List of Abbreviations
OAB - overactive bladder
CTD - connective tissue dysplasia
GIT - gastrointestinal tract
UDS - urodynamic study
SUI - stress urinary incontinence
POP - pelvic organ prolapse
Ultrasound — ultrasound examination
ICS - International Continence Society
POP-Q - Pelvic Organ Prolapse Quantification
Terms and Definitions
Pelvic organ prolapse (POP) is a pathological process characterized by the descent of the pelvic floor and pelvic organs, isolated or combined [1-4].
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Pelvic organ prolapse (POP) is a pathological process characterized by the descent of the pelvic floor and pelvic organs, isolated or combined [1-4]. Genital prolapse should be considered a type of pelvic floor hernia occurring in the area of the vaginal introitus. For isolated descent of the anterior vaginal wall, it is appropriate to use the term "cystocele"; for descent of the posterior wall, "rectocele" [5].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The etiology of anatomical and functional disorders of the pelvic organs, specifically POP, is multifactorial [6].
Risk factors for POP include: familial POP [5], vaginal deliveries, connective tissue dysplasia, overweight/obesity, smoking, increased intra-abdominal pressure, cough, and estrogen deficiency [7-11].
The risk of developing POP increases with complicated pregnancy and labor, including surgical delivery assistance, rapid labor, perineal tears, and macrosomia [12-15].
1.3 Epidemiology of the Disease or Condition
According to global data, from 2.9 to 53% of women report various manifestations of POP [16-19]. Up to 47% of patients with pelvic organ prolapse are women of working age [20].
The disease often manifests as early as reproductive age and has a progressive character.
According to the Women's Health Initiative Study, among 16,616 perimenopausal women, the detection rate was 14.2% for uterine prolapse, 34.3% for cystocele, and 18.6% for rectocele [21]. In most cases, pelvic organ prolapse (POP) is virtually asymptomatic, indicating its even higher prevalence in the population [22, 23].
1.4 Features of Coding the Disease or Condition
N81.0 Female urethrocele
N81.1 Cystocele
N81.2 Incomplete uterovaginal prolapse
N81.3 Complete uterovaginal prolapse
N81.4 Uterovaginal prolapse, unspecified
N81.5 Vaginal enterocele
N81.6 Rectocele
N81.8 Other forms of female genital prolapse
N81.9 Female genital prolapse, unspecified
N99.3 Postprolapse of vaginal vault after hysterectomy
1.5 Classification of the disease or condition
To assess the severity of POP, specifically the position of the pelvic floor during maximum straining (Valsalva maneuver), numerous classifications have been proposed.
M.S. Malinovsky classification [24], according to which:
- grade 1 prolapse: the vaginal walls reach the introitus, uterine descent is observed (the external os of the cervix is below the interspinal plane);
- grade 2 prolapse (incomplete uterine prolapse): the cervix extends beyond the genital hiatus, while the uterine body remains above it;
- grade 3 prolapse (complete prolapse): the entire uterus is located below the genital hiatus (within the hernia sac).
Currently, the Baden-Walker system and the Pelvic Organ Prolapse Quantification (POP-Q) system are used to classify POP. In 1992, Baden and Walker proposed a semiquantitative system for assessing the degree of pelvic floor insufficiency. This classification is based on determining the distance between the prolapsed organ and the hymen during physiological straining. The unit of measurement is equal to half the distance from the normally positioned organ to the hymen (the "halfway" system): grade 1, descent halfway to the hymen; grade 2, to the hymen; grade 3, halfway past the hymen; grade 4, complete prolapse.
However, the POP-Q classification [25] has become the most widely accepted and is recommended for daily clinical practice by leading national and international urogynecological organizations, including the American Urogynecological Society, the Society of Gynecologic Surgeons, and the International Continence Society (ICS) [26, 27]. This classification allows for a quantitative assessment of vaginal wall descent by measuring 9 parameters in the sagittal plane (see Figure 1, Appendix G1).
Measurements are taken using a special instrument with a centimeter scale along the midsagittal line with the patient in the supine position or at an angle during maximum POP manifestation (Valsalva maneuver). The level of the hymen—the hymenal ring—serves as the plane that can be precisely visually identified and relative to which the points and parameters of the system are described. The anatomical position of the 6 determined points (Aa, Ba, Ap, Bp, C, D) is measured in positive or negative values relative to the level of the hymenal ring. The remaining 3 parameters (TVL, GH, PB) are measured in absolute values. The location of the following points is noted on the anterior vaginal wall.
Point Aa, located along the midline 3 cm proximal to the external urethral meatus, corresponding to the location of the urethrovesical segment. Normally, it corresponds to -3 cm, and with marked descent, it reaches +3 cm.
Point Ba, representing the most distal position of any part of the anterior vaginal wall from the cervix or vaginal cuff (Point C) to Point Aa. Normally, Point Ba is located at a distance of -3 cm, and in complete pelvic organ prolapse, it has a positive value equal to the total vaginal length.
Point C, representing the most distal part of the cervix or vaginal cuff. The location of the following points is noted on the posterior vaginal wall:
Point Ap, located along the midline 3 cm proximal to the hymenal ring.
Point Bp, analogous to Point Ap, corresponding to the most distal point of any part of the posterior vaginal wall from the cervix. The parameter TVL describes the total vaginal length, GH describes the genital hiatus length, and PB describes the perineal body length.
