Stress maneuvers should be performed at cysto-

an abdominal approach, as a recent randomized

metric capacity for the best chance of eliciting

trial demonstrated equivalent intermediate term

leakage. Urodynamics, using a vaginal pack,

outcomes and perioperative complication rates in

unmasked occult stress incontinence in 6–9% of

obese patients undergoing sacrocolpopexy when

patients with moderate to large cystoceles.38

compared to nonobese counterparts; however,the

However, prior studies have shown that stress

difference between these patients lies in exposure

incontinence may not be detected by urodynam-

and operative time.42

ics in up to 25% of women, and that postopera-

tive stress incontinence may be present as a new

Conservative Management

finding in 10% of patients after prolapse

repair.39,40 Ballert et al. determined the risk

of Prolapse

of surgical intervention for anti-incontinence

procedure in a patient with no preoperative

symptomatic or occult stress incontinence to be

The primary indications for conservative man-

8.3%; the risk of surgical intervention for a

agement of pelvic organ prolapse are patient

patient with clinical stress incontinence not

preference for nonsurgical management or

reproduced on urodynamic testing and not

comorbidities which make the patient a poor

receiving a concomitant anti-incontinence pro-

surgical candidate. Pessaries come in a variety

cedure at the time of prolapse repair was deter-

of shapes and sizes, and are often constructed of

mined to be approximately 30%.41 Additionally,

silicone or inert plastic. The pessary is fitted by

the CARE trial noted that a Burch performed at

trial and error and should be comfortable for

the time of sacrocolpopexy in patients without

the patient and retained during valsalva maneu-

urodynamically proven leakage significantly

vers and activity. Sexual activity is possible with

reduced postoperative stress incontinence when

the pessary in place, depending upon the type of

compared to patients receiving sacrocolpopexy

pessary used. Several short-term studies have

alone.37

demonstrated that 75–90% of women were sat-

isfied with a pessary as primary prolapse

Indications for Management

management.43,44 Factors associated with unsuc-

cessful pessary placement include hysterectomy,

increased parity,prior prolapse procedure,short

Pelvic organ prolapse can be treated in a variety

vaginal length (less than 6 cm), and wide vagi-

of different ways depending upon symptoms,

nal introitus (four fingerbreadths or more).44-46

patient preference, and surgical risk. Approxi-

In patients successfully fitted with a pessary,

mately, 50% of parous women have prolapse, but

significant improvements in prolapse symp-

most are low grade,asymptomatic or only mildly

toms, voiding symptoms, and incontinence were

symptomatic, and only roughly half of the

noted.44-46 However, in a study comparing

women with symptomatic prolapse desire treat-

patient-centered goals in patients with prolapse

ment.8,15 Pelvic organ prolapse may progress if

managed surgically versus nonsurgical manage-

left untreated; however, many studies document

ment,patients treated surgically reported higher

a dynamic state with a process involving both

satisfaction and goal attainment scores.47

progression and regression over time.2,4

Once properly fitted with a pessary,the patient

Women may base the decision for treatment on

must demonstrate removal and replacement of

severity of symptoms, lifestyle, child-bearing sta-

the pessary. Many patients opt to remove the

tus, sexual activity, or a variety of other reasons.

pessary each evening; however, the pessary may

Age,overall health status,and medical comorbidi-

stay in place for up to 6–8 weeks at a time. The

ties are other factors that the surgeon should bear

pessary should be cleansed with soap and water

in mind when assessing management options.

prior to reinsertion. The patient should be re-

Conservative options or obliterative procedures

examined periodically while using a pessary to

may be more realistic in a patient who is a border-

evaluate for vaginal abrasions or erosions. If

line or poor surgical candidate with significant

atrophic vaginitis is present, patients should be

symptoms to limit surgical stress and anesthetic

instructed to use intermittent vaginal estrogen

time, especially if sexual activity is of no concern.

cream to restore the vaginal mucosa. If ulcer-

Obesity should not deter from consideration of

ations or suspicious lesions are noted, a biopsy

474

Practical Urology: EssEntial PrinciPlEs and PracticE

should be obtained. Pessary use should be dis-

molecules which stabilize collagen, thereby pre-

continued for noncompliant patients, as, if

venting rapid breakdown by collagenases and

neglected, severe erosions into the bowel and

cytotoxic host immune responses. However,

bladder have been reported.

