Practice Issues

What Is New in Pelvic Organ Prolapse?

Best Articles From the Past Year
Kimberly S. Kenton, MD, MS

T his month we focus

on current research
in pelvic organ prolapse.
Dr. Kenton discusses
five recent publications,
which are concluded
with a bottom line
that is the take-home
message. The complete
reference for each can
be found in Box 1 on this
page, along with direct
links to the abstracts.
(Obstet Gynecol 2015;126:11025)
DOI: 10.1097/AOG.0000000000001130
Pelvic Organ Prolapse and Incontinence 1523 Years
After First Delivery: A Cross-Sectional Study
The identification of modifiable factors associated
with pelvic floor disorders remains challenging given
the oftentimes long delay between exposure and
symptom development, especially for pelvic organ
prolapse (POP). Most high-quality data are limited to
short-term outcomes after delivery. These authors
conducted a cross-sectional study of 3,115 women
who delivered their first child at Trondheim Univer-
sity Hospital in Norway between 1990 and 1997 to
study the association between pelvic floor dysfunction
and route of delivery. They aimed to calculate the risk
of pelvic floor dysfunction, including POP, urinary
incontinence, and fecal incontinence, based on deliv-
Dr. Kenton is from the Division of Obstetrics and Gynecology-Female Pelvic
Medicine and Reconstructive Surgery (Urogynecology), Northwestern University
Feinberg School of Medicine, 250 E Superior, Chicago, Illinois; e-mail:
kkenton@nmff.org.
Financial Disclosure
The author did not report any potential conflicts of interest.
2015 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/15
Box 1. Abstracts Discussed in This Commentary
1. Vollyhaug I, Mrkved S, Salvesen , Salvesen K.
Pelvic organ prolapse and incontinence 1523
years after first delivery: a cross-sectional study.
BJOG 2015;122:96471. Available at: http://dx.
doi.org/10.1111/1471-0528.13322.
2. Allen-Brady K, Cannon-Albright LA, Farnham JM,
Norton PA. Evidence for pelvic organ prolapse pre-
disposition genes on chromosomes 10 and 17. Am J
Obstet Gynecol 2015;212:771.e17. Available at:
http://dx.doi.org/10.1016/j.ajog.2014.12.037.
3. Detollenaere RJ, den Boon J, Stekelenburg J, In-
tHout J, Vierhout ME, Kluivers KB, van Eijndhoven
HW. Sacrospinous hysteropexy versus vaginal hys-
terectomy with suspension of the uterosacral liga-
ments in women with uterine prolapse stage 2 or
higher: multicentre randomised non-inferiority trial.
BMJ 2015;351:h3717. Available at: http://dx.doi.
org/10.1136/bmj.h3717.
4. Wiegersma M, Panman CMCR, Kollen BJ, Berger
MY, Lisman-Van Leeuwan Y, Dekker JH. Effect of
pelvic floor muscle training compared with watch-
ful waiting in older women with symptomatic mild
pelvic organ prolapse: randomised controlled trial
in primary care. BMJ 2014;349:g7378. Available at:
http://dx.doi.org/10.1136/bmj.g7378.
5. Siddiqui NY, Grimes CL, Casiano ER, Abed HT, Jep-
pson PC, Olivera CK, et al. Mesh sacrocolpopexy
compared with native tissue vaginal repair: a sys-
tematic review and meta-analysis. Obstet Gynecol
2015;125:4455. Available at: http://dx.doi.org/10.
1097/AOG.0000000000000570.
ery method. Women were retrospectively allocated to
the delivery groupspontaneous vaginal, cesarean, or
operative (forceps or vacuum) according to their
deliverythat was most likely to cause pelvic floor
injury (operative.normal vaginal.cesarean). In addi-
tion to national database records, all women com-
pleted symptom questionnaires, including the
validated Pelvic Floor Distress Inventory (PFDI-20),
querying symptom bother from pelvic floor disorders.
Fifty-three percent of eligible women (n51,641)

