Pelvic Organ Prolapse

Pelvic Organ Prolapse 47 Olukunle Ajayi and Victor N. Chilaka Learning Objectives By the end of the chapter, the reader should be able to: • Define pelvic organ prolapse (POP) and appreciate its prevalence and significance in contemporary practice • Understand the significant aetiological factors in POP and be able to take a good history from the patients with this condition and initiate necessary investigations • Examine POP showing understanding of the various compartments involved and understand the principles of grading POP using the POP-Q system • Understand the principles of management of the different forms and combinations of pelvic organ prolapse: (a) The preventive measures and pelvic floor health (b) Strengths and limitations of pelvic floor physiotherapy (c) The pros and cons of using vaginal pessaries (d) The principles of surgical correction of POPs and surgical complications (e) The advantages of the use of surgical mesh and its limitations 47.1 Introduction Pelvic organ prolapse is defined as the descent or herniation of pelvic organ from their normal anatomical position. Pelvic floor dysfunction covers a broader range of conditions, including pelvic organ prolapse (POP), urinary incontinence O. Ajayi York Teaching Hospital NHS, East Riding Hospital, and Scarborough Hospital, York, UK V. N. Chilaka (*) Women’s Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar (UI) and faecal incontinence (FI) [1]. As life expectancy increases in the developed countries, the prevalence of POP will continue to rise, and it is a matter of time before the same trend is observed in developing countries. It is expected that the United States will experience a 46% increase in pelvic organ prolapse between 2010 and 2050 [2]. The demand for treatment of non-communicable disease and age-related medical conditions such as pelvic organ prolapse is set to continue to increase as the health of the population improves. 47.2 Prevalence Surgery for prolapse accounts for approximately 20% of elective major gynaecological surgery and up to 59% of operations in older women. The lifetime risk of having surgery for prolapse is 11%, and a third of these are for recurrent prolapses. As many as 50% of parous women have some form of prolapse, but only about 20% will be symptomatic. The prevalence of POP in post-menopausal women is as follows: anterior prolapse – 51%, posterior prolapse – 27%, and uterine/vault prolapse – 20% [3]. Vault prolapse is also seen in 1.8% of women who have had a hysterectomy for benign conditions, but in 11.6% in those who had a hysterectomy because of prolapse [4, 5]. Classification Traditionally, POP is classified as follows: (i) Anterior compartment prolapse (cystourethrocele) when the bladder and/or urethra herniated through the anterior vagina wall (ii) Posterior compartment prolapse (rectocoele) occurs when the rectum herniates through the posterior vaginal wall © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 F. Okonofua et al. (eds.), Contemporary Obstetrics and Gynecology for Developing Countries, https://doi.org/10.1007/978-3-030-75385-6_47 497 498 (iii) Apical compartment prolapse (utero-vagina prolapse/ vault prolapse) occurs when the cervix and uterus or the bowel herniating through the vagina vault in patients who had a hysterectomy O. Ajayi and V. N. Chilaka Anatomic Relations for the POP-Q Systems D Grading Systems (a) General System of Grading Prolapses: First Degree: Lowest part of prolapse descends halfway down the vaginal axis to the introitus. Second Degree: Lowest part of the prolapse extends to the level of the introitus and through the introitus on straining. Third Degree: Lowest part of the prolapse extends through the introitus and lies outside the vagina. Procidentia describes a third-degree uterine prolapse. (b) Baden and Walker Classification (1972): Grade I Descent of any organ to the vaginal mid-plane Grade II Descent to the hymenal ring Grade III Descent halfway through the introitus Grade IV Complete eversion These systems lacked scientific accuracy. (c) The Pelvic Organ Prolapse Quantification (POP-Q) and Scoring System ICS committee on standardisation [6]. This ICS accredited staging is similar to Baden and Walker system but involves well-defined anatomic relations. Measurements are taken in the left lateral position at rest and maximal Valsalva, thus providing an accurate and reproducible method of quantification. Grade O: No descent in pelvic organs during straining Grade I: Leading surface of prolapse does not descend below 1 cm above the hymenal ring Grade II: Leading edge of prolapse extends from 1 cm above to 1 cm below the hymenal ring Grade III: From 1 cm below the hymenal ring but without complete vaginal eversion Grade IV: Complete vaginal eversion 