles of healthcare providers, the discussion surrounding pelvic floor trauma in childbirth has not always been completely rational. However, after 25 years of urogynaecological research in this field it should be possible to determine whether pelvic floor trauma in childbirth is myth or reality, and, if real, whether it matters for the pathogenesis of incontinence and prolapse. On reviewing the available evidence, it appears that there are sufficient grounds to assume that vaginal delivery (or even the attempt at vaginal delivery) can cause damage to the pudendal nerve, the inferior aspects of the levator ani muscle and fascial pelvic organ supports. Risk factors for such damage have been defined and variously include operative vaginal delivery, a long second stage, and macrosomia. It is much less clear, however, whether such trauma is clinically relevant, and how important it is in the aetiology of pelvic floor morbidity later in life.

Posterior pelvic floor compartment disorders.
Davis K, Kumar D
Best Pract Res Clin Obstet Gynaecol 2005 Sep 27;.

Posterior pelvic floor compartment disorders generally refer to functional anorectal disturbances that by definition are symptom-based rather than anatomical defect-based and have a significant impact on quality of life. Symptoms attributed to the posterior compartment are often non-specific and associated with structural, neuromuscular and functional defects giving rise to symptoms of prolapse, pelvic pressure, faecal incontinence, stool trapping and constipation. They may range from mild to incapacitating and occur in varying combinations. While symptoms of constipation and incontinence may conceptually represent the opposing extremes of normal anorectal function, the dynamic interrelationships between the different pathophysiological mechanisms involved in the development of these disorders suggest a more complex explanation. Faecal continence and defecation are dependent on several neurological and anatomical factors that involve coordinated physiological processes, including intestinal transit and absorption, colonic transit, rectal compliance, anorectal sensation and continence mechanism. However, it is well recognized that pelvic floor symptoms originating from one compartment do not imply absent pathology in another compartment. Furthermore, symptoms associated with one disorder (such as constipation related to functional obstructed defecation) can be causative in the sequential development of other pelvic floor disorders, such as a urogenital prolapse syndrome, that may further exacerbate symptoms. In addition, it has been found that treatment that corrects one problem may improve, worsen or even predispose to other symptoms from another compartment. Consequently, while the concept of global pelvic floor dysfunction has emerged, the traditional single speciality referral and evaluation of pelvic floor problems continues to foster potentially segregated management strategies that can overlook the relevance of concomitant symptomatology. The evaluation and treatment of posterior pelvic compartment disorders needs to assume an individualized but multidisciplinary therapeutic approach. Given the variation in surgical approaches described to correct anatomical integrity of posterior pelvic compartment deficits, the consensus on optimal management has yet to be achieved. Therefore, it is critical that outcome measures following surgery are clearly defined. Treatment is to a great extent dictated to by functional severity and the impact that symptoms have on quality of life. Long-term follow-up should ensure that the potential for complications is minimized and satisfactory bowel, bladder and sexual function is maintained.

The use of prosthetics in pelvic reconstructive surgery.
Birch C
Best Pract Res Clin Obstet Gynaecol 2005 Sep 23;.

With an ageing population, increasing numbers of women are presenting with pelvic floor disorders. The lifetime risk of undergoing prolapse or incontinence surgery in the USA is 1 in 11. With a recognized reoperation rate exceeding 30% for prolapse surgery, attempts are being made to improve our primary surgical outcomes. The introduction of synthetic and biological prostheses have been proposed to reduce recurrence rates whilst maintaining vaginal capacity and coital function. The role of synthetic prostheses is well established for use in continence surgery in the form of midurethral slings and for abdominal sacrocolpopexy to correct vault prolapse. However, postoperative morbidity-specifically the risk of mesh erosion-has limited their use for vaginal prolapse surgery. Biological prostheses have been introduced to offer an alternative for use in these repairs. While these grafts largely obviate the problem of erosion there are concerns regarding longevity, and only short-term outcome data are currently available. The role of prosthetics in pelvic floor surgery is an evolving and controversial field. Current and future research should be directed at evaluating the safety and efficacy of specific products and comparison of subjective and objective outcome parameters to standard surgical techniques for pelvic organ prolapse.

Prevalence of rectocele in young nulliparous women.
Dietz HP, Clarke B
Aust N Z J Obstet Gynaecol 2005 Oct;45(5):391-4.

