Мodern approaches to diagnosis and conservative treatment of genital prolapse in women in the practice of gynecologist

Apolikhina I.A., Chochueva А.S., Saidova А.S., Gorbunova Е.А., Kagan I.I.

1Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, Moscow 117997, Ac. Oparina str. 4, Russia 2First Moscow State Medical University, Ministry of Health of Russia, Moscow 119048, Trubetskaya str. 8, Russia 3Orenburg State Medical University, Ministry of Healthcare of the Russian Federation, Orenburg 460000, Sovetskaya str. 6, Russia
Objective. To acquaint readers with modern approaches to diagnosis and treatment of genital prolapse in women.
Material and methods. A systematic review of the published literature on the diagnosis and treatment of pelvic organ prolapse (POP).
Results. Analysis of published data shows that modern principles of diagnosis of genital prolapse, such as perineal ultrasound 2D and 3D ultrasound, greatly extends the examination of patients with pelvic floor changes, it allows to objectify the process of examination and treatment.
The use of pessaries is the first line of conservative treatment POP. A variety of shapes and sizes allows individual selection of the desired type for each patient. Pessaries have virtually no contraindications, which allows to recommend them almost all patients with POP.
Conclusion. Taking into account the efficiency of the above approaches to diagnosis and treatment of genital prolapse in women, it is necessary their implementation in practical healthcare.

Keywords

pessaries
pelvic organ prolapse
urinary incontinence
conservative treatment

Supplementary Materials

  1. Table 1. Symptoms of pelvic organ prolapse
  2. Тable 2. Pelvic Organ Prolapse Quantification System (POP-Q)
  3. Table 3. Muscle Strength Grading Scale (Oxford Scale)
  4. Figure 1. The anatomical landmarks to determine the degree of pelvic organ prolapse by POP-Q.
  5. Figure 2. The structure of m. levator ani.
  6. Figure 3. Levator ani muscle palpation demonstrated using a model. (a) Normal left-side levator ani muscle (L) attachment. (b) Right-side avulsion. PB, pubic bone; U, urethra.
  7. Figure. 4. Diagrammatic representation of classification system for palpation of levator ani muscle (LAM) avulsion
  8. Fig. 5 A. The patient of 65 years with POP, before the introduction of the pessary. During the uroflowmetry marked obstructive voiding type: reduced max. urinary flow rate (7.4 ml / s) environments. rate of urination and urine volume at miktsii. Fig. 5 B. The same patient after the introduction of the pessary. Restoration of normal indicators - non-obstructive urinary type: max. urination rate (20.6 ml / sec), and residual urine volume reduction to 0 ml.
  9. Fig. 6. The patient, 69 years old. Pelvic organ prolapse 3 stage. Figure a) before and c) after the introduction of the pessary.

References

1. Aylamazyan E.K., ed. Pelvic organ prolapse in women: etiology, pathogenesis, diagnostic principles. Manual for physicians. St. Petersburg: Publishing house of the N-L; 2010. 48p. (in Russian)

2. Mustkivi N.A. The correction of genital prolapse laparoscopic access. Diss. Moscow; 2010. 26p. (in Russian)

3. Davila G.W., Baessler K., Cosson M., Cardozo L. Selection of patients in whom vaginal graft use may be appropriate. Consensus of the 2nd IUGA Grafts Roundtable: optimizing safety and appropriateness of graft use in transvaginal pelvic reconstructive surgery. Int. Urogynecol. J. 2012; 23(Suppl. 1): S7-14.

4. da Silva-Filho A.L., Martins P.A., Parente M.P., Saleme C.S., Roza T., Pinotti M. et al. Translation of biomechanics research to urogynecology. Arch. Gynecol. Obstet. 2010; 282(2): 149-55.

5. Fonti Y., Giordano R., Cacciatore A., Romano M., La Rosa B. Post partum pelvic floor changes. J. Prenat. Med. 2009; 3(4): 57-9.

6. Diez-Itza I., Arrue M., Ibañez L., Paredes J., Murgiondo A., Sarasqueta C. Influence of mode of delivery on pelvic organ support 6 months postpartum. Gynecol. Obstet. Invest. 2011; 72(2): 123-9.

7. Haylen B.T., Freeman R.M., de Ridder D., Swift S.E., Berghmans B., Lee J. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol. Urodyn. 2010; 29(1): 4-20, Int. Urogynecol. J. 2010; 21(1): 5-26.

