Clinical review

Fortnightly review: Diagnosing and managing genitourinary prolapse

^a Department of Obstetrics and Gynaecology Southmead Hospital Bristol BS10 5NB

Correspondence to: Mr Jackson

	Introduction

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Genitourinary prolapse occurs when faults develop in the mechanisms for vaginal and uterine support (fig 1). An understanding of these mechanisms and systematic repair of these faults will restore normal structure and function. Treatment of prolapse comprises about 20% of gynaecological surgical workload,¹ and with an aging, yet more active, population this contribution will increase. Cystourethrocele is seen most commonly, followed by uterine descent and rectocele. After a hysterectomy the vagina may be susceptible to prolapse owing to loss of support of the vaginal vault.

View larger version (44K): [in this window] [in a new window]   Fig 1 Coronal section of pelvis showing cystourethrocele, enterocele, and rectocele

	Methods

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We conducted a Medline search from January 1966 to July 1996 and identified 8802 references to the term prolapse; these were reduced to 544 when we used the additional terms vagina, surgery, genitourinary, conservative, pessary, randomised, and outcome. We identified further references by hand searching relevant textbooks in the library of the Royal College of Obstetricians and Gynaecologists. We did not find any prospective trials comparing the effect of different treatments on outcome measures for prolapse. Observational studies have been published examining the pathophysiology and anatomy of prolapse, and these have stimulated interest in this subject.

	Anatomy

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The pelvic viscera are supported by the pelvic floor, with the pubococcygeal portion of the levator ani decussating around the lower vagina and urethra before attaching anteriorly to the pubic bone (fig 2). The vaginal wall consists of an inner epithelial lining surrounded by endopelvic fascia, which is composed of smooth muscle, elastin, and collagen and is attached to deeper pelvic supports. The cervix and upper third of the vagina are supported by the uterosacral and cardinal ligaments (part of the paracolpium). The middle third is attached by the pubocervical fascia to the arcus tendineus fasciae pelvis (the so called white line), which runs along the pelvic floor between the pubic symphysis and the ischial spine. The lower third is fused with the urogenital diaphragm, comprising the levator ani fascia, perineal membrane, and perineal body (fig 3).²

View larger version (62K): [in this window] [in a new window]   Fig 2 Anatomy of pelvic floor

View larger version (98K): [in this window] [in a new window]   Fig 3 Anatomy of vaginal support. The bladder has been removed at the vesical neck. (Reproduced with permission of JOL DeLancey)

	Causes

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The causes of genitourinary prolapse are summarised in the box.

Childbirth: Vaginal delivery results in pelvic floor dysfunction, which manifests as urinary incontinence.³ It may also predispose to subsequent prolapse. This may occur secondary to mechanical damage, particularly after forceps deliveries⁴ or denervation of the pelvic floor.⁵ The risk of denervation is increased by prolonged labour and large babies,⁶ and prolapse is associated with such denervation.⁷

Connective tissue disease: Some women may have a congenital predisposition to prolapse because of abnormal collagen metabolism. Genitourinary prolapse is associated with joint hypermobility⁸ and reduced vaginal collagen content.⁹

Iatrogenic causes: Division of the uterosacral and cardinal ligaments without reattachment to the vaginal vault at the time of hysterectomy predisposes to subsequent prolapse of the vaginal vault.² There is a further risk of enterocele after vaginal hysterectomy, probably due to inadequate approximation of the uterosacral ligaments at the time of surgery.

	Symptoms

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Some of the symptoms of genitourinary prolapse are given in the box. Mild genitourinary prolapse may be an asymptomatic incidental finding noted at the time of vaginal examination. As such, it is best noted, but the patient should not be informed that she has a prolapse unless she mentions symptoms. Symptoms associated with more significant prolapse include feeling a lump within the vagina and observing a bulge if displacement is beyond the introitus. Displacement may result in dragging or aching discomfort, often localised to the back, and if prolapse is beyond the introitus tissue can become excoriated (decubitus ulcer), resulting in blood stained vaginal discharge.

