7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure
Author
JEricJelovsek,MD,MMEd,
FACOG,FACS

SectionEditor
DeputyEditor
LindaBrubaker,MD,FACS,FACOG KristenEckler,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:Nov09,2015.
INTRODUCTIONPelvicorganprolapse(POP)affectsmillionsofwomenapproximately200,000inpatientsurgical
proceduresforprolapseareperformedannuallyintheUnitedStates[1,2].Elevento19percentofwomenwillundergo
surgeryforprolapseorincontinencebyage80to85years,and30percentofthesewomenwillrequireanadditional
prolapserepairprocedure[3,4].
WomenwithsymptomaticPOPexperiencedailydiscomfort,aswellasinterferencewithsexualfunctionandexercise.
Reconstructivesurgeryforwomenwithprolapseconsistsofsomecombinationofresuspensionofthevaginalapex
andanteriorandposteriorvaginalwalls.ThechoiceofaprimarysurgicalprocedureforwomenwithPOPdependsupon
avarietyofconsiderations,includingtheanatomicsiteofprolapse,presenceofurinaryorfecalincontinence,health
status,andpatientpreferences.
TheprocessofchoosingasurgicalprocedureforwomenwithPOPwhohavenothadapriorprolapserepairwillbe
reviewedhere.EvaluationofwomenwithPOP,conservativemanagement,andspecificrepairproceduresare
discussedseparately.(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinical
manifestations,andmanagement"and"Vaginalpessarytreatmentofprolapseandincontinence"and"Pelvicorgan
prolapseinwomen:Surgicalrepairofapicalprolapse(uterineorvaginalvaultprolapse)"and"Pelvicorganprolapsein
women:Surgicalrepairofanteriorvaginalwallprolapse"and"Surgicalmanagementofposteriorvaginaldefects"and
"Pelvicorganprolapseinwomen:Obliterativeprocedures(colpocleisis)".)
CANDIDATESFORSURGICALTREATMENTCandidatesforsurgicalrepairofPOParewomenwith
symptomaticprolapsewhohavefailedordeclinedconservativemanagement.
WomenwithsymptomaticprolapseReconstructivesurgeryforPOPshouldbeperformedonlyinwomenwho
havesymptomaticprolapse,withfewexceptions.SurgicalcorrectionofasymptomaticPOPornonbothersomePOPis
ofuncertainbenefitandaddsperioperativerisks.
POPsymptomsincludepelvicpressure,sensationofavaginalbulge,urinaryretention,and/ordifficultdefecation
somewomenneedtoreducetheprolapseusingafingerinthevagina(alsoreferredtoassplinting)tourinateor
defecate.Prolapsedvaginaltissuemayprotrude,leadingtochronicdischargeandbleedingfromulceration.Such
symptomsmayinterferewithdailyactivities,sexualfunction,orexercise.(See"Pelvicorganprolapseinwomen:An
overviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Clinical
manifestations'.)
ManywomenhaveasymptomaticPOPapproximately40percentofwomenarefoundtohavestageIIorgreater
prolapseuponroutinepelvicexamination[58].ThereisnoindicationforrepairofasymptomaticPOPasanisolated
procedure.
Whenwomenundergootherpelvicprocedures(eg,vaginalhysterectomy,stressurinaryincontinence[SUI]surgery),
somesurgeonsrepairasymptomaticprolapsetopreventtheneedforsubsequentsurgery.Thispracticeisbasedupon
theassumptionthatprolapsewillprogress.Thisapproachmakessensetopatientsandsurgeonsbutremains
unprovenandmayincreasesurgicalmorbidity.Interestingly,thenaturalhistoryofprolapsedoesnotfollowa
progressivecourseinallwomen.Datasuggestthatthecourseisprogressiveuntilmenopause,afterwhichthedegree
ofprolapsemayfollowacourseofalternatingprogressionandregression[911].Ontheotherhand,inadditionto
premenopausalstatus,riskfactorsfortheprogressionofPOPincludeobesityandhysterectomy[12,13].(See"Pelvic
organprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",
sectionon'Riskfactors'.)
GiventhepaucityofdataregardingrepairofasymptomaticPOP,formostwomenwithasymptomaticstage0to2
prolapsewhoareundergoingotherpelvicfloorprocedures(eg,SUIsurgery),wesuggestnotperformingprolapse
repair.Prolapserepairforasymptomaticwomenatthetimeofotherpelvicsurgeryisareasonableoptioninwomen
withadvancedprolapse(stages3or4)orriskfactorsforprolapseprogression(eg,concomitanthysterectomy,
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