8. Bump R.C., Mattiasson A., Bø K., Brubaker L.P., DeLancey J.O., Klarskov P. et al. The standardization of female 1159 pelvic organ prolapse and pelvic floor dysfunction. Am. J. Obstet. Gynecol. 1996; 175(1): 10-7.

9. Korshunov M.Yu. Prolapse of pelvic organs in women: a personalized approach to diagnosis, surgical correction and evaluation of treatment outcomes. Diss. St. Petersburg; 2016. (in Russian)

10. Dietz H.P., Shek K.L. Validity and reproducibility of the digital detection of levator trauma. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2008; 19(8): 1097-101.

11. Dietz H.P., Simpson J.M. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008; 115(8): 979-84.

12. Dietz H.P., Lanzarone V. Levator trauma after vaginal delivery. Obstet. Gynecol. 2005; 106(4): 707-12.

13. Kearney R., Miller J.M., Ashton-Miller J.A., Delancey J.O. Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet. Gynecol. 2006; 107(1): 144-9.

14. Otcenasek M., Krofta L., Baca V., Grill R., Kucera E., Herman H. et al. Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based threedimensional reconstruction and comparison with a model of a healthy nulliparous woman. Ultrasound Obstet. Gynecol. 2007; 29(6): 692-6.

15. Dietz H.P., Gillespie A., Phadke P. Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust. N. Z. J. Obstet. Gynaecol. 2007; 47(4): 341-4.

16. Hirai K., Sumi T., Kanaoka Y., Ishiko O. Female urinary incontinence: diagnosis, treatment and patients’ concerns. Drugs Today (Barc.). 2002; 38(7): 487-93.

17. Dietz H.P., Wilson P.D. Anatomical assessment of the bladder outlet and proximal urethra using ultrasound and videocystourethrography. Int. Urogynecol. J. Pelvic Floor Dysfunct. 1998; 9(6): 365-9.

18. Dietz H.P., Lekskulchai O. Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms. Ultrasound Obstet. Gynecol. 2007; 29(6): 688-91.

19. Blain G., Dietz H.P. Symptoms of female pelvic organ prolapse: correlation with organ descent in women with single compartment prolapse. Aust. N.Z. J. Obstet. Gynaecol. 2008; 48(3): 317-21.

20. Dietz H.P., Kamisan Atan I., Salita A. The association between ICS POPQ coordinates and translabial ultrasound findings. Ultrasound Obstet. Gynecol. 2016; 47(3): 363-8. doi: 10.1002/uog.14872.

21. Dietz H.P., Clarke B., Herbison P. Bladder neck mobility and urethral closure pressure as predictors of genuine stress incontinence. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2002; 13(5): 289-93.

22. Dietz H.P., Nazemian K., Shek K.L., Martin A. Can urodynamic stress incontinence be diagnosed by ultrasound? Int. Urogynecol. J. 2013; 24(8):1399-403.

23. Dietz H.P. Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet. Gynecol. 2004; 23(1): 80-92.

24. Dietz H.P., Clarke B. The urethral pressure profile and ultrasound imaging of the lower urinary tract. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001; 12(1): 38-41.

25. Huang W.C., Yang J.M. Bladder neck funneling on ultrasound cystourethrography in primary stress urinary incontinence: a sign associated with urethral hypermobility and intrinsic sphincter deficiency. Urology. 2003; 61(5): 936-41.

26. Schaer G.N., Perucchini D., Munz E., Peschers U., Koechli O.R., Delancey J.O. Sonographic evaluation of the bladder neck in continent and stress-incontinent women. Obstet. Gynecol. 1999; 93(3): 412-6.

27. Wijma J., Tinga D., Visser G. Perineal ultrasonography in women with stress urinary incontinence and controls: the role of pelvic floor muscles. Obstet. Gynecol. Invest. 1991; 32(3): 176-9.

28. Dietz H.P., Jarvis S.K., Vancaillie T.G. The assessment of levator muscle strength: a validation of three ultrasound techniques. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2002; 13(3): 156-9; discussion 9.

29. Braekken I.H., Majida M., Engh M.E., Bø K. Test-retest reliability of pelvic floor muscle contraction measured by 4D ultrasound. Neurourol. Urodyn. 2009; 28(1): 68-73.

30. Dietz H.P., Wilson P.D., Clarke B. The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle excercises. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001; 12(3): 166-8.

31. Sultan A.H., Kamm M.A., Hudson C.N., Bartram C.I. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994; 308(6933): 887-91.