Symptoms are often worse at the end of the day and after the patient has been standing for a long time. Coital problems, including loss of sensation and orgasm, dyspareunia, and vaginal flatus may be prominent. General discomfort in the vagina postmenopausally is more often associated with vaginal atrophy than prolapse, and a trial of topical vaginal oestrogen treatment daily for four to six weeks should be considered if the prolapse is mild.

Associated genitourinary symptoms may include urinary stress incontinence due to urethral hypermobility, although only 50% of women with genuine stress incontinence have clinically important prolapse of the anterior vaginal wall.¹ If cystourethrocele results in kinking of the urethra the urinary stream may be poor, with recurrent urinary tract infections if voiding is incomplete. In extreme cases chronic urinary retention with overflow incontinence may ensue. Rectocele may cause difficulty with defaecation (dyschezia) or a sensation of incomplete defaecation, which is sometimes relieved by digital reduction of the prolapse.

The patient's perception of the trouble her symptoms cause must be considered when management options are being evaluated. Patients' perception should also become a key outcome measure in studies of genitourinary prolapse, but validated symptom questionnaires need to be developed before reproducible comparisons are possible.¹⁰

	Diagnosis

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Examination
Genitourinary prolapse is diagnosed clinically (fig 4). Bimanual examination should be performed to exclude the rare possibility of an associated pelvic mass. A prolapse can usually be seen when the patient is lying on her back or side, although it may be necessary to examine her standing up to reproduce the conditions under which prolapse occurs. Descent to or beyond the introitus is observed after asking the patient to bear down.

View larger version (116K): [in this window] [in a new window]   Fig 4 Cystourethrocele and uterine descent

The vaginal walls, fornices, and cervix are then assessed by inserting a Sims' speculum along the posterior vaginal wall. Gentle retraction of the posterior vaginal wall affords a view of the cervix, lateral and anterior fornices, and anterior vaginal wall. If important cystourethrocele is present the view of the cervix will be obscured and reduction with an examining finger or sponge forceps is necessary. The posterior vaginal wall is then assessed by retracting the anterior vaginal wall.

Enterocele and rectocele are difficult to differentiate clinically, although with the patient standing a cough impulse indicating an enterocele can be appreciated on combined rectal and vaginal examination.

Prolapse can vary in extent from some movement on coughing (this being normal in parous women) to descent to or beyond the introitus. For many years uterine descent has been classed as grades 1-3. Grade 1 is descent within the vagina, grade 2 is descent of the cervix to the introitus, and grade 3, or procidentia, is descent of the uterus outside the introitus. However, this classification is subjective and insensitive and takes no account of cystocele, enterocele, or rectocele. Detailed objective measures of the degree of prolapse are a prerequisite for evidence based studies, and recommended parameters for measuring pelvic organ prolapse have now been agreed by the International Continence Society.¹¹

Investigation
As the diagnosis of prolapse is clinical, minimal additional investigation is usually required. However, it is important to be aware that other disease may occasionally be present (fig 5). With a large cystocele the ureterovesical junctions and lower ureters may descend, resulting in potential ureteric obstruction. Therefore, procidentia should be investigated by measuring serum urea and creatinine concentrations and by renal ultrasonography. Concurrent lower urinary tract symptoms such as incontinence should be assessed by cystometry before surgery. Cervical cytology is essential before considering hysterectomy, and any suspected pelvic mass should be investigated. The value of defaecography to evaluate posterior vaginal wall prolapse is undecided.

View larger version (109K): [in this window] [in a new window]   Fig 5 Left: Paraurethral cysts are rare, but as they occur laterally to the urethra they can usually be differentiated from urethrocele clinically. Right: Urethral diverticula may occur in the midline, mimicking urethrocele. Bottom: Urethrogram shows diverticulum

	Management

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Prevention
Childbirth–Appropriate management of labour may have a prophylactic role. The increasing rate of caesarean section in the United Kingdom and better management of labour, with a reduction in instrumental trauma and prolonged labour, may result in a reduction in the incidence of prolapse secondary to obstetric causes.