3 cm C Ba Aa Bp Ap TvI gh gh pb tvl Aa Ba C D Bp Ap pb Genital hiatus Perineal body Total vaginal length Midline point of the anterior vaginal wall 3 cm proximal to the ext. meatus Most distal/dependent position of the anterior vaginal wall from the vaginal vault or anterior fornix to Aa Most distal/dependent edge of cervix or vault Location of the posterior fornix Most distal/dependent position on posterior vaginal wall from the vaginal vault or posterior fornix to Ap Point on midline posterior vaginal wall 3 cm proximal to the hymen Examples Normal Anatomy −3 Aa 2 gh −3 Ap −3 Ba 3 pb −3 Bp −8 C 10 tvl 10 D Complete Vaginal Vault Eversion +3 Aa 4.5 gh +3 Ap +8 Ba 1.5 pb +8 Bp +8 C 8 tvl – D 47 Pelvic Organ Prolapse 47.3 Aetiological Factors The triad of age, childbirth injury and increased intraabdominal pressure are the main contributing factors to pelvic organ prolapse. The striated muscles of the pelvic floor in common with other striated muscles undergo gradual denervation with age that results in weakening of the muscles. Also, denervation injury occurs commonly at childbirth. These, coupled with a marked reduction of oestrogen in the menopausal women and increased intra-abdominal pressure in patients with obesity, chronic cough and constipation, are common aetiological factors in the development of POP. Other factors include some exercises as weight lifting, high-impact aerobics and long-distance running increase. Surgical operations as Burch colposuspension, needle suspension (Pereyra & Stamey), Manchester and even hysterectomies can predispose women to POP. Genetics may also be an essential factor in the aetiology of POP as it has been observed that it may be commoner in whites when compared with black populations. 47.4 Epidemiology Few epidemiological studies concerned with the prevalence of pelvic floor dysfunction have been carried out in developing countries. As the vast majority of developing countries resources are directed at life-threatening conditions such as post-partum haemorrhage, unsafe abortion, cervical cancer, violence against women and gender inequality, research into pelvic organ prolapse has taken backstage. Moreover, significant cultural barriers in reaching women in certain parts of Africa, the sensitive nature of the questions and examinations concerned with the evaluation of pelvic floor dysfunction have contributed to less research in this area. A review of the demographics of pelvic floor disorders indicates that a fifth of parous women have a pelvic organ prolapse. It is generally accepted that 50% of women will develop pelvic organ prolapse (POP), but only 10–20% of those seek evaluation for their condition. The peak incidence of symptoms attributed to POP is between the ages of 70 and 79, while POP symptoms are still relatively common in younger women [7]. A North American Actuarial analysis revealed that a woman up to the age of 80 years has 11% risk of needing surgery for pelvic floor weakness and if she has an operation, she has a 29% risk of requiring further surgery [8]. POP seems commoner in Whites, although good epidemiological data are still lacking. Van Dongen [9] concluded that genital prolapse was 80 times commoner in Whites than Blacks in South Africa. He proposed five factors to explain this observation: 499 1. The smaller circumference of the pelvis in Blacks requires shorter suspensory ligaments from the pelvic sidewalls to the cervix and vagina, and shorter ligaments are less likely to stretch than longer ones. 2. The deeper pelvis in black women allows for a thicker cardinal and uterosacral ligaments, which because of their vast bulk are less likely to stretch or tear. 3. The longer supra-vaginal cervix in black women allows larger and stronger attachments for the cardinal and uterosacral ligaments. 4. Blacks inherently have tougher connective tissue than their white counterparts based on preliminary histological studies, showing a higher collagen content in their ligaments. 5. The more significant lumber lordosis in Blacks results in the diversion of abdominal forces towards the pubic bone and anterior abdominal wall rather than towards the pelvic diaphragm. More work is required to identify the reasons for the observed racial differences. Clinical Presentation Clinical presentation depends on the compartment mainly affected and could be a combination of the compartments involved as well as sexual. Careful history taking is essential in evaluating pelvic dysfunction. It is crucial to ascertain the patient’s symptoms, the severity of the symptoms, the patient’s perception of the problems and what the patient wishes or their specific goals for consultation. 