Surgical management of pelvic organ prolapse in women

Maher C, Feiner B, Baessler K, Glazener CMA

Published Online:

August 8, 2010

Pelvic organs, such as the uterus, bladder or bowel, may protrude into the vagina due to weakness in the tissues that normally support them. The symptoms that they cause vary depending on the type of prolapse and include bladder, bowel and sexual problems, pain and a prolapse sensation. The types of repair surgery vary depending on the type of prolapse and associated symptoms. The impact of pelvic organ prolapse surgery on bowel, bladder and sexual function can be unpredictable and may make symptoms worse or result in new symptoms, such as leakage of urine or problems with intercourse.

The review found 40 trials amongst 3773 women with a variety of types of prolapse. The trials showed that abdominal sacral colpopexy may be better than vaginal sacrospinous colpopexy for uterine or vaginal vault prolapse. Limited evidence suggests that vaginal surgery may be better than transanal surgery for posterior vaginal wall prolapse. The use of grafts (biological or synthetic) reduces the risk of recurrent anterior wall prolapse, determined on examination. Evidence of benefit to the woman, including symptoms and quality of life improvement, is lacking for the use of grafts over native tissue repairs. However, there was not enough evidence on most types of common prolapse surgery nor about the use of mesh or grafts in vaginal prolapse surgery.

Abstract (click to read)

Background:

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.

Objectives:

To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.

Search strategy:

We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.

Selection criteria:

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

Data collection and analysis:

Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.

Main results:

Forty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.

For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.

For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.

Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).

Authors' conclusions:

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

This record should be cited as:

Maher C, Feiner B, Baessler K, Glazener CMA. Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub4

Assessed as up to date:

November 17, 2009

Find the research

Get full text at The Cochrane Library

Primary Review Group:

Incontinence Group

Health topics:

Gynaecology > Urinary incontinence > Surgery

Urology > Incontinence > Surgery

Gynaecology > Pelvic organ prolapse

Urology > Pelvic organ prolapse

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Surgical management of pelvic organ prolapse in women

More like this

Copyright © 2011 - The Cochrane Collaboration