POP-Q staging is performed based on the most distal part of the vaginal wall (the dominant component of POP):
Stage 1: descent of the distal component is more than 1 cm above the hymenal ring;
Stage 2: descent is less than 1 cm above and no more than 1 cm below the hymenal ring;
Stage 3: descent is greater than 1 cm below the hymenal ring, but less than 2 cm less than the total vaginal length;
Stage 4: complete eversion of the vagina, with the leading prolapse point at a distance of > TVL - 2.
All information in the POP-Q classification is encoded by 9 parameters and the POP stage, allowing for a standardized registry of examination data for patients with POP.
1.6 Clinical presentation of the disease or condition
The most common symptoms of POP are [81]:
local vaginal symptoms: vaginal discomfort, sensation of a foreign body in the perineal region, passage of air from the vagina during intercourse or physical activity (queefing);
urinary tract symptoms: storage symptoms (urinary incontinence, pollakiuria), voiding symptoms (dysuria, hesitancy, prolonged micturition, need for manual assistance to void, need to change body position to initiate or complete urination), post-micturition symptoms (urinary dribbling, sensation of incomplete bladder emptying);
gastrointestinal symptoms: constipation, fecal urgency, flatal or fecal incontinence, sensation of incomplete bowel evacuation, need for manual assistance (digital pressure on the perineum or posterior vaginal wall) to defecate;
sexual dysfunction (dyspareunia, loss of vaginal sensitivity).
In some cases, the condition may be completely asymptomatic.
The severity and predominance of specific symptoms of this pathology mainly depend on the type and stage of prolapse. It has been proven that women with POP symptoms are diagnosed with a greater degree of pelvic organ descent compared to those with asymptomatic disease [29], which demonstrates a strong correlation between the stage and the clinical presentation of this condition [30].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostic criteria:
The diagnosis of POP is established based on complaints, medical history, and physical examination. At the same time, it is necessary to conduct a detailed history taking, identify potential risk factors for this pathology, and assess the impact of symptoms on quality of life.
2.1 Complaints and Anamnesis
See section "Clinical Presentation of the Disease".
2.2 Physical Examination
It is recommended to perform a physical examination in all patients with pelvic organ prolapse [27, 31].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comments: The general examination should primarily aim to identify markers of connective tissue dysplasia (CTD): increased skin elasticity, joint hypermobility, tendency to bruise, presence of lower extremity varicose veins, etc. The severity of POP is directly dependent on the severity of extragenital CTD manifestations. The more pronounced the CTD manifestations, the earlier and more severe the onset of POP [32].
It is recommended to perform a visual inspection of the external genitalia, speculum examination of the cervix and vaginal walls, and a bimanual pelvic examination in all patients to establish the diagnosis [11, 31].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comments: To visualize the pelvic floor defect, sterile Sims vaginal specula are used, inserted sequentially into the vaginal fornices [27]. At the same time, it is necessary to pay attention to:
the shape and location of the external urethral meatus, the degree of mobility of its mucosa, and the presence of possible pathology (urethral mucosal prolapse, urethral polyp, destruction);
the condition of the vaginal mucosa, the presence of scars and deformations, and the presence and character of vaginal discharge;
the condition of the anterior and posterior vaginal walls at rest and during strain, and the degree of descent;
the condition of the cervix, its shape, location, and mobility, or in the absence of the cervix, the location of the vaginal fornices;
the location of the uterine body, its shape, and mobility;
the condition of the pelvic floor muscles and the presence of defects;
the condition of the perineal body (tendineum), its dimensions, and mobility.
Depending on the examination results, specific defects identified, and the stage of POP, the tactics and scope of surgical treatment are determined.
It is recommended to perform a cough test and straining test (Valsalva maneuver) without POP reduction in patients with POP for the objective diagnosis of stress urinary incontinence and, potentially, fecal incontinence [31, 33].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
Comments: It should be noted that the cough test is performed when the patient has an urge to urinate and has at least 300 ml of urine in the bladder.
It is recommended that patients with pelvic organ prolapse (POP) be assessed for muscle strength and the effectiveness of pelvic floor muscle contractions [31, 34].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: To do this, the patient is asked to squeeze the levator ani muscles around the examiner's finger. The condition of the perineal skin and vaginal mucosa is also assessed, as vaginal epithelial atrophy resulting from estrogen deficiency is generally combined with atrophy of the urethra and surrounding tissues. Next, the diameter of the vaginal introitus and the length of the perineal body are assessed (soft tissue tears are more commonly noted in women with a short perineum). A bimanual examination is performed to assess the size and mobility of the uterine body and appendages.
At the end of the examination, a transrectal digital examination is performed to assess tone and check for the presence of an enterocele or rectocele.
2.3 Laboratory Diagnostics
It is recommended that patients with POP undergo a general (clinical) urinalysis and microbiological (culture) urine test for aerobic and facultative anaerobic opportunistic microorganisms if urinary tract symptoms are present [15, 31].
GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).
It is recommended that patients with POP undergo a cervical cytology smear test to rule out cervical pathology and determine the extent of surgical treatment [35].
GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).
2.4 Instrumental Diagnostics
It is recommended that patients with POP undergo a comprehensive pelvic ultrasound examination (transvaginal and transabdominal) [5, 36, 37].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
Comments: Currently, numerous imaging methods for the pelvic floor in women suffering from POP have been proposed, allowing for a detailed study of anatomy: pelvic magnetic resonance imaging [15], radiological methods [22, 31], and ultrasound. Performing these may be indicated for patients with POP in complex cases, particularly in cases of disease recurrence [5].
Patients with POP complaining of dysuric disorders are recommended to undergo ultrasound examination of the urinary tract and kidneys, and measurement of urinary flow rate (uroflowmetry) with determination of post-void residual urine volume (using an abdominal ultrasound transducer) to rule out concomitant pathology [22, 31].
GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).
Patients with POP who present with gastrointestinal symptoms are recommended to undergo an evaluation of rectal evacuation function (defecography), anorectal manometry, and transrectal ultrasound of the rectum (to detect anal sphincter defects in fecal incontinence) [31].
GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).
2.5 Other Procedures
It is recommended that patients with POP presenting with complaints of urinary incontinence or difficulty urinating consult a urologist to rule out lower urinary tract pathologies [31].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
It is recommended that patients with POP undergo invasive urodynamic testing if they present with complaints of urgency urinary incontinence or difficulty urinating [31, 38].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: This testing method provides additional information on the functional state of the detrusor and urethral sphincter, confirming detrusor overactivity in patients with overactive bladder (OAB) symptoms and stress urinary incontinence when these complaints are present. Currently, there is no consensus on the appropriateness of urodynamic testing in the presence of severe POP without prior correction of the latter. In contemporary foreign literature, the significance and necessity of performing urodynamic testing with prolapse reduction to assess for occult stress urinary incontinence and potential detrusor overactivity has been repeatedly raised [39-42], particularly in women with severe cystocele. At the same time, one must account for the possibility of overcorrection of POP leading to urethral compression due to reduction, which acts as a testing artifact.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
To determine the management strategy (conservative or surgical treatment), the obstetrician-gynecologist should consider the following points:
1. informed consent of the patient;
2. patient's condition and age, disease duration, necessity of preserving reproductive and sexual function;
3. complaints, severity of the clinical picture, and its impact on quality of life;
4. availability of conditions for surgical treatment (absence of contraindications, extragenital pathology, and concurrent gynecological diseases requiring simultaneous treatment).
3.1 Conservative Treatment
It is recommended that all patients with POP be offered lifestyle modifications, including weight loss, restriction of heavy lifting, and the prevention and treatment of constipation [43, 44].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: Weight loss, reduction of physical activity associated with increased intra-abdominal pressure, and the treatment of constipation objectively help reduce the severity of POP symptoms by decreasing the impact of elevated intra-abdominal pressure on the pelvic floor [45].
It is recommended that all patients with POP and vaginal mucosal atrophy use local estrogen preparations to improve trophism and blood circulation, and enhance the reparative and regenerative properties of the vaginal mucosa [44, 46].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: Low-dose local (vaginal) estrogen therapy is preferred for peri- and postmenopausal women complaining of vaginal dryness, dyspareunia, or discomfort during sexual intercourse associated with this condition [47, 48].
Long-term follow-up (6–24 months) demonstrates no systemic effect of local estrogens on the endometrium.
At the start of treatment, medications are administered daily at a therapeutic dose for 2–4 weeks, and as improvement occurs, reduced to twice a week on a long-term basis.
It is recommended that all patients with POP stage 1 or 2 be prescribed a pelvic floor muscle training program [31, 49-51].
LeR ALoE 1Level of Evidence Recommendation A (Level of Evidence - 1).
Comments: It is possible to use the set of exercises proposed by Kegel [52] to slow down the progression of pelvic floor muscle dysfunction [53]. Kegel exercises can be supplemented with vaginal trainer sets, which are weights of various masses for prolonged retention in the vagina (vaginal cones and weighted balls), as well as various biofeedback (BFB) therapy modalities.
According to a 2011 Cochrane systematic review, pelvic floor muscle training has a positive effect on the severity of POP symptoms (including lower urinary tract symptoms) and reduces the stage of POP by 17% compared to active surveillance [54]. Electromyostimulators may also be used to restore pelvic floor muscle tone.
It is recommended to use pessaries as a conservative treatment option (as an alternative to surgery) in patients with POP [31, 56-59].
Level of Evidence CGrade of Recommendation 2Level of Evidence C (Reliability of Evidence Level - 2).
Comments:
Indications for pessary use:
Preparation for surgical treatment
Inability to perform surgical treatment
The patient must be informed about the possibility of POP progression and the potential need for surgical intervention.
There are numerous pessaries that differ in shape and size [57]. Two classes of pessaries are distinguished: supportive and space-filling.
According to studies, applying the corresponding type of pessary is most appropriate for each stage of prolapse.
Criteria for the efficacy of pessary fitting and wear:
the largest of the fitted pessaries causes no discomfort in an upright posture or during physical activity (coughing, walking, sneezing, straining);
the pessary can be inserted and removed from the vagina without obstruction;
the pessary does not cause obstructive urination or defecation;
the pessary does not provoke occult urinary incontinence. The primary reasons for discontinuing pessary use, identified in 40% of cases, include [61]: discomfort during wear, development of urinary incontinence, pain syndrome, vaginal discharge, complications (colpitis, pressure sores, fistulas, ulcers), as well as the patient's choice in favor of surgery. Silicone pessaries are preferable to latex ones because they are more flexible and less porous, which prevents bacterial growth and mucosal trauma [81].
3.2 Surgical Treatment
It is recommended that patients with anterior vaginal wall prolapse undergo surgical treatment in the form of anterior colporrhaphy [31, 62-65].
Level of Evidence CGrade of Recommendation 2Level of Evidence C (Reliability of Evidence Level - 2).
Comments: The use of synthetic mesh or biological grafts in transvaginal repair of anterior vaginal prolapse offers minimal benefits compared to native tissue repair [66]. Complications of mesh implants include obstructive voiding, retroperitoneal hematomas, and vaginal mucosal erosion [67].