47.4.1 General Symptoms These may vary in magnitude and depends on the site of prolapse. Feeling of discomfort or heaviness in the pelvis with ‘lump or something coming down’ is quite common. This sensation tends to worsen with prolonged standing and towards the end of the day. They may also experience difficulty in inserting tampons or tampons could be spontaneously extruded. A good number will complain of chronic low backache. In advanced prolapse, there could also be decubitus ulcerations and lichenification, with vaginal discharge or bleeding. Sexual symptoms are not uncommon, and they may experience dyspareunia with slackness at coitus, lack of sensations, sexual satisfaction and orgasms. In severe cases, there could be apareunia, urinary incontinence during sexual intercourse, embarrassment or fear of leaking urine to the avoidance of intercourse altogether. There is, therefore, an essential need to ask about sexual functions as many women in the developing countries may not volunteer this information, but it could be a significant part of their distress. 500 47.4.2 Anterior Compartment Apart from complaining of something coming down, protrusion or mass par vaginam, LUTS (hesitancy urgency frequency and sensation of incomplete emptying) are very common complaints of anterior compartment prolapse. There could also be digitation or positional change to help voiding. They also tend to present with recurrent UTIs, terminal urinary dribbling, and at times difficulty in initiating urination (hesitancy). 47.4.3 Posterior Compartment They may have difficulty in opening the bowels, tenesmus, faecal urgency, with anal or vaginal digitation to defecate. There could also be incomplete bowel emptying, incontinence of flatus or stool, and faecal urgency. In cases of rectal prolapse, there may be a painful lump at the anal margins. 47.4.4 Others Symptoms of other underlying condition that could precipitate or worsen pelvic floor dysfunction should be determined for instance: chronic cough/chronic obstructive pumonary disease, ascites, abdominopelvic mass such as big uterine fibroids, chronic constipation. The quality of life (QoL) assessment reveals the severity of symptoms and quantifies the impact on the quality of life. It is always good practice to recheck QoL after interventions to determine their impact. It is essential to ascertain if the woman wishes to resume sexual activity (if stopped prior to consultation). This has an implication on the choice of conservative management like the vaginal pessary, or surgical approach to the treatment of POP. 47.4.5 Examination It is essential to offer an explanation of the steps involved in the examination to the patient, and ensure verbal consent and a chaperone. General examination including Body Mass Index (BMI) assessment, relevant systems, such as chest for features of COPD, abdomen for masses and the neurological system should be examined in detail. 47.4.6 Pelvic Examination This should start with an inspection of the vulva. Procidentia is immediately visible. Ulcerations may be present posteriorly. A speculum examination should be done in the dorsal O. Ajayi and V. N. Chilaka position to inspect vaginal wall and cervix, followed by a digital examination to assess the uterine size, and adnexa. The pelvic floor muscle tone and the patient’s ability to perform a pelvic floor contraction should also be assessed. The patient is then examined in the left lateral position with the aid of a Sim’s speculum. Pelvic organ prolapse quantification (POP-Q) method or the more widely used Baden-Walker halfway system is used to grade the stage of prolapse. At times, it may be necessary to have the patient to stand up and strain in other to demonstrate the prolapse adequately. Rarely, a rectal examination may be indicated to check for anal sphincteric tone, pelvic floor tone and stool consistency. 47.4.7 Investigation Clinical assessment is sufficient in most cases of POP. However, if urinary symptoms are present, a midstream urine should be dipped and if suspicious of infection be sent for microscopy, culture and sensitivity.) Urodynamic studies are indicated if there are concomitant lower urinary tract symptoms as stress incontinence urgency and urge incontinence or suspected voiding disorders. It is noteworthy that USI may be unmasked by anterior colporrhaphy. It is always good practice to check for urinary incontinence during examination for POP, and if USI is confirmed, a continence procedure may be done at the same time as the repair. Other investigations that are rarely required include renal tract ultrasound, which should be considered in chronic urinary residual and recurrent UTIs. Severe may be associated with obstructive uropathy, and intravenous urogram may be useful. Procidentia is often associated with some degree of ureteric obstruction. Pelvic fluoroscopy or MRIs may be used in detecting enterocoeles, and Isotope defaecography can be used in detecting rectocoeles. Cystourethroscopy can be used to investigate severe irritative symptoms, to exclude chronic follicular or interstitial cystitis. 