1102 VOL. 126, NO. 5, NOVEMBER 2015 OBSTETRICS & GYNECOLOGY

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
agreed to participate. Fifteen to 23 years after their
first delivery, 53% of women reported symptoms from
at least one pelvic floor disorder: 11% reported pro-
lapse, 47% urinary incontinence, and 9% fecal incon-
tinence. When cesarean was compared with
spontaneous vaginal delivery, the adjusted odds ratio
(OR) for prolapse symptoms was 0.42 (95% confi-
dence interval [CI] 0.210.86) and for urinary incon-
tinence was 0.65 (95% CI 0.460.92). Operative
vaginal delivery (forceps and vacuum) increased the
risk of prolapse symptoms (OR 1.73, 95% CI 1.21
2.48) and fecal incontinence (OR 1.96, 95% CI 1.26
3.06) compared with spontaneous vaginal delivery.
Similarly, there was a higher prevalence of women
without pelvic floor symptoms in the cesarean deliv-
ery group (OR 1.74, 95% CI 1.232.45) and a higher
prevalence of women with two or more pelvic floor
disorders in the operative vaginal delivery group (OR
1.60, 95% CI 1.092.33) when compared with spon-
taneous vaginal delivery. There was no difference in
outcomes between forceps and vacuum.
Bottom Line: This study supports previous studies
demonstrating an association between operative vag-
inal delivery and development of pelvic floor disor-
ders, including POP.
Evidence for Pelvic Organ Prolapse Predisposition
Genes on Chromosomes 10 and 17
Although POP is a prevalent disorder among women,
resulting in high costs to women and society, most of
our current understanding of the natural history and
progression of the disease relies on studies, such as the
one above, investigating factors associated with dis-
ease development. Allen-Brady and her colleagues are
among the first to study molecular and genetic
mechanisms leading to developing prolapse by using
genome-wide linkage analysis to identify genes that
predispose women to developing POP. They pre-
viously identified and recruited women with a family
history of prolapse to be part of a genetic study of
high-risk pedigrees and performed a linkage analysis,
which included sibling pairs who underwent surgery
for prolapse. They discovered that linkage evidence
for prolapse resided on chromosome 9q21. The aim
of this study was to expand or loosen their definition
of prolapse to also include women with prolapse
symptoms (as reported on validated pelvic floor
symptom questionnaire PFDI-20) who may not have
undergone surgical treatment (which they hypothesize
is a marker for more severe disease). Their complete
pedigree resource contains 299 familial prolapse cases
in 83 high-risk pedigrees. The genome-wide linkage
VOL. 126, NO. 5, NOVEMBER 2015
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
analysis was done under general dominant and
recessive models. Linkage analysis defining prolapse
as bothersome symptoms showed genome-wide link-
age on chromosome 10q24-26 (recessive model,
maximum heterogeneity logarithm of odds 3.4),
suggestive evidence on chromosomes 6 and 17, and
an additional region on chromosome 10. Because
some of the participants were used in previous linkage
analysis, the authors also performed linkage analysis
in only the 225 newly recruited participants. In this
subset, evidence of genome-wide linkage was
observed on chromosome 17q25 (recessive model,
maximum heterogeneity logarithm of odds 3.3) and
suggestive evidence on chromosomes 10 and 11. In
summary, using the Utah high-risk prolapse pedigree
resource, evidence for linkage was identified on
chromosomes 10q24-26 and 17q25, suggesting that
these regions may contain prolapse disposition genes.
Bottom Line: The authors identified chromosomal re-
gions with linkage evidence for POP using a symp-
tom-base definition for prolapse. The genes identified
are among the first biologically plausible genes pro-
viding evidence that genetic factors contribute to the
etiology of prolapse.
Sacrospinous Hysteropexy Versus Vaginal
Hysterectomy With Suspension of the Uterosacral
Ligaments in Women With Uterine Prolapse Stage 2
or Higher: Multicentre Randomised Non-
Inferiority Trial
Traditionally, reconstructive surgeons perform hys-
terectomy at the time of apical prolapse repair;
however, more recently, some surgeons and patients
have started to challenge this practice with an increase
in uterus-preserving prolapse surgery. Few well-
