eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence

Uterine Prolapse: Follow-up

Author: George Lazarou, MD, FACOG, Assistant Professor, Department of Obstetrics and Gynecology, Women's Health, Director, Urogynecology/Reconstructive Pelvic Surgery, Jack D Weiler Hospital, Albert Einstein College of Medicine; Chief, Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Bronx-Lebanon Hospital Center.
Coauthor(s): Richard J Scotti, MD, FACOG, FACS, Director of Obstetrics/Gynecology, Montefiore Medical Center, Chief, Urogynecology and Reconstructive Surgery, North Central Bronx Hospital; Associate Professor, Department of Obstetrics/Gynecology, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Aug 14, 2007

Outcome and Prognosis

For the first time in history, large numbers of women are living long enough to develop pelvic floor disorders. UP is one of the more common pelvic floor defects and is a challenge to the practicing gynecologist and reconstructive pelvic surgeon. A complete pelvic examination, with particular attention to pelvic support defects, is vital to accurate diagnosis and treatment. Close communication with the patient, her family, and her primary care physician is essential for optimal understanding, informed consent, and management.

Offer conservative treatments as the first option, and always try them before any surgical endeavor. Educating the patient and her family strengthens the doctor-patient relationship and improves compliance. When a surgical intervention is undertaken, the primary goals are to restore anatomy and to maintain normal function. Preoperatively, a thorough assessment of all risks or possible complications and a complete discussion of alternatives with the patient are key elements in the decision-making process. Age alone should not be a factor in the decision; rather, the patient's baseline function is an important guideline to selecting the treatment that will provide the best quality of life.

Future and Controversies

Abdominal approach

When operating on patients with UP, rationales for performing a concomitant hysterectomy include the long-term success of the surgery (which can theoretically be affected by the prolapsed uterus) and removal of a nonfunctioning organ in postmenopausal women. In addition, any uterine or cervical pathology (eg, large fibroid uterus, endometriosis, pelvic inflammatory disease, endometrial hyperplasia, carcinoma) may require removal of the uterus.

No evidence indicates that hysterectomy has any effect on long-term success of sacropexy. Furthermore, the efficacy of incontinence surgery, with complete pelvic floor reconstruction, is not affected by whether a hysterectomy is performed.28 The authors advocate hysteropexy when the uterus is normal and the patient desires future childbearing. The duration of surgery is shorter, and the uterus itself can serve as the bridge between the vagina and sacrum, thus avoiding the use of autologous, heterologous, or synthetic materials.

If the uterus is too bulky, hysterectomy is preferable. The decision may be made intraoperatively, and the patient should be appropriately counseled. If the uterus is to be preserved, preoperative endometrial biopsy and/or ultrasound imaging is strongly recommended.

Vaginal approach

With a trend toward minimally invasive endoscopic surgery, procedures have been developed to accomplish repair of pelvic defects via laparoscopic approaches. Although results in short-term subjective reports are excellent, objective data are lacking. Few clinical trials have compared laparoscopic procedures with conventional open procedures. Consequently, the exact benefits and risks of operative laparoscopy for patients with pelvic floor defects are not known. The attractive advantages of laparoscopic vault suspension are shorter hospitalizations, better cosmetic results, less morbidity, and shorter postoperative recovery periods.

Any advanced laparoscopic reconstructive pelvic surgery requires good operative skills and determination on the part of the surgeon. Most experts agree that the learning curve is usually steep, and complications are more likely to occur in early experiences. A review of techniques for endoscopic repair of UP is beyond the scope of this article, but the goal of any laparoscopic approach is to perform the abdominal procedures through the laparoscope. Before any definitive recommendations are made, prospective randomized trials comparing laparoscopic approaches to open procedures are desirable. Nonetheless, many excellent surgeons have reported excellent results with laparoscopic Burch, paravaginal repair, and sacral colpopexy.

 


More on Uterine Prolapse

Overview: Uterine Prolapse
Workup: Uterine Prolapse
Treatment: Uterine Prolapse
Follow-up: Uterine Prolapse
References
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References

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Further Reading

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Keywords

UP, prolapsed uterus, pelvic organ prolapse, POP, urinary incontinence, UI, genitourinary prolapse, procidentia, pelvic relaxation, pelvic floor defects, multiparity, genital atrophy, hypoestrogenism, pelvic tumors, sacral nerve disorders, diabetic neuropathy, obesity, Marfan syndrome, lower urinary tract dysfunction, hydronephrosis, obstructive nephropathy, urinary retention, hysterectomy, sacral colpopexy, sacral uteropexy, sacropexy, hysteropexy, sacrospinous ligament fixation, modified McCall culdoplasty, iliococcygeus fascia suspension, Kegel exercises, pessary, pessaries

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Contributor Information and Disclosures

Author

George Lazarou, MD, FACOG, Assistant Professor, Department of Obstetrics and Gynecology, Women's Health, Director, Urogynecology/Reconstructive Pelvic Surgery, Jack D Weiler Hospital, Albert Einstein College of Medicine; Chief, Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Bronx-Lebanon Hospital Center.
George Lazarou, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urogynecologic Society, and National Association for Continence
Disclosure: Nothing to disclose.

Coauthor(s)

Richard J Scotti, MD, FACOG, FACS, Director of Obstetrics/Gynecology, Montefiore Medical Center, Chief, Urogynecology and Reconstructive Surgery, North Central Bronx Hospital; Associate Professor, Department of Obstetrics/Gynecology, Albert Einstein College of Medicine
Richard J Scotti, MD, FACOG, FACS is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Medical Association, and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

Medical Editor

Jordan G Pritzker, MD, MBA, FACOG, Assistant Professor of Obstetrics, Gynecology, and Women's Health, Women's Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Dept of Obstetrics and Gynecology, Long Island Jewish Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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