nonsurgical treatment for pelvic organ prolapse: …...prevention, diagnosis, treatments, and...

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14 OSTOMY WOUND MANAGEMENT ® MARCH 2012 www.o-wm.com CONTINENCE COACH Dr. Muller is the Executive Director, National Association For Continence (NAFC). Dr. Parker-Autry is a second year fellow/clinical instructor, Division of Uro- gynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham. The NAFC is a national, private, nonprofit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Managment peer-review process. Nonsurgical Treatment for Pelvic Organ Prolapse: Calling on Nurses for Pessary Fittings Nancy Muller, PhD, MBA; and Candace Parker-Autry, MD P elvic organ prolapse (POP) and urinary incontinence are common conditions that significantly affect quality of life for many women. Current treatment options include nonsurgical and surgical interventions; both have proven ef- ficacy. Although surgical repair of POP is the only “cure” for this problem, nonsurgical options have been shown to satis- factorily manage symptoms of prolapse and urinary inconti- nence. 1 This article briefly reviews the definition and clinical presentation of POP and discusses the use of a pessary for nonsurgical treatment. What is POP? The female pelvic floor is complex, and its function is dependent on musculoskeletal connections to pelvic bones to support the abdominal and pelvic viscera. The organs supported by these connections are the blad- der, uterus, vagina, and rectum (see Figure 1). The pelvic floor often is described as a hammock whose attachments to the pelvic bones secure the pelvic organs in their proper place. When the musculoskeletal connections are broken or stretched, POP may occur. POP’s causes are multifactorial and consistently associated with multiparity, hysterectomy, family history, increasing age, and chronic constipation. Figure 2 illustrates various forms of prolapse. A cystocele is the most prevalent type of prolapse and represents at least half of all cases. When a cystocele occurs in combination with another type of prolapse, it most often is a rectocele, where the rectum herniates. A prolapsed uterus used to be treated strictly by a hysterectomy, but more recently procedures have been aimed at preserving the uterus. This, in part, is because some now believe removal of the uterus precipitates a risk factor for prolapse of other pelvic organs because of the space created by its absence and the trauma of the surgery itself to supporting ligaments and muscles. POP is classified in stages and compartments to enhance clinical understanding and provide enhanced description. The compartments classify the location of the prolapse and include anterior (bladder), posterior (rectum), apical (cer- vix/uterus, vaginal apex), and perineal. Stages are used to de- scribe the anatomic severity of the prolapse and are measured using the Pelvic Organ Prolapse Quantification (POPQ) ex- amination with maximum valsalva effort (see Table 1). 2 Symptoms. POP is a very common condition. Stages I and II have been demonstrated in up to 50% of women who have had a vaginal delivery. However, only 20% of symptomatic women seek care. 3 Women with prolapse often complain of visualization or sensation of a vaginal bulge and pelvic pressure or heaviness that may be con- stant or that occurs with increased activity. Symptomatic prolapse also presents with other pelvic floor disorders such as overactive bladder, difficulty voiding/defeca- tion, urinary/fecal incontinence, and sexual dysfunction. Women may experience bothersome symptoms even with Stage I prolapse, as well as at higher stages. Surgical/definitive treatment. Women with symptom- atic prolapse have nonsurgical and surgical options for its treatment and symptom relief. Surgical treatment is the Table 1. Pelvic Organ Prolapse Quantification (POPQ) Staging System Stage 0 No prolapse (apex can descend within 2 cm of hymen) Stage I Leading edge descends to 1 cm above hymen Stage II Leading edge descends to within 1 cm of the hymen Stage III Leading edge extends >1 cm beyond hy- men but <2cm of total vaginal length Stage IV Complete eversion, leading edge >2 cm of total vaginal length Figure 1. The female anatomy. Figure courtesy of the National Association For Continence. DO NOT DUPLICATE

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Page 1: Nonsurgical Treatment for Pelvic Organ Prolapse: …...prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound

14 OSTOMY WOUND MANAGEMENT® MARCH 2012 www.o-wm.com

CONTINENCE COACH

Dr. Muller is the Executive Director, National Association For Continence (NAFC). Dr. Parker-Autry is a second year fellow/clinical instructor, Division of Uro-gynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham. The NAFC is a national, private, nonprofit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Managment peer-review process.

Nonsurgical Treatment for Pelvic Organ Prolapse: Calling on Nurses for Pessary FittingsNancy Muller, PhD, MBA; and Candace Parker-Autry, MD

Pelvic organ prolapse (POP) and urinary incontinence are common conditions that significantly affect quality

of life for many women. Current treatment options include nonsurgical and surgical interventions; both have proven ef-ficacy. Although surgical repair of POP is the only “cure” for this problem, nonsurgical options have been shown to satis-factorily manage symptoms of prolapse and urinary inconti-nence.1 This article briefly reviews the definition and clinical presentation of POP and discusses the use of a pessary for nonsurgical treatment.

What is POP? The female pelvic floor is complex, and its function is dependent on musculoskeletal connections to pelvic bones to support the abdominal and pelvic viscera. The organs supported by these connections are the blad-der, uterus, vagina, and rectum (see Figure 1). The pelvic floor often is described as a hammock whose attachments to the pelvic bones secure the pelvic organs in their proper place. When the musculoskeletal connections are broken or stretched, POP may occur. POP’s causes are multifactorial and consistently associated with multiparity, hysterectomy, family history, increasing age, and chronic constipation.

