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Genital prolapse surgery: A study of methods, clinical outcome and impact of pelvic floor muscle function
Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objective: To evaluate whether a shift in the extent of genital prolapse surgery occurred between 1983 and 1993. If such a shift occurred, the need for subsequent prolapse surgery; the prevalence of symptoms of pelvic floor dysfunction (PFD) in women six years after vaginal prolapse surgery. And also to analyze predictive factors and the subjective and objective outcomes of prolapse surgery at long term follow up. To evaluate whether neurophysiologic findings of the pelvic floor muscles and anorectal manometry measurements respectively are associated with pre- and postoperative symptoms and the extent of prolapse.

Methods/material: A retrospective study of 542 consecutive patients, operated on for genital prolapse, with primary surgery during 1983 and 1993 in three Swedish hospitals was conducted. Data were obtained from the patient records and were analyzed with emphasis on demographic, clinical and surgical data. A postal questionnaire with validated questions concerning symptoms of PFD was in 1999 sent to women operated in 1993 for primary POP and no subsequent POP surgery.

A prospective study of 42 women with genital prolapse, stage 2-3, scheduled for vaginal prolapse surgery was carried out. Preoperatively the women were examined with anorectal manometry, pudendal nerve neurography and concentric needle electromyography of the pubococcygeus muscles and the external anal sphincter muscle. Posterior colporrhaphy was part of the prolapse surgery in all women. Anatomical and subjective outcomes were evaluated six years postoperatively.

Results: A shift from complete to selective repairs was seen between the two time periods, and posterior repair was often omitted in the latter period. The prevalence of subsequent prolapse surgery increased in the 1990s and the increase was more common in women with a selective repair than in those with complete repair. At long term, PFD-symptoms commonly occurred and were found to be associated with the extent of the prolapse surgery. Symptoms of prolapse and bowel emptying improved significantly after POP surgery in the prospective study. The cure rates of rectocele and apical descent were high, but low concerning cystocele. The results of the neurophysiologic investigations and anal sphincter pressures showed associations with the symptoms and the extent of the prolapse; the individual characteristics showed no discriminatory values.

Conclusion: The extent of the surgical prolapse procedures changed between the two study periods and the extent of subsequent surgery also was greater in the second period. Symptoms of PFD and recurrence of prolapse, especially of the anterior compartment, were frequently seen. Prolapse and bowel symptoms were associated with the function of pelvic floor muscles but neither the results of the neurophysiologic nor the anorectal manometry measurements of the pelvic floor muscles were found to predict anatomical or subjective outcomes of POP surgery. More knowledge is needed of the pathophysiology of PFD in order to develop better means of prevention and to optimize treatment of POP. Development of new methods for identifying all defects of the pelvic floor and surgical techniques for restitution is also warranted for improving outcome of surgical treatment of genital prolapse.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 96 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1103
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-17417ISBN: 978-91-7393-689-7 (print)OAI: oai:DiVA.org:liu-17417DiVA: diva2:209050
Public defence
2009-03-27, Bohmanssonsalen, Universitetssjukhuset, Örebro, Örebro, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2009-03-23 Created: 2009-03-23 Last updated: 2013-10-10Bibliographically approved
List of papers
1. Primary surgery of genital prolapse: a shift in treatment tradition.
Open this publication in new window or tab >>Primary surgery of genital prolapse: a shift in treatment tradition.
2006 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, Vol. 85, no 9, 1104-1108 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The use of complete repairs in genital prolapse surgery has been questioned because of the possible adverse effects of the surgery on the urogenital and sexual function and selective repairs have been advocated. The aims of this study were to establish information about genital prolapse surgery and to analyze whether a shift from extensive prolapse surgery with complete repairs to selective repairs occurred during a 10-year period.

METHODS: A retrospective study of 610 consecutive patients operated upon for genital prolapse during 1983 (Period I) and 1993 (Period II) in a sample of three Swedish hospitals was conducted. Data were obtained from the patient records. 542 women had primary surgery and were analyzed with emphasis on demographic, clinical, and surgical data.