47.5 Management of POP The current approach to the management of POP involves: (i) Preventive measures (obstetric and non-obstetric measures) (ii) Conservative management using a combination of lifestyle interventions, behavioural strategies, physical or physiotherapy (iii) Surgical management 47 Pelvic Organ Prolapse 47.5.1 Preventive Measures 47.5.1.1 Eradicate Harmful Obstetric Practices: Fundal Pressure The use of fundal pressure to accelerate labour or aid the bearing down urge during childbirth has no place in modern obstetric practice but still employed by some birth attendants in developing countries. Limit Prolonged Second Stage Avoidance of prolonged second stage of labour through careful monitoring employment of partograph as well as assisted vaginal delivery reduces the impact of excessive denervation injury that almost invariably accompanies childbirth. Eradicate Prolonged Obstructed Labour It is essential to sustain the efforts over the past decades of ensuring trained birth attendant in labour. Partograph use in labour is essential for early diagnosis and intervention to limit pelvic floor damage. It is also essential to address the causes of delay in the transfer of women in labour and accessing emergency obstetric services. 501 cate the pelvic floor muscles. In stress incontinence, PFMT works by increasing the tone and strength of the pelvic muscles. PFMT has also been shown to reduce the rate of progression of pelvic organ prolapse. PFMT success depends on the patient’s ability to perform the exercise correctly [10]. 47.6 Pelvic Floor Exercise The pelvic muscle is graded using the Oxford scale from 0 to 5. (Table 47.1). A 2014 multicentre randomised controlled trial (RCT) comparing individualised pelvic floor muscle training with no intervention found a statistically significant improvement in subjective assessment of prolapse symptoms in the intervention group. No significant improvement in objective assessment of anatomy, as assessed by the pelvic organ prolapse quantification system (POP-Q), was reported [11]. 47.6.1 Vaginal Pessaries Non-obstetric Factors It is necessary to avoid and also treat any factor that leads to chronic increases in intra-abdominal pressure (constipation, obesity, chronic chest conditions and obstructive airways disease and asthma). Hormone Replacement Therapy (HRT) with estrogens may also decrease the incidence of prolapse, but randomised controlled trials (RCTs) are needed to support this view. HRT is rarely used in developing countries but does reduce the lower genital tract symptoms. There is also a need to emphasise smaller family size and improvements in antenatal and intrapartum to maintain a healthier pelvic floor. Caesarean section seems protective of urogenital prolapse. Antenatal and postnatal pelvic floor exercises have not been shown conclusively to reduce the incidence of prolapse, but may be protective. Pelvic floor exercises (PFE) have not been shown to prevent prolapses, but may slow its progression and prevent urinary stress incontinence and should be encouraged. PFE may have a role in cases of mild prolapse in younger women who are yet to complete their family. Lifestyle Interventions This may include dietary advice, weight loss, laxative use, avoidance of high-impact exercise. Pelvic Floor Re-education or Pelvic Floor Muscle Training: (PFMT) Graded muscle training alone, or in combination with physical adjuncts such as vaginal cones, electrical stimulation and biofeedback are used to re-edu- Vagina pessaries have been available in some form for over 4000 years. The first pessaries described were pomegranate skins [12]. The commonest pessary in use is the ring type. Made of polypropylene, easy to insert and remove. It could be inserted and removed by well-motivated patients (at bedtime or before coitus as the patient deems fit. It does not preclude sex. The optimal size is usually determined by trial and error. It is essential that the pessary is shown to the patients to allay fear and ensure compliance. The optimal time interval for change of pessary has not been determined. Most clinicians change pessaries between 4 and 6 months in order to rule out pressure ulceration or impaction. Slight blood loss during pessary use may indicate ulceration, but care is needed in the post-menopausal women to rule our cervical or endometrial cancer by proper clinical evaluation. If there is ulceration, do not replace pessary, use oestrogen cream vaginally to encourage healing and pessary is replaced after healTable 47.1 Modified Oxford grading of pelvic floor muscle Grade