designed randomized comparative effectiveness trials
exist to either support or refute the risks and benefits
of hysterectomy compared with uterine preservation
at the time of prolapse surgery. This multicenter
randomized comparative effectiveness trial performed
in the Netherlands tested the hypothesis that vaginal
sacrospinous hysteropexy was not inferior to vaginal
hysterectomy with uterosacral ligament suspension
for correcting stage II or greater symptomatic POP.
Concomitant anterior and posterior vaginal wall and
incontinence surgeries were allowed. The primary
outcomestage II or greater apical prolapse with both-
ersome bulge symptoms or repeat surgery for apical
prolapsewas assessed at 12 months. Secondary out-
comes included recurrent stage II or greater prolapse
in any compartment; no prolapse beyond hymen, no
bothersome bulge symptoms, and no further
Kenton Whats New in Pelvic Organ Prolapse? 1103
treatment for prolapse; and quality of life and compli-
cations. Permanent sutures were used for both the
hysteropexy and uterosacral ligament suspension.
Nearly all patients had a concomitant anterior colpor-
rhaphy and 2950% a posterior colporrhaphy. A 7%
noninferiority margin was selected. No patients in the
hysteropexy group and 4% in the vaginal hysterec-
tomy with uterosacral ligament suspension group
had stage II or greater apical prolapse or underwent
recurrent apical prolapse surgery, leading the authors
to conclude that sacrohysteropexy was not inferior to
vaginal hysterectomy with uterosacral ligament sus-
pension; although, recurrent prolapse in anterior or
posterior compartments or both was considerably
higher in both groups (50% after sacrospinous hyster-
opexy and 44% after vaginal hysterectomy with ute-
rosacral ligament suspension). Functional outcomes,
hospital stay, complications, postoperative recovery,
and sexual functioning did not differ among treatment
groups.
Bottom Line: These data are consistent with a growing
body of evidence that suggests sacrospinous hystero-
pexy is a reasonable alternative to extirpative surgery
for apical prolapse with vaginal hysterectomy and ute-
rosacral ligament suspension. Short-term anatomic
outcomes, subjective outcomes, complications, and
reoperation rates are similar for both procedures.
Although longer-term outcomes are needed, surgeons
should discuss the risks and benefits of sacrospinous
hysteropexy with patients planning surgery for apical
prolapse.
Effect of Pelvic Floor Muscle Training Compared
With Watchful Waiting in Older Women With
Symptomatic Mild Pelvic Organ Prolapse:
Randomised Controlled Trial in Primary Care
Increasing data indicate that women are most both-
ered when the leading edge of the prolapse protrudes
beyond the hymen. Likewise, surgery for POP is
typically reserved for women with stage II or greater
prolapse (leading edge of prolapse is within 1 cm of
the hymen); although, women with early stages of
prolapse may still report bothersome symptoms.
Pelvic floor physical therapy is clearly advantageous
for many pelvic floor disorders such as urinary and
fecal incontinence, but its utility for treatment of POP
is less clear. The investigators present a randomized
controlled trial of pelvic floor muscle training for
women with symptomatic early-stage II and I pro-
lapse. Women were recruited from primary care
practices if they answered affirmatively to symptoms
of vaginal bulging, pelvic heaviness, urinary inconti-
1104 Kenton Whats New in Pelvic Organ Prolapse?
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
nence, or splinting to assist voiding or defecation or
both. Women with symptomatic prolapse within the
hymen were eligible for inclusion and randomized to
a formal pelvic floor muscle training program super-
vised by a specialized pelvic floor physical therapist or
to no treatment. Patients were assessed 3 months after
beginning treatment with validated pelvic floor symp-
tom and quality-of-life questionnaires assessing pro-
lapse, urinary, bowel, and sexual symptoms. Women
underwent a median of seven (interquartile range 59)
pelvic floor muscle-training sessions, and 41% were
still undergoing physical therapy at 3-month follow-
up. Pelvic Floor Distress Inventory scores improved
significantly more in the pelvic floor muscle training
group (P5.005); however, the 9-point greater
improvement did not meet the accepted minimum