RESULTS: The demographic and clinical data of the patients showed no significant differences between the two periods. In Period I, 69% of the patients underwent complete repair compared with 37% in Period II (p<0.001). The proportion of prolapse operations without posterior colporrhaphy increased significantly from the first to the second period from 14 to 43% (p<0.001).

CONCLUSION: The surgery for genital prolapse seems to have changed from complete repairs towards selective repairs and posterior colporrhaphy was more often avoided in the second period. The implication of this shift in surgical treatment on pelvic floor function is not known. Further studies are needed to disclose the effect of the surgery on pelvic floor function and dysfunction in the long term.

Place, publisher, year, edition, pages
Taylor & Francis, 2006
Keyword
Genital prolapse, pelvic floor dysfunction, pelvic surgery, posterior repair, retrospective study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17399 (URN)10.1080/00016340500470168 (DOI)16929416 (PubMedID)
Available from: 2009-03-23 Created: 2009-03-23 Last updated: 2009-05-08Bibliographically approved
2. Genital prolapse surgery after a shift in treatment tradition: an analysis of subsequent prolapse surgery
Open this publication in new window or tab >>Genital prolapse surgery after a shift in treatment tradition: an analysis of subsequent prolapse surgery
2008 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, Vol. 87, no 4, 449-456 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To determine whether the shift in treatment tradition of genital prolapse surgery was followed by a change in the occurrence of subsequent prolapse surgery, and to analyze the complementary and recurrent surgery with respect to the size of the prolapse and the extent of the primary surgery.

Methods: A retrospective study of patients consecutively operated with primary prolapse surgery in three Swedish hospitals in two time periods: 261 patients in 1983 (Period I) and 281 patients in 1993 (Period II). Clinical data were obtained from the patient records. A follow-up period of 6 years was used for both periods.

Results: Subsequent prolapse surgery was seen significantly more often in Period II than in Period I (7.7 versus 2.7%), and after selective repairs compared with complete repairs (7.7 versus 3.2%). Despite a significant reduction in the use of posterior repair between the time periods, no significant increase was seen in complementary posterior repairs compared with complementary repair in any of the other compartments. Size of the prolapse at the primary surgery or hysterectomy did not seem to influence the occurrence of subsequent prolapse surgery. The postoperative complication rate was significantly higher after complete repairs than after selective repair, and especially when posterior repair was included in the operation.

Conclusion: Subsequent prolapse surgery is slightly more common after selective repair than after complete repair. However, selective repairs are encumbered with a lower complication rate. The results of this study appear to be in favor of a restrictive use of 'prophylactic' posterior repair.

Place, publisher, year, edition, pages
Informa, 2008
Keyword
Pelvic organ prolapse, prolapse surgery, recurrence, subsequent surgery
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17411 (URN)10.1080/00016340801986763 (DOI)18382873 (PubMedID)
Available from: 2009-03-23 Created: 2009-03-23 Last updated: 2009-04-25Bibliographically approved
3. Factors associated with symptoms of pelvic floor dysfunction six years after primary operation of genital prolapse
Open this publication in new window or tab >>Factors associated with symptoms of pelvic floor dysfunction six years after primary operation of genital prolapse
Show others...
2008 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, Vol. 87, no 9, 910-915 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To determine prevalence of pelvic floor dysfunction (PFD) symptoms in women six years after primary pelvic organ prolapse (POP) surgery and analyze predictive factors for these symptoms. DESIGN: Cross-sectional observational study.

Setting: Three Swedish hospitals.

Sample: Women who underwent primary POP surgery in 1993 and had no subsequent POP surgery during the following six years.

Methods: Clinical data from patient records and a postal questionnaire concerning symptoms of PFD completed in 1999.

Main outcome measures: Prevalence of PFD symptoms, predictive factors.