Characteristics 0 No discernible contraction 1 Flickering contraction, not visible on inspection of the perineum 2 Weak squeeze, distinctly palpable contraction. No lift 3 Moderate squeeze, palpable upward and forward movement. Definite lift 4 Good muscle strength, elevation possible against slight resistance. Good squeeze with lift 5 Very strong muscle strength, contraction possible against vigorous resistance. Strong squeeze with lift 502 O. Ajayi and V. N. Chilaka ing. Pessary offers several advantages: It is effective, no risk of anaesthesia, affordable, reusable and it is authors’ opinion that pessary use should be widely advocated in combination with supervised pelvic floor exercise in a resource-poor setting. Space occupying pessaries like the shelf pessary precludes sexual intercourse and are therefore unsuitable for sexually active women. The shelf pessary may be quite challenging to change and be embedded in the vaginal wall. Some pessaries are designed for stress incontinence while others have dual action for stress incontinence as well as control of pelvic organ prolapse symptoms. Complications of the pessary include pain, urinary incontinence and retention, vaginal discharge and ulcerations, which can lead to fistula formation if neglected. Before using these in the tropics, it is essential to ensure that the patient must be able to keep follow-up appointments A simple guideline for pessary selection is provided in Table 47.2. 47.7 Surgical Management of Pelvic Organ Prolapse Surgery aims to restore the anatomy of the vagina and pelvic floor, as well as sexual functions, and the correction of urinary and faecal incontinence. It is also essential to have it in mind to reduce and prevent recurrent and de novo prolapses, urinary and faecal incontinence. Table 47.2 Pessary selection guide Pessary Ring Ring with support Gellhorn standard Gellhorn short Shaatz Ring with knob Cube Donut Dish Dish with support Hodge Gehrung Gehrung with knob Inflatoball Shelf 1st/2nd degree Prolapse √ √ √ √ √ √ 3rd degree Prolapse SUI Cystocoele Rectocoele √ √ 47.7.1 Anterior Repair White described the paravaginal repair of cystocoele in 1909. Four years later, Kelly described the anterior vaginal repair with a central plication of pubo-cervical fascia using interrupted and absorbable sutures. Cautious trimming of excess vaginal skin is done by many but offers no advantage to a good plication. The vaginal is then closed with interrupted or continuous locking sutures. Conventional anterior repair is the most commonly performed operation for cystocoele and now looked upon as traditional repair. Permanent or absorbable meshes may be used for recurrent prolapses. De novo stress incontinence (5%) and de novo detrusor overactivity (5%) are known urinary complications of anterior repair [12]. 47.7.2 Posterior Repair This is the traditional way for the correction of rectocoele and deficient perineum. It is the meeting point of colorectal surgeons (trans-anal correction), and the gynaecologists (transvaginal or posterior repair). It involves levator plication, but recent reports of only fascial repair yielded about 80% success rate with fewer complications. The procedure involves excision of any perineal scarring and the posterior vaginal wall opened. The rectocoele is mobilised from the vaginal epithelium by blunt and sharp dissection. The para-rectal and rectovaginal fasciae from each side are approximated using interrupted polyglycolic (Vicryl, Ethicon) sutures. The posterior wall is closed with continuous locked polyglycolic (Vicryl, Ethicon) sutures. Perineoplasty is done by placing deeper absorbable sutures into the perineal muscles and fascia. √ √ √ 47.8 √ √ √ The conventional approach is vaginal hysterectomy with the additional repair of the vaginal walls. The first successful vaginal hysterectomy was credited to Langenback in 1813. The Moschowitz procedure (closure of the peritoneum of the cul-de-sac); McCall culdoplasty (approximating the uterosacral ligaments to obliterate the peritoneum of the posterior cul-de-sac as high as possible) and suturing the cardinal and uterosacral ligaments to the vaginal cuff may also reduce subsequent enterocoele and vault prolapse [13, 14]. Manchester repair is no longer as popular as it used to be. Described in 1888 Archibald Donald. It is an alternative to vaginal hysterectomy for patients with uterine prolapse, although this may have been a more useful technique for patients with an elongated cervix rather than real uterine descent. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Vaginal Hysterectomy 47 Pelvic Organ Prolapse In 1966, Williams [15] described a technique for transvaginal uterosacral-cervical ligament plication. He reported on the outcomes of 20 women undergoing this procedure, with three ‘failures’ encountered within a 6-month follow-up period. His method involved a posterior colpotomy with the division of the uterosacral ligaments from the cervix. The ligaments are then plicated across the midline and reinsertion into the cervix. The cardinal ligaments are then plicated anteriorly across the midline. Richardson [16] first described the concept of sacrospinous hysteropexy in 1989. The cervix or uterosacral ligament is transfixed to the sacrospinous ligament using either permanent or delayed absorbable sutures. In 2001, Maher [17] reported a small comparison study between sacrospinous hysteropexy and vaginal hysterectomy with sacrospinous vault fixation, with no differences in objective or subjective outcomes at follow-up. The technique of posterior vaginal slingplasty was first described in 2001 [18], using a mesh kit to create ‘neo-uterosacral ligaments’. One prospective comparison study quoted a 91.4% patient satisfaction rate post-surgery, Conservation of the prolapsed uterus is a valid option: medium-term results of a prospective comparative study with cumulative data suggest a high incidence of mesh complications with up to a 21% mesh erosion rate [19]. 47.9 Vaginal Vault Prolapse Surgeries Sacrospinous fixation either unilateral (commonly on the right) or bilaterally (rarely performed) is the commonest surgery for treatment of vaginal vault prolapse. It involves the fixation of the vaginal vault to the sacrospinous ligament. It has a very high success rate, but surgery is done under limited visibility with the risk of injury to the pudendal nerves and vessels. The procedure was modified by Miya using a unique hook (Miya Hook) to attach stitch to the sacrospinous ligament. The stitch is then passed through the vaginal vault to attach it to the sacrospinous ligament. Recent advancement in surgical instrumentation has led to a new generation of stitching devices as Capio (Boston Scientific) Fixt (Bard) and I-Stitch (AMI). These have a significant advantage over the Miya hook, which requires more extensive dissection [1]. Success rates of 98% have been reported, but there is a small risk of cystocoele formation, urinary stress incontinence and post-operative dyspareunia. Alternative fixation to the ileo-coccygeal ligament (ICF) is equally successful but has a lower satisfaction rate because of the higher incidence of cystocoeles. Re-attachment of the vault to the pubo-cervical fascia, rectovaginal fascia, and uterosacral ligaments have also been described, but these operations are complicated and carry a high risk of injuries to ureters. 503 47.10 Abdominal Approach to POP Surgery Several methods for open abdominal hysteropexy have been described, including transfixing the uterus to the anterior abdominal wall and ventral fixation to the pectineal ligaments. Most techniques use the sacral promontory as the fixation point, giving rise to the term ‘abdominal sacrohysteropexy’. Abdominal suture sacrohysteropexy was described as early as 1957 [20], with the uterine fundus being fixed to the sacral promontory with silk sutures. More recent techniques have utilised a variety of synthetic meshes to aid fixation. In 1993, Addison [21] first described a technique for resuspending the uterus to the sacrum using MersileneTM (Ethicon US, LLC USA) polyester fibre mesh. Leron and Stanton [22] followed-up 13 women undergoing abdominal sacrohysteropexy and found it to be a safe and effective surgery for the management of uterine prolapse. Farkas et al. [23] described a technique for uterine suspension using a ‘wrap-around’ insert of Gore-Tex (W.L. Gore & Associates, Inc., Newark, USA) for women with prolapse secondary to bladder exstrophy. 47.11 Laparoscopic Approach The advantages of laparoscopic surgery are well documented. Several laparoscopic uterine suspension procedures have been described using different methods. Laparoscopic ventrosuspension involves suturing the round ligaments to the rectus sheath. It has been shown to have poor outcomes, with one case series of nine women reporting recurrent prolapse in all but one patient within 6 months [24]. Chen et al. [25] used mesh to suspend the uterus by attachment to the anterior abdominal wall. While they reported good outcomes, all patients experienced significant pain or dragging sensations over the mesh attachment site. Laparoscopic uterosacral ligament plication was first described by Wu et al. [26] in 1997, with excellent results in a small case series. Maher et al. [27] modified this technique to include re-attachment of the uterosacral ligaments to the cervix and closure of the pouch of Douglas, with an objective success rate of 79% in 43 women at 12 months. Recent techniques have focused on the use of the sacral promontory as a point of fixation. Krause