Background: It is generally assumed that fascial defects in the rectovaginal septum are the result of childbirth. However, rectoceles do occur in women who have never delivered vaginally. Aims: To determine the incidence of rectocele in a cohort of asymptomatic, young nulliparous women. Methods: Observational cohort study on 178 nulliparous caucasian women (aged 18-24) recruited for a twin study of pelvic floor dysfunction. All women were interviewed and examined by translabial ultrasound, supine and after voiding. In 52 women, 3D imaging was obtained and 171 datasets were complete and available for analysis. Ultrasound findings were reviewed for rectovaginal septal integrity by an assessor blinded against interview and demographic data for rectovaginal septal integrity. Results: A discontinuity of the anterior rectal wall with extrusion of rectal mucosa or contents (depth of >/= 10 mm) was observed in 21/171 (12%). The depth of this herniation ranged from 10 to 25 mm and was filled with stool (n = 10) or rectal mucosa (n = 11). Defects were associated with a higher BMI (P = 0.049), with the complaint of constipation (P = 0.049) and non-significantly with straining at stool (P = 0.09). Descent of the ampulla to beyond the level of the symphysis pubis without fascial defect, that is, significant perineal relaxation, was observed in 23/171 (13%). Conclusions: Twelve percent of 171 young nulligravid caucasian women showed a defect of the rectovaginal septum. Associations were observed with higher body mass index and a history of constipation. It is hypothesised that in some women defects of the rectovaginal septum and perineal hypermobility may be congenital in nature.

P-QOL: a validated questionnaire to assess the symptoms and quality of life of women with urogenital prolapse.

Digesu GA, Khullar V, Cardozo L, Robinson D, Salvatore S
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):176-81; discussion 181. Epub 2004 Oct 21.

To develop a simple, valid, reliable questionnaire to assess the severity of symptoms and their impact on the quality of life in women with urogenital prolapse. Women recruited from gynaecology outpatient clinics were asked to complete a prolapse quality of life questionnaire (P-QOL) before their hospital visit. At the time of the visit, they were examined supine using the International Continence Society (ICS) prolapse score (POP-Q). A second P-QOL was posted and completed by patients 2 weeks later. The validity was assessed by measuring levels of missing data, comparing symptom scores between affected and asymptomatic women and comparing symptom scores with objective prolapse stages. The internal reliability was assessed by measuring the Cronbach alpha coefficient; 155 symptomatic and 80 asymptomatic women were studied. Severity according to P-QOL strongly correlated with the vaginal examination findings (p < 0.01, rho > 0.5). The total scores for each P-QOL domain were significantly different between symptomatic and asymptomatic women (p < 0.001). All items achieved a Cronbach alpha greater than 0.80 showing good inter-rater reliability. The test-retest reliability confirmed a highly significant correlation between the total scores for each domain. A P-QOL questionnaire for English-speaking patients has been developed which is reliable and valid.

Pelvic Organ Prolapse.
Weber AM, Richter HE
Obstet Gynecol 2005 Sep;106(3):615-634.

Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, and enterocele, is a common group of clinical conditions affecting millions of American women. This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse. The evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often challenging for the clinician to determine which symptoms are attributable to the prolapse itself and will therefore improve or resolve once the prolapse is treated. When treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; and surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms require additional management. Virtually all women with prolapse can be treated and their symptoms improved, even if not completely resolved.

Scientific basis for use of grafts during vaginal reconstructive procedures.
Silva WA, Karram MM
Curr Opin Obstet Gynecol 2005 Oct;17(5):519-529.

PURPOSE OF REVIEW: The use of graft material and mesh in the setting of pelvic organ prolapse surgery has gained increasing popularity and attention in spite of lack of scientific evidence to support their use. The objective of this review is to discuss available synthetic and biologic graft materials, review operative techniques, and evaluate the anatomic and functional results of published data on graft augmented prolapse repairs and antiincontinence procedures. RECENT FINDINGS: Natural biologic graft materials (such as fascia lata) have been used to augment prolapse surgery and have a theoretical advantage of causing less erosions; however, a renewed interest in the employment of synthetic mesh in the anterior and posterior segments has increased, partly due to the need to find improved materials with less inconsistent material strength. The insertion of 'tension-free' meshes for anterior and posterior vaginal wall prolapse may be promising, but studies with longer follow-up are necessary to determine their true efficacy and safety profile. SUMMARY: The recent introduction of newer graft materials and minimally invasive surgical techniques for pelvic organ prolapse repair and stress incontinence has rapidly grown, despite the relative lack of evidence-based information to document their long-term efficacy and safety. Their current use must take into account the risk-benefit profile and be individualized for each surgical candidate. The ultimate goal is to correct both the anatomic and functional derangements seen in this patient population, while improving quality of life.