It is recommended to perform surgical treatment in the scope of colpoperineorrhaphy and levatoroplasty for female patients with posterior vaginal wall prolapse [31, 62-65, 80].
Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)
Comments: The use of synthetic mesh or biological grafts in transvaginal repair of posterior vaginal wall prolapse does not improve outcomes in primary patients [68, 69].
It is recommended to perform surgical treatment in the scope of total vaginal hysterectomy (with or without adnexa), anterior colporrhaphy, colpoperineorrhaphy, and levatoroplasty for patients with uterine and vaginal wall prolapse [31, 70, 71].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
Comments: In women with uterovaginal prolapse, vaginal hysterectomy followed by correction of the vaginal vaults is the operation of choice in 82% of cases. One of the common methods of vaginal fixation to prevent or eliminate post-hysterectomy vaginal vault prolapse and enterocele is McCall culdoplasty (laparoscopic McCall culdoplasty), Halban, or Moschcowitz procedure. Here, the complex of uterosacral [61] and cardinal ligaments is sutured to the posterior peritoneal surface, achieving closure of the cul-de-sac.
It is recommended to perform surgical interventions aimed at partial vaginal obliteration (LeFort-Neugebauer median colporrhaphy, colpocleisis (Labhardt operation)) for patients with pelvic organ prolapse (POP) [31].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
Comments: Median colporrhaphy, as the least invasive and most effective technique, is the operation of choice for patients over 70 years of age with severe forms of pelvic organ prolapse who are not sexually active. Following median colporrhaphy, subsequent examination and diagnosis of cervical and vaginal diseases are no longer possible.
It is recommended to perform the Manchester operation in cases of cervical elongation and vaginal wall prolapse [4, 72].
LoR AGoE 1Level of Recommendation A (Level of Evidence - 1)
Comments: Amputation of the elongated and prolapsed cervix is performed, along with the transection of the cardinal ligaments and their fixation to the anterior surface of the cervix.
It is recommended to perform various types of uterine/cervical fixation—sacrospinous fixation and sacral colpopexy (sacral hysteropexy/promontopexy)—in the presence of apical prolapse [4, 66, 72, 73].
GCR BLEL 2Grade of Recommendation B (Level of Evidence - 2)
Comments: One of the methods to treat uterovaginal prolapse is sacrospinous fixation of the uterus or vaginal cuff [66, 73]. The surgery is performed via a vaginal approach, allowing simultaneous correction of concomitant pathology (rectocele, stress urinary incontinence). The technique is indicated for vaginal vault prolapse and enterocele. The essence of the surgery is to correct the prolapse by fixing the vaginal apex/cervix to the sacrospinous ligaments, pulling it upward and laterally toward the pelvic wall.
During sacrocolpopexy [74, 75] (with or without supracervical hysterectomy) via laparotomy or laparoscopy, the distal 2/3 of the posterior vaginal wall/uterine body (if preserved) is fixed to the anterior longitudinal ligament of the sacrum using a mesh implant, with additional mesh fixation to the anterior vaginal wall and possible plication of the uterosacral ligaments. The technique is indicated for apical prolapse and enterocele. According to Cochrane Collaboration data [4], the efficacy of sacrocolpopexy surpasses various vaginal approaches, including sacrospinous fixation, uterosacral colpopexy, and pelvic floor repair using mesh implants.
Routine intraoperative cystoscopy during POP surgery is recommended when the surgical procedure performed carries a significant risk of bladder or ureteral injury. These procedures include uterosacral ligament vaginal vault suspension, sacrocolpopexy, and anterior colporrhaphy [76, 77].
It is recommended to perform laparoscopic or robot-assisted sacral colpopexy/hysteropexy (promontofixation) in the presence of apical prolapse [72, 74, 75, 80].
GPP BLE 2Grade of Recommendations B (Level of Evidence 2).
Comments: Laparoscopic or robot-assisted sacral colpopexy or hysteropexy, being a minimally invasive method, has advantages over open surgery regarding postoperative pain and recovery time.
It is recommended to perform simultaneous correction of POP and stress urinary incontinence in patients presenting with both sets of symptoms to increase treatment efficacy, although patients should be warned about a higher risk of complications with combined treatment compared to staged correction [78, 79].
Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)
For patients suffering from POP who do not complain of urinary incontinence (UI), it is not recommended to perform prophylactic surgeries to eliminate potential UI during POP correction [80].
Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)
For patients suffering from POP who are at high risk of prolapse recurrence (repeat surgeries, complete pelvic organ prolapse, genetically predisposed POP), it is recommended to perform surgeries using mesh implants [80].
Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)
Comments: the use of mesh implants can reduce the risk of prolapse recurrence in repeat surgeries, stage 3 and 4 prolapse, and in patients with Ehlers-Danlos syndrome. At the same time, the use of synthetic implants can lead to complications such as mesh erosion into the vagina, dyspareunia, and pelvic pain. These surgeries are preferably performed in specialized clinics.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
There is no specific rehabilitation.
It is recommended to consult a physical therapist to determine a rehabilitation program after identifying the cause of abnormal uterine bleeding (AUB) [35].
CGR CLEL 5Level of Clinical Recommendation C (Level of Evidence - 5)
5. Prevention and Dispensary Observation
Specific prevention for POP has not been developed. Main preventive measures:
Careful management of labor (avoiding prolonged traumatic labor).
Treatment of extragenital pathology (conditions leading to increased intra-abdominal pressure).
Layer-by-layer anatomical restoration of the perineum after delivery in the presence of tears, episiotomy, or perineotomy.
Hormonal therapy for hypoestrogenic states.
