Evaluation and treatment of pelvic organ prolapse : clinical, radiological and histopathological aspects

Objective: To assess the use of cystodefecoperitoneography (CDP) in clinical and radiological diagnosis of cystocele; to study the correlation between clinical and radiological findings at CDP and to evaluate if anatomical topography and structural abnormality corresponds to symptomatic presentation when assessing posterior vaginal wall prolapse; to evaluate if xenograft used at rectocele repair was associated with adverse clinical and histological inflammatory reactions; to prospectively examine if rectocele repair using xenograft is a safe method providing satisfactory clinical and symptomatical outcome; and to investigate the prevalence and risk factors of genital prolapse and urinary incontinence in female patients operated for rectal prolapse.

Methods: The following methods were used: The Pelvic organ prolapse quantification system (POPQ), CDP, bowel function questionnaires, pelvic floor surveys, histological, histopathological and clinical inflammatory quantification. Statistical analysis was performed using non-parametric statistics, correlation coefficients and logistic regression.

Results: Statistical analysis demonstrated a moderate correlation between the current definition of cystocele at CDP and POP-Q (r=0.67). An attempt to provide an alternative definition of cystocele at CDP had a similar outcome (r=0.63). Correlation statistics demonstrated that POP-Q did not reliably predict visceral involvement and prolapse size compared to CDP. There was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001) although severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging in general. There were no significant changes in inflammatory cell counts, histopathological inflammatory grading or clinical inflammatory quantification following xenograft augmented rectocele repair. Postoperative complications following rectocele xenograft repair were similar to suture repair. At clinical examination 12-months following xenograft rectocele repair of 29 patients with > stage II rectocele, 21 patients had stage I prolapse and 14 patients had no rectocele (P < 0.001) at defecography. Symptoms of rectal emptying difficulties remained in a majority of patients although decreased. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (OR 3.1, 95% Cl 1.4-6.9) and vaginal wall prolapse (OR 3.2, 95% Cl 1.3-7.8) compared to a matched control group. There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence.

Conclusions: Using the current methods and definition of cystocele at CDP, the agreement with clinical findings is limited and the value of bladder contrast uncertain. Vaginal topography and POP-Q staging neither predict radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological assessment may be a useful complement in the evaluation of posterior vaginal wall prolapse. Porcine collagen mesh was not associated with an adverse inflammatory response at clinical or histological evaluation and appears to be a safe material when used for rectocele repair. Rectocele repair using xenograft improved anatomical support, but there is a substantial risk for recurrence with unsatisfactory anatomical and functional outcome one year after surgery. Our results indicate a strong association between rectal- and genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.

List of scientific papers

I. Altman D, Mellgren A, Kierkegaard J, Zetterstrom J, Falconer C, Lopez A (2004). "Diagnosis of cystocele - the correlation between clinical and radiological evaluation. " Int Urogynecol J Pelvic Floor Dysfunct 15(1): 3-9; discussion 9.
https://doi.org/10.1007/s00192-003-1111-y

II. Altman D, Lopez A, Kierkegaard J, Zetterstrom J, Falconer C, Pollack J, Mellgren A (2004). "Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography. " Int Urogynecol J Pelvic Floor Dysfunct Sep 14: Epub ahead of print.
https://doi.org/10.1007/s00192-004-1220-2

III. Altman D, Mellgren A, Blomgren B, Lopez A, Zetterstrom J, Nordenstam J, Falconer C (2004). "Clinical and histological safety assessment of rectocele repair using collagen mesh. " Acta Obstet Gynecol Scand 83(10): 995-1000.
https://doi.org/10.1111/j.0001-6349.2004.00646.x

IV. Altman D, Zetterstrom J, Lopez A, Anzen B, Falconer C, Hjern F, Mellgren A (2004). "Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh - a prospective study." Diseases of the Colon and Rectum. [Accepted]
https://doi.org/10.1007/s10350-005-0023-y

V. Altman D, Zetterstrom J, Nordenstam J, Schultz I, Lopez A, Hjern F, Mellgren A (2004). "Pelvic organ prolapse and urinary incontinence in women with surgically managed rectal prolapse: a population based case-control study." [Submitted]