1/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

premenopausalstatus,obesity).
CombinedsurgicaltreatmentofPOPandSUIisdiscussedseparately.(See"Pelvicorganprolapseandstressurinary
incontinenceinwomen:Combinedsurgicaltreatment",sectionon'SUIwithasymptomaticPOP'.)
WomenwhodeclineorfailconservativetherapyFirstlinemanagementofPOPisconservativetherapy.The
mainstayofnonsurgicaltreatmentforPOPisthevaginalpessary.Pessariesaresiliconedevicesthatareinsertedinto
thevaginaandsupportthepelvicorgans.Pelvicfloormuscleexerciseisanotherconservativetreatmentoption.(See
"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,and
management",sectionon'Conservativemanagement'.)
Prolapseistypicallyachronicproblem,andmanywomenultimatelyprefersurgerytoconservativetherapysince
successfulsurgerydoesnotrequireongoingmaintenance.Inthepatientswhocanbefitwithapessary,approximately
40percentofwomendiscontinuepessaryusewithinonetotwoyearsofuse.Itisdifficulttoestimatehowmany
womenwhochoosetohaveapessarygoontohavesurgery.(See"Vaginalpessarytreatmentofprolapseand
incontinence",sectionon'Outcomesofpessarytreatment'.)
WomenfinishedwithchildbearingPelvicsupportmaybedisruptedduringpregnancy,andparticularlyfollowinga
vaginalbirth.MostsurgeonsrecommenddelayingsurgicalmanagementofPOPuntilchildbearingiscomplete.Small
casestudieshavereportedsuccessfulpregnancyafteruterinesparingsurgery,butnostudyhasspecifically
investigatedtheriskofdevelopingrecurrentPOPafterdelivery.Sevenpregnancieshavebeenreportedwithone
followingvaginalandcesareandelivery[13].
YoungorelderlywomenPatientsatayoungageareathigherriskofprolapserecurrencebutloweroverallriskof
complicationsfromsurgerycomparedwitholderwomen(table1)[1416].However,procedureswithlongerefficacy
(eg,abdominalsacralcolpopexyratherthanvaginalsacrospinousligamentsuspension)havehighersurgicalrisk.
Thus,itisrecommended,especiallyforyoungerpatients,tounderstandthatchoosingprocedureswithhigherefficacy
maycomeattheexpenseofhigherrisk.
POPrepaircanbesafelyperformedinmanyelderlywomen.Incontrastwithyoungerwomen,olderwomenareat
lowerriskofrecurrenceandhigherriskofcomplicationsfromsurgerycomparedwithyoungerwomen[1416].Ina
cohortof267patientswhowere>or=75yearsold,26percentofthepatientshadasignificantperioperative
complicationatthetimeofsurgeryforPOP.Themostcommonperioperativecomplicationwasbloodtransfusionor
significantbloodloss,pulmonaryedema,andpostoperativecongestiveheartfailurehowever,theoverallperioperative
morbidityrateinelderlywomenwhoundergourogynecologicsurgeryislow.Independentriskfactorsthatwere
predictiveofapatienthavingaperioperativecomplicationwerethelengthofsurgery,coronaryarterydisease,and
peripheralvasculardisease[17].
ObesewomenAlthoughobesityisariskfactorfornewonsetandrecurrentPOP[14,15],obesewomenappearto
havenodifferenceinoutcomeofsurgicalcorrectionofapicalprolapsecomparedwithnonobesewomen[18].Many
surgeonsfeelthatobesepatientsaregoodcandidatesforthemostdurablerepair,abdominalsacrocolpopexy.
Unfortunately,theopenabdominalapproachintheobesepatientincreasestheriskusuallyintheformofwound
complications[19].
GENERALAPPROACHTOCHOICEOFPROCEDUREThechoiceofaprimaryprocedureforPOPincludesa
varietyoffactors:
ReconstructiveorobliterativeMostwomenwithsymptomaticPOParetreatedwithareconstructiveprocedure.
Obliterativeprocedures(eg,colpocleisis)arereservedforwomenwhocannottoleratemoreextensivesurgeryor
whoarenotplanningfuturevaginalintercourse.
ConcomitanthysterectomyWhenapicalprolapseisrepaired,thedecisionmustbemadewhethertoperforma
hysterectomyasapartoftheprocedure.
SurgicalrouteforrepairofmultiplesitesofprolapseReconstructivesurgeryforPOPofteninvolvesrepairof
multipleanatomicsitesofprolapse(apical,anterior,posterior).Thechoiceofsurgicalroutedependsuponthe
optimalapproachforthecombinationofprolapsesites.
ConcomitantantiincontinencesurgerySymptomaticPOPoftencoexistswithSUIand,insomewomen,anal
incontinence.POPrepairmustbecoordinatedwithtreatmentofincontinence.
UseofsurgicalmeshSurgicalmeshisusedinabdominalPOPrepair.Useintransvaginalprocedureshas
increased,butquestionshavearisenaboutthesafetyofthisapproach.
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

2/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

AsummaryofallmajordecisionsinvolvedinchoosingaprimarysurgicalproceduretorepairPOPispresentedinthe
figure(algorithm1).
RECONSTRUCTIVEVERSUSOBLITERATIVEPROCEDURESThechoiceofareconstructiveorobliterative
proceduredependsuponthemedicalstatusandsexualfunctionofthepatient.
Reconstructivesurgerysurgicallycorrectstheprolapsedvaginaandaimstorestorenormalanatomy,whileobliterative
surgerycorrectsprolapsebyremovingand/orclosingoffalloraportionofthevaginalcanal(ie,colpocleisisor
colpectomy)toreducetheviscerabackintothepelvis[20].Anotherdifferencebetweenthetwotypesofproceduresis
thatreconstructivesurgerycanbeperformedusingavaginalorabdominalapproach,whileallobliterativesurgeriesare
performedusingthevaginalapproach.
MostwomenwithsymptomaticPOParetreatedwithareconstructiveprocedure.Obliterativeproceduresarereserved
forwomenwhocannottoleratemoreextensivesurgeryorwhoarenotplanningfuturevaginalintercourse.The
advantagesofobliterativeproceduresinthispopulationarethatsuchprocedurestypicallyhaveashortoperative
duration,lowriskofperioperativemorbidity,andanextremelylowriskofprolapserecurrence.Theobvious
disadvantagesaretheeliminationofthepotentialforvaginalintercourse,aswellastheinabilitytoevaluatethecervix
oruterusviaavaginalroute(eg,cervicalcytologyorendometrialbiopsy).
Colpocleisisishighlyeffectivewithlowmorbidityforcorrectingapicalprolapseinsuchwomen.Colpocleisisdoesnot
appeartoalterbodyimageandregretaftertheprocedureisuncommon(lessthan10percent).Therefore,an
obliterativeoperationisanoptionforwomenwhoarenotcandidatesformoreextensivesurgeryorarewillingtoaccept
thelossofvaginalintercourse.
ObliterativeproceduresforPOParediscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Obliterative
procedures(colpocleisis)".)
CONCOMITANTHYSTERECTOMYHysterectomyisoftenperformedatthetimeofPOPrepair.Thispracticeis
dependentuponthesurgicaltechniqueusedforpelvicreconstructionandotherpotentialbenefits.Ontheotherhand,
thereisconcernthatconcomitanthysterectomymayincreasetheriskofsomeperioperativecomplications(eg,mesh
erosion)and,additionally,anincreasingnumberofwomenwishtoconservetheiruterusasanimportantcomponentof
theirbodyimage.
DuringPOPrepair,surgeonshavegenerallyperformedhysterectomyratherthanuterinesparingproceduresbased
uponseveralassertions:
Apicalprolapseisoftenpresentinwomenwithsymptomaticprolapse,andthemostcommonlyperformed
techniquesforapicalprolapserepairrequirehysterectomy.Inabdominalsacralcolpopexyandtransvaginal
sacrospinousligamentsuspension,hysterectomyisrequiredbecausetheapexiselevatedbyaffixingthevaginal
cufftoasupportstructure(eg,thesacrospinousligamentortheanteriorlongitudinalligamentofthesacrum).
Thecommonwisdomhasbeenthatretainingtheuterusincreasestheriskofrecurrentprolapse,althoughthere
arenodatatosupportthis.TheroleofhysterectomyatthetimeofsurgeryforPOPiscurrentlydebatableand
therearenodatasupportinghysterectomyatthetimeofsurgeryforPOP.Therearethreeunderpoweredstudies
thatdescribeuterinepreservationatthetimeofsurgeryforPOPanduterinepreservationdidnotaffecttheriskof
POPrecurrence[2123].
Hysterectomyeliminatescurrentorfuturecervicalorintrauterinepathology.However,suchbenefitsareless
relevantwithcurrentadvancesinminimallyinvasivetreatmentofabnormaluterinebleedingandincervical
cancerscreening.Uterinecancertypicallypresentsatanearlystagewithuterinebleeding,andthus,preventive
measuresarenotroutinelyrecommendedforaverageriskwomen.
Inaretrospectiveanalysisofpathologyfindingsatreconstructivepelvicsurgerywithhysterectomy,overa3.5
yearperiod,17of644patients(2.6percent)hadunanticipatedpremalignantormalignantuterinepathology.Two
(0.3percent)hadendometrialcarcinoma.Allcasesofunanticipateddiseasewereidentifiedinpostmenopausal
women[24].
Potentialdisadvantagesofhysterectomyandtheassociatedpelvicfloordissectionareanincreasedriskofpelvic
neuropathyanddisruptionofnaturalsupportstructuressuchastheuterosacralcardinalligamentcomplex[25].
Uterinesparingprocedurescorrectapicalprolapsebyattachingtheloweruterusorcervixtoasupportstructure.These
techniquesarenotwidelyused,sincetheyhavenotbeenwellevaluatedandmostsurgeonshavenotbeentrainedto
performthem.
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