Hormone replacement therapy–Postmenopausal oestrogen supplementation increases skin collagen content¹² and causes trophic alterations in vaginal epithelium. Whether hormone replacement therapy increases the biomechanical strength of tissue or prevents the occurrence of genitourinary prolapse is unclear.

Pelvic exercises–Because of the anatomical connections between the pelvic floor, urethra, and vagina, exercising the pelvic floor may, in theory, prevent prolapse occurring secondary to pelvic floor laxity.

Conservative management
Incidental mild prolapse found at the time of routine pelvic examination, if not associated with symptoms, needs no treatment. Often reassurance and explanation is all that is required. With mild symptoms conservative management should be offered in the first instance. The risks of surgery and anaesthesia should not be taken lightly, especially in elderly women, and the long term morbidity from surgery, including coital difficulties and pain, are often understated.

General–Simple treatment of exacerbating factors such as obesity and concurrent chronic coughs is likely to ameliorate the condition.

Hormone replacement therapy–Hormone replacement therapy increases postmenopausal vaginal collagen turnover,¹³ but whether spontaneous anatomical remodelling and repair of established prolapse can occur is unknown.

Pelvic floor exercises–Pelvic floor exercises are an established treatment for urinary stress incontinence,¹⁴ but whether they benefit established prolapse has not been studied.

Vaginal pessaries–Genitourinary prolapse can be reduced with vaginal pessaries (box). Pessaries may be appropriate while the patient is awaiting definitive surgery and when surgery is declined or contraindicated because of pregnancy or for medical reasons. Pessaries are commonly rings, and, although they are made of inert plastic, they should be changed every six months to prevent erosion of or embedding in the vaginal wall. The use of oestrogen cream with vaginal pessaries reduces discomfort and erosion. Sizes vary, and the appropriate size is determined at the time of digital examination by estimating the distance from the posterior aspect of the symphysis pubis to the posterior vaginal fornix. Occasionally, although the pessary seems to be the right size, rings will not stay in place. In this case a shelf pessary can be helpful, especially with vault prolapse or enterocele. As well as being used for definitive treatment vaginal pessaries can be used diagnostically: when it is unclear whether a patient's symptoms stem from uterovaginal prolapse the effect of reduction can be assessed by temporary insertion of a pessary. Relief of symptoms would then be an indication for surgery.

Surgery
Ideally, surgery will correct prolapse while maintaining coital function and preserving continence. It is important to ask whether the woman is sexually active before considering vaginal surgery as this may alter the surgical approach, or indeed defer surgery. Care not to reduce the vaginal capacity with overaggressive or repeated vaginal surgery is essential but has been overlooked in the past partly because of a failure to appreciate the underlying anatomical defects. A move towards reconstructive vaginal and abdominal surgery for prolapse and away from excisional, obliterative surgery should reduce this often hidden morbidity.

Types of repair
Anterior colporrhapy, otherwise known as anterior repair, has been the favoured operation for cystocele (fig 6). Colpoperineorrhaphy, or posterior repair, is favoured for rectocele. Care must be exercised when removing the redundant vaginal epithelium as vaginal narrowing can result in severe dyspareunia. This is common after posterior repair, particularly when mid-vaginal levator sutures have been inserted.¹⁵ The levator ani muscles do not normally meet between the rectum and vagina, and suturing them together at the time of posterior repair will lead to coital pain. Prolapse of the anterior vaginal wall may be due to detachment of the lateral vaginal support to the arcus tendineus fascia pelvis. In this case paravaginal repair, either by the transvaginal or abdominal route, is gaining popularity.^{16 17}

View larger version (39K): [in this window] [in a new window]   Fig 6 Anterior colporrhaphy. Redundant vaginal epithelium is excised and endopelvic fascia is opposed before closing vaginal incision

It has been asserted that surgical cure of some forms of cystourethrocele is associated with subsequent stress incontinence, perhaps secondary to an intrinsic problem with the sphincter that is revealed when the urethra becomes straight again. However, a preoperative and postoperative prospective clinical and urodynamic study has shown no evidence that bladder or urethral function is compromised by colporrhaphy or vaginal hysterectomy,¹⁸ although excessive and unnecessary dissection of the bladder neck should be avoided in women who are continent.