cross-linking can result in encapsulation of the

Additional conservative measures include

graft material as tissue in-growth is retarded

lifestyle modifications such as weight control

and the graft is not incorporated. Some of the

and activity limitations, and pelvic floor muscle

cross-linked products have pores constructed

exercises although no strong conclusive evi-

throughout the graft to aid in host-cell infiltra-

dence has been demonstrated in the literature to

tion and collagen deposition. Noncross-linked

support these measures in managing pelvic

grafts have better tissue incorporation, but the

organ prolapse. Obese and overweight women

rapid reaction may cause weakening of the graft.

do have increased risk of prolapse, noted to be

Xenografts and allografts are carefully pro-

30–50% higher than their normal-weight coun-

cessed, but carry an estimated one in two mil-

terparts, with the associated risk of prolapse

lion risk of transmitting a viral infection.49

progression in this group of women being

Synthetic meshes vary in composition and

increased by 30–70% depending upon prolapsed

construction.Pore size and fiber type are physical

compartment.9 Interestingly, a 10% weight loss

properties of the mesh that are most important

was not associated with regression.11 Pelvic floor

in promoting neovascularization and host cell

exercises, or kegel exercises, have been shown to

infiltration, resulting in tissue in-growth. Meshes

be effective in preventing progression of severe

with pores smaller than 10 mm allow bacterial

prolapse in one study of elderly Thai women

penetration of the mesh but prevent the entry of

when performed on a daily basis.48

macrophages and leukocytes, thereby increasing

the risk of infection. Additionally, fibroblasts are

Biosynthetics

unable to traverse the pores and incorpora-

tion with collagen deposition is not allowed to

occur, placing the material at risk for extrusion.

The application and use of biomaterials and

Meshes are constructed from a variety of materi-

synthetic meshes were introduced to the field of

als and are available as absorbable, nonabsorb-

pelvic reconstructive medicine as a response to

able, monofilament, and multifilament fibers.

high rates of prolapse repair failure, seen in up

Multifilament meshes have been found to have

to 30% of cases. Graft materials were employed

more intense lymphoplasmocytic and granu-

to augment the repair, in hopes to reinforce and

lomatous responses with less collagen deposition

strengthen the affected compartments. The

as compared to monofilament fiber types, rein-

most current literature demonstrates clear

forcing the idea that monofilament mesh is better

advantages in success with the use of mesh

incorporatedwithlowererosionrates.50 Generally,

grafts in the sacrocolpopexy and midurethral

the monofilament, macroporous polypropylene

sling for incontinence; however, the evidence

mesh is the most widely used mesh in pelvic

supporting use of grafts in anterior and poste-

reconstruction due to efficacy and complication

rior repairs is less compelling.

rates, with erosion rates estimated at 0–10%.51

Grafts can be constructed of a variety of mate-

Synthetic meshes are commercially available

rials, including autografts (rectus fascia or fascia

for prolapse surgery as sheets of various sizes or

lata), allografts (cadaveric fascia lata, dermis,

as part of a “kit.” The prolapse kits are mesh

and dura mater), xenografts (porcine smooth

grafts for the anterior or posterior compart-

intestinal submucosa and dermis or bovine peri-

ments applied transvaginally using a minimally

cardium and dermis), and synthetic meshes. The

invasive technique. Mesh erosion or infection

success of the graft is dependent upon tissue in-

was the most common complication noted in a

growth and collagen deposition with ensuing

systematic review of 3,425 patients undergoing

complications and failure if the graft is not

prolapse repair using the mesh kits from 24

incorporated or becomes encapsulated.

studies. Other complications included fistula

Xenografts are irradiated or chemically steril-

formation and dyspareunia at rates higher than

ized tissues that are treated to remove their cel-

traditional transvaginal prolapse repairs or sac-

lular components thereby reducing antigenicity.

rocolpopexy.52 Recently, the FDA has issued a

These materials may be cross-linked to large

warning regarding the potentially serious