3/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

Advantagesofuterinesparingtechniquesareashorteroperativedurationandlessbloodlosshowever,theirefficacy
iscontroversial[21,22,2629].TworandomizedtrialsinwomenwithstageIIorhigherPOPthatcomparedtransvaginal
sacrospinoushysteropexywithvaginalhysterectomy(withuterosacralorsacrospinousligamentsuspensionofthe
vaginalvault)yieldedconsistentresults:therateofprolapserecurrenceafter9to12monthswashigherinwomenwho
underwenthysteropexyinbothtrials,butreachedstatisticalsignificanceinonetrial(27versus3percent[28])andnot
theother(25versus13percent[27]).Operativeduration(59versus120minutesinonetrial[27])andbloodloss(20
versus120mLinonetrial[27])weredecreasedforsacrospinoushysteropexycomparedwithvaginalhysterectomy
complicationratesweresimilarforthetwogroups.Furtherstudyisneededtoevaluatetheefficacyofuterinesparing
techniques.
Aproposedadvantageofuterinesparingsurgeryisadecreasedimpactonsexualfunctionhowever,thisbenefitis
uncertain.Theonlystudyofthisissuefoundnodifferenceineffectonsexualfunctioninwomenwhounderwent
sacrospinoushysteropexycomparedwithvaginalhysterectomy[30].Also,studiesofhysterectomyforPOPandother
indicationshavegenerallyfoundnoimpactonsexualfunction.(See"Choosingarouteofhysterectomyforbenign
disease",sectionon'Pelvicorganprolapse'.)
Uterinesparingtechniquesofferthepotentialforpreservingfertility.Therearefewdata,however,regardingtheriskof
intrapartumcomplicationandpostpartumrecurrenceofprolapsefollowingtheseprocedures[22,31].
Whileuterinesparingtechniquesmayofferbenefitsofdecreasedoperativedurationandbloodloss,theirefficacyand
decreasedriskremainsunproven.Giventhecurrentdata,forwomenundergoingapicalprolapserepair,wesuggest
performingconcomitanthysterectomyratherthanuterinepreservation.Auterinesparingprocedureperformedbya
surgeonfamiliarwiththenecessarytechniquesisareasonablealternativeforwomenwhostronglyprefertopreserve
theiruterusandareawareofthepotentialriskofrecurrentprolapserequiringneedforfuturehysterectomyandthe
uncertaintyregardingtheimpactoffuturepregnancyonthedurabilityoftherepair.
CONCOMITANTREPAIROFAPICALANDANTERIORORPOSTERIORPROLAPSEReconstructivesurgery
forPOPofteninvolvesrepairofmultipleanatomicsitesofprolapse(apical,anterior,and/orposterior).Repairofeach
prolapsesiteandhowtobestperformacombinedreconstructionmustbeconsideredwhenchoosinganoverall
surgicalapproach.Thecommonteachingisthatallproceduresshouldbeperformedusingoneroute(vaginalor
abdominal),sinceitisgenerallypreferredtoavoidbothabdominalandvaginalincisions.Insomeinstances,however,
surgeonsmaycombinethetwosurgicalapproaches.
Choiceofsurgicalrouteismainlyofconcerninwomenwhorequirerepairofapicalprolapse,sinceisolatedrepairof
anteriororposteriorvaginalwallprolapseistypicallyperformedtransvaginally(posteriorprolapsecanalsoberepaired
endoanally).Repairofapicalprolapseabdominallywithsacralcolpopexyresultsinalowerrateofrecurrence,while
transvaginalrepair(eg,sacrospinousligamentfixation,uterosacralligamentfixation)hasashorterrecoveryandless
morbidity.Thechoiceofsurgicaltechniqueforspecificanatomicsitesofprolapseisdiscussedseparately.(See
"Surgicalmanagementofposteriorvaginaldefects",sectionon'Surgicalapproaches'and"Pelvicorganprolapsein
women:Surgicalrepairofapicalprolapse(uterineorvaginalvaultprolapse)",sectionon'Abdominalversusvaginal
approach'and"Pelvicorganprolapseinwomen:Surgicalrepairofanteriorvaginalwallprolapse".).
Patientswithapicalprolapsehaveahighrateofanteriorprolapseandalowerrateofposteriorprolapse[32].Itis
controversialwhetherrepairofapicalprolapseissufficienttosupporttheanteriorandposteriorvaginalwallsorif
additionalproceduresarerequiredtoaddressanteriorand/orposteriorprolapse.Ifthevaginalmuscularisiswell
suspendedattheapex,manyanteriordefects(55percentinonestudy)[33]andsomeposteriordefectswillresolve.
Ontheotherhand,correctionofanteriororposteriorprolapsedoesnotrepairapicaldescent.Theapproachto
concomitantrepairofmultiplesitesofprolapsevariesbysurgicalrouteandbysiteofprolapse.
Repairofanteriororposteriorprolapsealoneappearstohaveahigherfailureratethanwhentheseproceduresare
combinedwithapicalprolapserepair.ThiswasillustratedinUnitedStatesnationalstudyof2756womenandfoundthe
following10yearreoperationrates:anteriorrepairversuscombinedanteriorandapicalrepair(20.2versus11.6
percent)anteriorandposteriorrepairversuscombinedanterior,posterior,andapicalrepair(14.7versus10.2percent)
andposteriorrepairversuscombinedposteriorandapicalrepair(14.6versus12.9percent)[34].Hysterectomyfor
prolapseandtheomissionofappropriateprolapserepairsareriskfactorsforreoperationofprolapse[35,36].The
incidenceofreoperationwithin10yearsofsurgeryis7.4percentwhenvaginalhysterectomyisdonealoneforprolapse
andjust2percentwhenconcomitantpelvicfloorrepairsareundertakenatthetimeofhysterectomy[35].Thelong
recognizedimportanceofapicalvaginalsupporthasalsobeenquantifiedinbiomechanicalstudies.Supportofthe
vaginalapexeliminatesanteriorvaginalwalllaxityin63percentofwomenwithstage3or4apicalprolapse[33]and
theseanalysesrevealthat>70percentofanteriorwallprolapseisaccountedforbylossofuterineorapicalvaginal
prolapse[37,38].
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