Performance of a set of exercises to strengthen the pelvic floor muscles.
6. Organization of Medical Care
Indications for scheduled hospitalization in a medical organization:
1) Surgical treatment of pelvic organ prolapse.
Indications for discharge from the medical organization:
1) Clinical recovery
7. Additional Information
Not applicable.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Score performance |
|---|---|---|
1. | Pelvic ultrasound performed comprehensive (transvaginal and transabdominal) | Yes/No |
2. | Visual inspection of the external genitalia, examination of the cervix and vaginal walls using specula, and bimanual vaginal examination were performed | Yes/No |
3. | Adequate surgical treatment performed in accordance with indications | Yes/No |
References
Show references
Culligan PJ (2012) Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 119:852-860.
Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. (2010) An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol. .
Doaee M. et al. Management of pelvic organ prolapse and quality of life: a systematic review and meta-analysis // International Urogynecology Journal. - 2014. - Vol. 25, no. 2. - P. 153-163. .
Maher C. et al. Surgical management of pelvic organ prolapse in women: a short version Cochrane review // Neurourology and Urodynamics: Official Journal of the International Continence Society. - 2008. - Vol. 27, no. 1. - P. 3-12. .
Ramage L. et al. Magnetic resonance defecography versus clinical examination and fluoroscopy: a systematic review and meta-analysis // Techniques in Coloproctology. - 2017. - Vol. 21, no. 12. - P. 915-927. .
Bump R.C. Norton P.A. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25(4):723-46. .
Lince S. L. et al. A systematic review of clinical studies on hereditary factors in pelvic organ prolapse
// International Urogynecology Journal. - 2012. - Vol. 23, no. 10. - P. 1327-1336. .
Feiner B, Fares F, Azam N, Auslender R, David M, Abramov Y (2009) Does COLIA1 SP1-binding site polymorphism predispose women to pelvic organ prolapse? Int Urogynecol J Pelvic Floor Dysfunct 20(9):1061-1065. .
Kluivers KB, Dijkstra JR, Hendriks JC, Lince SL, Vierhout ME, van Kempen LC (2009) COL3A1 2209G > A is a predictor of pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 20(9):1113-1118. .
Zenebe C. B. et al. The effect of women's body mass index on pelvic organ prolapse: a systematic review and meta analysis // Reproductive Health. - 2021. - Vol. 18, no. 1. - P. 1-9. .
Madhu C. K., Hashim H. Surgery for pelvic organ prolapse // European Urology Supplements. - 2018. - Vol. 17, no. 3. - P. 119-125. .
Iglesia C., Smithling K. R. Pelvic organ prolapse // American Family Physician. - 2017. - Vol. 96, no. 3. - P. 179-185. .
Handa VL, Blomquist JL, Knoepp LR, Huskey KA, McDermott KC, Munoz A. Pelvic floor disorders 5- 10 years after vaginal or cesarean childbirth. Obstet Gynecol. 2011;118(4):777-784. .
Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2105;26(11):1559-1573. .
Lin F. C. et al. Dynamic pelvic magnetic resonance imaging evaluation of pelvic organ prolapse compared to physical examination findings // Urology. - 2018. - Vol. 119. - P. 49
Ward R. M. et al. Genetic epidemiology of pelvic organ prolapse: a systematic review // American Journal of Obstetrics and Gynecology. - 2014. - Vol. 211, no. 4. - P. 326-335. .
Krasnopolsky V.I., Buyanova S.N., Petrova V.D. Combined treatment of patients with prolapse of internal genital organs and urinary incontinence using anti-stress technologies: A manual for physicians. - M., 2003. - 41 p. .
Garshasbi A., Faghih-Zadeh S., Falah N. The status of pelvic supporting organs in a population of iranian women 18-68 years of age and possible related factors. Arch Iran Med 2006;9(2):124-8. .
Nygaard I., Barber M.D., Burgio K.L. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300(11):1311-6. .
Kulakov V.I., Chernukha E.A., Gus A.I. et al. Assessment of the pelvic floor state after vaginal delivery. - Akusherstvo i Ginekologiya. - 2004. - P. 26-30. .
Hendrix S.L., Clark A., Nygaard I. et al. Pelvic organ prolapse in the Women»s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186(6):1160-6. .
Thakar R., Stanton S. Management of genital prolapse. BMJ 2002;324(7348): 1258-62. .
Samuelsson E.C., Victor F.T., Tibblin G., Svardsudd K.F. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180(2):299-305. .
Gorbenko O.Yu. et al. Etiology, pathogenesis, classification, diagnostics and surgical treatment of internal genital prolapse //Voprosy ginekologii, akusherstva i perinatologii. - 2008. - Vol. 7. - No. 6. - P. 68-78. .
Madhu C. et al. How to use the pelvic organ prolapse quantification (POP-Q) system? //Neurourology and urodynamics. - 2018. - Vol. 37. - No. S6. - P. S39-S43. .
Bump R.C., Mattiasson A., Bo K. et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175(1):10-7. .
American College of Obstetricians and Gynecologists et al. Pelvic organ prolapse //Female Pelvic Medicine & Reconstructive Surgery. - 2019. - Vol. 25. - No. 6. - P. 397-408. .
Veit-Rubin N. et al. Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis //International Urogynecology Journal. - 2016. - Vol. 27. - No. 10. - P. 1469-1478. .
Digesu G.A., Chaliha C., Salvatore S. The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 2005;112(7):971-6. .
Swift S.E., Tate S.B., Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003;189:372-7.
