Female pelvic floor disorders : clinical aspects on surgical treatments

Background and aims: The life-time risk for a woman to undergo pelvic floor reconstructive surgery due to prolapse or incontinence is 20% and the high risk for recurrence after prolapse surgery is a major challenge. Surgical reconstruction of the perineal body is commonly performed, although studies assessing results of this procedure are scarce. Mid-urethral sling surgery has a cure rate of 80%, but whether the sling endures a subsequent delivery is largely unknown. In this thesis we aimed to investigate whether the choice of suture material has an impact on vaginal wall prolapse repair; whether cervical amputation results in similar cure rates in comparison to vaginal hysterectomy in women with uterine prolapse; if a subsequent delivery jeopardizes results from incontinence surgery; if physiotherapy and surgical treatment is equally effective in women with symptoms related to a poorly healed second-degree perineal tear.

Methods and main results: Study I and II are both register-based cohort studies based on data from the Swedish National Quality Register for Gynecological Surgery (GynOp). In Study I, 731 women who underwent primary anterior colporrhaphy and 384 women who underwent primary posterior colporrhaphy were included. We found a significantly lower rate of women reporting vaginal bulging symptoms one year after anterior colporrhaphy if a slowly absorbable monofilament suture was used compared to a more rapidly absorbable multifilament suture, 22% vs 30% (aOR 1.6, 95% CI 1.1-2.3). There was no difference between the suture groups in the posterior colporrhaphy cohort. In Study II, women with uterine prolapse who had undergone either cervical amputation (n=1979) or vaginal hysterectomy (n=1195) were analyzed. There were no differences between the two groups regarding neither symptom relief nor patient satisfaction at one year after surgery. Vaginal hysterectomy was associated with a higher rate of severe complications compared to cervical amputation, 1.9 % vs 0.2 % (p < 0.001). Study III is a cross-sectional, survey-based study. National registers were used to identify women with a delivery subsequent to a mid-urethral sling procedure (n=207) and a matched control-group including women without childbirth after a mid-urethral sling procedure (n=521). Validated questionnaires investigating urinary symptoms were mailed to the study participants. Patient reported stress urinary incontinence was present in 22% of the women with a delivery after a mid-urethral sling procedure and in 17% of the women in the control group (aOR 1.2, 95% CI 0.7-2.0). Vaginal childbirth after mid-urethral sling surgery did not increase the risk of stress urinary incontinence compared to cesarean delivery. Study IV is a randomized controlled trial where 70 women with a poorly healed second degree perineal tear, minimum six months post-partum, were randomized to either surgery or tutored pelvic floor muscle therapy. In an intention-to-treat analysis with worst case outcome imputation, treatment success at 6 months followup was significantly more frequent in the surgery group, 71% vs 11%, p<0.001.

Conclusions: In conclusion, the use of slowly absorbable monofilament sutures in anterior colporrhaphy was associated with a lower risk of symptomatic prolapse at one year postoperatively, compared to more rapidly absorbable multifilament sutures. In women with uterine prolapse, cervical amputation seems to result in similar patient reported outcomes as compared to vaginal hysterectomy, but comes with a lower risk of severe complications. Childbirth after a mid-urethral sling procedure does not increase the risk for recurrent stress urinary incontinence and the mode of a subsequent delivery does not seem to impact continence status. Finally, surgical treatment was superior to pelvic floor muscle therapy in providing symptom relief in women with poorly healed second-degree perineal tears.

List of scientific papers

I. Bergman I, Westergren Söderberg M, Kjaeldgaard A, Ek M. Does the choice of suture material matter in anterior and posterior colporrhaphy? International Urogynecology Journal. 2016 Sep;27(9):1357-65.
https://doi.org/10.1007/s00192-016-2981-0

II. Bergman I, Westergren Söderberg M, Kjaeldgaard A, Ek M. Cervical amputation versus vaginal hysterectomy; a population-based register study. International Urogynecology Journal. 2017 Feb;28(2):257-266.
https://doi.org/10.1007/s00192-016-3119-0

III. Bergman I, Westergren Söderberg M, Lundqvist A, Ek M. Associasions between childbirth and urinary incontinence after midurethral sling surgery. Obstetrics and Gynecology. 2018 Feb;131(2):297-303.
https://doi.org/10.1097/AOG.0000000000002445

IV. Bergman I, Westergren Söderberg M, Ek M. Perineorrhaphy compared with pelvic floor muscle therapy in women with late consequences of a poorly healed second-degree perineal tear: a randomized controlled trial. Obstetrics and Gynecology. 2020 Feb 9.
https://doi.org/10.1097/AOG.0000000000003653