Pelvic organ prolapse and urinary incontinence in nulliparous women at the United States Military Academy.
Larsen WI, Yavorek TA
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 3;.

The objective of this study was to evaluate both baseline pelvic support and incontinence in relation to physical activity in nulliparous college women. Participants were examined using the pelvic organ prolapse and quantification system (POP-Q) and completed a questionnaire. Women with stage 0 prolapse and any other stage were compared. Potential risk factors and levels of physcial activity were analyzed using the chi-square test. We evaluated 144 women. Fifty percent had stage 0 support and 50% had stage I or II. Nineteen percent of participants reported incontinence. No risk factors for prolapse were identified, however running was associated with incontinence. Forty-six percent of physically active nulliparous college students had stage I pelvic support without identifiable risk factors. Stage I and II prolapse represent normal support.

Pelvic Organ Prolapse in Defecatory Disorders.
Klingele CJ, Bharucha AE, Fletcher JG, Gebhart JB, Riederer SG, Zinsmeister AR
Obstet Gynecol 2005 Aug;106(2):315-320.

Objective: To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorders with that in control subjects. Methods: In 55 subjects with fecal incontinence, 42 subjects with obstructed defecation, and 45 healthy subjects without defecatory symptoms, a urogynecologist assessed pelvic organ prolapse by the pelvic organ prolapse quantification system, and a gastroenterologist evaluated perineal descent during simulated evacuation. A multiple logistic regression model evaluated whether obstetric-gynecological variables, including pelvic organ prolapse, could discriminate among controls, subjects with fecal incontinence, and subjects with obstructed defecation. Results: Fifty-five percent of controls, 42% of those with obstructed defecation, and 29% of those with fecal incontinence had stage II or greater prolapse by clinical examination. Eleven percent of controls, 7% of those with obstructed defecation, and 47% of subjects with fecal incontinence had a forceps delivery. Eighteen percent of controls, 31% of those with obstructed defecation, and 64% of those with fecal incontinence had a hysterectomy. Even after controlling for a higher prevalence of obstetric risk factors and hysterectomy, fecal incontinence was associated with a lower risk of stage II or greater pelvic organ prolapse (odds ratio for fecal incontinence in >/= stage II pelvic organ prolapse relative to stage 0 pelvic organ prolapse = 0.1, 95% confidence interval 0.01-0.53). In contrast, pelvic organ prolapse severity was not associated with control versus obstructed defecation status. Seven percent of controls, 18% of subjects with obstructed defecation, and 7% of those with fecal incontinence had increased perineal descent during simulated evacuation. Excessive perineal descent was associated (P < .01) with pelvic organ prolapse. Conclusion: Despite a higher prevalence of risk factors for pelvic floor injury, pelvic organ prolapse severity was lower in those with fecal incontinence than in subjects without bowel symptoms. However, a subset of subjects with defecatory disorders, predominantly obstructed defecation, have excessive perineal descent, which is associated with pelvic organ prolapse. Level of Evidence: II-3.

A comparison of preoperative and intraoperative evaluation of patients undergoing pelvic reconstructive surgery for pelvic organ prolapse using the pelvic organ prolapse quantification system.
Vierhout ME, Stoutjesdijk J, Spruijt J
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 29;.

Objective:To compare the pre- and intraoperative situation using the POP-Q system during optimally standardized conditions of both examinations. Study design: In a prospective observational study, 108 women were compared. The POP-Q in the outpatient department (preoperative) was compared with the situation just prior to surgery after full anesthesia was reached (intraoperative). During the intraoperative measurement, traction with 0.5 kg force was applied on all relevant places. Results: The pre- and intraoperative measurements were all significant correlated with the R-values between 0.43 and 0.85. All six points, which are measured during the POP-Q, were more prolapsed in the intra- as compared with the preoperative situation. The points Bp, C, and D were significantly more prolapsed, but for the points Aa, Ba, and Ap this was not significant. Fifteen patients were upstaged by the intraoperative measurements and five patients were downstaged in the overall POP-Q grading system. Conclusions: Intraoperative evaluation of the prolapse can reveal significant changes as compared with the preoperative situation. In general, the prolapse is more pronounced especially in the middle and posterior compartment.

Uterus Preservation in Surgical Correction of Urogenital Prolapse.