Gvozdev M.Yu., Tupikina N.V., Kasyan G.R., Pushkar D.Yu. Pelvic organ prolapse in the clinical practice of a urologist: guidelines No. 3 //Metodicheskie rekomendatsii. - 2016. - No. 3. - P. 58. .
Buyanova S.N., Titchenko L.I., Yakovleva N.I. et al. Phenotypic complex of connective tissue dysplasia in women. Klinicheskaya Meditsina 2003;8:42-8. .
Dietz H.P. et al. Pelvic organ descent in young nulligravid women //American Journal of Obstetrics and Gynecology. - 2004. - Vol. 191. - No. 1. - P. 95-99. .
Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurouro. .
Savelyeva G.M. et al. National Guidelines //Akusherstvo - Moscow: Geotar-Media. - 2015. .
Dietz H.P. Ultrasound in the assessment of pelvic organ prolapse //Best Practice & Research Clinical Obstetrics & Gynaecology. - 2019. - Vol. 54. - P. 12-30. .
Orno A. K., Dietz H. P. Levator co-activation is a significant confounder of pelvic organ descent on Valsalva maneuver //Ultrasound in Obstetrics and Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. .
Amir B. et al. SOGC Committee opinion on urodynamics testing //Journal of Obstetrics and Gynaecology Canada. - 2008. - Vol. 30. - No. 8. - P. 717-721. .
Collins C.W., Winters J.C. AUA/SUFU adult urodynamics guideline: a clinical review. Urol Clin North Am 2014;41(3):353-62. .
Ghoniem G.M., Walters F., Lewis V. The value of the vaginal pack test in large cystoceles. J Urol 1994;152:931.
Marinkovic S.P., Stanton S.L. Incontinence and voiding difficulties associated with prolapse. J Urol 2004;171:1021-8. .
Versi E., Lyell D.J., Griffiths D.J. Videourodynamic diagnosis of occult genuine stress incontinence in patients with anterior vaginal wall relaxation. J Soc Gynecol Investig 1998;5:327-30. .
Li C., Gong Y., Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis //International Urogynecology Journal. - 2016. - Vol. 27. - No. 7. - P. 981-992. .
NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management: © NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management. BJU Int. 2019 May;123(5):777-803. doi: 10.1111/bju.14763. PMID: 31008559. .
Giri A. et al. Obesity and pelvic organ prolapse: a systematic review and meta-analysis of observational studies //American Journal of Obstetrics and Gynecology. - 2017. - Vol. 217. - No. 1. - P. 11-26. .
L. Cardozo, G. Bachmann, D. McClish, D. Fonda, and L. Birgerson, “Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital Therapy Committee.,” Obstet. Gynecol., vol. 92, no. 4 Pt 2, pp. 722-727, Oct. 1998, doi: 10.1016/s0029-7844(98)00175-6.
C. Rueda, A. M. Osorio, A. C. Avellaneda, C. E. Pinzon, and O. I. Restrepo, “The efficacy and safety of estriol to treat vulvovaginal atrophy in postmenopausal women: a systematic literature review.,” Climacteric, vol. 20, no. 4, pp. 321-330, Aug. 2017, doi: 10.1080/13697137.2017.1329291.
Y. S. V. Yureneva, E. E. I. Ermakova, and G. A. V. Glazunova, “Genitourinary syndrome of menopause in peri- and postmenopausal patients: Diagnosis and therapy (short clinical guideline),” Akush. Ginekol. (Sofiia)., vol. 5_2016, pp. 138-144, May 2016, doi: 10.18565/aig.2016.5.138-144.
Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women [systematic review]. Cochrane Database of Systematic Reviews 2011; issue 12, art. no.: CD003882. .
Braekken IH, Majida M, Engh ME, et al. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010;203:170.e1-170. .
Dumoulin C, Hay-Smith EJ, Mac Habee-Seguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;(5): CD005654. .
Huang YC, Chang KV. Kegel Exercises. 2020 May 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. .
Park SH, Kang CB, Jang SY, Kim BY. [Effect of Kegel exercise to prevent urinary and fecal incontinence in antenatal and postnatal women: systematic review]. J Korean Acad Nurs. 2013 Jun;43(3):420-30. .
Hagen S., Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2011;(12):CD003882. .
Vizintin Z, Lukac M, Kazic M, Tettamanti M. Erbium laser in gynecology. Climacteric. 2015;18 Suppl 1:4-8. .
Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal pessaries: case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1173-1178. .
Robert M, Schulz JA, Harvey MA, et al. Urogynaecology Committee. Technical update on pessary use. J Obstet Gynaecol Can 2013;35:664-674. .
Clemons JL, Aguilar VC, Tillinghast TA, et al. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet Gynecol 2004;190:1025-1029. .
Cundiff GW, Amundsen CL, Bent AE, et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol 2007;196:405.e1-405.e8. .
Pott-Grinstein E., Newcomer J.R. Gynecolgist»s patterns of prescribing pessaries. J Reprod Med 2001;46:205-8. .
A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365-1373 discussion 1373-1374. .
Paraiso MF, Barber MD, Muir TW, et al. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006;195:1762- 1771. .
Cundiff GW, Weidner AC, Visco AG, et al. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol 1998;179:1451-1456 discussion 1456-1457. .
Chen L, Ashton-Miller JA, Hsu Y, et al. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol 2006;108:324-332. .
Chmielewski L, Walters MD, Weber AM, et al. Reanalysis of a randomized trial of 3 techniques of anterior colporrhaphy using clinically relevant definitions of success. Am J Obstet Gynecol 2011;205(69):e1-e8. .