et al. [28] carried out laparoscopic sacral suture hysteropexy, placing sutures through the posterior aspect of the cervix and transfixing to the sacral promontory via the right uterosacral ligament. Objective correction of prolapse was seen in 94% of patients at a mean of 20.3 months follow-up. Cutner et al. [29] developed the technique of laparoscopic uterine sling suspension. The peritoneum is opened over the sacral promontory, and the rectum is reflected laterally. A tunnel is created by blunt dissection underneath the 504 peritoneum from the sacral promontory to the insertion of the uterosacral ligament complex into the cervix on either side. Mersilene tape on a needle is placed through the cervix, through the uterosacral ligaments and through the peritoneal tunnels on each side, before being bilaterally tacked to the sacral promontory to suspend the uterus. This technique aims for the sling to resemble newly created uterosacral ligaments. The laparoscopic polypropylene cervical en-cerclage hysteropexy was recently modified in Oxford. A method of complete cervical en-cerclage was developed using a bifurcated polypropylene mesh [30]. The technique involves using a 5 cm wide strip of polypropylene under the peritoneum and attached to the sacral promontory [31]. O. Ajayi and V. N. Chilaka The use of Type 1 mesh is well established and has common usage in sacrocolpopexy and mid-urethral slings. However, the medical community has become aware of some of the complications that have attracted high media attention. because of potential litigations. The use of mesh for prolapse and incontinence in gynaecology is now under intense scrutiny. This has been secondary to a realisation that vaginal mesh extrusion rates are higher than previously thought. Indeed, the use of transvaginal mesh for vaginal prolapse appears to have a relatively high complication rate, with mesh erosion reported in up to 10% of cases [35]. This is secondary to mesh lying adjacent to the vaginal wall that has been weakened by a surgical incision and subsequent scarring. With an abdominal approach, the mesh extrusion rate is considerably less, as the vaginal incision is avoided. 47.12 Controversies in Surgical Management of Pelvic Organ Prolapse 47.14 Conclusions While vaginal hysterectomy has served patients and gynaecologists well for many years, its continued routine use has been subject to debate. Many gynaecologists argue that the uterus itself is healthy and the underlying pathophysiology is a connective tissue deficiency [32], whether congenital or acquired through childbirth or ageing, and that uterine prolapse is merely a symptom, not the disease. Vaginal hysterectomy fails to address this underlying deficiency in connective tissue, with relatively high recurrence rates of 10–40% described in the literature [3, 33]. When there is a loss of apical support, a traditional vaginal hysterectomy will not correct the defect. This is most readily apparent when women present with procidentia. Furthermore, hysterectomy removes a healthy organ that may play a role in a woman’s individual and sexual identity. Finally, the satisfaction rate of vaginal hysterectomy for prolapse are not significantly different from uterine preservation [34]. POP continues to afflict millions of women in sub-Saharan Africa, and as life expectancy increases, there is bound to be an increase in demand for treatment. POP, in many cases, arise as a consequence of carrying out biological functions. Managing POP is mainly by instituting relatively inexpensive measures – simple lifestyle modifications, pelvic floor exercise, use of vagina pessaries and surgical management. Although misconceptions and beliefs of women arise in developing countries about the aetiology of POP, ignorance and the poor help-seeking behaviour of women suffering from POP are well documented. The problem is compounded by a dearth of professionals, lack of resources and political will to fund health education and research in this area. With renewed interest in women’s health in the sustainable development goal, continued local and national efforts to partner with patient, healthcare planners and providers, pelvic organ prolapse on women in the sub-Saharan Africa will receive the attention it deserves. 47.13 Use of Mesh in Surgical Repair of POP References Use of synthetic mesh is becoming increasingly common in urogynaecological practice. It does offer additional support to endopelvic fascia and vaginal epithelium. The ideal mesh (Type 1) should be durable and flexible, allowing ease of use, and should have an adequate pore size (>75 microns). This allows access to leucocytes and fibroblasts to control infection around it and also reduces the risk of rejection. 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