Costantini E, Mearini L, Bini V, Zucchi A, Mearini E, Porena M
Eur Urol 2005 Jun 15;.

OBJECTIVE: This study aimed to evaluate the efficacy of colposacropexy with uterine preservation as therapy for uterovaginal prolapse. Surgical techniques, efficacy and overall results are described. METHODS: In this prospective, controlled study, 34 of the 72 consecutive patients with symptomatic uterovaginal prolapse were treated with colposacropexy with uterus conservation (hysterocolposacropexy, HSP) and the other 38 with hysterectomy followed by sacropexy (CSP). Anchorage was achieved with two rectangular meshes in CSP and with one posterior rectangular and one anterior Y-shaped mesh in HSP. Check-ups were scheduled at 3, 6 and 12 months and then yearly. Pre-operative patient characteristics, operative and post-operative events and follow-up results were recorded. Mean follow-up was 51 months (range 12-115). RESULTS: No significant differences emerged in demographic and clinical characteristics between the HSP and CSP groups. Mean operating times, intra-operative blood loss and hospital stay were significantly less after HSP (p<0.001). At follow-up success rates were similar in the two groups in terms of uterine and upper vaginal support (100%). Recurrent low-grade cystoceles developed in 1/38 (2.6%) in the CSP group and in 5/34 (14.7%) in the HSP group (p=NS), recurrent low-grade rectocele developed in 6/38 (15.8%) and in 3/34 (8.8%) patients respectively (p=NS). No patient required surgery for recurrent vault or uterus prolapse. Urodynamic results showed that pressure/flow parameters improved significantly (p<0.001) in both groups. Thirty-one of the 34 patients (91%) in the HSP group and 33/38 (86.8%) in the CSP group were satisfied and would repeat surgery again. CONCLUSIONS: Colposacropexy provides a secure anchorage, restoring an anatomical vaginal axis and a good vaginal length. HSP can be safely offered to women who request uterine preservation. Whether the uterus was preserved or not, patients had similar results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions. HSP has shorter operating times and less blood loss.

Low risk of ureteral obstruction with "deep" (dorsal/posterior) uterosacral ligament suture placement for transvaginal apical suspension.
Aronson MP, Aronson PK, Howard AE, Morse AN, Baker SP, Young SB
Am J Obstet Gynecol 2005 May;192(5):1530-6.

OBJECTIVE: Transvaginal uterosacral ligament fixation (USLF), often called "high" USLF, is associated with a 1.0% to 10.9% ureteral obstruction rate. Anatomic relations and pelvic rotation with positioning imply "high" (cephalad) suture placement may bring sutures closer to the ureter. We examined the ureteral obstruction rate with a "deep" (dorsal/posterior) uterosacral ligament suture placement modification of a standard USLF procedure. STUDY DESIGN: At the University of Massachusetts and Tufts, 411 consecutive patients underwent Mayo culdoplasty utilizing > or = 3 uterosacral sutures placed "deep" bilaterally. Intraoperative cystoscopy was performed. RESULTS: One patient (0.24% [.01%-1.35%]) had ureteral obstruction attributable to USLF. Two had obstruction secondary to concomitant procedures. Compared with previous published series, the odds of ureteral injury secondary to USLF was 4.6 times lower (95% CI 2.31-9.24; P < .0001). CONCLUSION: Placement of USLF sutures "deep" (dorsal/posterior) increases the margin of safety for the ureter and, in this study, decreased the ureteral injury rate nearly 5-fold.

Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population.
Kahn MA, Breitkopf CR, Valley MT, Woodman PJ, O'Boyle AL, Bland DI, Schaffer JI, Grady JJ, Swift SE. Am J Obstet Gynecol 2005 May;192(5):1516-22.