Sung VW, Rardin CR, Raker CA, et al. Porcine subintestinal submucosal graft augmentation for rectocele repair: a randomized controlled trial. Obstet Gynecol 2012;119:125-133. .
Mangir N, Roman S, Chapple CR, MacNeil S. Complications related to use of mesh implants in surgical treatment of stress urinary incontinence and pelvic organ prolapse: infection or inflammation? World J Urol. 2020. .
Karram M, Maher C. Surgery for posterior vaginal wall prolapse. Int Urogynecol J 2013;24:1835- 1841. .
Maher C, Feiner B, Baessler K, et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. Cochrane Database Syst Rev 2016; issue 2, art. no.: CD012079. .
Barber MD, Brubaker L, Burgio KL, et al. Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vagin. .
Johnson N. et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials //BMJ. - 2005. - Vol. 330. - No. 7506. - P. 1478. .
Serati M. et al. Robot-assisted sacrocolpopexy for pelvic organ prolapse: a systematic review and meta-analysis of comparative studies //European Urology. - 2014. - Vol. 66. - No. 2. - P. 303-318. .
Petri E, Ashok K. Sacrospinous vaginal fixation—current status. Acta Obstet Gynecol Scand 2011;90:429-436. .
Siddiqui NY, Grimes CL, Casiano ER, et al. Society of Gynecologic Surgeons Systematic Review Group. Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis [systematic review]. Obstet Gynecol 2015;125:44-55.
Hudson CO, Northington GM, Lyles RH, et al. Outcomes of robotic sacrocolpopexy: a systematic review and meta-analysis. Female Pelvic Med Reconstr Surg 2014;20:252-260 (Systematic review). .
Brubaker L, Cundiff G, Fine P, et al. A randomized trial of colpopexy and urinary reduction efforts (CARE): design and methods. Control Clin Trials 2003;24:629-642. .
Barber MD, Brubaker L, Menefee S, et al. Operations and pelvic muscle training in the management of apical support loss (OPTIMAL) trial: design and methods. Contemp Clin Trials 2009;30:178-189.
“Maher, C., et al. Laparoscopic colposuspension or tension-free vaginal tape for recurrent stress urinary incontinence and/or urethral sphincter deficiency-a randomised controlled trial. Neurourol Urodyn., 2004. 23: 433.”
“Baessler K. et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence //Cochrane Database of Systematic Reviews. - 2018. - №. 8.”
“Maher, C., et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev, 2013: CD004014. https://www.ncbi.nlm.nih.gov/pubmed/23633316.”
Pizzoferrato A. C. et al. Management of female pelvic organ prolapse—Summary of the 2021 HAS guidelines //Journal of Gynecology Obstetrics and Human Reproduction. – 2023
Appendix A1. Working Group Composition
Leyla V. Adamyan - Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Deputy Director of the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Honored Worker of Science of Russia, Head of the Department of Reproductive Medicine and Surgery at the A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, Chief Obstetrician-Gynecologist of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, the Russian Association of Gynecological Endoscopists, the Russian Endometriosis Association, and the Russian Society of Obstetricians and Gynecologists.
Elena N. Andreeva - Doctor of Medical Sciences, Professor, Director of the Institute of Reproductive Medicine, Head of the Department of Endocrine Gynecology, Professor at the Department of Endocrinology of the National Medical Research Center for Endocrinology of the Russian Ministry of Health, Professor at the Department of Reproductive Medicine and Surgery of the A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, the Russian Association of Gynecological Endoscopists, the Russian Endometriosis Association, the Russian Society of Obstetricians and Gynecologists, and the International Society of Gynecological Endocrinology.
Natalya V. Artymuk - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova at Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Siberian Federal District, member of the Russian Society of Obstetricians and Gynecologists.
Tatyana E. Belokrinitskaya - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining at Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Far Eastern Federal District, member of the Russian Society of Obstetricians and Gynecologists.
Vitaly F. Bezhenar - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics, Gynecology and Neonatology at the First Pavlov State Medical University of St. Petersburg of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, the Russian Association of Gynecological Endoscopists, and the Russian Society of Obstetricians and Gynecologists.
Mikhail Yu. Gvozdev — Doctor of Medical Sciences, Professor at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry.
Gevorg R. Kasyan — Doctor of Medical Sciences, Professor at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry.
Stanislav I. Kiselev - Doctor of Medical Sciences, Professor at the Department of Reproductive Medicine and Surgery, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, recipient of the Russian Government Prize in Science and Technology, member of the Russian Association of Gynecological Endoscopists and the Russian Society of Obstetricians and Gynecologists.
Anna I. Malyshkina – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics, Gynecology and Medical Genetics, Ivanovo State Medical Academy of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, and the Russian Society of Obstetricians and Gynecologists.
Aleksandr A. Popov - Doctor of Medical Sciences, Professor, Head of the Department of Endoscopic Surgery, Moscow Regional Research Institute of Obstetrics and Gynecology, member of the Russian Association of Gynecological Endoscopists and the Russian Society of Obstetricians and Gynecologists.
Dmitry Yu. Pushkar - Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Head of the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry. Honored Worker of Science of Russia. Chief Urologist of the Russian Ministry of Health.
Oleg S. Filippov - Doctor of Medical Sciences, Deputy Director of the Department of Medical Care for Children and Obstetrics Services of the Russian Ministry of Health, Professor at the Department of Obstetrics and Gynecology, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.
