Pelvic Prolapse: What Does The Urologist Contribute?

Main Category: Urology / Nephrology
Also Included In: Women's Health / Gynecology
Article Date: 11 Aug 2008 - 0:00 PDT

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UroToday.com - Any urologist dealing with incontinence in the female patient must deal with pelvic organ prolapse. At a minimum the urologist must evaluate the patient for prolapse and make an appropriate referral to either another urologist or a gynecologist for management. Other degrees of involvement range from evaluation and complete treatment to evaluation and treatment of complications following prolapse surgery.

The role of the evaluation is to diagnose the extent of the problem and to implement management. During the history symptoms pertaining to prolapse should be sought. An assessment of bother should be elicited and a discussion should be had as to the treatment expectations. A variety of condition specific questionnaires are available to aid in quantifying symptoms and to assess quality of life and bother. A pelvic exam is performed to assess the health of the vaginal mucosa and to assess and grade any prolapse. A stress test is performed to assess for stress incontinence. The muscular integrity of the pelvic floor and the external anal sphincter should also be assessed. A post void residual is checked. Further evaluation with imaging and or urodynamics is performed on a case by case basis. Once the diagnosis of prolapse is made then a decision regarding treatment should be made. Conservative treatment with pelvic muscle exercises or a pessary may suffice. If surgical treatment is to performed the approach should be based on the patient's problems and her expectations for recovery and durability.

The most common complications of prolapse surgery that the urologist will deal with are; persistent or de novo incontinence, new onset of recurrent infections, hematuria, pain and obstruction. Incontinence should be worked up with a history and physical and urodynamics. If there is any concern for foreign material in the bladder or urethra a cystoscopy should be performed. Cystoscopy should also be performed in the case of persistent infections or hematuria. Urodynamics may be helpful to diagnose obstruction but it is reasonable to take down a sling or anterior repair without urodynamic proof of obstruction if there is a clear temporal relationship between the surgery and the onset of obstruction.

Mesh used in prolapse repairs should be removed in the case of pain, infection or misplacement. Mesh in the bladder can be removed endoscopically, laparoscopically or with an open technique. Mesh extrusion can be treated with partial removal and flap closure over the defect. When recurrent incontinence or prolapse occurs following a mesh repair one can consider placing additional mesh but if one procedure has failed it is reasonable to consider a different approach on a second repair. In summary the urologist who deals with incontinence must evaluate the patient for prolapse and treat or refer those patients who need surgical treatment. Urologists will also be asked to evaluate patients with complications following prolapse surgery as many of these patients may require a cystoscopy and or urodynamic testing. Treatment of complications following prolapse surgery will depend on the nature of the complication.

Presented by: E. Ann Gormley, MD, FACS, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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