OBJECTIVE: The purpose of this study was to evaluate the association of constipation symptoms and anal incontinence with vaginal wall and pelvic organ descent in a general gynecologic population. STUDY DESIGN: In this multicenter, cross-sectional study, 1004 women attending routine gynecologic healthcare underwent pelvic organ prolapse quantification (POPQ) measurements, and were surveyed regarding anal incontinence, digitation, < 2 bowel movements (BMs)/week, and > 25% frequency of: straining, hard/lumpy stools, and incomplete emptying. Constipation scores reflected the sum of positive responses. Associations between POPQ measurements (Ba, C, Bp, gh+pb), constipation scores, and anal incontinence were evaluated using multivariable regression. RESULTS: Of 119 women with Bp > or = -1.00, 47% reported no constipation symptoms. Hard/lumpy stools (26%), incomplete emptying (24%), and straining (24%) were more prevalent; fewer women reported < 2 BMs/week (15%) or digitation (7%). Constipation scores were weakly correlated with Bp, gh+pb (both r < .1, P < .02). Women reporting > or = 2 symptoms had greater gh+pb measurements than women reporting 0 or 1 symptom (P = .03). Women with anal incontinence had greater gh+pb and gh values than women without anal incontinence (P < .01). POPQ measurements were regressed separately onto (1) total constipation scores, (2) dichotomized scores, and (3) individual symptoms, with BMI, age, number of vaginal deliveries (NVD), weight of largest vaginal delivery (WLVD), race, hysterectomy, study site, and income included as covariates. Total constipation scores and dichotomized scores were nonsignificant in all models. With regard to individual symptoms, straining at stool was significant in the models for Ba and gh+pb, with greater Ba and gh+pb measurements among strainers relative to nonstrainers. CONCLUSION: Most associations between bowel symptoms and vaginal or pelvic organ descent were weak. After controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent.

Suburethral sling treatment of occult stress incontinence and intrinsic sphincter deficiency in women with severe vaginal prolapse of the anterior vs posterior/apical compartment.
Clemons JL, Aguilar VC, Sokol ER, Sung VW, Myers DL. Am J Obstet Gynecol 2005 May;192(5):1566-72.

The purpose of this study was to compare the efficacy of a Mersilene mesh suburethral sling for occult stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with severe vaginal prolapse of the anterior compartment to the posterior/apical compartment. STUDY DESIGN: This was a retrospective study that compared women with stage or grade III/IV prolapse of the anterior compartment (group 1) with the posterior/apical compartment (group 2); both groups demonstrated occult SUI (leakage only with prolapse reduced) and ISD on urodynamics, and underwent concurrent pelvic reconstructive surgery. The sling was defined as efficacious if SUI was prevented in 85% of women and if obstructive symptoms (de novo or worsening urge incontinence, or urinary retention greater than 2 weeks) occurred in less than 10% of women. RESULTS: There were 39 women in group 1 and 25 women in group 2. There were no differences between women in group 1 or group 2 in preoperative demographics (except parity) or urodynamic findings. SUI cure rates were lower for group 1 than group 2, but this difference was not significant (87% vs 100%, P = .15). Rates of de novo or worsening urge incontinence (8% vs 4%, P = 1.00) and urinary retention (none occurred) were similar between groups. CONCLUSION: In women with severe vaginal prolapse, slings effectively treat occult SUI and ISD, whether associated with anterior or posterior/apical prolapse.

High Complication Rate Identified in Sacrocolpopexy Patients Attributed to Silicone Mesh.
Govier FE, Kobashi KC, Kozlowski PM, Kuznetsov DD, Begley SJ, McGonigle KF, Muntz HG.
Urology 2005 May 20;.

OBJECTIVES: To report on our experience using a preconfigured Y-shaped silicone-coated polyester mesh and polypropylene mesh for vaginal vault suspension. A variety of materials have been used for both open and laparoscopic sacrocolpopexy in the management of vaginal vault prolapse. Recently, a preconfigured Y-shaped silicone-coated polyester mesh was introduced to facilitate the vaginal cuff suspension to the sacrum. METHODS: We reviewed the data of 45 consecutive patients who underwent abdominal (n = 28) or laparoscopic (n = 17) sacrocolpopexy. Of the 45 patients, 21 underwent silicone mesh suspension of the vaginal cuff to the anterior sacrum, with a mean follow-up of 23 months (range 16 to 41). A comparative analysis was performed of 24 patients who underwent the same procedure with polypropylene mesh. RESULTS: Of the 21 patients in the silicone group, 5 (23.8%) have had a major complication (four vaginal mesh erosions and one mesh infection) after a median follow-up of 9.5 months (range 4 to 20). The presenting symptoms were persistent or new vaginal discharge and/or nonspecific pelvic pain. One patient underwent successful removal of the mesh transvaginally, but the rest required abdominal exploration. To date, the 24 patients who underwent vaginal cuff suspension with polypropylene mesh have had no vaginal mesh extrusions or infections, with a mean follow-up of 12 months (range 1 to 38). CONCLUSIONS: Silicone-coated polyester mesh has recently been associated with a high rate of vaginal erosion when used as a transvaginal suburethral sling. Our experience specifically with vaginal vault suspension corroborates this. We have abandoned the use of silicone mesh because of the unacceptably high extrusion rate and presently use polypropylene mesh.