Conflict of interest:
All members of the working group declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Obstetrician-gynecologists, general practitioners, family physicians
Students, residents, postgraduate students;
Faculty members, researchers.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference-method control or a systematic review of randomized clinical trials with meta-analysis |
2 | Individual studies with reference-method control or individual randomized clinical trials and systematic reviews of studies of any design, excluding randomized clinical trials, utilizing meta-analysis |
3 | Studies without sequential reference-method control or studies with a reference method not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design, excluding RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports, or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Levels of Evidence (LoE) rating scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic,
rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered criteria of effectiveness (outcomes) are important, all studies have high or satisfactory methodological quality, their conclusions regarding the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines have been developed taking into account the following regulatory legal and other documents:
1) Order of the Ministry of Health of the Russian Federation No. 1130n dated October 20, 2020 "On Approval of the Procedure for Providing Medical Care in the Field of 'Obstetrics and Gynecology (Excluding Assisted Reproductive Technologies)'" (as amended);
2) Savelyeva G.M. et al. National Guidelines //Akusherstvo - Moscow: Geotar-Media. - 2015.
3) Gvozdev M.Yu., Tupikina N.V., Kasyan G.R., Pushkar D.Yu. Pelvic organ prolapse in the clinical practice of a urologist: guidelines No. 3 //Metodicheskie rekomendatsii. - 2016. - No. 3. - P. 58.
Surgical options for pelvic organ prolapse (POP)
Surgery for anterior vaginal wall prolapse (in NMU: Surgery for anterior vaginal wall descent)
Anterior colporrhaphy
Laparoscopic Richardson procedure (repair of lateral pubocervical fascia defects)
Anterior colporrhaphy in patients at high risk of recurrence (repeat surgeries, multiple risk factors for recurrence)
Mesh implants
Concomitant surgery for concurrent urinary incontinence
Surgery for uterine prolapse or vaginal vault/cervical stump prolapse
Colpoperineorrhaphy and levatorplasty
Manchester operation
Sacrospinous fixation
Sacrocolpopexy
Laparotomic
Laparoscopic
Robot-assisted
Sacrohysteropexy
Laparotomic
Laparoscopic
Robot-assisted
Surgery for posterior vaginal wall prolapse (in NMU: Surgery for posterior vaginal wall descent)
Colpoperineorrhaphy and levatorplasty
Colpoperineorrhaphy in patients at high risk of recurrence (repeat surgeries, multiple risk factors for recurrence)
Mesh implants
Hysterectomy and obliterative vaginal surgeries
Vaginal hysterectomy
Laparotomic hysterectomy
Laparoscopic hysterectomy
Robot-assisted hysterectomy
Sacrocolpopexy with hysterectomy (with or without supracervical hysterectomy)
Laparotomic
Laparoscopic
Robot-assisted
Colpocleisis (Le Fort-Neugebauer median colporrhaphy, vagino-perineal colpocleisis (Labhardt operation))
Surgeries with simultaneous correction of urinary incontinence
Burch procedure with genital prolapse correction
Suburethral sling procedure with genital prolapse correction (Sling operations for urinary incontinence, retropubic tension-free vaginal tape urethropexy, transobturator tension-free vaginal tape urethropexy).
Figure 1. Schematic representation of parameters determined according to the POP-Q classification.
Figure 2. Types of pessaries.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Among gynecological diseases, about 30% account for pelvic organ prolapse. Every year this pathology progresses and becomes "younger", affecting not only elderly and parous women. Increasingly, it is observed even in young, nulliparous girls.
Normally, the bladder, uterus, vagina, and rectum are supported by ligaments and muscles. However, the natural position of the pelvic organs can be disrupted by traumatic childbirth, chronic diseases, genetic predispositions, decreased levels of female sex hormones, etc.
Pelvic organ prolapse is a condition in which the alignment of the uterus and vaginal walls is disrupted, characterized by the displacement of the genital organs toward the vaginal introitus or their protrusion beyond its borders.
Descent and prolapse of the uterus and other organs, or prolapse, is a progressive condition, but initially it develops quite slowly and without pronounced symptoms, which is why it is noticed at later stages.
The main complaints that bring a woman to an obstetrician-gynecologist with vaginal wall descent and uterine prolapse of varying severity include: discomfort when walking, frequent urination, urinary incontinence, and bowel dysfunction.
The most important rule in uterine and vaginal wall descent is not to endure the discomfort and to consult a doctor in a timely manner for treatment.
The doctor evaluates the structure of the vaginal walls and supporting apparatus, as well as the condition of the uterus and its cervix. General urinalysis and urine culture, swab culture, pelvic ultrasound, and cystoscopy (examination of the bladder from the inside using a special thin instrument) are performed.
Urinary incontinence is checked using the cough test. The woman sits in the gynecological chair with a full bladder and, on the doctor's command, begins to cough. If the resistance of the urethra is insufficient due to weakened ligaments and excessive mobility, involuntary urine leakage occurs. Sometimes the doctor simulates intra-abdominal pressure by pressing with a tupfer (a clamp with a twisted gauze sponge) on the fundus and posterior wall of the bladder.
In case of significant urination disorders, a urodynamic study (UDS) is performed. It assesses bladder function, tone, sensitivity, and the contractility of its walls. With significant bladder prolapse (grade 3 and higher), UDS is not performed because the natural anatomy is distorted.
Vaginal wall descent and uterine prolapse are treatable. Conservative treatment is possible for this pathology. It consists of special therapeutic exercises aimed at strengthening the pelvic floor muscles, and wearing a uterine ring (pessary), which is inserted into the vagina and keeps the cervix in the correct position. However, this is a temporary solution to the problem.
A radical and most effective method for treating vaginal wall descent and uterine prolapse is surgical intervention.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not required.