32. Lewicky-Gaupp C., Hamilton Q., Ashton-Miller J., Huebner M., Delancey J.O., Fenner D.E. Anal sphincter structure and function relationships in aging and fecal incontinence. Am. J. Obstet. Gynecol. 2009; 200(5): 559. e1-5.

33. Yagel S., Valsky D.V. Three-dimensional transperineal ultrasonography for evaluation of the anal sphincter complex: another dimension in understanding peripartum sphincter trauma. Ultrasound Obstet. Gynecol. 2006; 27(2): 119-23.

34. Lee J.H., Pretorius D.H., Weinstein M., Guaderrama N.M., Nager C.W., Mittal R.K. Transperineal three-dimensional ultrasound in evaluating anal sphincter muscles. Ultrasound Obstet. Gynecol. 2007; 30(2): 201-9.

35. Weinstein M.M., Pretorius D.H., Jung S.A., Nager C.W., Mittal R.K. Transperineal three-dimensional ultrasound imaging for detection of anatomic defects in the anal sphincter complex muscles. Clin. Gastroenterol. Hepatol. 2009;7(2): 205-11.

36. Park S.H., Kang C.B., Jang S.Y., Kim B.Y. Effect of Kegel exercise to prevent urinary and fecal incontinence in antenatal and postnatal women: systematic review. J. Korean Acad. Nurs. 2013; 43(3): 420-30.

37. Herderschee R., Hay-Smith E.J., Herbison G.P., Roovers J.P., Heineman M.J. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst. Rev. 2011; (7): CD009252.

38. Miller J.M., Perucchini D., Carchidi L.T., DeLancey J.O., Ashton-Miller J. Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet. Gynecol. 2001; 97(2): 255-60.

39. Peschers U.M., Gingelmaier A., Jundt K., Leib B., Dimpfl T. Evaluation of pelvic floor muscle strength using four different techniques. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001; 12(1): 27-30.

40. Clemons J.L., Aguilar V.C., Tillinghast T.A., Jackson N.D., Myers D.L. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am. J. Obstet. Gynecol. 2004; 190(2): 345–50.

41. Cundiff G.N., Amundsen C.L., Bent A.E., Coates K.W., Schaffer J.I., Strohbehn K. et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am. J. Obstet. Gynecol. 2007; 196(4):405. e1-8.

42. Oliver R., Thakar R., Sultan A.H. The history and usage of the vaginal pessary: a review. Eur. J. Obstet. Gynecol. Reprod. Biol. 2011; 156(2): 125-30.

Received 17.10.2016

Accepted 11.11.2016

About the Authors

Apolikhina Inna A., MD, professor, obstetrician-gynecologist of the highest category, a physical therapist, head of the department of gynecology and aesthetic rehabilitation, Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia; Professor, Department of Obstetrics, Gynecology, Perinatology and Reproductive, First Moscow State Medical University, Ministry of Health of Russia. 117997, Russia, Moscow, Ac. Oparina str. 4. E-mail: i_apolikhina@oparina4.ru
Chochueva Adalina S., resident of the 1st year of study, Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia.
117997, Russia, Moscow, Ac. Oparina str. 4. Tel.: +79262628361
Saidova Aina S., MD, obstetrician-gynecologist gynecology department of aesthetic and rehabilitation, Research Center for Obstetrics, Gynecology and Perinatology,
Ministry of Health of Russia. 117997, Russia, Moscow, Ac. Oparina str. 4. Tel.: +79262066051. E-mail: dr.saidova@gmail.ru
Gorbunova Elena A., obstetrician-gynecologist, a physiotherapist aesthetic gynecology department and rehabilitation, Research Center for Obstetrics,
Gynecology and Perinatology, Ministry of Health of Russia. 117997, Russia, Moscow, Ac. Oparina str. 4. E-mail: el_gorbunova@oparina4.ru
Kagan Ilya I., MD, professor of Prof. S.S. Mikhailov Department of Operative Surgery and Topographic Anatomy, Orenburg State Medical Academy.
460000, Russia, Orenburg, Sovetskaya str. 6. E-mail: kaganil@mail.ru

For citations: Apolikhina I.A., Chochueva А.S., Saidova А.S., Gorbunova Е.А.,
Kagan I.I. Мodern approaches to diagnosis and conservative treatment
of genital prolapse in women in the practice of gynecologist.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2017; (3): 26-33. (in Russian)
http://dx.doi.org/10.18565/aig.2017.3.26-33

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