Robotic-assisted pelvic organ prolapse surgery.
Ayav A, Bresler L, Hubert J, Brunaud L, Boissel P.
Surg Endosc 2005 Jun 13;.

This study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system. METHODS: During a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed. RESULTS: All but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45-280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results. CONCLUSION: Our experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.

Bowel, bladder and sexual function in women undergoing laparoscopic posterior compartment repair in the presence of apical or anterior compartment dysfunction.
Thornton MJ, Lam A, King DW. Aust N Z J
Obstet Gynaecol 2005 Jun;45(3):195-200.

Abstract Objective: The aim of the study was to analyse the functional outcome of women undergoing a laparoscopic posterior compartment repair in the presence of anterior or apical compartment dysfunction. Design: Prospective cohort study. Methods: Forty women, median age 65 years (41-78), with symptoms of genital prolapse 31 (78%), urinary dysfunction 32 (80%) and bowel dysfunction 40 (100%), underwent laparoscopic posterior compartment repair in conjunction with an anterior compartment repair. Pre-operative and postoperative bowel and bladder function was prospectively assessed with a Wexner continence score, Vienna constipation score and a urinary dysfunction score. Twenty-eight (70%) and 24 patients (60%) had pre-operative urodynamics and anorectal manometry. Post-operatively all women were also assessed with a Watt's sexual dysfunction score and a linear analogue patient satisfaction score. Twelve women (30%) had postoperative anal manometry. Results: At 20 months median follow-up, 30 (97%), 20 (62%) and 12 (31%) women reported improvement in their prolapse, urinary and bowel symptoms, respectively. Post-operatively, one woman reported denovo faecal incontinence, four worsening obstructive defecation and three denovo urinary dysfunction. Nine women (35%) reported denovo dyspareunia. The mean time to clinical deterioration following surgery was 11 months. Bowel function improvement was the only factor to significantly correlate with postoperative patient satisfaction. Conclusion: The functional outcome of laparoscopic posterior compartment repair in the presence of anterior compartment dysfunction is disappointing. Preoperative counselling is important to ensure that patients have reasonable and realistic expectations from repair surgery, and an understanding that anatomical improvement might not be followed by long-term functional improvement.

The inhibition of neutrophil antibacterial activity by ultra-high molecular weight polyethylene particles.
Bernard L, Vaudaux P, Merle C, Stern R, Huggler E, Lew D, Hoffmeyer P
Biomaterials 2005 Sep;26(27):5552-7.

Following infection, bacterial killing by polymorphonuclear leukocytes (neutrophils) is the main host defense against bacteria. Our hypothesis is that particles of ultra-high molecular weight polyethylene (UHMWP) may impair local neutrophil function and consequently reduce neutrophil bacterial killing. To determine how the in vitro phagocytic-bactericidal activity of neutrophils was affected by exposure to wear particles, tests were run comparing the effects of different particle composition, and different concentrations and sizes of UHMWP particles. There was a significant correlation between the number of particles and the decrease in neutrophil bactericidal activity (p<0.01), and the greatest effect was obtained with a concentration of 10(7)UHMWP/ml. There was a significant decrease in neutrophil bactericidal activity by incubation with particles of 0.1-5mum (p<0.01), but not with larger size. The results suggest that neutrophil functional defects triggered by the presence of UHMWP particles may potentially contribute to the susceptibility of loose implants to bacterial infections.

Site-Specific Rectocele Repair Compared With Standard Posterior Colporrhaphy.
Abramov Y, Gnadhi S, Goldberg RP, Botros SM, Kwon C, Sand PK
Obstet Gynecol Surv 2005 May;60(5):297-298.