clinically important difference for the PFDI-20. Most
of the improvement in PFDI-20 scores was attributed
to improvement in urinary symptom scores rather
than prolapse or bowel symptoms. Neither group
experienced significant changes in anatomic prolapse
outcomes.
Bottom Line: Although the authors conclude that pel-
vic floor muscle training should be considered in
women with symptomatic mild prolapse, their data
do not really support this conclusion. There was no
change in prolapse symptoms (as measured by the
prolapse subscale of the PFDI-20) or anatomic pro-
lapse findings 3 months after pelvic floor muscle train-
ing. In contrast, their findings are consistent with prior
literature, which report that pelvic floor symptoms,
particularly urinary symptoms, improve with pelvic
floor muscle training.
Mesh Sacrocolpopexy Compared With Native Tissue
Vaginal Repair: A Systematic Review and Meta-
analysis
Women have a 12.6% lifetime risk of undergoing
surgery for POP; yet the optimal surgical approach
remains unclear. As discussed in an earlier article,
controversy exists over uterine preservation com-
pared with extirpation; likewise, augmentation of
surgical repair with synthetic mesh compared with
native tissue repairs relying on the patients own tis-
sues is debated. Different risks and benefits are asso-
ciated with each type of procedure and should be
individualized for each woman. This article is a sys-
tematic review comparing mesh sacrocolopexy with
native tissue vaginal repair for women with apical
POP, which includes anatomic outcomes, symptom
outcomes, and adverse events at least 6 months after
surgery. Comparative studies assessing outcomes of
OBSTETRICS & GYNECOLOGY
sacrocolopexy (open, laparoscopic, or robotic) with
permanent mesh and native tissue repairs (uterosacral
and sacrospoinous ligament suspensions, McCalls cul-
doplasty, Manchester-Fothergill procedure, and ilio-
coccygeus vaginal suspension) in women with any
stage of apical prolapse and at least 6 months of
follow-up were included in the analysis. Vaginal mesh
procedures were excluded. Thirty-four studies met
inclusion criteria, and 13 (five randomized trials and
eight cohort studies) were included in this systematic
review evaluating medium-term anatomic success.
Seventy-nine studies were included in the adverse
event analysis. The most common definitions of surgi-
cal failure were stage II or greater prolapse or prolapse
beyond the hymen. Twelve studies with moderate evi-
dence quality showed better anatomic durability and
success with mesh sacrocolpopexy compared with
native tissue vaginal repairs. Including just randomized
trials, there was significantly greater likelihood of
anatomic success with mesh sacrocolpopexy compared
with native tissue vaginal repairs (pooled OR 2.04, 95%
CI 1.123.72). These results were supported by
the nonrandomized comparative studies. There were
inconsistent results resulting in very low-quality
evidence showing no difference in reoperation between
mesh sacrocolpopexy and native tissue vaginal repair.
Functional outcomes were more difficult to ana-
lyze and interpret. There was insufficient evidence to
compare functional bladder or bowel outcomes
among procedures and low-quality evidence suggest-
ing no difference in postoperative sexual function.
Moderate-quality evidence showed shorter operative
times with native tissue repairs, and low-quality
evidence showed no difference in hospital stay
between procedures. Although adverse events were
uncommon, more ileus or small bowel obstructions
(OR 9.45, 95% CI 3.3926.4), less dyspareunia (OR
0.42, 95% CI 0.250.72), and more mesh or suture
complications (OR 3.26, 95% CI 1.626.56) were
identified after mesh sacrocolopexy (P5.001).
Bottom Line: Surgeons offering reconstructive sur-
gery for apical prolapse should discuss risk and bene-
fits of both mesh sacrocolpopexy and native tissue
vaginal repairs with each patient to help her select
the operation that best meets her needs. Patients
who prioritize anatomic outcomes and durability
may prefer a mesh sacrocolopexy; however, when mi-
nimizing risks of adverse events or reoperation, there
is no strong evidence supporting one approach over
the other.

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rev 1/2015

VOL. 126, NO. 5, NOVEMBER 2015 Kenton Whats New in Pelvic Organ Prolapse? 1105

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.