If there is concurrent urinary stress incontinence a Burch colposuspension will correct cystocele, as well as giving excellent long term urinary continence.¹⁹ When uterine prolapse is present vaginal hysterectomy is the procedure of choice. This can be combined with anterior or posterior repair when, as is commonly the case, concurrent cystocele and rectocele are present. Although uncommonly performed today, cervical amputation with a Manchester or Fothergill repair can be performed for mild uterine descent, especially when the cervix has become enlarged and conservation of the uterus is desired. A retrospective comparison of Manchester repair with vaginal hysterectomy for uterine prolapse found that both procedures had a similar outcome.²⁰

Recurrence of problems
The incidence of recurrent prolapse is reported to be 16%.²¹ This may be due to a failure to correct the precise initial anatomical defect or it may arise as a complication of the original surgery. Such examples include enterocele after Burch colposuspension, cystocele after sacrospinous fixation, and rectocele or enterocele after sacrocolpopexy. Vaginal vault prolapse will occur if the vault is not secured to the uterosacral ligaments at hysterectomy. Repair can be effected vaginally or suprapubically, and the patient's medical condition and wishes about sexual activity need to be considered when planning surgery.

The simplest procedure is colpocleisis, or occlusion of the vaginal lumen, which can be performed under local anaesthesia. This is appropriate only for sexually inactive women, but it has low morbidity and a low rate of recurrence²² and is a useful technique in frail elderly women. Sacrospinous fixation, with stitching of the vaginal cuff to the sacrospinous ligament, does not alter vaginal capacity, and recovery time is quick as it is a vaginal repair. Although infrequent, complications are serious as damage can occur to the pudendal artery, pudendal nerve, or sciatic nerve. Injuries may be minimised by avoiding the lateral third of the sacrospinous ligament and placing the stitch superficially.²³ One year cure rates of 90% have been reported with this technique.²⁴

Sacrocolpopexy uses the abdominal approach, the vaginal vault being attached by non-absorbable mesh to the sacral promontory.²⁵ Vaginal anatomy is not distorted, but this procedure also carries the risk of haemorrhage from the sacral venous plexus. Cure rates of 88%-97% have been reported between one and 10 years later.^{26 27} Alternatively, the Zacharin procedure corrects the anatomical defect by closing the levator hiatus and suturing the vagina to the levator plate.²⁸ It entails more extensive dissection than colposacropexy, and a retrospective comparison of the two procedures, both performed by the same surgeon, has shown colposacropexy to have superior results.²⁹ Laparoscopic sacrocolpopexy has also been described,³⁰ but no long term follow up data are available.

Outcome measures
We did not find any studies that had examined different surgical techniques in a prospective controlled manner. In addition to the procedure performed, outcome may depend on the skill of the surgeon and the quality of the tissues. Improving tissue quality preoperatively with oestrogen has been assessed in one randomised placebo controlled trial.³¹ Vaginal wall thickness was increased and the incidence of postoperative cystitis decreased. Long term outcome was not assessed.

	Conclusions

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The treatment of genitourinary prolapse is under review. The lack of controversy and research based evidence may, in part, reflect misplaced satisfaction with established practice. However, early studies of recurrence rates and coital satisfaction after vaginal surgery suggest that a hidden morbidity needs to be considered. Until recently, no scientific methodology has been available to assess symptoms or objective degree of genitourinary prolapse; without such methodology the design of clinical trials has been problematic. A better understanding of the underlying pathoanatomy of prolapse has generated increasing interest within this subject, and further research is required into both the underlying pathophysiology and clinical outcome of conservative and surgical treatment.

	References

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