4/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

AbdominalrouteTheabdominalroutehasbeenusedfortherepairofbothanteriorandposteriorprolapse.
AnteriorprolapseAmongwomenundergoingsacralcolpopexywhoalsohavesymptomaticanteriorprolapse,
anteriorvaginalwallsupportcanbeachievedtransabdominallyeitherbysacralcolpopexyaloneorbyacombined
procedurewithparavaginalrepair.Dataarelimitedontheefficacyandcomparativeefficacyoftheseprocedures:
Asystematicreviewof62studiesofsacralcolpopexyfoundfewdataregardingtheefficacyofsacralcolpopexy
aloneforanteriorprolapse[39].
Aliteraturereviewoffiveobservationalstudiesreportedthatcombinedsacralcolpopexyandparavaginalrepair
successfullytreatedanteriorprolapsein76to97percentofwomen[40].
Theonlycomparativestudywasaretrospectivecohortstudyof170womeninwhichaconclusioncouldnotbe
reachedsinceonlysixpatientsrequiredreoperationforanteriorprolapserecurrence[41].
Unfortunately,interandintraexaminerreliabilityoftheclinicalexaminationforcentral,superior,andrightandleft
paravaginaldefectsispoor[42].Sinceitisdifficultforexaminerstoagreeonwhetheraparavaginaldefectispresent,
inourpractice,wedonotroutinelyperformparavaginaldefectrepairsforanteriorwallsupportandfeelthatagood
apicalsuspensionobviatestheneedforaseparaterepairoftheanteriorwall.(See"Pelvicorganprolapseinwomen:
Diagnosticevaluation",sectionon'Inspectionforparavaginaldefects'.)
PosteriorprolapseRepairofposteriorvaginalwallprolapseatthetimeofabdominalsurgerycanbeperformed
inoneofthreeways:
Modifyingthesacralcolpopexytoextendtheposteriormeshdowntherectovaginalseptum.Somedatasuggest
thatextendingthemeshtotheperinealbodyusingacombinedabdominalandvaginalapproach(sometimes
referredtoassacrocolpoperineopexy)increasestheriskofmesherosion[43].
Posteriorcolporrhaphy,whichisavaginalprocedure.
Endoanalorendorectalposteriorrepairhowever,thetransvaginalapproachappearstobesuperiortothese
approaches.(See"Surgicalmanagementofposteriorvaginaldefects",sectionon'Vaginalversustransanal
approach'.)
IntheColpopexyandUrinaryReductionEfforts(CARE)trial,whichevaluatedtheroleofBurchcolposuspensionin
womenundergoingsacralcolpopexy,87of298women(29percent)underwentposteriorvaginalwallrepairinwhich
colporrhaphy,perineorrhaphy,orsacrocolpoperineopexywasusedaccordingtosurgeondiscretion[44].Womenwho
didordidnotundergoposteriorrepairhadasimilarrateofimprovementinbowelsymptoms,includingobstructive
symptoms(constipation,incompleteemptyingandofpainand/orirritationwithdefecation)posterioranatomic
outcomeswerealsosimilarforthetwogroups.
Observationalstudiesofsacralcolpopexywithposteriormeshextension,butwithoutposteriorcolporrhaphy,havehad
widelyvariableresults.Intwoprospectivestudies,therateofrecurrenceofposteriorprolapsevariedfrom8percentat
oneyear[45]to57percentattwoyears[46].
Thedecisiontoperformaposteriorcolporrhaphyisdependentuponwhetherthepatienthaspatientsposterior
prolapserelatedand/ordefecatorysymptomsandthedegreeofprolapseoftheposteriorwall.Inourpractice,in
patientswithposteriorwallprolapse,weextendthemeshdowntheposteriorvaginalwalltothelowerhalfofthe
vagina.Whensymptomsarebothersomeand/ortheprolapseoftheposteriorwallextendstoorbeyondthehymen,we
generallyperformaposteriorcolporrhaphy.
VaginalrouteInwomenundergoingatransvaginalapicalsuspension,theoptimalmanagementofseparately
addressinganteriorandposteriorwallprolapseisunclear.Manysurgeonsperformasimultaneousanteriororposterior
colporrhaphy,whileothersthinkthataneffectivevaginalapicalsuspensionobviatesforaseparateanteriororposterior
procedure.
Highratesofanteriorwallprolapsehavebeenreportedforsacrospinousligamentsuspensionoruterosacralligament
suspensionincombinationwithanteriorcolporrhaphy(29percent),andevenhigherforanteriorcolporrhaphyalone(30
to40percent)[47].However,mostofthesestudiesusedadefinitionoffailuredefinedasrecurrenceofstageIIor
highernewevidencesuggeststhatthisdefinitionistoostrictandhasbeenbasedonexpertopiniononlyandnotdata.
Currentevidencesupportsadefinitionofsuccessasapatientsperceptionofbother,whichtypicallycorrespondsto
prolapsebeyondthehymen[48].Usingthisdefinition,moststudiesinvestigatingtheefficacyofanteriorcolporrhaphy
showhighsuccessratesandlowreoperationrates.(See"Pelvicorganprolapseinwomen:Surgicalrepairofapical
prolapse(uterineorvaginalvaultprolapse)",sectionon'Outcome'and"Pelvicorganprolapseinwomen:Surgicalrepair
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