The authors conducted a review of the medical charts of all patients between July 1998 and June 2002 who had undergone repair of advanced posterior vaginal prolapse and had at least 1 year of follow up. They identified 124 consecutive patients who had undergone site-specific rectocele repair and 183 consecutive patients who had standard posterior colporrhaphy without levator ani plication. This paper presents a comparison of patient outcomes from each of these procedures.A standard method was used for posterior colporrhaphy with no plication of the levator ani. In the site-specific procedure, the dissection to the rectovaginal septum was extended laterally to the arcus tendineus levator ani muscles and inferiorly to the perineal body, leaving an avascular plane of endopelvic connective tissue on the rectum. At this point, specific defects in the Denonvilliers' fascia were identified with the surgeon's finger in the patient's rectum. Using Allis clamps, connective tissues were pulled together over the defect and sutured using interrupted 0 polygalactin 910 sutures.There were no significant differences in patient characteristics or operative data between the 2 groups, but there were significant differences in rates of recurrence. Recurrence of posterior vaginal prolapse beyond the midvaginal plane (33% vs. 14%, P = .001) or recurrence beyond the hymenal ring (11% vs. 4%, P = .02), and recurrence of a symptomatic bulge (11% vs. 4%, P = .02) were significantly more common among the patients who underwent site-specific repair compared with those who had posterior colporrhaphy. Also, the mean postoperative Bp point was significantly higher in the site-specific group (-2.2 vs. -2.7, P = .001).The percentage of patients with dyspareunia before and after surgery for vaginal prolapse increased significantly (8% vs. 17%, P = .001). Postoperative reports of constipation, diarrhea, abdominal pain, fecal incontinence, and flatus incontinence remained essentially unchanged from preoperative rates. There were no significant differences in pre- and postoperative symptoms, including dyspareunia, between the 2 groups. Rates of de novo occurrence and improvement of symptoms were similar in both groups.

Sacrocolpopexy for vault prolapse and rectocele: do concomitant Burch colposuspension and perineal mesh detachment affect the outcome?
Baessler K, Stanton SL
Am J Obstet Gynecol 2005 Apr;192(4):1067-72.

OBJECTIVE: This study compares the effect of abdominal sacrocolpopexy with posterior Teflon mesh interposition with and without concomitant Burch colposuspension on the posterior compartment. STUDY DESIGN: This retrospective review includes 49 consecutive women who underwent sacrocolpopexy for vault or uterine prolapse stage 2 or higher and rectocele; 25 of them had a concomitant Burch colposuspension for urodynamic stress incontinence. Postoperative bladder, bowel and sexual function and recurrent pelvic organ prolapse was assessed at > or =12 months. RESULTS: There was no recurrent vault prolapse. Rectoceles (stage 2) recurred in 5 women (21%) without and in 8 women (36%) with Burch colposuspension ( P > .05). The mesh became detached by >2 cm from its perineal position in 30% of the cases, which was associated with excessive defecation straining ( P = .04). Rectocele stages significantly correlated with mesh detachment ( P > .001) but not with obstructed defecation ( P > .05). CONCLUSION: Sacrocolpopexy was effective if the mesh did not become detached from its perineal position. Concomitant Burch colposuspension did not seem to affect the posterior compartment adversely in this small case series.

The role of the nurse in the use of vaginal pessaries to treat pelvic organ prolapse and/or urinary incontinence: a literature review.
McIntosh L
Urol Nurs 2005 Feb;25(1):41-8.

The available literature between 1990 and 2004 was reviewed to determine if the nurse's role in the use of vaginal pessaries to treat pelvic organ prolapse and/or urinary incontinence is well defined. Forty-five articles were reviewed, including one written by a physician's assistant, two written by both a physician and a registered nurse, seven written by registered nurses, 34 written by physicians, and one unpublished manuscript. Nurses could make a valuable contribution to the bank of information available on the use of vaginal pessaries to treat stress urinary incontinence and pelvic organ prolapse.

Paravaginal defects: prevalence and accuracy of preoperative detection.
Segal JL, Vassallo BJ, Kleeman SD, Silva WA, Karram MM
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):378-83; discussion 383. Epub 2004 Jul 1.

The objective of this study was to determine the prevalence of paravaginal defects and to report the correlation between diagnosing a paravaginal defect preoperatively and observing the presence of one intraoperatively. This was a prospective study in which 77 patients with at least stage 2 prolapse of the anterior vaginal wall who desired surgical correction of their prolapse were assessed pre- and intraoperatively for the detection of a paravaginal defect. In order to differentiate a midline or central defect from a paravaginal defect, an index finger or ring forceps was placed vaginally toward each ischial spine separately. If the prolapse became reduced, the patient was clinically diagnosed with a paravaginal defect on that side. The intraoperative visualization or palpation of the pubocervical fascia detached from the arcus tendineus fasciae pelvis was used as the gold standard in diagnosing a paravaginal defect. The overall prevalence of a paravaginal defect in patients with at least stage 2 prolapse of the anterior vaginal wall was 37.7%. The sensitivities for detecting a left, right and bilateral paravaginal defect were 47.6, 40.0 and 23.5%, respectively, while the specificities for each side were 71.4, 67.3, and 80.0%, respectively. The overall prevalence of a paravaginal defect in patients with anterior vaginal wall prolapse is low. The standard clinical evaluation used to preoperatively detect a paravaginal defect in our hands is a poor predictor for the actual presence of a paravaginal defect.