Figure 2 illustrates various forms of prolapse. A cystocele is the most prevalent type of prolapse and represents at least half of all cases. When a cystocele occurs in combination with another type of prolapse, it most often is a rectocele, where the rectum herniates. A prolapsed uterus used to be treated strictly by a hysterectomy, but more recently procedures have been aimed at preserving the uterus. This, in part, is because some now believe removal of the uterus precipitates a risk factor for prolapse of other pelvic organs because of the space

created by its absence and the trauma of the surgery itself to supporting ligaments and muscles.

POP is classified in stages and compartments to enhance clinical understanding and provide enhanced description. The compartments classify the location of the prolapse and include anterior (bladder), posterior (rectum), apical (cer-vix/uterus, vaginal apex), and perineal. Stages are used to de-scribe the anatomic severity of the prolapse and are measured using the Pelvic Organ Prolapse Quantification (POPQ) ex-amination with maximum valsalva effort (see Table 1).2

Symptoms. POP is a very common condition. Stages I and II have been demonstrated in up to 50% of women who have had a vaginal delivery. However, only 20% of symptomatic women seek care.3 Women with prolapse often complain of visualization or sensation of a vaginal bulge and pelvic pressure or heaviness that may be con-stant or that occurs with increased activity. Symptomatic prolapse also presents with other pelvic floor disorders such as overactive bladder, difficulty voiding/defeca-tion, urinary/fecal incontinence, and sexual dysfunction. Women may experience bothersome symptoms even with Stage I prolapse, as well as at higher stages.

Surgical/definitive treatment. Women with symptom-atic prolapse have nonsurgical and surgical options for its treatment and symptom relief. Surgical treatment is the

Table 1. Pelvic Organ Prolapse Quantification (POPQ) Staging System

Stage 0 No prolapse (apex can descend within 2 cm of hymen)

Stage I Leading edge descends to 1 cm above hymen

Stage II Leading edge descends to within 1 cm of the hymen

Stage III Leading edge extends >1 cm beyond hy-men but <2cm of total vaginal length

Stage IV Complete eversion, leading edge >2 cm of total vaginal length

Figure 1. The female anatomy. Figure courtesy of the National Association For Continence.

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Page 2: Nonsurgical Treatment for Pelvic Organ Prolapse: …...prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound

MARCH 2012 OSTOMY WOUND MANAGEMENT® 15www.o-wm.com

CONTINENCE COACH

only “cure” for POP and aims to re-establish the attachment of the vaginal apex to pelvic ligaments; correct connective tissue defects in the anterior (bladder) and posterior (rec-tum) vaginal wall; and return the normal vaginal axis. The decision to proceed with surgical repair should be made with consideration to: 1) POP severity; 2) patient desire for definitive management; 3) patient expectations for symp-tom relief; 4) desire for sexual activity; and 5) patient co-morbidities. Eleven percent of women will undergo surgery for incontinence or prolapse. Although success rates have been found to be 75%, at least 29% of women who have one prolapse surgery may require repeat surgery.4 As such, if definitive treatment is not desired, a nonsurgical route should be considered.

Nonsurgical treatment. One nonsurgical approach involves use of a pessary. Pessaries are silicon devices placed inside of the vagina to support pelvic organs in the anterior, apical, and posterior compartments. Pessa-ries are designed in a variety of shapes and sizes to indi-vidually correct different types of prolapse (see Figure 3). Pessary use should be considered for women who have well-estrogenized vaginal epithelium (or women willing to use vaginal estrogen to prepare the epithelium) and

women who are comfortable with placement and remov-al of the device in the vagina.

Pessary fitting. Pessary fitting is accomplished by trial and error. Therefore, a fitting visit should allow adequate time. A well-fitted pessary is retained in the vagina with valsalva (in lithotomy and standing position), while walk-ing, and while toileting. A properly fitted pessary should be barely noticeable. The effectiveness on symptom relief may not be realized until after continued use.

Pessary care. Pessaries require upkeep and need to be removed and cleaned on a regular basis. The ring and dish pessaries can be removed daily and cleaned. Donut, cube, and gelhorn pessaries can be retained in the vagina for 1 to 3 months and often are removed and cleaned in the office. Most women can learn to care for their pessaries themselves. Vaginal estrogen cream should be used at least three times per week with all pessary use to maintain normal vaginal epi-thelium and to reduce the risk of ulceration. Pessaries should be removed before sexual intercourse.

Clinicians need to discuss both nonsurgical and surgical op-tions with patients with symptomatic POP, particularly given the recently raised concerns about the safety and efficacy of trans-vaginally placed mesh in POP repair. Although many patients undergoing mesh-augmented vaginal repairs heal well without problems, a small but notable group of these patients experience permanent and life-altering consequences, including ongoing pain and dyspareunia, based on limited data to date.5 Nonsurgi-cal options are appealing to many women; more nurses should be specially trained in pessary fitting. It is an easily acquired skill, enhanced with experience. Take on the challenge! n

References1. Nager CW, Richter HE, Nygaard I, Paraiso MF, Wu JM, Kenton K, et al.

Incontinence pessaries: size, POPQ measures, and successful fitting. Int Urogynecol J. 2009;20:1023–1028.

2. Bump RC, Mattiasson A, Bo K, Brubaker L, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17.

3. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol. 2000;183(2):277–285.

4. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol. 1997;89:501–506.

5. Committee on Gynecologic Practice. Vaginal placement of synthetic mesh for pelvic organ prolapse. Committee Opinion No. 513. American College of Obstetricians and Gynecologists. Am J Obstet Gynecol. 2011; 118:1459–1464.

Figure 3. Various pessaries. Figure courtesy of the Na-tional Association For Continence.

Figure 2. Types of prolapse: a. cystocele; b, rectocele; c. uterine. Figure courtesy of the National Association For Continence.

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