5/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

ofapicalprolapse(uterineorvaginalvaultprolapse)",sectionon'Outcome'and"Pelvicorganprolapseinwomen:
Surgicalrepairofanteriorvaginalwallprolapse".)
Inourpractice,whenapicalprolapse,aswellasstageIIanteriororposteriorvaginalwallprolapse,arepresentduring
thepreoperativeexamination,weperformananteriororposteriorcolporrhaphyinadditiontoatransvaginalapical
suspension.
CONCOMITANTINCONTINENCESURGERY
UrinaryincontinenceSymptomaticPOPoftencoexistswithSUI.WomenwithsymptomsofbothPOPandSUI
aretreatedwithacombinedprolapserepairandcontinenceprocedure.
AnotherimportantpatientpopulationconsistsofwomenwithstageIIorhigherapicalprolapsewhoremaincontinent
despitelossofanteriorvaginalandbladder/urethralsupport.Unfortunately,13to65percentofcontinentwomen
developsymptomsofSUIaftersurgicalcorrectionofprolapse.Thislikelyoccursbecausetheprolapsekinksand
obstructstheurethrathisobstructionisalleviatedwhentheprolapseisrepaired.Thisisreferredtoas"occult"or
"potential"stressincontinence.
AllwomenwithapicalprolapseshouldhaveapreoperativeevaluationforoccultSUIwithclinicalorurodynamicurinary
stresstestingwithandwithoutreductionofprolapse.However,preoperativeprolapsereductiontestingdoesnot
accuratelypredictpostoperativestressincontinence(approximately40percentofwomenwithnegativetestingwill
developpostoperativestressincontinence).
Apredictionmodelexistsforcalculatingawoman'sindividualriskofpostoperativeSUIaftersurgeryforprolapsein
womenwhodonothaveSUIbeforesurgery.Thisstressurinaryincontinenceriskcalculatorcanbeusedinthepatient
andsurgeon'sdecisionregardingperformanceofaconcomitantcontinenceprocedureatthetimeofprolapsesurgery
(figure1)[49].
ForwomenwithstageIIorgreaterPOPwhoareundergoingabdominalsacrocolpopexy,regardlessoftheresultsof
preoperativetestingforoccultSUI,highqualitydatasupportaconcomitantBurchcolposuspensionratherthan
sacrocolpopexyalone.Similarly,forwomenwithstageIIorgreaterPOPwhoareundergoingvaginalvaultsuspension,
regardlessoftheresultsofpreoperativetestingforoccultSUI,aconcomitantmidurethralslingratherthanvaginalvault
suspensionalonesignificantlydecreasestheriskofpostoperativeSUI,butisaccompaniedbyanincreasein
postoperativecomplications[50].ConcomitantsurgeryforPOPandSUIisdiscussedindetailseparately.(See"Pelvic
organprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment",sectionon'POPwithno
symptomsofSUI'.)
AnalincontinenceRepairofPOPmayimprovesymptomsinwomenwhohavebothersomesymptomsofboth
POPandanalincontinence.WhenPOPisthepatient'sprimarycomplaint,somesurgeonschoosetorepairPOPprior
torecommendingsurgeryforanalincontinence.
DataaremixedregardingtheimpactofPOPrepair,specificallyrectocelerepair,onanalincontinence[5154].A
prospectivestudyof101womenundergoingrectocelerepairreportedthat63percentwhohadanalincontinence
preoperativelyreportedresolutionorimprovementinthesesymptomsatoneyearaftersurgery[51].Incontrast,ina
retrospectiveseriesof231womenwhounderwentposteriorcolporrhaphy,theprevalenceoffecalincontinence
increasedpostoperativelyfrom4to11percent,and19percentofpatientsdevelopedincontinenceofflatus[52].
Furtherstudyisneededtoevaluatethisissue.
Analincontinenceisdiscussedindetailseparately.(See"Fecalincontinenceinadults:Etiologyandevaluation".)
MESHAUGMENTATIONSurgicalmeshuseisstandardinabdominalsacralcolpopexy.Theuseofsurgicalmesh
fortransvaginalPOPrepairhasbeenintroducedwiththegoalofreducingtheriskofrecurrentprolapse,butthis
approachiscontroversial.Atpresent,potentiallyhighersuccessratesresultingfromtheuseofsomemeshproducts
fortheanterior,andpossiblytheapex,ofthevaginaareaccompaniedbyahighercomplicationratethantraditional
vaginalsurgery.
Useofsurgicalmeshinpelvicreconstructivesurgeryisdiscussedindetailseparately.(See"Overviewoftransvaginal
placementofmeshforprolapseandstressurinaryincontinence".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
th