Use of porcine small intestinal submucosa in the surgical treatment of recurrent rectocele in a patient with Ehlers-Danlos syndrome type III.
Sardeli C, Axelsen SM, Bek KM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 12;.

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders involving various organ systems. We report the case of a female patient with Ehlers-Danlos syndrome type III (EDS III) presenting with a recurrent rectocele in whom porcine small intestinal submucosa mesh was used successfully to correct the defect in the rectovaginal fascia.

Risk factors for mesh erosion after transvaginal surgery using polypropylene (Atrium) or composite polypropylene/polyglactin 910 (Vypro II) mesh.
Achtari C, Hiscock R, O'reilly BA, Schierlitz L, Dwyer PL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 19;.

The objective of this study was to identify the risk factors associated with the occurrence of mesh erosion (ME) during the first 6 post-operative months in patients having undergone transvaginal repair of pelvic organ prolapse (POP) with Atrium or Vypro II mesh. We retrospectively reviewed the records of 198 consecutive patients who underwent vaginal reconstructive surgery reinforced either by Atrium or Vypro II mesh between February 1999 and July 2003. Univariable and multivariable logistic regression was performed to assess associations between measured covariates and ME. Fourteen patients [7.1%, 95% confidence interval (CI): 3.9-11.6] developed vaginal ME. We found that, in the Vypro II mesh patients, the surgeon experienced in the technique had less erosions than less experienced surgeons (2.9 vs 15.6%, p=0.02). There was no statistically significant difference between the monofilament polypropylene (Atrium) and the composite polypropylene/polyglactin 910 (Vypro II) mesh (7.2 vs 6.9%, p=0.41) when adjusted for surgeon experience and patient age. There was no association between mesh type (Atrium or Vypro II) and vaginal ME following transvaginal repair of POP. Surgeon experience and patient age were associated with ME.

Anterior enterocele: a report of three cases.
Tulikangas PK, Lukban JC, Walters MD
Int Urogynecol J Pelvic Floor Dysfunct 2004 Sep-Oct;15(5):350-2. Epub 2004 Jun 03.

Anterior enterocele is an uncommon finding in patients with pelvic organ prolapse. We reviewed 490 consecutive operations for pelvic organ prolapse. Three anterior enteroceles were identified in a series of 193 enterocele repairs (1.6%). The presentation and treatment of each of these patients is reviewed.

Severity of pelvic organ prolapse associated with measurements of pelvic floor function.
Ghetti C, Gregory WT, Edwards SR, Otto LN, Clark AL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 20;.

This study tested the hypothesis that clinical measurements of the superficial perineum and of pelvic floor muscle (PFM) function correlate with the severity of pelvic organ prolapse. This retrospective cross-sectional study assessed 1037 women in an academic urogynecologic practice. Greatest descent of prolapse, by the Pelvic Organ Prolapse Quantification system, was correlated with two assessments of levator function-the Oxford grading scale and levator hiatus (LH) size measured by digital examination. Correlations were calculated using Pearson's correlation for continuous variables and Kendall's tau-b. Severity of prolapse correlated moderately with genital hiatus (GH) (r=0.5, p<0.0001) and with LH (transverse r=0.4, p<0.0001; longitudinal r=0.5, p<0.0001), but weakly with the Oxford grading scale (r=-0.16, p<0.0001). LH correlated with GH (r=0.5, p<0.0001) but not with perineal body (r=0.06, p=0.06). Both GH and LH size are associated with the severity of prolapse. LH size correlates more strongly to prolapse severity than assessment of PFM function by the Oxford grading scale.

Evolution of the female pelvis and relationships to pelvic organ prolapse.
Schimpf M, Tulikangas P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 15;.

The female pelvis provides support for the lower limbs as well as for the gastrointestinal tract, the bladder, and the reproductive organs. It must also serve as a passageway for defecation, urination, and, possibly, delivery of an infant. The bones, ligaments, and muscles of the human female pelvis have evolved from our early ancestors. Pelvic organ prolapse may occur because of the limitations involved with adapting the pelvic bones, muscles, and ligaments previously used for other purposes into a supportive role. Here we review these changing roles and functions of nonhuman primate and human female anatomy.