Results: Urinary incontinence episodes > or =weekly were reported by 41%, feeling of vaginal bulging by 18% and solid stool incontinence by 15%. Thirty nine percent were sexually active; 15% refrained completely from sexual activity because of own discomfort or pain and 46% had no sexual activity due to lack of or sick partner. Discomfort or pain during sexual activity was experienced by 42%. Previous incontinence surgery and urinary incontinence prior to POP surgery were predictive factors for urinary incontinence. Anterior repair was protective for the postoperative symptoms of incomplete bladder and bowel emptying and vaginal bulging. Posterior repair was a risk factor for incomplete bowel emptying and solid stool incontinence. The association between posterior repair and discomfort or pain during sexual activity was not significant.

Conclusion: The prevalence of PFD symptoms six years after primary POP surgery seemed high. The extent of POP surgery was predictive for postoperative symptoms of urinary and bowel dysfunction but not for discomfort or pain during sexual activity.

Place, publisher, year, edition, pages
Informa/Talor & Francis, 2008
Keyword
Genital prolapse, pelvic floor dysfunction, pelvic organ prolapse surgery, predictive factor, symptom
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17413 (URN)10.1080/00016340802311243 (DOI)18720035 (PubMedID)
Available from: 2009-03-23 Created: 2009-03-23 Last updated: 2009-04-25Bibliographically approved
4. Pelvic floor neuropathy in relation to symptoms, anatomy and outcome of vaginal prolapse surgery: a neurophysiologic study
Open this publication in new window or tab >>Pelvic floor neuropathy in relation to symptoms, anatomy and outcome of vaginal prolapse surgery: a neurophysiologic study
(English)Manuscript (Other academic)
Abstract [en]

The aims of this study were to analyze whether neurophysiologic findings of pelvic floor muscles could predict preoperative symptoms of pelvic floor dysfunction and the extent and degree of pelvic organ prolapse and to investigate associations between neurophysiologic findings and the anatomic and subjective outcome of surgery. Forty two women with prolapse stage 2-3 were preoperatively examined with pudendal nerve neurography and concentric needle electromyography of the pubococcygeus and the external anal sphincter muscles. Posterior colporrhaphy was part of the prolapse surgery in all women. Anatomical and subjective outcomes were evaluated median six years postoperatively. The electromyographic findings of the pelvic muscles showed some associations with symptoms of pelvic floor dysfunction but none with degree of prolapse; no discriminatory values were obtained. EMG findings could not predict the outcome of pelvic organ prolapse surgery in terms of changes in symptoms of pelvic floor dysfunction or anatomical outcome.

Keyword
EMG; Genital prolapse surgery, Neuromuscular damage, Outcome, Pelvic floor neuropathy, Pudendal nerve latency
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17415 (URN)
Available from: 2009-03-23 Created: 2009-03-23 Last updated: 2010-01-14Bibliographically approved
5. The predictive value of anorectal manometry on subjective and objective findings and outcome of pelvic organ prolapse surgery: A prospective study
Open this publication in new window or tab >>The predictive value of anorectal manometry on subjective and objective findings and outcome of pelvic organ prolapse surgery: A prospective study
(English)Manuscript (Other academic)
Abstract [en]

The objectives were to evaluate associations between anal sphincter pressure and a) stage of prolapse and b) bowel and prolapse symptoms; and to determine the predictive value of the manometric measurements on symptomatic and anatomical outcomes of prolapse surgery-. Forty two women with prolapse stage 2-3 participated in the study. Pre- and postoperative evaluation of the patients was done by using a symptom questionnaire and doing clinical examinations and anorectal manometry. The vaginal prolapse surgery always included at the very least posterior colporrhaphy. Median follow-up time was 6.4 years. The symptoms vaginal protrusion and feeling of incomplete bowel emptying were associated with levels of anal sphincter pressure. Anorectal manometric measurements could not predict the subjective and anatomical outcomes of POP surgery. Symptoms of prolapse and bowel emptying “sensations” were significantly reduced. The cure rates of rectocele and apical descensus were high, whereas the cure rate was low for cystocele.

Keyword
Anorectal manometry Bowel dysfunction; Fecal incontinence; Genital prolapse surgery, Outcome
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17416 (URN)
Available from: 2009-03-23 Created: 2009-03-23 Last updated: 2010-01-14Bibliographically approved

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