th

http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

6/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfo
andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Pelvicorganprolapse(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Surgicalcandidatesforpelvicorganprolapse(POP)repairarewomenwithsymptomaticprolapsewhodeclineor
failconservativetherapy(eg,vaginalpessaries).(See'Candidatesforsurgicaltreatment'above.)
ThereisnoindicationforrepairofasymptomaticPOPasanisolatedprocedure.WealsosuggestNOT
performingprolapserepairformostasymptomaticwomenwhoareundergoingotherpelvicfloorprocedures(eg,
stressurinaryincontinence[SUI]surgery)(Grade2C).Prolapserepairatthetimeofotherpelvicsurgeryisa
reasonableoptioninwomenwithadvancedprolapseorwomenwithriskfactorsfordevelopingprolapse
progression(eg,concomitanthysterectomy,premenopausalstatus,obesity).
Womenwhoareelderly,unabletotolerateextensivesurgery,anddonotplanfuturevaginalintercourseare
candidatesforobliterativePOPsurgery.(See'Reconstructiveversusobliterativeprocedures'above.)
Forwomenundergoingapicalprolapserepair,wesuggestperformingconcomitanthysterectomyratherthan
uterinepreservation(Grade2B).Auterinesparingprocedureperformedbyasurgeonfamiliarwiththenecessary
techniquesisareasonablealternativeforwomenwhostronglyprefertopreservetheiruterusandareawareof
thepotentialriskofrecurrentprolapseandtheuncertaintyregardingobstetricoutcomes.(See'Concomitant
hysterectomy'above.)
Forwomenwhoareundergoinganabdominalapicalsuspensionprocedurewhorequirerepairofanteriorand/or
posteriorvaginalwallprolapse(see'Abdominalroute'above):
Forwomenwithanteriorvaginalwallprolapse,wesuggestapicalsuspensionaloneratherthancombined
withabdominalparavaginalrepair(Grade2C).
Formostwomenwithposteriorvaginalwallprolapse,wesuggestextendingthevaginalmeshfromthe
apicalsuspensiondowntheposteriorvaginalwalltothelowerhalfofthevagina(Grade2C).When
symptomsarebothersomeand/ortheprolapseoftheposteriorwallextendstoorbeyondthehymen,we
suggestperformingaposteriorcolporrhaphy(Grade2C).
Forwomenwhoareundergoingatransvaginalapicalsuspensionprocedurewhorequirerepairofanteriorand/or
posteriorvaginalwallprolapse,wesuggestconcomitantanteriorand/orposteriorcolporrhaphy(Grade2C).(See
'Vaginalroute'above.)
POPoftencoexistswithSUI.SomewomenwithadvancedPOPremaincontinentdespitelossofanteriorvaginal
andbladder/urethralsupport.ThesewomenmaydevelopsymptomsofSUIaftersurgicalcorrectionofthe
prolapse.(See'Urinaryincontinence'above.)
AllwomenplanningrepairofapicalprolapseshouldhaveapreoperativeevaluationforSUIwithclinicalor
urodynamicurinarystresstestingwithandwithoutreductionofprolapse.However,preoperativeprolapse
reductiontestingdoesnotaccuratelypredictpostoperativestressincontinence(approximately40percentof
womenwithnegativetestingwilldeveloppostoperativeSUI).Thistestingmayimpactsurgicaldecisionmaking,
particularlyforwomenundergoingtransvaginalapicalprolapserepair.(See'Urinaryincontinence'above.)
WomenwithsymptomaticapicalPOPandnoSUIsymptomsmayhaveoccultSUIandmaybenefitfroma
prophylacticcontinenceprocedureatthetimeofPOPrepair.Apatient'sindividualriskcanbecalculatedusinga
denovoSUIriskcalculator.(See'Urinaryincontinence'aboveand"Pelvicorganprolapseandstressurinary
incontinenceinwomen:Combinedsurgicaltreatment",sectionon'POPwithnosymptomsofSUI'.)
UseofsurgicalmeshfortransvaginalPOPrepairhaspotentiallyhigheranatomicsuccessratesthanrepair
withoutmesh,butalsoappearstoresultinsimilarsubjectivesuccessratesandahighercomplicationratethan
traditionalvaginalsurgery.(See'Meshaugmentation'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

7/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

REFERENCES
1.JonesKA,ShepherdJP,OliphantSS,etal.TrendsininpatientprolapseproceduresintheUnitedStates,1979
2006.AmJObstetGynecol2010202:501.e1.
2.BoylesSH,WeberAM,MeynL.ProceduresforpelvicorganprolapseintheUnitedStates,19791997.AmJ
ObstetGynecol2003188:108.
3.OlsenAL,SmithVJ,BergstromJO,etal.Epidemiologyofsurgicallymanagedpelvicorganprolapseandurinary
incontinence.ObstetGynecol199789:501.
4.AsanteA,WhitemanMK,KulkarniA,etal.ElectiveoophorectomyintheUnitedStates:trendsandinhospital
complications,19982006.ObstetGynecol2010116:1088.
5.EllerkmannRM,CundiffGW,MelickCF,etal.Correlationofsymptomswithlocationandseverityofpelvic
organprolapse.AmJObstetGynecol2001185:1332.
6.GutmanRE,FordDE,QuirozLH,etal.Isthereapelvicorganprolapsethresholdthatpredictspelvicfloor
symptoms?AmJObstetGynecol2008199:683.e1.
7.SwiftS,WoodmanP,O'BoyleA,etal.PelvicOrganSupportStudy(POSST):thedistribution,clinicaldefinition,
andepidemiologicconditionofpelvicorgansupportdefects.AmJObstetGynecol2005192:795.
8.MouritsenL,LarsenJP.Symptoms,botherandPOPQinwomenreferredwithpelvicorganprolapse.Int
UrogynecolJPelvicFloorDysfunct200314:122.
9.BradleyCS,ZimmermanMB,QiY,NygaardIE.Naturalhistoryofpelvicorganprolapseinpostmenopausal
women.ObstetGynecol2007109:848.
10.HandaVL,GarrettE,HendrixS,etal.Progressionandremissionofpelvicorganprolapse:alongitudinalstudy
ofmenopausalwomen.AmJObstetGynecol2004190:27.
11.DietzHP.Prolapseworsenswithage,doesn'tit?AustNZJObstetGynaecol200848:587.
12.KudishBI,IglesiaCB,SokolRJ,etal.Effectofweightchangeonnaturalhistoryofpelvicorganprolapse.
ObstetGynecol2009113:81.
13.DllenbachP,KaelinGambirasioI,DubuissonJB,BoulvainM.Riskfactorsforpelvicorganprolapserepairafter
hysterectomy.ObstetGynecol2007110:625.
14.DiezItzaI,AizpitarteI,BecerroA.Riskfactorsfortherecurrenceofpelvicorganprolapseaftervaginalsurgery:
areviewat5yearsaftersurgery.IntUrogynecolJPelvicFloorDysfunct200718:1317.
15.NieminenK,HuhtalaH,HeinonenPK.Anatomicandfunctionalassessmentandriskfactorsofrecurrent
prolapseaftervaginalsacrospinousfixation.ActaObstetGynecolScand200382:471.
16.WhitesideJL,WeberAM,MeynLA,WaltersMD.Riskfactorsforprolapserecurrenceaftervaginalrepair.AmJ
ObstetGynecol2004191:1533.
17.SteppKJ,BarberMD,YooEH,etal.Incidenceofperioperativecomplicationsofurogynecologicsurgeryin
elderlywomen.AmJObstetGynecol2005192:1630.
18.BradleyCS,KentonKS,RichterHE,etal.Obesityandoutcomesaftersacrocolpopexy.AmJObstetGynecol
2008199:690.e1.
19.DiwadkarGB,BarberMD,FeinerB,etal.Complicationandreoperationratesafterapicalvaginalprolapse
surgicalrepair:asystematicreview.ObstetGynecol2009113:367.
20.DenehyTR,ChoeJY,GregoriCA,BreenJL.ModifiedLeFortpartialcolpocleisiswithKellyurethralplicationand
posteriorcolpoperineoplastyinthemedicallycompromisedelderly:acomparisonwithvaginalhysterectomy,
anteriorcolporrhaphy,andposteriorcolpoperineoplasty.AmJObstetGynecol1995173:1697.
21.HefniM,ElToukhyT,BhaumikJ,KatsimanisE.Sacrospinouscervicocolpopexywithuterineconservationfor
uterovaginalprolapseinelderlywomen:anevolvingconcept.AmJObstetGynecol2003188:645.
22.MaherCF,CaryMP,SlackMC,etal.Uterinepreservationorhysterectomyatsacrospinouscolpopexyfor
uterovaginalprolapse?IntUrogynecolJPelvicFloorDysfunct200112:381.
23.vanBrummenHJ,vandePolG,AaldersCI,etal.Sacrospinoushysteropexycomparedtovaginalhysterectomy
asprimarysurgicaltreatmentforadescensusuteri:effectsonurinarysymptoms.IntUrogynecolJPelvicFloor
Dysfunct200314:350.
24.FrickAC,WaltersMD,LarkinKS,BarberMD.Riskofunanticipatedabnormalgynecologicpathologyatthetime
ofhysterectomyforuterovaginalprolapse.AmJObstetGynecol2010202:507.e1.
25.NesbittREJr.Uterinepreservationinthesurgicalmanagementofgenuinestressurinaryincontinence
associatedwithuterovaginalprolapse.SurgGynecolObstet1989168:143.
26.DiwanA,RardinCR,KohliN.Uterinepreservationduringsurgeryforuterovaginalprolapse:areview.Int
UrogynecolJPelvicFloorDysfunct200415:286.
27.CarramoS,AugeAP,PacettaAM,etal.[Arandomizedcomparisonoftwovaginalproceduresforthetreatment
ofuterineprolapseusingpolypropylenemesh:hysteropexyversushysterectomy].RevColBrasCir200936:65.
28.DietzV,vanderVaartCH,vanderGraafY,etal.Oneyearfollowupaftersacrospinoushysteropexyandvaginal
http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

8/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

hysterectomyforuterinedescent:arandomizedstudy.IntUrogynecolJ201021:209.
29.RooversJP,vanderVaartCH,vanderBomJG,etal.Arandomisedcontrolledtrialcomparingabdominaland
vaginalprolapsesurgery:effectsonurogenitalfunction.BJOG2004111:50.
30.JengCJ,YangYC,TzengCR,etal.Sexualfunctioningaftervaginalhysterectomyortransvaginalsacrospinous
uterinesuspensionforuterineprolapse:acomparison.JReprodMed200550:669.
31.KovacSR,CruikshankSH.Successfulpregnanciesandvaginaldeliveriesaftersacrospinousuterosacral
fixationinfiveofnineteenpatients.AmJObstetGynecol1993168:1778.
32.RooneyK,KentonK,MuellerER,etal.Advancedanteriorvaginalwallprolapseishighlycorrelatedwithapical
prolapse.AmJObstetGynecol2006195:1837.
33.LowderJL,ParkAJ,EllisonR,etal.Theroleofapicalvaginalsupportintheappearanceofanteriorand
posteriorvaginalprolapse.ObstetGynecol2008111:152.
34.EilberKS,AlperinM,KhanA,etal.OutcomesofvaginalprolapsesurgeryamongfemaleMedicarebeneficiaries:
theroleofapicalsupport.ObstetGynecol2013122:981.
35.BlandonRE,BharuchaAE,MeltonLJ3rd,etal.Incidenceofpelvicfloorrepairafterhysterectomy:Apopulation
basedcohortstudy.AmJObstetGynecol2007197:664.e1.
36.AltmanD,FalconerC,CnattingiusS,GranathF.Pelvicorganprolapsesurgeryfollowinghysterectomyon
benignindications.AmJObstetGynecol2008198:572.e1.
37.SummersA,WinkelLA,HussainHK,DeLanceyJO.Therelationshipbetweenanteriorandapicalcompartment
support.AmJObstetGynecol2006194:1438.
38.HsuY,ChenL,SummersA,etal.Anteriorvaginalwalllengthanddegreeofanteriorcompartmentprolapseseen
ondynamicMRI.IntUrogynecolJPelvicFloorDysfunct200819:137.
39.NygaardIE,McCreeryR,BrubakerL,etal.Abdominalsacrocolpopexy:acomprehensivereview.Obstet
Gynecol2004104:805.
40.MaherC,BaesslerK.Surgicalmanagementofanteriorvaginalwallprolapse:anevidencebasedliteraturereview.
IntUrogynecolJPelvicFloorDysfunct200617:195.
41.ShippeySH,QuirozLH,SansesTV,etal.Anatomicoutcomesofabdominalsacrocolpopexywithorwithout
paravaginalrepair.IntUrogynecolJ201021:279.
42.WhitesideJL,BarberMD,ParaisoMF,etal.Clinicalevaluationofanteriorvaginalwallsupportdefects:
interexaminerandintraexaminerreliability.AmJObstetGynecol2004191:100.
43.ViscoAG,WeidnerAC,BarberMD,etal.Vaginalmesherosionafterabdominalsacralcolpopexy.AmJObstet
Gynecol2001184:297.
44.BradleyCS,NygaardIE,BrownMB,etal.Bowelsymptomsinwomen1yearaftersacrocolpopexy.AmJ
ObstetGynecol2007197:642.e1.
45.GuiahiM,KentonK,BrubakerL.Sacrocolpopexywithoutconcomitantposteriorrepairimprovesposterior
compartmentdefects.IntUrogynecolJPelvicFloorDysfunct200819:1267.
46.BaesslerK,SchuesslerB.Abdominalsacrocolpopexyandanatomyandfunctionoftheposteriorcompartment.
ObstetGynecol200197:678.
47.WeberAM,WaltersMD,PiedmonteMR,BallardLA.Anteriorcolporrhaphy:arandomizedtrialofthreesurgical
techniques.AmJObstetGynecol2001185:1299.
48.BarberMD,BrubakerL,NygaardI,etal.Definingsuccessaftersurgeryforpelvicorganprolapse.Obstet
Gynecol2009114:600.
49.JelovsekJE,ChaginK,BrubakerL,etal.Amodelforpredictingtheriskofdenovostressurinaryincontinence
inwomenundergoingpelvicorganprolapsesurgery.ObstetGynecol2014123:279.
50.WeiJT,NygaardI,RichterHE,etal.Amidurethralslingtoreduceincontinenceaftervaginalprolapserepair.N
EnglJMed2012366:2358.
51.GustiloAshbyAM,ParaisoMF,JelovsekJE,etal.Bowelsymptoms1yearaftersurgeryforprolapse:further
analysisofarandomizedtrialofrectocelerepair.AmJObstetGynecol2007197:76.e1.
52.KahnMA,StantonSL.Posteriorcolporrhaphy:itseffectsonbowelandsexualfunction.BrJObstetGynaecol
1997104:82.
53.HefniM,ElToukhyT,BhaumikJ.Vaginalsacrospinouscolpopexyandperineorrhaphyforfaecalincontinence:
preliminaryreport.EurJObstetGynecolReprodBiol2003110:211.
54.HeriotAG,SkullA,KumarD.Functionalandphysiologicaloutcomefollowingtransanalrepairofrectocele.BrJ
Surg200491:1340.
Topic14212Version12.0

http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTime

9/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

GRAPHICS
Riskfactorsforrecurrentpelvicorganprolapse
Riskfactor*

Adjustedoddsratio(95%confidenceinterval)

Age
<60years [1]

3.2(1.66.4)

<60years [2]

4.1(1.610.4)

<73years [3]

6.3(2.317.5)

Preoperativepelvicorganprolapsestage(POPQ)
Stage3or4 [1]

2.7(1.35.3)

Stage3or4 [2]

3.9(1.213.0)

Stage4 [4]

5.6(1.129.3)

BodyMassIndex>26kg/m 2

2.9(1.16.7)

Bodyweight>65kg [2]

4.0(1.69.6)

[3]

*Thecomparatorforeachriskfactorgroupisthegroupofwomenwithpelvicorganprolapsethatarenot
includedinthespecifiedgroup(eg,thecomparatorfor>60yearsis60yearsORforstage4isstage1,2,or
3).
References:
1.Whiteside,JL,Weber,AM,Meyn,LA,Walters,MD.Riskfactorsforprolapserecurrenceaftervaginal
repair.AmJObstetGynecol2004191:15338.
2.DiezItza,I,Aizpitarte,I,Becerro,A.Riskfactorsfortherecurrenceofpelvicorganprolapseafter
vaginalsurgery:Areviewat5yearsaftersurgery.InternationalUrogynecologyJournal2007
18:131724.
3.Nieminen,K,Huhtala,H,Heinonen,PK.Anatomicandfunctionalassessmentandriskfactorsof
recurrentprolapseaftervaginalsacrospinousfixation.ActaObstetriciaEtGynecologicaScandinavica
200382:4718.
4.Jeon,MJ,Chung,SM,Jung,HJ,Kim,SK,Bai,SW.Riskfactorsfortherecurrenceofpelvicorgan
prolapse.Gynecologic&ObstetricInvestigation200866:26873.
Graphic79651Version4.0

http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTim

10/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

Choosingaprimaryprocedureforpelvicorgan
prolapse:Majordecisionpoints

Graphic56020Version3.0

http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTim

11/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

Riskcalculatorofdenovostressincontinenceafterprolapse
surgery

From:JelovsekJE,ChaginK,BrubakerL,etal.Amodelforpredictingtheriskofdenovostressurinary
incontinenceinwomenundergoingpelvicorganprolapsesurgery.ObstetGynecol2014123:279.
DOI:10.1097/AOG.0000000000000094.ReproducedwithpermissionfromLippincottWilliams&
Wilkins.Copyright2014AmericanCollegeofObstetriciansandGynecologists.Unauthorized
reproductionofthismaterialisprohibited.
Graphic103962Version1.0

http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTim

12/13

7/25/2016

Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure

ContributorDisclosures
JEricJelovsek,MD,MMEd,FACOG,FACSNothingtodisclose.LindaBrubaker,MD,FACS,FACOGNothingto
disclose.KristenEckler,MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy

http://www.uptodate.com/contents/pelvicorganprolapseinwomenchoosingaprimarysurgicalprocedure?topicKey=OBGYN%2F14212&elapsedTim

13/13